CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2024 DEC 23 AMID: 59
TO PERSON OR PROPERTY
RECEIVED
CITY CLERK
1. Claims for death, injury to person, orto personal property must be filed not later than six (f) months after the occurrence (Go. Code 59112).
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:
DAVID VANCE REFAS 2/7/47
FULL NAME DATÉ OF BIRTH
den i Vance Ryar 909,641-5513
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO 1/424 seatbeleatRe CA 92334 1 ! Rita
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE 11424 Jutate Of traten Rad NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM 92337
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 1662024-1124-TIME: /PA tAPEAM CAM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) Tocate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
3. HOW DID DAMAGE OR INJURY OCCUR?
outa in Reserve
4. WERE POLICE AT THE SCENE? •YES ONO 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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $7,741=31 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach z estimalsa, 247 12 DAMAGES INCURRED TO DATE:
Item/Date: 6-4-2024 Amount: $ 536.31
Htem/Date:la-67024 to 1/25-2024 Amount: $2,76/ + 31
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $2,297.12 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Brakes 6=4-2024 Amount: $ 534.81
Item/Date: Frost en Amount: §2 7 61 0/
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: §1312
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information attach adional pages, # necessin , 297-12 NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: | ) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: (1
DATE: TIME: D AM 0 PM DATE: _ _ TIME:
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.
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 SIGNED BY THE CLAIMANT.
To
PARKWAY
7 SIDEWALK gaur
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 DÉCLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Lavid Vance Ryas
SIGNATURE OF CLAIMANT OR AGENT
DAViD VANCE LOJAS 17-2/2024
TYPE OR PRINT NAME
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 CLERK'S DATE
CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY
1. Claims for death, injury to person, or 1o 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 Ofl
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., R Address: 290 W. Rialto Al
CLAIMANT INFORMATION:
FULL NAME DATE OF BIRTH
AlD
ance Paras
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
Retire
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE
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: 6687024 tol1242024TIME:GAMtOll.P.mO
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse s.
Where appropriate, give street names and addresses, measurements and landmarks.
3. HOW DID DAMAGE OR INJURY OCCUR?
Roton Bal Road in Resources, off a Turbad ARE gang
4. WERE POLICE AT THE SCENE? D YES D NO WERE PARAMEDICS AT THE SCENE? DYES O NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name ol employee causing the injury or damage, if known.
Bad Pord.
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ÉSTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Brakes. 6-6-2024 Amount: $534r8
Item/Date: Front end o Cer Amount: $/761:
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:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L
DATE: TIME: •AM • PM DATE: _TIME:
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 directior of accident by "X" and by showing house numbers or distances to street comers.
If a cityltown vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yours 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 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 SIGNED BY 7 174131
5:3.681 /
22971 Rentside are Souts
to
PARKWAY
SIDEWALK
recons.
I HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE THOSE MATTERS WHICH ARE HEREIN STATED ÚPON 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
1.2 - 21-2024
SIGNATURE OF CLAIMANT OR AGENT
12-212024
I ema Veteran of the Vietnam Wer.
I have a hard time to do writing
On Pape and Forna. I sam sorry fer
my spelling Furting
Thank you /.....A..
Store Coupon Ant. (-1.43)
2773386
Order #: 2251998
BRAKE SYSTM INSPECTN 0.00 N
9581146 1 @ 0.00 Pope Bong!
Order #: 2251998
Total Discount (50.00) Pep Boys #680
Sub-Total 512.22 16711 VALLEY BLVD
Tax 24.59 FONTANA, CA 92335
Total 536.81 (909) 823-7131
Visa (D) 536.81 www.pepboys.com
Account: XXXXXXXXXXXX0846 06/06/20.24 11:57:21 AM PST
Auth: 09353D (A) Trans.: 126794 Store: 0680
Total Tender Reg.: 105 T111: 105
536.81 Cashier: 492624
Change Due 0.00
Service Work Order COMPLETE
Application Label: VISA CREDIT
AID: A0000000031010
TVR: 0880008000 068010512679420240606
TSI: E800
AC: F9FAFC3008A52CE2 ENV HAZ WASTE FEE 0. 25 T
ARC: 00 LAB2683 1 @ 0.25
Order #: 2251998
COMP VEHICLE INSP 0.00 N
0787533 1 @ 0.00
Thank you for shopping at Pep Boys. Order #: 2251998
We accept most returns within 90 days FRONT ROTORS) PKG 281.98 T with the original receipt. For more 0068510 1 @ 281.98
details, please refer to the return FRNT RTR W BRK SRV 0.00 policy in-store or at www.pepboys.com 2358530 2 @ 0.00
Submit your rebate on-line at PROSTOP BRAKE ROTOR 281.98 www.pepboys.com/rebates 9334784 2 @ 140.99
Service Work Order Number Order#: 2251998
2251998 FRONT BRAKES PREMIUM PKG 229.99 T
0635102 1 @ 229.99
FRONT BRAKE LBR 175.00
0635428 1 @ 175.00
2251998
Store Coupon Ant. (-31.25)
2773386
BRAKE PADS 34.99
Customer Copy 2741888 1 @ 34.99
Store Coupon Amt. (-6.25)
2773386
BRKE FLUID CHNGE LB 62.01
9045347 1 @ 62.01
Store Coupon Ant. (-11.07)
2773386
MAGI DOT 3BRKFIN320 790
Pep Bat Invoice customer Copy Page
PEP BOYS AUTO #680
16711 VALLEY BLVD.
16711 VALLEY BLVD
FONTANA, CA 92335
(909) 823-7131
BAR# ARD303408
EPA# CAL000082946
Service Manager: ANDY MEDRANO TRACKING ID# •
Store ID# Service Work Order #
Insurance: If you have any questions 0680 2256196
Policy Number: or concerns, please call:
(909) 823-7131
Name: DAVID ROJAS Year: 2007 Darlo: 2024-11-25
Address: Make: TOYOTA Entered By! ANDY M
City: Model: COROLLA Time In: 08:26:23
State: Engine: 417841.8L 1ZZ.FE te/Time Promise
Vin No.: Parts Retum 202-112 121148
Zip:
Home Phone: Licenso No:
Contact Phone: Mileage: 78834 Customer Waiting
Color:
Storage Charges: Are valise et in kh uncandid to mord len 7 tushoes dey! vy be cud of the cunar expone a more intermio, stees ace store Menepa Kind
HAT THE VEHICLE MAY BE PARCEO IN THE PEP BOYS PARIN LOT AND THAT VEHICLES AGE LEFT OVERNIGHT AT OWNER'S RESX Inital Estimete Parte S: Labor $ : Total S: Date and Time:
1761.31 2024-11-25 08:25:23
I acknowledge notice and oral approval of an increase in the original estimated price (signature or initials)
YOU WILL NOT BE CHARGED A TIRE HANDLING CHARGE IF YOU CHOOBE TO DISPOBE OF YOUR ONK TIRES.
NOTICE: - IF YOU BBCT IO DISPOSE OF YOUR OWN TIRES, YOU ARE REBPONBIBLE FOR PROPERLY DISPOSING OF YOUR USED TIRES IN
ACCORDANCE WITH EPA GUIDBLINES ARD ANY APPLICABLB LAWS
CUSTOMER SIGNATURE
TYPE PART DESCRIPTION CODE MECHANIC HRLY HRS aTY SOURCE EACH TOTAL RATE
PK 2758776 PROTECTED TIRE INSTALLATION PKG
1801 90 DAYS WHEEL BALANCE UNDER 16 N RAFAEL D 22.81 91.24 LB 1897 TIRE MOUNTING N RAFAEL D 0.00 0.00
PN 6001 TIRE HANDLING CHARGE PEPBOYS N 3.00 12.00
PN TV413 30413500PEP 1 14 RUBBER VALVE STEM : 4.19 16.76 PN 4002 ROAD HAZARD WARRANTY N 90.00
Package SubTotal : 210.00
PN 90000080714 Cooper Adventurer Al Seaso 195/65R15 91H N' 149.99 290.96 PROMO -75.00
Warranty: 65K Buy 2 Tires, Get 2 Free when
Installed
85.000 MILE PRORATED
LB 1113 FREE ALIGNMENT CHECK RAFAEL D 0.00 0.00
PN 520-449 LOWER CONTROL ARM OP 279.99 279.99
PO# 10605183
PN 520-450 LOWER CONTROL ARM OP 279.99 279.99
PO# 10605193
LB 1716 Remove & Replace F Control Arm - Lower, Both N- RAFAEL D 158.00 442.40 442.40 :
oT 9690163 PEPGUARD LIMITED EXTENDED LABOR WARRANTM 75.21 75.2t LB COMPUTERIZED WHEEL ALIGNMENT N RAFAEL D : 98.99 99.99 LB COMPLIMENTARY VEHICLE INSPECTION RAFAEL D 0.00 0.00
Paris, 978.70 Labor: 633.63 Other: 75.21 TaX: 7377 Total: 1761.31 Tender Date : 11/25/2024 Tender Time: 12:14 PM
POS Trans # : 129061 Store : 0680
NEED A TOW? CALL 1-800-PEP-BOYS or BRENDANIELS
800-PEP-BOYS 1-800-737-2697
invoice - Customer Copy Page 3
Pep Boy!
LR 3 RR 4 LR RR WhiteWall
Position:
S5
Invoice History
REVISION CONTACT TYPE AMOUNT PHONE DATE TIME
AUTH_BY
initial DAVID ROJAS 809.96 (909)841-5513 202411-25 08:31:04 ANDY M
authorize TV413 30413500PEP 1 14 RUBBER VALVE STEM 4 4,19
18.76 aulhorize 1801 90 DAYS WHEEL BALANCE UNDER 16
22.81 91.24
authorize 80000080714 Cooper Adventurer All Seaso 195/85R15 91H 4 149.99 599.96
authorize 4002 ROAD HAZARD WARRANTY
22.50 20,00
authorize 6001 TIRE HANDLING CHARGE PEPBOYS 3.00
12.00 authorize 1897 TIRE MOUNTING 0.00
0.00 save DAVID ROAS 1177.58 (908)641-5513 202411-25 09:21:50 ANDY M
authorize COMPUTERIZED WHEEL ALIGNMENT 99.99 99.99
authorize 1113 FREE ALIGNMENT CHECK 0.00
0.00 authorize 520-449 LOWER CONTROL ARM 1 279.99
279.99
aulhorize 520-450 LOWER CONTROL ARM 279.99
279.99
authorize 9690163 PEPGUARD LIMITED EXTENDED LABOR WARRANTY 75.21
75.21 authorize 1716 Ramove & Replace F Control Arm - Lower, Both 1 442.40 442.40 authorize COMPLIMENTARY VEHICLE INSPECTION -1 0.00
0.00 authorizo 1113 FREE ALIGNMENT CHECK -1 0.00 0.00
Service Information
Tire Tread Depth (32nde) LF:: 8 Tire Traad Depth (32nds) LR: 8 Tire Tread Depth (32nd8) RR:: 3 Tire Tread Depth (32nda) RF: 8 State Inspection Expiration Date:: 8
1801 90 DAYS WHEEL BALANCE UNDER 16
OK,YEL,RED,NC/Front Brake Gauge Reading (Ok, Yellow, Red or Not Checked): OK,YEL,RED.NC/Rear Brake Gauge Reading (Ok, Yellow, Red or Not Checked):
oK OK
TIRE MOUNTING
OK,YEL, RED, NC/Front Brake Gauge Reading (OK, Yellow, Red or Not Checkedy: OK,YEL,RED, NC/Rear Brake Gauge Reading (Ok, Yallow, Red or Not Checked):
OK OK
NEED A TOW? CALL 1-800-PEP-BOYS or
800-PEP-BOYS 1-800-737-2697 HIDASENTE
:OJAS Year: 2007 Date: 2024-06-06
athereaf Rd Make: TOYOTA Entered By: ANDY M
Model: COROLLA Time In: - 08:38:08
Engine: 4-1794 1.8L 1ZZ-FE Date/Time Promised: 2024-06-06 11:53:20 Vin No.: Old Parts Returned: no
5513 License No:
-5513 Mileage: 75124 Customer Waiting
Color:
•
storage Charges: Any veticle that is it unellanded for more then 7 tueines des rey be toned of the cunero expense. Far more infarmation, pies sue Store Mang
S ON THIS WORK ORDER AND TO FURNISH TRE NECESSARY MATERIALS AND ITS EMPLOYEES TO OPERATE THE VEHICLE FOR PURFOSES OF INSPECTION, TESTING AN ESTIMATE. I UNDERSTAND THAT UNLESS DIRECTLY CAUSED BY PEP BOYS. IT IS NOT RESPONSIBLE FOR ANY LOSS OR DAMAGE TO THE VEHICLE OR ITS CONTENTS:
KING LOT AND THAT VEHICLES ARE LEFT OVERMICHT AT OWNERS RISK X
Parts S: Labor $ : Total $ : Date and Time:
317.28 194.69 536.81 2024-06-06 08:38:08
1 oral approval of an increase in the original estimated price ls)
CODE MECHANIC HRLY HRS QTY SOURCE EACH TOTAL
RATE
s) PKG
DRUMS WITH BRAKE SERVICE N ERIC H 0.00 0.00
ROTOR N 140.99 281.98
EAR WARRANTY
Package SubTotal : 281.98
3 PREMIUM PKG
nty 24 Mo/24K Miles
$ LABOR N ERIC H 1 175.00 143.75
-31.25
N 1 34,99 28.74
... 6.25.
ME WARRANTY
HANGE LABOR N ERICH ..1 62.01 50.94
-11.07
AKE FLUID 320Z N 7,99 656
-1.42
Package SubTotal: 229.99
AL HAZARDOUS WASTE FEE 0.25 0.25
RY VEHICLE INSPECTION N ERIC H - .- .0.00 0.00
1 INSPECTION ERIC H ..00 0.00
I:19469 Diner: 02572207 Tax: 24.59 Total: 536.81
06/06/2024 Tender Time: 11:57 AM
126794 Store : 0680
105 Tender Till #: 105
492624
--
NEED A TOW? CALL 1-800-PEP-BOYS or
1-800-737-2697
Invoice - Customer Copy - Page 3
Pep Boy!:
Tire Tread Depth (32nds) LF:: 6 Tire Tread Depth (32nds) LR:: 6 Tire Tread Depth (32nds) RR:: 6 Tire Tread Depth (32nds) RF:: 6 State inspection Expiration Date:: 6
Decimal Point Required For All Entries: LF Brake Lining (32nds).:: 6 RF Brake Lining (32nds).: 6 LR Brake Lining (32nde):: 6 RR Brake Lining (32nds).:: 6 LF Rotors or Drums Thickness (in : 6 RF Rotors or Drums Thickness (in : 6 LR Rotors or Drums Thickness (in : 6 RR Rotors or Drums Thickness (in : 6 BRAKE FRICTION MEASUREMENTS:
Parking Brake Operational
- -