Recording Requested By City of Carson When recorded, mail to: City Clerk’s Office 701 E. Carson Street Carson, CA 90745

___________________________ Space above this line for Recorder’s use _________________

FOR

Describe Purpose Of Dedication

FOR VALUABLE CONSIDERATION, receipt whereof is hereby acknowledged,

Grantor's Legal Name Or Company Name

DO(ES) HEREBY DEDICATE TO THE CITY OF CARSON, CALIFORNIA, a Municipal Corporation, its successors and assigns, the to construct, maintain, operate, repair, alter, replace, and remove utilities over, under, along and across the following described parcel of real property situated in the City of Carson, County of Los Angeles, State of California:

As described in Exhibit “A” and depicted on Exhibit “B” attached hereto and made a part hereof.

together with all necessary and convenient means of ingress and egress to and from said rightofway or strip or parcel of land, for the purpose of constructing, reconstructing, maintaining, operating, repairing, renewing, or enlarging in any manner the improvements, together with any and all of the purposes hereinbefore mentioned.

TO HAVE AND TO HOLD the above granted and described premises unto the CITY OF CARSON, CALIFORNIA, its successors and assigns forever.

IN WITNESS HERETO, the grantor(s) have hereunto set their hands and Seals this __________ day of _________________, 20______.

Search No. _____________ Parcel _____________ Index Map _____________ R- ________________ Supervisorial District No. _____________________	Signature: Title: Signature: Title:

NOTE: Acknowledgment forms attached.

ACKNOWLEDGMENT

State of California

County of_________________________

On_________________beforeme, ______________________________________

(Insert Name of Notary Public and Title)

Personally appeared_______________________________________________________

Who proved to me on the basis of satisfactory evidence to be the person(s) whose

Name(s) is/are subscribed to the within instrument and acknowledged to me that

He/she/they executed the same in his/her/their authorized capacity (ies), and

That by his/her/their signature(s) on the instrument the person(s), or the entity

Upon behalf on which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California

That the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature__________________________ (Seal)

RECORDING REQUESTED BY:

AND

WHEN RECORDED MAIL TO:

City Clerk

701 E. Carson St.

Carson, CA 90745

______________________________________________________________________________________

CERTIFICATE OF ACCEPTANCE

This is to certify that the interest in real property conveyed by the within deed or grant to the City of Carson, a political corporation and/or government agency, is hereby accepted, as authorized by order of the City Council of the City of Carson on October 14, 1968, and the grantee consents to the recordation thereof by its duly authorized officer.

City of Carson

By _________________________________	_________________

Donesia Gause-Aldana, MMC	Date

City Clerk

Also known as:

GRANTOR'S NAME

Address Adjacent to Area of Dedication