California Code, Streets and Highways Code - SHC § 5626

The superintendent of streets may file in the office of the county recorder of the county in which the parcel of property is located, a certificate substantially in the following form :

Pursuant to the authority vested in me by the Improvement Act of 1911, I did, on the ________ day of ________, 19__, cause the sidewalk, curb, or park or parking strip, bulkheads, retaining walls, or other works (as the case may be) in front of the real property hereinafter described, to be repaired and improved, and the legislative body of said city (county, or city and county) did, on the ________ day of ________, 19__, by Resolution No.________ assess the cost of such repair upon the real property hereinafter described, and the same has not been paid nor any part thereof, and the said city (county, or city and county), does hereby claim a lien on said real property in the sum of ________ dollars ($________), and the same shall be a lien upon said real property until the said sum, with interest at the rate of ______ percent per annum, from the said ________ day of ________, 19__ (insert date of confirmation of assessment), has been paid in full and discharged of record.

The real property hereinbefore mentioned and upon which a lien is claimed, is that certain piece or parcel of land lying and being in the (name of city, or city and county) the county of ________, State of ________, and particularly described as follows:

Dated this ________ day of ________, 19__.