Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-03733/USCOURTS-cand-3_18-cv-03733-2/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 42:1983 Civil Rights Act

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Stipulated Protective Order 3:18-cv-03733-JST

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

SAN FRANCISCO DIVISION

DEBBY DIZON, 

 Plaintiff,

 V.

CITY OF SOUTH SAN FRANCISCO,

DIANA QUINTERO, INDIVIDUALLY 

AND AS AN OFFICER OF THE 

SOUTH SAN FRANCISCO POLICE 

DEPARTMENT, CHRISTOPHER 

DEVAN, INDIVIDUALLY AND AS

AN OFFICER OF THE SOUTH SAN 

FRANCISCO POLICE DEPARTMENT, 

JEFF AZZOPARDI, INDIVIDUALLY 

AND AS CHIEF OF THE SOUTH SAN 

FRANCISCO POLICE DEPARTMENT; 

KEITH A. WALL, INDIVIDUALLY

AND AS A LIEUTENANT OF THE 

SOUTH SAN FRANCISCO POLICE 

DEPARTMENT; DONALD D. OLSEN, 

INDIVIDUALLY AND AS A

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CASE NO: 3:18-cv-03733

STIPULATED PROTECTIVE 

ORDER

JAIME A. LEAÑOS, Esq. - SBN: 159471

LAW OFFICES OF MORALES & LEAÑOS

75 East Santa Clara Street, Suite 250

San Jose, CA 95113

Telephone: (408) 294-6800

Facsimile: (408) 294-7102

E-mail: jleanoslaw@pacbell.net

SUZANNE A. LUBAN, Esq. – SBN: 120629

559 Nathan Abbott Way

Stanford, CA 94305

Telephone: (650) 724-6345 Facsimile: (650) 723-4426

E-mail: lubanlaw@sbcglobal.net

Attorneys for Plaintiff

Case 3:18-cv-03733-JST Document 31 Filed 12/04/18 Page 1 of 15
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Stipulated Protective Order 3:18-cv-03733-JST

SERGEANT OF THE SOUTH SAN 

FRANCISCO POLICE DEPARTMENT,

AND DOES 4-10, INCLUSIVE,

 Defendants.

1. PURPOSES AND LIMITATIONS

Disclosure and discovery activity in this action are likely to involve production of 

confidential, proprietary, or private information for which special protection from 

public disclosure and from use for any purpose other than prosecuting this litigation 

may be warranted. Accordingly, the parties hereby stipulate to and petition the court 

to enter the following Stipulated Protective Order. The parties acknowledge that this 

Order does not confer blanket protections on all disclosures or responses to discovery 

and that the protection it affords from public disclosure and use extends only to the 

limited information or items that are entitled to confidential treatment under the 

applicable legal principles. The parties further acknowledge, as set forth in Section 

12.3, below, that this Stipulated Protective Order does not entitle them to file 

confidential information under seal; Civil Local Rule 79-5 sets forth the procedures 

that must be followed and the standards that will be applied when a party seeks 

permission from the court to file material under seal.

2. DEFINITIONS

2.1 Challenging Party: a Party or Non-Party that challenges the designation of 

information or items under this Order.

2.2 “CONFIDENTIAL” Information or Items: information (regardless of how it is 

generated, stored or maintained) or tangible things that qualify for protection under 

Federal Rule of Civil Procedure 26(c). Among other items, all recordings, materials, 

and documents that are subject to the superior court’s sealing order issued on October 

1, 2018 in San Mateo Superior Court Case No. 17NM001867B shall constitute 

“Confidential Information or Items.”

2.3 Counsel (without qualifier): Outside Counsel of Record and House Counsel (as

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Stipulated Protective Order 3:18-cv-03733-JST

well as their support staff).

2.4 Designating Party: a Party or Non-Party that designates information or items 

that it produces in disclosures or in responses to discovery as “CONFIDENTIAL.” 

2.5 Disclosure or Discovery Material: all items or information, regardless of the 

medium or manner in which it is generated, stored, or maintained (including, among 

other things, testimony, transcripts, and tangible things), that are produced or 

generated in disclosures or responses to discovery in this matter.

2.6 Expert: a person with specialized knowledge or experience in a matter 

pertinent to the litigation who has been retained by a Party or its counsel to serve as an 

expert witness or as a consultant in this action.

2.7 House Counsel: attorneys who are employees of a party to this action. House 

Counsel does not include Outside Counsel of Record or any other outside counsel.

2.8 Non-Party: any natural person, partnership, corporation, association, or other 

legal entity not named as a Party to this action.

2.9 Outside Counsel of Record: attorneys who are not employees of a party to this 

action but are retained to represent or advise a party to this action and have appeared 

in this action on behalf of that party or are affiliated with a law firm which has 

appeared on behalf of that party.

2.10 Party: any party to this action, including all of its officers, directors, 

employees, consultants, retained experts, and Outside Counsel of Record (and their 

support staffs).

2.11 Producing Party: a Party or Non-Party that produces Disclosure or Discovery 

Material in this action.

2.12 Professional Vendors: persons or entities that provide litigation support 

services (e.g., photocopying, videotaping, translating, preparing exhibits or 

demonstrations, and organizing, storing, or retrieving data in any form or medium) 

and their employees and subcontractors.

2.13 Protected Material: any Disclosure or Discovery Material that is designated as

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Stipulated Protective Order 3:18-cv-03733-JST

“CONFIDENTIAL.” 

2.14 Receiving Party: a Party that receives Disclosure or Discovery Material from a 

Producing Party.

3. SCOPE

The protections conferred by this Stipulation and Order cover not only Protected 

Material (as defined above), but also (1) any information copied or extracted from 

Protected Material; (2) all copies, excerpts, summaries, or compilations of Protected 

Material; and (3) any testimony, conversations, or presentations by Parties or their 

Counsel that might reveal Protected Material. However, the protections conferred by 

this Stipulation and Order do not cover the following information: (a) any information 

that is in the public domain at the time of disclosure to a Receiving Party or becomes 

part of the public domain after its disclosure to a Receiving Party as a result of 

publication not involving a violation of this Order, including becoming part of the 

public record through trial or otherwise; and (b) any information known to the 

Receiving Party prior to the disclosure or obtained by the Receiving Party after the 

disclosure from a source who obtained the information lawfully and under no 

obligation of confidentiality to the Designating Party. Any use of Protected Material 

at trial shall be governed by a separate agreement or order.

4. DURATION

Even after final disposition of this litigation, the confidentiality obligations imposed 

by this Order shall remain in effect until a Designating Party agrees otherwise in 

writing or a court order otherwise directs. Final disposition shall be deemed to be the 

later of (1) dismissal of all claims and defenses in this action, with or without 

prejudice; and (2) final judgment herein after the completion and exhaustion of all 

appeals, rehearings, remands, trials, or reviews of this action, including the time limits 

for filing any motions or applications for extension of time pursuant to applicable law.

5. DESIGNATING PROTECTED MATERIAL

5.1 Exercise of Restraint and Care in Designating Material for Protection. Each 

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Stipulated Protective Order 3:18-cv-03733-JST

Party or Non-Party that designates information or items for protection under this 

Order must take care to limit any such designation to specific material that qualifies 

under the appropriate standards. The Designating Party must designate for protection

only those parts of material, documents, items, or oral or written communications that 

qualify – so that other portions of the material, documents, items, or communications 

for which protection is not warranted are not swept unjustifiably within the ambit of 

this Order.

Mass, indiscriminate, or routinized designations are prohibited. Designations that are 

shown to be clearly unjustified or that have been made for an improper purpose (e.g., 

to unnecessarily encumber or retard the case development process or to impose 

unnecessary expenses and burdens on other parties) expose the Designating Party to 

sanctions.

If it comes to a Designating Party’s attention that information or items that it 

designated for protection do not qualify for protection, that Designating Party must 

promptly notify all other Parties that it is withdrawing the mistaken designation.

5.2 Manner and Timing of Designations. Except as otherwise provided in this 

Order (see, e.g., second paragraph of section 5.2(a) below), or as otherwise stipulated 

or ordered, Disclosure or Discovery Material that qualifies for protection under this 

Order must be clearly so designated before the material is disclosed or produced.

Designation in conformity with this Order requires:

(a) for information in documentary form (e.g., paper or electronic documents, but 

excluding transcripts of depositions or other pretrial or trial proceedings), that the 

Producing Party affix the legend “CONFIDENTIAL” to each page that contains 

protected material. If only a portion or portions of the material on a page qualifies for 

protection, the Producing Party also must clearly identify the protected portion(s) 

(e.g., by making appropriate markings in the margins).

A Party or Non-Party that makes original documents or materials available for 

inspection need not designate them for protection until after the inspecting Party has

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Stipulated Protective Order 3:18-cv-03733-JST

indicated which material it would like copied and produced. During the inspection 

and before the designation, all of the material made available for inspection shall be 

deemed “CONFIDENTIAL.” After the inspecting Party has identified the documents

it wants copied and produced, the Producing Party must determine which documents, 

or portions thereof, qualify for protection under this Order. Then, before producing 

the specified documents, the Producing Party must affix the “CONFIDENTIAL” 

legend to each page that contains Protected Material. If only a portion or portions of 

the material on a page qualifies for protection, the Producing Party also must clearly 

identify the protected portion(s) (e.g., by making appropriate markings in the 

margins).

(b) for testimony given in deposition or in other pretrial or trial proceedings, that 

the Designating Party identify on the record, before the close of the deposition, 

hearing, or other proceeding, all protected testimony. 

(c) for information produced in some form other than documentary and for any 

other tangible items, that the Producing Party affix in a prominent place on the 

exterior of the container or containers in which the information or item is stored the 

legend “CONFIDENTIAL.” If only a portion or portions of the information or item 

warrant protection, the Producing Party, to the extent practicable, shall identify the 

protected portion(s).

5.3 Inadvertent Failures to Designate. If timely corrected, an inadvertent failure to 

designate qualified information or items does not, standing alone, waive the 

Designating Party’s right to secure protection under this Order for such material. 

Upon timely correction of a designation, the Receiving Party must make reasonable 

efforts to assure that the material is treated in accordance with the provisions of this 

Order.

6. CHALLENGING CONFIDENTIALITY DESIGNATIONS

6.1 Timing of Challenges. Any Party or Non-Party may challenge a designation of 

confidentiality at any time. Unless a prompt challenge to a Designating Party’s 

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Stipulated Protective Order 3:18-cv-03733-JST

confidentiality designation is necessary to avoid foreseeable, substantial unfairness, 

unnecessary economic burdens, or a significant disruption or delay of the litigation, a 

Party does not waive its right to challenge a confidentiality designation by electing not 

to mount a challenge promptly after the original designation is disclosed.

6.2 Meet and Confer. The Challenging Party shall initiate the dispute resolution 

process by providing written notice of each designation it is challenging and 

describing the basis for each challenge. To avoid ambiguity as to whether a challenge 

has been made, the written notice must recite that the challenge to confidentiality is 

being made in accordance with this specific paragraph of the Protective Order. The 

parties shall attempt to resolve each challenge in good faith and must begin the 

process by conferring directly (in voice to voice dialogue; other forms of 

communication are not sufficient) within 14 days of the date of service of notice. In 

conferring, the Challenging Party must explain the basis for its belief that the 

confidentiality designation was not proper and must give the Designating Party an 

opportunity to review the designated material, to reconsider the circumstances, and, if 

no change in designation is offered, to explain the basis for the chosen designation. A 

Challenging Party may proceed to the next stage of the challenge process only if it has 

engaged in this meet and confer process first or establishes that the Designating Party 

is unwilling to participate in the meet and confer process in a timely manner.

6.3 Judicial Intervention. If the Parties cannot resolve a challenge without court 

intervention, the Designating Party shall file and serve a motion to retain 

confidentiality under Civil Local Rule 7 (and in compliance with Civil Local Rule 79-

5, if applicable) within 21 days of the initial notice of challenge or within 14 days of 

the parties agreeing that the meet and confer process will not resolve their dispute, 

whichever is earlier. Each such motion must be accompanied by a competent 

declaration affirming that the movant has complied with the meet and confer 

requirements imposed in the preceding paragraph. Failure by the Designating Party to

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Stipulated Protective Order 3:18-cv-03733-JST

make such a motion including the required declaration within 21 days (or 14 days, if 

applicable) shall automatically waive the confidentiality designation for each 

challenged designation. In addition, the Challenging Party may file a motion 

challenging a confidentiality designation at any time if there is good cause for doing 

so, including a challenge to the designation of a deposition transcript or any portions 

thereof. Any motion brought pursuant to this provision must be accompanied by a 

competent declaration affirming that the movant has complied with the meet and 

confer requirements imposed by the preceding paragraph.

The burden of persuasion in any such challenge proceeding shall be on the 

Designating Party. Frivolous challenges, and those made for an improper purpose 

(e.g., to harass or impose unnecessary expenses and burdens on other parties) may 

expose the Challenging Party to sanctions. Unless the Designating Party has waived 

the confidentiality designation by failing to file a motion to retain confidentiality as 

described above, all parties shall continue to afford the material in question the level 

of protection to which it is entitled under the Producing Party’s designation until the 

court rules on the challenge.

7. ACCESS TO AND USE OF PROTECTED MATERIAL

7.1 Basic Principles. A Receiving Party may use Protected Material that is 

disclosed or produced by another Party or by a Non-Party in connection with this case 

only for prosecuting, defending, or attempting to settle this litigation. Such Protected 

Material may be disclosed only to the categories of persons and under the conditions 

described in this Order. When the litigation has been terminated, a Receiving Party 

must comply with the provisions of section 13 below (FINAL DISPOSITION).

Protected Material must be stored and maintained by a Receiving Party at a location 

and in a secure manner that ensures that access is limited to the persons authorized 

under this Order.

7.2 Disclosure of “CONFIDENTIAL” Information or Items. Unless otherwise 

ordered by the court or permitted in writing by the Designating Party, a Receiving

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Stipulated Protective Order 3:18-cv-03733-JST

Party may disclose any information or item designated “CONFIDENTIAL” only to:

(a) the Receiving Party’s Outside Counsel of Record in this action, as well as 

employees of said Outside Counsel of Record to whom it is reasonably necessary to 

disclose the information for this litigation and who have signed the “Acknowledgment

and Agreement to Be Bound” that is attached hereto as Exhibit A;

(b) the officers, directors, and employees (including House Counsel) of the 

Receiving Party to whom disclosure is reasonably necessary for this litigation and 

who have signed the “Acknowledgment and Agreement to Be Bound” (Exhibit A);

(c) Experts (as defined in this Order) of the Receiving Party to whom disclosure is 

reasonably necessary for this litigation and who have signed the “Acknowledgment 

and Agreement to Be Bound” (Exhibit A);

(d) the court and its personnel;

(e) court reporters and their staff, professional jury or trial consultants, mock 

jurors, and Professional Vendors to whom disclosure is reasonably necessary for this 

litigation and who have signed the “Acknowledgment and Agreement to Be Bound” 

(Exhibit A);

(f) during their depositions, witnesses in the action to whom disclosure is 

reasonably necessary and who have signed the “Acknowledgment and Agreement to 

Be Bound” (Exhibit A), unless otherwise agreed by the Designating Party or ordered 

by the court. Pages of transcribed deposition testimony or exhibits to depositions that 

reveal Protected Material must be separately bound by the court reporter and may not 

be disclosed to anyone except as permitted under this Stipulated Protective Order.

(g) the author or recipient of a document containing the information or a custodian 

or other person who otherwise possessed or knew the information.

8. PROTECTED MATERIAL SUBPOENAED OR ORDERED PRODUCED IN 

OTHER LITIGATION 

If a Party is served with a subpoena or a court order issued in other litigation that 

compels disclosure of any information or items designated in this action as

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Stipulated Protective Order 3:18-cv-03733-JST

“CONFIDENTIAL,” that Party must: 

(a) promptly notify in writing the Designating Party. Such notification shall include 

a copy of the subpoena or court order; 

(b) promptly notify in writing the party who caused the subpoena or order to issue 

in the other litigation that some or all of the material covered by the subpoena or order 

is subject to this Protective Order. Such notification shall include a copy of this 

Stipulated Protective Order; and 

(c) cooperate with respect to all reasonable procedures sought to be pursued by the 

Designating Party whose Protected Material may be affected.

If the Designating Party timely seeks a protective order, the Party served with the 

subpoena or court order shall not produce any information designated in this action as 

“CONFIDENTIAL” before a determination by the court from which the subpoena or 

order issued, unless the Party has obtained the Designating Party’s permission. The 

Designating Party shall bear the burden and expense of seeking protection in that 

court of its confidential material – and nothing in these provisions should be construed 

as authorizing or encouraging a Receiving Party in this action to disobey a lawful 

directive from another court.

9. A NON-PARTY’S PROTECTED MATERIAL SOUGHT TO BE PRODUCED 

IN THIS LITIGATION

(a) The terms of this Order are applicable to information produced by a Non-Party 

in this action and designated as “CONFIDENTIAL.” Such information produced by 

Non-Parties in connection with this litigation is protected by the remedies and relief 

provided by this Order. Nothing in these provisions should be construed as prohibiting 

a Non-Party from seeking additional protections. 

(b) In the event that a Party is required, by a valid discovery request, to produce a 

Non-Party’s confidential information in its possession, and the Party is subject to an 

agreement with the Non-Party not to produce the Non-Party’s confidential 

information, then the Party shall: 

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Stipulated Protective Order 3:18-cv-03733-JST

(1) promptly notify in writing the Requesting Party and the Non-Party that some or 

all of the information requested is subject to a confidentiality agreement with a NonParty;

(2) promptly provide the Non-Party with a copy of the Stipulated Protective Order 

in this litigation, the relevant discovery request(s), and a reasonably specific 

description of the information requested; and 

(3) make the information requested available for inspection by the Non-Party. 

(c) If the Non-Party fails to object or seek a protective order from this court within 

14 days of receiving the notice and accompanying information, the Receiving Party 

may produce the Non-Party’s confidential information responsive to the discovery 

request. If the Non-Party timely seeks a protective order, the Receiving Party shall 

not produce any information in its possession or control that is subject to the 

confidentiality agreement with the Non-Party before a determination by the court. 

Absent a court order to the contrary, the Non-Party shall bear the burden and expense 

of seeking protection in this court of its Protected Material.

10. UNAUTHORIZED DISCLOSURE OF PROTECTED MATERIAL

If a Receiving Party learns that, by inadvertence or otherwise, it has disclosed 

Protected Material to any person or in any circumstance not authorized under this 

Stipulated Protective Order, the Receiving Party must immediately (a) notify in 

writing the Designating Party of the unauthorized disclosures, (b) use its best efforts 

to retrieve all unauthorized copies of the Protected Material, (c) inform the person or 

persons to whom unauthorized disclosures were made of all the terms of this Order, 

and (d) request such person or persons to execute the “Acknowledgment and 

Agreement to Be Bound” that is attached hereto as Exhibit A.

11. INADVERTENT PRODUCTION OF PRIVILEGED OR OTHERWISE 

PROTECTED MATERIAL

When a Producing Party gives notice to Receiving Parties that certain inadvertently 

produced material is subject to a claim of privilege or other protection, the obligations

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Stipulated Protective Order 3:18-cv-03733-JST

of the Receiving Parties are those set forth in Federal Rule of Civil Procedure 

26(b)(5)(B). This provision is not intended to modify whatever procedure may be 

established in an e-discovery order that provides for production without prior privilege 

review. Pursuant to Federal Rule of Evidence 502(d) and (e), insofar as the parties 

reach an agreement on the effect of disclosure of a communication or information 

covered by the attorney-client privilege or work product protection, the parties may 

incorporate their agreement in the stipulated protective order submitted to the court.

12. MISCELLANEOUS

12.1 Right to Further Relief. Nothing in this Order abridges the right of any person 

to seek its modification by the court in the future.

12.2 Right to Assert Other Objections. By stipulating to the entry of this Protective 

Order no Party waives any right it otherwise would have to object to disclosing or 

producing any information or item on any ground not addressed in this Stipulated 

Protective Order. Similarly, no Party waives any right to object on any ground to use 

in evidence of any of the material covered by this Protective Order.

12.3 Filing Protected Material. Without written permission from the Designating 

Party or a court order secured after appropriate notice to all interested persons, a Party 

may not file in the public record in this action any Protected Material. A Party that 

seeks to file under seal any Protected Material must comply with Civil Local Rule 79-

5. Protected Material may only be filed under seal pursuant to a court order 

authorizing the sealing of the specific Protected Material at issue. Pursuant to Civil 

Local Rule 79-5, a sealing order will issue only upon a request establishing that the 

Protected Material at issue is privileged, protectable as a trade secret, or otherwise 

entitled to protection under the law. If a Receiving Party's request to file Protected 

Material under seal pursuant to Civil Local Rule 79-5(d) is denied by the court, then 

the Receiving Party may file the information in the public record pursuant to Civil 

Local Rule 79-5(e) unless otherwise instructed by the court.

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Stipulated Protective Order 3:18-cv-03733-JST

13. FINAL DISPOSITION

Within 60 days after the final disposition of this action, as defined in paragraph 4, 

each Receiving Party must return all Protected Material to the Producing Party or 

destroy such material. As used in this subdivision, “all Protected Material” includes 

all copies, abstracts, compilations, summaries, and any other format reproducing or 

capturing any of the Protected Material. Whether the Protected Material is returned or 

destroyed, the Receiving Party must submit a written certification to the Producing 

Party (and, if not the same person or entity, to the Designating Party) by the 60-day 

deadline that (1) identifies (by category, where appropriate) all the Protected Material 

that was returned or destroyed and (2) affirms that the Receiving Party has not 

retained any copies, abstracts, compilations, summaries or any other format 

reproducing or capturing any of the Protected Material. Notwithstanding this 

provision, Counsel are entitled to retain an archival copy of all pleadings, motion 

papers, trial, deposition, and hearing transcripts, legal memoranda, correspondence, 

deposition and trial exhibits, expert reports, attorney work product, and consultant and 

expert work product, even if such materials contain Protected Material. Any such 

archival copies that contain or constitute Protected Material remain subject to this 

Protective Order as set forth in Section 4 (DURATION).

IT IS SO STIPULATED, THROUGH COUNSEL OF RECORD.

I hereby attest that I have on file all holographic signatures corresponding to any 

signatures indicated by a conformed signature /S/ within this e-filed document. 

Respectfully submitted,

Dated: November 30, 2018 McNAMARA, NEY, BEATTY, SLATTERY, 

BORGES & AMBACHER LLP

By: /s/ Noah G. Blechman 

NOAH G. BLECHMAN

By: /s/ Amy S. Rothman

AMY S. ROTHMAN

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Stipulated Protective Order 3:18-cv-03733-JST 

Attorneys for City of South San Francisco, 

 Diana Quintero, Christopher Devan, Jeff 

Azzopardi, Keith A. Wall, Donald D. Olsen 

Dated: November 30, 2018 LAW OFFICES OF MORALES & LEAÑOS

 

By: /s/ Jaime A. Leaños 

SUZANNE A. LUBAN, Attorney at Law 

By: /s/ Suzanne A. Luban 

 

Attorneys for Plaintiff Debby Dizon 

_______________________ 

ORDER

PURSUANT TO STIPULATION, IT IS SO ORDERED.

Dated: _____________, 2018 _____________________________________ 

 HON. JON S. TIGAR 

 United States District Judge 

December 4

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Exhibit A to Stipulated Protective Order 3:18-cv-03733-JST

 

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EXHIBIT A

ACKNOWLEDGMENT AND AGREEMENT TO BE BOUND

I, _____________________________ [print or type full name], of 

_________________ [print or type full address], declare under penalty of perjury 

that I have read in its entirety and understand the Stipulated Protective Order that 

was issued by the United States District Court for the Northern District of 

California on [date] in the case of Debby Dizon, v. City of South San Francisco, et 

al.; Case No. 3:18-cv-03733-JST. I agree to comply with and to be bound by all 

the terms of this Stipulated Protective Order and I understand and acknowledge 

that failure to so comply could expose me to sanctions and punishment in the 

nature of contempt. I solemnly promise that I will not disclose in any manner any 

information or item that is subject to this Stipulated Protective Order to any person 

or entity except in strict compliance with the provisions of this Order.

I further agree to submit to the jurisdiction of the United States District Court for 

the Northern District of California for the purpose of enforcing the terms of this 

Stipulated Protective Order, even if such enforcement proceedings occur after 

termination of this action.

I hereby appoint ___________________ [print or type full name] of ___________

_____________________________ [print or type full address and phone number] 

as my California agent for service of process in connection with this action or any 

proceedings related to enforcement of this Stipulated Protective Order.

Date: ______________________________________

City and State where sworn and signed: _________________________________

Printed name: _______________________________

Signature: __________________________________

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