CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY
2024 JUN 26 AM IO: 41
1. Cams for dah, reury to person, or to person pay is tie and ate then se ly montes her the curence fox Code 013E CELY ED
2. Claims for damages to real property must be filed not later than one (1) year after the occumence (Gov. Code 5911.2). RETURNtORK
3.READ ENTRE CLAM FOR BEFORE FLING Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETALS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
MaRyann Sandoval
DATE OF BIRTH
FULL NAME
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. (
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECENE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
03/23/2024 TIME: 9:17 • АМ ФУРМ
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: —
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on dagram on reverse side of this sheet Where appropriate, give street names and addresses, measurements and landmarks.
East Bound on Sherman way and Etiwanda
3. HOW DID DAMAGE OR INJURY OCCUR?
othe was not wisable with the low lamina trem SReet light Mignment became out of balance and ended up with a fh
tipe and the and tike needing replacement
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? • YES ANO
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.
Pothole was veRy large applaximately 2 filet lin diameter and 6-12 inches deep. Picture of pothole is attached for pRoof
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 465.06 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Alignment estimates - Giving an arg of Both 104.97 Replacement of 2 tiRes recast is BoR Amount: $ 360.09
fouR tires total6720.18)
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $.
Iter/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. MINESSES TO DALAGE OR IRY List ai persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: (_ )
DATE: TIME: • AM LIPM DATE: TIME: • AM OPM
9. PLEASE READ THE FOLLOWING CAREFULLY:
ofaccident by "X" and by showing house numbers or distances to street comers.
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 yoyrse fos your fehicle wen 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 anthe tife of the accident by "B-1" and the point of impactby "X". -
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED OX THE EEAMTANT.
N
Etiwanda
- E CURB sherman way
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
MaRyann Sandoral 06/10/2024
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
CITY OF RIALTO
2024 JUN 26 AM 10: 41
RECEIVED Sherman way and Etiwanda
CITY CLERK
pothole on
WELLS FARGO
CITY CLERA RECEIVED 2024 JUN 26 AM IO: 41 CITY OF RIALTO VISA SIGNATURE®
CARD $7,137.22
Outstanding balance
Balance Information
Payment Due Information
Minimum payment (due on 04/12/24) Make a payment
Balance Summary
Total credit limit
Outstanding balance
Available credit
Cash advance limit
Available for cash advances
Last statement balance 03/18/24
Last payment received 03/12/24
Next statement date
Activity
Pending transactions
First
Previous
Next
Transaction Date Posting Date Description Amount Running balance Posted Transactions
03/31/24 03/31/24 TMOBILE*PREPD
AUTOPY 877-778-2106
WA
03/31/24 03/31/24 AFTERPAY 185-
52896014 CA
03/30/24 03/30/24 ALDI 79085 PALMADALE
CA
03/30/24 03/30/24 SMART AND FINAL 437
PALMDALE CA
03/29/24 03/29/24 COSTCO GAS #0762
LANCASTER CA
03/29/24 03/29/24 COSTCO WHSE #0762
LANCASTER CA
03/29/24 tZ/6Z/80 COSTCO WHSE #0762
LANCASTER CA
03/29/24 t2/62/80 COSTCO WHSE #0762
LANCASTER CA
03/29/24 tz/62/80 ALDI 79085 PALMADALE
CA
03/29/24 t2/62/20 CVS/PHARMACY
#09785 LANCASTER
CA
03/28/24 03/28/24 AMERICAS TIRE CAL 44 $720.18
PALMDALE CA
03/27/24 03/27/24 GRAND PANDA
NEWHALL CA
03/26/24 03/26/24 HP *INSTANT INK 855-
785-2777 CA
tZ/92/80 t2/92/80 CVS/PHARMACY
#09785 LANCASTER
VIEW SALES INVOICE
AMERICA'S TIRE 3/28/2024
6:07 PM
MARYANN PHAM
2014 TOYOTA Plate#:
COROLLA Miles 127,796
17"BASE Coraue Specs: 80
2024 JUN 26 AMIO: 41 CITY OF RIALTO
CAL 44 CA# ARD278480
38235 47TH ST E 1258009
PALMDALE, CA 93552
661.998.2488
Salesperson 888
DAX G H
Estimated Completion Time: 06:52 PM :
Article Qty Description FET Price Amount
------
106141 4 225 94W XL BSW 121.00 484.00
ROAD HUGGER GTZ A/S
TIRE MILEAGE WARRANTY: 45000
BOLT PATTERN: 5-100
INFLATION F: 029 R: 029
4 CERTIFICATES FOR 19.86 79.44
REPLACEMENT
For tire certificate details, see
www.americastire.com/customer-service/certificates
80075 4 STATE REQUIRED 1.75 7.00
NRM TIRE FEE
80224 4 WASTE TIRE 2.75 11.00
DISPOSAL FEE
4 INSTALLATION & 22.00 88.00
LIFE OF TIRE MAINTENANCE
Terms and Conditions can be found at
www.americastire.com/customer-service/invoice-terms
The tire and/or wheel you have chosen is different
from the original equipment provided with your
vehicle and may change its handling or stability
information is available from your
America's Tire salesperson.
•
Sub Total: 669.44
Sales Tax: 50.74
•
Sales Total: 720.18
•
Tendered: 720.18 (VIS)
Tkn# XXXXXXXX Ath# 028590
Tendered Today: 720.18
Tendered Total: 720.18
3/29/ Tekion Repair Orders
Ton's TIRE
Forte selencas
AND RUTO REPAIR
V
Jeff Sage
Sales Manager
43104 10th St W., Lancaster, CA 93534
P (661) 945-7173 F (661) 949-3560
[email protected]
www.teamtire.com C/R O None
Concern C/S
1. 00RBA - 4 WHEEL ALIGNMENT
4 WHEEL ALIGNMENT
O Open CP 1.30 hrs $139.95
Cause
Add Cause
Corrections
Pay Typo*
Totei 85te
W
1.30 $139.95
Toyota of Lancaster Op1. 4ALIGN - 4 WHEEL ALIGNMENT O Edit 43301 12th St. West
OEM Opcode: 00RBA 0
Lancaster, CA 93534
Labor Hrs * isbor Rate* Bill Hirs * Labur Prien "
1.30 hr Fixed : 1,30 hr $ 139.9
Tech story
SITE PERFORMED FOUR WHEEL ALIGNMENT.
AM 10: 41
CLERA Add Story Line
CITY OF RIALTO Parts $0.00
CITY
Part Quantit
2024 JUN 26
Select a value
Acid Erit Ocerations
Fees $0.00
Fee Code Total Price Total Cost
Select $ 0.00 0.00
2 estmate --. ..
- Toyota of lancastee
- Tom's TiRe
Total $139.95 Review Service
https://app.tekioncloud.com/ro/auotes/660749e97a7c03315A2efff7/servira/fA0740fR3hQ223493h79555h 111 M. Pham Retail U.S. POSTAGE PAID site
FROM: _ FCM LETTER , * hess
PALMDALE, CA 93550-06 areness
JUN 24, 2024
CITY OF RIALTO
92378 $0.92
2024 JUN 26 AM 10:44 RDC99
S2324A500832-9
RECEIVED
CITY CLERX
92376-643090