CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 OCT 28 AMIO: 16
TO PERSON OR PROPERTY
RECEIVED
CITY CLERA
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gow. 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:
Raymond Ayers Ir
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: 10. 21.24 10.00 TIME: DAM DIPM
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. my car was parked on lilac in tront of
3605llac weere it was towed for no reasor
3. HOW DID DAMAGE OR INJURY OCCUR?
my velcle was towed
4. WERE POLICE AT THE SCENE? EYES NO WERE PARAMEDICS AT THE SCENE? • YES• 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.
my truck was towed for no reasom which
Caused me to
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $634.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: tow Invoice Amount: $_634.00
Item/Date: Amount: $
RA
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 134. 00 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: L
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: (
TELEPHONE: L)
DATE: TIME: • AM OPM
DATE: TIME: DAM 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 comers. 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 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 → NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
SIDEWALK
THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE. 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 I CERTIE NO DESI ADELINED PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SENATURE OF CLAIMED OR AGENT
TYPE OR PRINT NAME mond Ayers Jo 10.28.24
DATE
Selt
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
PEPES TOWING SERVICE
14351 VETERANS WAY
MORENO VALLEY, CA. 92553
951-653-2423
DEBIT SALE
•
REF#: 00000001
Batch #: 239 RRN: 1022200825
10/22/24 13:08:25
Inv/Tkt #: 46582
APPR CODE: 401151
Trace: 1
DEBIT Chip
AMOUNT $634.00
APPROVED
DEBIT
AID: A0000000980840
TVR: 80 80 04 80 00
TSI: 68 00
THANK YOU
CUSTOMER COPY
Pepe's Towing Service Impound Invoice
PO Box 7450, Moreno Valley CA 92552
Touring • Service Phone: (951) 682-5682 | Fax: (951) 682-5030 Printed 10/22/2024 Released To RAYMOND AYERS JR
Phone:
Invoice # 24-1021-46582 Reason for Impound 22651-0 EXPIRED REGISTRATION Call # 46582 VIN Number
Case # 932411654 Model 2004 Chevrolet Suburban (Tan)
Case # 932411654 Drivable
Account RIALTO PD Keys
No
Date/Time Requested 10/21/2024 10:03 AM Towed from 630 S LILAC AVE RIALTO Date/Time Dispatched 10/21/2024 10:04 AM Stored at Willow Yard Date/Time Arrived to scene: 10/21/2024 10:15 AM 2879 S. Willow Avenue, Bloomington CA 92316 Date/Time Towing Time: 10/21/2024 10:29 AM
Date/Time Destination Arrival: 10/21/2024 10:45 AM
Date/Time Completed: 10/21/2024 11:00 AM
Date/Time Impounded: 10/21/2024 11:00 AM
Driver Dustin D.
Truck TRK 64
Date/Time Released: 10/22/2024 1:05 PM
Days Held in Impound 2 days
Notes
Storage charges Quantity Price Line Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 2 $77.00 $154.00 Towing charges Quantity
Price Line Total
(Towing) Admin Fee $95.00 $95.00
(Towing) TOWING FEE PORT TO PORT (price per hour) I(an) $385.00 $385.00
Towing SubTotal $480.00
Storage - Storage Fees SubTotal $154.00
Subtotal $634.00
Taxes $0.00
Grand Total $634.00
Amount Due: $0.00 / Paid
Visa payment (Ref # 3997/AUTH/401151) of $634.00 applied on 10/22/2024 Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you.
Damage Disclaimer:
I Have been advised that my vehicle may be damaged if winched, towed, unlocked, jump started, tire changed or left on unattended premises. I recognize the difficulty involved and I agree not to hold Pepe's Towing Service responsible for such damages should it result. I, the undersigned do hereby certify that I am legally suth aced codentold to take possession of the vehicle described and all personal property therein. I have received the vehicle and all personal property in Signature: Date:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice 10/22/24, 12:28 PM Invoice
Pepe's Towing Service Impound Invoice
PO Box 7450, Moreno Valley CA 92552
Phone: (951) 682-5682 | Fax: (951) 682-5030 Printed 10/22/2024 Toting ferrier
Invoice # 24-1021-46582 Reason for Impound 22651-0 EXPIRED REGISTRATION Call # 46582 VIN Number
Case # 932411654 Model
2004 Chevrolet Suburban (Tan)
Case # 932411654 Drivable No
Account RIALTO PD Keys No
Date/Time Requested 10/21/2024 10:03 AM Towed from 630 S LILAC AVE RIALTO Date/Time Dispatched 10/21/2024 10:04 AM Stored at Willow Yard Date/Time Arrived to scene: 10/21/2024 10:15 AM 2879 S. Willow Avenue, Bloomington CA 92316 Date/Time Towing Time: 10/21/2024 10:29 AM
Date/Time Destination Arrival: 10/21/2024 10:45 AM
Date/Time Completed: 10/21/2024 11:00 AM
Date/Time Impounded: 10/21/2024 11:00 AM
Driver Dustin D.
Truck TRK 64
Notes
Storage charges Quantity Price Line Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 2 $77.00 $154.00 Towing charges Quantity Price
Line Total
(Towing) Admin Fee 1 $95.00
$95.00
(Towing) TOWING FEE PORT TO PORT (price per hour) 1(1h) $385.00 $385.00 Towing SubTotal $480.00
Storage - Storage Fees SubTota $154.00
Subtotal $634.00
Taxes $000
Grand Total $634.00
Amount Due: $634.00
Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you.
Signature: Date:
CA# 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice https://app.towbook.com/impounds.Impound.aspx?id=20629831 1/1
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
VEHICLE REPORT NOTE: CHP 180 IS FURNISHED TO ALL PEACE
OFFICERS BY THE CALIFORNIA HIGHWAY PATROL
CHP 180 (Rev. 4-16) OPI 061
REPORTING DEPARTMENT FILE NO.
RIALTO PD 3609 10-21-24 1000 932411654
LOCATION TOWED / STOLEN FROM ODOMETER READING VIN CLEAR IN SVS* (X] YES • NO DATE / TIME DISPATCH NOTIFIED 630 S LILAC AVE [LOG NO.
LIC. CLEAR IN SUS? [X] YES NO 10-21-24 1000
YEAR MAKE MODEL BODY TYPE COLOR LICENSE NO.
2004 CHEV SUBURBAN 4DR X ONE MONTH/YEAR STATE
TAN • TwO 05/2023 CA
VEHICLE IDENTIFICATION NO. ENGINE NO. [VALUATION BY
X OFFICER OWNER
Das 501-4000 4001+
Г REGISTERED OWNER
•I SAME AS RIO LEGAL OWNER 7
ILLO JOSEPH D BK ONE NA
8691 MOODY ST PO BX 11606
CYPRESS CA 90630 LEXINGTON, KY 40576
L
[X] STORED • IMPOUNDED • RELEASED • RECOVERED - VEHICLE / COMPONENT
TOWING / STORAGE CONCERN (NAME, ADDRESS, PHONE)
STORAGE AUTHORITY / REASON
PEPES TOW - 2775 N LOCUST AVE RIALTO, CA 92376 (909) 574 - 1490 22651 (O)(1)(A)
REASON FOR STOP
AIRBAG? DRIVEABLE?
VIN SWITCHED?
1124
EX YES •NO 1 X 2 L YES - NO • JUNK X UNK
• YES
CONDITION YES NO ITEMS YES NO ITEMS
YES NO ITEMS YES NO TIRES / WHEELS CONDITION
WRECKED X SEAT (FRONT) X
REGISTRATION X CAMPER X LEFT FRONT FAIR
BURNED HULK per 431(c) CVC SEAT (REAR) ALT. /GENERATOR X VESSEL AS LOAD
X RIGHT FRONT FAIR
VANDALIZED RADIO X BATTERY
FIREARMS X LEFT REAR FAIR
ENG. / TRANS. STRIP X TAPE DECK X DIFFERENTIAL
X OTHER X RIGHT REAR FAIR
MISC. PARTS STRIP X TAPES TRANSMISSION
X X SPARE UNK
BODY METAL STRIP X OTHER RADIO X AUTOMATIC X
HUB CAPS YES
SURGICAL STRIP per 431(b) CVC X IGNITION KEY X MANUAL X
SPECIAL WHEELS NO
RELEASE VEHICLE TO A RIO OR AGENT • AGENCY HOLD 22850.3 CVC
GARAGE PRINCIPAL / AGENT STORING VEHICLE (SIGNATURE) DATE / TIME DUSTIN / PEPES 10-21-24 1000
NAME OF PERSON / AGENCY AUTHORIZING RELEASE L.D. NO. DATE DRICE RIANTO 10/21/24 CERTIFICATION: I, THE UNDERSIGNED, DO HEREBY CERTIFY THAT I AM LEGALLY PD 01760 AUTHORIZED AND ENTITLED TO TAKE POSSESSION OF THE ABOVE DESCRIBED VEHICLE
SIGNATURE OF PERSOMAUTHQRIZING RELEASE IGNATURE OF PERSON TAKING POSSESSION • STOLEN VEHICLE / COMPONENT • EMBEZZLED VEHICLE PLATE(S) REPORT
DATE / TIME OF OCCURRENCE DATE / TIME REPORTED
NAME OF REPORTING PARTY (R/P) DRIVER LICENSE NO. / STATE
LAST DRIVER OF VEHICLE DATE / TIME ADDRESS OF RIP
TELEPHONE OF RIP
*ERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS ( SIGNATURE OF PERSON MAKING REPORT
IE STATE OF CALIFORNIA THAT THE FOREGOING IS TRUE AND CORREC [LIST PROPERTY, TORES, VERCE DAMAGE, ARRESTSI
DRIVER'S NAME ARRESTED / SECTION? REPORTED BY [CARGO / TYPE? VALUES
PARKED SANCHEZ
I BILL OF LADING ATTACHED
VEH PARKED ON POSTED NO PARKING RMV 10.28.040(D). VEH TEMP PLATE UTL, VIN SHOWS VEH REGISTRATION EXPIRED OF 05/2023.
NOTHING OF VALUE MISC TOOLS AND ITEMS. 3&S 360.
FRONT LEFT SIDE RIGHT SIDE REAR
SIGNATURE OF OFFICER TAKING REPORT TOP
T.D. NO. TSUPERVISOR REQUIRED NOTICES SENT TO REGISTERED X YES IDATE NOTIFIED CSANCHEZ 02504 DS AND LEGAL OWNERS PER 22852 CV?
• NO
An Internationally Accredited Agency Chp180_0416.pof
XR
NO
STOPPING
ANY
TIME
NO
TRUCK
STOPPING
ANY TIME
COYMEY
SPÈED
LIMIT
40 7SYB620
CE/TEMPORARY IDENTIFICATION:
efore delivery to the purchaser) 61046638
VEHICLE NTIFICATION NUMBER
EMFORARY OK PERMANENT LICENSE PLATE NUMBER
0f/1: 024-
APTISTE NO CIT • STATE RIP CODET
SAN BERNEDNO. CA 92201
IMPORTANT! ENTER BQTH DEALER'S AND SALESPERSOR'S NOMEERS The SA notice of purenase of vehicle. Do not use as an application for regis ation pette Here
/ /
DEC California 2024
ROS* 61046638 CHEV VIN: 3GNEC16T54G260861 EXPIRES: 12/15/2024