CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 MAY -1 PM 1: 59
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). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING
Rialto City Clerk's Office
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:
Patricia Mendoza
-
FULL NAME DATE OF BIRTH
ST Rialto, CA 92376.
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: _ April 8th 2023 TIME: 8-10
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. ST. 5 EucalyPtUS Ave Street Rialto Passing W noelle
light but not passing poplar sT.
3. HOW DID DAMAGE OR INJURY OCCUR?
Ding dude Stent and ahaded my
rim
4. WERE POLICE AT THE SCENE? DYES DINO WERE PARAMEDICS AT THE SCENE? DYES DANO
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.
Rialto city Street Too many
Ringe city ta pet tin streets too "
Flat tres $ damaged rims on your car.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 120.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Replace tire Amount: $_ 120.00
Item/Date: Replace Rim Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 120.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date/New Tive 224.40
Amount: $
Item/Date:_ New rim
Amount: $ 073.15
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 991. 91
$
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: — Roben Mencoza
NAME:
-
ADDRESS: _
- ADDRESS: _
Rallo, CA 92376
TELEPHONE:
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: _
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: L
TELEPHONE: L)
DATE: TIME:
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. 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 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 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
PARKWAY
7 SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS IOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
5-1-2523
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 AVE
W MILL ST
TAMARISK AVE
: AVE S EUCALYPTUS AVE
E MERRILL AVE
E MERRILL AVE
VON S S EUCALYPTUS AVE
TAMARISK AVE
W MILL ST
NEW & USED RIALTO
Jose
BALANCE - BALANCEO 650E. Foothill Blvd.
(Between Eucalyptus & Acacia)
SE ARREGLAN LLANTAS Rialto, CA. 92376
WE FIX FLAT TIRES Tel. (909) 874-5853
BRAKES & ALIGMENTS ITRES Fax (909) 874-5852
CUSTOMER
ORDER NO.
DATE
NAME•
ADDRESS
— TEL..
QUANT. DESCRIPTION
PRICE AMOUNT
CASL
No Warranty on used tires. New tires have a six months SUB. TOTAL warranty on manufacturer defects only,unless otherwise
specified above. I agree to terms and conditions TAX
Customer Signature TOTAL
20 FONTANA 16444 South Highland Avenue
Fontana, CA 92336
NISSAN NISSAN Phone: (909) 574-2288
Fax: (909) 574-2295
www.FontanaNissan.com
PARTS & SERVICE HOURS
Monday - Friday: 8:00 A.M. to 5:00 P.M.
Saturday: 7:00 A.M. to 4:00 P.M.
BAR # ARD00255102 EPA# CAL000330650
HANDLING CHARGE. RETURNED ITEMS MUST BE IN THE ORIGINAL UNOPENED BOX OR CONTAINER. PLEASE NOTE RETURN/REFUND POLICY: ALL RETURNS MUST BE ACCOMPANIED BY THIS INVOICE AND ARE SUBJECT TO A 30% RETURNS ON SPECIAL ORDER PARTS OR ELECTRICAL PARTS. THAT THE DEALERSHIP WILL NOT ACCEPT RETURNS OR MAKE REFUNDS AFTER 30 DAYS. NO REFUNDS OR ALL PARTS AND ACCESSORIES ARE SOLD BY OUR DEALERSHIP AS IS.
OUR DEALERSHIP DISCLAIMS ALL WARRANTIES, EXPRESSED
THE ENTIRE RISK AS TO THE QUALITY AND PERFORMANCES OF THE VEHICLE AND PARTS AND ACCESSORIES IS WITH THE CUSTOMER AND. IN CONNECTION WITH THE SALE OF PARTS
CUSTOMER AND POSSIBLY THE MANUFACTURER AND NOT THE DEALERSHIP ASSUME
CUSTOMER SAL NOTE ENTO YO COVER FROM THE DEALERSHIP ANY CORNEGUENIAL DAMACE, DAMACES TO PROPERA DAMAGES FOR LOSS OF USE, LOSS OF TIME, LOSS OF PROFITS OR INCOME, OR ANY OTHER INCIDENTAL DAMAGES.
DATE ENTERED YOUR ORDER NO.
DATE SHIPPED INVOICE DATE
15 APR 23 INVOICE
• 15 APR 23 JUMBE
15 APR 12:18 0276221
**QUOTE**
ACCOUNT NO. P100
(909) 574-2288 PAGE 1 OF 1
RETAIL CASH
-O FONTANA, CA 92336
SHIP VIA SLSM. B/L NO.
TERMS [F.O.B. POINT
668 CASH
PART NO. FONTANA, CA
SHIP
DESCRIPTION LIST NET AMOUNT
40300- 6LB3B WHEEL-ALU 528
OETIR-03055 693.15 693.15 693.15
HANKOOK 2 RACK 243.10 224.40 224.40
TD1
TIRE DISPOSAL 1 TIRE 1.50
TT1
TIRE TAX 1 TIRE 1.75
**** INVOICE QUOTE - DO NOT PAY ****
Receive 15% off MSRP on your next
ourchase of OEM Parts with this PARTS
invoice. 920.80
order parts on line and save 20% ! SUBLET
FREIGHT 0.00
www.fontananissancaparts.com SALES TAX
CUSTOMER'S SIGNATURE 71.11
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE.
DealerCAP o xtpi1.100_1
ORIGINAL COPY