CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 JUN 28 • AM|I: 30
TO PERSON OR PROPERTY
CITY CLERT RECEIVEL
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:
Jocelyn MOVIRRETE
FULL NAME DATE OF BIRTH
RICto CA 92374
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 same as addRess lIsted alove
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: May 29,2023 - TIME: _ 8:40 AM DAM
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.
The incident occuRed around 8.40 pm.i was driving with
3 other Passenyers as we drove down fuculpus we made
a left on Mill st where seconds after we nit a pothole
3. HOW DID DAMAGE OR INJURY OCCUR?
The damage to the vehicle occured after hitting thre
Pothoe on Mill, an immediately afer hitting the pothar my car made a bad shock sound. Which resulted in damages to the stRuTs.
4. WERE POLICE AT THE SCENE? •YES• 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 employee causing the injury or damage, if known.
The hitting of the pothole resulted in immediate damaye to my caR ast damaged the struts of my car. At this
time the pothole is Still Present.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,451. 69 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date:_ STRUT G 05|29/23 Amount: $ 697.04
Item/Date: JabOR + RORiRS 05/29/23 Amount: $ 706, 95
DOWNEY NISSAN
7321 FIRESTONE ELVD
DOWNEY, CA 90241
CITY OF RIALTO 562-334-1089
2023 JUN 28 AMII: 31 SALE
RECEIVED MID: 4684 Store: 0001
CITY GLERK REF#: 00000026
Batch #: 012 RRN: 315300664387
06/01/23 17:42:31
Invoice #: 359509
Trans ID: 463153025517936
APPR CODE: 06944D
VISA Chip
*******2012 **/**
AMOUNT $1,451.69
APPROVED
CAPITAL ONE VISA
AID: A0000000031010
TVR: 00 80 00 80 00
TSI: E8 00
CUSTOMER COPY
7321 Firestone Blvd.
Downey, CA 90241
Phone: (562) 334-1089
DOWNEY NISSAN Fax: (562) 334-1191
www.downeynissan.com CITY OF RIALTO
B.A.R. # ARD 253766
E.P.A. CAL 000425141 2023 JUN 28 AMII: 31
KECEIVEL
CITY. CLERK
CELL: 626-277-6179
CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE
160815 INVOICE NO
CHRIS 1203 C125 06/01/23 NCCS359509
LABOR RATE LICENSE NO [MILEAGE COLOR STOCK NO.
114,697 /
YEAR / MAKE / MODEL DELIVERY DATE DELIVERY MILES
15/NISSAN/VERSA/4DR SDN CVT 1.6 SV 01/02/15
VEHICLE 1.D. NO. SELLING DEALER NO. RODUCTION DA
1/15/1
F. T. E. NO. P. O. NO. R. O. DATE
05/31/23
DECINENE DUONE BUSINESS PHONE COMMENTS
MO: 114699
COMMENTS
THANK YOU FOR ALLOWING DOWNEY NISSAN TO SERVICE
YOUR VEHICLE. DURING YOUR VISIT OUR TECH NOTED THE
FOLLOWING ITEMS ARE NEEDING ATTENTION SOON.
PLEASE CALL YOUR ADVISOR AT 562.334.1090
TO SCHEDULE AN APPOINTMENT.
55NIZEAF *EXPRESS AIR FILTER TECH: 1516 FOLLOW-UP: 06/07/23 $58.85 55NIZECF *EXPRESS CABIN FILTE TECH: 1516 FOLLOW-UP: 06/07/23 $104.95
TOTALS -
*****************************xxxxxxxxxxxx****************** * NEXT RECOMMENDED SERVICE:
* 05/31/2023 / 114701 MI 55NIZINSP ULTI POINT INSP
***·*·*·*************************************************************** THANK YOU FOR CHOOSING DOWNEY NISSAN! TOTAL LABOR... 706.95 WE VALUE YOUR BUSINESS AND WE ARE DRIVING TO BE THE BEST. TOTAL PARTS... 697.04 AFTER YOUR VISIT TODAY YOU MAY RECEIVE A SURVEY FROM NISSAN. TOTAL SUBLET..
YOUR FEEDBACK IS VERY IMPORTANT TO US AND NISSAN. EVERY 0:00 TOTAL G.O.G....
SURVEY COUNTS FOR US TO SEE HOW WE ARE PERFORMING. IF YOU TOTAL MISC CHG. 0.00 HAVE ANY ISSUES OR SUGGESTIONS PLEASE CALL YOUR SERVICE TOTAL MISC DISC - 20.00 ADVISOR OR MYSELF, THE SERVICE MANAGER. ONCE AGAIN THANK YOU TOTAL TAX.. 67.70 FOR YOUR BUSINESS AND YOUR TIME.
TOTAL INVOICE $ 1451.69
SERVICE DIRECTOR RICARDO GONZALEZ 562-334-1089
MAIN SERVICE NUMBER 562-334-1177
SERVICE HOURS
MON -FRI. . 7:00AM-6:00PM
SATURDAY 7: 00AM -5:00PM
SUNDAY 8: 00AM -1:00PM
By-
тра
PAGE 3 OF 3
NOTICE TO' CUSTOMĚR: PLEASE READ IMPORTARS INFORMATION ON-BACKens tynolis Company ERANTANE 7321 Firestone Blvd.
Downey, CA 90241
Phone: (562) 334-1089
DOWNEY NISSAN Fax: (562) 334-1191
www.downeynissan.com CITY OF RIALTO
™M B.A.R. #ARD 253766
E.P.A. CAL 000425141 2023 JUN 28 AM||: 3l
RECEIVEL
CITY CLERX
CELL: 626-277-6179
CUSTOMER NO. ADVISOR TAG NO.
INVOICE DATE INVOICE NO
160815 CHRIS 1203 C125 06/01/23
NCCS359509
LABOR RATE LICENSE NO. MILEAGE STOCK NO.
114,697 R
YEAR/ MAKE/ MODEL DELIVERY DATE DELIVERY MILES
15/NISSAN/VERSA/4DR SDN CVT 1.6 SV 01/02/15
SELLING DEALER NO PRODUCTION DATE
11/15/14
(E.T. E. NO. P.O. NO. R. O. DATE
05/31/23
RESIDENCE PHONE BUSINESS PHONE COMMENTS
MO: 114699
JOB# 3 CHARGES -
LABOR-
J# 3 55NIZSTATEINS STATE INSPECTION TIR TECH(S): 1516
0.00 TIRE INFLATION INSPECTION, ADJUST TIRE PRESSURE LEFT FRONT,
RIGHT FRONT, LEFT REAR & RIGHT REAR
STATE INSPECTION FOR TIRES
TIRE INSPECTION COMPLETED. ADJUSTED TIRE PRESSURE TO
MANUFACTURER SPECIFICATIONS
JOB# 3 TOTALS
JOB# 3 JOURNAL PREFIX NCCS JOB# 3 TOTAL 0.00
JOB# 4 CHARGES-
LABOR
J# 4 5SNIZINSP MULTI POINT INSP. TECH(S) : 1516 0.00
PERFORM MULTI POINT INSPECTION
PERFORMED MULTI POINT INSPECTION.
JOB# 4 TOTALS -
JOB# 4 JOURNAL PREFIX NCQS JOB# 4 TOTAL 0.00
JOB# 5 CHARGES-
LABOR-
J# 5 55NIZAGREEMENT CUSTOMER AGREEMENT TECH(S): 1516 0.00 CUSTOMER AGREES DEALER TO CONTACT THEM VIA PHONE. TEXT
MESSAGE, EMAIL, PRE-RECORDED AUDIO OR VOICEMAIL.
JOB# 5 TOTALS-
JOB# 5 JOURNAL PREFIX NCCS JOB# 5 TOTAL 0.00
JOB# 6 CHARGES
LABOR-
J# 6+10NIZ4WALIGN *FOUR WHEEL ALIGNMEN TECH(S): 1516
139.95
Added Operation (CHRISTIAND @ 05/31/2023 10:59)
PERFORM 4 WHEEL ALIGNMENT PER FACTORY SPECIFICATIONS
COMPLETE
JOB# 6 TOTALS-
LABOR 139.95
JOB# 6 JOURNAL PREFIX NCCS JOB# 6 TOTAL 139.95
ESTIMATE- ------
CUSTOMER HEREBY ACKNOWLEDGES RECEIVING
ORIGINAL ESTIMATE OF $1160.00 (+TAX)
APPROVED ADDITIONAL COST OF $292.00 FOR TOTAL ESTIMATE OF $1452.00 (+TAX) ON 06/01/23 AT 04:31p
BY CRISTOBAL NAVARRETE COMMENTS
COMMENTS----
APT CHRIS D
RECOMMENDED NOT DONE/ DECLINED SERVICES.
PAGE 2 OF 3
NOTICE TO 88S SRiÉR: PLEASE READ PORFANA FN-RATION ON-BACK Reynals Company ERANTIVE 7321 Firestone Blvd.
Downey, CA 90241
Phone: (562) 334-1089
DOWNEY NISSAN Fax: (562) 334-1191
www.downeynissan.com CITY OF RIALTO
B.A.R. #ARD 253766
E.P.A. CAL 000425141 2023 JUN 28 AM||: 31
RECEIVED
CITY CLERK
CELL: 626-277-6179
CUSTOMER NO. ADVISOR TAG NO. INVOICE DATE
160815 INVOICE NO.
CHRIS 1203 C125 06/01/23 NCCS359509
LABOR RATE LICENSE NO. MILEAGE STOCK NO
114,697 /
YEAR / MAKE / MODEL DELIVERY DATE DElIVERY MILES
15/NISSAN/VERSA/4DR SDN CVT 1.6 SV 01/02/15
VEHICLE I.D. NO. SELLING DEALER NO [PRODUCTION DATE
11/15/14
F. T. E. NO. P. O. NO. R. O. DATE
05/31/23
RECINENNE DUnNIE BUSINESS PHONE COMMENTS
MO: 114699
JOB# 1 CHARGES.
LABOR
J# 1 11NIZ001DIAG1 AXLE/SUSP DIAG 1 567.00
CUSTOMER STATES WHEN MAKING A SHARP TURN AND ACCELERATING
THERE IS A LOUD CLICK NOISE CHECK AND ADVISE
VERIFIED CONCERN AND ISOLATED LOUD CLUNKING NOISE COMING FROM FRONT STRUTS. RECOMMENDING REPLACEMENT OF BOTH FRONT REMOVED AND REPLACED BOTH FRONT STRUTS. VERIFIED NOISE IS NO LONGER PRESENT. VEHICLE IS IN GOOD CONDITION AT THIS TIME.
TAKE NO FURTHER ACTION.
PARTS- OTY- - - FP-NUMBER-. DESCRIPTION- • - -UNIT PRICE- E4000-9K03NW COMPLETE STRUT A 339.04 339.04
E4C01-9KF0JNW COMPLETE STRUT A 358.00 358.00
TOTAL - PARTS 697.04
MISC- CODE- •-DESCRIPTION- CONTROL NO--...
21 MAKE YOUR OWN COUPON - PTS -20.00
TOTAL - MISC - 20.00
JOB# 1 TOTALS-
LABOR 567,00
PARTS 697.04
MISC -20.00
JOB# 1 JOURNAL PREFIX NCCS 1 TOTAL 1244.04
JOB# 2 CHARGES-
LABOR.
J# 2 55NIZ01M OIL CHANGE SERVICE TECH(S) : 1516 INTERNAL IL AND OIL FILTER CHANGE: DRAIN ENGINE OIL, INSTALL
ENUINE NISSAN OIL FILTER, NEW DRAIN PLUG SEAL AND
ADD UP TO SQTS OF NISSAN O-20W SYNTHETIC OIL
PREVENTIVE MAINTENANCE
COMPLETED EXPRESS SERVICE OIL CHANGE
PARTS- •QTY - - - FP-NUMBER- -DESCRIPTION- -UNIT PRICE- 1 15208-65F0E OIL FILTER INTERNAL
11026 -JA00A WASHER DRAIN INTERNAL
TOTAL - PARTS 0.00
G.O.G. & SUPPLIES-
5.0 999BK00W20Q /UNIT INTERNAL
TOTAL - GOG 0.00
MISC - CODE- -- DESCRIPTION- •CONTROL NO
18 HAZARDOUS WASTE DISPOSAL FEE INTERNAL
TOTAL - MISC 0.00
JOB# 2 TOTALS-
JOB# 2 JOURNAL PREFIX NCOS JOB# 2 TOTAL 0.00
PAGE 1 OF 3
NOTICE TO EOSTOMĚR: PLEASE REEKIPORFAN INFRATION ON.BACK Raymado Company ERUTINE Technician Inspection Report
CITY OF RIALTO
Customer Name: Vehicle Year/Model: 15 NISSAN VERSA Printed1706/61/2883 16:31:561 Phone: (H) (909) VIN:
Odometer: 414692 vE
Service Advisor: CHRIS Technician: MICHAEL BORGE RO: 359509 IT Y Tag: C125
INSPECTION RESULT - OK WILL REQUIRE FURTHER ATTENTION REQUIRES IMMEDIATE ATTENTION Green Yellow Red
Serviced
Washer fluid Front / Rear Brake Linings
Power steering fluid (if equipped) LF RF
Coolant Green Green
Engine oil Yellow Yellow
Red Red
Operation of horn, exterior lights, interior lights
Windshield wiper operation, condition of blades, washer spray Windshield for cracks, chips, pitting LR RR
Engine air filter Green Green
Cabin air filter (if equipped) Yellow Yellow
Red Red
Tire rotation
Wheel alignment Serviced
Cooling system (components, leaks, damage) Inspection Not Taken Climate control 2mm or greater
Engine/transmission mounts 4mm to 6mm
3mm or less
Engine oil leaks
Transmission fluid leaks Check Tires / Tread Depth
LF RF
Driveline/axle fluid leaks
Green Green
Power steering and linkage (looseness, leaks, damage)
Yellow Yellow
Suspension components (looseness, leaks, damage) Red
Red
CV axle and boots (looseness, leaks, damage)
Drive belts)
Brake system (leaks, condition, damage) LR RR
Green Green
Fuel system (components, leaks, damage)
Yellow Yellow
NOT APPLICABLE Clutch (operation, leaks)
Red Red
Exhaust system (leaks, damage)
Serviced
Warning lights on
7/32" or Greater
Recommended maintenance 4/32" to 6/32"
Brake fluid 3/32 or Less
NOT APPLICABLE Transmission fluid (if equipped w/dipstick) Check Battery Performance
Good Serviced
Fair
Bad
Inspection Not Taken
AMII: 31 2023 JUN 28
CITY OF RIALTO
CITY OF RIALTO
2023 JUH 28 AM||: 31
RECEIVED
CITY CLERK
CITY OF RIALTO
2023 JUN 28 AMI: 31
RECEIVEL
CITY CLERA
SA PROC 977
FRI 23 JUN 2023
02 H
2023 JUN 28 AM!!: CITY OF RIALTO
38 11C CLERK EIVEL
( 3
Rialto city CleRks office
150s. Palm Ave
RInHo CA 92310
UNITED STATES
POSTAL SERVICE®