J. Declaration

I, _________________________, declare under penalty of perjury that the information on this form is true and correct to the best of my knowledge. The information has been verified by me or under my supervision and is the most current information available.

Signature: _________________ Title: __________________ Date: _____________

Introduction: By July 1 of each year, the California Public Utilities Commission (Commission) is required to establish and furnish to the California Transportation Commission a priority list of railroad grade separation projects most urgently in need of separation or elimination. Nominations for alteration or reconstruction of existing separation projects must be submitted on the GSN-2 Form by October 21, 2005, in the Commission's OII. All nominations are reviewed and taken into consideration for the development of the Commission's Priority List. Incomplete and late-filed applications will not be processed or included in the Priority List. Please follow the instructions below to complete the application. Should you need assistance with this form please contact Rosa Muñoz at (213) 576-7078 or at rxm@cpuc.ca.gov.

INSTRUCTIONS:

A. INFORMATION ABOUT THE NOMINATING PARTY:

In the spaces provided, enter name, address, e-mail address and contact person along with contact's title and phone number. In the "Alternate" section, list consultant information if they are processing the nomination.

B. CROSSING LOCATION AND PROJECT TYPE:

Provide the PUC and DOT crossing identification numbers for the existing structure along with the street location, nearest cross street, city, county and the railroad track owner. Please specify if the project is an alteration or reconstruction. If the reconstruction involves the relocation of the existing separation, then enter "NEW" for the Federal and PUC numbers.

C. CLEARANCES:

Provide the information requested about the physical attributes of existing separation. The Horizontal Width should be measured between the edge of roadway/curb to the opposite edge of roadway/curb. For the Height Clearance, measure from the top of rail to bottom of structure, or, measure from the center of the roadway to bottom of structure. Also specify if the structure is an Overpass or Underpass.

D. SPEED REDUCTION AND/OR SLOW ORDER

Quantitatively identify any vehicular speed reduction that may be due to the presence of the

structure. For example, speed over the structure being reduced from 60 mph to 30 mph. Information regarding a railroad slow order may be obtained from the railroad company (see Appendix 4 for list of Railroads).

E. AVERAGE DAILY VEHICLE & TRAIN VOLUMES

Provide an average 24-hour day count of vehicles and trains and enter the date when count was taken. The count should be completed by the filing due date and should not be more than one year old. If a current count is not available, provide the information along with the date of the most current count. Do not estimate the data.

F. ACCIDENT HISTORY DATA:

Provide a count of the total number of accidents that may be attributed to the presence of the grade separation structure. Include a copy of the data and source(s).

G. COSTS AND CONTRIBUTIONS:

Complete the worksheet to determine the total project costs. Also enter the amount of the total costs expected from the sources on GSN-2 Form. Indicate the amount sought from the state fund either the partial amount needed to fund the project, the maximum state allocation of five million dollars per project, or the amount if applicant is seeking multiple-year funding.

H. PROBABILITY OF FAILURE DATA:

Please specify the date the structure was constructed and the date the structure was last evaluated for probability of failure. Attach a copy of the evaluation with recommendations for corrective action(s) to the original GSN-2 Form. If retrofitting work is in progress or has been completed, attach a summary of work completed and the completion dates. Also specify if other work is being planned for completion prior October 21, 2005.

I. ATTACHMENTS

Please attach a location map and two photographs of the existing structure (one from each approach) showing the entire separation and pertinent crossing geometrics.

J. DECLARATION: Please complete the declaration with the information requested and sign.