CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2023 JUN 30 PM 3: 53
TO PERSON OR PROPERTY
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 5911.3.L ER A
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:
Lidia Herrera
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP Rialto Ca 92376 HOME TELEPHONE NO.
N/A ().
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
Rialto Ca 92376
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 4/14/23 TIME: • AM 1PM
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.
In Frent M. home
1040 N willow au Apt
3. HOW DID DAMAGE OR INJURY OCCUR?
police _hin
Parked Vehicle. venice pleas sec se my attached
police report
4. WERE POLICE AT THE SCENE? Z/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.
Police vehicle crashed and
damaged my park venicle
$6500.00
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:
4/14/23 4500. 0
Item/Date: Amount: $
Item/Date: Amount: $
2 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: 2008 nissan Armada 4/14/23 Amount: $ 4500.00 Item/Date: _
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) Police Report NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: L). TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
N/A NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( TELEPHONE: |)
DAM 0] PM DATE: _ TIME: • AM I PM
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.
See Attached police
CURB
PARKWAY report
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 10 1, ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Hel 430/23
DATE
TYPE OR PRINT NAME
Self Agent
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 3 STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Report Subject To Change
TRAFFIC CRASH REPORT
CHP 555 Page 1 (Rev. 2-22) OPI 060
SPECIAL CONDITIONS CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
INJURED
COURTESY REPORT SAN BERNARDINO SUPERIOR COURT SAN 9860-2023-02087 2 RIALTO
BERNARDINO JUSTICE CENTER
COUNTY CIVIBERA/PROEXAIET BEAT DAY OF WEEK TOW AWAY
KILLED
SAN BERNARDINO S M TW IT FS YES X NO
CRASH OCCURRED ON CRASH DATE CRASH TIME (2400) NOTIF, TIME (2400) NCIC # OFFICER ID
MO DAY YEAR
WILLOW AVE 06/14/2023 1345 06/14/2023 1346
STATE HWY REL DIGITAL MEDIA
AT INTERSECTION WITH DYES
OR: SHAMROCK ST YES X NO KINO
LOCATION GPS COORDINATES FOR LOCATION (LCC.) AND AREAS) OF IMPACT (AOI (Ni SAME AS LOCATION REFER TO NARRATIVE AOT | LAT. LONG. AO| LAT. LONG.
34.118566 -117.374800 34.118566 -117.374800 2 34.118729 -117.374840 LONG. AOT LONG. LAT LONG.
AOL LAT.
3 34.118756 -117.374838 5
STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER PARTY DRIVER'S LICENSE NÚMBER
CA G 2018 FORD EXPLORER WHI/BLK CA
DRIVER NAME (FIRST, MIDDLE, LAST)
ISIS DOLORES GUILLEN OVUNER S NAME
SAME AS DRIVER
STREET ADDRESS CITY OF RIALTO
150 S PALM AVE OWNER'S ADDRESS
SAME AS DRIVER
PARKED! CITYISTATEIZIP 150 S PALM AVE RIALTO CA 92376
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER • DRIVER X OTHER RIALTO CA 92376
SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE OWN ARRANGEMENTS Mo Day Year
CLIST
BRN BRN 5' 1" 140 H PRIOR MECHANICAL DEFECTS NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE TOP VIV
UNK NONE MINOR
INSURANCE CARRIER POLICY NUMBER
49 SELF INSURED SELF INSURED MOD. X MAJOR ROLL-OVER
**-****
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
TRAVEL LANES LANES LIMIT
WILLOW AVE
N/B 35 CAL-T
PARTY DRIVER'S LICENSE NUMBER CLASS AIR BAG SAFETY EQUIP. VEH, YEAR MAKEMODEL/COLOR LICENSE NUMBER STATE CA M G 2004 MERZ 300 SERIES GLD CA
2 DRIVER NAME (FIRST, MIDDLE, LAST)
KARINA ERLINDA ESPINOSA OWNER'S NAME X SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
PARKED CITY/STATE/ZIP
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER X OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT BIRT HDATE Year RACE OWN ARRANGEMENTS Mo.
BRN BRN 5' 4" 115 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE
POLICY NUMBER UNK NONE MINOR
INSURANCE CARRIER
NONE NONE 01 X MOD ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
LANES LANES LIMIT CA DOT.
TRAVEL
N WILLOW AVE N/B 1 35 CAL T MC/MX
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG (SAFETY EQUIP, VEH. YEAR MAKE/MODELICOLOR LICENSE NUMBER STATE CA P 2008 NISS ARMADA WHI CA
DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME
SAME AS DRIVER
STREET ADDRESS LIDIA HERRERA
OWNER'S ADDRESS SAME AS DRIVER
DARKE
CITY/STATE/ZIP RIALTO CA 92376
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER SEX I HAIR EYES HEIGHT WEIGHT BIRTHDATE Vear RACE OWN ARRANGEMENTS Mo
PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VENICE IDENTIFICATION NUMBER
UNKNOWN VEHICLE TYPE SRIRE VARIOUS SAMAGE TUP VALV
POLICY NUMBER NONE
INSURANCE CARRIER 07
MOENGO X MOD MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
LANES LANES LIMIT DOT
TRAVEL
WILLOW AVE
S/B 35 CAL-T
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED HARRISON P STEWART, 022641 NO N/A
An Internationally Accredited Agency Destroy Previous Editions 4 STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Report Subject To Change
TRAFFIC CRASH REPORT
CHP 555 Page 1 (Rev. 2-22) OPI 060 Page 1 of 7
SPECIAL CONDITIONS NUMBER HIT & RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER COURTESY REPORT SAN BERNARDINO SUPERIOR COURT SAN 9860-2023-02087
ON-DUTY EMERGENCY VEHICLE RIALTO BERNARDINO JUSTICE CENTER
NUMBER COUNTY CIVIEERIRURROBARET BEAT DAY OF WEEK TOW AWAY KILLED
SAN BERNARDINO SM TWTFS YES I NO
CRASH OCCURRED ON: CRASH DATE EAR CRASH TIME (2400) NOTIF, TIME (2400) INCIC # UNPICER MO
WILLOW AVE 06/14/2023 1345 06/14/2023 1346
STATE HWY REL DIGITAL MEDIA
AT INTERSECTION WITH
•YES
OR SHAMROCK ST •YESX]NO NING
GPS COORDINATES FOR LOCATION (LOC.) AND AREA(S) OF IMPACT (AOM) IX SAME AS LOCATION •REFER TO NARRATINE LONG. AOT LAT, LONG.
-117.374800 2 34.118729 -117.374840
LAT. LONG. AOI LAT.
34.118756 -117.374838 5
PARTY DRIVER'S LIGENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA G 2018 FORD EXPLORER WHI/BLK 1410349 CA
DRIVER NAME (FIRST, MIDDLE, LAST) ON-DUTY EMERGENCY VEHICLE
ISIS DOLORES GUILLEN OWNER'S NAME
SAME AS DRIVER
STREET ADDRESS CITY OF RIALTO
TRIAN
150 S PALM AVE OWNER'S ADDRESS SAME AS DRIVER
PARKEDT CITY/STATE/ZIP
VEHICLE 150 S PALM AVE RIALTO CA 92376
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF OFFICER DRIVER X OTHER
BICY- SEX HAIR EYES HEIGHT TWEIGHT BIRTHDATE RACE
CLIST Mo. Day Year OWN ARRANGEMENTS
F BRN BRN 5' 1" 140 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
UNK. NONE MINOR →*-
INSURANCE CARRIER POLICY NUMBER
49 SELF INSURED SELF INSURED MED X MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
TRAVEL LANES LANES LIMIT
WILLOW AVE
N N/B 35 CAL-T. TCPIPSC MC/M
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VER. YEAR MAKE MODEL/COLOR LICENSE NUMBER STATE CA C M 2004 MERZ. 300 SERIES GLD CA
DRIVER NAME (FIRST. MIDDLE. LAST)
KARINA ERLINDA ESPINOSA OWNER'S NAME X SAME AS DRIVER
STREET ADDRESS
OWNER'S ADDRESS SAME AS DRIVER
CITY/STATEIZIP
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF OFFICER DRIVER OTHER SEX HAIR TEYES HEIGHT TWEIGHT BIRTHDATE Year RACE
Mo OWN ARRANGEMENTS
BRN BRN 5' 4" 115 PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFIGATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE TOR VILY
OPER: INSURANCE CARRIER POLICY NUMBER UNK. NONE MINOR
ATOR
NONE NONE 01 X MOD MAJOR
ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRUI TOTAL CONCIE
TRAVEL LANES LANES LIMIT
WILLOW AVE N/B 35 CAL.T
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA 2008 NISS ARMADA WHI CA
NAME (FIRST. MIDDLE, LASTI
OWNER: NAME
SAME AS DRIVER
STREET ADDRESS LIDIA HERRERA
TRIAN
OWNER'S ADDRESS SAME AS DRIVER
CITY/STATE/ZIP:
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER X] OTHER SEX HAIR EYES HEIGHT WEIGHT Mo BIRTHDATE Year RACE OWN ARRANGEMENTS PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER.
UNKNOWN VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
TOP VIEW
POLICY NUMBER UNK. 7 NONE MINOR 2006
INSURANCE CARRIER 07
MOENGO X MOD. MAJOR ROLL OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
LANES LANES LIMIT CA
TRAVEL WILLOW AVE
S/B 35 CAL-T
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED HARRISON P STEWART, 022641 X] YES • NO N/A
An Internationally Accredited Agency Destroy Previous Editions 5 6/30/23, 2:55 PM 14087 jpg
2:53 Hill!
00 Done
IMG_3225 00
_ HDR
https://mail.google.com/mail/u/O/#inbox/FMfcgzGtvsRJQLdTmMngGWjHMwwfQcpj?projector=1 1/6
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Report Subject To Change
TRAFFIC CRASH REPORT
CHP 555 Page 1 (Rev. 2-22) OPI 060 Page 1 of 7
SPECIAL CONDITIONS UNSER CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
INJURED
COURTESY REPORT RIALTO SAN BERNARDINO SUPERIOR COURT SAN 9860-2023-02087
BERNARDINO JUSTICE CENTER
MEER HITS RUN COUNTY DAY OF WEEK
CIVIBERIN/RE OBARIET BEAT TOW AWAY
KILLED MISDEMEANOR
SAN BERNARDINO SMT WTFS YES X NO
CRASH OCCURRED ON CRASH TIME (2400) NOTIF. TIME (2400) NCIC # OFFICER ID MO. CRASH DATE EAR
WILLOW AVE 06/14/2023 1345 06/14/2023 1346
AT INTERSECTION WITH STATE HWY REL DIGITAL MEDIA
DYES
OR: SHAMROCK ST •YESX NO & NO
LOCATION SPS COORDINATES FOR LOCATION (LOC.) AND AREA(S) OF IMPACT (AOl) IN SAME AS LOCATION •REFER TO NARRATIVE
LAT. LONG. LAT. LONG.
LOC
34.118566 -117.374800 34.118566 -117.374800 34.118729 -117.374840 1 LAT. LONG. LAT. LONG LAT. LONG.
34.118756 -117.374838 4 5
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA C L G 2018 FORD EXPLORER WHI/BLK CA
DRIVER NAME (FIRST, MIDDLE, LAST)
ISIS DOLORES GUILLEN
ONCES NAME
SAME AS DRIVER
PEDES- STREET ADDRESS CITY OF RIALTO
TRIAN
150 S PALM AVE OWNER'S ADDRESS | SAME AS DRIVER
PARKED CITYISTATE/ZIP
VEHICLE 150 S PALM AVE RIALTO CA 92376
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: DRIVER BICY- SEX [HAIR EYES THEIGHT WEIGHT RACE
CLIST Mo. BIRTHDATE Your Day OWN ARRANGEMENTS
F BRN BRN 5'1" 140 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE TOP VIV
UNK. | NONE MINOR ***
INSURANCE CARRIER POLICY NUMBER
49 SELF INSURED SELF INSURED X MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU SPEED -****
TRAVEL LANES LIMIT CA DOT.
WILLOW AVE LANES
N N/B 35 CAL.T TCP/PSC _ MC/MX
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA C M G 2004 MERZ 300 SERIES GLD CA
DRIVER NAME (FIRST, MIDDLE, LAST)
KARINA ERLINDA ESPINOSA OWNER'S NAME X SAME AS DRIVER
STREET ADDRESS
TRIAN
OWNER'S ADDRESS X | SAME AS DRIVER
CITY/STATE/ZIP
VEHICLE
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER & OTHER BICY SEX HAIR EYES HEIGHT | WEIGHT BIRTHDATE Yes RACE OWN ARRANGEMENTS CLIST Mo.
F BRN BRN 5'4" 115 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE TOP YIEV
OPER- POLICY NUMBER UNK. NONE MINOR
INSURANCE CARRIER
NONE NONE 01 X MOD MAJOR
ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
TRAVEL LANES LANES LIMIT CA BOT
N WILLOW AVE N/B 35 CAL-T — TOP/PSC
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 3 CA P 2008 NISS ARMADA WHI 8YIW344 CA
DRIVER NAME (FIRST, MIDDLE, LAST)
OWNER'S NAME SAME AS DRIVER
STREET ADDRESS LIDIA HERRERA
TRIAN
OWNER'S ADDRESS I SAME AS DRIVER
PARKED CITY/STATE/ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER XOTHER
SEX HAIR HEIGHT WEIGHT RACE OWN ARRANGEMENTS
MoRTHDATE Year
PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
UNKNOWN VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
TOP AL
POLICY NUMBER •UNK. • NONE • MINOR **
INSURANCE CARRIER 07
MOENCO X MOD. MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
LANES LANES LIMIT CA DOT
TRAVEL WILLOW AVE
S/B 1 35 CAL-T TCP/PSC. _ MC/MX
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED HARRISON P STEWART, 022641 [X] YES NO N/A
An Internationally Accredited Agency Destrov Previous Editions 7 STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL Report Subject To Change
TRAFFIC CRASH REPORT
CHP 555 Page 1 (Rev. 2-22) OPI 060 Page 1 of 7
SPECIAL CONDITIONS HIT & RUN CITY JUDICIAL DISTRICT | LOCAL REPORT NUMBER FELONY
COURTESY REPORT RIALTO SAN BERNARDINO SUPERIOR COURT SAN 9860-2023-02087
ON-DUTY EMERGENCY VEHICLE BERNARDINO JUSTICE CENTER
NUMBER COUNTY CIVIRER/PROBARIET BEAT DAY OF WEEK TOW AWAY
PULLCU MISDEMEANDR
SAN BERNARDINO SM TWTF S YES X NO
CRASH OCCURRED ON CRASH TIME (2400) NOTIF. TIME (2400) NCIC # OFFICER ID MO. CRASH ATE EAR DAY YEAR
WILLOW AVE 06/14/2023 1345 06/14/2023 1346
STATE HWY REL DIGITAL MEDIA
AT INTERSECTION WITH
•YES
OR: SHAMROCK ST
GPS COORDINATES FOR LOCATION (LOC.) AND AREA(S) OF IMPACT (AOl) X SAME AS LOCATION •REFER TO NARRATIVE AOT LAT. LONG AOT LAT. LONG.
34.118566 -117.374800 34.118566 -117.374800 34.118729 -117.374840 AOI LAT. LONG. AOT LAT. LONG ACI LAT. LONG.
3 34.118756 -117.374838 4 5
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA 2018 FORD EXPLORER WHI/BLK CA
DRIVER NAME (FIRST. MIDDLE, LAST) ON-DUTY EMERGENCY VEHICLE
ISIS DOLORES GUILLEN OWNER'S NAME
SAME AS DRIVER
STREET ADDRESS CITY OF RIALTO
TRIAN
150 S PALM AVE OVER'S ADDRESS •SAME AS DRIVER
PARKED CITY/STATE/ZIP 150 S PALM AVE RIALTO CA 92376
VEHICLE
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER X OTHER BICY: SEX HAIR EYES HEIGHT WEIGHT RACE
GLIST BIRTHDATE OWN ARRANGEMENTS
F BRN BRN 5' 1" 140 PRIOR MECHANICAL DEFECTS: Y NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE TOP VELV
INSURANCE CARRIER POLICY NUMBER •UNK. NONE MINOR
49 SELE INSURED SELF INSURED MOD. X MAJOR ROLL-OVER
THRU TOTAL -*****
DIR OF ON STREET OR HIGHWAY LANE SPEED
TRAVEL LANES LIMIT CA
WILLOW AVE
N N/B 35 CAL-T TCP/PSC. MC/MX
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 2 CA M G 2004 MERZ 300 SERIES GLD CA
DRIVER NAME (FIRST, MIDDLE, LAST)
KARINA ERLINDA ESPINOSA OWNER'S NAME X SAME AS DRIVER
PEDES- STREET ADDRESS
TRIAN
OWNER'S ADDRESS SAME AS DRIVER
PARKED CITY/STATE/ZIP
VEHICLE
RIALTO CA 92376 DISPOSITION OF VEHICLE ON ORDERS OF OFFICER DRIVER OTHER
BICY- SEX HAIR EYES THEIGHT WEIGHT RACE OWN ARRANGEMENTS CLIST Ma THAT Year
F BRN BRN 5' 4" 115 H PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
NONE VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
UNK NONE MINOR
INSURANCE CARRIER POLICY NUMBER
ATOR
NONE NONE 01 MOD. MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL SPEED
TRAVEL LANES LANES LIMIT CA DOT.
WILLOW AVE N/B 35 TCP/PSC MGMX
CAL-T
PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH. YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 3 CA P P 2008 NISS ARMADA WHI CA
DRIVER NAME (FIRST. MIDDLE, LAST)
OWNER'S NAME SAME AS DRIVER
PEDES- STREET ADDRESS LIDIA HERRERA
OWNER'S ADDRESS SAME AS DRIVER
PARKED CITY/STATE/ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER X OTHER BICY- SEX THAIR EYES HEIGHT WEIGHT Mo. BIRTHDATE Year RACE OWN ARRANGEMENTS IST
PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
UNKNOWN VEHICLE TYPE DESCRIBE VEHICLE DAMAGE
TOP VIV
POLICY NUMBER UNK. NONE 7 MINOR 300
INSURANCE CARRIER 07
MOENGO X MOD. MAJOR ROLL-OVER
DIR OF ON STREET OR HIGHWAY LANE THRU TOTAL
LANES LANES LIMIT CA DOT.
TRAVEL
WILLOW AVE 35
S S/B CAL-T TCP/PSG
PREPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REVIEWED HARRISON P STEWART, 022641 [X] YES I NO N/A
An Internationally Accredited Agency Destroy Previous Editions 8