CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2022 JAN 24 AM 8: 01
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
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).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Gregory Marble 03-04-1955
-
FULL NAME DATE OF BIRTH
5938 Grandone # 105 251 575-0060
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Same Some
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Same as above
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
10:3010
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: /-3-22 TIME: 11:00 X AM O PM
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. ave (Iteaded west) oN Stover st west of riverside appe bstoO yrds 7rom intersectin of Rivers de ve
3. HOW DID DAMAGE OR INJURY OCCUR?
Pot hole in street
4. WERE POLICE AT THE SCENE? DESO WERE PARAMEDICS AT THE SCENE? YESTERO
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.
Pothole in street
appx
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 2000°0 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
1-3-22 Hemate: Wheel "TiRe Left Front Amounts Cppe 2000° Item/Date: Amount: $
appx
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 2000°° ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
00 Item/Date: 1-3-22. E8º 2000
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: NiCole COFFMAN NAME: sregory Marbley
ADDRESS: 5938 Grand vome de 105 ADDRESS: 5938 Grand Ave $105 TELEPHONE: 951) 2200-9069 TELEPHONE: 251 575-0060
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: No injuries
NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L
DATE: TIME: • AM • PM 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*.
bintof
iM PRENOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT. ace dent
st.
Slance
CURB
PARKWAY
SIDEWALK
I HAVE READ FRE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Iregor y Marbley 1-14-22
TYPE OR PRINT NAME DATE
Serf
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 BATTERIES NEW O USED O Engine & Transmission REPAIR ORDER
WAS NO JUNTS
QTY. PART NO. DESCRIPTION PRICE
General Mechanic
NO. 1143
2554 Main St. • Riverside, CA 92501
(951) 742-5353 DATE
1/22
New years Guarantee Used days Guarantee BAR Reg No: ARD00293277 EPA No: CAL000443093 ENGINE O Gas • Diesel LABOR CHARGE
MATERIAL USED NAME
Lubrication
QTY. PART NO. DESCRIPTION 1 Gregory Marbly
ADDRESS Change Oil
New 820
5938 Grand Ave Change Oil
Fitter Cart.
New 4/17285 89:0 MAKE TYPE OR MODEL YEAR RECEIVED
AM Change Trans. Oil
Merceded c730
SERIAL NO ENGINE NO. PROMISED Change Diff. Oil
Pack Front
ODOMETER LICENSE NO. PHONE WHEN READY Wheel Brgs.
TERMS
•NO Adjust Brakes
ORDER WRITTEN BY PHONE Check Brake fluid
LICENSE STATE
Rotate Tires
OPER NO. DESCRIPTION OF LABOR Change Coolant
Whee Remove & Reparee $ 30
Tires Repiace $180;9
225 40 17
OUTSIDE REPAIRS
TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within GAS, OIL, & GREASE days of the date shown above if I choose not to authorize the services recommended.
GAL. GAS @
• By FAX
Original Estimate:$ Authorized by: • By E-MAIL QTS. OIL @ O In Person
BROUGHT FORWARD Phone No.: Time:
• By Phone GREASE @
TOTAL PARTS Additional Cost:$ • By FAX TOTAL GAS, OIL, & GREASE= QTY. ACCESSORY NO. ACCESSORIES PRICE WARRANTY Revision Details: • By E-MAIL METHOD OF
TOTAL LABOR
Authorized by: • In Person PAYMENT
• By Phone • CASH TOTAL PARTS S71014
Phone No.: Time:
Additional CostS •CHECK ACCESSORIES
Revised Estimate:$ • Bv FAX
Revision Details: O By E-MAIL • CHARGE GAS. OIL, & GREASE Authorized by: O In Person LABOR: OUTSIDE REPAIRS
Phone No.: O By Phone
Date: Time: •FLAT CA TIRE FEE
On all parts New, Rebuilt or Use days guarantee, no refunds or exchanges • HOURLY TAX 3 39 1
TOTAL ACCESSORIES NOT RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF • вотн
FIRE THEFT OR ANY OTHER CAUSE BEYOND OUR CONTROL
TOTAL AMOUNT $ 7159 09
Rizzco Automotive Repair inc
6110 Jurupa ave Sub Estimate For Or
Riverside, CA. 92504 003438
Phone: 951-688-3122 Fax: 951-354-9207
ARD00207055
European Car Specialist 1249902
Estimate for Services Estimate Date: 1/11/2022
MARBLEY, GREGORY A 2003 Mercedes-Benz - C230 - 1.8L, In-Line4 (110CI) VIN(Not / 5938 GRAND AVE APT 105 Lic # : CL317 - CA Odom. In: 0
Riverside, CA 92504
Cell: 951-575-0060 VIN#: WDBRN40J3 3A480315
Part Description / Number Qty Sale Ext Labor Description Extended WHEEL 1.00 800.00 800.00 WHEEL - Remove & Replace - Each - [DOES NOT 96.93 6-6-47-1511 include balance or refinish.]
WHEEL - Balance - One 48.46
Shop Supplies 2.00
FOUR WHEEL ALIGNMENT - Adjustment - [DOES 218.09
NOT include straightening or replacement of
components.]
Parts/Supplies: 802.00 Labor: 363.48 HazMat/Fees: 0.00 Tax: 70.00 Total : $ 1,235.48 Thank you for you business!
I hereby authorize the above repair work to be done along with the necessary material and hereby grant you and/or your employees permission to operate the vehicle described for testing and/or inspection. Express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto SMOG: I understand that I can have emission service and/or adjustments done elsewhere. I hereby waive this right TEARDOWN ESTIMATE: I understand that my vehicle will be reassembled within _days of the date shown above if I choose not to authorize the service recommended. All Parts removed will be discarded unless instructed otherwise: Save all Parts _ NOT RESPONSIBLE FOR LOSS OR DAMAGE TO
CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE, THEFT OR ANY OTHER CAUSE Signature Date Time