(a) If the participant meets all the requirements for an exemption from the ignition interlock device requirement provided in Vehicle Code section 23573(g)(1)(A), he or she shall submit an Exemption for Ignition Interlock Device, form DL 4054B (REV. 1/2010), which is hereby incorporated by reference, to the department within 30 days from the mail date of the notification of the requirement to install ignition interlock device. The original completed form DL 4054B (REV. 1/2010), shall be submitted to the department at a local public field office, or mailed to the Department of Motor Vehicles, Mandatory Actions Unit, Mail Station J233, P.O. Box 942890, Sacramento, California, 94290-0001.