CITY OF RIALTO CITY CLERK'S DATE STAMP
10 LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2023 JAN 23 AMII: 27
RECEIVED
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). CITY CLERK
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code 5911.2).
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:
Yadira N. MedinaRivera
DATE OF BIRTH
Hesperia, CA 92345
HOME TELEPHONE NO.
(ОМТ Ex #
Kialto, CA 92376
ELEPHONE NO.
VE Banning, CA 92220
CLAIM
1):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1/18/23
TIME: 7:10 am DAMOPM
Where appropriate, give street names and addresses, measurements and landmarks. 2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet. peffer st. Fent going sent better, betwee-Foothin& fucaluptus
3. HOW DID DAMAGE OR INJURY OCCUR?
Was inevitable, My Tire Was Slashed /see pictung)
4. WERE POLICE AT THE SCENE? I YES ANO WERE PARAMEDICS AT THE SCENE? YES ANO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town Пе слу у 3 on a female henner.
yar cili a to Complain 4 cl
told Contraction would Art soon. Wen it yever did.
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: 16.99
Amount: $
Item/Date: 267.89
Any Easideration wie be precated fort you!
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 28%.88 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: heel spen Amount: $ 16.59
Item/Date: 067.89
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 254.85
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 INURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
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.
CURB
see My diapam.
PARKWAY
7 SIDEWALK
A
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 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. N 20 SIGNATURE OF CLAIMANT OR GENT
YADIRA N. MEDINA RiVERA 120/22
TYPE OR PRINT NAME DATE/
ELf
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 Meden
1|18/23
Rialto Ave
foothic Bl. E
Biseline Rd
CITY CLERA RECEIVED 2023 JAN 23 CITY OF RIALTO
in saddad
AMI: 27
When dealed the cit to Combin a few mon thago, al has
At is ever demick a tie due to hitting pot tele
aud submit a biie, so here it is!
167 W San Bernardino Ave Store: 579
¡ires LES SCHWAB Rialto, CA 92376
Invoice: 57900166382
(909) 546-3405 Salesperson: Francine M
Work Order #: 57900166339 ARD 303202
Customer Information Vehicle Information
Customer ID: A057914896 Vehicle: 2017 MERCEDES BENZ C300 Name: YADIRA MEDINARIVERA Color:
Address:
Mileage: 72,814
City, State, Zip: BANNING, CA 92220 License:
Phone:
Comments: 80 on alignment replace front tires.
Les Schwab Invoice
Qty Product Code Product Description Price/ea FET Amount 2 13718 WHEEL SPIN BALANCE
$16.99 $0.00 $33.98
2 707238 225/45R-18 91V CINTURATO P7
D$267.89 $0.00 $535.78
1 12857 ALIGNMENT CHECK
$109.99 $0.00 $109.99
1 12815 COMPLIMENTARY ALIGNMENT CHECK
($109.99) $0.00 ($109.99)
2 165936 1100K TIRE PRESSURE MONITORING SYSTEM SENSOR
$7.99 $0.00 $15.98
REBUILD KIT
Parts Subtotal: $551.76
Labor Subtotal: $33.98
Sales Tax: $42.76
Tire Fee: $3.50
Invoice Total: $632.00
Payment Method: DSCVR Approval# 01986R Card# XXXXXXXXXXXX1144 $200.00 MC Approval# 08320B Card# XXXXXXXXXXXX2787 $200.00
VISA Approval# 09892D Card# XXXXXXXXXXXX2532 $232.00
DOT: Tire(s) has been electronically registered.
Wheel Position: LF, RF
Service Checklist:
Visual Tire Inspection | Comments: FRONT NEW || REAR 4/32 Tire Pressure Check | Comments: SET TO DOOR
Front End Component Check | Comments: TIGHT
Visual Shock/Strut Inspection | Comments: NOT SEEPING
Visual Brake Inspection | Comments: FRONT 9MM
CITY CLERA RECEIVED 2023 JAN 23 AMII: 27 CITY OF RIALTO Invoice Date/Time: 01-19-2023 03:48 PM Page 1 of 2
167 W San Bernardino Ave Store: 579
Tires LES SCHWAB Rialto, CA 92376
Invoice: 57900166382
(909) 546-3405 Salesperson: Francine M
Work Order #: 57900166339 ARD 303202
Customer Information Vehicle Information
Customer ID: A057914896 Vehicle: 2017 MERCEDES BENZ C300 Name: YADIRA MEDINARIVERA Color:
Address: Mileage: 72,814
City, State, Zip: BANNING, CA 92220 License:
Phone:
Remember to rotate your tires every 5,000 miles for maximum mileage - and it's freel Les Schwab electronically registers your tire purchase with the tire manufacturer at no charge to you, in accordance with NHTSA's tire registration requirements.
Free air checks for the life of the tires.
SAEJ2492 WARNING: THE FOLLOWING APPLIES TO VEHICLES WITH MODIFIED SUSPENSION/RIDE HEIGHT The suspension/ride height of this vehicle has been modified. As a result, this vehicle may handle differently than that of factory equipped vehicles.
As with any vehicle, extreme care must be used to prevent loss of control or roll-over during sharp turns or abrupt maneuvers. Always wear seat belts and drive safely, recognizing that reduced speeds and specialized driving techniques may be required. Failure to drive this vehicle safely may result in serious injury or death. Do not drive this vehicle unless you are familiar with its unique handling characteristics and are confident of your ability to maintain control under all driving conditions. Some modifications (and combinations of modifications) are not recommended and may not be permitted in your state. Consult your owner's manual, the instructions accompanying this product and state laws before undertaking these modifications. You are responsible for the legality and safety of the vehicle you modify using these components.
Your car may have a tire pressure monitoring system that uses a warning light to alert the driver of low tire pressure or system failure. Pursuant to NHTSA, Les Schwab must install all tire and wheel combinations with functioning TPMS sensors; including tires and custom wheels or winter tires and wheels. The TPMS light may illuminate after routine service and require additional action. We offer and recommend monthly air checks.
THANK YOU FOR YOUR BUSINESS
Authorized By:
YADIRA MEDINARIVERA (909) 646-2848 01-19-23 11:52 AM $632.00 YADIRA MEDINARIVERA (909) 646-2848 01-19-23 11:54 AM $632.00 ASSIGNMENT OF WARRANTIES - LIMITATION OF REMEDIES. SELLER ASSIGNS TO PURCHASER ALL RIGHTS AND REMEDIES UNDER MANUFACTURER EXPRESS AND IMPLIED WARRANTIES BUT OTHERWISE EXCLUDES ALL LIABILITY FOR WARRANTY DAMAGES. INCIDENTAL AND CONSEQUENTIAL DAMAGES OF ANY TYPE WHATSOEVER EXCLUDED TO EXTENT LAW ALLOWS. ALL CLAIMS AND RETURNED GOODS MUST BE ACCOMPANIED BY THIS INVOICE.
Adar. M ц..
Customer Signature X
CITY CLERK RECEIVED 2023 JAN 23 AM II: 28 CITY OF RIALTO * indicates promotional price
For more information on our products and services, visit www.LesSchwab.com.
All parts new unless specified.
Invoice Date/Time: 01-19-2023 03:48 PM Page 2 of 2
167 W San Bernardino Ave Store: 579
fIres LES SCHWAB Rialto, CA 92376 Invoice: 57900166436
(909) 546-3405 Salesperson: Michael M S
ARD 303202
Customer Information Vehicle Information
Customer ID: A057914896 Vehicle: 2017 MERCEDES BENZ C300 Name: YADIRA MEDINARIVERA Color:
Address: Mileage:
City, State, Zip: BANNING, CA 92220 License:
Phone:
Comments: REPLACED LEFT FRONT TIRE DUE TO SIDEWALL DAMAGE FROM POTHOLE. RIGHT FRONT REPLACED DUE TO LOW TREAD. INVOICE #57900166382
Les Schwab Invoice
Qty Product Code Product Description Price/ea FET Amount 1 12817 COMPLIMENTARY TIRE INSPECTION $0.00 $0.00 $0.00 Parts Subtotal: $0.00
Labor Subtotal: $0.00
Sales Tax: $0.00
Tire Fee: $0.00
Invoice Total: $0.00
Payment Method: ZERO BALANCE $0.00
THANK YOU FOR YOUR BUSINESS
ASSIGNMENT OF WARRANTIES - LIMITATION OF REMEDIES. SELLER ASSIGNS TO PURCHASER ALL RIGHTS AND REMEDIES UNDER MANUFACTURER EXPRESS AND IMPLIED WARRANTIES BUT OTHERWISE EXCLUDES ALL LIABILITY FOR WARRANTY DAMAGES. INCIDENTAL AND CONSEQUENTIAL DAMAGES OF ANY TYPE WHATSOEVER EXCLUDED TO EXTENT LAW ALLOWS. ALL CLAIMS AND RETURNED GOODS MUST BE ACCOMPANIED BY THIS INVOICE.
Customer Signature X Customer Not Available: 7 - Other/COVID-19 Social Distance STREMBLER 202031323144828
CLERA
* indicates promotional price
or more information on our products and services, visit www.LesSchwab.com ill parts new unless specified
Invoice Date/Time: 01-20-2023 09:41 AM Page 1 of 1
167 W San Bernardino Ave Store: 579
fires LES SCHWAB Rialto, CA 92376
Estimate: 57900166339
(909) 546-3405
Salesperson: Michael M S
Est. Time Expected: 11:45 AM ARD 303202
Customer Information Vehicle Information
Customer ID: A057914896 Vehicle: 2017 MERCEDES BENZ C300 Name: YADIRA MEDINARIVERA
Color:
Address:
Mileage: 1
City, State, Zip: BANNING, GA 92220 License:
Phone:
Comments: 80 on alignment replace front tires.
Les Schwab Estimate
Qty Product Code Product Description Price/ea FET Amount 2 13718 WHEEL SPIN BALANCE
$16.99 $0.00 $33.98
2 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT
$7.99 $0.00 $15.98
2 707238 225/45R-18 91V CINTURATO P7 D$267.89
$0.00 $535.78
12857 ALIGNMENT CHECK
$109.99 $0.00 $109.99
1 12815 COMPLIMENTARY ALIGNMENT CHECK
($109.99) $0.00 ($109.99)
Sales Tax: $42.76
Tire Fee: $3.50
Estimate Total: $632.00
The original estimated price was $668.83. The current estimated price is $632.00. I acknowledge notice and oral approval of an increase in the original estimated price.
Meshen Die
Customer Signature X
CITY CLERK RECEIVEL 2023 JAN 23 AMII: 28 CITY OF RIALTO Les Schwab will not be responsible for loss or damage to vehicles or other property left on Les Schwab's premises. Please remove all personal property from your vehicle. • indicates promotional price
For more information on our products and services, visit www.LesSchwab.com.
All parts new unless specified.
Estimate Date/Time: 01-19-2023 11:37 AM Page 1 of 1
2023 JAN 23 AMI1: 28
CITY OF RIALTO
CITY CLERK RECEIVEL 2023 JAN 23 AMII:. CITY OF RIAL
R009225 THANK YOU for visiting Les Schwab
1/19/23 2:49 PM
55SWF4JB6HU201350
55SWF4JB6HU201350 Odometer:72814
GREGORY YADSBNZ
Mercedes-Benz 2017 205 (C) Code 459
4-Wheel Total Alignment
Front: Left Front: Right
Actual Before Specified Range Actual Before Specified Range -1.4° -1.4° Camber -0.5° -0.4°
10.4° 10.4° Caster 9.6° 9.6°
0.14° 0.31°* 0.07° 0.24° Toe 0.15° 0.17° 0.07° 0.24°
6.6° 6.6° SAI 5.0° 5.0°
5.2° 5.2° Included Angle 4.5° 4.5°
Turning Angle Diff.
Front
Actual Before Specified Range
Cross Camber -0.9°* -1.0°* -0.4° 0.4°
Cross Caster 0.8°* 0.8°* -0.5° 0.5°
Total Toe 0.29° 0.49°* 0.14° 0.48°
Rear : Left Rear : Right
Actual Before Specified Range Actual Before Specified Range -2.2° -2.2° Camber -1.6° -1.6°
0.18° 0.16° 0.07° 0.31° Toe 0.19° 0.19° 0.07°0.31°
Rear
Actual Before Specified Range
Total Toe 0.37° 0.35° 0.26° 0.50°
Thrust Angle 0.00° -0.01° -0.13° 0.13°
CITY CLERK RECEIVEL 2023 JAN 23 CITY OF RIALTO
ANIl: 28
* This value is not within specification. Tire wear, handling and safety problems may result.