CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2022 MAR 24
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY CITY CLERK RECEIVED CITY OF RIALTO AM 9:18
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Wen Xu
FULL NAME DATE OF BIRTH
Rialto. CA 92376
HOME ADDRESS INCLUỜING CITY, STATE & ZIP HOME TELÉPHONE NO. T 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):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: Магси 22 5 HAMOPM
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.
Etiwanda Ane and Riverside /tre. Rials. CH 92376
3. HOW DID DAMAGE OR INJURY OCCUR?
Big Potholes on the street without any sign or
cones around at 5Am in the morning cout see
dark sufounding
4. WERE POLICE AT THE SCENE? • YESANO WERE PARAMEDICS AT THE SCENE? YES ANO
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.
Flat tire right away, cant drive
$ 180. 2
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
The replacement / March 232022 Amount:$ 137. Ex
Item/Date:
Item/Date: Dented Rims Merc 23,2022 Amount: S. 40. t
2 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 180. 2x ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Tine replacement
/March 23. 2022 Amount: $ 133, F
Item/Date: Dented Rime
March, 4, 2022 Amount: $_ 41.70
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 180. %€
$
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Ju sure NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
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:
DATE: _ TIME:
DAM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
of accident by "X" and by showing house numbers or distances to street corners. For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place 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.
CURB
Riverside Aue
Etiwanda Ane PARKWAY
SIDEWALK
THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Wen Xu 2022
TYPE OR PRINT NAME Mar 2f
DATE
RELATIONSHIP TO CLAIMANT
RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150S. PALM AVE., RIALTO, CA 92376 NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) 3 VARGAS
Tives & Wheels
6155 951-640-0352
630 W. Rialto Ave., #A-7, Rialto, CA 92376
CUSTOMER DATE 3-2322
ORDER NO.
Wen X
NAME
ADDRESS
PHONE #
SOLD BY CASH C.O.D CHARGE ON ACCT
MDSE RETD PAID OUT
QUAN. DESCRIPTION
PRICE AMOUNT
TIRE(S)
USED TIRE(S)
WHEEL(S)
USED WHEEL
BALANCE - MOUNTING
BRAKES
DISPOSAL FEES
FIX FLAT
LUG NUT(S)
VALVE STEM
MANUFACTURER - WARRANTY
All sales are final warranty is for the treadlife on any kind of defect on tires LABOR limited manufactures warranty unless road hazard insurance is obtained.
Tires are prorated according to use. Not Responsible for tire clearance or SUBTOTAL stripped lugs or broken studs. If you are satisfied tell others, if not tell us.
Drive with confidence your family deserves it thank-you for you purchase, with us you'll always have a friend. No Warranty On Used Tires. TAX SALES No se admiten devoluciones, las llantas estan garantizadas por qualquler TOTAL 4/ defecto solo en uso normal recargo por uso de llanta, si compra seguro esta le cubrira contra cualquier cosa de por vida de la llanta. Maneje con DEPOSIT seguridad, su familia se lo merese. Gracias por su compra. Con nosotros siempre tiene un amigo. No Garantia en Llantas Usadas. BALANCE All claims and returned goods MUST be accompanied by this bill. 4 Pcp Boyi
Pep Boys #1669
484 W. Valley Blvd.
Rialto. CA 92376
(909)877-3421
www.pepboys.com
03/23/2022 10:54:01 AM PST
Trans.: 013569 Store: 1669
Reg.: 105 Till: 105
Cashier: 805377
Service Work Order COMPLETE
166910501356920220323
215/55R17 SOLARUS AS 87.50 T
TIR90000034363 1 @ 87.50
Order #: 2072017
TIRE INSTALLATION PACKAG 39.12 T
9084807 1 @ 39.12
1897 TIRE MOUNTING 0.00 N
9125984 1 0.00
TIRE HNDLNG CH PBY 3.00 N
8585558 1 @ 3.00
LIFE BAL 16-19IN 18.99 N
2152257 1 @ 18.99
ROAD HAZARD WARRANT 13.13
9158085 1 @ 13.13
30413509PEP RUB STE 4.00 T
0106386 1 B 4.00
Order #: 2072017
Sub-Total 126.62
Tax 7.09
Total 133.71
Cash 140.00
Total Tender 140.00
Change Due -6.29
000 Invoice - Customer Copy - Page 1
Pry Happ
PEP BOYS AUTO # 1669
PEP BOYS #1669
484 W VALLEY BLVD
RIALTO, CA 92376
(909) 877-3421
BAR# ARD274223
EPA# CAL000353367
Service Manager: JENNIFERRAY TRACKING ID#*
Store ID # Service Work Order #
Insurance If you have any questions
1669 2072017
Policy Number: or concerns, please call:
(909) 576-9669
Name:
Yoar: Date :
Address: 2022-03-23
Make:
Entered By: ESTEBAN R
City: Modol:
Time In: 09:47:46
State: Engine:
Date/Time Promised: 2022-03-23 10:52:08
Zip: Vin No.:
Old Parts Returned:
Home Phone: Liconso No:
Contact Phone: Mileage:
Customer Waiting
Color:
storage Charges: A virule that is left untiended for more than 1 bunnees dav may be loud at ine anner axpanse. for rice fanesion please noe Store Manspe X
Initial Estimate Parts S: Labor S: TotalS: Date and Time:
107.63 18.99 133.71
2022-03-23 09.47:46
I hereby authorize Pep Boys to perform the repairs on this work order and to furnish the necessary materials and its employees to operate the vehicle for purpose of testing. is an estimate. I understand inspection and delivery. I understand that any cost quoted that unless directly caused by Pep Boys, it is not responsible for any loss or damage to the vehicle or its contents;
overnight at owner's risk that the vehicle may be parked in the Pep Boys parking lot and that vehicles are lett
CUSTOMER'S RIGHTS
(1) You may reguest a written estimate for repairs which cost in excess of $50; (2) You may not be charged more than 10% in excess of your written
estimate unless you have consented to the additional costi (3) We may not perform repairs which you did not originally authorize unless we obtain your consent to perform those repairs; entitled to the return of (4) You are
warranty agreement; (5) If you have questions about Pep Boys liability If your vehicle any replaced parts unless we are required to return chose to the manufacturer under a please ask an Associate. is damaged while at Pep Boys,
YOU WILL NOT BE CHARGED A TIRE HANDLING CHARGE IF YOU CHOOSE TO DISPOSE OF YOUR OWN TIRES. - IF YOU ELECT TO DISPOSE OF YOUR OWN TIRES, YOU ARE RESPONSIBLE FOR PROPERLY DISPOSING OF YOUR USED TIRES IN
ACCORDANCE WITH EPA GUIDELINES AND ANY APPLICABLE LAWS
TYPE PART DESCRIPTION CODE MECHANIC
HRLY HRS QTY SOURCE EACH TOTAL
RATE
PK 9084807 TIRE INSTALLATION PACKAGE
TIRE MOUNTING GUSTAVO P
0.00 0.00
PN 6001 TIRE HANDLING CHARGE - PEPBOYS
3.00 3.00
LINETIME WHEEL BALANCE 16-19 N N GUSTAVO P
18.99 18.99
PN 4000 ROAD HAZARD WARRANTY
13.13 13.13
PN TV413 30413500PEP 1 1/4 RUBBER VALVE STEM
4.00 4.00
Package SubTotal : 39.12
PN 90000034363 Stafire Solarus A S 216/66R17 N
87.50 87.50
40,000 MILE PRORATED
Parts: 107.63 Labor : 18.99 Other: 0.00 Tax: 7.09 Total : 133.71 Tender Date : 03/23/2022 Tender Time: 10:54 AM
POS Trans # : 13569 Store: 1669
Tender Register: 105 Tender Till #: 105
Tender Cashier: 805377
NEED A TOW? CALL 1-800-PEP-BOYS or
1-800-737-2697
6 Invoice - Customer Copy - Page 2
Pep Don't
General Comments
FRONT DRIVER WHEEL HAS A DENT IN TIE THE WHEEL WITH A SMALL LEAK. ADVISED CUSTOMER TO TAKE TO A WHEEL SHOP F REPAIRS. CUSTOMER REQUESTED WHEEL BE PUT BACK ON.
Customer Declined: Alignment
Code Descriptions
N:New
***** Tire Information *****
DOT Numbers :
1320
Tire Position
Existing Tire Position New Tire Position
LF 1 RF 2 LF RF Return Tires:
LR 3 RR 4 LR RR White Wall
Position:
S
Invoice History
REVISION # CONTACT TYPE AMOUNT PHONE DATE TIME
AUTH_BY
initial JULIUS ALAM 119.48
(714)726-5457 2022-03-23 09:47:47 ESTEBAN R
authorize TV413 30413500PEP 1 1/4 RUBBER VALVE STEM
4.00 4.00
authorize LIFETIME WHEEL BALANCE 16-19IN
1899 18.99
authorize 4000 ROAD HAZARD WARRANTY 5.99 5.99
authorize 90000034363 Startire Solarus A S
87.50 87.50
authorize 6001 TIRE HANDLING CHARGE • PEPBOYS
300 3.00
- -
authorize TIRE MOUNTING 0.00
0.00 Service Information
TIRE MOUNTING
OK,VEL,RED,C/Front Brake Gauge Reading (OK, Yellow, Red or Not Checked): OK,YEL,RED, NC/Rear Brake Gauge Reading (OK, Yellow, Red or Not Chacked): NC NG
NEED A TOW? CALL 1-800-PEP-BOYS or
1-800-737-2697
7 Etiwanda Ave
8 SEPT
215/
A WARNING: EVERY AR
# 0E) 100
MIGHELIN®
TUBELESS
53 MADE I!
OL
11 TREADWEAR 1520
215/55RL7
TRACTION
TEMPERATURE