CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 JUN 23 PM 1: 09
TO PERSON OR PROPERTY KECEITE
CITY CLERA
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:
Charlene Gross-Warren
FULL NAME DATE OF BIRTH
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: _ 5/12/25 TIME: 6:00 p.m. CAMPM
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. at the sidewalk in front of 1085 N Sandalwood Avenue, Rialto CA 92376 I've attached photos/video of damage.
3. HOW DID DAMAGE OR INJURY OCCUR?
There is a city-owned tree on my yard. The roots from this tree damaged the water line that extends from my yard to the sidewalk, connecting to the water meter which caused extensive flooding.
4. WERE POLICE AT THE SCENE? YES 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.
City-owned tree on my property near sidewalk; tree roots have grown extensively causing the water line to break.
This caused the need for me to take the work day off and hire and pay someone to come out and fix it.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $751.66 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: 5/13/25 (water line repair) Amount: $200.00
Item/Date: 5/13/25 (missed work day; no running water due to damage) Amount: $477.30 =75166
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: estimate of increased water bill usage from the flooding on 5/12/25 Amount: $74.36 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: Matt (Fontana Water Company employee) NAME:
ADDRESS: 15966 Arrow Route ADDRESS:
Fontana CA 92335
TELEPHONE: ( ) 909-822-2201 TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: |) TELEPHONE: | )
DATE: TIME: •AM • PM DATE: TIME: • AM C] 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. 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
PARKWAY
7 SIDEWALK
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THEFOREGOING IS TRUE AND CORRECT Charlene Gross-Warren
SIGNATURE OF CLAIMANT OR AGENT
Charlene Gross-Warren 6/23/25
TYPE OR PRINT NAME DATE
Self
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
WATER COMPANY
15966 Arrow Routs, Fontana, CA 92335 (909) 822-2201
June 16, 2025
Customer History Listing
Office: 5 6/16/20255:03:36 PM
Date Selection: 00/00/00 to 00/00/00
Customer Number: 10046403
Account Number: 104640 A/R Amount Due: $223.75
Conn #: F66460
Meter Number: 54387906 Meter Size Code: 5/8"
Meter Location: 01 - RR LEFT CORNER
Turn On Date: 00/00/00 Number of Digits: 44
Bill To
Name: Charlene Gross Service Address: Charlene Gross
Address:
Reading History:
Service (Meter TV Read Status → Read Date → Previous Reading » Current Reading v |Consumption » Unit Of Measure Water 54387906 Actual Read 6/5/2025 1,420 1,456. 36. CCF to increased Water 54387906 Actual Read 5/7/2025 1,393. 1,420. 27. CCF woter Water 54387906 Actual Read 4/7/2025 1,367. 1,393. 26. CCF usaage Water 54387906 Actual Read 3/6/2025| 1,347. 1,367. 20. CCF Water 54387906 Actual Read 2/6/2325| 1,333. 1,347. 14. CCF Water 54387906 Actual Read 1/7/2025 1,312. 1,333. 21. CCF Water 54387906 Actual Read 12/5/2024 1,291. 1,312. 21. CCF Water 54387906 Actual Read 11/5/2024 1,273. 1,291. 18. CCF Water 54387906 Actual Read 10/7/2324 1,244. 1,273. 29. CCF Water 54387906 Actual Read 9/4/2024| 1,220. 1,244. 24. CCF Water 54397906 Actual Read 3/2/2024 1,195. 1,220. 25. CCF Water 54387906 Actual Read 7/3/2024 1,179. 1.195. 16. CCF Water 54287906 | Verified Read 6/5/2024| 1,164. 1,179. 15. CCF Bill History:
INVOICE
DATE INVOICE NO YOUR COMPANY
05/13/2025 No. 1
INVOICE TO
MICHAEL ARMENTA MAINLINE SERVICE REPAIR $200.00 05/13/2025 Due on Receipt
QUANTITY DESCRIPTION UNIT PRICE TOTAL
1 Repair Water Mainline service $200 $200
Michael Armenta