CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2074 JAN -8 AMII: 16
TO PERSON OR PROPERTY RECEIVES
CITY CLERA
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:
pеarce.... DATE OF BIRTH
FULL NAME
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. san ernardin Ca 92404
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):
1-4-24 TIME: • АМ П РМ
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE:
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheef.
Where appropriate, give street names and addresses, measurements and landmarks.
Realto police statiole
Insi
3. HOW DID DAMAGE OR INJURY OCCUR?
narfec fer release
moneyd
was not suppose
4. WERE POLICE AT THE SCENE? • YES D NO WERE PARAMEDICS AT THE SCENE? •YES CINO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/towr employee causing the injury or damage, it known TOULO
_ need artfun vehicite
= $ 7300
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:
of Car 1216.80
Item/Date: retease Amount: $
In fon Amount 5 5 1500
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: _ ADDRESS:
NIA
TELEPHONE: | TELEPHONE: L)
DATE: TIME: • АМ ПРМ. DATE:
TIME: • AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X* and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the accident by "B-1" and the point of impact by "X"
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
7/1 SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE I CERTIFY OR DECI ARFIINNER PENAI TV NE DED IIIDY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT T
1-8-24
TYPE OR PRINT NAME DATE
mumself
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 # COuTO* GOOD TO BE
RELEASED 1/312$
STATE OF CALIFORNIA
DEPABIMENT OF CALIFORNIA HIGHWAY PATROL
NOTE: CHP 180 IS FURNISHED TO ALL PEACE
VICLE REPORT EVIDENCE HOCo OFFICERS BY THE CALIFORNIA HIGHWAY PATROL CrP 180 (Rev. 4-16) OPI 061
REPORTING DEPARTMENT LOCATION CODE DATE / TIME OF REPORT NOTICE OF STORED VEHICLE
DELIVERED PERSONALLY
SALTO PD 3609 12-19-23 932314714
LOCATION TOWED / STOLEN FROM ODOMETER READING VIN CLEAR IN SVS? L YES DATE/ TIME DISPATCH NOTIFIED LOG NO 10T// MEDICAL CENTER SR UC. CLEAR IN SVS? YES NO 12-29-23 1310 BODY TYPE LICENSE NO. • ONE MONTH/YEAR STATE
2013 VW PASSAT 4-DR GREY TWO 09- 2Y
VEHICLE IDENTIFICATION NO. ENGINE NO. VALUATION BY OFFICER OWNER L 0-500 L 501-4000-4001+ 4.00
REGISTERED OWNER 7 LEGAL OWNER
MOTORS INC
SRA BERMIAZSENO CA 92404 SAN BERNARDINO LP 924IU
L
• STORED IMPOUNDED RELEASED • RECOVERED - VEHICLE / COMPONENT
TOWING / STORAGE CONCERN (NAME, ADDRESS, PHONE) STORAGE AUTHORITY / REASON REASON FOR STOP TOWING 2775 DERES N LOCUST AUT RIALT 22655.5 AIRBAG? DRIVEABLE? VIN SWITCHED?
5 HOOTINU EYES • NO •1 M YES • NO • JUNK • YES
CONDITION YES NO ITEMS YES NO ITEMS YES NO ITEMS YES NO TIRES / WHEELS CONDITIN
WRECKED SEAT (FRONT) REGISTRATION CAMPER LEFT FRONT FATR BURNED HULK per 431(c) CVC SEAT (REAR) ALT. / GENERATOR VESSEL AS LOAD RIGHT FRONT FLAT
VANMALIZED RADIO BATTERY FIREARMS LEFT REAR FADE
TRANS. STRIP TAPE DECK DIFFERENTIAL OTHER RIGHT REAR FLAR MISC. PARTS STRIP TAPES TRANSMISSION SPARE
UNix
BODY METAL STRIP OTHER RADIO AUTOMATIC HUB CAPS
NO
SURGICAL STRIP per 431(b) CVC IGNITION KEY MANUAL SPECIAL WHEELS NU RELEASE VEHICLE TO: • RIO OR AGENT AGENCY HOLD | 22850.3 CVC SARE PRINCIPAL GET TORN VEHIC ENCH. LI 17
I.D. NO. DATE
CERTIFICATION: I, THE UNDERSIGNED, DO HEREBY CERTIFY THAT I AM LEGALLY DATA 02334 14/24 AUTHORIZED AND ENTITLED TO TAKE POSSESSION OF THE ABOVE DESCRIBED VEHICLE
SIGNATURE OF PERSONT SIGNATURE OF PERSON TAKING POSSESSION • STOLEN VEHICLE COMPONENT EMBEZZLED VEHICLE • PLATE(S) REPORT DATE / TIME OF OCCURRENCE DATE / TIME REPORTED NAME OF REPORTING PARTY (R/P) DRIVER LICENSE NO. / STATE
LAST DRIVER OF VEHICLE DATE / TIME ADDRESS OF R/P TELEPHONE OF RIP
I CERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF SIGNATURE OF PERSON MAKING REPORT THE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT.
REMARKS
[LIST PROPERTY, TOOLS, VEHICLE DAMAGE, ARRESTS]
DRIVER'S NAME ARRESTED / SECTION? REPORTED BY CARGO / TYPE? VALUE $ •YES LANO CL SavEs O YES ANO L BILL OF LADING ATTACHED
VEHICLE WAS JAVOLVED IN A SHorTING WEAR
THE 5400 BLK DF Ni EUCAUYTTUS ANa. VEHICLE
wAs SHOT MUTIPLE TIMES. JEH WAS JO wES
FOR EVIDENCE HOLD PER CN 22655.5 (B
FRONT LEET-SIDE RIGHT SIDE REAR
TOP
SIGNATURE OF OFFICER TAKING REPERT I.D. NO. SUPERVISOR e REQUIRED NOTICES SENT TO REGISTERED ¡ DATE NOTIFIED ....
Pepe's Towing Service Impound Invoice
PO Box 7450, Moreno Valley CA 92552
Phone: (951) 682-5682 | Fax: (951) 682-5030 Printed 1/4/2024 Released To LA SHAY ELLIS 395 SAN FELIPE 12 SAN BERNARDINO CA 92408 Phone:9099913458 Invoice # 23-1229-27505 Reason for 22651-B BLOCKING HIGHWAY Call # 27505 Impound
Case # 932314714 VIN Number
Case # 932314714 Model 2013 Volkswagen Passat (Gray)
Account RIALTO PD License Plate
Date/Time Requested 12/29/2023 2:58 PM Drivable Yes
Date/Time Dispatched 12/29/2023 2:58 PM Keys No
Date/Time Towing Time: 12/29/2023 3:19 PM Towed from WEST TENTH ST AND NORTH MEDICAL CENTER DR SAN Date/Time Destination Arrival: 12/29/2023 3:39 PM BERNARDINO Date/Time Completed: 12/29/2023 3:58 PM Stored at Rialto Yard 2775 N Locust, Rialto CA 92377
Date/Time Impounded: 1/3/2024 1:58 PM
Driver Fernando C.
Truck TRK 10
Date/Time Released: 1/4/20243:06 PM
Days Held in Impound 2 days
Notes EVIDENCE
Storage charges Quantity Price Line Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 1 $70.00 $70.00 Towing charges Quantity Price Line Total
(Towing) Admin Fee 1 $95.00 $95.00
(Towing) TOWING FEE PORT TO PORT (price per hour) 1 h $350.00 $350.00 Towing SubTotal $445.00
Storage - Storage Fees SubTotal $70.00
Subtotal $515.00
Taxes $0.00
Grand Total $515.00
Amount Due: $0.00 / Paid
Cash payment (Ref # CASH) of $515.00 applied on 1/4/2024 Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you. 1 one 0+24
Signature:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice https://app.towbook.com/impounds/lmpound.aspx?id=17124231#Payment City of Rialto
POLICE
150 S Palm Ave
Rialto, CA 92376-6487
+1 (909) 820-2525
city of Rialto
01/04/2024 12:59PM PD24-000001553
000648-0003
Payment Effective Date 01/04/2024
MISCELLANEOUS
Vehicle Release Fee
(629833)
Item: 629833
1 @ $216.8000
Vehicle Release Fee $216.80
629833)
Payment Id: 10001 ------
$216.80
$216.80
Subtotal $216.80
Total
$220.00
CASH -$3.20
CASH -----
-$3.20
Change due
Paid by: camy
Thank you for your payment
CUSTOMER COPY