CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JAN 19 PM 3: 11
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:
Ray mundu Alcaraz JR.
FULL NAME
DATE OF BIRTH
• Hesperia, CA
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP DICINICOS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Hesperia, CA
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ 1/16 /2023
TIME: • AM 0 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. on street w. Rena Sante Pluy between two stoplight's of IN. locust Ave and. Orcured ap3:38am.
3. HOW DID DAMAGE OR INJURY OCCUR?
over large Pothole / untilled Street asphalt
openin in frant at current into citt Construction in right lane, Vlaurel ave corner bt target fodd distb.
4. WERE POLICE AT THE SCENE? EYES NO WERE PARAMEDICS AT THE SCENE? DYES 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.
Rialto citt did not dose off street with potholes
Knowing it's possible can damage vehicle
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:
see attached Rim's anti 673.93
Item/Date:
Amount: $
Item/Date: sec attached Rim's and fires 1,525.12
Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2,199.05 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: Target food warehouse
NAME:
ADDRESS: 2245 Whenis ance
ADDRESS:
puki Rialta
TELEPHONE: (909 5741 3200
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME: _
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: L)
DATE: TIME:
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 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.
Warehouse Construction
Light Constructor making
zone zone
Eigh
_Pothole
-CURB
Lavrel Ave
Target I.10cuSt Ave
distrubiticia Fosil
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Mal mindi Acarar Th 1119/23
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 Tires LES SCHWAB 13374 Main Street, Suite D Store: 581
Hesperia, CA 92345 Quote: 58100144472
442-267-9119 Salesperson: isaac G
ARD 301933
Customer Information Vehicle Information
Customer ID: A057020511 Vehicle:
Name:
Color:
Address: Mileage:
City, State, Zip: HESPERIA, CA 92344 License:
Phone: (626) 391-9490
Les Schwab Quote
Qty Product Code Product Description Price/ea
FET Amount
4 1036446 4 WHEELS INSTALL PACKAGE: 5 LUGNUTS/KEY $20.50 $0.00 $82.00
4 590816 16X7 5-100/4.5 MYSTIQUE
$176.99 $0.00 $707.96
4 16958 Pass Tire TPMS Rebuild w/Disp $0.00
$0.00 $0.00
4 957068 215/55R-16 93V G FIT LH41
$127.99 $0.00 $511.96
4 13718 WHEEL SPIN BALANCE $16.99
$0.00 $67.96
4 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $31.96
4 1046759 PASSENGER TIRE DISPOSAL $2.99
$0.00 $11.96
Sales Tax: $104.32
Tire Fee: $7.00
Quotation Total: $1,525.12
4 16958 Pass Tire TPMS Rebuild w/Disp
$0.00 $0.00 $0.00
4 957068 215/55R-16 93V G FIT LH41 $127.99
$0.00 $511.96
4 13718 WHEEL SPIN BALANCE $16.99 $0.00
$67.96
4 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $31.96
4 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $11.96
Sales Tax: $43.09
Tire Fee: $7.00
Quotation Total: $673.93
* indicates sale price
For more information on our products and services, visit www.LesSchwab.com.
Prices good for 30 days, excluding promotions. Quote Expires on 02-17-2023.
Quote Date/Time: 01-18-2023 04:00 PM Page 1 of 1
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