CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 17 PM 2:14
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).
3. READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Rialto City Clerk's Office Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Karen Rivera
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: — 12/09/2022 TIME: 5:15 IX AM • 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.
Intersection of Monte Ave and Riverside Ave, in front of 2230 office building
3. HOW DID DAMAGE OR INJURY OCCUR?
Man hole cover was not properly covered (sealed). It was not visible on the road, both tires and rims on passenger side where severely damaged.
4. WERE POLICE AT THE SCENE? X YES •NO WERE PARAMEDICS AT THE SCENE? • YES X 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.
After construction was completed on road the contractor (Calmex Engineering Inc.) failed to seal the man hole.
After accident contractor inspected site and agreed to take financial responsibility. Manhole was patched on 12/09/22
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: American Tire Depot/Alignment Estimate Amount: $ 112.00 Item/Date: Garcias Tires/New Tires Estimate Amount: $ 470.00 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: CITY OF RIALTO Item/Date: Lexus Of Riverside 2,317.71
Garcias Tires/Immediate tire repair (while waiting on new tires) JANT 123.002:14 Item/Date: _ Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: K$C 13022.73
CITY CLERT
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Keilah Serrano
NAME: Pablo Vega
ADDRESS: Highland CA 92346 ADDRESS:
Colton CA 92316
TELEPHONE: TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: )
DATE: TIME: • AM • PM DATE:
TIME: • AM 0 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 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. 2230
Building. Monte Ave
XE open
CURB mannde S. Riverside Ave
Mindanao
PARKWAY
SIDEWALK
3 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.
ENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
haven Were 1|17/23
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
CITY OF RIALTO
2023 JAN 17 PM 2:14
RECEIVED
CITY CLERK
CITY OF RIALTO
2023 JAN 17 PM 2:14
CITY CLERK RECEIVED
Rialto Police Courtesy Notice
Date 12.4.27 -Time Day of Week
Comment
221209-0053
X CARDENAS
Officer Badge No
CONTACT RIALTO P.D.-(909) 820-2550 FOR FURTHER INFORMATION (Over)
CITY CLERX RECEIVED 2023 JAN 17 PM 2: 14 CITY OF RIALTO CALMEX ENGINEERING, INC.
Asphalt Paving
Tom Martinez | Project Manager
Office: (909) 546-1311 Cell: (909) 635-8273 Fax: (909) 874-9463 Email: [email protected]
CITY CLERK MECCITEL 2023 JAN 17 PM 2: 14 CITY OF RIALTO 3150 Adams Street • Riverside, CA 92504-4011
CUFRVERSISE Parts Fax: (951) 352-4783 • Toll-Free: (800) 899-LEXUS OF RIVERSIDE Parts Dept.: (951) 354-4103 • Service Appt.: (951) 354-4143 www.lexusofriverside.com
BAR # ARD 285098 HOURS: (M-F) 7:00 AM - 6:00 PM, (Sat) 8:00 AM - 5:00 PM. (SUN) CLOSED EPA#: CAL000420243
DISCLAIMER OF WARRANTIES ADDITIONAL REPAIRS AUTHORIZED: I ACKNOWLEDGE NOTICE AND ORA Any warranties on the products sold hereby are those made by the manufacturer. The APPROVAL OF AN INCREASE IN THE seller hereby expressly disclaims all warranties, either express or implied, including ORIGINAL ESTIMATED PRICE any implied warranty of merchantability or fitness for a particular purpose, and neither assumes nor authorizes any other person to assume for it any liability in connection ESTIMATE $ TIME _ PMO with the sale of said products. ADDITIONAL $ _ DATE -
ALL PARTS INSTALLED ARE NEW UNLESS OTHERWISE SPECIFIED AS BEING USED OR REMANUFACTURED. TOTAL $ OK'D.
Quote only
Invoice to:022887 ] payment Cash
KAREN RIVERA Page 1
Attention: JTHBE1D28E5011431
Invoice# Q00002
origIn#
Invoiced 12/09/22 12:00
PO#
Tax#
sisp JUVENTINO FLORES
For office Use vehicle Information
s1sp/Proj: 512/007 Stn: Y41 Prt: Z41 Lines: 4
Added: 12/09/22 11:57 67L001 50 M01
VEN PART NUMBER DESCRIPTION QTY BIN LIST SELL XSELL
LEX 4261A53311 WHEEL, DISC CH 1 NONSTK 838.59 838.59 838.59 LEX 4261A53341 WHEEL, DISC CH 1 ADD 842.63 842.63 842.63 010 CW1 RE-CHROME WHEE 1 300 225.00 225.00 225.00
010 CW1 RE-CHROME WHEE 1 300 225.00 225.00 225.00
NO RETURNS ON SPECIAL ORDER, ELECTRICAL, INSTALLED OR SALES OVER 30 DAYS. 20% RESTOCK ON RETURNABLE ITEMS ALL PACKAGING/LABELS NEEDED.
Parts Accessories Misc/Deposits Subtotal Tax
1,681.22 450.00 .00 2,131.22 186.49 20317071
Notice to Consumer: Please Read Important Information on Reverse Side I ACKNOWLEDGE RECEIPT OF THE PARTS AND LABOR LISTED ABOVE:
@Dealer Computer services, Inc. 2008 ACCOUNTING
285 S La Cadena Drive,
GARCIAS TIRES Colton CA 92324 Phone: (909) 824 - 7110
285 S LA CADENA DR
COLTON, CA 923243417 Phone
12/09/2022 09:29:45
DEBIT CARD
DEBIT SALE
State: Zip:
Card F ription Price Amount
VISA
Network: ire(s) D0111-1
US DEBIT
Chip Card A0000000980840
AID:
5 Ч/ 34
SEQ #:
1897
Batch #.
5 INVOICE
142496
Approval Code: 46K7/37
Enby Method: Chip Read
Issuer - PIN Bypassen 1ounting
Mode:
SALE AMOUNT $123.00 ler Metal TPM$ON/A
r-235х4=140
CUSTOMER COPY
ial Seal • Plug
L rur un Spare
Rotation • 1/2 Rotation • 1/4 Rotation
New Used Wheel(s)
Remove Wheel Locks)
• Spline • Tuner Key
Lugnut(s)
Wheel Repair L Crack (s) L Dent (s)
Rush Service $
• We recommand you move vehiclo with Tow truck, Customor Initials. Tax We recommend replace lugnuts and studs, Customers Initlais • TIRES NOT INSTALLED on the car Only mounted on wheels, Customer Inttlals Carry out. Not Installed On Wheels, Initials Labor 5
••• We recommend wheel(s) replacement, Initials
Changed Tire size, Initials Subtotal
WHEEL REPAIRS DO
PSI
Miles Yoar Lic. Plato/ "
FL FR
cash Debit Credit card
SiL-
BL BR
30 DAYS LIMITED WARRANTY ON USED TIRES. LABOR CHARGES APPLY. WE ARE NOT RESPONSIBLE FOR: STRIPPED STUDS AND LUG NUTS, DEFECTIVE PRESSURE SENSORS, HUBCARS, CENTER CAPS, STUDS AND LUG NUTS.
AR BAGS AND DAMAGE TO ALUMINUM OR CUSTOM WHEELS WHEN CHANGING TIRES. WE ARE NOT RESPONSBLE Date Deposit FOR ANY ITEM LEFT FOR 30 DAYS AND WILL BE DISPOSED OF ACCORDINGLY. WE ARE NOT RESPONSIBLE FOR DEPOSITS LEFT MORE THAN 30 DAYS OF INVOICE DATE AND WILL BE FORFEITED AND LOST. WHEEL REPAIRS HAVE NC WARRANTY. ALL CLAIMS MUST BE ACCOMPANIED BY THIS BILL ALL DEPOSITS ARE NON REFUNDABLE / NO CONSEQUENTIAL DAMAGE COVERAGE. NO ROAD HAZARD COVERAGE / NO REFUNDS. UNDER ALL CIRCUUSTANCES, THE COST OF MOUNTING, Balance
BALANCING AND ANY OTHER SERVICE CHARGE, INCLUDING APPLICABLE TAXES, ARE REQUIRED TO BE PAID BY THE CONSUMER Customer Signature: Total:
CITY RECEIVEL 2023 JAN 17 CITY
OF
CLERK
PH 2: 14 RIALTO
AMERICAN FIND STORE HOURS
AND LOCATIONS OHLINE
TIRE DEPOT AMERIGANTIREDEPOT.COM
Started Time: 12/9/2022 1:38:47 PM
A BIGBRAND TIRE & SERVICE COMPANY Invoiced Time: 12/9/2022 2:53:19 PM Invoicer: 1164-2534501
CUSTOMER INFORMATION VEHICLE INFORMATION STORE LOCATION RIVERA, KAREN Cust # ED-7011099 2014 Lexus IS350 Base RIALTO #1164 BAR#: ard301170 Engine: 3.5L V6 F DOHC 24V 110 E VALLEY BLD EPA# CAL000470371 Plate # RIALTO. CA 92376
Phone: VIN Number: Phone: (909) 341-0909
Emails: Vehicle Service Emails Inactive Miles: 171812 Started By HC185 Invoiced By: HERACLIO CERVANTES (HC185)
BRANG PAST DESCRIPTION TECH SALESPERS PRICE TOTA
LBR UCI CHECK SUSPENSION CAR FELL IN POT HOLE RM805 HC185 $0.00 1.0000 $0.00 LBR LABAC ALIGNMENT CHECK - CUSTOMER REQUEST RM905 HC185 $0.00 1.0000 $0.00
CHECK CAMBER, CASTER AND TOE WHERE APPLICABLE
Recommended Services Not Performed
** Services Recommended by: H185 **
BRAND PART DESCRIPTION QTY PRICE TOTAL
LBR LABAS VEHICLE ALIGNMENT - STANDARD (2 OR 4 WHEEL) 1.00 112.00 112.00 Prices valid for 90 days
Vehicle Tire Pressure - F: 35 R: 38
Invoiced Summary
Revisions Payment Invoice Totals
Date Employee Previous Revised Type Auth Email/ Phone# Type Amount Parts: $0 CASH 0.00 FET: $0.00
Shop Fees: $0.00
NonTax: $0.00
Tax: $0.00
I acknowledge below and receipt of this invoice Total:
$0 00
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, wor or darnaged 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 aulhorization will be secured priorla 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 sisawhere for the purpose oftasting andor inspection. An express mechanic's lien is hereby acknowledged on above vahicle lo secure the amount of repairs therela Dealer not responsible for unavailability of parts or delays in parts shipments beyond dealers contral not forloss or damage to vehicle or articles ient in vehicle in case of fire, theft or any other cause beyond our control.
Additional terms nolice and oral approval of an increase in the original aslimated price. See welisite for warranty details.
Customer Inibals:
CITY CLERK RECEIVED 2023 JAN 17 PM 2: 15 CITY OF RIALTO Paga 1 of 1