Fill and Sign the Informed Consent Template Winston Salem State University

California Environmental Protection Agency AIR RESOURCES BOARD California Air Resources Board - SSD/CPB/EES - 6th Floor, P.O. Box 2815, Sacramento, California 95812 - Attn: Harold Holmes "INTRASTATE LOCOMOTIVE SURVEY" A. COMPANY - GENERAL CONTACT INFORMATION: Company Name(s):____________________________________________________________________________ Contact Name/Title(s): _________________________________________________________________________ Address - Street: ______________________________________________________________________________ Address - P.O. Box: ___________________________________________________________________________ City: __________________________________________ Zip Code: ___________________________________ Office: ( Fax: ( ) ____________________________ Cell: ( ) _______________________________________ ) _____________________________ Email Address: _____________________________________ Website (if applicable) : _______________________________________________________________________ Number of Employees: ________________________________________________________________________ If you own the fueling facility(s)/location(s), who is/are your primary diesel fuel supplier(s) (over the last three years): ___________________________________________________________________________________________ If you use another parties' fueling facility(s)/location(s), who is/are the owner/operator(s) of the fueling facility(s), and who is their primary diesel fuel supplier(s) - if known (over the last three years):_______________________ ____________________________________________________________________________________________ Primary diesel fuel delivery method(s) (e.g., pipeline, truck to supply tank, truck to locomotive, etc.) to the fueling facility(s): ____________________________________________________________________________________________ A. INSTRUCTIONS FOR COMPANY - GENERAL CONTACT INFORMATION: Company Name: Name of company or owner/operator. Contact Name/Title: Name of primary company contact and title (e.g., CEO, GM, Superintendent). Address: Company street and mailing address (i.e., P.O. Box). City/Zip Code: City and zip code where company is located. Office/Cell/Fax: Company and Contact phone numbers. Email Address: Company and/or Contact email address. Website Address: Company website address - http://www.???.com/ - if applicable. Number of Employees: Number of California employees with your company. Own Fuel Facility: If you own your fueling facility, who has been your primary fuel supplier over the past three years? Another Owner's Facility(s): If another company owns the fuel facility(s) your locomotives primary utilize, which company or operator owns that fueling facility(s)? If known, who is/are their primary fuel supplier(s)? Primary Delivery Method: Which is the primary delivery method to the fueling facility or directly to your locomotives? (e.g., pipeline, ship, truck to locomotive or truck to supply tank, etc.).