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So JQWW Cmmty Permanent HMW Colleotlon Raclilty <br /> 7IJ0 SwA RA BrIdgeftd Strew <br /> socton,p 95206 <br /> 2094U.S670 <br /> Fox 5672 <br /> ftl IL ___ <br /> 1 to a DATA SHEET & WAMER <br /> Mrayune(p ease print) a eiv+off print your <br /> oa nas:eol <br /> l !� <br /> I � <br /> Cx Code Tap umber <br /> C&d,1152 t2.0 33/ — z <br /> 81* ® laws unfit the we of thio type of wM collection <br /> MM totOO MO (27 PITO 6 o,22® amouth- to those bwift <br /> �! tat:tt;+gttirtxi by kw to Ile t K ,of nut xa®te per tnoatlt8atnaesses that Comte <br /> it staler M p�aip�III No at:o hanlar to manifest and tt:ttspon tboir <br /> tto your maor atfeatsgo%fillowittt;waiver of}lability. wt taerw the <br /> ® hraaoftlds oft you,COMMt adtb the Govnty Bttvf MIH rtrnem to satott»ioo your <br /> I <br /> Mdo <br /> bit"oa *at I SM <br /> eat to s ly gx $ <br /> man»a I00 Idlo (Z' ono or 520 )pf Mty Generator (CE.9Q®) ar6o <br /> Lthe tativot of tlaa Per manta basod on m wv l <br /> dbPW 041 11190115 Or d dl I 4n ®t accepted it the ttate of <br /> of al, }}be the nsibility of the CBSQQ to 9`y tt <br /> DO NOT WMT6 BELOW THIS L <br /> 1N RY <br /> (To be cotnplated by 9000"00 ol) <br /> lieuNaomi PmE6 iv ot'Coat. Prt Total <br /> 2 <br /> Riam <br />