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State of California — The Resources Agency <br />DEPARTMENT OF PARKS AND RECREATION <br />City of San Leandro <br />Project Application Form <br />PROJECT NAME <br />REQUESTED GRANT AMOUNT <br />PROJECT SITE NAME and PHYSICAL ADDRESS where <br />LAND TENURE (0 all that apply) <br />PROJECT is located (including zip code) <br />(Use latitude and longitude if there is no street address) <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 />Name (typed or printed) and Title Email address Phone <br />GRANT CONTACT - For administration of if rant different from AUTHORIZED REPRESENTATIVE <br />g ( ) <br />Name (typed or printed) and Title Email address Phone <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 />Signature of AUTHORIZED REPRESENTATIVE as shown in Resolution Date <br />Print Name <br />Title <br />12 <br />