CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY
2023 FEB 24 PM 2: 03
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 5911.2). RECEIVED
3. READ ENTIRE CLAIM FOR BEFORE FILING into city Clerks orrice
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
RAMirO TORRES.
FULL NAME DATE OF BIRTH
COLTON, CA. 92324
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: WED. FEB O 2023 TIME: /0:15-10:20LAMDPM
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.
CROSS STREETS: FOOTHILL BLUD. + DEPPERAAVE
HAPPENED ONNPEPPER AVE. NORTH BOUND BEFORE
W. SPRUCE ST.
3. HOW DID DAMAGE OR INJURY OCCUR?
DRIVING NORTH BOUND, HIT A POT HOLE, TIRE
BLEW OUT
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? YESENO
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.
POT HOLE ON N. PEPPER AVE.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 110 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimales, elc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: NEW TIRE 02.13.2022 Amount: $ 110
Item/Date: Amount: $.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: EW TIRE 02.13.2023 Amount: $ 110
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 110-
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: DWIN TORRE
ADDRESS: ADDRESS:
COLTONI CA
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NA
ADDRESS: ADDRESS:
TELEPHONE: ) TELEPHONE: )
DATE: TIME: • 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 leller "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.
CITY CLERK RECEIVED 2023 FEB 24 PM 2: 04 CITY OF RIALTO
CURB PEPP ORVIVE
NORTH
W SPRULE ST
PARKWAY
SIDEWALK
MATY
WALGREENS
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 I CERTIFY(OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
RAMIRO TORRES. 02.14.2023.
TYPE OR PRINT NAME DATE
MYSELF
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 2/14/2023
Buddy's V Tires Shop
NEW & USED TIRES INVOICE
1395 W. Mission Bivd
Ontario, CA 91762 DATE
(909 984-7400) 909 757-2257 VISA Ech 6,2023
ATM DATE PROMISED
"NAME
M maNo lorres LICENSE+
ADDRET
MAKE
VIN
STATE ZIP CODE MODEL
colten cd 923,24 MILEAGE
WORK PHONE 955/5
BODY & STYLE
NOTES
QUANTITY DESCRIPTION
LIST PRICE TOTAL
https://outlook.office365.com/mail/inbox/id/AAQkADgyODFjNjgzLTNiZWQtNDU5Mi1hOGUzLTNkZDYxOGRINGU5ZQAQACM84mQVoUhAr4ZQOy05L. 1/2 4 Nes 235/40RI8 Otam
Buk00o /nstalled Relanced Mail - KFC K312064 - Outlook
All ucal Alliliment
Dispur/ Tics
SIGNATURE torres
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SIGNATURE ABOVE CONSTITUTES AOCEPTANCE OF ABOVE WORK AS BEING SATISFACTORY AND THAI THE CAR HAS BEEN LEFT IN GOOD CONDITION. TOTAL MATERIALS NOTE: WARRANTY NOT NALID WITHOUT THIS RECEPT. BY RUMNING YOUR TIRE LOW OR WITHOUT AIR YOU WEL LOOSE YOUR HARRANTY AUTOMATICALLY IS THE OWNERS TAX RESPONSIBLTY TO CHECK THE TIGHTNESS OF THEIR WHEELS AFTER 10 TO 25 MILES OF DRIVING AND EVERY 40 MILES THEREAFTER UNTIL LUG NUTS HOLD THEIR TORQUE TOTA, LA DON?
BUDDY'S V TIRES WILL NOT BE RESPONSIBLE FOR ANY WHEELS OR TRES LEFT BEHND BY CUSTOMER NO ROAD HAZARD WARRANTY ON ANY TIRE SUCH AS ANY SIDEWALL DAMAGE, INCLUDING PENETRATION, DAMAGE ON LON PROFILE TIRES OR LARGE OR SMALL CUTS. NO TOW SERVICE HARRANTY.
TOTAL
2/14/2023 Mail - KFC K312064 - Outlook
https://outlook.office365.com/mail/inbox/id/AAQkADgyODFjNjgzLTNiZWQtNDU5Mi1hOGUzLTNkZDYxOGRINGU5ZQAQACM84mQVoUhAr4ZQOy05L.. 1/2 2/14/2023 Mail - KFC K312064 - Outlook
A3A3038
2023 FEB 24 PM 2: 04
CITY OF RIALTO
https://outlook.office365.com/mail/inbox/id/AAQkADgyODFjNjgzLTNiZWQtNDU5Mi1hOGUzLTNkZDYxOGRINGU5ZQAQACM84mQVoUhAr4ZQOy05L.. 1/2 2:55 • 5Gč 70
Rialto - Foothill Boulevard
Edit
Wednesday 10:18 PM
CITY CLERK RECEIVED 2023 FEB 24 PM 2: 04 CITY OF RIALTO https://outlook.office365.com/mai/inbox/id/AAQkADgỳ8U₽j\igž297ł£W@\bUSV1h0GUzLTNkZDYхOGRINGU5ZQAQАЕme7Vz49ERKnNwRyБf?Pz/twğ/2 2:55 •8 70
Rialto - Foothill Boulevard
Edit
Wednesday 10:20 PM
LIVE V
CITY CLERX RECEIVEU 2023 FEB 24 PM 2: 04 CITY OF RIALTO https://outlook.office365.com/mail/inbox/id/AAQkADgỳ8BFR\jgź297ł£W@#\ЬU5i1hОGUzLTNkZDYxOGRINGU5ZQAQАЕme7\z49ЕRКnNwRyBPZ/tL/đ/2