CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAR -4 AMII: 08
TO PERSON OR PROPERTY
RECEIVED
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:
Bruce Olsen
FULL NAME -
DATE OF BIRTH
6050 La Costa Place, Fontana, CA 92336 848, 466-3413
HOME ADDRESS INCLUDING CITY, STATE & ZIP
Cell HOME TELEPHONE NO.
b050 La CosTa Place, Fontana, CA92336 1848) 466-3413
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP
BUSINESS TELEPHONE NO. Cell
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE ame
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 2-18-24
TIME: • AM • PM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet. 1 mento se
3. HOW DID DAMAGE OR INJURY OCCUR?
Hit a pothole
4. WERE POLICE AT THE SCENE? YESTO NO WERE PARAMEDICS AT THE SCENE? O YES ON
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.
Pot holes in the road in Rialto
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 565,88 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
No place detage to Me mum e 565.88
Item/Date: Resist com
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $565.88 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date:
Nore 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:
Nore
TELEPHONE:
TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS: None
ADDRESS: _
TELEPHONE: ( TELEPHONE: _)
DATE: TIME: 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. 2024 MAR
CURB
PARKWAY AMII: 08
SIDEWALK
THAVE REE ON AMAND KNOW THE CONTENTS THEREOF AND CERTIFY THAT THESE TRIBE VE TO BE EXCEPT AS TO REGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Erva Olsen 3-2-24
TYPE OR PRINT NAME DATE
Self
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 Bruce Olsen
From: Michele Aguirre < [email protected]>
Sent: Monday, February 26, 2024 2:14 PM
To: Bruce Olsen
Subject: Claim Against the City - Vehicle Damage
Attachments: Liability Claim Form.paf
Importance: High
Good Afternoon Mr. Olsen,
It was a pleasure speaking with you today. Per our conversation, a copy of your letter dated February 22, 2024, was sent to the Maintenance and Facilities Department for response regarding the damages your vehicle incurred as a result of potholes. All requests for reimbursement, as a result of damages, go through the City of Rialto - City Clerk's Office. They are located at 290 W. Rialto Avenue, Rialto, CA 92376. They can be reach at (909) 820- 2519. For more information regarding Claims Against the City please click the following link: https://www.yourrialto.com/161/City-Clerk-Management-Services. For your convenience, I have also attached a copy of the Claim form for you. Please complete the form and return it to the City Clerk's Office at the address | listed above, or contained in the form, along with your letter and attachments.
If you have any further questions, please feel free to call me at the number listed below.
Regards,
MICHELE R. AGUIRRE
Executive Assistant
CITY OF RIALTO
Maintenance & Facilities / Engineering Services
335 W. Rialto Avenue, West Parking Lot, Rialto, CA 92376 Phone: 909-421-7279
Email: [email protected] | Website: www.yourrialto.com CITY CLERK RECEIVED 2024 MAR -4 AMII: 08 CITY OF RIALTO Hours of Operation: M - Th, 7:00 a.m. to 6:00 p.m.
ALD
BRIDGE TO PROGRESS
Bruce Olsen 6050 La Costa Place, Fontana, CA 92336
Telephone * 848-466-3413 *E-mail * [email protected] February 22, 2024
The Honorable Deborah Robertson
Mayor of Rialto
150 South Palm Avenue
Rialto, CA 92376
Dear Mayor Robertson,
Greetings! On Sunday the 18' of February. 2024 I was driving down the ramp onto the 210 going west from Alder Avenue and hit a pothole (one of a series of at least three in a row) almost all the way down the ramp at the point where it is necessary to merge onto the highway.
My "run flat" left tire blew out immediately as you can see by the attached photos taken at Mountain View Tiree where I had to buy a replacement tire for a net cost of $565.68 per the attached paid Invoice from Mountain View Tire.
This then is a respectful request for you to authorize reimbursement to me in the amount of S565.68 for the blown tire.
Not to be presumptuous, but a copy of this letter has also been sent simultaneously to Mr.
Edward Carillo. City Treasurer; along with all the same attachments.
For the record. this is a true statement by me. the undersigned. of all the facts, with no intent to commit fraud or to deceive.
Thanking you in advance for your consideration. and if anyone has questions, feel free to call me or email me at the phone number or email above.
Tallar
Bruce Olsen CITY CLERK RECEIVEU 2024 MAR - 4 AMII: 08 CITY OF RIALTO CC: Edward Carillo - City Treasure - Rialto. CA
Attachments: Two (2) Pictures of blown left tire
Two page copy of Invoice for replacement tire from Mountain View Tire Bruce Olsen
From: Bruce Olsen
Sent: Thursday, February 22, 20249:36 AM
2524 MAR -4 AMIL: dITY OF RIALTO
To: Bruce Olsen
Subject: BLOWN TIRE PIX CITY CLERK RECEIVED
/CITY OF RIHI To
202, MAR -4 AMH: 08,
RECEN
SITY OLL
LC
- H1X2
BAR#299547/EPA#CAL000460997
17040 S. HIGHLAND AVE
FONTANA,CA 92336
ADUNTAIN VIEW (909)232-8770 205
TIRE& AUTOVSERVICE ... at Front keis
Guest ID: 1717010725 Year: 2013
Name: BRUCE OLSEN 02/21/24 15:38:08
Make 429212
Accress 6050 LA COSTA ?. Mocei 740L1 BASE
Aucress 2 invoice #: 419073
I No PO Number:
C!v State 2p FONTANA ON 92230 VIN
Un:: Number'
ore none (048) 4063113 Celo:
No k Phone Email Address none
Engine Fleet/Whoiesale N
Other Phone Mileage In 1792/0
Est Created On 02/18:24 16:04:26
Tax Exempt # Mieage Out. 179270
Manager RYAN JONES inspect Due
Services Recuested:
LEFT PRONT TIRE NEEDS A NEW TIRE $565868
Car
Qly. Part i Loc Description
Part Labor Amount
Tire Pressure Spec: Not Avadace Wheel Torque: Not Avalabe Tire Pressure IN Tire Pressure OUT Tread Depth
Brake Pads
35 psi 35 psI. 35 psi 35 ps. 132.. - 122
132 1132
35 psi 35 psi. 35 ps 35 psi 132 - 132
132 132.
INGLUDED WITH EVERY, VISIT
COURTESY INSPECTION
1 TPC NO CHARGE
TIRF PRESSURE CHECK & INFLATE
NO CHARGE
TIRE
CUTTIRE A PIR PZERO
426 99 0.00 426 99
The Size 245/40R20 Speed Rating Y Ply X
Lead Range B Sidewall Bow bad dey so
DOT Numbers
*93to:3213423 Mig. Date 34th week of 2023
MV ROHAZARD COVERAGE 08 32 0.00
TIRE RECYCLING FEE 68.32
1.70 0.00 4.40
CA TIRE FEE
TOTAL RE 0.00 1.75
TIRE SERVICE 501.46
REINSTALL
Peckage Incluces Mounting Balercing, Standard Veive Stem TPMS 0.00 30 99 30.99 spect end Reset app. cable /en men! Creck Wired Terge PLUS 211
30.00 Customer Wishes To Discard Old Parts ••
DRIVE 500.00 Date 2021/2024 APPROVAL # 021549 ENTRY: LOOKUP → 3005 CRED : 22 2 24 14 3300 2024
Transaction ID 110240526703137034
Teminal iD -
6 months no morest on this perchase if paid in father 5 months If you do not pay this purchase balance full with 6 months, intererwill bö-charged at 2000% APR for the cale o'the barchase AR 380: 022:2021 and elvary with the mamet besed on the Pomme Rate Mined payments respired Your cart agreement the terma stame eferard aericable law gover the lemme eti, dolored interest purchase SEE NEXT PAGE * C 11:
INVOICE NO OF BAR#200547PA#CAL000460097 INVO CE
CUSTOMER COPY
•
BAR#299547/EPA#CAL000460997
17040 S. HIGHLAND AVE PAGE 2
FONTANA, CA 92336
MOUNTAIN VIEW (909)232-8770
TIRE & AUTO SERVICE
Guest ID: 1717010726 Voar 2013 Dato/Timo 02/21/24 15:38:08 Vame: BRUCE OLSEN Макс BVW Estrate # 429212
Address E09C LA COSTA Merel 140. BAS invoice #t 4'9073
Aloress 3 Po Number
City State 210 FONTANA. CA. 0/336 VIN Unt Number
Home Phone. (846) 466 3416 Coor Emall Acidress none
Work Phone Engine Fleet/Wholesale. N
Other Phone 0- Mileage in. 179270 Est Created On: 02/18/24 16:04:26 ax Exempt * Mileage Out. 179270
Manager RYAN JONES Inspect Due
Services Requested
LEST PRONT TIRE NEEDS A NEWTRE
Car
Qty. Part # Loc Description Part Labor Amount
PAV TYPE AMERICAN EXPRESS 65.93 Date: 221/2024 APPROVAL#: 862037 ENTRY: CHIP CREDIT CARD XXXXXXXXXXXX-1029.
transaction i 110240526704501655
Application /D A000000025010801 Terminal ID: 1
MEY
INVOICE INVOICE BAR#209547 EPA#CAL 000460997 INVOICE
SUB TOTA: 532 45
CP 174375-300 A MANSOUR SALES TAX 3343
GRAND TOTAL 565 88
....
10003
Catton Wa may have demovedyoursenesp) during the service so for moment safety reasons you should returm after 25 miles to have your winesir etorqued. Please retum to any Monro-operated ocation including this onelto com pi mentary retoroung Some Che
Guest signature
we papercompete.
PAV AMT CITY CLERA RECEIVED 2024 MAR - 4 AMI: 08 CITY OF RIALTO DRIVE 500 CO 2/21/202.4
CREDIT 65 88 2/21/2024
PAYMENT COLLECTED BY. R JONES
CUSTOMER COPY
Bruce Olsen
6050 La Costa
Fontana, CA 92336 97624
FOREVER
FOREVER
AM 11: 08 City Realto _City Claks Office
CITY OF RIALTO SLULTED TV CLERA 290 W. Rialto Avenue
. 2024 MAR - 4 Rialto, CA
92376