CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR 30 PM 4: 21
TO PERSON OR PROPERTY
RECHIVED
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: 150S. Palm Ave., Rialto, CA 92376
Address: 290W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Paulina Corren
FULL NAME DATE OF BIRTH
colton (A92324
HOME ADDRESS INCLUDING CITY, STATE & ZIP
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: _ 3/9/23 TIME: 4:00 ДАМ ДАЖ
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. pepper & Riate
3. HOW DID DAMAGE OR INJURY OCCUR?
pothole
4. WERE POLICE AT THE SCENE? •YES/NO WERE PARAMEDICS AT THE SCENE? YES 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.
flat tire due to large deep pot hale
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 151.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
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: NAME:
ADDRESS: ADDRESS:
TELEPHONE: (
TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
A
NAME: _ NAME:
ADDRESS: 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.
CURB
Pepper
PARKWAY
7 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 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Paulina Correa 3/3023
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
SONORA TIRES INC
- 17977 VALLEY BLVD
BLOOMINGTON, CA. 92316
909-877-6350
DEBIT SALE
REF#: 00000005
Batch #: 256 RRN: 310180408
10:04:08
03/10/23
APPR CODE: 406358
Trace: 5
Chip
DEBIT
************9882
AMOUNT $151.00
APPROVED
US DEBIT
AID: A0000000980840
TVR: 80 80 04 80 00
TSI: 68 00
THANK YOU
CUSTOMER COPY
SONORA TIRES Invoice
MUFFLERS - BRAKES - ALIGNMENTS
17977 Valley Blvd Date Invoice#
Bloomington, CA 92316 3/10/2023 133407
909-877-6350
MON-FRI 8:00 AM - 6:00 PM
SONORATIRESINC.COM SATURDAY
03/10/2023 8:00 AM - 5:00 PM
SUNDAY 8:00 AM - 2:00 PM
CUSTOMER INFORMATION: VIN #
RAMIRO CORREA
Year Make & Model Mileage
TOYOTA CAMRY 2012 150000
FREE FLAT TIRE REPAIR & FREE TIRE ROTATIONS FOR THE LIFE OF TIRES, WITH PURCHASE OF PAYMENT TYPE NEW TIRES ONLY. (TIRE ROTATIONS RECOMMENDED EVERY 3.000 MILES OR EVERY OIL CHANGE REPARACION DE LLANTA Y ROTACION GRATIS POR VIDA DE LA LLANTA. ROTACION SE RECOMIENDA CADA 3,000 MILLAS DEBIT
QTY ITEM CODE PART# DESCRIPTION
Price E... Amount
1 2156016 FALKEN SN 250 215/60R16 95T FALKEN SN250 A/S BW
93.04 93.04T
1 CA Fee CA FEE
1.75 1.75
Labor
ON NEW TIRES 48.00 48.00
FEES CREDIT CARD
FEES DEBIT CARD CUSTOMER 1.00 1.00
MANUFACTURER MILEAGE WARRANTY NO WARRANTY
ON USED TIRES.
40, 00045,000 50,000 55,000 NO WARRANTY
ON ANY TYPE OF
60,000 65,000 70,000 80,000 RIM REPAIR
NO WARRANTY ON TIRES RAN FLAT
NO WARRANTY ON POT HOLE DAMAGE TIRES SONORATIRESINC yalpas Subtotal $143.79 NO REFUNDS ON USED TIRES.
RETIGHTENING OF LUG NUTS EVERY 5,000 MILES REFERALS &
NO EXCHANGE OR REFUND, ALL. SALES ARE FINAL Follow us on Instagram! REVIEWS ARE Sales Tax (7.75%) $7.21 DEPOSETS ARE NOT REFUNDABLE NO EXCEPTIONS Tag us in your photos GREATLY
NEW TIRES ARE COVERED ENDER MANUFACTURER DEFECTS
ONLY. NO ROAD HAZARD INCLUDED #sonoratiresinc APPRECIATED! Total $151.00
Catalytics are not warranted against back fire for as long as your own your vehicle. Regular tune-ups recommended every 20,000 miles. No warranty on any labor brakes when customer supplies brake pads. I hereby authorize the above repair work to be done along with the necessary material. & hereby grant you permission to operate the car or truck heroin described on streets, highways for the purpose of testing and/or inspection of vehicle. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. Special ordered custom wheels are manufactured to Payments/Credits -$151.00 meet your car owner specifications & applications, once you accept & sign your order you became liable & unconditionally accept ownership, there is no refund on deposit or exchange except in the case of factory defects. We're not responsible for lost hub caps, wheel locks. All auto parts are NEW unless otherwise specified on invoice
Balance Due $0.00
WASTE MANAGENMENT BOARD ID NUMBER #1105995-01 BUREAU OF AUTOMOTIVE REPAIR LICENSE NUMBER: #279748
SIGNATURE: Thank You For Your Business!