HomeMy Public PortalAboutC-23-189 BLACK KNIGHT PATROL 2023 FAMFEST SPAON, C4
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City of Carson
Community Services Department '
Application Service Provider ABilt%flo"
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Dear Applicant,
On behalf of the City of Carson, I would like to thank you for taking the time to explore business
opportunities with the City by applying to provide services for an event at a City facility. As part
of our application process, you must complete, sign, and return the following forms. Submission
of these forms does not guarantee that you will be provided the business opportunity you seek.
Your prompt assistance in submitting the requested documentation to the City staff member listed
below will be appreciated and will help expedite the application process. Please send your
completed application and attachments directly to the following address:
City of Carson
Attn: Adrianna Gonzalez
(Event Coordinator's Name)
18601 S. Main St. Carson, CA 90248
(Enter Event Coordinator's address (i.e., city hall, corporate yard, or specific park address)
Email: agonzalez@carsonca.gov
(Enter event coordinator's email address)
Should you have any questions, please feel free to contact the staff member listed below .
Truly,
Adrianna Gonzalez
(Name)
Reservations Coordinator
(Title)
532227.5 CFN
2
Checklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITY SERVICES OFFICE USE ONLY)
X PService Provider Application Agreement
X Invoice for Future Event Date'
X K (� Business License (if applicable)
X4Proof of Insurance/Certificate of Insurance
X Waiver, Release, Hold Harmless, Agreement Not to
UT Sue, Indemnification, and Photo Release
X`-�Q Current Copy of W-9 Form (if not on file already)
1 The date of the Event shall be listed on the Invoice for Future Event Date (IFED). If the Service Provider Application is
approved, then the IFED will be processed as an invoice for services rendered for the Event. No payment will be made
until the conclusion of the Event, at earliest.
532227.5 CFN AS OF 3/14/2023
08/24/23
(Date)
Black Knight Patrol Inc.
(Company)
505 S Pacific Ave. Ste 201
(Company Address)
San Pedro, CA 90731
(City, State ZIP)
Insurance Requirements
Dear Black Knight Patrol Inc.
(Enter Provider's Name)
Please be advised pursuant to your desire to work with the City of Carson, you are required to
submit the following:
✓ Compliant Certificates of Liability Insurance (to be maintained for the duration of services
against claims which may arise from or in connection with the services), evidencing the
coverage(s) as indicated below.
Certificates of insurance, as well as additional insured and waiver of subrogation
endorsements in favor of the City, must be submitted in their entirety before any services
are provided or the event takes place. Failure to submit such required forms shall be cause
for City of Carson to reject or terminate any service provider application agreement.
The City of Carson reserves the right to modify these requirements based on the nature of the
risk, prior events, insurance coverage, or other special requirements.
MINIMUM SCOPE AND LIMIT OF INSURANCE
General Liability Insurance: Coverage shall be at least as broad as Insurance Services Form
CG 00 01 covering CGL on an "occurrence " basis, including property damage, bodily injury
and personal & advertising injury with limits no less than $1,000,000 per occurrence and
$2, 000, 000 aggregate.
Additional Insured Status
The City of Carson, and its elected and appointed officials, employees, volunteers and agents, are
to be covered as additional insureds with respect to liability arising out of their work or
operations performed at or on behalf of the City -sponsored event including materials, parts, or
equipment furnished in connection with the event.
532227.5 CFN AS OF 3/14/2023
5
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
❑ Carson Event Center Human Services Z Recreation ❑ Transportation
2023 Fam Fest Stevenson Park 8/26/23
Event: Event Location: Event Date:
Name of Service Provider: Black Knight Patrol Inc.
Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability
company, specify here):
S -Corp
Business Form/Entity Type (if general partnership, limited partnership, limited liability partnership,
or other, specify here):
S -Corp
Business Entity State of Incorporation (if applicable): CA
Type of Service: Event Overnight Security
Contact Person: Erick QJeda Garcia
Emer. Contact: Dispatch
Billing Address:
Phone #: ( 424) 308-3998
Phone #: ( 213) 985-6499
505 S. Pacific Ave. Ste 201
01007.0001/532227.8 Street
San Pedro, CA 90731
city State
ZIP
Proof of Insurance (check one)? Wes ONO
If no, would you like to purchase special event insurance through the City (check one)? []Yes ✓INo
If no, you must request a waiver of insurance requirements.
Do you request a waiver of insurance requirements? (check yes if you checked no in the two boxes
above) ❑ Yes ❑✓ No
Special Instructions / Notes:
(BKP) to provide overnight security for the 2023 Fam Fest from Friday night at 9pm,
after set-up and the park closes, to Saturday morning at 7am when staff arrive for the event.
532227.5 CFN AS OF 5-25-2023
Total of 10 hours - $45/hour = $450
If Service Provider wishes to request any special accommodation needed to facilitate provision of the
services, please identify it here or contact the staff member referenced on Page 1 of this application:
N/A
Total Service Fee $450
NOTE: If service provider is unable to provide the services as proposed or requested or the City
of Carson cancels the service for any reason, the associated fees will not be paid.
[remainder ofpage intentionally left blank]
532227.5 CFN AS OF 5-25-2023
D
Further Terms of Service Provider Application Agreement:
The undersigned signatory of Service Provider (Service Provider being the above -referenced person
or entity seeking to provide services at the above -referenced event, including all its officers, agents,
employees and volunteers) hereby represents and warrants that he or she is duly authorized by
Service Provider to execute and deliver this application on behalf of Service Provider, and that by so
executing this application, and in consideration for the City's review of this application, Service
Provider is bound by these terms.
Service Provider understands and agrees to comply with the City's "Service Provider Rules &
Regulations," which are set forth below and incorporated herein by this reference.
Service Provider agrees to indemnify and release City in connection with its proposed services in
accordance with the "Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and
Photo Release" submitted concurrently herewith.
Service Provider agrees to maintain all required insurance coverages and comply with all associated
insurance requirements as set forth on the above "Insurance Requirements" page, which is
incorporated herein by reference. Service Provider agrees that all required policies shall contain, or
be endorsed to contain, an agreement by Service Provider to waive all rights of subrogation and
contribution against the City, its elected or appointed officers, officials, employees and agents, for all
losses and liabilities paid under the terms of any policy which arise from the activities or operations
of, or the services performed by, Service Provider, regardless of any prior, concurrent, or subsequent
non-active negligence by the City.
In the event there is more than one person or entity named in this Service Provider Application
Agreement as the Service Provider, then all obligations, liabilities, covenants and conditions
hereunder shall be joint and several.
This Service Provider Application Agreement, unless and until accepted, approved, and executed by
the City Manager or designee, is only an application for provision of services to City, and does not
constitute an approval or authorization for Service Provider to perform or provide any service to City.
Neither Service Provider nor any of its agents or employees shall be deemed agents or employees of
the City, nor a member of a joint enterprise with the City. Neither Service Provider nor any of its
agents or employees shall at any time or in any manner represent that Service Provider or any of its
agents or employees are agents or employees of City, or that it is a member of a joint enterprise with
City. Subject to the requirements of this Service Provider Application Agreement, neither the City
nor any of its employees shall have any control over the manner, mode or means by which Service
Provider, its agents or employees, perform the services set forth herein.
In the event that part of this Agreement is declared invalid or unenforceable by a valid judgment or
decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of
532227.5 CFN AS OF 3-14-2023
the remaining portions of this Agreement which are hereby declared as severable and shall be
interpreted to carry out the intent of the parties hereunder.
Service Provider acknowledges that the City of Carson's consideration of Service Provider's
application to provide the above -referenced services is on the express condition that Service Provider
represents and warrants that it is and will be in compliance with all applicable restrictions on the use
of intellectual property, including copyright laws, in connection with the services proposed to be
provided. Service Provider shall indemnify, defend, and hold harmless the City against any penalties,
claims, or liabilities arising from or in connection with Service Provider's noncompliance with same.
The undersigned, on behalf of Service Provider, agrees that Service Provider seeks and is willing to
provide the above -referenced service(s) on the date and time of the above -referenced event.
This Service Provider Application Agreement has been executed on the dates written below.
APPLICATION SUBMISSION (wet signature required; no electronic signatures):
SERVICE PROVIDER: Black Knight Patrol Inc.
8/24/23
c (Signature of, ice Prov er's Authorized Representative) (Date)
Erick R. OjedaGarcia
(Printed Name of Service Provider's Authorized Representative)
(Space below this line for City use only)
------------------------------------------------------------------------------------------------------------------------
APPLICATION APPROVAL:
CITY OF CARSON
-f %n% GEW6 &TJ on
l td ,� oy- 7417_3
(Signature of City Manager or Designee) (Da )
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532227.5 CFN AS OF 3-14-2023
Service Provider Rules & Regulations
1. SERVICE PROVIDER APPLICATION: Upon acceptance, approval, and execution of a
service provider application by the City of Carson ("City"), these rules and provisions shall
become binding and a part of the Service Provider Application Agreement between the applicant
(being the entity providing a service to City as specified in the service provider application),
including its officers, employees, agents and volunteers ("Provider"), on the one hand, and the
City, on the other hand. Any additions and amendments thereto that may be established or put
into effect by the City, and provided in writing to the Provider, shall also become binding and a
part of the Service Provider Application Agreement.
2. PAYMENT/CANCELLATION: If the Provider is unable to perform or cannot provide the
services as requested, or the City cancels the service for any reason, the associated fees for
service will not be paid.
3. CANCELLATION: No refunds will be given unless the subject event is cancelled by the
City's Community Services Department. Applications may be denied or events cancelled in
favor of City programs.
4. PROPERTY LOSS OR DAMAGES: The City is not responsible for any damage to, loss or
theft of the Provider's property, or that of Provider's agents, employees or invitees.
5. CHARACTER OF ENTERTAINMENT: The Provider shall observe, obey and comply with
all applicable local, state and federal laws, and all applicable policies, rules, regulations and
terms and conditions governing use of City facilities. The Provider will forfeit all rents or other
fees paid if ejected from premises for violations of same. Ejection shall not release Provider
from any obligations for the payment of rents or other fees not yet paid under such permit or
additionally incurred. The policy of the City is to serve the public in the best possible manner.
The Provider shall at all times cooperate to this end.
The policies, rules, regulations and conditions governing use of City facilities are subject to
change without notice to Provider unless the change affects a permit already issued to Provider.
Provider shall be solely responsible for the orderly conduct of all persons using the premises by
its invitation, either expressed or implied, during all times covered by the Service Provider
Application Agreement. The City reserves the right to eject or cause to be ejected from the
premises any person or persons due to unlawful conduct.
6. RESPONSIBILITY: The Provider shall provide all material, equipment, and personnel
necessary for provision of the service described in this agreement.
7. MOVE-IN/MOVE-OUT: Move -in to the event area will be set for each venue. Unless
otherwise stated, Provider will be required to keep its area fully set up and manned until the
event is officially over. Please note that these times are subject to change.
8. SAFETY: Standing on chairs, tables or other rental equipment is prohibited. This equipment is
not engineered to support your weight. The City of Carson, its employees, agents, or officers will
not be responsible for injuries or falls caused by the improper use of furniture. Please assist in
our efforts to provide a SAFE WORKING ENVIRONMENT.
532227.5 CFN AS OF 3-14-2023
M
9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the volume or intensity
of any and all noise or light generating mechanisms (including, but not limited to, loudspeakers,
radios, television sets, musical instruments, entertainers, or blinking or flashing lights) in the
reasonable judgment of the City.
10. FLAMMABLE MATERIALS — All decorations, props and electrical equipment must be
fireproof or of fire retardant materials, must meet City requirements and are subject to removal.
Candles and other open flame devices will not be permitted except as authorized on this
agreement; subject to Fire Department regulations.
11. COPYRIGHT INFORMATION: Provider is responsible for licensing fees as required by
law. Provider may be subject to legal action for the use, display or sale of any item using any
copyrighted and/or trademarked name or logo which has not been specifically authorized under
license from the trademark holder.
12. PERMITS AND LICENSE: Provider shall procure at its own cost and expense all the
required licenses and permits applicable to Provider's use or activity.
13. OBLIGATION FOR CLEANLINESS: Provider agrees that the facility and any other
surrounding City property (including parking lots) used by the Provider must be left in a clean
and orderly condition (equal to or better than the condition existing prior to the event). If
additional maintenance is required, other than the normal cleaning process, the Provider will be
charged additional fees based on the cost of such maintenance.
14. DISPUTES: All points not covered by the Service Provider Rules & Regulations are subject
to the decision of the appropriate City representative.
15. FLOOR MANAGEMENT: The City will appoint a Floor Manager who is authorized to
enforce these rules and regulations.
16. SPACE ASSIGNMENT: Event space is assigned to providers at the sole discretion of the
City. Concerns regarding competitive or specific types of providers should be communicated to
the City at the time of application.
17. RULE CHANGES: The City reserves the right to make reasonable changes to the foregoing
rules, event hours and move-in/move-out arrangements at any time without notice to Provider,
unless the change affects a permit already issued to Provider.
532227.5 CFN AS OF 3-14-2023
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 10
I Erick Qjeda Garcia ("individual") [on behalf of
Black Knight Patrol ("Exhibitor"), and as a bona fide agent of Exhibitor duly authorized to execute this
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification agreement ("Agreement") on behalf of Exhibitor]
(individual and Exhibitor hereinafter collectively referred to as "Signatory," and the term "Signatory" includes Exhibitor's officers,
officials, employees, agents and volunteers), seek acceptance by the City of Carson of an application to provide services in/at
2023 Fam Fest ("Event") on Saturday, August 26, 2023 ("Date").
Signatory understands that accidents, illnesses, and injuries can arise out of the Event; knowing the risks, nevertheless, and in
consideration of the acceptance of an application to provide a service at the Event on the Date, Signatory hereby waives, releases
and discharges the City of Carson, its elected and appointed officers, officials, employees, agents and volunteers (collectively
"City," and individually, "City Party"), and from and against any and all claims or liabilities to Signatory or any other person or
entity, including but not limited to claims or liabilities for bodily injury, illness, death, or property damage, arising out of or
connected in any way with Signatory's participation in, presence at, or performance of services at or for the Event, even though
that liability may arise out of negligence or carelessness on the part of City, and Signatory agrees to waive its rights to make any
such claims through any action or proceeding against the City or any City Party. However, Signatory understands that this paragraph
is not intended to release any party from any act or omission of "gross negligence."
Signatory hereby grants City the right to photograph or video -record Signatory during or in connection with the Event, and to use
Signatory's photographed or video -recorded likeness, and any image, silhouette, or reproduction of the voice or appearance of
Signatory taken during or in connection with the Event ("Likeness"), for any purpose, including publicity and promotion of City
and its events, and creation or production of materials in any form for such purpose, with no claim of entitlement to any license fee
or royalty of any kind from City. Signatory hereby waives any right to the intellectual property of Signatory's Likeness.
Signatory further agrees to indemnify, defend and hold harmless City and each City Party from and against any and all claims,
liabilities, losses, damages, expenses, and costs (including without limitation costs and fees of litigation) of every nature (including,
but not limited to, property damage, bodily injury, or death), whether imposed by law or otherwise, sustained or alleged to be
sustained by any person or entity (whether they be members of the public visiting the Event, employees of the City, other Exhibitors
at the Event, or otherwise), occurring at, arising from, or connected with Signatory's preparation or performance of services at the
Event, Signatory's actions, inactions, or use of facilities at the Event, or any equipment, machinery or items displayed or used by
the Signatory at or for the Event, except for such claim, liability, loss, damage, expense, or cost which was caused by the sole
negligence or willful misconduct of the City.
In giving the foregoing releases and waivers, Signatory expressly waives any and all rights conferred upon it by the provisions of
California Civil Code Section 1542, which Signatory understands reads as follows:
"A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor
at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the
debtor or released party."
This waiver shall be effective as a bar to any and all actions, fees, damages, losses, claims, liabilities and demands of whatsoever
character, nature and kind, that are known or unknown, or suspected or unsuspected, that may arise from or relate in any way to
Signatory's participation in the Event.
This Agreement shall be binding on Signatory's successors, heirs and assigns, and shall not expire. No oral representations,
statements or inducements, apart from this written form, have been made with regard to the subject matter of this form. If any
portion of this form is declared invalid by a court of competent jurisdiction, the remainder shall continue in full force and effect.
By signing below, Signatory acknowledges and represents that it has read and understands the above, and that it voluntarily agrees
to its terms.
By signing below, Signatory acknowledges and represents that it has read and understands the above, and that is voluntarily
agrees to its terms.
SIGNED: /G Q��rLCli1-LI.CL
NAME: Erick R. OjedaGarcia
ORGANIZATION: Black Knight Patrol Inc.
DATE: 8/24/23
01007.0001/781805.1 AS OF 3-14-2023
ACORO0DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
08/23/2023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Ambrin Allison
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
NAME:
AssuredPartners of California Ins Services, LLC
(661) 616 4715 FAX, (661) 616-4715
A/CNNo
ExtI: No):
5001 California Ave.
E-MAIL ambrin.Allison@assuredpartners.com
ADDRESS:
Suite 150
INSURER(S) AFFORDING COVERAGE NAIC #
Bakersfield CA 93309
INSURERA: Summit Specialty Ins Cc 16889
INSURED
INSURERB: Security National Ins Co 19679
Black Knight Patrol, Inc.
INSURER C: Corepointe Insurance Company 10499
505 S. Pacific Ave
INSURER D:
Suite 201
INSURER E
San Pedro CA 90731
INSURER F:
COVERAGES CERTIFICATE NUMBER: 23/24 GL/AU/WC/XS REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
AU1JL1Z5UbK1
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD
LIMITS
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
EACH OCCURRENCE $ 1,000,000
PREMISES Ea occurrence 5 100,000
X Errors & Omissions
MED EXP (Any one person) s 5,000
PERSONAL& ADV INJURY S 1,000,000
A
X $5.000 Deductible
Y
Y
SCGLOO5000040001
05/15/2023
05/15/2024
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ❑ PRO ❑
JECT LOC
GENERAL AGGREGATE $ 2,000,000
PRODUCTS-COMP/OPAGG S 2,000,000
S
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
X
ANYAUTO
BODILY INJURY (Per person) S
B
OWNED SCHEDULED
AUTOS ONLY AUTOS
Y
Y
SPP1807358-01
05/15/2023
05/15/2024
BODILY INJURY (Per accident) S
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
PROPERTYDAMAGE S
Per accident
S
BRELLALIAB
X
OCCUR
EACH OCCURRENCE S 2,000,000
A
ESS LIAB
*DED
CLAIMS -MADE
SXCS005000010501
06/02/2023
05/15/2024
AGGREGATE s 2,000,000
RETENTION S
S
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory In NH)
N/A
Y
CPW1001217
03/08/2023
03/08/2024
�/
/NSTATUTE ETH
E.L. EACH ACCIDENT S 1,000,000
E.L. DISEASE - EA EMPLOYEE S 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT 5 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
RE: Project: FAM Fest. GLIAU: Certificate Holder and its elected and appointed officials, employees, volunteers and agents are Additional Insured as
respects to referenced project per forms (GL) CG20100413 and (AU) CA9903120514. This Insurance is Primary & Non -Contributory to any other Insurance
per form CG20100413.GL/AU/WC: A Waiver of Subrogation is added in favor of the Additional Insured per forms (GL) CG24040509, (AU) CA9901880514
and (WC) WC040306. Endorsements apply only as required by current written contract on file.
31f \avIR4w'II Lei 0
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Insurance Approved THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Carson DJ ACCORDANCE WITH THE POLICY PROVISIONS.
701 E Carson St 08/23/23
AUTHORIZED REPRESENTATIVE
Carson CA 90745 I �/
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Black Knight Patml, Inc
505 S Pacific Ave suite 201
San Pedro, CA 90731 US
accounting@blackknightpatrol.com 1310112www.blackknightpatrol.com
BILL TO
City of Carson
Attn: Accounts Payable
701 East Carson Street
Carson, CA 90745
Security Services- Faith, Family & Friends Fest 10 45.00 450.00
Unarmed Unarmed - 2100 - 0700
Faith, Family & Friends Fest Event on
08/25/23 -08/26/23