CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2023 AUG 24 PM 2: 29
TO PERSON OR PROPERTY
MECEIVED
CITY CLERK
1. Claims for death, irjury to person, or to personal property must be filed not later than six 6) months after the occurrence (Gov. Code 59112).
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:
Ameliz Vazques
FULL NAME DATE OF BIRTH
14192371
HOME ĂDDRESS 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: Merch 2, 2023 • TIME: 5:30 DAM O PM
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. iz to Nia Schoo AN leFt and oN She
right, side is Roden 2Fen d hit the big see pothole
3. HOW DID DAMAGE OR INJURY OCCUR?
14'23 Despepper the leFt lare. AN Pepper ard Mills, The side iF Pia/to diah Schoo/ aid quebe riant olde oF Street is Araleo afe, There Was alot of potholes that 1 Was frynn to MisaNdA
4. WERE POLICE AT THE SCENE? • YES ENO
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
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 622,26 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date:_ Tire 3/11/23 Amount: $ 14l0, 65
Item/Date: Rem Amount $ 455.4)
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 622.26 ESTIMATED PROSPECTIVE DAMAGES, AS FAR,AS KNOWN:
Item/Date:
Amount: $ 455, 6l
Item/Date: Tir
Amount: $ 166,65
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $422,26
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:
ADDRESS:
ADDRESS: _
TELEPHONE: L
TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: | 1
DATE: TIME:
• AM • 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.
CURB
PARKWAY
SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT ORAGENT /
Tmelia 8/24625
TYPE OR PRINT NAME DATE
CeLE
RELATIONSHIP TO CLAIMANT
RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72)
AMERICAN
FIND STORE HOURS
TIRE DEPOT AND LOCATIONS ONLINE
AMERICANTIREDEPOT.COM
A BIGBRAND TIRE & SERVICE COMPANY Started Time: 3/11/2023 10:59:56 AM CITY OF RIALTO Promised Time: 3/11/2023 1:00:00 PM
Estimate#: 1163-2927601
CUSTOMER INFORMATION VEHICLE INFORMATION 2022
AMELIA, VAZQUEZ Cust #: ED-6037379 Plate #: LOOSE CA STORE LOCATION VIN Number: UNSPECIFIED RIALTO#1163: 29 BAR#:ard301169
RLALTO. CA 92376 R 185 E FOOTHILL BLVD EPA#:CAL000470360 Miles: BALTO CA92376
Phone C/
Emails: Vehicle Service Emails Inactive Phone: (909) 279-1567 Started By JS180
BRAND HART NUMBER
DESCRIPTION
KMH 2253352 TECH SALESPERS PRICE
@225/45R17 91W MAJESTY SOLUS KU50 BSWKMH Totel
CR778 J$180 $124.99 1.0000
.. CONSUMER ADVISORY ******* THIS IS A 'W" RATED TIRE. IT HAS A MAXIMUM SPEED OF 168 MPH. IT HAS "W" $124.99 HANDLING CHARACTERISTICS. CONSULT YOUR OWNERS MANUAL FOR THE PROPER SPEED RATING RECOMMENDED FOR YOUR VEHICLE. CUSTOMERS INITIALS --
CDF CDF TIRE RECYCLING
CR778 JS180 $4.75 1.0000 $4.75
LBR WBHS HIGH SPEED WHEEL BALANCE
CR778 JS180 $20.25 1.0000 $20.25
SHP wW LEAD FREE WHEEL WEIGHTS - PARTS
CR778 SS 180 $4.50 1.0000 $4.50
STF STF CALF. STATE TIRE FEE
CR778 JS180 $1.75 1.0000 $1.75
I have been informed of the benetits of BBT's Tire Maintenance Certificate program. ALL-WHEEL DRIVE VEHICLE NOTICE - Most design and tread depth. Please consult your owners manual for the Original Equipment Vehicle Manufacturers recommendations. TWO manuracturers recommend the roiling radius of all 4 tires must be the same. Tires should be replaced in sets of 4 to match brand, size, TIRE PURCHASE ONLY - SAFETY ADVISORY - The Tire Association Council states that if only two new tires are installed on the front of a vehicle, the rear worn tires could loose their grip under load or slippery conditions causing toss of control Vehicle Tire Pressure - F: R:
Estimate Summary
Revisions Payment
Invoice Totals
Date Employee Previous Revised Type Auth Email/ Phone#
Type Amount Parts: $134.24
FET: $0.00
Shop Fees: $0.00
NonTax: $22.00
Tax: $10.41
acknowledge below and receipt of this invoice
Total: $166.65
•This estimate is based on our inspection at this time and does not cover additional parts and labor which may be required after the work has been started. After the work has started, worn or damaged parts which are not evident on first inspection may be discovered. This estimate cannot cover such contingencies in cases where aciditional work is deemed necessary. customer authorization will be secured prior to commencement of that addltional work. This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the vehicle herein described on the streets, highways or elsewhere for the purpose of testing and/or shipments beyond dealers control not for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond our control. 12 months/12,000 miles for parts inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. Dealer not responsible for unavailabilly of parts or delays in parts and labor. 6 months/6,000 miles for alignment warranties See website for additional warranty details. All parts are new unless otherwise specified.
Customer Initials:
Additional terms notice and oral approval of an increase in the original estimated price.
AMERICAN
FIND STORE HOURS
AND LOCATIONS ONLINE
TURE DEPOT
AMERIGANTIREDEPOT.COM
A BIGBRAND TIRE & SERVICE COMPANY Started Time: 3/11/2023 10:59:56 AM CITY OF RIALTO Invoiced Time: 3/11/2023 11:41:24 AM
Invoice#: 1163-2927601
CUSTOMER INFORMATION 2022 л
AMELIA, VAZQUEZ VEHICLE INFORMATION STORE LOCATION
Cust #: ED-6037379 Plate #: LOOSE CA
VIN Number: UNSPECIFIED RIALTO #1163 < 29 BAR#:ard301169 RLALTO, CA 92376 /aSE. EOOTHILL BLD EPA#:CAL000470360
Miles: 1
C AALTO. CAO2376
Emails: Vehicle Service Emails Inactive Phone: (909F279-1567 Started By: JS180
Invoiced By: JOSEPH SIMONDS II (JS180)
BRAND PART DESCRIPTION
KMH 2253352 TECH SALESPERS PRICE CITY TOTAL
@225/45R17 91W MAJESTY SOLUS KU50 BSW KMH - CR778
JS180 $124.99 1.0000
Tire Serial # 2022 $124.99
.. CONSUMER ADVISORY ********** THIS IS A "WRATED TIRE. IT HAS AMAXIMUM SPEED OF 168 MPH. IT HAS "W" HANDLING CHARACTERISTICS. CONSULT YOUR OWNERS MANUAL FOR THE PROPER SPEED RATING RECOMMENDED FOR YOUR VEHICLE CUSTOMERS
INITIALS
COF CDF TIRE RECYCLING
CR778 JS180 $4.75 1.0000
$4.75
LBR WEHS HIGH SPEED WHEEL BALANCE
CR778 JS180 $20.25 $20.25
1.0000
SHP ww LEAD FREE WHEELWEIGHTS - PARTS
CR778 JS180 $4.50 1.0000 $4.50
STF STF CALIF. STATE TIRE FEE
CR778 JS180 $1.75 1.0000 $1.75
I have been informed of the benefis of 887's Tire Afaintenance Certifcate program. ALL-WHEEL DRIVE VEHICLE NOTICE -Most manufacturers recommend the rolling radius of all 4 tires must be the same. Tires should be replaced in sets of 4 to match brand, size, design and tread depth. Please consult your owners manual for the Original Equipment Vehicle Manufacturers recommendations. TWO TIRE PURCHASE ONLY - SAFETY ADVISORY - The Tire Association Council states that if only two new tires are installed on the front of a vehicle, the rear worn tires could loose their grip under load or slippery conditions causing loss of control
Vehicle Tire Pressure - F: R:
Invoiced Summary
Revisions Payment
Invoice Totals
Date Employee Previous Revised Type Auth Email/ Phone#
Type Amount Parts: $134.24
CCD2 166.65 FET:
$0.00
1971803698
AMELIA VAZQUEZ Shop Fees: $0.00
Mastercard 8737
NonTax: $22.00
Tax: $10.41
azguy
I acknowledge below and receipt of this invoice
Total: $166.65
This estimate is based on our inspection at this time and does not cover aditional parts and labor which may he required after the work has been started. After the work has started, wor or damaged parts which are not evident on first inspection may be discovered. This estimate cannot cover such contingencies. In cases where additional work is deemed necessary, customer authorization will be secured prior to commencement vehicle herein described on the streets, highways or elsewhere forthe purpose oftesting and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto of that additional work. This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the 12 months/12,000 miles for parts and labor. 6 months/6,000 miles for alignment warranties See website for additional warranty details. All parts are new unless otherwise specified. Dealer not responsible for unavallability of parts or delays in parts shipments beyond dealers control not for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond our control.
Customer Initials:
Additional terms notice and oral approval of an increase in the oricinal estimated price.
6 ORDER UPDATE: ALY 74834/170310 KIA.. CITY OF RIALTO
2023 AUG 24 PM 2:29
eBay <[email protected]>
Sat 3/4/2023 6:08 AM CITY CLERA RECEIVEL
To:
ebay
•
Hi Amelia, your order is being shipped!
Tracking Number: 127337X54298715419
Track order Go to site
Tracking data usually becomes available within a few hours after the shipment. -
Your order will ship to: Estimated delivery:
Amelia Vazquez Wed, Mar 08 - Mon, Mar 13
Rialto, Ca 92376-3760
United States
ALY 74834/170310 KIA Forte GT 2022 2023 Wheel
Grey Machined #529...
Total: $455.61
Order number: 03-09780-04714
Item ID: 195576530432
Seller: aaaahubcapheaven
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Order information Shipping address Order total
Buyer eyecandiet Amelia Vazquez
Seller 1 item $395.00
assahubcapheaven 900 E Wabush st
Placed on Mar 3. 2023 Shipping $30.00
United States Tax
Payment method Credit Card $30.61
Paid on Mar 3, 2023 Order total $455.61
Items bought from aaaahubcapheaven
Order number: 03-09780-04714
Quantity Item name
Shipping service item price
ALY 74834/170310 KIA Forte GT 20222023 Wheel Grey Machined #S2910M7800 195576530432) FedEx Ground or FedEx Home Delivery AUG 24 CITY OF RIALTO
TY CLER* RECEIVEL
PM 2:29