CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR - 3 AMII: 19
ANCIPATED AND 17, 1911
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Claims for deah, injury to person, or lo personal property must be filed not laler than six (6) months afler ihe occurrence (Gov. Code §911.2). 2: Claims for damages to real property must be filed not later tham one (1) year after the occurrence (Gov: Code 9911.2).
3.READ ENTIRE CLAIM FOR BEFORE FILING RETURN TO:
Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, IF NECESSARY. TO GIVE FULL DETAILS Mail: 150 S Palm Ave., Riallo, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Niki Carter
FULL NAME DATE OF BIRTH
Corona CA 92883
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: 02/26/2023 3:15 BAM DIPM TIME:
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC. - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give streel names and addresses, measurements and landmarks.
Intersection of Roubideux and Market St
3. HOW DID DAMAGE OR INJURY OCCUR?
On my way home Sunday Morning from FEDEX Hub I turned Left from Market St onto Ro on my way to 15 freeway
4. WERE POLICE AT THE SCENE? YES• NO WERE PARAMEDICS AT THE SCENE? • YESKNO
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.
A huge pothole in the middle of the intersection due to on going construction
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 132.69 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Front passenger side tire 02/28/2023 Amount S 124.27 Item/Date: Front passenger side tire 02/28/2023 Amount 5 / 32,669 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $_ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Hem/Date: Front tassenger tre 3/4/23 121.77
Amount: $
front assenge fire 3/423 Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES
$ 132-109
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach addilional pages, it necessary) AAA Auto Club
ADDRESS: _
ADDRESS: _
TELEPHONE: 800-400-4222
TELEPHONE: )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:_
NAME:
ADDRESS: N/A
ADDRESS:
TELEPHONE: ( TELEPHONE: |
DATE: TIME:
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. open field Truck
gas statition
Pothole
Roubideux South
CURB
X
7 _PARKMAY
SIDEWALK Market FIELD
St Wes
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 IGERTIFY (ORECLARE)UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF ČLAIMANT OR AĞENT
Niki Carter 02/28/2023
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 10:20 1
Siri
AGUA MANSA RD
20TH ST pothole
AVALON ST RUBIDOUX-BLVD
HALL AVE MARKET ST-
WALLACE ST Fairmau
51°
AQI 19 •
35TH
isi
AMERICA'S TIRE 3/03/2023
9:10 AM
NIKKI CARTER
COMA CA 02883
(H)
2013 HONDA Plate#:
CIVIC SEDAN Miles: 14,701
16" BASE EX/EX-L Torque Spees: 80
CAL 14 CAH
4583 MILLS CIRCLE Invoice #
ONTARIO, CA 91764 1793798
909.484.0361
Salesperson 9€
CHRISTIAN C Layaway Acct
1383130773
Article Oty Description EFT Price
Amount
* THIS IS NOT A SALES INVOICE! - LAYAWAY DEPOSIT *
68925
NAM 85.00 85.00
BOLT PAT IN: 6-11ANTY: 40000
INFLATION F:28 R:28
80017 1 CERTIFICATES FOR
NAM REFUND, REPLACEMENT 14.65 14.65
For tire certificate detalls, see
www.amerloastire.com/customer-service/certificates
80075 1 STATE REQUIRED
NAM 1.75 1.75
TIRE FEE
80224 1 WASTE TIRE
NAM 2.50 2.50
DISPOSAL FEE
80219 1 INSTALLATION &
22.00 22.00
NAM LIFE OF TIRE MAINTENANCE
Terme and Conditions can be found at
www.americastire.com/customer-service/involce-terms
When replacing less than four tires, America's
fire recommends that the new tires will be placed
on the rear of the vehicle
The tire and/or wheel you have chosen Is different
from the original equipment provided with your
vehicle and may change Its handling or stability
characteristics.
urther Information is available from voi
nerica's Tire salegpersoi
Sub Total: 125.90
Sales Tax: 6.79
Sales Total: 132.69
Tendered Today: .00
Tendered Total: .00
Balance Due: 132.69
www.amerlcastire.com/tire-registration
AMERICAN Please Remit to:
QUOTE ONLY Big Brand Tire & Service
TIRE DEPOT 14401 Princeton Avenue
A BIGBRAND TIRE & SERVICE COMPANY Moorpark, CA 93021
Promised Time:
CUSTOMER INFORMATION VEHICLE INFORMATION
STORE LOCATION
RIALTO #1164 BAR# ard301170
110 E VALLEY BLVD EPA# CAL000470371
RIALTO, CA 92376
Phone: (909) 341-0909
Completed By
BRAND PART NUMBER DESCRIP TON
SALESPER: PRICE Total
IRI 6133544007557 @205/55R16XL 94V SEFAR IRI
AQ819 $74.99 1 $74.99
Minimum Mileage Warranty: 50000
******** CONSUMER ADVISORY ********* THIS IS A "V" RATED TIRE. IT HAS A MAXIMUM SPEED OF 149 MPH. IT HAS "V" RATED HANDLING CHARACTERISTICS. CONSULT YOUR OWNERS MANUAL FOR THE PROPER SPEED RATING RECOMMENDED FOR YOUR VEHICLE. CUSTOMERS INITIALS....
CDF CDF TIRE RECYCLING 1
AQ819 $4.75 $4.75
LBR WBHS HIGH SPEED WHEEL BALANCE AQ819 $20.25
1 $20.25
SHP WW LEAD FREE WHEEL WEIGHTS - PARTS AQ819 $4.5
1 $4.50
EW EW TIRE MAINT. CERT. - CUST. SERVICE AQ819
$12 1.00 $12.00
LIFETIME REPLACEMENT/REPAIR/REFUND CERTIFICATE **** SEE WEBSITE FOR DETAILS LBR LABAC ALIGNMENT CHECK - CUSTOMER AQ819 $0 $0.00
1 REQUEST
CHECK CAMBER, CASTER AND TOE WHERE APPLICABLE
STF STF CALIF. STATE TIRE FEE AQ819 $1.75 1 $1.75
have been informed of the benefits of BBT's Tire Maintenance Certificate program. ALL-WHEEL DRIVE VEHICLE NOTICE - Most manufacturers recommend the rolling radius of all 4 tires must be the same. Tires should be replaced in sels of 4 to match brand, size, design and tread depth. Please consult your owners manual for the Original Equipment Vehicle Manufacturers recommendations. TWO TIRE PURCHASE ONLY - SAFETY ADVISORY - The Tire Association Council states that if only two new fires are installed on the front of a vehicle, the rear worn fires could loose their grip under load or slippery conditions causing loss of control.
AMERICAN Please Remit to:
QUOTE ONLY Big Brand Tire & Service
TIRE DEPOT 14401 Princeton Avenue
A BIcBRAND TIRE & SERVICE COMPANY Moorpark, CA 93021
Promised Time:
CUSTOMER INFORMATION VEHICLE INFORMATION
STORE LOCATION
RIALTO #1164 BAR#:ard301170
110 E VALLEY BLVD EPA#:CAL000470371
RIALTO. CA 92376
Phone: (909) 341-0909
Completed By
Quick Quote Summary
Revisions Payment Invoice Totals
Date Employee Previous Revised Type Auth Email/Phone# Type Amount Sub-Total: $118.24 Tax: $6.53
FET: $0.00
Shop Charges: $0.00
I acknowledge below and receipt of this invoice
Total: $124.77
This estimate is based on our inspection at this time and does not cover additional parts and labor which may be required after the work has been started. After the work has started, worn or damaged parts which are not evident on first inspection may be discovered. This estimate cannot cover such contingencies. In cases where additional work is deemed necessary, customer authorization will be secured prior to commencement of that additional work. This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the vehicle herein described on the streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. Dealer not responsible for unavailability of parts or delays in parts shipments beyond dealers control not for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond our control. 12 months/12,000 miles for parts and labor. 6 months/6,000 miles for alignment warranties See website for additional warranty details. All parts are new unless otherwise specified.
Customer Initials:
Additional terms notice and oral approval of an increase in the original estimated price.