CITY CLERK'S DATE STAMP
CITY OF RIALTO CITY OF RIALTO
HANNO CHAE LIABILITY
2025 MAY 29 AMIO: 13
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVEL
CITY CLER*
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 5911.2).
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:
lavid. Vane RejAs
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: 11-25-7024 TIME: 20:00 MAMOPM
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. 330
3. HOW DID DAMAGE OR INJURY OCCUR?,
Bal Road Condition see
Радя 1
4. WERE POLICE AT THE SCENE? DYES• 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.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $1741.31 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: 31
11-25-2024 Amount: $ / 16/
Item/Date:
Amount: $.
Item/Date:
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 51,761-81 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 11-25: 2024 Repai Amount: $ 4, 741-81
Hem/Date: 21-25-2024 claim fre 1-4-2024 Amount $ 534,31 TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 2,293, 12
7. WITNESSES TO DAMAGE OR INJURY List all persons known fo 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: | 1
DATE: TIME: DAM OPM DATE: TIME: DAM OPM
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. f 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 vehich 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.
CURB
PARINA erraide AVE
7 sovere Weat
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 DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
May 26,2025
TYPE OR PRINT NAME ATE (
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 CHI
GEORGE HILLS
CITY OF RIALTO
2025 MAY 29 ANIO: 12
RECEIVEL
CITY CLER*
March 31, 2025
David Rojas
11424 Leatherleaf Rd.
Fontana, CA 92337-1420
RE: Our Client: City of Rialto
Claim Number: GHC0079507
Date of Loss._ - June 6,2024
Dear David Rojas,
George Hills is the liability claims administrator for the City of Rialto. It is our function to review claims on behalf of the city and provide recommendations regarding them.
After completing our review of the referenced incident, we have determined that your claim should be rejected, as the required burden of proof to establish fault against the city has not been met.
You will be receiving a formal rejection notice which will provide additional information regarding your claim.
If you have any questions, please contact the undersigned.
Kindest Regards,
George Hills Company
cumulldara
Cynthia Lara
Claims Representative
Phone: (909) 632-4134
Email: [email protected]
CC: City of Rialto
P.O. BOX 278, RANCHO CORDOVA, CA 95741
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Invoice - Customer Copy - Page 1
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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 concer 82iase calli:
Name: DAVID ROJAS Year: 2007 Date: 2024-11-25
Address: Make: TOYOTA Entered By: ANDY M
City: Model: COROLLA Time In: 08:25:23
State: Engine: 4-1794 1.8L 1ZZ-FE Date/Time Promised: 2024-11-25 12:11:48- Zip: Vin No.: Old Parts Roturned: no
Home Phone: License No:
Contact Phone: Mileage: 78634 Customer Waiting
Color:
rage Charges: Any votic the is ft unctiondo for make then 7 busines * be tamed et lio caneris expansa. For more intormation, piceed see Stare Ma EUVERY. I UNDERSTAND THAT ANY COSY QUOTED IS 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 CONTEN THAT THE VEHICLE MAY BE PARKED IN THE PEP BOYS PARKING LOT AND THAT VEHICLES ARE LEFT OVERNIGHT AT OWNER'S RISK.
X
initial Estimate Parts S: Labor S: TotalS: Date and Time:
978.70 633.63 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 CHOOSE IO DISPOSE OF YOUR OWN TIRES.
NOTICE: - IF YOU ELECT IO DISPOSE OF YOUR OWN TIRES, YOU ARE RESPONSIBLE FOR PROPERLY DISPOSING OF YOUR USBD TIRES IN
ACCORDANCE WITH EPA GUIDELINES AND ANY APPLICABLE LAWS
CUSTOMER SIGNATURE
TYPE PART DESCRIPTION CODE MECHANIC HRLY HRS QTY SOURCE EACH TOTAL RATE
PK 2758776 PROTECTED TIRE INSTALLATION PKG
LB 1801 90 DAYS WHEEL BALANCE UNDER 16 N RAFAEL D 22.81 91.24 LB 1897 TIRE MOUNTING 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 22.50 90.00
Package SubTotal : 210.00
PN 90000080714 Cooper Adventurer All Seaso 195/6581591H N 4 149.99 299.96 PROMO -75.00
Warranty: 65K Buy 2 Tires, Get 2 Free when
installed
65,000 MILE PRORATED
LB 1113 FREE ALIGNMENT CHECK RAFAEL D 0.00 0.00
PN 520-449 LOWER CONTROL ARM N OP 279.99 279.99
PO# 10605183
PN 520-450 LOWER CONTROL ARM N 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 PEPGUARD LIMITED EXTENDED LABOR WARRANTM 75.21 75.21 LB COMPUTERIZED WHEEL ALIGNMENT RAFAEL D 99.99 99.99
LB COMPLIMENTARY VEHICLE INSPECTION N RAFAEL D - 0.00 0.00 Parts: 978.70 Labor: 633.63 Other: 75.21 Tax : 73.77 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
BO0-PEP-BOYS 1-800-737-2697