CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2021 DEC 22 AM IO: 28
TO PERSON OR PROPERTY
RECEIVED
CITY CLERA
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code $911.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
GabrielVillanuera
- -
FULL NAME DATE OF BIRTH
Ontario CA 91764
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): San ber nadino, A 92404
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 12/20/21 TIME: 10100a DAM DPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks. fing north an Riverside an fist passing slack on
hand sides
3. HOW DID DAMAGE OR INJURY OCCUR?
So I hit a pot holes and It destroyed my cars tire
and damaged the rim. Cracked a embier on the rim.
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? DYEBONO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
It wus pot hole the size of a small tire,
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 38 1.00 364.73 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: fires, allignment 12/22/21 Amount: $ 364.73
Item/Date: tires palligenument 12/22/21 Amount: $ 267.39 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $_
Item/Date:
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: L
TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: | )
DATE: TIME: •AM 0PM
DATE: TIME:
•AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X".
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT. eNerSiUE ave X
/ PARKWAY tree
SIDEWALK Jz
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Gabriel lanverg 12/21/21
TYPE OR PRINT NAME
DATE
selt
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 2W
429
IDVANT
AMERICAN :
American Tire Depot
TIRE DEPOT 110 E Valley Blvd PAGE 1
RIALTO,CA 92376
Complete Auto Care (909)341-0909
Create Date: 12/22/21 09:55:30
Customer ID: 0 Year: Date/Time: 12/22/21 09:56:47
Name: Make: Work Order #: 56999
Address: Model: Invoice #:
Address 2: Lic No:
City, State, Zip Code: VIN: Email Address:
Home Phone: 0) - Color: PO Number:
Work Phone: 0) - Engine: Fleet/Wholesale: N
Mobile Phone: () - Mileage In:
Tax Exempt #: Mileage Out: EPA#: EPA
BAR#: BAR
Service comments:
TIRE PRESSURE: LF _ RF_ LR_ RR _ SPARE _
TREAD DEPTH: LF_/32 RF LR_/32 LR_/32 SPARE SPARE_/32
BRAKE PAD THICKNESS: LF _ RF _ LR_RR_
Qty. Part # RFR Loc Description Parts Labor Total
Tire Inflation: Not Available Torque: Not Available
1 6133544007601 225/40R18 IRIS SEAR 92W XL 88.99 0.00 88.99 IRIS 225/40R18 92 XL BW
TRF CALIFORNIA TIRE RECYCLE FEE 1.75 1.75
MB MOUNT BALANCE TIRE & WEIGHTS 2.99 21.99
----- TDF TIRE DISPOSAL FEE 3.99 3.99
WTD8915 21716 TPMS SERVICE KIT 6-115 8.00 8.00
RH ROAD HAZARD WARRANTY 16.00 16.00
1 N2 NITROGEN FILL 8.00 8.00
1 VALIGN 0.00 109.99 109.99
INSPECT VEHICLE SUSPENSION SYSTEM
CORRECT AND ADJUST ALL O.E.
ADJUSTABLE ALIGNMENT ANGLES
WARRANTY 3 MONTHS / 3000 MILES
WHICH EVER COMES FIRST
***
*** Customer Wishes To Retain Old Parts
I GRANT AMERICAN TIRE DEPOT PERMISSION TO OPERATE THE VEHICLE HEREIN DESCRIBED FOR THE PURPOSE OF
TESTING, INSPECTING, INCLUDES REMOVAL OF WHEELS
AND DRUMS FOR THE PURPOSE OF INSPECTING THE BRAKES, SERVICING OR DELIVERY I RELEASE AMERICAN TIRE DEPOT FROM RESPONSIBILITY FOR LOSS OR DAMAGE TO VEHICLE OR CONTENTS THEREIN.
IN CASE OF FIRE, THEFT OR OTHER CAUSE BEYOND
AMERICAN TIRE DEPOTS CONTROL. I AUTHORIZE THE REPAIR AND SERVICE WORK LISTED ON THIS WORK ORDER TO BE PERFORMED FOR THE AMOUNT SHOWN BELOW. OLD PARTS WILL NOT BE RETUNED UNLESS I SPECIFY. ****ALL PARTS ARE NEW UNLESS OTHERWISE SPECIFIED** CUSTOMER SIGNATURE:
PARTS TOTAL 129.72
TECH: SALES TAX 8.68
LABOR TOTAL 128.99
GRAND TOTAL 267.39
THIS IS A PHONE QUOTE WORK ORDER
Auto Service Cemder
WO # 1-30457 Page 1 of 1
Date 03/30/15 Emp: 1-9 MN / 1-50 JT Dealer ID#: 155919
In Mar 30, 2015 10:31 AM Contact:
Promised ****WORK ORDER****
Sold To: Ship To: Unit#:
TIRE QUOTES QUALITY Vehicle:
WWW.QUALITYTIREONE.COM License: QUOTE
476W VALLEY BL
Mileage: In: 0 Out: 0
RIALTO CA 92376 Vin#:
Business Phone: 909-421-1889 PO#:
BAR ID: ARD00255833
EPA ID: CAL000334183
Salesman Mechanic Part # QTY Description Parts Labor FET 109055366 1.00 225/40R18 92W EAGLE SPORT A/S 50K 198.99 0.00 0.00 NITROGEN 1.00 NIT NITROGEN TIRE SERVICE 9.99 0.00 0.00
WEIGHTS 1.00 BALANCE ELECTRONIC SPIN BALANCE 0.00 14.99 0.00 V1 1.00 STEMS RUBBER VALVE STEMS 2.99 0.00 0.00
STAX 1.00 STAX STATE TIRE RECYCLING FEE 1.75 0.00 0.00
TD 1.00 DISPOSAL TIRE DISPOSAL 4.99 0.00 0.00
TPP 1.00 TPP TIRE PROTECTION PLAN - 15.00 0.00 0.00
9 29866 1.00 ALIGNMENT FOUR WHEEL ALIGNMENT 0.00 99.99 0.00
SEE REVERSE SIDE FOR WARRANTY
1 HEREBY AUTHORIZE the above repair work to be done along with necessary matenals. You and REVISED REPAIR AUTHORIZATION your employees may operate above vehicle for purposes of testing. inspection or delivery at my risk. An express mechanics lien is acknowleaged on above vehicle to secure the amount of repairs thereto. ADDITIONAL $ _ PLUS TAX EMPLOYEE You will not be held responsible for loss or damage to vehicle or articles left in vehicle in case of fire theft, accident or any other cause beyond vour control or for any delays caused by unavailability of DESCRIPTION parts or delays in parts shipments by the supplier or transporter. I UNDERSTAND THAT ALL CHARGES ARE DUE WITHIN 30 DAYS FROM BILLING DATE, IF PAYMENT IN FULL IS NOT MADE BY THEN I HEREBY AGREE TO PAY SIMPLE INTEREST AT THE RATE OF 1 1/2% PER MONTH (18% PER ANNUM) ON THE DECLINING UNPAID BALANCE UNTIL PAID IN FULL. I ACKNOWLEDGE RECEIPT OF A COPY OF THIS AGREEMENT. AUTHORIZED BY X.
COLLECTION FEES WILL BE ADDED IN THE EVENT OF NON-PAYMENT. TIME DATE _PHONE ALL PARTS NEW, UNLESS OTHERWISE STATED.
I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF ANY INCREASE IN THE ORIGINAL ESTIMATED PRICE x _ DATE _
CUSTOMER SIGNATURE
Parts: 233.71
Labor: 114.98
Subtotal: 348.69
Sales Tax: 16.04
Signature: GOOD YEAR Total: $364.73
SET AIR PRESSURE TO MFG. SPEC [email protected]
SPEC _RF LF RR _LR