CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 FEB - 8 PM 12: 06
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:
Julia Loeffert -
FULL NAME DATE OF BIRTH
Rialto, 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):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: November 8, 2022 TIME: 6:10 L AM XI 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.
Alder & Terra Vista - Driving Southbound on Alder, turning right onto Terra Vista
3. HOW DID DAMAGE OR INJURY OCCUR?
I was on my way home during a heavy rain storm on November 8, 2023. I was driving Southbound on Alder (from Riverside Ave.) and turned right onto Terra Vista. I hit a major pothole in the intersection and popped my driver's side front tire. The intersection was flooded and I could not see the pothole.
4. WERE POLICE AT THE SCENE? •YES X NO WERE PARAMEDICS AT THE SCENE? • YES IX 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.
There had been contractors working in that area for weeks. The trench that was dug was filled with sand. Because of the heavy rain, the sand had washed away. Knowing that the storm was coming, the City should have filled the trench, at least in the intersection where water would gather, with asphalt.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 810.98 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Replace both front tires. Tire shop would not just replace Amount: $ 810.98 Item/Date: one tire. Amount: $
#5 - when I came home the evening of the 9th, the pothole had been filled with asphalt.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 810.98 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
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.
Casa Grande
Terra Vista
CURB
PARKWAY
S SIDEWALK
E W
N
Riverside Ave.
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 (OR ECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT O
Julia Loeffert 1/23/23
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 - 150S. PALM AVE., RIALTO, CA 92376 * Attached photos were taken at 6:15 am on November 9th, after the water in the intersection had dissipated.
AMERICA'S TIRE 11/11/2022
1:36 PM
ERIC LOEFFERT
2023 FEB - 8 CITY OF RIALTO
RIALTO, CA 92377
909.771.9759 (M)
PM12:06
2020 TOYOTA
CAMRY Mileage Unknown CITY CLERX RECEIVEL
19" BALE XSE Torque Specs: 80
CAL 40 CA# Invoice #
16065 SIERRA LAKES PKWY 1451439
FONTANA, CA 92336
909.770.5001
Salesperson 909
ERICK J M
Estimated Completion Time 03:19 PM
Article Oty Description FET Price Amount
2 235/40 92V SL BSW 307.00 614.00
- REPLACING BOTH FRNTS
-SPARE IS CURRENTLY ON
BOLT PATTERN: 5-114.3
CERTIFICATES FOR 46.25 92.50
REFUND, REPLACEMENT
For tire certificate details, see
www.americastire.com/customer-service/cerlificates
STATE REQUIRED 1.75 3.50
NAM TIRE FEE
80224 WASTE TIRE 2.50 5.00
NRM DISPOSAL FEE
91123 INSTALLATION & 24.00 48.00
NAM LIFE OF TIRE MAINTENANCE
APPOINTMENT: 11-11-2022 1:30 PM
When replacing less than four tires, America's
Tire recommends that the new tires will be placed
on the rear of the vehicle
Sub Total: 763.00
Sales Tax: 47.98
Sales Total: 810.98
Tkn# XXXXXXXX1327 Ath// 08236D Tendered: 810.98 (VIS)
Tendered Today: 810.98
Tendered Total: 810.98
www.americastire.com/tire - registration
All photos taken November 9, 2023 at 6:15 am, after water in intersection had dissipated.
CITY OF RIALTO
2023 FEB -8 PM 12: 06
CITY CLERK RECEIVED
Standing on Alder looking west on Terra Vista.
Close up of trench - Standing on Terra Vista, facing south
CITY OF RIALTO
2023 FEB -8 PM 12: 07
CITY CLERK RECEIVED
Northwest corner of Alder and Terra Vista - Zoomed in area where front driver's side tire hit deep trench. Within the Crosswalk on Terra Vista, running along Alder.
Standing on Terra Vista, facing Alder (Kucera Middle School in the background).