CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2022 NOV 30 PM 12: 05
TO PERSON OR PROPERTY
CITY CLERK RECEIVED
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:
Clande KonieTr
FULL NAME DATE OF BIRTH
Riato, Ca. 92377
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): Rits, Ca. 9227>
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 10-29-2022 TIME: 7,45
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 Sort bond Riverside Are Curb lape
3. HOW DID DAMAGE OR INJURY OCCUR?
While drivin, South or Dinside are
4. WERE POLICE AT THE SCENE? • YESIANO 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.
very are Pothor. to falld in A Report Abun This And Was Told by Dispatales that ar offer word be furt to This LocaTor ASAP $ 450. 00
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:
Item/Date: Amount: $
Item/Date: Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 450. 00 LAbOL
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN
Hem/Date: Crack upper Coptrol Arms Tarte
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: | ) 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: • 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.
Pot
AVe
Rivekside
CURB South
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.
STERATURE OF CLAIMANT OR AGENT
Claude Louie 11-30-2022
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 Bob & Al's Tires
106 N. Mt Vernon
San Bernardino CA 92410
909-885-3759
11/11/2022 2:36 PM page 1
Invoice #57670
LOUI, CLAUDE Day Phone :
RIALTO CA 92377
Vehicle : 1996 Toyota T100 - Pickup 3.4 L 3378 CC V6 5VZFE Created: 11/11/2022 7:17:22 AM Odometer In : 0
Complete: 11/11/2022 2:36:12 PM Odometer Out : 0
Invoiced : 11/11/2022 2:36:12 PM
Qty Code/Tech* Reference Description Condition Unit Price Price LABOR LOWER CTRL ARMS $450.00 $450.00
Labor $450.00
Parts $0.00
Sublet/Misc. $0.00
Other Charges $0.00
Charges $0.00
Sales Tax Tax @ $0.00 * 8.7500% $0.00
Total Due $450.00
I hereby authorize the repair work herein set forth to be done along with the necessary material and agree that you are not responsible for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond your control. I hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or Inspection. An express garagekeeper's lien is hereby acknowledged on above vehicle to secure the amount or repairs thereto. All Vehicles left over 48 hrs. after repairs are completed WILL INCUR A $5.00 PER DAY STORAGE FEE, 12 Month or 12,000 Mile Warranty On Repairs.
Customer Signature
_ BOB AND ALS TIRES
106 N MTN VERNON AVE
SAN BERNARDINO, CA. 9241
909-885-3759
DEBIT SALE
REF#: 00000032
Batch #: 358 RRN: 1111231702
11/11/22 15:17:02
APPR CODE: 341624
Trace: 32
DEBIT Chip
************3183
AMOUNT $450.00
APPROVED
US DEBIT
AID: A0000000980840
TVR: 80 80 04 80 00
TS: 68 00
THANK YOU
CUSTOMER COPY
THANK YOU for visiting Bob and Als
Work Order: R000001
VIN:
Year: 96
JT4TN14DXT0018026
Date 11/11/22 2:19 PM
Toyota 1996 T100 4X2 Extra Cab
Thrust Line Alignment
Before Measurements
Left Front Right Front
40psi 38psi
1.2° -0.3° -0.3°
0.9° 0.5°
Camber Camber
2.8° 1.3°
(1 2 6° 3 7°
Caster Caster
0.27 Front 0.07
21° 0.13°
Toe Toe
35°
Total Toe
20.05° 0.05
0.04°
Steer Ahead
Left Rear 29psi 27psi
Right Rear
-0 0. . 0°
Camber Camber
Rear
-0 18° 0.08°
Toe Toe
L0°
Total Toe
-0. 30
Thrust Angle
Current Measurements
Left Front Right Front
40psi 40psi
1.2° -0.3"
0:9°' 0.5°
Camber Camber
2.8° 1.3°
2.6° 7°
Caster Caster
Front 0.07
16° 0 .17°
Toe 0.53 Toe
0.32°
Total Toe
0,05
00°
Steer Ahead
40psi Opsi
Left Rear Right Rear
-0:10 0.0°
Camber Camber
Rear 0.06°
-0 117°
Toe Toe
-0 11°
Total Toe
-0 12°
Thrust Angle
•• T-Mobile = 8:44 AM
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••.
BILLING ADDRESS
Claude Louie
Rialto, CA 92377
SHIPPING ADDRESS
Claude Louie
Rialto, CA92377
1996 Toyota T100 Rear
Wheel Drive Front Upper
2 Piece Control Arm with
Ball Joint Set AM
Autoparts AM-1254608189
Part Number: AM-
1254608189
PRICE: COST:
$126.99 QTY: 1
$126.99
Subtotal: $126.99
Tax: $9.84
Discount: $0.00
Shipping & Handling: $
Order Total: $136.83