CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 MAR 26 PM 4:35
TO PERSON OR PROPERTY
CITY CLERK RECEIYEU
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:
Julie Ann Ortega
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A N/A
-
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: _ March 3, 2024 TIME: 1:00-1:15 X AM • PM
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.
The island in between NE and SE corner of Riverside Avenue and Baseline Avenue by Tacos Gavilan. (Pictures included of intersection and damages)
3. HOW DID DAMAGE OR INJURY OCCUR?
On the early morning of March 3, 2024 at around 1:00am-1:15am, while going SB on Riverside Ave, the island that was apparently just placed on Baseline Ave was not painted yellow at the tip nor any metal pole with yellow reflectors or white sign or traffic cone to indicate the cement island was there. At the time, it was moderately raining. dark and the island could not be seen when turning in the left turn lane at the SB Riverside light in order to go east on Baseline Avenue. This caused a road hazard. My car hit the ip of the ilan on my lit front chiver tire and eased approximately get damage acring to Pep aya i redlande, Sama Club Sen Bernardino & Toyota Si
4. WERE POLICE AT THE SCENE? •YES IX NO WERE PARAMEDICS AT THE SCENE? •YES XI 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.
The City of Rialto's Public Works/Maintenance and Facilities Department failing to paint new island yellow at the tip or placing a metal pole with yellow reflectors with white sign or at least traffic cones to indicate the cement island was present caused a road hazard. My car hit the tip of that island on my left front driver's tire and caused approximately $3358.53 in damage according to Pep Boys in Redlands ($199), Sam's Club San Bernardino ($229,88) & Toyota SB ($2929.65)
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:
235/45R18 94V new tire needed/March 4, 2024 at Sam's Club SB (DONE) Amount: $ 229.88 paid Item/Date: _
Item/Date: wheel alignment needed/March 4th, 2024 at Pep Boys Redlands (DONE)Amount: $ 199.00 paid tem/Date: Front L shock absorber bent w/no dampening. Recommend front L & R shocks, top hats and wheel bearings be replaced. Amount: $2929.65 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 3358.53 $
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Front L shock absorber bent w/na dampening. Recommend front L& R shocks, top hats and wheel bearings be replaced (Appt on 3/unt: $ 2929.65 to be paid on 3/27124 Item/Date:
Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $. 3358.53
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Kathleen Ortega Vega (passenger) NAME:
ADDRESS: — ADDRESS:
TELEPHONE: _ TELEPHONE: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED: 2024 CITY NAME: NAME:
ADDRESS: N -11
ADDRESS: _
TELEPHONE: TELEPHONE: L
DATE: TIME: • AM •PM DATE: _ _ TIME: •AME 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 ITHE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASATE PROPER DAORAM SIGNED BY THE CLAMANT. versal
CURB Baseline Ave W
PARKWAY
7 SIDEWALK
Stater Bros
IAVE 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 TR SAFRTIEYIAD NECI ADELINDED DEALI TY NE BED ILDY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Julie Ann Ortega 3/26/24
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 sam's club. 2024 MAR 26 PM 4: 36 CITY OF RIALTO
CLERX
(909 ) 796 - 1505
SAN BERNARDINO, CA
03/04/24 08:05 4265 06624 042 3282
JULIE
TMA ITEMS FOLLOW
ORDER NUMBER 0048570057916
5 TIRE INSTAL 20.00 N
5 TIRE INSTAL 20.00 N
980197525 235/45R18 209.88 T
157611 RECYC. FEE 1.75 N
980197525 235/45R18 209.88 T
157611 RECYC. FEE 1.75 N
TMA ITEMS COMPLETE
SUBTOTAL 463.26
TAX 1 8.750% 36.73
TOTAL 499.99
499.99
AMERICAN EXPRESS**********1 003 I O
APPROVAL # 829182
AID A000000025010801
AAC AF36CCFBE95529B5
TERMINAL # 19082284
*NO SIGNATURE REQUIRED
CHANGE DUE 0.00
New! Free shipping for Plus members.
Learn more: samsclub.com/freeshipping
visit samsclub. com to see your savings
# ITEMS SOLD 4
TC# 6467 3722 7566 6637 3723 2
*** MEMBER COPY ***
Pep Boy Courtesy Vehicle Inspection
Name Julie ORTEGA Work Order #2308802 * Require Attention Tech Fernando M Date 03/04/2024 • Suggested Repair
Store REDLANDS, 1650W REDLANDS BLVD REDLANDS, CA92373 Phone (909) 792-9110 © Checked & Passed Make TOYOTA * Not Applicable
Year 2019 Model AVALON Engine V6-3456 3.5L DOHC
* Yes
Color Mileage 36623 VIN
License Plate * NO
Manual or Automatic? Automatic Drive Train FWD Inspection/Smog Exp.
Customer Initial Request/Comments
Original Request Alignment
Additional Required Services 2 tires, LF camber kit bolt,LF quick strut * REQUIRE ATTENTION • SUGGESTED REPAIR
• LF Tire Tread • Shocks & Struts
1/32 LF strut possible is bent,
• RF Tire Tread
1/32 CITY OF RIALTO
• Steering & Suspension 2024 MAR 25 PM 4: 36
LF camber/ caster out, camber kit bolt+ strut quick strut) LIGHTING & © Exterior Lights © Wiper Blades
WIPERS
DASHBOARD P as
LIGHTS
UNDER HOOD Battery State of Health # Fluids * Air Filter • Hoses • Cabin Air Filter
STEERING & * Steering & Suspension
SUSPENSION LF camber/ caster
out, camber kit bolt+ strut/
quick strut)
SHOCKS & • Shocks & Struts
STRUTS LF strut possible is bent,
EXHAUST 1 Exhaust
TIRE Tire Size Front 235/45/18 Tire Size Rear 235/45/18
EVALUATION
Speed Rating Load Range/Index
© TPMS Equipped? Feathering?
® Suggest Balance? * Cupping?
® Suggest Alignment?
LF RF RR LR
Tire Pressure Tire Pressure Tire Pressure Tire Pressure Initial: 35 psi Initial: 35 psi Initial: 35 psi Initial: 35 psi Current: 35 psi Current: 35 psi Current: 35 psi Current: 35 psi * Tire Tread © Tire Tread © Tire Tread © Tire Tread
1 / 3 / 3(32nd) Inside / Center 0 se 3(32nd) 91 9/ 9(32nd) 9/ 9 / (32nd) Inside / Center /Outside Inside / Center /Outside Inside / Center /Outside 1/32 1/32 9/32 9/32
Pap Boy! Courtesy Vehicle Inspection
BRAKE ® Front Visual Evaluation * Rear Visual Evaluation
EVALUATION RF LR
LF RR
® Brake Friction ® Brake Friction ® Brake Friction Brake Friction Inner Pad Inner Pad Inner Pad/Shoe Inner Pad/Shoe
Outer Pad Outer Pad Outer Pad/Shoe Outer Pad/Shoe
* Rotor i Rotor a Rotor/Drum * Rotor/Drum
Actual: Actual: Actual: Actual:
Machine to: Machine to: Machine to: Machine to: 2024 MAR 26 CITY Discard: Discard: Discard: Discard:
oF
WHEELS M Wheels Torqued to: RI
TORQUED
ALTO
OBD TEST CODE ® OBD Test Code
(na Initial Vent Temperature (na initial High Side Reading ® Initial Low Side Reading * Compressor Engages EVALUATION ma Cooling Fan
Pep Boys
REDLANDS BLV
REDLANDS, 192-992373
(909)
www.pepboys.com
03/04/2024 12:49:27 PM PST
Trans.: 159933 Store: 0833
Reg.: 105 Till: 105
Cashier: 495381
Service work Order COMPLETE
LIFETIME WHL ALIGN 199.99 N
1170564 1 @ 199.99
Order #: 2308802
COMP VSHICLE INSP 0.00 N
0787538 1 @ 0.00
Order #: 2308802 2024 MAR 26 PM 4: 36 CITY OF RIALTE
ENV HAZ WASTE FEE 0.25 T RECEIVLO
LAB2688 1 @ 0.25 CITY CLERK
Order#: 2308802
Sub-Total 200.24
Tax 0.00
Total 200.24
AmEx (D) 200.24
Account:
Auth: 853366(A)
Total Tender 200.24
Change Due 0.00
Application Label: AMERICAN EXPRESS
AID: A000000025010801
TVR: 0800008000
TSI: F800
AC: B40E40DC26D177P9
ARC: 00
Thank you for shopping at Pep Boys.
We accept most returns within 90 days
with the original receipt. For more
details, please refer to the return
policy in-store or at www.pepboys.com
Submit your rebate on-line at
www.pepboys.com/rebates
Service Work Order Number
2308802
Customer Copy
0933105 1599320240304
PREPARED FOR
Repair Estimate JULIE ORTEGA
Service Advisor Date 03/26/2024 01:50 PM
GARY GAMBOA (5629) 2019 Toyota AVALON
[email protected] VIN
Mileage 36,645
RO# 820790
2024 CIT
Service Name Price
[Primary]: 11TOZDC: DRIVEABILITY CUSTOMER STATES DRIVER FRONT STRUT MAY BE "BENT" ", STATESSHE WENT OVER A CENTER ISLAND ON THE ROAD AND GOT A FLAT -CHECK $0.00
AND ADVISE
[Primary]: 11TOZ01 : FEE ACKNOWLEDGEMENT CUSTOMER APPROVES AND AGREES TO THE 5.
CHECK OUT/DIAGNOSTIC FEEOF $199.00 CHECK OUT FEE INCLUDES UP TO AN HOUR OF CHECKOUT/DIAGNOSTIC PER CUSTOMER CONCERN CUSTOMER IS RESPONSIBLEFOR THE $0.00
MINIMUM CHECK OUT/DIAGNOSTIC FEE REGARDLESS IFCONCERNS A NORMAL CONDITION, CAUSED BY AN OUTSIDE INFLUENCEAND/OR CANNOT BE DUPLICATED.
X
[Primary]: 94TOZ04 : MULTI POINT INSPECT CUSTOMER AUTHORIZES MULTI POINT VEHICLE INSPECTIONCHECK TIRE PRESSURES AND ADJUST AS NEEDEDPERFORM DRIVER FLOOR $0.00 MAT INSPECTION TO ENSURE FACTORY ANDINSTALLED CORRECTLY. [Primary]: 95TOZ: RECOMMENDATIONS REC $0.00
Shock Absorber Replacement - Front: replace both front shocks and top hat (with bearing) - the left front shock has bent and does not have any dampening - recommend replacement as a set to maintain $1878.84 handling and vehicle dynamics
*Alignment: with suspension work $139.95
*Tires - 2: 235/45r18 - front two tires are moderately low on tread and have excessive camber wear $40.00 Wheel Bearing Replacement - Front: replace left front wheel bearing, feels rough when turned by hand $1010.81 Printed on March 26, 2024
Quote expires on April 25, 2024
Subtotal $3069.60
Total $3069.60
Toyota of San Bernardino (909) 571-5088
650 West Auto Center Drive
San Bernardino, CA 92408
(909) 571-5098
(909) 571-5098
Deferred by GAMBOA GARY on3/11/2024 at
PM
^ View Media
(909) 571-5098