CITY CLERK'S DATE STAMP
CITY OF RIALTO
SALT, CANE CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES 2022 DEC 12 AMII: 26
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Ciaims for death, injury to person, or to personal property must be filed not iater than six (6) months after the occurrence (Gov. Code 5911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 5911.2).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
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:
BAILEY STARK
FULL NAME DATE OF BIRTH
RANCHO CUCAMONGA, CA 91739
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: 11- 24-2022 TIME: 2:13 LI AM 24 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.
Between Rialto Ave and Foothill BuD going North onpepper ave north of the railroad passing.
3. HOW DID DAMAGE OR INJURY OCCUR?
venicie nit a large, deep pothole in the road ranging linches deep and a foot and half wide
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS AT THE SCENE? •YES ENO
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.
I was driving north on pepper ave in the city of fialto cohen my vehicle went over a pothole and the impact popped my front passenger tire.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 285.90 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Right front passenger tire Amount: $ /37.55
Item/Date: Amount: $_
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $131.55 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Alignment Amount: $ /48. 35
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $148.35
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE: L
DATE: _ TIME: 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 comers.
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
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.
CERTIFY (ORDECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OÉ CLAIMANT OR AGENT
BAILEY STARK 12-3-22
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 - 150S. PALM AVE., RIALTO, CA 82376 Paly sto
FOOTHILL BLVD
cuL phone
Repare and
aCCeSSOKIES
_ N PePPER AVE
W SECOND ST
X X X CALLROAD XXX
XX
EL TOKO MARKET
W RIALTO AVE
Barley Steve 12-3-22 3\4
11/25/2022
AMERICA'S TIRE 8:59 AM
2021 TOYOTA Miles: 18,706
Torque Specs: 80
COROLLA
18"ALUMN SE CVT Invoice #
1453486
CAL 40 CAf
16065 SIERRA LAKES PKWY
FONTANA, CA 92336
909.770.5001
Salesperson 12
ADAM MH 10:30 AM Amount
Estimated Completion Time FEL Price.
89.98 359.92
Article Oly Description 82W XL BSW
4225140 R18 BRAVURIS 5HM
88057 BAR BARUM
NAM TIRE MILEAGE WARRANTY: 40000
ALL 4 ONE TIRE LOSE IN BAY O
14.65 58.60
BOLT PATTERN: 5-100
INFLATION F:33 R:30 CERTIFICATES FOR
80017 REFUND, REPLACEMENT
NAM For tire certificate detalls, see 1.75 7.00
www.americatire.com/customer - service/certificates
STATE REQUIRED 2.50 10.00
80075 4
TIRE FEE
NAM 4 WASTE TIRE 88.00
80224 DISPOSAL FEE 22.00
NRM 4 INSTALLATION &
80219 LIFE OF TIRE MAINTENANCE
Terme and Conditione can be foundat www.americasiire.com/customer-service/involce-terms The tire and/or wheel you have chosen is different rom the original equipment provided. with you ehicle and may change its handling or stabilit
Further information is available from your characteristics.
America's Tire salesperson.
523.52
Sub Total: 28.68
sales Tax: 552.20
Sales Total:
12-3-22 (MSC)
552.20
Tendered: 552.20
Tkn# XXXXXXXX1980 Athl/ 03956S Tendered Today:
Tendered Total: 552.20
www.americastire.com/tire-registration
4/4
Barley Stark
SANTA ANA CA 926
8: DEC 2022 PM 7 FOREVER / USA
CITY OF RIALTO
2022 DEC 12 AMII: 26
RECEIVEU
Rialto City clerk's Office
150 S. Palm Ave
Rialto, CA 92316
92376-848799