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Park/Facility /Field <br />Date Submitted <br />CITY OF SANTA ANA <br />PARKS, RECREATION AND COMMUNITY SERVICES AGENCY <br />Park/Facility /Field Modification Request Form <br />(Please complete one form per project) <br />7/17/2007 <br />Group/Individual Requesting <br />Modification <br />Non - Profit Tax ID No.: <br />Contact Person Name <br />Address <br />Phone Number: <br />Fax Number: <br />E -mail: <br />Certificate of Liability Insurance attached? <br />❑ <br />Yes <br />❑ <br />No I <br />Site plan/drawing enclosed? <br />❑ <br />Yes <br />❑ <br />No <br />Projected Start Date: I Projected Completion Date: <br />Brief description of proposed modification (s): <br />Brief description of how project will be funded: <br />Impact on park/facility /field during improvement /maintenance: <br />Applicant Signature <br />Approved/ Denied by <br />Conditions: <br />25E -43 <br />Date: <br />Date: <br />