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<br />12 <br /> <br /> <br /> <br /> <br />State of California – The Resources Agency <br />DEPARTMENT OF PARKS AND RECREATION <br /> <br />City of San Leandro <br />Project Application Form <br />PROJECT NAME REQUESTED GRANT AMOUNT <br />$ <br />PROJECT SITE NAME and PHYSICAL ADDRESS where <br />PROJECT is located (including zip code) <br />(Use latitude and longitude if there is no street address) <br />LAND TENURE ( all that apply) <br /> <br /> Owned in fee simple by APPLICANT <br /> Available (or will be available) under <br />a _________year lease or easement <br />NEAREST CROSS STREET <br />COUNTY OF PROJECT LOCATION <br />APPLICANT NAME AND MAILING ADDRESS <br />AUTHORIZED REPRESENTATIVE AS SHOWN IN RESOLUTION <br /> <br /> ___________________________________________________________________________________ <br />Name (typed or printed) and Title Email address Phone <br /> <br />GRANT CONTACT - For administration of grant (if different from AUTHORIZED REPRESENTATIVE) <br /> <br /> ___________________________________________________________________________________ <br />Name (typed or printed) and Title Email address Phone <br /> <br />GRANT SCOPE: I represent and warrant that this APPLICATION PACKET describes the intended use of the <br />requested GRANT to complete the items listed in the attached Project Scope/Cost Estimate Form. I declare <br />under penalty of perjury, under the laws of the State of California, that the information contained in this <br />APPLICATION PACKET, including required attachments, is accurate. <br /> ____________________ <br />Signature of AUTHORIZED REPRESENTATIVE as shown in Resolution Date <br /> <br />Print Name <br /> <br />Title <br /> <br /> <br />176