ITY OF CHULA VISTA
DONATION ACCEPTANCE FORM:
Name of donor: _ P - ( 7rf) Pot() 12 j
Address: Iblp l 2Qr c`- City: State:C'tj_ Zip:q' J
R)
Description. of donation.: I
t
k y r' t1 9 - tlG ( 0 Y`- dl In hAA ac q IV -\,- 3v 5a< v t Le tieWike S ear a_ p1 i<
Donor estimate of current value.
Potentialimmediateor initial.: acquisitionor installationcost, anyon-goingmaintenanceor 0r
replacement cost: 0 ('
r ''' rr
1' S_ U ll` t N nn o_ rivrl o —
MM
0 1069 --mi
intended use:
Conditions: of acceptance or donor designa..tion:
Remarks;
City departmentreceiving donation: C
APPROVED./ DISAPPROVED
Date : Department Head' s Signature
Date. City Manager' s Signature
Date Submitted to Council DateApprovedby Council
Date Mayor'. s Isignature
Note: TheCityofChulaVistacannotguarantee: fiiturefiindingforrepair; maintenance, useorreplacementofdonatedi(ems.
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