CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 AUG - 4 PM I: 35
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:
ADRIAN LEE JONES
FULL NAME
DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP
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
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: _ JuLy 8, 2023 8:00 AMOPM TIME:_
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.
ON RIALTO AVE. VUST WEST OF PEPPER AVE (I HAVE PICTURES AND VIDEO ThE LARGE POTHOLE IS ON THE NORTH SIDE OF RIALTO AVE. JUST BEFORE THE TRAILER PARK ENTRANCE.
3. HOW DID DAMAGE OR INJURY OCCUR?
LARGE POTHOLE IN STREET (PICTURES AND VIDEO). DAMAGED MY TIRES.
4. WERE POLICE AT THE SCENE? YES/ANO WERE PARAMEDICS AT THE SCENE? DYES KNO
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.
N/A THE POTHOLE IN THE STREET IS THE CAUSE.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $. 447.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ Please see attached estimates (7/25/23) Amount: S.
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 447.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Amount: $
Item/Date:
Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: 447.00
$
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) N/A Pictures and video
ADDRESS:
ADDRESS:
TELEPHONE: L
TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
N/A N/A (ONLY TIRE DAMAGE)
ADDRESS:
ADDRESS:_
TELEPHONE: L)
TELEPHONE: (
DATE: TIME:
• АМ • PM DATE: TIME: _
• АМ • РМ
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.
South
EAST
Rialto An WEST
- CURB
PARKWAY large pothole
SIDEWALK
North
HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Adrian Jones
от 314/2023
TYPE OR PRINT NAME
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
Rialto
73 F | 287 m
LDW Malfunction
BSW See Owner's Manual
185266 mil
0O 45.4A
Walmart Auto Care Center Walmart Vehicle: N/A Print date: 07-25-2023 16:38:28 Walmart #1862, 1366 S Riverside Ave, Rialto, CA 92376-7608 Tire Size: 235/45R18 Service Writer / Greeter: SHERREE s.
Phone: 909) 820-9912
Tire Quote CITY OF RIALTO
2023 AUG -4 PM 1: 35
GENERAL RECEIVED Available today
GENERAL ELAN RA/S 235/458184V CITY CLERK
• Summer 60,000 Miles • Speed Rating: V (149 mph) • Load Index: 94 (1477 bs)
5.0 year tread life based on 12k miles/y
Description
Qty Price
Tire
CLEARANCE $218.00
VALUE INSTALLATION PACKAGE
Life Time Balance and Rotation
$30.00
TPMS Service Pack
$6.00
Road Hazard Warranty
$20.00
Tire Mounting
Included
50-Mile Re-Torque
Included
Total (Excluding Disposal, Tax & Govt. Fees): $274.00
-Scan with Walmart App to
view online.
Tire UPC: 051342190546
Tire Location: #101
Disclaimer
Walmart recommends purchasing 4 tires for better saftey & performance.
Lifetime Balance includes balancing and rotating the covered tire for the life of the tire on the original vehicle it is installed on. Tire Pressure Monitor System reset is required on some vehicles. All vehicles with TPMS require a service pack when the tire is removed from the rim. Replacement of nonfunctional sensors and sensor packs are considered as additional costs. Road Hazard Warranty includes unforeseen hazards of the road, flat repair and free replacement reflected on this quote are subject to change based on date and availability. For special order tires visit www.walmart.com of non-repairable tires within the first 25% of treadwear. Honored at all Wal-Mart Auto Care Center locations nationwide. Don't see your tires in-stock? 24-48 hour delivery with Special Ordering See an associate for details. Prices It is our intent to have every item in stock. Occasionally, items may not be available. We reserve the right to limit quantities. Prices do not include taxes and tire fees.
Tires LES SCHWAB 167 W San Bernardino Ave Store: 579
Rialto, CA 92376 Quote: 57900185528
(909) 546-3405 Salesperson: Jesus V
ARD 303202
Customer Information Vehicle Information
Customer ID: Vehicle:
Name: Color:
Address: Mileage:
CITY CLERK RECEIVED 3 AUG - 4 PM I: ITY OF RIALTO
City, State, Zip: License:
Phone:
Les Schwab Quote
Qty Product Code Product Description Price/ea FET Amount 2 16958 Pass Tire TPMS Rebuild w/Disp $0.00
$0.00 $0.00
2 13718 WHEEL SPIN BALANCE $16.99
$0.00 $33.98
2 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $15.98 2 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00
$5.98
2 957429 235/45R-18XL 98W S FIT LH01 $191.99 $0.00 $383.98 Sales Tax: $31.46
Tire Fee: $3.50
LoOK Quotation Total:
$474.88
2 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00
$0.00
2 13718 WHEEL SPIN BALANCE $16.99 $0.00 $33.98
13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $15.98 2 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $5.98
2 1134132 235/45R-18 94V PURE CONTACT LS $219.99 $0.00 $439.98 Sales Tax: $35.80
Tire Fee: $3.50
70k Quotation Total:
$535.22
2 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00
$0.00
2 13718 WHEEL SPIN BALANCE $16.99 $0.00 $33.98
2 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $15.98 2 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $5.98
2 775873 235/45VR-18 94V REPUTATION NLW3 $252.99 $0.00 $505.98 Sales Tax: $40.91
80k Tire Fee:
$3.50
Quote Date/Time: 07-25-2023 04:28 PM Page 1 of 2
(ires LES SCHWAB 167 W San Bernardino Ave Store: 579
Rialto, CA 92376 Quote: 57900185528
(909) 546-3405 Salesperson: Jesus V
ARD 303202
Customer Information Vehicle Information
Customer ID: Vehicle:
Name: Color:
Address: Mileage:
City, State, Zip: License:
Phone:
Les Schwab Quote
Qty Product Code Product Description Price/ea FET Amount Quotation Total: $606.33
CITY CLERK RECEIVEL 2023 AUG - 4 PM I: 35 CITY OF RIALTO * indicates sale price
For more information on our products and services, visit www.LesSchwab.com.
Prices good for 30 days, excluding promotions. Quote Expires on 08-24-2023.
Quote Date/Time: 07-25-2023 04:28 PM Page 2 of 2