CITY CLERK'S DATE STAMP
CITY OF RIALTOOF FIALTO
C.I:
LIABILITY
MARL Ph 3: 41 2011 F
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY ** RE
CITY CLL
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: 290W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Javier Navarre -
FULL NAME DATE OF BIRTH
-
HOME ADDRESS INCLUDING CITY, STATE & ZIP J 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: 3/12/24 TIME: 4:45
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.
ABaut 200 Feet West of 2430 west Baseline Road.
In Betwein Alder and Tamarind AVe, In Front of an emety Field.
Pothole is about 4 Feet Long and about 2 Feet wife
3. HOW DID DAMAGE OR INJURY OCCUR?
Changing Lanes. Hit Pathale. Damaged Sidewall of tire.
was falf By Public works ta File Claim.
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS 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.
City of Rialto Fails ta inspect / Fill Pot hale After
3 weeks on arterial Roads.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 168.39 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 5. dewall tire 3/12/24 Amount: $ 168.89
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 168.89 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Side Wall of tire 3/12/24 Amount $ 168.89
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. 169.89
7. WITNESSES TO DAMAGE 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:
NAME: NIA
ADDRESS: ADDRESS:
TELEPHONE: ( TELEPHONE:
DATE: TIME: • AM • PM DATE: TIME: •AM 0 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. 2430 W. Basiline
Wareheuse empty house warehouse
Lot
Avenué west
฿-1/x Baseline
CURB
AVE Road
PARKWAY
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.
I CEDTIEV IOR NECI ARE INDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SENATURE OF CLAIMANT OR AGENT
Javier Navarro 3/13/2024
DATE
TYPE OR PRINT NAME
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
QUOTE
Quote ID: 227289903
Dealer Info This is the
PADILLA TIRE & AUTO REPAIR INC tire
15808 FOOTHILL BLVD Similar
FONTANA, CA 92335
to the damaged
(909) 350-4492
[email protected] Hankook tire
original tire
Quote Information
Created By : ABE PADILLA was a
Printed On : 03/13/2024 07:31:53 60k Mile
TIfe.
This one is cheaper
Name Description Qty Retail Cost Total
Than
origina |
04539 235/45R18 94V HER ROADTOUR CONNECT PCV 1 $168.89 $168.89 Mount Mount 1 $10.00 $10.00
New Tire Fee CA New Tire Tax 1 $1.75 $1.75
Balance Tire Balance 1 $10.00 $10.00
Tire Disposal Tire Disposal Fee 1 $4.00 $4.00
Call for an Appointment: (909) 350-4492 QUOTE SUMMARY
Sub Total $194.64
Tax $13.09
Total $207.73
235/45R18
235/45R18 94V HER ROADTOUR CONNECT PCV
Load/Speed 94V Extended Mobility N Tread Depth 10.5
Mileage Warranty 70K Load Range Standard Load
Ply SL Max Load Single 1477@44
Season Designation All Other Overall Diameter 26.34
Sidewall Black Wall Rim Width Max 9
SHIP_WEIGHT 25.83 Rim Width Min 7.5
UTQGL 620AA Rpm 787
6251 Sierra Ave Store: 570
Tires LES SCHWAB Fontana, CA 92336 Quote: 57000349593
9094286769 Salesperson: Patricia E
ARD 301931
Customer Information Vehicle Information
Customer ID: Vehicle:
Name: Color:
Address: Mileage:
City, State, Zip: License:
Phone:
Les Schwab Quote
Qty Product Code Product Description Price/ea FET Amount 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00
1202858 235/45R-18 IMOVE GEN2 AS $96.99 $0.00 $96.99
13718 WHEEL SPIN BALANCE $16.99 $0.00 $16.99
13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $7.99 1 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $2.99
зек Sales Tax: $8.37
Tire Fee: $1.75
Quotation Total: $135.08
1 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00 1 1041791 235/45R-18 94V ROAD CONTROL 2 $193.99 $0.00 $193.99 13718 WHEEL SPIN BALANCE $16.99 $0.00 $16.99
13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $7.99 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $2.99
Sales Tax: $15.88
70k Tire Fee: $1.75
Quotation Total: $239.59
1 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00 1 941798 235/45R-18XL 98Y EXTREME CONTACT DWS06+ $244.99 $0.00 $244.99 1 13718 WHEEL SPIN BALANCE $16.99 $0.00 $16.99
1 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $7.99 1 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $2.99
sek Sales Tax: $19.84
Tire Fee: $1.75
Quote Date/Time: 03-13-2024 03:55 PM Page 1 of 2
6251 Sierra Ave Store: 570
Tires LES SCHWAB Fontana, CA 92336 Quote: 57000349593
9094286769 Salesperson: Patricia E
ARD 301931
Customer Information Vehicle Information
Customer ID: Vehicle:
Name: Color:
Address: Mileage:
City, State, Zip: License:
Phone:
Les Schwab Quote
Qty Product Code Product Description Price/ea FET Amount Quotation Total: $294.55
1 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00 775873 235/45VR-18 94V REPUTATION NLW3 $252.99 $0.00 $252.99 -- WHEEL SPIN BALANCE $16.99 $0.00 $16.99
13718
1 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $7.99 $0.00 $7.99 1 1046759 PASSENGER TIRE DISPOSAL $2.99 $0.00 $2.99
8ek Sales Tax: $20.46
Tire Fee: $1.75
Quotation Total: $303.17
* indicates sale price
For more information on our products and services, visit www.LesSchwab.com.
Prices good for 30 days, excluding promotions. Quote Expires on 04-12-2024.
Quote Date/Time: 03-13-2024 03:55 PM Page 2 of 2
PADILLA TIRE & AUTO REPAIR, INC.
15808 FOOTHILL BLVD.
FONTANA, CA 92335
(909) 350-4492
BAR# ARD00220653 EPA#CAL000171971
New & Used Tires - Brakes - Shocks - Struts - Rack n Pinion 4 Wheel Alignment - Engine Diagnostic & Scope
Invoice #80262 Page:1
NAVARRO, JAVIER Phone:
Vehicle : 2022 Toyota Camry 2.5 L 2487 CC L4 DOHC 16 Valve Tag/State :
VIN
Fleet #/Driver : Odometer In : 8850
Created : 3/14/2024 8:45:28 AM PDT
Invoiced : 3/14/2024 3:04:31 PM PDT
Labor/Notes
Qty Technician Reference Description Unit Price Price
2 MOUNTED TIRE MOUNTED $10.00 $20.00
2 BALLANCED TIRE BALANCED $10.00 $20.00
Parts
Qty Code Reference Description Condition Unit Price Price 2- 04539 235/45R18 94V HER ROADTOUR CONNECT PCV $168.89 $337.78 2- TIREDISPOSAL TIRE DISPOSAL FEE $4.00 $8.00
2- CTF CA TIRE FEE $1.75 $3.50
Labor $40.00
Tires $337.78
Charges $11.50
Sales Tax Sales Tax @ 7.75% $26.18
Total $415.46
Credit Card (VISA): $415.46 PAYMENT $415.46
BALANCE DUE $0.00
Approvals
Approval #1 So. sales Tax: 2.08, Autoried by iN AS Date: 202412:5 Empy: TRAC min, Approval Method: ImPerS.0 Suble/sc: $0.00 Charges: 411.50 Shop Supplies: $0.00 Haz Mat:
Approval Amount: $415.46
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 vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or 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 $25.00 PER DAY STORAGE FEE. NO WARRANTY ON USED TIRES. ALL PARST ARE NEW UNLESS OTHERWISE SPECIFIED.
Customer Signature