CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
2025 JUL - 2 AMID: 41
TO PERSON OR PROPERTY
1. Clains for deal, Intury do person, op to personal property must be led not later than sir (6) months alice the accumence (Gow. Code §91 12). I CLERA 2 Clalma for damages to real property must be lad not lasse than one (1) yese atter the occurance (Gov. Codo 5911.2). 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: 150 S. Palm Ave., Raito, CA 9237 Address: 290 W. Riallo Ave., Rialto, CA 92371
CLAIMANT INFORMATION:
Patricia Cordura
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TÉLEPHONE NO.
IA
N 1 N
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM same as above (if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 4/27/25 TIME: 2:00 2 PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Desaibe fully and (I applicable) locate on diagram on reverse side of this sheet.
Where appropnate, give street names and addresses, measurements and landmants In tront of my house, my car What was, currently
egistered was towed while we were San Diego.
turned home to our car missing, çal
3. HOW DID DAMAGE OR INJURY OCCUR?
Car uns tower when it nes parked unre outside our S registered
4. WERE POLICE AT THE SCENE? EYES DO NO WERE PARAMEDICS AT THE SCENE? •YES KINO to our address.
5. WHAT PARTICULAR ACT OR ÓMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town I believe this citation is ill warranted. I live here, I Summer vacation
& GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective inhey de damage HOW WAS THE ABOVE AMOUNT COMPUTED? Be specilic, Ast doctor blls, repate estimales, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: 4127/25, Vehicle release fee to Rallice Amounts 216.80 Item/Date: 6|27/25 $ 583.00 paid to Amount $ 583.00
pepe's tore back
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $. 799.80 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
item/Date: Amount $.
Item/Date: Amount: $.
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $.
7. WITNESSES TO DAMAGE OR BLJURY LIst all persons known to have informaton (attach adollional pages, It necessary) NAME: Dine Cordura NAME:
ADDRESS. ADDRESS:_
TELEPHONE: |) TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/ME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: (
DATE: TIME: DA40PM. DATE: TIME • AM OPM
9. PLEASE READ THE FOLLOWING CAREFULLY: Documentation at stored report receipts of accident by "X" and by showing house numbers or distances to street comers. l a city/lown vehicle was Involved, despnate by letter "A" location of the Cly/Town vehicle when you first saw It, and by "B" location of yourselt of your vehicle when you first saw Cly/Town vehicle; location of Cly/Town vehicle at me of accident by "A-1" and location of yoursell of your vehicle at the time of the aceldent 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 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.
ICERTIFY IOR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURÉ OF CLAIMANT OR AGENT
atrick Cordura 7/1/25
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
STATE OF GALFORERA
DEPARTMENT OF CALFORAR INCHMAY PATROL
NOTE: CHP 10D IS FURISHED TO ALL PEACE
VEHICLE REPORT STORED OFFICERS BY THE CALIFORIA HIGHVINY PATROL CHP 180 (Rox, 4-16) OP1 061
REPORTINS DEPAOTMEMT LOCKRON CODE DATE/ TIME OF REPORT NOTICE OF STORED VEHICLE FILENO.
RIALTO PD 3609 DELMERED PERBONALLY
06/272025 1334 932507553
LOCATION TORED / STOLEN FROM ODOMETER READING VIN CLEAR I SUST EE YES CONO OATE / TIME DISPATCH NOTIFIED LOS NO. 3040 N DAISY DR DIGITAL 06/27/2025 1334 N/A
YEAR MAKE MODEL BODY TYPE COLOR LICENSE RED. • ONE MONTH/YEAR STAIE 2008 CHEV SUBURBAN SUV WHITE Ed TRO 07/25 CA
VEHICLE DEMTIRIORTIOM RIO. EMINE NO. WALMATION BY BE OFFICER I OWNER N/A • DX/ DX ]*01+O]:
Г REGISTERED OWNER 7 LEGAL ORNER 7
CORDURA DINO E, OR CORDURA CORDURA DINO E. OR CORDURA
PATRICIA, PATRICIA,
RIALTO CA 92377 RIALTO CA 92377
J
Eg STORED • IMPOUNDED • RELEASED • RECOVERED - VEHICLE/ COMPONENT
TOWING/STORAGE CONCERN MIE, ADDRESS, PHONE) STORAGE ADTHORITY I REASON PEPES TOWING 2775 N LOCUST AVE, RIALTO, CA 92377 (909) 574-1490 CVC 22651(K) RERSON FOR STOP DRIMEABLE? VIN SWITCHED?
1124 FU
2E YES • NO • JUNK
SONATION TES пЕНа VEE YES NO YES NO TO MEETS COMPTON
ARECKED SEAT (FRONT) X X CAM LEPT FRONT FAIR
CORNED HULK per 4394-) CNC SEAT (REARI ALT. I GENERATOR VESSEL AS LOAD X RIGHT FRONT FAIR xX
RADIO BATTERY FIREARLES X | LEFT REAR FAR
ENG. /TRAME. STRIP TAPE DECK DIFFERENTIAL X OTHER RIGHT REAR FAIR
MISC, PARTS STEP TAPES TRANSMESSION MISC ITEMS X SPARE
BODY METAL SURP X OTHER RADO X AUTOMATIC HUB CAPS NO
SURGICAL STRIP per 4344 CVC X IGMATION KEY X MANDAL SPECIL WHEELS NO RELEASE VEHICLE TO: X RID OR AGENT • AGENCY HOLD 20003 GARAGE PRINCIPAL I AGENT STORING VEHICLE PICANTURE DATE/ TIME JAVIERPEPES 1262025 1358
KAME OF PERGON /AGENCY AUTHORI a RELENTE LO. NO. DATE
CERTIFICATION: 1, THE UNDERSIGNED, DO HERESY CERTIFY THAT I AM LEGALLY Smart 2300 106,20 AUTHORIZED AND EIRED TO MC POEMELMON OF THE ABOVE ORSCHMED VEHICRE.
SIGNATURE OF PE ON AUTHORIZING RELEASE
CHATURE OF POSITA
STOLEN VEHICLE / COMPONENT • EMBEZZLED VEHICLE • PLATE/S) REPORT DATE / TME OF OCCURRENCE DATE / TIME REPORTED MAME OF REPORTING PARTY (RIP) DEVER LICENSE NO. I STATE
LAST DRIVER OF VEHICIE DATE/TILE ADDRESS OF RIP TELEPHOME OF RIP ( )
CERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAINS OF SIGNATIE OF PERSON MAING REPORT THE BIATE OF OACSFOFARA THAT THE FORESCIA IS TRUE AND CORRECT.
REMARKS
(LIST PROPERTY, TOOLS, VEHICLE DAMAGE, ARRESTS)
DRNERS MANE ARRESTED / CEMBO? REPORTED BY CARCOMTE VALUES UNOCC/PARKED G. RIVAS YES 69NO
VEHICLE TAGGED FOR 72 HOURS ON 06/23/2025 AT 1256 HOURS. ON THE ABOVE DATE AND
TIME, VEHICLE REMAINS ON CITY STREET WITH UNBROKEN CHALKMARK AND TAG ON WINDSHIELD. MISC DENTS+SCRATCHES 360 OF VEHICLE. MISC PROPERTY OBSERVED INSIDE VEHICLE. NOTHING OF SIGNIFICANT VALUE OBSERVED INSIDE VEHICLE. AXON FOOTAGE AVAILABLE. VEHICLE WAS CITED FOR RMC 10.28.050.
LEFT SIDI GHT SIDE
SIGNATURE OF OFFICER THE S REPORT L0, 10. SUPERVE OR REQUIRED NOTICES SENT TO REEISTERED • YEE DATE NOTIRED G. RIVAS 02745 JB MOLETAL ONDERERER 2A52 DICT • NO
An Internationally Accredited Agency
6/27125, 4:49 PM Invoice
Pepe's Towing Service Impound Invoice
PO Box 7450, Moreno Valley CA 92552 Printed 6/27/2025
Phone: (951) 682-5682 | Fax : (951) 682-5030
Towing Sovie
Released To DINO CORDURA Phone:
Invoice # 25-0627-61155 Reason for 22651-K ABANDON OVER 72 HRS Call # 61155 Impound
Case # 932507553 VIN Number
Model 2003 Chevrolet Suburban (White)
Case # 932507553
Account RIALTO PD License Plate
Date/Time Requested 6/27/2025 1:49 PM Drivable Yes
Date/Time Dispatched 6/27/2025 1:50 PM Keys No
Date/Time Arrived to scene: 6/27/2025 1:56 PM Towed from , USA (3540 North Daisy Drive)
Date/Time Completed: 6/27/2025 2:49 PM
Stored at Rialto Yard
Driver Javier H.
2775 N Locust, Rialto CA 92377
Truck TRK 47
Date/Time Released: 6/27/20254:46 PM
Days Held in Impound 1 days
Notes
Storage charges Quantity Price Line Total
(Storage - Storage Fees) Impounds/Storage: Daily Impound Rate 1 $77.00 $77.00 120M THAT
Towing charges Quantity Price Line Total
(Towing) TOWING FEE PORT TO PORT (price per hour) 1(1h) $385.00 $385.00 (Towing) Admin Fee 1 $121.00 $121.00
Towing SubTotal $506.00
Storage - Storage Fees SubTotal $77.00
Subtotal $583.00
Taxes $0.00
Grand Total $583.00
Amount Due: $0.00 / Paid
Visa payment (Ref # CC 6797 APV 04593l) of $583.00 applied on 6/27/2025 Pepe's Towing Service appreciates your business; if you have any questions regarding this invoice, please contact us at 951-682-5682. Thank you.
Damage Disclaimer:
I Have been advised that my vehicle may be damaged if winched, towed, unlocked, jump started, tire changed or left on unattended premises. I recognize the difficulty involved and I agree not to hold Pepe's Towing Service responsible for such damages should it result. I, the undersigned do hereby certify that I am legally satisfactory condition
Signature: Date:
CAR 117433 USDOT: 1005094
Upon request, you are entitled to receive a copy of the Towing and Storage Fees and Access Notice City of Rialto
POLICE
150 S Palm Ave
Rialto, CA 92376-6487
+1 (909) 820-2525
City of Rialto
06/27/2025 04:19PM
002679-0003 PD24-000006792
Payment effective date 06/27/2025
MISCELLANEOUS
Vehicle Release Fee
(629833)
2025 629833
1 e $216.80 $216.80
Payment Id: 73083
$216.80
Subtotal $216.80
Total $216.80
POLICE CC MERCHANT $216.80
Visa ************6797
Ref=b12c60ca-816a-44d7-8cc1-e257299ca54f
Auth=07059I
Change due $0.00
Paid by: DINO
Comments: 932507553
Thank you for your payment
City of Rialto COPY
DUPLICATE RECEIPT