I, the undersigned owner of the property, or the agent representing the property owner at the address indicated below, hereby grant consent to the City of Emeryville and / or its agents to enter upon said property for the purposes of removing graffiti from my property located at:

Address:*

I understand that the painting and / or removal of graffiti will be done at no cost to me.

I understand that the services provided are limited to the removal of graffiti or the painting of the immediate area where the vandalism appears. Every effort will be made to match the color of the building; however colors cannot be matched exactly.

I hereby release and hold harmless the City of Emeryville, its officers, agents and employees of and from any and all liability, claims, causes of actions or obligations whatsoever arising out of or in any way related to entry upon my property for the purpose of removing graffiti.

This consent shall remain in full force and effect unless and until I provide a written revocation to the City of Emeryville.

First Name: *

Last Name: *

Street Address: *

Telephone No: *

Signature: _____________________________________

Date: _________________________________________

Please forward to:

Attn: Victor Gonzales
1333 Park Ave
Emeryville, CA 94608

Fax: 510 596-4359