CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY CLAIM FOR DAMAGES CITY OF RIALTO
TO PERSON OR PROPERTY 20Z4 OCT 31 PIS 1:44
2. Clams for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2). 1. Claims for death, injury to person, or ia personal property must be fled nat fater than six (6) months after the occurrence (Gov. Cade Pay LIVE L RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS CLAIMANT INFORMATION:
Albert Ortiz 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 RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 5/31|24 TIME: 2:40 JAMOPM
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 East Rialto Avenue, Crossing N. Peller ave between the
Arco and 76 Gas Stations, Guiny Eastbound towards
San Bernardino
3. HOW DID DAMAGE OR INJURY OCCUR?
water Manhe or was ast and layng sidew but
Go feet away. Drove over it and Damaged transmission
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? YESTNO
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.
City of Rialto
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $3,800 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Kia Dealer 5/31/24 via Phane Amount: $ 3,800 Item/Date: Kia Dealer in Verson (0l1/24 Amount: $ 3,683:56 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $3,680.00 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: Priscilla Martinez
NAME:
ADDRESS:
ADDRESS:
TELEPHONE:
TELEPHONE: L 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE: ( TELEPHONE: L)
DATE: TIME: • АМ •РМ
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 letler "A* location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle accident by "B-1" and the point of impact by "X". 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 → NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT. repperpree 2888
2 Park
носу Arco Gas
East Rialto
CURB
101s
PARKWAY Machab
76 SIDEWALK PI • Peffer
have Ave Gas
1055
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.
N CERTIFY OR DELARE LINNER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Albert Ortiz
TYPE OR PRINT NAME 10/31/24
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
VALLEY KIA
R/O Open Date RIO Number
FONTANA 6/01/24
16272 S Highland Ave - Fontana, CA 92336 SERVICE DEPARTMENT HOURS 6181946/1 Time Received Time Promised
Phone: (909) 350-2700 Fax: (909) 350-2780 7:00 a.m. to 6:00 p.m.
Monday - Friday 9:38 6/01 17:00
www.valleykia.com Current Mileage
B.A.R. # ARD00190201 8:00 a.m. to 2:00 p.m. Saturday Mileage Out 136372
Estimate of Repairs Service Advisor / Key Tag #
175.00 RAUL PARIS/551
ORTIZ, MARIO
Work Phone Vehicle Identification Number
Home Phone Delivery Date
In-Service Date
Year Make 9/02/17
Model Body 9/02/17
2017 KIA FORTE Color
License Number
K8072 CENTURY SERVICE PLUS 100000 or 9/02/27 Ded O WHITE CENTURY MAINTENANCE PLUS 45000 or 9/02/21 Ded 0
Job Number Description of Work
PERFORM 360 VEHICLE INSPECTION. $29.99 VALUE Code
COMPLIMENTARY WITH ANY SERVICE. INSPECT AND SET TI KCP1 MPI RE PRESSURE AS PER CALIFORNIA AB32 LF RF LR RR Internal Job Number Description of Work
VALLEY KIA NOW OFFERS FLEXABLE PAYMENT PLAN FOR Code
PARTS & SERVICE. DONT PUT OFF THOSE IMPORTANT REPA 999
IRS. SEE ADVISOR FOR DETAILS OR VALLEYKIA. COM Internal Job Number Description of Work
CUSTOMER STATES Code
he hit a man hole and now has transmission 111
Customer Pay
Customer Pay
Job Number Description of Work
Code
4. Job Number Description of Work
Code
ERMS: STRICTLY CASH UNLESS ARRANGEMENTS MADE
• other cause beyond your control or for any delays caused by unavailablity of parts or delays in parts shipments by the supplier or transporter. I hereby grant you or your empioyees permission to operate the ereby authorize the repair work above to be done along with the necessary material and agree that you are not responsible for loss or damage to vehicle or articles left in the vehicle in case of fire, theft. or cle herein described on streets, highways, or elsewhere for testing and/or inspection. An express mechanic's lien is hereby acknowiedged on above vehicle to secure the amount of repairs thereto." SCLAIMER OF WARRANTIES.
• warranties on the products sold hereby are those made by the manufacturer. The seller hereby expressly disclaims all warranties either express or implied, including any implied warranty of merchantabsty or iss for a particular purpose and the selier neither assumes nor authorizes any other person io assume for it any liability in connection with the sale of said products. Any limitation contained herein does not apply re prohibited by law. 2012 DEALERTRACK SYSTEMS. In - Domierep Application Group (800 945-1025 Parts Transactions •l View a tour
Counter Salo • Counterperson: CESAR JUAREZ Actions Print Name: Q CASH SALE Quate Number: Q008504969 Invoice #:
A/R #: PO #:
A/R Terms: Make/Model:
Email: VIN:
Phone:
Price Level: Retail
Sale Type: Retail
Nunber/Description Din/Shels Rty/AvI List Net :Action
Par=
86511 B0000 COVER-FR BUMPER RACK 1/EP 402.15 398.13 398.13 80 0 86522 B0000 MOULDING-FRONT BUMPE TOP BIN 1/EP 147.40 145.93 145.93 96985 3X000 SENSOR-EXTERNAL AMBI L7 8 1/EP 29.98 29.68 29.68 29110 B0000 PANEL ASSY-UNDER COV 202 C 1/1. 96.52 95.55 95.55 45000 2F511RCA REMAN TRANSMISSION SPORD 1/EP 1192.50 1180.58, 1180.58 1 0 45000 2F511RCA-C Core Charge: 450002F511RC 1/EP 1000.00 1000.00 1000.00 • 0 UM013 CH059 ATF TYPE 4(M) (12) A 5 5/47 20.21 20.21 101.05 Promo Messages: ** EPA ID-CĂL000417194 "*
Previous Next
Freight:
Function KIu
Fees/Discounts:
Parts: 2956.92
Taxes: 228.70
Deposit:
# Shipping Total: 3179.62
Save Exit Delete
Every thing 10 Hrs
trans only o tos
22955
750
80 22005 pre paid 1, 002
Depasit.
4980° 3,6808
VALLEY KIA
16272 S LSHLAND AVE
FONTANA, LA 42156
09:05:56
06 07,2024
CREDIT CARD
MC SALE
XxXXXXXXXXX4221
Card #
Chip Card: CAPITAL ONE
A00000000-41010
AID: 5
SEQ #: 239
Batch #: 6181946
REFERENCE 066952
Approval Code: Contactless
Entry Method:
Issurer
Mode:
SALE AMOUNT $1000.00
CUSTOMER COPY
VALLEY KIA RIO Open Date
R/O Number
FONTANA 06/01/24 6181946/1
16272 S Highland Ave - Fontana, CA 92336 SERVICE DEPARTMENT HOURS R/O Close Date Status 7:00 a.m. to 6:00 p.m. 06/14/24
Phone: (909) 350-2700 Fax: (909) 350-2780 Monday - Friday Pre-Invoice www.valleykia.com 8:00 a.m. to 2:00 p.m. Saturday Mileage In Mileage Out B.A.R. # ARD00190201 136372
136373
Service Advisor / Tag #
ORTIZ, MARIO RAUL PARIS/551
Work Phone Vehicle Identification Number
Home Phone Delivery Date
In-Service Date
Year 09/02/17 09/02/17
Make Model
Body Color License Number
2017 KIA FORTE 4D
K8072 WHITE
DESCRIPTION OF SERVICE AND PARTS
Cell: Email: AMOUNT
#1 - KCP1 MPI: PERFORM 360 VEHICLE INSPECTION. $29.99
VALUE***SEE ATTACHED INSPECTION SHEET***
COMPLIMENTARY WITH ANY SERVICE. INSPECT AND SET TI
RE PRESSURE AS PER CALIFORNIA AB32 IF__. _RR_
Tech: BRANDON A ESCOBEDO (32 ) AWU2
Internal
#2 - 999: VALLEY KIA NOW OFFERS FLEXABLE PAYMENT PLAN FOR PARTS & SERVICE. DONT PUT OFF THOSE IMPORTANT REPA
IRS. SEE ADVISOR FOR DETAILS OR VALLEYKIA. COM
#3 - 111: CUSTOMER STATES
he hit a man hole and now has transmission
transmission has hole in it all fluid leaked out
due to impact
Tech: BRANDON A ESCOBEDO (32 ) AWU2
Installed 45000 2F511RCA : REMAN TRANSMISSION 1330.00
[email protected] 1180.58
Core Chg 45000 2F511RCA-C : Core Charge: 450002F511 [email protected] Installed UM013 CH059 : ATF TYPE 4 (M) (12) 1000.00 replaced transmission and performed adaptive [email protected] 101.05 customer declined to replace front bumper cover, values reset and oil pressure characteristics. front bumper molding, external sensor and lower
engine under cover.
TERMS: STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. *T hereby authorize the repair LABOR work hereinafter to be done along with the necessary material and agree that you are not operate the vehicle herein described on streets, highways, or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto." SHOP SUPPLIES
HAZARDOUS MATERIALS
SALES TAX OR TAXI.D.
sale of said products Any limitation contained herein does not apply where prohibited by law. SPECIAL ORDER DEPOSIT
DISCOUNTS
TOTAL DUE
NO RETURN ON ELECTRICAL OR SAFETY ITEMS OR SPECIAL ORDERS.
X
© 2012 DEALERTRAOX SYSTEMS Ing - Dealership Applicaton Group (800) 945-1028 VALLEY KIA R/O Open Date R/O Number
FONTANA 06/01/24 6181946/2
SERVICE DEPARTMENT HOURS R/O Close Date Status
16272 S Highland Ave - Fontana, CA 92336 7:00 a.m. to 6:00 p.m.
Phone: (409) 350-2700 Fax: (909) 350-2780 06/14/24 Pre-Invoice Monday - Friday
www.valleykia.com 8:00 a.m. to 2:00 p.m. Saturday Mileage In Mileage Out B.A.R. # ARD00190201 136372 136373
Service Advisor / Tag #
RAUL PARIS/551
ORTIZ, MARIO Work Phone Vehicle Identification Number
Home Phone Delivery Date In-Service Date
09/02/17 09/02/17
Year Make Model Body
Color License Number
2017 KIA FORTE 4D
WHITE
K8072
DESCRIPTION OF SERVICE AND PARTS
Sub Total: 3611.63 AMOUNT
10% OFF COUPON
************************************************************ - 100.00 * **ALL PARTS ARE NEW UNLESS OTHERWISE SPECIFIED** *
************************************************************ TERMS: STRICTLY CASH UNLESS ARRANGEMENTS ARE MADE. "I hereby authorize the repair LABOR 1330.00 PARTS 2281.63
DEDUCTIBLE . 00
operate the vehicle herein described on streets, highways, or elsewere for the purpose of testing SUBLET and/or inspection. An express mechanic's lien is hereby acknowledged on above vehicle to secure • 00 the amount of repairs thereto. SHOP SUPPLIES .00
ISCLAIMER OF WARRANTIES. Any warranties on the products soid hereby are those made by HAZARDOUS MATERIALS • 00 he manufacturer. The seller hereby expressly disclaims all warranties either express or implied SALES TAX OR TAX I.D. 171.93 ncluding any implied warranty of merchantability or fitness for a particular purpose, and the seller neither assumes nor authorizes any other person to assume for it any liability in connection with the SPECIAL ORDER DEPOSIT • 00 sale of said products. Any limitation contained herein does not apply where prohibited by law. DISCOUNTS - 100.00
TOTAL DUE 3683.56
NO RETURN ON ELECTRICAL OR SAFETY ITEMS OR SPECIAL ORDERS.
X
02012 DEALERTRACK SYSTEMS, In - Desiarah: Application Croup (800) 945.1028
CUSTOMER COPY
$2683.56 SALE AMOUtaT
Issuer Mode:
Chip Read Enty Mettod:
0575+2 Approval Code:
6181946 REFERENCE
246 Batch #:
SEQ #:
A0000000041010 ATD:
CAPITAL ONE Chip Card:
xXXXXXXXXXXX+921 Card 7
MC SALE
CREULT CARD
11:38:58 06 15 202+
FONTANA, CA 42336
16272 5 HIGHLAND AVE
VALLEY KIA
Peppertice Mobile
Home Park
Medical Dispensary MDspensany 9
El Toro Market
tar world Plaza
ARCO
E Ria o Ave E Rialto Ave W Rialto Ave W Rialt
tta St
CounFbp Bitco ATM
ly's Coin C
Oran st per Ave
echala "Google
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