CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 FEB 26
PH 1: 41
TO PERSON OR PROPERTY
RECEIVEL
CITY CLEAK
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:
EARl Ittompson
FULL NAME DATE OF BIRTH
(HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 390 Walters St. ColtoN, CA 92324
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: — 2|8|24 _ TIME: 1 AM WAMOPM
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.
Rialto Ave going west past raulroad tracks
before meridian
3. HOW DID DAMAGE OR INJURY OCCUR?
- Pothole two torn tires on New car
on my way to work
4. WERE POLICE AT THE SCENE? YES NO WERE PARAMEDICS AT THE SCENE? DYES 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.
Pool of water with big whole underit
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:
Item/Date: 24824 2 tires torn Amount $ 25248
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 25246 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 248/24 Two Tires
Amount: $ 25246
Item/Date:
Amount: $_
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $25246
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: 1)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE:
DATE: TIME:
DATE: TIME:
DAM OPM
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 accident by "B-1" and the point of impact by "X" 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 → NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT. 0-96
RAiLTON TEEDE Rial tale
CURB
PARKWAY
Tel
SIDEWALK
AVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS OSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRI I CERTIFY/OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT~
TYPE OR PRINT NAME 2126/24
Grandfather
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 Bob & Al's Tires
106 N. Mt Vernon
San Bernardino CA 92410
909-885-3759
2/8/2024 11:42 AM
page 1
Invoice #67567
THOMPSON, EARL Day Phone
Created : 2/8/2024 11:41:12 AM
Complete : 2/8/2024 11:42:17 AM
Invoiced : 2/8/2024 11:42:17 AM
Qty Code/Tech* Reference Description
Condition Unit Price Price
225/50ZR17 98W FORTUNE PHI-R XL BW HWY $77.00 $154.00
2 MISPOSAL BEANE $25.00 $75.00
$5.00 $10.00
Labor $85.00
Parts $154.00
Sublet/Misc. $0.00
Other Charges $0.00
Charges
$0.00
Sales Tax Tax @ $154.00 * 8.7500%
$13.48
Total Due $252.48
Tires were Donage Due it
CITY OF RIALTO 2024 FEB 26 PM |: 41 ECEIVEL CITY CLERA to a Port hole. •
I hereby authorize the repair work herein set forth to be done along with the necessary material and agree that you are not responsible for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond your control. I hereby grant you and/or your employees permission to operate the venice herein described on streets, highways or elsewhere for the purpose of testing and/ol Inspection. An express garagekeeper's lien is hereby acknowledged on above vehicle to secure the amount or repairs thereto. All Vehicles left over 48 hrs. after repairs are completed WILL INCUR A $5.00 PER DAY STORAGE FEE. 12 Month or 12,000 Mile Warranty On Repairs.
Customer Signature
Bob and Als Tires
106 Mt Vernon Ave
San Bernardino, CA, 92410
(909)885-3759
Order# 67567
Date/Time: 2/8/2024 11:44:21 AM
Trans Type: Sale
Amount: $252.00
Entry Method: KEYED
Cardholder: THOMPSON EARL
Card Type: CENA
Card Number: XXXXXXXXXXX3213
OrderID: 1737093674
TransID: 2088764370
AuthCode: 4508
RefCode: 2088764370-4508
Consumer acknowledges receipt of goods and/or
services in the amount shown hereon and
agrees to perform the obligations set forth by
the cardmember's agreement with the issuer.
Authorized Signature