CITY CLERK'S DATE STAMP
CITY OF RIALTO
MANI, CANE
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2075 JUL -8 PM 3:24
TO PERSON OR PROPERTY
RECEIVEL
CiTY
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 §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:
Alberto Carlos Alvarez
-
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
L
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):
7/3/2025- TIME: 2:25 AM M
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: .
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet. wary workon were reparing the street on North Pepper
Ave and San Bernardino Ane in the city of hialto. I was driving Southbound on N. Pepper Ave at the time of incident Stret and were felting workers were repairmy the asphalt on the Vehicles
tuck on all y whels. Tehic cant be driven an highway.
4. WERE POLICE AT THE SCENE? • YES INO WERE PARAMEDICS AT THE SCENE? • YES ENO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town " Cry she workers pared fash asphalt on road
Let Vehides crike through the tresh asphalt
causing majar damage to my y tires.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_ 1,/41.21 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE: 7-3-25
Item/Date: tires on my 2023 ToYota fundra amounts 1, 141.21 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 5- 1, 141.21 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Y tires 7-3-25 Amount: $_ 1,141.21
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: _ N/A 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: |) TELEPHONE: L)
DATE: TIME: DAM OPM DATE: TIME: ДАМ ПРМ
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. 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 vehic hen 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 th accident by "B-1" and the point of impactby "X".
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
South
ves
CURB
San Bernardino Ave
PARKWAY
East
SIDEWALK
North
/CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Alberto Carlos Alvaver 7-7-2025
TYPE OR PRINT NAME 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 1630 E 1st Street Store: 585
Tires LES SCHWAB Beaumont. CA 92223 Quote: 58500223621
951-845-0505 Salesperson: Mia E P
ARD 303011
Customer Information Vehicle Information
Customer ID: A05857071 Vehicle: 2023 TOYOTA TUNDRA PICKUP Name: ALBERTO ALVAREZ Color: WHITE
Address: Mileage:
City, State, Zip: License:
Phone:
Comments: TIRES HAVE TAR ON THEM COMPROMISING THE TREAD Les Schwab Quote
Qty Product Code Product Description Price/ea FET Amount 4 16958 Pass Tire TPMS Rebuild w/Disp $0.00 $0.00 $0.00 4 15676 265/70R18 DUELER H/T 685 $232.48 $0.00 $929.92
4 13718 WHEEL SPIN BALANCE $17.99 $0.00 $71.96
4 13537 TIRE PRESSURE MONITORING SYSTEM REBUILD KIT $8.99 $0.00 $35.96 4 1046759 PASSENGER TIRE DISPOSAL $4.99 $0.00 $19.96
4 1260064 AMERICAS BEST TIRE WARRANTY $0.00 $0.00 $0.00 Sales Tax: $76.41
Tire Fee: $7.00
Quotation Total: $1,141.21
OF
. r
CL
RIALTO
* indicates sale price
For more information on our products and services, visit www.LesSchwab.com.
Prices good for 30 days, excluding promotions. Quote Expires on 08-04-2025.
Quote Date/Time: 07-05-2025 03:31 PM Page 1 of 1
INNER-CITY AUTO REPAIR & TIRES ESTIMATE #
373 E 5th St
Beaumont, CA. 92223 003113
Phone: 951-849-6552 Fax: 951-845-9000
ARD00298209
Quality work you can trust CAL000331820
Estimate for Services Estimate Date : 717/2025
alvarez, alberto 2023 Toyota - Tundra SR5 - 3.4L, V6 (210CI) VIN(A).
Lic # : Odom. In: 0
Home: VIN#:
Part Description / Number Qty Sale Ext Labor Description Extended 265/70R18 116T Michelin LT Trai $1200 quote 0.00
All four tires covered in tar and makes driving unstable. 0.00 2025 JUL - 8 PM 3:25 CITY OF RIALTO
Parts/Supplies: 0.00 Labor: 0.00 Total: $ $0.00
Thank you for your patronage!
4 tires completly damaged.
I cant drive the truck on
fraway, as it shakes violently
and is going to ruin my
suspension and brakes and other
Parts.
My driveway is also getting
stained from all the tor
On tires and I live in a
association community.
Roads need to be closed
when adding or repairing
asphalt on city strats.
The original tives are only
at LEs SCHWAß tire
company.
CITY CLERY. 2025 JUL - 8 PH 3:25 CITY OF RIALTO
CITY OF RIALTO
2025 JUL - 8 PH 3:25
CITY CLERA
2025 JUL - 8 PM 3: 25 CITY OF RIALTO
CITY OF RIALTO
2025 JUL - 8 PH 3:25
RECEIT: CITY CLLiA
A. Alvarez - SN BERNARDINO CA 923
7 JUL 2025 PM6 L
City of Rialto 2025 1-?
ATTN: City Clerks office CITY 0F RU
150 S. Palm Ave
Rialto, ca 92376
92376-646799