CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAR - 9 PM 3: 34
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:
RODOLFO E. PADILLA
FULL NAME
DATE OF BIRTH
LOMA LINDA CA 92354
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BALTO CA 9237L
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: _ 03 - 01 TIME: 6330 •AMPM
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.
I WAS DRIVING WEST iT FAST ON MERRIL ST ON 03-01-2023
AROUND 6:30 PM E HIT, A POTHOLE AND MY TWO TIRES WÉRE DEMAGE (SEVERE DANAGE) TIRE NEED TO BE ORDEL BY THE DEALER, TOOK DAYS TO BE REPLACED
3. HOW DID DAMAGE OR INJURY OCCUR?
I HIT AR BOTHOLES ON MERRIL, IT'S DESCRIBE ON DIAGRAM
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? •YES ENO
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 Lot of Motholas IN the City I got Two, savordy
cIty of RiALto,, aud this is vot.
Inc fiRst Time that happen, this time I decidad to complan 1060.90
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: 1060.90 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 2 TIRES DEMAGE ON 03.01-2033 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 27D CITY OF NAME:
NAME: 2023 MAR - 9 PM 36 34
RI
ADDRESS: ADDRESS:
30.. AL
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.
L
W CURB MERRIL E
EUCALIPTUS 778838
PARKWAY
SIDEWALK
5 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 TRUE I CERTIFY. OR DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Podofo E PADILLA 03/9/2023
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
CITY OF RIALTO
2023 MAR - 9 PM 3: 34
RECEIYER
CILY CLERK
CITY OF RIA
2023 HER - 9 PN 3: 34
C CEIVED
CLERK
ASYMMETRIC
BMCS598896
M BMW OF ONTARIO
1350 Auto Center DEVEY OF RIALTO
Ontario, CA 91761
909-906-4050 909-531139249 PM 3: 34 BMCS598896
www.bmwotontario.com
CITY CLERA RECEIVED
1001IBMCS598896 CELL: 909-770-3541
CUSTOMER NO.
HOVING TAG NO.
INVOICE DATE INVOICE NO
258732 SHEIKH BINAZEEM 87392 8622 03/02/23 BMCS598896
LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO.
RODOLFO E PADILLA 23,826 BLK SAPPH M 31620A
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
21/BMW/5 SERIES/4DR SDN 540I 04/01/21 21
LOMA LINDA, CA 92354-6751
SELLING DEALER NO. PRODUCTION DATE
235 11/01/20
FT. E. NO. P. O. NO. R. O. DATE
03/02/23
BUSINESS PHONE COMMENTS
909-770-3541 MO: 23830
.......
NOTE TO CONSUMER: PLEASE READ
IMPORTANT INFORMATION ON EITHER
LABOR BACK SIDE OR LAST PAGE HEREOF
J# 1 36BMZTIRE02 REPLACE 2 TIRES TECH (S) :144478 100.00 REPLACE 2 TIRES ON THE PASSENGER SIDE DUE TO HAVING IMPACT Customer agrees that this Agreement includes DAMAGE. all of the terms and conditions on the front and RIGHT FRONT TIRE AND RIGHT REAR TIRE HAD SIDEWALL DAMAGE either back side or last page hereof, that this Agreement cancels and supersedes any prior
WHICH CAUSED TIRES TO GO FLAT
agreement including oral agreements, and as
RIGHT FRONT AND RIGHT REAR TIRE WERE REPLACED, RIGHT FRONT of the date above comprises the entire agree- TIRE OLD DOT DM7U JN1R 1222, NEW DOT DMU JN1R 4222. RIGHT ment between Customer and Dealer relating to REAR TIRE OLD DOT DMK6 JAR 4020, NEW DOT DMK6 JAR 2222. these repairs or other matters referred to on the front or back side of this document. Customer
PARTS- -QTY - - - FP-NUMBER -DESCRIPTION- - UNIT PRICE- also acknowledges receipt of copy of this invoice. 36-11-2-471-812 GOODYEAR EAGLE F1 A 389.85 389.85 Arbitration Agreement. Customer agrees that 1 36-11-5-A50 - 741 GOODYEAR EAGLE F1 A 483.00 483.00 Customer or Dealership may elect to resolve 2 1101 WEIGHTS 5.99 11.98 any dispute by binding arbitration pursuant to TOTAL - PARTS 884.83 the Arbitration Provision on either the back side or last page of this document.
MISC - - CODE -DESCRIPTION- •-CONTROL NO-•
CTT2 CALIFORNIA TIRE TAX-2 3.50
EXCI2 TIRE DISPOSAL 2 4.00
TOTAL - MISC 7.50
JOB# 1 TOTALS-
LABOR 100.00
PARTS 884.83
MISC 7.50
JOB# 1 JOURNAL PREFIX BMCS JOB# 1 TOTAL 992.33
JOB# 2 CHARGES-
LABOR -
J# 2 00BMZ2 TIRE PRESSURE CHECK TECH(S): 144478 INTERNAL CUSTOMER REQUESTS TIRE PRESSURE CHECK.
Record Tire Pressure Measurements After Service Complete. 38/44psi
JOB# 2 TOTALS.
JOB# 2 JOURNAL PREFIX BMCS JOB# 2 TOTAL 0.00
JOB# 3 CHARGES-
LABOR
J# 3 00BMZ1 MULTI-POINT INSP TECH(S) : 144478 INTERNAL
CUSTOMER REQUESTS COMPLIMENTARY VEHICLE INSPECTION.
Provide Copy of Report to Customer. Document and Review Technician Recommendations.
Some items may not be inspected depending upon vehicle
PERFORMED MULTI POINT INSPECTION
JOB# 3 TOTALS-
JOB# 3 JOURNAL PREFIX BMCS JOB# 3 TOTAL 0.00
BAR # 00270169 • DEALER #
PAGE 1 OF 3 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 04:35pm EPA# CAR000275842 The Reynolds and Reynolds 6882 C 0725)
BMCS598896
BMW OF ONTARIO
1350 Auto Center DrieTY OF RIALTO
Ontario, CA 91761
909-906-4050 909-35123921R - 9 РН 3: 340л
www.bmwofontario.com
RECEIVED
CITY CLERK
1001IBMCS598896 CELL: 909-770-3541
CUSTOMER NO. ADVISOR TAG NO.
258732 INVOICE DATE INVOICE NO
SHEIKH BINAZEEM 87392 8622 03/02/23 BMCS598896
LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO.
RODOLEO E PADILLA 23,826 BLK SAPPH M 31620A
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
21/BMW/5 SERIES/4DR SDN 540I 04/01/21 21
COMA LINDA, CA 92354-6751
SELLING DEALER NO. PRODUCTION DATE
235 11/01/20
FT. E. NO P. O. NO. R. O. DATE
03/02/23
BUSINESS PHONE COMMENTS
909-770-3541 MO: 23830
JOB# 4 CHARGES-
NOTE TO CONSUMER: PLEASE READ
IMPORTANT INFORMATION ON EITHER
LABOR BACK SIDE OR LAST PAGE HEREOF
J# 4 04BMZOPI ONLINE PAYMENT INVT TECH(S) : 144478 INTERNAL Online Payment Invitation will be automatically sent to Customer agrees that this Agreement includes customer when Repair Order is invoiced. all of the terms and conditions on the front and either back side or last page hereof, that this
Agreement cancels and supersedes any prior
agreement including oral agreements, and as
of the date above comprises the entire agree-
JOB# 4 TOTALS-
ment between Customer and Dealer relating to
these repairs or other matters referred to on the
JOB# 4 JOURNAL PREFIX BMCS JOB# 4 TOTAL 0.00 front or back side of this document. Customer JOB# 5 CHARGES- also acknowledges receipt of copy of this invoice.
Arbitration Agreement. Customer agrees that
LABOR
Customer or Dealership may elect to resolve
J# 5 04BMZWASH CAR WASH TECH(S) : 144478 INTERNAL any dispute by binding arbitration pursuant to CUSTOMER REQUESTS COMPLIMENTARY CAR WASH. the Arbitration Provision on either the back side Wash and Shammy-Dry Vehicle Exterior. Vacuum Interior or last page of this document.
Carpets and Mats.
JOB# 5 TOTALS
JOB# 5 JOURNAL PREFIX BMCS JOB# 5 TOTAL 0.00
JOB# 6 CHARGES-
LABOR -
J# 6 04BMZLOANERRES LOANER RESERVED TECH(S) : 144478 INTERNAL LOANER VEHICLE RESERVED. VEHICLE ODOMETER MUST NOT EXCEED 4500 MILES.
REFER TO LOANER AGREEMENT FOR MORE INFORMATION
JOB# 6 TOTALS.
JOB# 6 JOURNAL PREFIX BMCS JOB# 6 TOTAL 0.00
JOB# 7 CHARGES-
LABOR -
J# 7 OOBMZZTOUCHLESS TOUCHLESS SERVICE TECH(S) : 144478 INTERNAL JOB# 7 TOTALS-
JOB# 7 JOURNAL PREFIX BMCS JOB# 7 TOTAL 0.00
JOB# 8 CHARGES-
LABOR -
J# 8 OOBMZKEYREAD KEY READ TECH(S) : 144478 INTERNAL
BAR # 00270169 • DEALER #
PAGE 2 OF 3 CUSTOMER COPY [CONTINUED ON NEXT PAGE] 04:35pm EPA# CAR000275842 The Reynolds and Reynolds Company 1S C6TB892 5 (0T/23
BMCS598896
BMW OF ONTARIO
1350 Auto Center Priye RIALTO
Ontario, CA 91761
909-906-4050 290943P1-3924м 3: 34 BMCS598896
www.bmwofontario.com
RECEIVED
CITY CLERK
1001IBMCS598896 CELL: 909-770-3541
CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE INVOICE NO
258732 SHEIKH BINAZEEM 87392 8622 03/02/23 BMCS598896
LABOR RATE LICENSE NO. MILEAGE COLOR STOCK NO.
RODOLFO E PADILLA 23, 826 BLK SAPPH M 31620A
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
21/BMW/5 SERIES/4DR SDN 540I 04/01/21 21
LOMA LINDA, CA 92354-6751
SELLING DEALER NO. PRODUCTION DATE
235 11/01/20
F. T. E. NO. P. O. NO. A. O. DATE
03/02/23
BUSINESS PHONE COMMENTS
909-770-3541 MO: 23830
CUSTOMER REQUESTS FOR BMW OF ONTARIO SERVICE ADVISOR TO NOTE TO CONSUMER: PLEASE READ
PERFORM KEY READ AT THE TIME OF WRITE UP IN ORDER TO IMPORTANT INFORMATION ON EITHER
DETERMINE CONDITION BASED SERVICE AND OPEN RECALLS/CAMPAIGNS BACK SIDE OR LAST PAGE HEREOF ON CUSTOMERS VEHICLE. CUSTOMER CAN BE SHOWN THE KEY READ ON REQUEST IF THE OWNERSHIP INFORMATION MATCHES. KEY READ IS Customer agrees that this Agreement includes all of the terms and conditions on the front and
PERFORMED AT NO CHARGE TO THE CUSTOMER. KEY DATA IS ALSO AVAILABLE FOR VIEWING AT ANY TIME THROUGH THEIR VEHICLES ON either back side or last page hereof, that this Agreement cancels and supersedes any prior
BOARD COMPUTER OR IDRIVE SYSTEM ON SELECT MODELS. KEY READ agreement including oral agreements, and as IS ALSO ONLY AVAILABLE ON SELECT MODELS. CHECK AND ADVISE of the date above comprises the entire agree- KEY READ PERFORMED TO HELP INFORM THE CUSTOMER OF CONDITION ment between Customer and Dealer relating to BASED SERVICE AND ANY OPEN RECALLS OR CAMPAIGNS. these repairs or other matters referred to on the front or back side of this document. Customer
also acknowledges receipt of copy of this invoice.
JOB# 8 TOTALS -- Arbitration Agreement. Customer agrees that Customer or Dealership may elect to resolve
JOB# 8 JOURNAL PREFIX BMCS JOB# 8 TOTAL 0.00 any dispute by binding arbitration pursuant to the Arbitration Provision on either the back side
ESTIMATE-- or last page of this document.
CUSTOMER HEREBY ACKNOWLEDGES RECEIVING
ORIGINAL ESTIMATE OF $1060.82 (+TAX)
COMMENTS- -
X04PKOZ79D: CUSTOMER REQUESTED A LOANER CC created 2023-02-28 10:44:
00am taken by Aiskel Cueto
RECOMMENDED NOT DONE DECLINED SERVICES
THE FOLLOWING TECHNICIAN RECOMMENDATIONS WERE
DECLINED BY THE CUSTOMER:
TOTALS -
100.00
884.83
TOTAL MISC CHC. 7:00
TOTAL MISC DISC 68.50
TOTAL TAX...
TOTAL INVOICE $ 1060.90
CUSTOMER SIGNATURE
BAR # 00270169 • DEALER #
EPA# CAR000275842
PAGE 3 OF 3 CUSTOMER COPY [END OF INVOICE 04:35pm
The Reynolds and Reynolds Company ERAINTIN
SF668892 Q (01/23