CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 JUN 17 AMIO: 54
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
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. Chaims for damages to real property must the filed not later than one (1) year after the occumence (Ger. 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:
OMAR Hassan
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: April 26,2024 _ TIME: 10:70 AM 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.
On Alva mansa Road near Enterprise Road and s.
Riverside Ave. The industrian Corridor. Near fesex
locater at 330 Relovice Drive.
3. HOW DID DAMAGE OR INJURY OCCUR?
It was raining and there were massime for holes that
the city had notice of. Due to the rail, I did not see
the marine nut holes and thus my car dear into the hole.
4. WERE POLICE AT THE SCENE? • YES D/NO WERE PARAMEDICS AT THE SCENE? •YES DO 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 masse pot holes that the city is/ was awar of
Diner the industries asper of this load. Due to net hole, my to la had a blown our tiled ad a beat rim.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 1,165.53 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
2 slown out finel-Arril 26 189.53
Item/Date: _ Amount: $
Item/Date: Cracker beat Rim - Aro:" 26 Amount: $ 125
Tor Home -Arril 2t $ 851
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $- N/A ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
NIA CITY OF RIAL T Amount:$.
Item/Date:
2824 JUN 17 AMIO: Spount: $.
Item/Date:
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: RECEIVED
7. WITNESSES TO DAMAGE OR MUR LS l person know 10 have information catach achine pages of esan) NAME: Besides tow dever and reone NAME: _
ADDRESS: who worked on My cur, none. ADDRESS. -
TELEPHONE: () TELEPHONE: L)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NIA NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: |)
DATE: TIME: L AM LI PM DATE: TIME: L AM LI 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 frst saw City/Town vehicle; location of City/Town vehice 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.
CURB
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 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
OmaR f. Hassan June 1y, 2024
TYPE OR PRINT NAME DATE
self
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) DETIDA AI AIRTA. DIA TA RITU I EDUE NECINE - 1ED C DAIM AVE DINI TA CA 03370 1200377 Rancho Towing
42620 Rio Nedo, Temecula CA 92590 #250381
TOWING Phone: (951) 296-9101 | Fax: (951) 296-9119
CITY OF RIALTO Printed 4/26/2024
Invoice# 250381 Authorized 202Y JUN 17 AMIO: 54
Call # 250381 by
Tow From 30B RESCuEd re Ripomington, CA 92316, USA (305 Tow Reason Tow
Resource Drive RA
Dispatcher Morgan liffy
Tow To
Driver Mr. K
Truck FB 042
Date/Time Requested 4/26/2024 @ 11:49 AM
Contact
Notes $851.00 COLLECT FROM CUSTOMER AT DROP
2 BLOWN TIRES PASSENGER SIDE
PICK UP: PARKING LOT
DROP: RESIDENCE
Year Make Model Color VIN Plate Odometer
2024 Audi 55 Sportback Gray WAUC4DF59RA025821 9LCF102 CA - Charge Description Quantity Price Line Total
Unloaded/Enroute Mileage 43 $6.00 $258.00
Loaded/Hooked Mileage $12.00 $468.00
Tow Hookup $125.00 $125.00
Grand Total $851.00
Amount Due: $0.00
Cash payment of 5851.00 a926/2024
Rancho Towing appreciates your business. If you have any questions regarding this invoice, please contact us at 951-296-9101. Thank you.
Signature:
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice 18184 Valley BlaY OF RIALTO
Bloomington 264, 37316
Phone: (840) 888-7826 AM/O: 5
LAE RECEIVED
CITY CLERK
Wheel Repair & Refinish
New & Used Tires
Name: Address:
City: State: _Zip:_
Phone: Date: 4-26-24
Make: Lic Plate:_ _ Miles:_
OTY. DESCRIPTION LABOR PARTS
1 125
2 3
4 5
6 9
10 Deposit S Terms: Other •
Balance $ TOTAL PARTS
Labor
Sales Tax
Total
Thank You for Your Business Signature Date
FIND SPORE HOURS
AMERICAN
AND LOCATIONS OMLINE
AMERICANTIREDEPOT.COM
TIRE DEPOT Started Time: 4/26/2024 11:13:15 AM
ITY OF RIALTO Invoiced Time: 4/26/2024 3:39:30 PM
A BeGBRAND TIE & SERVICE COMPANY
Invoice#: 11643- 17248m1
IS OMAR NEORMANUN
HASSAN, OMAR Cust #: ED-4756359 2024 AUDI S5 PREMUM PLUS. RIALFO #1164 BAR#.ard301170 RECEIVE 110 E VALLEY BLVD EPA#:CAL000470371
Engine: V6-2995CC 3.0L .
Plate #: NO PLATE CA RIALTO. CA 92376
CITY CLERK
VIN Number: WAUC4DF59RA025821 Phone- (909) 341-0909
Emaits: Vehicle Service Emats Inactive Miles: 1661 Started By AQ819 Invoiced By. ALAN QUINONEZ (AQ819)
CNT 03586300000 265/30R20XL 94Y CONTISPORTCONTACT 5P CNT - AM810 AQ819 $370.99 2.0000 $741.98 Tire Serlale AFKUD75W4423 AFKUD75W4423
* CONSUMER ADVISORY THIS IS A "Y" RATED TIRE. IT HAS AMAXINUM SPEED OF 186 ALPH. IT HAS "Y" RATED HANOLING CHARACTERISTICS. CONSULT YOUR OWNERS MINUAL FOR THE PROPER SPEED RATING RECONMENDED FOR YOUR VEHICLE. CUSTOMERS
INITIALS
CDF CDF TIRE RECYCLING AM810 AQ819 $5.00 2.0000 $10.00
LBR WBHS HIGH SPEED WHEEL BALANCE AM810 AQ819 $20.75 2.0000 $41.50 SHP ww PREMIUM WHEEL WEIGHTS AM810 AQB19 $4.50 2.0000 $9.00 STF CALF. STATE TIRE FEE 2.0000 $3.50
DSC DISCOUNT CUSTOMER DISCOUNT/REBATE AMBIO AQB19 $35.00 -2.0000 $-70.00 LBR DEW GUEST DECLINED TIRE MAINTENANCE CERTIFICATE -- AM810 AQ819 $0.00 1.0000 $0.00
EXTENDED WARRANTY
EXTENDED WARRANTY OFFER HAS BEEN DECLINED. EW PRICE OFFER IS VALID FOR 30 DAYS AFTER INVOICE DATE.
Vehicle Tire Pressure - F:38 R. 38
Pace 1 of 2
FIND STORE HOURS
AMERICAN AND LOCATIONS ONLINE
AMERIGANTIREDEPOT.COM
TIRE DEPOT Started Time: 4/26/2024 11:13:15 AM
Invoiced Time: 4/26/2024 3:39:30 PM
A BOOBMAND TIE & SERVICE COMDANY Y OF RIALTO
MORL LOCATON
COMERINI
BAR#:ard301170
HASSAN, OMAR Cust #: ED-4758359 2024 AUDI SS PREMUM PLUS 110 E VALLEY BLVD EPA#:CAL000470371
Engine: V6-2995CC 3 OL RECEiYEU
RIALTO. CA 92376
Plate #: NO PLATE CA CITY CLERA
VIN Number: WAUC4DFS9RA025821 Phone: (909) 341-0909
Miles. 1681 Started By AQ819
Emails: Vehicle Service Emails inaclive invoiced By: ALAN QUINONEZ (AQ819) Invoiced Summary
Revisions Payment Invoice Totals
Emp. Prev. Revised Type Auth Emall/ Phone Type Amount Parts: $690.98 Date
CCD2 789.53 FET: $0.00
2114578456 Shop Fees: $0.00
OMAR HASSAN
American Express 2008 NonTax: $45.00
EMV: APPLABEL:AMERICAN Tax: $53.55
EXPRESSIAID:A000000025010801T
VR.0880008000|IAD: 06570103A0A00
OTSI:E800JARQC:3F1BAB551B86DD
19/ARC:00|CVM:S
Total: $789.53
I acknowledge below and receipt of this invoice
This estimate Is based on our inspection at this time and does not cover additional parte and labor which may be required afterthe work has been started. After the work has started, wor or damaged parts which are not evident on first inspecilon may be discovered. This estimate cannot cover such contingencles, in cases where additional work is deemed necessary, customer authorization will be secured prior to commencement of that additional work. This estimate expires 15 days from date. I hereby authorize the repair work to be done along with the necessary material and hereby grant you and or your employees permission to operate the vehicle herein described on the streets, highways or elsewhere for the purpose oftesting and/or inspection. An express mechanic's lien is hereby acknowiedged on above vehicle to secure the amount of repairs thereto.
Dealer not responsible for unavailabllity of parts or delays in parts shipments beyond dealers controi not for loss or damage to vehicle or articles left in vehicle in case offire, theft or any other cause beyond our control. 12 months/12,000 mlles for parts and labor. 6 months/8,000 miles for alignment warrantles See website for additional warranty details. All parts are new unless otherwise specifted.
Customer Signature or Initials:
acknowledge notice and oral approvat oran increase in the original estimated price
CITY OF RIALTO
- Front passanger
tive
-blown out
- bent /cracked sim
CITY OF RIALTO
2024 JUN 17 AMIO: 54
- Back Passanger tire CITY CLERK RECEIVED
- Slown out phe
- Serattled to lil
Retail U.S. POSTAGE PAID
FCM LG ENV
OmaR tassan HEMET, CA 92543
JUN 14, 2024
HAS SAVE
923 6 $1.63
RDC 99 R2305H130544-12
2024 JUN 17 AM 10: 54 CITY OF RIALTO
ELLERA
Rialto's City Clerk's office
150 S. Palm Ave.
Rialto, CA 92376
pollen