CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR - 7 PM 4: 44
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:
Victor Sanchez
FULL NAME
DATE OF BIRTH
Mantelaid CA 91763
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 Montclair CA 9763
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: — 2•27•2023 TIME: 3:30
A AM D 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 SYCAMORE Ave. HalF of Black away from Victorist.
going west. fam Sycamore.
3. HOW DID DAMAGE OR INJURY OCCUR?
it was a Pot hale that made He damage to my
tre and rim. Tempormy asphat disolve because ne of rain and made pot holes on le street SycAmoRE & Victoria st
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? • YES / NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town He Construction of Rialto CA had. temporary Asphalt
to work on. were it created Pot holes. Victria Came
out of cunk at 3am and drove through Sycamore street
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 280° HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: / New TIRE 245/40818 2/28/23 150
Amount: $
Item/Date: I Wheel Repair 3/6/2023 130
Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 28000 $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:TiRE 2/28/2023 150
Amount: $.
Hem/Date: WHEEL REPAIR. 3/6/2023 130
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 28005
$
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Vicheria Since Viltr Sale
NAME:
ADDRESS: _
ADDRESS:
Malto CA Montolore CA
91763
TELEPHONE:
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: _ )
DATE: TIME: •AM • PM
DATE:_ TIME:
ШАМ РМ
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 comers.
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.
Charia SYCAmoRE Are → west.
CURB
RIALTO Construction
PARKWAY
SIDEWALK
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 // IGERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Victor Sandez 03/07/2023
TYPE OR PRINT NAME DATE
Co cuner Faller/ Daughter.
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 "Kialto lire Center
MICHELIN 392 E. Foothill Blvd. CITY OF RIALTO
ARIDGESTUnE Rialto CA 92,376 MAR - 7 PH 4: 44
GOOD YEAR (909) 258-2078 RECEIVED
CITY CLERK
CUSTOMER
ORDER NO. DATE 2/28/23
Victor Sancher
NAME
VEHICLE Chenvolet Camaro
PHONE #
SOLD BY CASH C.O.D. CHARGE ON ACCT MDSE RETD PAID OUT
QUAN DESCRIPTION PRICE
NEW TIRES
6 Months Warranty 245/40k20
USED TIRES
NO Warranty
MOUNTED TIRES
BALANCE TIRE
PATCHED T.
ROTATION
LABOR
TIRE DISPOSAL
PLUG / PLOGA
TAX
Deposito 8100°°
TOTAL $/50
Thank you!
CITY OF RIALTO
NEW & USED TIRES • TIRE REPAIR • TIRE BALAN FAR - 7 PH 4: 44 Rialto Tire Center / RECEIVED
MICHELIN 392 E. Foothill Blvd. CITY CLERK
SBIDGESTONE Rialto CA 92376
GOOD YEAR (909) 258-2078
CUSTOMER
ORDER NO. DATE 3/6/2023
Victor Sanchez
NAME
VEHILE 2015 ChevypOEN Camaro:
SOLD BY CASH C.O.D. CHARGE ON ACCT MDSE RETD PAID OUT
QUAN DESCRIPTION PRICE
1 NEW TIRES Westlake
6 Months Warranty 245|40218 150
USED TIRES
NO Warranty
MOUNTED TIRES
BALANCE TIRE
PATCHED T.
ROTATION
1 LABOR Wheel Repair 130
TIRE DISPOSAL
PLUG / PLOGA
TAX
TOTAL 280
Thank you!
CITY OF RIALTO
2023 MAR - 7 PM 4: 44
CITY CLERK RECEIVED
Thy had many pot holes
from rain on temporary
Asphalt 2/27/23-316/23
APAIR Dote WELDED
ZUEDAY 3/1/23 WHEEL
REPAIR
Stell
Leaks)
3/6/23 Retroned For
repair Agam
•The shop Is
trying to fix it. CITY CLERK RECEIVED 2023 MAR - 7 PM 4: 44 CITY OF RIALTO
CITY OF RIALTO
2023 -7
PM 4: 44
CTY C VE
CITY OF RIALTO
2023 MAR - 7 PM 4:44
3/6/2023 CITY CLERK RECEIVED
pot Hale
Rialto* SYCAMOR S
AV
600
VICTORA 2і