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iai~i2oo~ <br />CITY OF SANTA ANA <br />PARKS, RECREATION AND COMMUNITY SERVICES AGENCY <br />ParkfF'acilittifField 1~Todification Request Form. <br />(Please complete one form per project) <br />Park/Facili /Field <br />Date Submitted <br />Group/Individual Requesting <br />Modification Non-Profit Tax ID No.: <br />Contact Person Name <br />Address <br />Phone Number: Fax Number: E-mail <br />Certificate of Liability Insurance attached? ^ Yes ^ No Site plan/drawing enclosed? ^ Yes ^ No <br />Projected Start Date: Projected Completion Date: <br />Brief description of proposed modification(s): <br />Brief description of how project will be funded and funding source: _ <br />Impact on park/facility/field during improvement/maintenance: <br />Applicant Signature <br />Approved /Denied by ___ <br />Date Received and Filed by Board of Parks and Recreation <br />Conditions (if any): <br />Date: <br />Date: <br />3 <br />25R-21 <br />