HomeMy WebLinkAboutCP 3537; |Graham, David|Medina Benjamin and Eunice|; 2008-0423714: Easement2008-0423714
RECORDING REQUESTED BY
AND WHEN RECORDED,
PLEASE MAIL TO:
City Clerk
City of Carlsbad
1200 Carlsbad Village Drive
Carlsbad, California 92008 '
MAIL TAX STATEMENTS TO:
EXEMPT
Please record this document at no fee
as it is to the benefit of the City (Gov.
Code [6103]).
8183
AUG 07, 2008 4:55 PM
OFFICIAL RECORDS
SAN DIEGO COUNTY RECORDER'S OFFICE
GREGORY , I. SMITH, COUNTY RECORDER
FEES: 0.00
OD NA
PAGES:8
The undersigned grantor(s) declare(s):
Documentary transfer tax is $ 0.00 /
( ) computed on full value of property conveyed, or
( ) computed on full value less value of liens and
encumbrances remaining at time of sale.
( ) Unincorporated area: (x) City of Carlsbad . and
FOR A VALUABLE CONSIDERATION,
receipt of which is hereby acknowledged.
Space above this line for Recorder's use.
206-200-01Assessor's Parcel No.:
Project No. & Name: CP 3537; NORTH AGUA
HEDIONDA INTERCEPTOR SEWER REALIGNMENT
CITY OF CARLSBAD
TlLDAM E. PLUMMEff, Deputy City Engineer
GRANT DEED OF
WASTEWATER PIPELINE EASEMENT
BENJAMIN MEDINA AND EUNICE MEDINA, HUSBAND AND WIFE AND
DAVID GRAHAM A SINGLE MAN, ALL AS JOINT TENANTS
does hereby grant to City of Carlsbad, a Municipal Corporation, its successors and assigns, an easement for the
purposes.
Wastewater Pipeline Purpose: The easement granted herein shall be granted for the following
purposes: the construction, operation, repair, reconstruction and all activities necessary to construct, reconstruct,
operate, maintain and repair facilities designed for the general purpose of collecting, and transporting all wastewater.
Said facility may include pipelines, and structures designed to control the flow of wastewater and all
facilities and structures associated with said use which are designed to facilitate the use and protect the facility from
natural and other forms of damage. The use shall also include a means of access to and from structures of said
facility for the purpose of constructing, operating, repairing, maintaining, inspecting and reconstructing said facility.
08/17/98 Rev
1
8184'
The uses described herein shall be exclusive to the Grantee. Grantor herein agrees that no buildings
and/or structures will be erected, walls constructed, fences built nor trees planted without the express written approval
of the Grantee, nor may the easement be used by the Grantor or any other person or entity, including other utilities,
whether public or private, for uses whether compatible or incompatible with the uses described herein without the
express written approval of the Grantee.
LOCATION OF EASEMENT:
The easement granted herein shall be located within and upon the properties more particularly
described in Exhibit "A" and Exhibit "B" attached hereto and by this reference made a part hereof.
Executed by the Grantor this 77 day of.
20Qft.
GRANTORS:
Benjamin Medina David Graham
(name of grantor) /-, (name of grantor)
By: v^^X-^-jfo-TyW^ ^^O^w By:
(sign 6^e) (sign here)
OWNER OWNER
(title of signatory) (title of signatory)
Eunice Medina
(name of grantor) /
By: .xvQ^flW yVLdx^^K.
(sign here)
ATTORNEY-IN-FACT
FOR EUNICE MEDINA, OWNER
(title of signatory)
(Notarial acknowledgment of execution of PROPERTY OWNER must be attached.)
(Chairman, president or vice-president and secretary, assistant secretary, CFO or assistant treasurer must sign for
corporations. Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary
under corporate seal empowering the officer(s) signing to bind the corporation.)
(If signed by an individual partner, the partnership must attach a statement of partnership authorizing the partner to
execute this instrument.)
APPROVED AS TO FORM:
RONALD R. BALL
City Attorney
BV. .
RQtfALD KEMP, Deputy City^(ttorney
08/17/98 Rev
2
8185
EXHIBIT "A"
LEGAL DESCRIPTION
SERVIENT TENEMENT
THE SOUTHEASTERLY 127.00 FEET OF LOT 5, IN BLOCK "D" OF BELLA VISTA,
MEASURED AT RIGHT ANGLES TO THE SOUTHEASTERLY LINE THEREOF, IN THE CITY
OF CARLSBAD, COUNTY OF SAN DIEGO, STATE OF CALIFORNIA, ACCORDING TO MAP
THEREOF NO. 2152, FILED IN THE OFFICE OF THE COUNTY RECORDER OF SAN DIEGO
COUNTY MARCH 7, 1929 TOGETHER WITH THAT PORTION OF LOT 6 IN BLOCK "D" OF
SAID MAP NO. 2152 LYING WESTERLY OF A LINE RUNNING PARALLEL WITH AND
DISTANT 300.00 FEET WESTERLY, MEASURED AT RIGHT ANGLES, FROM THE
EASTERLY LINE THEREOF.
PARCEL 1 - SEWER EASEMENT
A STRIP OF LAND, 20.00 FEET IN WIDTH, LYING WITHIN THE HEREINABOVE DESCRIBED
SERVIENT TENEMENT, BEING 10.00 FEET NORTHEASTERLY AND SOUTHWESTERLY,
MEASURED AT RIGHT ANGLES, FROM THE FOLLOWING DESCRIBED CENTERLINE:
BEGINNING AT THE SOUTHWESTERLY CORNER OF THE HEREINABOVE DESCRIBED
SERVIENT TENEMENT; THENCE ALONG THE WESTERLY LINE THEREOF NORTH
18W22" EAST, 103.15 FEET TO THE TRUE POINT OF BEGINNING; THENCE LEAVING
SAID LINE SOUTH 70°58'12" EAST, 178.63 FEET TO A POINT ON THE EASTERLY LINE OF
THE HEREINABOVE DESCRIBED SERVIENT TENEMENT, DISTANT THEREON NORTH
03°49'22" EAST, 101.99 FEET FROM THE MOST SOUTHERLY CORNER THEREOF
THE SIDELINES OF SAID STRIP OF LAND TO BE PROLONGED OR SHORTENED SO AS TO
TERMINATE ON SAID WESTERLY AND EASTERLY LINES OF THE HEREINABOVE
DESCRIBED SERVIENT TENEMENT.
AREA = 3,572.65 SQ. FT
January 31,2007
U:\ldata\surveys\5104survMegals\5l04APN206-200-01 EXB A ESMT.doc
Page I of I
8186
LEGEND:
PROPERTY LINE
EXHIBIT "B"
EASEMENT PLAT
CENTERLINE OF EXISTING 15' SEWER EASEMENT IN FAVOR OF THE CITY OF
CARLSBAD REC'D. 3/5/64 AS F/P NO. 41718. O.R.
CENTERLINE OF PROPOSED 20' SEWER EASEMENT.
LINE
L1
L2
LENGTH
103.15
101.99
BEARING
N18'00'22"E
N03'49'22"E
POB1 N72'17'48"W 203.60
SAN DIEGUITO ENGINEERING, INC.
4407 MANCHESTER, SUITE 105
ENCINITAS, CA. 92024
PHONE: (760) 753-5525
CIVIL ENGINEERING • PLANNING
LAND SURVEYING
SHEET 1 OF 1 SHEET
LEGAL DESCRIPTION:
POR. LOTS 5&6, BLK D, MAP
NO. 2152
BASIS OF BEARINGS:
THE SOUTHERLY RIGHT OF WAY
LINE OF A PORTION OF ADAMS
STREET PER ROS 15053;
I.E. S86'07'25"E
POR. LOTS
LK D, MAP NO. 2152
A.P.N. 206-200^01
o
= 80'
160
UAldatoXsurveys O104SLRV\dwg\PLATS\5104_206-20Q-G _Exhibit_B.dwg l/Ji/2007 SDE5104
8187
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of California
County of
(Here insert name and title of the ojficer)
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
d and official seal.
Signature of Notary Public (Notary Seal)
ROSE S. FONSECA I
CommlMton * 1779529 K
Notary MbHc - California |
San Ot*go County
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
D Individual (s)
D Corporate Officer
D
D
D
D
(Title)
Partner(s)
Attorney-in-Fact
Trustee(s)
Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long as the
verbiage does not require the notary to do something that is illegal for a notary in
California (i.e. certifying the authorized capacity of the signer). Please check the
document carefully for proper notarial wording and attach this form if required.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signers) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signers) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/Aeyr is /a») or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re-seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
•J* Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
* Indicate title or type of attached document, number of pages and date.
<• Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document
2008 Version CAPA vl2.10.07 800-873-9865 www.NotaryClasses.com
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of California
County of OOP fl
before me, 1NO
personally appeared (YVedirAo^
u fttbliV.
iifi
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
WpNESS my hand and official seal
Signature of Notary Public (Notary Seal)
ROSE S. FONSECA
Commlttton # 1773529
Notary PubUc • California i
San Dl«ao County
20n
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
D Individual (s)
D Corporate Officer
D
D
D
D
(Title)
Partner(s)
Attorney-in-Fact
Trustee(s)
Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long as the
verbiage does not require the notary to do something that is illegal for a notary in
California (i.e. certifying the authorized capacity of the signer). Please check the
document carefully for proper notarial wording and attach this form if required.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signers) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
be/she/feeyr is /a») or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re-seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
•J* Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
•> Indicate title or type of attached document, number of pages and date.
* Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document
2008 Version CAPA v!2.10.07 800-873-9865 www.NotaryClasses.com
CALIFORNIA ALL-PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
State of California
County of
On "1/ri
I
before me,
personally appeared
(Here insert name and title of the officer)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
(Notary Seal)
ROtE S. FONSECA
Commtotlon # 1773629
NotoivPublic-California
San Ol«ao County
1.2011
ADDITIONAL OPTIONAL INFORMATION
DESCRIPTION OF THE ATTACHED DOCUMENT
(Title or description of attached document)
(Title or description of attached document continued)
Number of Pages Document Date
(Additional information)
CAPACITY CLAIMED BY THE SIGNER
D Individual (s)
D Corporate Officer
D
D
D
D
(Title)
Partners)
Attorney-in-Fact
Trustee(s)
Other
INSTRUCTIONS FOR COMPLETING THIS FORM
Any acknowledgment completed in California must contain verbiage exactly as
appears above in the notary section or a separate acknowledgment form must be
properly completed and attached to that document. The only exception is if a
document is to be recorded outside of California. In such instances, any alternative
acknowledgment verbiage as may be printed on such a document so long as the
verbiage does not require the notary to do something that is illegal for a notary in
California (i.e. certifying the authorized capacity of the signer). Please check the
document carefully for proper notarial wording and attach this form if required.
• State and County information must be the State and County where the document
signer(s) personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s) personally appeared which
must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
commission followed by a comma and then your title (notary public).
• Print the name(s) of document signers) who personally appear at the time of
notarization.
• Indicate the correct singular or plural forms by crossing off incorrect forms (i.e.
he/she/&eyr is /are) or circling the correct forms. Failure to correctly indicate this
information may lead to rejection of document recording.
• The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges, re-seal if a
sufficient area permits, otherwise complete a different acknowledgment form.
• Signature of the notary public must match the signature on file with the office of
the county clerk.
* Additional information is not required but could help to ensure this
acknowledgment is not misused or attached to a different document.
•;• Indicate title or type of attached document, number of pages and date.
<• Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer, indicate the title (i.e. CEO, CFO, Secretary).
• Securely attach this document to the signed document
2008 Version CAPA vl2.10.07 800-873-9865 www.NotaryClasses.com
8190
CERTIFICATION FOR ACCEPTANCE OF DEED
This is to certify that the interest in real property conveyed by the GRANT
DEED OF EASEMENT dated July 17, 2008, from Benjamin Medina, Eunice
Medina Husband and wife and David Graham a single man, all as joint tenants, to
the City of Carlsbad, California, a municipal corporation, is hereby accepted by
the City Council of the City of Carlsbad, California, pursuant to Ordinance No.
NS-422, adopted on September 16,1997, and the grantee consents to the
recordation thereof by its duly authorized officer.
DATED: August 5. 2008
SI/IERRY FREISINGER, Deputy Clerk
(SEAL)
Nease complete this information.
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL TO:
~ iT y o F Q,;:ia L-s /sn✓.:>
i{Jr:N.' rvtARK fslS/cvf?
I{:; 3 5 r /-112 r:1-o /9-y ti v~
CJ4~LS ~.40 CH 92CJ08
DOC# 2008-0258903
I 111111111111111111111111111111111111111111111111111111111111111111111
MAY 14, 2008 9:43 AM
IJ FFI Cl6-L Fi ECORD~'
'3-ilN DIEGO CCIIJfJT\' FiECOFiDEW:; OFFICE
CiRECilJF:'/ ,I ::;MITH. CCIUtH'( FiECCIRDER
FEES 32.00
PAGES: 5
1111111 11m Ulll 111111111111111111111111111111111111111111111111111111111111111
Space above this line reserved for Recorder's Use Only
Govt. Code 27361.6
(Please fill in document titfe(s) on this line)
Govt. Code 27324
THIS PAGE ADDED TO PROVIDE ADEQUATE SPACE FOR RECORDING INFORMATION
Govt. Code 27361.6
(Additional recording fee applies)
·General Power of Attorney
(with Durable Provision) ·
NOTICE: THIS IS AN IMPORTANT DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT
FACTS. THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON WHOM YOU DESIGNATE (YOUR "AGENT"}
BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO PLEDGE, SELL OR OTHERWISE DISPOSE OF
ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. YOU MAY SPECIFY THAT
THESE POWERS WILL EXIST EVEN AFTER YOU BECOME DISABLED, INCAPACITATED OR INCOMPETENT. THIS DOCUMENT
DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL OR OTHER HEALTH CARE DECISIONS FOR YOU. IF THERE IS ANYTHING
ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU. YOU MAY
REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
TO ALL PERSONS, be it known that I, _Eu.1 .... 1 ..... 0 ..... j .... c .... e'---"'-M .... e'"'"d...,.i .... o.._.a ________________ __,
of San Diego County. California
the undersigned Granter (hereinafter Principal), do hereby make and grant a general power of attorney to _____ _
Ben Medina of San Diego County, California
and do thereupon constitute and appoint said individual as my Attorney-in-Fact/Agent.
If my Agent is unable to serve for any reason, I designate __________________ _,
of __________________________ _, as my successor Agent.
My Attorney-in-Fact/Agent shall act in my name, place and stead in any way that I myself could do, if I were personally present,
with respect to the following matters, to the extent that I am permitted by law to act through an agent:
(NOTICE: The Principal must write his or her initials in the corresponding blank space of each box below with respect to each
of the subdivisions (A) through (N) below for which the Principal wants to give the agent authority. If the blank space within
a box for any particular subdivision is NOT initialed, NO AUTHORITY WILL BE GRANTED for matters that are included in that
subdivision. Cross out each power withheld.)
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(A)
(B)
(()
(D}
(E}
(F)
(G)
(H)
(I)
(J)
Real estate transactions
Tangible personai"property 'transactions
Bond, share and commodity transactions
Banking transactions
Business operating transactions
Insurance transactions
Gifts to charities and individuals other than Attorney-in-Fact/Agent
(If trust distributions are involved or tax consequences are anticipated,
consult an attorney.)
Claims and litigation
Personal relationships and affairs
Benefits from military service
Page 1 of 3 C> 2005 Socrates Media, LLC
LF205-1 • Rev. 03/05
'
[ ~ (K)
[ (jf-(L)
~f-(M)
,t (N)
Durable Provision:
[ 4\f ] (0)
Records, reports and statements
Full and unqualified authority to my Attorney-in-Fact/Agent to delegate any or all of the
fo,egoing powers to any person or persons whom my Attorney-in-Fact/Agent shall select
Access to safe deposit box(es)
All other matters
If the blank space in the block to the left is initialed by the Principal, this power of
attorney shall not be affected by the subsequent disability or incompetence of the
Principal.
Other Terms: ______________________________ _
My Attorney-in-Fact/Agent hereby accepts this appointment subject to its terms and agrees to act and perform in said fiduciary
capacity consistent with my best interests as he or she in his or her best discretion deems advisable, and I affirm and ratify all
acts so undertaken.
TO INDUCE ANY THIRD PARTY TO ACT HEREUNDER, I HEREBY AGREE THAT ANY THIRD PARTY RECEIVING A DULY
EXECUTED COPY OR FACSIMILE OF THIS INSTRUMENT MAY ACT HEREUNDER, AND THAT REVOCATION OR TERMINATION
HEREOF SHALL BE INEFFECTIVE AS TO SUCH THIRD PARTY UNLESS AND UNTIL ACTUAL NOTICE OR KNOWLEDGE OF
SUCH REVOCATION OR TERMINATION SHALL HAVE BEEN RECEIVED BY SUCH THIRD PARTY, AND I FOR MYSELF AND FOR
MY HEIRS, EXECUTORS, LEGAL REPRESENTATIVES AND ASSIGNS, HEREBY AGREE TO INDEMNIFY AND HOLD HARMLESS
ANY SUCH THIRD PARTY FROM AND AGAINST ANY AND ALL CLAIMS THAT MAY ARISE AGAINST SUCH THIRD PARTY BY
REASON OF SUCH THIRD PARTY HAVING RELIED ON THE PROVISIONS OF THIS INSTRUMENT.
Signed under seal this ___ J ~ ____ day of _-"~~~~-tJ-H:i__,__.,_ _____ __,, 20 0 2)
Signed in the presence of:
Witness
wwww.socrates.com Page 2 of 3 Cl 2005 Socrates Media, LLC
Lfl05-1 • Rev. 03/05
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
personally appeared
....... .),.. ___ _
who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s). or the entity upon behalf of
which the person(s) acted, executed the instrument
l certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph 1s
true and correct.
::::::: ~ylli -.r7·,-~-
SJJ• >J(, ':ct 0, r-.,.,
OPTIONAL-------------
Though the information below is not required by :aw, ii may prove valtHlbie to persons relymg on tile aocument
:md could prevent frauduim1/ removal and rea/tact1men/ of t!11s form tc anotfler doc0menr.
Description of Attached Document
f1t1e or Type of Document:
Document Date:
S,gner(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
Signer's Name:
Individual
Corporate Officer _.,., Title(s): _
Partner .. · Limited General
Attorney in Fae!
Trustee
Guardian or Conservator
Other ___ _
Number of Pages:
Signer's Name:---·-
Individual
Corporate Officer -T,tleis): ...
Partner -Limited General
Atlorney H1 Fact
Trustee
· Guardian or Conservator
. Other:
Signer Is Representing:------·
------. .----·---
~1r~~1~
l
NOTARY SEAL CERTIFICATION
(Government Code 27361. 7)
I CERTIFY UNDER PENAL TY OF PERJURY THAT THE NOTARY SEAL ON THE
DOCUMENT TO WHICH THIS STATEMENT IS ATTACHED READS AS FOLLOWS:
Commission Number: 15 ° 7 7 9 </ Date Commission Expires: Ao I 01 2()08
County Where Bond is Filed: __ S_CI_A_D_1._C?6--o _____________ _
Manufacturer or Vendor Number: __ '--'N'--'tv'-'-'-A__,__.,_\ ____________ _
(Located on both sides of the notary seal border)
Signature:~
FirmName (if applicable)
Place of Execution: ~, Sc,..r... Vk'.\w~os Date: SJ 1 $-' Jo B ------'-----'-='--'------=__,.____ ---+, ---+, -~---
Rec. Fom, #R10 (Rev. 8/13/97)