CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
CITY 2022 AUG 29 PM 12:24
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). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Address: 290 W. Rialto Ave., Rialto, CA 92376 CLAIMANT INFORMATION:
Jasmine Calanan 92395 DATE OF BIRTH
FULL NAME
Victamlle cit
HOME TELEPHONE NO.
HOME ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
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: 08.201.2022 TIME: 5:25 DAMOPM
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.
I was on sierra ave making a left hand turn from
stop sign and one i made my left turn on to riverside st Balts i hit a very lag pot hole and it popped mytire
In
3. HOW DID DAMAGE OR INJURY OCCUR?
right after made my torn my tire pepped. as hit Damage occurred white was driving and pot tE Hole.
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.
feel that if the city were to make sure
the road u pared correctly and make sure their
roads arent damaged my tire wouldnt have popped
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 313.08 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: 228.12
Tire / Labor / Disposal Amount: $
Item/Date: 129.05
Amount: $
Item/Date: Allanment
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 373.08 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Tre Maintellaberl Amount: $_ 228.12
Item/Date: AL44ment Amount: $ 129.95
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. 313.08
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Drasan Martines NAME:
ADDRESS: ADDRESS:
Victorville cA 92394
TELEPHONE: TELEPHONE: (
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:
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.
Sierra dre
CURB
PARKWAY
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 LOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
asmine Cachan 8. 29. 2022
TYPE OR PRINT NAME DATE
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 ROCK HONDA #462
CUSTOMER #: 1020789 91014 16570 South Highland Ave.
-ontana, CA 92336
Phone: (909) 330-7200
* INVOICE* Honda Service Direct: (909) 330-7016
Service Fax: (909) 330-7209
Hours of Operation
Mon - Fri 7:00AM - 6:00PM
PAGE 1 Sat 7:00AM - 5:00PM
Sun 8:00AM -3:00PM
SERVICE ADVISOR: 242492 Ricardo A Felix Jr
COLOR YEAR MAKE/MODEL LICENSE MILEAGE IN / OUT
SI Silver 22 HONDA ACCORD HYBRID 1HGCV3F93NA021983 5825/5825 T223 DEL. DATE PROD. DATE WARR. EXP. PROMISED PO NO. RATE PAYMENT INV. DATE 31MAY22 IS 18:00 29AUG22 CASH 29AUG22
R.O. OPENED BOOKED OPTIONS: SOLD-STK: NA021983 DLR :27226 ENG: 2. OL_16 - VALVE_DOHC_I- VTEC_4-CYLINDE
09:18 29AUG22 11: 39 29AUG22 TRN: CVT AUTOMATIC 3
LINE OPCODE TECH TYPE HOURS LIST NET TOTAL
A MOUNT AND BALANCE 1 TIRES - GOODYEAR EAGLE TOURING 235/40R19 -
PASSENGER FRONT
EMOUNT1 MOUNT AND BALANCE 1 TIRES
254649 CX 30.00 30.00
WK WEIGHT KIT 8.00 8.00
1 42751-GYR-056 TIRE (235/40R19) 181.76 181.76 181.76
1 TD TIRE DISPOSAL 3.00 3.00 3.00
1 TT TIRE TAX 1.75 1.75 1.75
1 WMK WHEEL MOUNTING KIT 0.00 0.00 0.00
1 42753-SB8-661 VALVE, RIM 4.21 4.21 4.21
PARTS: 185.97 LABOR: 30.00 OTHER: 12.75 TOTAL LINE A: 228.72 500 0.30
*************************** *****************
B PERFORM A 4 WHEEL ALIGNMENT
ALIGN PERFORM A 4 WHEEL ALIGNMENT
254649 CX 129.95 129.95
PARTS: 0.00 LABOR: 129.95 OTHER: 0.00 TOTAL LINE B: 129.95 500 1.20
* * *****************************************
************************ ****** *******-***************************** ESTIMATE: 379.95 29AUG22 09:18 SA: 242492
CONTACT:
******************* * ************************************ * HAZARDOUS WASTE DISPOSAL DESCRIPTION TOTALS
Original Estimate Total Additional Approved By: Date & Time Authorzation (Parts & Labor) Cost Authorized Obtained By: COSTS: We have added this 159.95
LABOR AMOUNT
cienhon.
charge to cover costs associated
• Fax See stinched
with the handling, management PARTS AMOUNT 185.97
-E-mail (See Attached)
Revised Estimate and disposal of toxic wastes or GAS, OIL, LUBE 0.00 •Fax (Soe Attuched) substances under
hazardous
SUBLET AMOUNT 0.00
California and Federal Law.
_ Tire pressure check/inflation service was performed. WASTE DISPOSAL COSTS * 12.75 • Customer declined tire pressure check/inflation service. TOTAL CHARGES 358.67
UNLESS OTHERWISE
you acknowledge that you were notified of and authorized the LESS DISCOUNT 0.00 Dealership to perform the services/repairs itemized in this Invoice and that you received Some Parts Not Returnable SALES TAX 14.41 for had the opportunity to inspect any replaced parts as requested by you.
AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY THIS AMOUNT 373.08
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON BACK.
DealerCAR 20% COK Got, LLC 106/15 SERVICE INVOICE TVRE 2 - SI2C LIMITED WARRANTY CALFORMA GUSTOMER COPYB.A.R. REG.# 300568 EPA# CAL000464681 THANK YOU TOR VISItINg KUCK MUNUA
Nork Order: R962235
_ast Name: J CALAHAN
First Name: JASMINE 1HGCV3F93NA021983
VIN:
_icense:
Year: 22
Technician: 254649
Odometer: 500
Date 8/29/22 10:35 AM
Honda 2022 Accord Hybrid 19" Wheel
4-Wheel Total Alignment
Before Measurements
Left Front Right Front
0.2° 0.8° -0.5° 0.2
-0:30 -0:80
Camber Camber
5.8° $.20 4,8° 4.8° 5.8°
5:00.
Caster Caster
-0.08° 0,08° Front 0,08 -0.08*
0.000 010°
-0.16 0.16°
0.06°
Total Toe
-0.05 0.05
-0.03°
Steer Ahead
Left Rear Right Rear
-0.7° -2.2° |
-1 g° " -1:700 M
Camber Camber
1.1 Rear
Toe 0,05* 0.32° Toe
0.24°
Total Toe
Thrust Angle
Current Measurements
Left Front
Right Fronte
-0.8* 0.8° 0.2
-0.30 -0:80
Camber
Camber
4.6° 4.8* 5.8°
5.20 5.00
Caster Caster
-0.08° 0.08° 0.06° -0.03°
Front o'.01°
0.00°
Toe -0,16° 0. 000 016
Total Toc
-0.05° 0.05°
d.00°
Steer Ahead
Left Rear Right Rear
+
0.7° | -2.2° -2,2° 1
-1:700 M
-1
Camber Camber
= 0.04° 0,16° 0.16°
Rear
0.08° 0: 090(1
0.09* 0.17 02(
Total Toe
Thrust Angle