CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 2023 JAN *6 PM 3:43
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occura@# Top. 092458112). RECEIT
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:
Alize Marian Valder
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP. HOME TELEPHONE NO.
San Bernardino, CA
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: Jan, 3, 23 TIME: 7:30 AMDAPM
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 driving down PePPer and I was coming
UP to a Stop Sign when i heard a huge noise
and my car alerted me that i had a flat.
3. HOW DID DAMAGE OR INJURY OCCUR?
Police spore to me and said They fixed
the streets but alot of the cement sunke
down causing huge potholes.
4. WERE POLICE AT THE SCENE? EYES O 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.
Kialto City :
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $53.18 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: Passenger Tire 1/4/22 Amount: $ 53.18
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $53. 8 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: rassenger Tire Amount: $ 53-18
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: Alize - Cannaber
NAME:
ADDRESS: San Bernardino ADDRESS: _
ca, 92407
TELEPHONE:
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _ N/A
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. 2023 JAN 6 P CITY OF RIALTO
CURB 1 PepPEr.st
PARKWAY
7/1 3:43
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
Ai ce valdez 116/23
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
AMERICAN FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERICANTIREDEPOT.COM
Started Time: 1/4/2023 8:42:01 AM
A BIGBRAND TIRE & SERVICE COMPANY Invoiced Time: 1/4/20235:08:42 PM Invoice#: 1163-2636619
CUSTOMER INFORMATION VEHICLE INFORMATION
VALDEZ, ALIZE Cust #: ED-5670797 STORE LOCATION
2015 Volvo S60 T5 Premier RIALTO #1163
Phone: BAR#: ard301169
Engine: L4-1969CC 2.0L 185 E. FOOTHILL BLVD
EPA#:CAL000470360
Emails: Vehicle Service Emails Inactive Plate # RIALTO, CA 92376 VIN Number: Phone: (909) 279-1567
Miles: 108379 Started By: JC331
Invoiced By: JOSEPH CASTILLO CATTANEO (JC331)
BRAND PART DESCRIPTION
DLN TECH SALESPERS PRICE OTY TOTAL
841623101152 TWI OUTSIDE PURCHASE - @P235/45R17XL 97W DH2 DLN - AL056 JC331 $86.99 1.0000 $86.99
Tire Serial# TBNAAPSC0622
Minimum Mileage Warranty: 50000
****** CONSUMER ADVISORY **** THIS IS A "W" RATED TIRE. IT HAS AMAXIMUM SPEED OF 168 MPH. IT HAS "W HANDLING CHARACTERISTICS. CONSULT YOUR OWNERS MANUAL FOR THE PROPER SPEED RATING RECOMMENDED FOR YOUR VEHICLE. CUSTOMERS INITIALS.
CDF CDF TIRE RECYCLING
AL056 JC331 $4.50 1.0000 $4.50
LBR WBHS HIGH SPEED WHEEL BALANCE
AL056 JC331 $20.99 1.0000 $20.99
SHP ww LEAD FREE WHEEL WEIGHTS - PARTS
AL056 JC331 $4.50 1.0000 $4.50
EW EW TIRE MAINT. CERT. -- CUST. SERVICE AL056
LIFETIME REPLACEMENT/REPAIR/REFUND CERTIFICATE *** SEE WEBSITE FOR DETAILS JC331 $14.00 1.0000 $14.00 STF STF CALIF. STATE TIRE FEE AL056
JC331 $1.75 1.0000 $1.75
I have been informed of the benefits of 887'3 Tire Maintenance Certificate progrem. ALL-WHEEL DRIVE VEHICLE NOT/CE - Most manufacturers recommend the rofling radius of all 4 tires must be the same. Tires should be replaced in sets of 4 to match brand, size, design and tread depth Please consur your owners manual for the Original Equipment Vehicle Menufacturers recommendations. TWO TIRE PURCHASE ONLY - SAFETY ADVISORY - The Tire Association Council states that if only two new tires are installed on the front of e vehicle, the rear wom tires could loose their grip under load or slippery conditions causing loss of control
SRV EWC TIRE MAINTENANCE CERT. - CREDIT
AL056 JC331 $88.99 -1.0000 $-86.99
CREDIT FOR TIRE PURCHASE PRICE UNDER THE TIRE MAINTENANCE CERTIFICATE PROGRAM ORIGINAL INVOICE * _DATE OF
PURCHASE
LBR UCI
AL056 JC331 $0.00 1.0000 $0.00
Vehicle Tire Pressure - F.36 R: 36
SCENERY 2023 JAN 6 PM 3:43 CITY OF RIALTO
AMERICAN
FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERICANTIREDEPOT.COM
A BIGBRAND TIRE & SERVICE COMPANY Started Time: 1/4/2023 8:42:01 AM Invoiced Time: 1/4/2023 5:08:42 PM
Invoice#: 1163-2636619
CUSTOMER INFORMATION VEHICLE INFORMATION
VALDEZ, ALIZE STORE LOCATION
Cust #: ED-5670797 2015 Volvo S60 T5 Premier
RIALTO #1163 BAR#.ard301169
Phone: Engine: L4-1969CC 2.0L
185E. FOOTHILL BLVD EPA#:CAL000470360
Emails: Vehicle Service Emails Inactive Plate #: RIALTO, CA 92376 VIN Number: Phone: (909) 279-1567
Miles: 108379 Started By: JC331
Invoiced By: JOSEPH CASTILLO CATTANEO (JC331)
Invoiced Summary
Revisions Payment
Invoice Totals
Date Employee Previous Revised Type Auth Email/ Phone# Type Amount Parts: $95.99
CASH 53.18 FET: $0.00
Shop Fees: $0.00
NonTax: $-50.25
Tax: $7.44
I acknowledge below and receipt of this invoice
Total: $53.18
This estimate is based on our inspection at this time and does not cover additional parts and labor which may be required after the work has been started. After the work has started, worn or damaged parts which are not evident on first inspection may be discovered. This estimate cannot cover such contingencies. In cases where additional work is deemed necessary, customer authorization will be secured prior to commencement of that additional work This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the vehicle herein described on the streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's llen is hereby acknowledged on above vehicle to secure the amount of repalrs thereto.
Dealer not responsible for unavailability of parts or delays in parts shipments beyond dealers control not for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond our control.
Additional terms notice and oral approval of an increase in the original estimated price. See welsite for warranty detalls.
Customer Initials:
CITY
CLERK RECEIVEL 2023 JAN 5 PM 3:43 CITY OF RIALTO