CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAR - 5 PM 12:49
TO PERSON OR PROPERTY
RECEIV
SITY CLERK
1. Claims for death, injury to person, orto 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: 150S. Palm Ave., Rialto, CA 9237(
Address: 290 W. Rialto Ave., Rialto, CA 9237
CLAIMANT INFORMATION:
VIRG HEAMS, IT
FULL NAME
DATE OF BIRTH
HOME ADDRESS 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: 2-20-24 TIME: 10:50 DAMPP
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet. Where appropnate, give street names and addresses measurements and landmarks. comp 1-10 FREEWAY AT AYAlA
D
3. HOW DID DAMAGE OR INJURY OCCUR?
LEAR TIRES ON THE LANSIDE.
4. WERE POLICE AT THE SCENE? DYES ENO WERE PARAMEDICS AT THE SCENE? • YESENO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the igary of damage, it known.
15 CONSIBLE-STREE
пр.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage 6 36080 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates DAMAGES INCURRED TO DATE:
Item/Date: 2/51/34 36080
Amount: $-
Item/Date:
Amount: $
13608°
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: Amount $ 360 80 Item/Date:
Amount: $_
Item/Date:
$ 36080
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TODAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) N/A
ADDRESS ADDRESS: _
TELEPHONE: TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
ADDRESS: ADDRESS: _
TELEPHONE: ( TELEPHONE: | )
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 f 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 hen 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. -
E/B- LANES
-CURB:
PARKWAY
Portole SIDEWALK
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. 1 I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF GLAIMANT OR AGENT
2-25-24
TYPE OR PRINT NAME DATE
SAME AS ABOVE
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, CÁ 92376 KUU3354
2/21/24 12:15 PM Al hires ana vneers
1FADP5FU3HL105720 909-874-8782
Odometer: 155554
carlos
Ford : C-MAX: 2017
ExpressAlign Total Alignment
Before Measurements
Left Front
Right Front
9° -0
Camber
Camber
4:90
Caster
Caster
Front
08° 04°
Toe
0.04° Toe
Total Toe
06°
Steer Ahead
Left Rear
Right Rear
+
0° -2:10
Camber Camber
Rear
0007° * .19°
0.26° Toe
Total Toe
Thrust Angle
Current Measurements
Left Front Right Front
-0 9°
Camber
Camber
4.90 Caster Caster
Front
10° 10°
Toe
Toe
Total Toe
00°
Steer Ahead
Left Rear
Right Rear
-2.0° -2.1°
Camber Camber
22° Rear
210
Toe Toe
Total Toe
Thrust Angle
One or more values are not within specification. Tire wear, handling and safety problems may result.
AT
TERES
WHEEL
N0.2
A1 Tires & Wheels
Incoice #100199560 www.A1TiresandWheels.net 909-874-8782 8 17827 VALLEY BLVD. BLOOMINGTON, CA 92316
Feb 21, 2024 12:36:41 PM Name
Express Item x1 $360.80
- 21-24
Subtotal Address
$360.80
CARLOS $0.00
ASK FOR
Total $360.80 Phone
MAKE MODEL YEAR
GOLOR VIN#
Sold to VIRGIL ADAMS HI
MasterCard 5026 (Chip ke d) QTY.
Auth Code: 113494 DESCRIPTION AMOUNT
A1 Application Label: Debit Mastercard
17827 VALLEY BLVD. BLOOMINGTON, CA 92316 NO.I WHEELS TIRES s Terminal ID: 2 Nees tires
Approved Online
AID: A0000000041010 225 50 17
AC: 014FFB666016E65B
Response Code: 00
FAX: 909.874.1243 909.874.8782 Mitestor 912
Alignment
Sign Here
I agree to pay the above total amoun!
according to the cardissuer agreement.
A1 Tires & Wheels
17827 Valley Blvd
Bloomington, CA 92316
(909) 874-8782 • 35,000 40,000 45,000
[email protected] • 50,000 60,000 80,000
• 1 YEAR LIFETIME M THREADWEAR
ODO # •ROAD HAZARD
CUSTOMER COPY SUB
One Year Manufacture's Warranty on New Wheels. TOTAL
No Warranty on Used Wheels
Special ordered custom wheels are manufactured to meet your car, own specifications & TAX application, once you accept & sign your order you become llable & unconditionally accept owmership, there is absolutely no refund on deposit, or exchange, except in the case of factory defects. We are not responsible for rims or tires left over 10 days. No Guarantee on Usad Tires.
No Refunds. No Exchange. All Sales are Final. TOTAL
Customer assumes all responsiblity of retightening lug nuts after 25 mile. TWD is not liable for injuries arising due to customer negligence.
RECEIVED BY: Thank You