CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 MAY 11 PM 2:39
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 occurance (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 Mall: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
CHRIS 7 FIELDS
FULL NAME DATE OF BIRTH
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):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 5/5/22 . TIME: 60. 30 AMOPM
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. 300 block of N Pepper Ave between Foothi
towaras do to ge ole as was it bed
3. HOW DID DAMAGE OR INJURY OCCUR?
TirE hit huge pothole which was the siz
it a complete lane
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? YES* NO
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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $270.55 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repalr estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 5/9/22 Amount: $ 270.55
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 270.55 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $ 270.55
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $270.55
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Sulvia Fields NAME:
ADDRESS: ADDRESS: —
Rialto - CA 92376
TELEPHONE: TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS:_ ADDRESS: _
TELEPHONE: ) TELEPHONE:
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*.
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
PEPPER AVI
CURB
p^4gY|q1E8001 RECEIVED CITY OF RIALTO
PARKWAY HAY |1 PM 2:39
77/ SIDEWALK
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 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
CHRIS A FIELDS 5/11/22
TYPE OR PRINT NAME
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 Pep Boy!
Pep Boys #0790
505 E FOOTHILL. BLVD
RIALTO. CA 92376
( 909)421-1177
www.pepboys.com
05/09/2022 10:38:17 AM PST
Trans.: 129958 Store: 0790
Reg.: 105 Till: 105
Cashier: 266780
Service Work Order COMPLETE
079010512995820220509
245/40R20 99W 229.99 T
TIR2247823 1 @ 229.99
Order #: 2274831
TIRE INSTALLATION PACKAG 20.99 T
9084807 1 @ 20.99
1897 TIRE MOUNTING 0.00 N
9125984 1 @ 0.00
TIRE HNDLNG CH PBY 3.00 N
8585558 1 @ 3.00
90 DAYS WHEEL BAL 2 17.99
9907940 1 @ 17.99
FREE ALIGNMENT CHEC 0.00
0399078 1 @ 0.00
Order #: 2274831
CAL TIRE TAX 1.75 T
8618344 1 @ 1.75
Order #: 2274831
Sub-Total 252.73
Tax 17.82
Total 270.55
Debit Card (R) 270.55
Account: XXXXXXXXXXXX4232
Trace #: 00825517
Auth: 053813(A)
Total Tender 270.55
Change Due 0.00
Thank you for shopping at Pep Boys.
We accept most returns within 90 days
with the original receipt. For more
details, please refer to the return
policy in-store or at www.pepboys.com
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RESPOND WITHIN (7) DAYS
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Invoice - Customer Copy - Page 1
Pop Bay$
PEP BOYS AUTO # 790
505 EAST FOOTHILL BLVD
505 E FOOTHILL BLVD
RIALTO, CA 92376
(909) 421-1177
BAR# ARD159110
EPA# CAD913263326
TRACKING ID# *
Service Manager: RICARDO MENDOZA
Store ID # Service Work Order #
If you have any questions 0790 2274831
Insurance:
or concerns, please call:
Policy Number : (909) 576-9250
Name: CHRIS FIELDS Year: Date: 2022-05-09
Address: Make: Non-Vehicle Entered By: LOUIS P
Model: Time In: 09.52:27
City: Rialto
Engine: Dato/Timo Promised: 2022-05-09 10:37:01
State: CA
92376 Vin No.: Old Parts Returned:
Zip:
Home Phone: License No:
Contact Phone: Mileage: 59525
Color:
Storago Charges: An vande a a lot uncondod to are on 7 Isses in
REY AUTHORIZE PEP BOYS TO PERFORM THE REPARS ON THE WORK CROER AND TO FURNISH THE NECESSARY WATERIALS AND ITS FME OMEES TO PERATE THE VENECT FOR PURPOSES OF BEST CON TESTION
ELVERY UNCE STAND THAT ANY COST CODIS AN ESTATE I I THAT UN IS DARE CTLY CAUSED BY PEP BOYS, I IS NOT RE SPONSE FOR ANY LOSS OR DAUNZ TO THE VERGLE ORITS CONTENE
THAT THE VERGE MAY DE PARKEDIN DEPROYS' PARNO LOT AND THAT VEHICLES ARE LEFT OMERNICHT AT OMNERS RISK Initial Eetimate Parts S: Labor S: Total S: Date and Time:
232.99 17.99 270.55 2022-05-09 09:52:27
I acknowledge notice and oral approval of an increase in the original estimated price (signature or initials)
YOU WILL NOT BE CHARGED A TIRE HANDLING CHARGE IF YOU CHOOSE TO DISPOSE OF YOUR OWN TIRES.
NOTICE: - IF YOU ELECT TO DISPOSE OP 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 0084807 TIRE INSTALLATION PACKAGE
TIRE MOUNTING DAVID J 0.00 0.00
LB - -
TIRE HANDLING CHARGE - PEPBOYS 3.00 3.00
PN 6001
90 DAYS WHEEL BALANCE 20 OR GREATER DAVID J 17.99 17.99 L8
LB FREE ALIGNMENT CHECK DAVID J 0.00 0.00
Package SubTotal : 20.99
Kumho PA51 245/40R20 N 229.99 229.99
PN 2247823
45,000 MILE PRORATED
N 1 1,75 175
SF CALIFORNIA TIRE TAX
Parts: 232.99 Labor: 17.99 Other: 1.75 Tax : 17.82 Total : 270.55 Tender Date: 05/09/2022 Tender Time: 10:38 AM
POS Trans # : 129958 Store : 0790
Tender Register: 105 Tender Till #: 105
Tender Cashier: 266780
General Comments
LOOSE RIM DECLINED ROAD HAZARD
NEED A TOW? CALL 1-800-PEP-BOYS or
1-800-737-2697
000 Invoice - Customer Copy - Page
Pep Bays
Customer Declined: RoadHazard
Customer Declined: Alignment
Code Descriptions
N:New
***** Tire Information *****
DOT Numbers:
Tire Position
Existing Tire Position New Tire Position
LF 1 RF 2 LF RF Return Tires:
LR 3 LR RR WhiteWall
RR 4 Position:
S5
Invoice History
CONTACT TYPE AMOUNT PHONE DATE TIME AUTH_BY
REVISION #
initial CHRIS FIELDS 252.73 (909)496-5345 2022-05-09 09:56:31 LOUIS P authorize 90 DAYS WHEEL BALANCE 20 OR GREATER 17.99 17.99 authonze CALIFORNIA TIRE TAX 1.75 1.75
FREE ALIGNMENT CHECK 0.00 0.00
authonze
authonze 2247823 Kumho PASt 229.99 229.99
6001 TIRE HANDLING CHARGE - PEPBOYS 3.00 3.00
authonze
TIRE MOUNTING 1 0.00 0.00
authorize
Service Information
TIRE MOUNTING OK,YEL,RED,NC/Rear Brake Gauge Reading (Ok, Yellow, Red or Not Checked):
OK,YEL,RED.NC|Front Brake Gauge Reading (Ok, Yellow, Red or Not Checked):
90 DAYS WHEEL BALANCE 20 OR GREATER
OK YEL RED.NC/Front Brake Gauge Reading (Ok, Yellow, Red or Not Checked): OK,YEL,RED,NC/Rear Brake Gauge Reading (Ok, Yellow, Red or Not Checked):
NEED A TOW? CALL 1-800-PEP-BOYS or
PEP-BOYS 1-800-737-2697