CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 30 PM I: 02
ПРОВАТО КОНАНАМ TO PERSON OR PROPERTY
RECEIYED
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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Nancy M Ochoa
FULL NAME DATE OF BIRTH
Rialto
1 HOME ADDRESS INCLUDING CITY, STATE & ZIP CA 92377 HOME TELEPHONE NO BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Same as above
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1/02/03 _ TIME: 7:00 *AMP
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 South on Locust Ave When my
Car went Over avery large pot hole. The previous
days & that Eary morning it had rained.
3. HOW DID DAMAGE OR INJURY OCCUR?
nave large Pet hoe three my gignment off The large
hit a pot hole. I had to take my car in to get an alignment
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? DYES DONO
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.
The potholes not covered or having any
Cautian Signs to war drivers. This was vey unsafe.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 259.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: Y2123 Amount: $ 259.00
Item/Date: Amount: $
2 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 259.00 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: | 1
TELEPHONE: L 1
DATE: TIME:
D AM • PM 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.
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.
Traveling Saith on locust Ave
01 Locust Av
South
asmatie CURB
PARKWAY
SIDEWALK
THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. 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 I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Nancy ochoa 127/23
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 3 BMCS594706
M BMW OF ONTARIO
1350 Auto Center Drive Ontario, CA 91761
(909) 390-7888
Direct Service Line (909) 402-3286
Service Fax (909) 390-0699 BMCS594706
www.bmwofontario.com
1001IBMCS594706
CUSTOMER NO. CELL: 909-746-7310
ADVISOR TAG NO.
35478 INVOICE DATE INVOICE NO
WILL SMITH 391 6297 01/02/23 BMCS594706
LABOR RATE LICENSE NO MILEAGE COLOR STOCK NO
ERIC M OCHOA 15, 878
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
RIALTO, CA 92377-3875 22/BMW/3 SERIES/4DR SDN 330I NA
VEHICLE ID. NO.
SELLING DEALER NO. PRODUCTION DATE
TE.T. E. NO. P. O. NO. R. O. DATE
01/02/23
RESIDENCE PHONE BUSINESS PHONE
COMMENTS
JOB# 1 CHARGES- MO: 15882
NOTE TO CONSUMER: PLEASE READ
LABOR- IMPORTANT INFORMATION ON EITHER
J# 1 00BMZ4WA BACK SIDE OR LAST PAGE HEREOF
WHEEL ALIGNMENT TECH(S) : 39364
CUSTOMER REQUESTS FOUR-WHEEL ALIGNMENT. 259.00 Customer agrees that this Agreement includes CUSTOMER REQUESTS FOUR-WHEEL ALIGNMENT. all of the terms and conditions on the front and PERFORMED FOUR WHEEL ALIGNMENT,ADJUSTED CAMBER/TOE either back side or last page hereof, that this Agreement cancels and supersedes any prior
JOB# 1 TOTALS- agreement including oral agreements, and as of the date above comprises the entire agree-
LABOR 259.00
ment between Customer and Dealer relating to
these repairs or other matters referred to on the
JOB# 1 JOURNAL PREFIX BMCS JOB# 1 TOTAL 259.00 front or back side of this document. Customer JOB# 2 CHARGES
also acknowledges receipt of copy of this invoice.
LABOR- Arbitration Agreement. Customer agrees that
J# 2 00BMZ1 Customer or Dealership may elect to resolve MULTI-POINT INSP TECH(S) : 39364 INTERNAL
CUSTOMER REQUESTS COMPLIMENTARY VEHICLE INSPECTION. any dispute by binding arbitration pursuant to the Arbitration Provision on either the back side
Provide Copy of Report to Customer. Document and Review or last page of this document.
Technician Recommendations.
Some items may not be inspected depending upon vehicle
configuration.
JOB# 2 TOTALS-
JOB# 2 JOURNAL PREFIX BMCS JOB# 2 TOTAL 0.00
JOB# 3 CHARGES
LABOR.
J# 3 00BMZ2 TIRE PRESSURE CHECK TECH(S) : 39364
INTERNAL
CUSTOMER REQUESTS TIRE PRESSURE CHECK.
Record Tire Pressure Measurements After Service Complete.
JOB# 3 TOTALS-
JOB# 3 JOURNAL PREFIX BMCS JOB# 3 TOTAL 0.00
JOB# 4 CHARGES-
LABOR-.
J# 4 04BMZWASH CAR WASH TECH(S) : 39364 INTERNAL
CUSTOMER REQUESTS COMPLIMENTARY CAR WASH.
Wash and Shammy-Dry Vehicle Exterior. Vacuum Interior
Carpets and Mats.
JOB# 4 TOTALS-
4 JOURNAL PREFIX BMCS J0B# 4 TOTAL 0.00
JOB# 5 CHARGES-
LABOR -
J# 5 04BMZSHUTTLE SHUTTLE TRANSPORT TECH(S) : 39364 INTERNAL PROVIDE COMPLIMENTARY SHUTTLE TRANSPORTATION.
THANK YOU
BAR # 00270169 • DEALER #
PAGE 1 OF 2 CUSTOMER COPY EPA# CAR000275842
[CONTINUED ON NEXT PAGE] 08:42am
The Reynolds and Reynolds Company ERAINTIN
F668892 Q (07/22
4 BMCS594706
M BMW OF ONTARIO
1350 Auto Center Drive Ontario, CA 91761
(909) 390-7888
Direct Service Line (909) 402-3286
Service Fax (909) 390-0699 BMCS594706
www.bmwofontario.com
1001IBMCS594706
CUSTOMER NO. CELL: 909-746-7310
ADVISOR TAG NO.
35478 WILL SMITH INVOICE DATE INVOICE NO
391 6297 01/02/23 BMCS594706
LABOR RATE MILEAGE COLOR
ERIC M OCHOA STOCK NO.
15,878 /
YEAR / MAKE / MODEL DELIVERY DATE
DELIVERY MILES
KIALIO, CA 92377-3875 22/BMW/3 SERIES/4DR SDN 330I NA
VEHICLE.D.NO. 'SELLING DEALER NO.
PRODUCTION DATE
ET. E. NO. TP. O. NO.
R.O. DATE
RESIDENCE PHONE 01/02/23
ALISINFOS PHANE COMMENTS
JOB# 5 TOTALS- MO: 15882
NOTE TO CONSUMER: PLEASE READ
IMPORTANT INFORMATION ON EITHER
JOB# 5 JOURNAL PREFIX BMCS J0B# 5 TOTAL
JOB# 6 CHARGES 0.00 BACK SIDE OR LAST PAGE HEREOF
Customer agrees that this Agreement includes
LABOR. all of the terms and conditions on the front and J# 6 0OBMZZTOUCHLESS TOUCHLESS SERVICE TECH(S) : 39364 either back side or last page hereof, that this INTERNAL Agreement cancels and supersedes any prior
JOB# 6 TOTALS- agreement including oral agreements, and as of the date above comprises the entire agree-
JOB# 6 JOURNAL PREFIX BMCS JOB# 6 TOTAL ment between Customer and Dealer relating to JOB# 7 CHARGES 0.00 these repairs or other matters referred to on the front or back side of this document. Customer
LABOR - • also acknowledges receipt of copy of this invoice.
J# 7 00BMZKEYREAD KEY READ Arbitration Agreement. Customer agrees that TECH(S) : 39364 INTERNAL Customer or Dealership may elect to resolve CUSTOMER REQUESTS FOR BMW OF ONTARIO SERVICE ADVISOR TO any dispute by binding arbitration pursuant to PERFORM KEY READ AT THE TIME OF WRITE UP IN ORDER TO the Arbitration Provision on either the back side DETERMINE CONDITION BASED SERVICE AND OPEN RECALLS/CAMPAIGNS or last page of this document.
ON CUSTOMERS VEHICLE. CUSTOMER CAN BE SHOWN THE KEY READ ON REQUEST IF THE OWNERSHIP INFORMATION MATCHES. KEY READ IS PERFORMED AT NO CHARGE TO THE CUSTOMER. KEY DATA IS ALSO
AVAILABLE FOR VIEWING AT ANY TIME THROUGH THEIR VEHICLES ON BOARD COMPUTER OR IDRIVE SYSTEM ON SELECT MODELS. KEY READ IS ALSO ONLY AVAILABLE ON SELECT MODELS.
KEY READ PERFORMED TO HELP INFORM THE CUSTOMER OF CONDITION BASED SERVICE AND ANY OPEN RECALLS OR CAMPAIGNS.
KEY READ PERFORMED
JOB# 7 TOTALS-
JOB# 7 JOURNAL PREFIX BMCS JOB# 7 TOTAL 0.00
ESTIMATE-
CUSTOMER HEREBY ACKNOWLEDGES RECEIVING
ORIGINAL ESTIMATE OF $259.00 (+TAX)
TOTALS-
259.00
0.00 0.00
TOTAL MISC CHG. 0.00
TOTAL MISC DISC
0:00
TOTAL TAX.
TOTAL INVOICE $ 259.00
CUSTOMER SIGNATURE
BAR # 00270169 • DEALER #
PAGE 2 OF 2 CUSTOMER COPY I END OF INVOICE J 08:42am EPA# CAR000275842 1/2/23, 8:46 AM about blank
BMW OF ONTARIO
1350 AUTO CENTER DRIVE
Ontario
California
909-390-7888
Sale
Date: 1/2/2023, 8:46:13 AM
Amount: $259.00
Card Number:************2372
Merchant Id: 715262
Terminal Id: 00000001
Auth Code: 001482
Auth Mode: Issuer
Application Name: Debit
Processed as: Debit
Reference No: 2017975988
Invoice No: 594706
Response: Approved
Entry Method:Chip Read
Match AVS: Not Present
Match CVV: Not Present
Match ZIP: Not Present
Chip Card AID:A0000000042203
TVR:0000048000
AD:0110A04003220000000000000000
000000FF
TSI:E800
ARC:0012
Client ID:
User Id: jjimenez
OCHOA NANCY M
Verified by PIN
1 Agree to Pay Above Total Amount According to Card Issuel agreement (Merchant agreement if Credit voucher)
about:blank 1/1 6