Fillable CLAIM FORM File with: A.G. Kawamura, Secretary California ... - pesticidefreezone

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CLAIM FORM File with: A.G. Kawamura, Secretary California Department of Food and Agriculture 1220 N Street Sacramento, CA 95814 Name of Claimant: Home Address: City, State, Zip: Daytime: Evening Cell/Pager: Date of Birth: Type of Loss: Personal Injury Other Property Damage When did injury or damage occur? Where did injury or damage occur? How did injury occur? What action or inaction of Department employee(s)...
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