CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CITY 2023 JAN 17 PM 2:26
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
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:
Matilde Jonathan Jimenez
FULL NAME DATE OF BIRTH
Fontang CA 92335
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: 01-08-2023 TIME: 8.00
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.
Located on locust And Riverside Ave. Potholes exact locahon is Between Brena Vista and 4 Casa Grande Dr. On Locust
AUl.
3. HOW DID DAMAGE OR INJURY OCCUR?
Driving south on Locust at night. Lighting is not well on street and Potheles are large. Driving through the Potholes 1s now damaged occured
4. WERE POLICE AT THE SCENE? • YES • NO WERE PARAMEDICS AT THE SCENE? • YES ONO
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.
Potholes/ Pour road Conditions / Bad lighting In Rialto.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1533.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
lem/Date: USed Tire and New Tire Tire/01-09-23 Amount: $ 40/143./2 Item/Date: Engine Shied cover! TAPe /1-14-23 Amount: $ 526. 74/10.75 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 1,533.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: Wheel Alignment/ 1-11-2023 Amount: $i29.99
Item/Date: Rim and Installation / 1-2-2023 Amount: $ 4$2.40 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $1533.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Deanna Marin
NAME:
ADDRESS: Fontana
ADDRESS:
CA 92335
TELEPHONE:
TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: | )
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 corners. 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 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 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. -a. Buera vis
Locust CURB Locust
Riverside
PARKWAY W
SIDEWALK
S +N
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.
JONATON- OF CLAIMAN OR AGENT
Matilde Jonathan Jimenez 01/17/2023
TYPE OR PRINT NAME
DATE
SELF
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 COSTCO Date: 01/09/23 Invoice #: 6270226526
Time In: 18:49:08
TIRE CENTER MEMBER PURCHASE INVOICE Membership#: 111950378020
MEMBER INFORMATION VPHICLE INFORMATION
JONATHAN JIMENEZ 2021 Kia K5 GT-Line
Color: WHITE License:
FONTANA, CA 92335-3796
Odometer: 53425
Wheel Torque: 94
Air Pressure: Front: 35 Rear: 35
ITEM# DESCRIPTION Qty SLIP PRINT
1662826 BFS WEATHERPEAK 1
ALL WEATHER TIRE
235/45R18 94V BW
BAN 006-021
70,000 Mile Warranty
TIRE
6850999 Warranty Tire Installation Fee 1
504595 Nitrogen Tire Inflation 1
1662826 235/1S818 112
V8TL
1662826 Road Hazard Warranty
EN STATE TIR 1.25-
1682826 255/15R18 23S.99.4
EN STATE TIR 1.25
FUTURE INSTL 9.99
SUBTOTAL 155.50
TOX 9.58
**** TOTAL
MER OUR 921
CASH 200.00
CHANGE 55.38
0. 7.75% TAX 9.58
TOTAL TAS 9.58
TOTAL NUMBER OF ITERS SOLD-
CASHIER: GARRETT S
01/0P/2023 18:51 827 7: 167
9200062702265263
1V6FUWP014822
NOTES:
See Additional Notes...
N
CITY CLERK RECEIVED 2023 JAN 17 PM 2:26 CITY OF RIALTO
*Inflation and Torque specifications are recommended by Manufacturer.
Best to Spare
_ Static Dynamic GAS
Blackwall Whitewall Sales Person
Page# 1
COSTCO Date: 01/09/23 Invoice #: 6270226526
Time In: 18:49:08
STIRE CENTER ADDITIONAL NOTES Membership #: 111950378020 * To Access your Bridgestone Tire Warranty Information, DOT numbers for new tires purchased, visit the links below. * Bridgestone Tire DOT Registration Web Address - https://www. bridgestonetire.com/customer-care/tire-registration
* Bridgestone Tire Warranty Information Web Address - https://www. bridgestonetire.com/customer-care/tire-warranties
* Read and follow all tire maintenance requirements outlined in the Tire Manufacturers' Warranty booklet provided at the time of purchase by hard copy or by reference to the Manufacturer's website.
CIT
Y CLERK RECEIVED 2023 JAN 17 PM 2:26 CITY OF RIALTO
VALLEY KIA R/O Open Date R/O Number
FONTANA 01/16/23
SERVICE DEPARTMENT HOURS R/O Close Date Status
16272 S Highland Ave - Fontana, CA 92336 7:00 a.m. to 6:00 p.m. 01/16/23 Final
Phone: (909) 350-2700 Fax: (909) 350-2780 Monday - Friday www.valleykia.com 8:00 a.m. to 2:00 p.m. Saturday Mileage In Mileage Out B.A.R. #ARD00190201 53505 53506
Service Advisor / Tag #
THOMAS ARGUELLE/265*W*
JIMENEZ, MATILDE J Work Phone
Vehicle Identification Number
Home Phone Delivery Date In-Service Date
FONTANA, CA 92335 10/09/20 10/09/20
Year Make Model Body
Color License Number
2021 KIA K5 GT-LINE GLACIAL WH
K12183
DESCRIPTION OF SERVICE AND PARTS AMOUNT
Email:
#1 - KCP1 MPI: PERFORM 360 VEHICLE INSPECTION. $29.99
VALUE***SEE ATTACHED INSPECTION SHEET***
COMPLIMENTARY WITH ANY SERVICE. INSPECT AND SET TI
RE PRESSURE AS PER CALIFORNIA AB32 LF RF IR_ RR_
#2 - 999: VALLEY KIA NOW OFFERS FLEXABLE PAYMENT PLAN FOR PARTS & SERVICE. DONT PUT OFF THOSE IMPORTANT REPA 2023 JAN 17 PM 2:26 CITY OF RIALTO IRS. SEE ADVISOR FOR DETAILS OR VALLEYKIA. COM TY CLERK ECEIVED #3 - Customer Reports:
replace under shield
Tech: ROBERT CULLUM (7) 165.00
Installed 29110 L3000 : PANEL ASSY-UNDER COV [email protected] 331.07 Installed 14206 08250B : CLIP [email protected] 8.72
Installed 11254 06256K: BOLT [email protected] 15.48
Sub Total: 520.27
ASST. MGR DISCOUNT -20.00
************************ **** ***** ***** ****
* **ALL PARTS ARE NEW UN ERWISE IED * *
************* *********** ******* ***** ***
TERMS: STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. "I hereby authorize the repair LABOR 165.00 work hereinafter to be done along with the necessary material and agree that you are not 355.27 PARTS
DEDUCTIBLE . 00
SUBLET . 00
and/or inspection.
the amount of repairs thereto." SHOP SUPPLIES . 00
HAZARDOUS MATERIALS . 00
SALES TAX OR TAXI.D. 26.47
neither assumes nor authorizes any other person to assume for it any liability in connection with the SPECIAL ORDER DEPOSIT . 00 sale of said products. Any limitation contained herein does not apply where prohibited by law. DISCOUNTS - 20.00 TOTAL DUE 526.74
V/MC/DISC 526.74
NO RETURN ON ELECTRICAL OR SAFETY ITEMS OR SPECIAL ORDERS.
X
© 2012 DEALERTRACK SYSTEMS, Inc. - Dealership Application Group (800) 945-1028 BAR#294237 / EPA#CAL000444598
17067 FOOTHILL BLVD PAGE 1
TIRECHOICE FONTANA,CA 92335
(909)822-0549
AUTO SERVICE CENTERS
Guest ID: 1613104391 Year: 2021 Date/Time: 01/11/23 13:49:43 Name: JOHNATHAN JIMENEZ Make: KIA Estimate #: 119363
Address: Model: K5 Invoice #: 109123
Address 2: Lic No: PO Number:
City, State, Zip: FONTANA CA. 92335 VIN: Unit Number:
Home Phone: Color: Email Address: na
Work Phone: Engine: 1.6L 14 Fleet/Wholesale:
Other Phone: Mileage In: 53228 Est Created On: 01/10/23 18:57:57 Tax Exempt #: Mileage Out: 53229
Manager: ROBERT LOPEZ Inspect Due:
Services Requested:
GENERAL INSPECTION
Car
Qty. Part # Loc Description Part Labor Amount
Tire Pressure Spec: Not Available Wheel Torque: Not Available Tire Pressure IN Tire Pressure OUT
35 psi 35 psi 35 psi 35 psi
35 psi 35 psi 35 psi 35 psi
INCLUDED WITH EVERY VISIT
1 CI COURTESY INSPECTION NO CHARGE
1 TPC TIRE PRESSURE CHECK & INFLATE NO CHARGE
TIRE SERVICE
1 ALIGNMENT WHEEL ALIGNMENT 0.00 129.99 129,99
TOTAL TIRE SERVICE: 129.99
*** Customer Wishes To Discard Old Parts ***
CITY CLERK RECEIVED 2023 JAN 17 PM 2:26 CITY OF RIALTO
SEE NEXT PAGE
INVOICE INVOICE BAR#294237 / EPA#CAL000444598 INVOICE
CUSTOMER COPY
LIMITED WARRANTY
Thank you for your business! We are committed to earning your trust by providing the expertise, convenience and value you expect, every time you visit us. If you have any questions regarding the service, you received or our limited warranty, please contact Customer Service at 800-876-6676 x3500 or visit our website at www.monro.com.
WHAT IS WARRANTEED AND FOR HOW LONG
Most parts and service purchased at the Company are covered by a minimum of twelve (12) months or 12,000 miles, whichever comes first, with some parts and service carrying a different warranty. This warranty is valid for replacement performed at any Company location. Please visit www.monro.com to find our locations.
Some exclusions may apply; please see details below. Auto parts which prove to be unserviceable during the warranty period will be replaced for free of any additional charge for parts or labor, except as noted under "Exclusions", below.
SERNICE PARTS ABOR
Batteries' ( Covered by battery manufacturer N/A
Brake Pads Varies on brake pad level? Varies on brake pad level Calipers Lifetime 12 months/12,000 miles
Catalytic Converters 60 months/50,000 miles 60 months/50,000 miles Flat Repair Lifetime/Fix Flat Only Lifetime/Fix Flat Only Mufflers Lifetime 12 months/12,000 miles
Rotors 12 months/12,000 miles 12 months/12,000 miles
Shocks and Struts Lifetime 12 months/12,000 miles
Steering and Suspension Lifetime 12 months/12,000 miles Tire Alignment' N/A 3 months/4,000 miles
Tire Balanced N/A | 3 months/4.000 miles
ALL LIFETIME WARRANTIES ARE VALID ONLY FOR AS LONG AS THE ORIGINAL CUSTOMER OWNS THE VEHICLE 'Batteries are covered by a separate performance warranty from the manufacturer. (This is on the back already) Brake Pad Frame rants
Silver Limited Lifetime *Manufacturer Defects Only None Gold Limited Lifetime *Manufacturer Defects Only 12 months/12,000 miles Platinum Lifetime 24 months/24,000 miles
Specialty Limited Lifetime *Manufacturer Defects Only None "If parts are required to restore vehicle to manufacture's alignment specifications, then those parts and the labor required to install them are not covered. *Lifetime balance is only warrantied so long as originally balanced tire remains on wheel. If needed, additional charge may apply for resetting the Tire Pressure Monitoring System (TPMS).
Other Exclusions: Replacement of anti-freeze or clamps is not included in the warranty on belts/radiator hoses. Cost of refrigerant and recharging of the air conditioning system is not included with the warranty on air conditioner parts or air conditioner compressors. Cost of additional brake system components, including rotors and drums and/or labor to restore brake system to its safe and proper operation is not included with the warranty on brake shoes, disc pads, calipers and/or wheel cylinders and all other hardware. Batteries are covered by a separate warranty by manufacturer.
TIRE WARRANTY
We are so confident of our top-quality tires, if you are not pleased with your purchase in the first 30 days or 500 miles, whichever comes first, you may return your undamaged tires and exchange them for any others of equal value or receive a full refund.
Tires purchased at the Company are covered by a manufacturer's limited warranty. Tire warranty information will be provided separately at the time of purchase.
For the following purchases: Falken, Pirelli, Achilles, Black Lion, Gallant, Landsail, Hankook, Yokohama, Laufenn, Ohtsu, Pantera and Vee Rubber to our Roadside Assistance brochure for complete details.
GENERAL PROVISIONS (APPLICABLE TO ALL WARRANTIES)
This warranty is valid only at Company locations: if the vehicle is serviced by anyone other than the Company, this warranty is void of that service.
No Company representative has authorization to alter or enlarge the warranties and their terms and conditions The original invoice from the store at which the original service was performed must be presented when making a warranty claim.
This warranty covers only the original purchaser of the services and/or the installed parts and the original vehicle; this warranty is not transferable This warranty does not apply to products or vehicles used for commercial, racing, or off-road purposes, or to damage caused by abuse or accident.
This warranty gives you specific legal rights, and you may also have rights which vary from state to state.
Any implied warranty of merchantability or fitness for a particular purpose is limited to the duration of the limited warranties stated herein
THE COMPANY WILL NOT BE LIABLE FOR INCIDENTAL OR CONCEQUANTIAL DAMAGES (SOME STATES DO NOT ALLOW THE
EXCLUSION OR THE LIMITATION OF INCEDENTAL OR CONSOUENTIAL DAMAGES SO THE ABOVE LIMITATION MAY NOT APPLY
TO YOU)
This warranty is given by: Monro, Inc (The "Company"), 200 Holleder Parkway, Rochester, NY 14615 .. Commercial vehicles excluded, (vehicles weighing 10,001llbs or more and commercial tires 17.5 or larger) BAR#294237 / EPA#CAL000444598
17067 FOOTHILL BLVD PAGE 2
TIRECHOICE FONTANA,CA 92335
(909)822-0549
AUTO SERVICE CENTERS
Guest ID: 1613104391 Year: 2021 Date/Time:
01/11/23 13:49:43
Name: JOHNATHAN JIMENEZ Make: KIA Estimate #
119363
Address: Model: K5 Invoice #: 109123
Address 2: Lic No: PO Number:
City, State, Zip: FONTANA. CA. 92335 VIN: Unit Number:
Home Phone: Color: Email Address: na
Work Phone: Engine: 1.6L14 Fleet/Wholesale: N
Other Phone: 0- Mileage In: 53228 Est Created On: 01/10/23 18:57:57 Tax Exempt #: Mileage Out: 53229
Manager: ROBERT LOPEZ Inspect Due:
Services Requested:
GENERAL INSPECTION
Car
Qty. Part # Loc Description Part Labor Amount
CITY CLERK RECEIVED 2023 JAN 17 PM 2:26 CITY OF RIALTO
INVOICE INVOICE BAR#294237 / EPA#CAL000444598 INVOICE
SUB TOTAL 129.99
TECH: 106945-0.00 J. CARRILLO SALES TAX 0.00
GRAND TOTAL 129.99
All parts are new unless otherwise specified. Please see reverse for warranty details. this invoice, If there was an increase in the original estimated price, I acknowledge notice and oral approval of an increase in the original estimated price. X Guest Signature
I certify that all repairs were properly completed..
Company Authorized Representative
CAUTION: Owners of Mag, Custom, Alloy, or Dual Wheels must have lug-nuts retorqued after 25 miles or 24 hours! The Company will gladly retorque these lug-nuts once after the first 25 miles at no charge.
Guest Initials
Did you have a 5-star visit today? Let us know GOl angle Flacebook *****
PAY AMT
CASH 129.99 1/10/2023
PAYMENT COLLECTED BY: R. LOPEZ
CUSTOMER COPY
Work Order: R000082
Year: 21
Technician: joe
Mileage: 53000
Date 1/10/23 7:07 PM
Kia: K5: Front Wheel Drive: 2021-22 2023 JAM 17 PM 2:26 CITY OF RIALTO Before Measurements
Left Front Right Front CITY CLERK RECEIVEL
0.0* -1.0% -1.0° 0.0
-0.5° -0.9°
Camber Camber
5,5 4.5° 5.5
4.6° 4.6°
Caster Caster
Front
0.16* -0.04
-0 26° -0.30°
Toe -0 .56° Toe
Total Toe
-0.05 0.05° 05
1.02°
Steer Ahead
Left Rear Right Rear
-0.5° -1.5° -1.5° -0.5°
-0.9° -1.4°
Camber Camber
Rear
4-0.02° 0.19° 0.19° -0.02°
-0.04° 0.26°
=0.03" 0.37°
Toe 0.21° Toe
Total Toe
-0.15°
Thrust Angle
Current Measurements
Left Front Right Front
0.0° -1.0* 21.04 0.0°
-0.6° -0.9°
Camber Camber
5.5 5.5°
4.6° 4.6°
Caster Caster
Front
-0.04° 0.16* 0.16° -0.04°
6770 0.09° -0.08° 0.32* 0.02°
Toe 0.11° Toe
Total Toe
-0.05° 00.05*0
0.04°
Steer Ahead
Left Rear Right Rear
-0.5° -1,5° -1.5° -0.5°
-0.9º -0.5°
Camber Camber
Rear
-0.02° 0.19° 0.19° -0.02°
0.10° -0.03° 0.15°
0.37 0.25° Toe
Total Toe
-0.03°
Thrust Angle
CITY OF RIALTO
2023 JAN 17 PM 2: 26
CITY CLERK RECEIVEL
JIMENEZ, MATILDE J
FONTANA, CA 92335
Payment Due Upon Receipt 01/12/23 Q000411089 1
Will Call FRANCISCO PEREZ
52910 L3320 : WHEEL ASSY-ALUMINIU EP
592.90 586.91 586.91
*********************************
* **ALL PARTS ARE NEW UNLESS
* OTHERWISE SPECIFIED**
*********************************
01/12/23 13:37:37 586.91
45.49 632.40
InstANSo
ToN-682.4
GOOD YEAR Fontana Tire Center
BRIDGESTONE
BFGoodrich (909) 350-8695
LOUISHTON 17890 Foothill Blvd., Fontana, CA 92335
CUSTOMER DATE
How doers 1/9/23
ADDRESS PHONE
get more done
VEHICLE YEAR MAKE MODEL VEHICLE MILEAGE
DESCRIPTION QTY S EACH PRICE
11884 FOOTHILL BLVD TIRE SALE • NEW
RANCHO CUCAMONGA, CA 91730 (909) 948-9200 • USED SE354518 03:12 PM BRAND MODEL
00052 42029 01/15/23
SALE SELF CHECKOUT
DOT #1
052427010483 GORILLA_TAPE <A, S> 9.98 DOT #2
GORILLA BLACK DUCT TAPE 3UYD
DOT #3
SUBTOTAL 9.98
SALES TAX 0.12 DOT #4
TOTAL $10.75
XXXXXXXXXXXX7808 DEBIT WHEEL SALE • NEW
USD$ 10.75 O USED
AUTH CODE 001159 BRAND SIZE
Chip Read Verified | By PIN
AID A0000000980840 US DEBIT
TIRE SERVICE • ROTATION
0645. 01/15/23 03:12 PM
• MOUNT / DISMOUNT TIRE
• BALANCING
0645 52 42029 01/15/2023 088/
RETURN POLICY DEFINITIONS TIRE REPAIR
POLICY EXPIRES ON • INSIDE PATCH
POLICY ID DAYS
04/15/2023
• PLUG
****** • VALVE STEM
DID WE NAJI 11
ACCESSORY SALE • TPM SENSORS
Take short survey for a chance TO WIN
$5,000 HOMF DEPOT GIFT CARD
Opine en espaniol • CAPS
www.homedepot.com/survey
User ID: H88 84992 84399 TERMS & CONDITIONS USED TIRES: NO WARRANTY, SUBTOTAL PASSWORD: 23065 84347 NO REFUNDS & NO RETURNS. PURCHASER ACCEPTS ALL LIABILITIES IF DAMAGE OR INJURY OCCURS FROM USED TIRES. SALES TAX Entries must be completed within 14 days NEW TIRES WARRANTY:
of purchase. Entrants must be 18 or
to enter. See complete rules on MILES MONTHS,
website. No purchase necessary.
WARRANTY LIMITED ONLY TO DEFECTS OF THE TIRE.
NAIL PUNCTURE OR DRIVING ON A FLAT IS NOT
COVERED. GRAND TOTAL 40
DEPOSIT h
SIGNATURE DATE BALANCE DUE