CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 AUG 13 PM 4: 29
TO PERSON OR PROPERTY
MECEIYED
CLY 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. 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:
Andy Mercado-Varquct
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO BUSINESS ADDRESS INGLUDING 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: 07/27/2024 -TIME: 4:20
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet. 16247655 Rialto Ave, Fontona, la 92335 4 hetween 1080 W The car was parked tooing West towards
arrow bival. Coordinates 34.09952° N, 117.40429°W
The tow truck driver tored my car to mae Withut preyer froteca not falling proper prosoira dealing tuith All-whoe-dane
4. WERE POLICE AT THE SCENE? DYES • 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 The diver Christian M, trut 52 improperty towed my vehil, mat any sensors, rimsubeal fant left sile e
ervice, contacted hu liatto PID
$ 7,
HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Urive sh aft, screw, rom censor, engine cover, kim, laytount: $ 6, 16l. 78 Item/Date: eés Pepes tawing Amount: $862.3
release
RPD
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 7,624,08 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $
Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES:
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE; | TELEPHONE: | )
DATE: TIME: • AM • PM DATE: TIME: • AM •] 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 SIGNER BY THE CLAIMANT. gure
CURBL xRialto Ave Arrow
Bive
PARKWAY
linden SIDEWALK Myphe
Cielo Viste LAS
Apostments LLC PAlMAS
! 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 CERTIFYJOR DĘCLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE GF CLAIMANT OR AGENT
andy mercado - Vuzquet 8/13 /2024
TYPE OR PRINT NAME DATE
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 ฿ 1224,4:40 PM
myKaarma
205-684-02-18 COVER SUBSTRUCTURE $226.10
$226.10 400T
205-401-13-00- EXCHANGE SPOKED
7X21 $1,249.76 AFA $1.249.76
WHEEL
WEIGHT 3MWEIGHT $8.65
$8.65 306
Parts Sales Amount: $4,158.33
Labor Type:CP Labor Hrs:8Hrs Labor Sales Amount: $2,239.60 Tax + MiscFees: $363.85
Total: $6.761.78
03113038
62:1k0 81908330z
CITY OF RIALTO
Tow damage Repair 2024 AUG 13 PM 4:29
RECEIVEL
Part# CITY CLERK
Part Description Qty Price Bin Total Price In Stock?
205-330-38-06 DRIVE SHAFT $1,701.30 311 $1,701.30
000-990-75-03 SCREW $30.72 019F $30.72
006-994-09-40 SNAP RING $7.02 012B $7.02
205-905-45-07 RPM SENSOR $168.98 N.A. $168.98
169-540-16-17 BRAKE WEAR SENSOR $30.72 012A $30.72
COVER FENGINE COMP. 406H $282.88
205-520-06-00 $282.88
BM
COVER FENGINE COMP. $226.10
฿226.10 IN.A.
205-524-07-30
BM
$226.10
COVER SUBSTRUCTURE $226.10 400
205-684-01-18
htps://app.mykaarma.com/sorvice.htm/@partner=mykaarma&skin=mykaarma?patner=mykaarma&skin=mykaarma#MENU@/nspect-INSPECTTABS
CITY OF RIALTO
2024 AUG 13 PM 4: 29
RECEIVEC
CITY CLERK
Rialto - Downtown Edit
July 30 3:57PM
O LIVE V
BE:
Cotision Prevention
Assist Plus
CITY CLERA
RECEIVEd
2024 AUG 13 PM 4: 29
CITY OF RIALTO
CITY CLERK
RECEIVED
2024 AUG 13 PM 4: 29
CITY OF RIALTO
Al and the po a Cay/Town v a was invoked Ay showing horr sos, place on " •OWING CARF CATION AND F datornation (atise" Tog.
Pepe's Towing Service
PO Box 7450, Moreno Valley CA 92552 Impound Ir
Fring O Phone: (951) 682-5682 | Fax: (951) 682-5030
Printe
Released To ANDY MERCADO VAZQUEZ
Invoice # Phone:951291
24-0727-40869 Reason for impound
Call # 22651-0 EXPIRED REGISTRATION
40869 VIN Number
Case # 55SWF6G87FU018457
932407958 Model
Lien Start Date 2015 Mercedes-Benz C-Class White
7/29/2024 Licensa Plate 7JHA244 (CA)
Case #
932407958 Drivable Yes
Account
RIALTO PD Keys No
Date/Time Requested 7/27/20244:03 PM
Towed from 1655 W Rialto Ave, Fontana, CA. 9.
Date/Time Dispatched 7/27/2024 4:03 PM
Stored at Willow Yard
Date/Time Arrived to scene; 7/27/2024 4:09 PM 2879 S. Willow Avenue, Blooming Data/Time Towing Time: 7/27/2024 4:21 PM
Date/Time Completed: 7/27/2024 4:27 PM
Date/Time Impounded: 7/27/2024 4:27 PM
Driver Christian M.
Truck TRK 52
Date/Time Released: 7/30/2024 1:52 PM.
Days Held in Impound 4 days
Notes
Quantity Pric
Storage charges
$77.0
Storage - Storage Fees) Impounds/Storage: Daily Impound Rate CITY CLERK RECEIVEL 2024 AUG 13 PM 4:29 CITY OF RIALTO