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CITY OF SANTA ANA <br />RFP NO.: 22-096 <br />ON CALL EMERGENCY ASPHALT" & PCC <br />OWNERSHIP AFFIDAVLT; <br />STATE OF CALIFORNIA ) <br />COUNTY OF ORANGE ) SS: <br />SANTA ANA ,�/ <br />-----tt—�C E'° , being duly sworn, deposes and says: <br />❑ INDIVIDUAL Tlrat ho/she is the party making ilia tirregoing proposal: <br />❑PARTNERSHIP That he/sire isa rrrember of the co-partrerldip una designated as: <br />and whn has boon and is rely vested with the nuthodty to makormd axecule instmrriaals for the co-parmorship <br />by: <br />who canstihrte tha o0ter mnmbars of the ao»parutanhip. <br />'CORPORATION That he is of: <br />f�rr.�n 'NM,tr,�m✓elv't Y"'n �.�,r,,.,,��� <br />a corporation Wiligli IS1 <br />EJ JOINT VENTURE That he is oP <br />one afthe pardon rnaldpg the foregoing proposal as a joint venture, and ilia hebbe has been and is duly vested <br />with the authority to execute instruments for on on behalf of the parties making said bid who are: <br />that such a bid is genuine and not collusive or sharp, and has not in any trlanner sought by collusion to secure any <br />advantage against the City ofSantatlna or any person interested in the proposed contract, for himself or any other <br />person. <br />Sig Sig aCONR <br />Subscribed and sworn to before me this _ day of 20 <br />Signature of officer Administering Oath (Notary Public) <br />A aryptt tor9 Ce <br />rM"anytheidengfyo}then dltddo IwhoSignedsM <br />doWm nt rnwhich th s certificateis attach .and <br />trvMluefness, accuracy,or validity oft tdocument, <br />stootc4ultanla,ce"Iyoy b� I g <br />Stilimille4itond sworn to (p a rmed) before area <br />WWAd tonne on the bn6dsn"diia tory evidence <br />to be the person($ I 6app rrree'd laeklm e. <br />CCLE77E L. CORDON <br />COMM. 92296433 <br />Notary Pubilc - California o <br />Riverside County <br />Comm. Expires Aug, 4, 2023 <br />Page 3 of 10 <br />