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: <br /> 1 <br /> i <br /> � <br /> ",••. .". CLA1h1:iNi WF��tE � <br /> ' , �ATE OF LOSS: , � <br /> Return within th`ee days to:�(_(�, �,(d�, " <br /> � . � <br /> CITY C07-0MENT SU���:ARY $'ri�ET <br /> DEPARTN�ra7 CITY <br /> � Review h Comments: Recommendation k Comments: <br /> + F�,�- f�i�/�E.d�,Y G.�'a�P /nJt' <br /> �K /��J,p /�✓,.JC l r GJ-C.Gf �E.C/J7i T �-,L � <br /> � lAr'i�/� �Ov�r7P .0 on) �aoFcJ.- �; . <br /> _('��.L�i%�>n1.t: ��e T'J'f.��E AtL Ss�--,� <br /> /�/'Fc9�.7ian) /1S yo .�FiJcj�T.l'F� J/ITc y -- <br /> � iN«<.�.i.✓G d'N.T',�,ic�,OlS �Mi WAliJ .JG c' nJa I <br /> ��Ei�J� coiY/iM4 Cv�T F bff%C S F"S � I <br /> u�J�crSJ wJ A c �� <br /> , -- //riTE iJj.� /Y 11PST2"F' <br /> '� J'do�7 c'�a... NfT/F/cl� S/T� J�iI/'— <br /> � � �ATG.S�' �'.CJ�=�r/f'�iC <br /> (continue onto back as necessary) (continue onto back ¢ s necessary) <br /> I <br /> Name of Dept. Contact and phone numb�r: Name of reviewing perso,i: <br /> � cJ c"���i,�/�;� c �,��� - �,�— r'� <br /> Department: �U�.Ruc• G.���.`_ - Phone No. : <br /> i� <br /> LOSS I(�FORMATION <br /> AUTO INCIOENT: <br /> City Ori��er's Name City Vehicle �7: <br /> Driver's Occupation: City Registration 11: <br /> Defensive Oriving Training: iJo Yes when: <br /> Equipment Training: No Yes When: <br /> � i <br /> . ` '�,� <br /> Distrioution tn: • <br /> Scott wetzel ii� �Z <br /> ._ Risk 1•tanager �,� � .��' F� � <br />' Other � ' <br /> /t � �1 % I/ � " ` � �� a�Q� �,.� � i <br /> //'/d 5�/� ��S /,-- � fyj' �5 �^ <br /> . � r �.a'' ����! J�ps ' <br /> � ,� o i <br /> I <br />