CITY OF RIALTO CITY CLERK'S DATE STAMP
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2024 ОСТ 31 PM |: 41
CRYOTERR
1. Claims for death, injury io person, oe to personal proporty must be fled not later than six (6) months afer the occumence (Gov. Code 59112).
2. Claims for damages to real peoperty must be fled not later than one (1) year after the Desumence (Gov. Code 5811.2). RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4.ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mall: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Ratto Ave., Rlatto, CA 92376
CLAIMANT INFORMATION:
Messa Mendoza/Larny Mendez
FULL MAHE NATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 1 BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different trom home address provided above):
1. WHEN DID DAMAGE OR NJURY OCGUR? DATE: 10-24-2024 TME: 2:05 DAM I2(PM 2 PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Dascribe fully and (it appicable) locate on diagram on paverse side of this sheet.
Where appeopriate, give staet names and addresses, measurements and landmarks.
Baland Maple
3. HOW DID DAMAGE OR INJURY OCCUR?
Driving on facill Dive and Mapie when 7 went over
1 pothole that had rocks of asphalt/ concrete avano
the street and a piece of the asphalt/ concrete nit mu
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? DYES ENO mi
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the nate of the city/town employee causing the injury or damage, if known.
Potholes not beng repaires
B. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury op damage $ 1, 402:29 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specitic, #st doctor blts, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Wheel гоха 80000
Amount: $
Hem/Date: Tire 235/35820 927 xL Amount: $ 436.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: =4,402.29 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Labor 1 30 Amount $ 70.50
Iter/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY LIst al persons known to have information attach additional pages, il necessary) NAME: NAME: _
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L).
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: _ 1 TELEPHONE: L
DATE: TIME: DATE: _ . TIME: DAM LPH
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehlcle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accidem 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 yoursel of your vahicle at the time of the acoldent 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.
Linder
PARKWAY
SIDEWALK
I CERTIFY IOR DECLARE INACD DENSITY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIOKATURE OF CLÁIMANT OR AGENT
Melissa Mendora 10-31-2024
TYPE OR PRINT NAME DATE
Muset
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 Tesla, Inc Invoice
Invoice date Invoice number
1018 E 20TH ST
SERVICE DEPARTMENT HOURS 31-OC1-2024 3000S0011485923
UPLAND, CA,US 91784-8235
Mon Fri8:00 a.m. -5:00 p.m Due Date
Ph.: Saturday-Sunday Sat-Sun:Closed
TESLA 31-Oct-2024
Date/Time Received Date/Time Promised
B.A.R. #ARD00310200 31-OCt-2024 09:47:24 31-DC-2024 12:15:40 Paid Odometer in Odometer Out
59114 Miles 59114 Miles
Ready Date
Service Advisor
Alexis Ginther
Bill To Mobile Phone Additional Phone Vehicle Identification Number Larry Mendez
Year Model License Plate Number Colour
2023 MODEL 3 Midnight Silver Metallic
Job Number Description Of Work Amount (USD)
Concern: Customer states: Wheel Damage - Selected Wheel: Left side reartire (customer approved wheel and tire replacement $1,402.29 Please put the old wheel in the 2nd row seat.) Zepair Notes: Removed and replaced left rear tie and wheel. Performed wheel balance anc orqued lug nuts to specification
Correction: Wheel-Reat - LH Labor Hours Price Adjustment Subtotal (Remove & Replace) - Remove and
Replace
0.30 70.50 0.00 70.50
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
1 WHEEL, 20X9.0J ET34, 1.00 800.00 800.00 0.00 800.00
UBERTURBINE(1234267-
00-A)
TIRE, 235/35R20 92Y XL 1.00 436.00 436.00 0.00 436.00
PIRELLI SUMMER
PZA(1044257-00-A)
Parts Subtotal 1,236.00
Pay Type: Customer Pay
Total Parts Amount 1,236.00
Total Labor Amount 70.50
Labor Hours 0.30
1,306.50
2 Concern: Check tire pressure and condition 0.00
Repair Notes: Adjusted tire pressure to specification.
Correction: Automated Tire Pressure Check (Adjustment Needed) 1 of 3
Pay Type: Goodwill - Service
Service Center hourly rate: USD 235
Notes: To assess your vehicle's Tire Wear and Condition, please see the Tire Care and Maintenance section from the digital Owner's Manual in your car.
All parts are new uniess otherwise specified. Total Parts (USD) 1,236.00 Total Labor (USD) 70.50
Accepted Payment Methods: Major Credit Cards (Visa, Mastercard, AMEX, etc.), Discount 0.00 Debit Card, Cashier's Check
Subtotal (USD) 1,306.50
You agree that You are entitled to a price estimate for the repairs you have authorized. Tax The repair price may be less than the estimate but shall not exceed (1) any price limited 95.79 estimate or (2) any parts and labor estimate by more than 10%. Additional repairs may Total Amount (USD) 1,402.29 not be performed without your consent. This estimated price for authorized repairs will be Amount Due From honored if your vehicle is delivered to Tesla's facility within the time periodagreed to by Customer (USD) 0.00 you and Tesla. You may waive your right to a written estimate and require that you be Paid by Customer notifed if the price exceeds an amount you have specified. Tesia is not responsible for (USD) 1,402.29 any personal items left in your vehicle; Tesla and its employees may access and operate your vehicle including on streets, highways, or public roadways for the sole purpose of testing and/or inspection of repairs; Tesla may update your vehicle's software in the course of a repair or as part of the standard vehicle maintenance process per your owner's manual and New Vehicle Limited Warranty; Tesla and its employees may access, download and use the information stared on your vehicle's data recorder to service and diagnose issues with your vehicle, and Tesla may store and aggregate such data for its own purposes; an express mechanic's lien is hereby acknowledged on your vehicle to secure the amount of repairs, storage and other applicable fees; the vehicle owner's insurance provides exclusive coverage for the vehicle while it is in Tesla's possession; and you may be charged storage fees of $35/day from the fourth working day after you are notified that repairs on your vehicle are complete and that the vehicle is ready for pick up.
Testa disclaims all express or implied warranties with respect to any repairs or products used in repairs, except as may be set forth in your Tesla-issued New or Used Vehicle Limited Warranty, Tesia Parts, Body, and Paint Repair Limited Warranty or other extended service agreement. Tesia is not responsible for repairs not performed by, or components not installed by, Tesia. Any parts (including tires/wheels) removed or replaced by Tesla during vehicle service will become the property of Tesla. However, at the time you authorize repairs, you nay request to receive (subject to any applicable core charge, which you agree to pay) or inspect replaced parts (excluding inflatable restraint system components), except body shop repair parts and parts required to be returned to the manufacturer or a third party under :
warranty, trade-in or exchange agreement, which will only be presented to you for examination and not returned. 1 authorize the repair work, including parts, materials and labor, on my vehicle to be done pursuant to the perms and conditions as set fortn in this service agreement document.
Signature:
Date: 0-31-2024
FullName:
Abuyer of this product in California has the right to have this product serviced or repaired during the warranty period. The warranty period will he extended for the number of whole days that the product has been out of the tuyer's hands for warranty repairs. If a defect exists within the warranty period, the warranty will not expire until the defect has been fixed. The warranty period will also be extended if the warranty repairs have not been performed due to delays caused by circumstances beyond the control of the buyer, or it the warranty repairs did not remedy the defect and the buyer notifies the manufacturer or seller of the failure of the repairs within 60 days after they were completed. If, after a reasonable number of attempts, the defect has not been fixed, the buyer may return this product for a replacement or a refund subject, in either case, to deduction of a reasonable charge for usage. This time extension does not affect the protections or remedies the buyer has under other laws. 2 of 3