CITY OF RIALTO CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2023 JUN 27 PM12: 57
CLAIM FOR DAMAGES
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. Cade 5911.2).
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: 150S. Palm Ave., Ratto, CA 92376 Address: 290 W. Rialto Ave., Riatto, CA 92376
CLAIMANT INFORMATION:
Clifford Moss fo
FULL NAME LATE OF BIRTH
RialtoCh. 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: 1/16/23 TIME: 11:45 • AM OPM
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 traveling Southbound on Riverside Ave I had
passed kandall Ave Just before Sun Bernardino Ave
when My car hit a large pot heleii' an e
3. HOW DID DAMAGE OR INJURY OCCUR?
Minen Eh.t the large pot hole it cause my drivers
side front tire to geflat and the Next morning my rear
passenger side tire beast flatt, The see bearing was replac
4. WERE POLICE AT THE SCENE? • YES ENO WERE PARAMEDICS AT THE SCENE? DYES 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.
there was heauy rain that night,
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: wheel bearin and has assemble Amount: $ 528.10 Iter/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 528. 10 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 528.10
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Clifford Moss Ir
NAME:
ADDRESS: _ ADDRESS:
-
Rialto CA. 92376
TELEPHONE: | TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME:_ NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: |)
DATE: TIME: DAM DPM 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 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. sancuparnardime fra
PARKWAY
SIDEWALK
^ A CERTIFY (OR DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURÉ OF CLAIMANT OR AGENT/
Clifford Mass de 4/27/23
TYPE OR PRINT NAME
self
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 A.C. TIRE SERVICE A.C. TIRE SERVICE
654 West Rialto Ave. 654 West Rialto Ave.
Rialto, CA 92376 Rialto, CA 92376
B.A.R.# AG211677 B.A.R.#AG211677
909.875.9644 309.875.9644
CUSTOMER NAME: DATE: CUSTOMER NAME: DATE:
2:23
1 2
STREET ADDRESS: STREET ADDRESS:
CITY: STATE: ZIP CODE: CELL PHONE: CITY: STATE: ZIP CODE: CELL PHONE:
YEAR: MAKE: MOPEL: MILEAGE: LICENCE #: YEAR: MAKE: MODEL: MILEAGE; LICENCE #:
PART No. OR DESCRIPTION NOI Rty PART No. OR DESCRIPTION Yes C ONOM NEW TIRES BY: NEW TIRES BY:
USED TIRES: USED TIRES:
THIS TIRE HAVE LIMITED MANUFACTURE WARRANTY ONLY NO ROAD HAZARD_ THIS TIRE HAVE LIMITED MANUFACTURE WARRANTY ONLY NO ROAD HAZARD
NO WARRANTY ON USED TIRES NO WARRANTY ON USED TIRES
Oper# REPAIR ORDER-LABOR INSTRUCTIONS Oper# REPAIR ORDER-LABOR INSTRUCTIONS TOTAL PARTS: TOTAL PARTS: /
New Tires Mounted Balanced and Installed on Vehicle: New Tires Mounted Balanced and Installed on Vehicle:
Use Tires Mounted and Installed on Vehicle: / Use Tires Mounted and Installed on Vehicle:
Wheel Alignment Wheel Alignment
New Brake Pads Installations Resurface Rotors New Brake Pads Installations Resurface Rotors TIRES REPAIR (FIX FLAT) TIRES REPAIR __(FIX FLAT)
Rotate Tires Rotate Tires
Balance Wheels: Balance Wheels:
TOTAL LABOR: TOTAL LABOR:
Service Note:- WASTE: Service Note:- WASTE:
REAR
AC TIRES SERVICE: Do not guartetce asod tita er used tacla, all work is fral no refunds or exchanges Customer PARTS: AC TIRES SERVICE: Do not murantee used bres er used wheels. ell work is final, no rafards or exchanges. Cuntons PARTS:
Is setlalied beeed on signing this lovoice, Note: All used fires are for tomporary uss and must replece 3s soon a netisfied based on signing this Involce. Hote: All used tires are for temporary use and must replace as soon os possibio with a nau fire AG TIRES SERVECE is not responsitla for last articles, Lo. Center caps, bub caps attachod LABOR. is possible with a now tire. AC TIRES SERVICE is not responsible for lost articles. Lo. Center cape, has copa atlashr LABORA to wheelo, spacers andlor loose luanuts, eto.; as well as not responsible for damace or incovenfence any usod to wheel, spacars andior loose lugnuts, etc.; as well as not responsible for damago or incovenlence any dead tire my cause you endies your vehicte. SALES TAX Une may causa you andlor your vehicle. SALES TAXI CUSTOMER SIGNATURE. TOYAR CUSTOMER SIGNATURE:
AMOUNTE AMOUNT:
veen quIe els cAD beeesCaPEe TI.....I. V...r... KEED THIE CHID COD DEEEDENCEC D All Make Auto INVOICE
26892 Base Line St 6362
Highland, CA. 92346
Org. Est. # 010032
Phone: 909-425-8200 Fax: 909-864-5649
BARE: ARD00227237
Happy Car - Happy You EPA#/:CUPA# PT009876
INVOICE Ref # : RTD Printed Date: 0725/2023 Work Completed: 01/25/2023 Moss, Clifford 2015 Ford - Fusion SE - 2L, In-Line4 (122CI) VIN(9) Lic#: Odometer In: 128746
Odometer Out: 128747
VIN#: Hat # : 8
Part Description Oty Sale Ext Labor Description Ext
KITOIL FILTER 1.00 10.02 10.02 lof smoke
ENGINE OIL FULL SYNTHETIC 6.00 9.66 57.96 EVAP AND SMOKE TEST 65.00 Engine Oil Drain Plug Gasket 1.00 4.18 4.18 Performed complet EVAP test and smoke EVAP and fuel tank.
Wheel Bearing And Hub Assembly 1.00 207.36 207.36 VEHICLE SAFETY INSPECTION n/c Sprayer Cleaner 4.00 Performed vehicle safety inspection. Checked all LIGHTS, fluids, belts, hoses, tires, brakes, engine cooling system, drive train, electrical, fuel system, exhaust system, A/C system, body. Road test venicle.
CHECK AND SET TIRE PRESSURE n/c
Performed tire inspection and inflated all 4 tire to recommended tire pressure for this vehicle - Check spare tire as well... and set to manufacturer's specification.
CHANGE OIL & FILTER 30.00
Drained engine oil - replaced with 6 quarts of new oil. Removed and replaced oil filter with new part. Checked and topped off all fluid levels, checked and adjust tire pressure. - Reset service reminder indicator
check exhaust /suspension noise noise n/c
Symptoms: rattle noise coming from exhaust system
2023 JUN 27 PM 12: 57 RECEIVLU CITY CLERK WHEEL HUB - Remove & Replace REAR RIGHT CITY OF RIALTO 131.40
Waste recovery Fee - EPA 4.00
[Recommendations ]
FRONT LEFT LOWER CONTROL ARM NEEDS REPLACING
REAR LOWER CONTROL ARM LEFT BUSHING TORN FROM
POT HOLE
PASSENGER AXLE BOOT RIPPIED
Org. Estimate 176.23 Revisions 303.67. Current Estimate 539.94 Labor: 226.40 evision { 1, Previous Estimate Amount: 176.27, Additional Cost: 363.67, Revised Estimste 539.94, Parts: $207.36 Labor: $13140 Sublet $0.0 Parts: 283.52 exas & Faes: S2491 Authorized by - Moss fand, Date - 1/25/2023, Time - 12:12 PM, Initiated By - Shop, Written By - Mangiane, Tom, Reason miney, Phone Number - CELL1: 909-645-5920
HazMat: 4.00
SubTotal: 513.92
Tax: 22.68
Total: 536.60
[ Payments - 1 Bal Due: $536.60
Vehicle Received: 1/25/2023 Customer Number: 1635
An express mechanic's lem is herety acknowedged on above car or truck to secure the amount of repairs thereto. Vehicle must be picked up in less than 3 days of pay $35 per day storage. All Parts are New unless otherwise designated. Warranty on new parts and labor is one year or 12,000 miles; whichever comes first. Warranty on work has to be performed at this location only & cannot exceed the original cost of repair. Warramty on USED parts is 30 days. No labor warranties if USED" parts are installed. All Warrantys are for the Original owner at the time of repairs.
NO WARRANTY ON CUSTOMER SUPPLED PARTS.
ALL MAJOR REPAIRS MUST RETURN WITH IN 500 MILES FOR INSPECTION - ENGINES AND TRANSNISSION - NOT RESPONSIBLE FOR LOSS OR DAMAGE TO CARS OR ARTICLES LEFT IN CARS IN CASE OF FIRE, THEFT OR ANY OTHER CAUSE.
Signature _ Date
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TID: 275200122974-02
01/25/2023 17:31
A* Sale
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$536.60
3051-185
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: Name: VISA DEBIT
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