CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2025 NOV 24 PM 3:32
TO PERSON OR PROPERTY
RECEIVED
CILY CLERX
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 5911.2).
3. READ ENTIRE CLAIM FOR BEFORE FILING ¡alto City Clerk's Offic
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS lail: 150 S. Palm Ave., Rialto, CA 9237 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
ERIKA RAMIREZ-BARAJAS
- DATE OF BIRTH
FULL NAME
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
N/A I NA
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 17 2025 TIME: 7:35 • AM X PM
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. southbound Locust Ave between Lowell st and stonehurst pr.
3. HOW DID DAMAGE OR INJURY OCCUR?
There were 3 large potholes in the road. I drove over one of them and it popped my front left tire. It was also raming and there was low visibility.
4. WERE POLICE AT THE SCENE? • YES ENO WERE PARAMEDICS AT THE SCENE? DYES KNO
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.
The potholes that were not (or had not been taken care of by the city. I immediatey submitted the information alaut the yotholes to City of Rialto public works (onire).
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 160.22 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Tire (item and installation) 1/18/2025 Amount: $. $ 160.22 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 160:22 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Amount: $_
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) MARIA CRISTINA BARALAS NAME: SERGIO RAMIREZ
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: |1
DATE: TIME: DAM OPM DATE: TIME: •AM 0 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. 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 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/F SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T HOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRU I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
ERIKA RAMIREZ-BARAJAS 11/24|2025
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 Spreen
SUBARU-
645 Auto Center Dr.
San Bernardino, California 92408
(909) 277-2700
BAR# ARD 312023 EPA# CAL-000492549
THIS FORM IS AN ITEMIZED LIST OF REPAIRS AND IS PART OF A REPAIR ORDER. THIS REPAIR ORDER CONTINUATION IS SUBJECT TO
ALL THE CONDITIONS OF THE ORIGINAL REPAIR ORDER
NOTICE TO CONSUMER: PLEASE READ
IMPORTANT INFORMATCELONE
CUSTOMER NO. 122171 LAUREN HIRTLE ¡VOICE DAT INVOICE NO 02890 TO 017 11/18/21 SUCS21221
LABOR RATE LICENSE NO. MILEAGE STOCK NO..
ERIKA RAMIREZ BARAJAS 23, 180 CRYSTAL BLA
DELIVERY I DELIVERY MILES
22/SUBARÜ/LEGACY SEDAN/2022 LEGACY 07/22/22 10
VEHICLE I.D. NO. SELLING DEALER NO. PRODUCTION DATE
[email protected] ET. ENO. P. O. NO. R. O. DATE
11/18/25
RESIDENCE DHONE DICINECE DUANE
E# N694367 MO: 23181
LABOR - - ...-
---_-
J# 1 04SUZTIRE-1 REPLACE ONE TIRE
CUSTOMER REQUESTS TO REPLACE LEFT FRONT TIREECHS): 03018 30.00 25VR8AGT
REPLACED ONE TIRE
J# 2 05SUZ7 XPRESSMULTI SESINSP HOURS:
0.00 TECH(S) :03018 0.00
CUSTOMER REQUESTS SUBARU MULTI POINT INSPECTION.
A $49.95 value.....Complementary.
CUSTOMER REQUESTS SUBARU MULTI POINT INSPECTION.
SUBARU MULTI POINT INSPECTION COMPLETED. SEE ATACHED SHEET TOTAL - LABOR 30.00
PARTS-. -OTY - - - FP-NUMBER - -DESCRIPTION- •-LIST PRICE-UNIT PRICE- JOB # 1 1 25VR8ACT 225/50 18.0 136.99 136.11
136.11
TOTAL - PARTS 136.11
MISC- - CODE- -DESCRIPTION-
-CONTROL NO.... ----..
JOB # 1 LDS LABOR DISCOUNT-SUBARU
TOTAL - MISC 17:80
ESTIMATE-
CUSTOMER HEREBY ACKNOWLEDGES RECEIVING
ORIGINAL ESTIMATE OF $171.00 (+TAX)
COMMENTS--
Mileage:23,180 VIN: 453BWAN63N3025278 ### Modified
net, Modified On: 11-18-2025, Status: Scheduled. Transport spee 0
ROP OFF
TOTALS -
***** TOTAL LABOR... 30.00
WE APPRECIATE YOUR BUSINESS AND ARE ** OTAL PARTS... 136.11 100% COMMITTED TO YOUR COMPLETE SATISFACTION ** OTAL SUBLET. 0.00 ** TOTAL G.O.G.... 0.00
YOUR INPUT IS VERY IMPORTANT TO US ** TOTAL MISC CHG. 0.00 IF YOU SHOULD RECEIVE A PHONE CALL OR A QUESTIONAIRE ** TOTAL MISC DISC ** PLEASE 11.90
TAKE A MOMENT TO LET US KNOW HOW WE ARE DOING ** TOTAL TAX. ** -----
THANK YOU! ** TOTAL INVOICE $ 160.22
YOUR SPREEN SUBARU SERVICE DEPT STAFF
**
**
**
ARE YOU SATISFIED WITH THE EXPLANATION OF WORK WE **
PERFORMED TO YOUR VEHICLE? **
CUSTOMER SIGNATURE
PAGE 1 OF 1 CUSTOMER COPY | END OF INVOICE 1
11:12am
TO REORDER CALL CONCEPT MARKETING (951) 656-7600 • ITEM #SH CASHIER INVOICE - - -
11/18/2025 11/13 AM PST
Spreen Subaru
645 AUTO CENTER DR
Mountain Motorcars, Inc. SAN BERNARDINO, CA, 92408
909-300-5147 (Office)
www.spreensubaru.com
[email protected]
BILLED TO DETAILS
DETAILS Approved (00)
VISA CARDHOLDER
TYPE CREDIT CARD - SALE
APPROVAL
TRANS ID 11001
TERMINAL 230024
AID NAME VISA CREDIT
AID A0 00 00 00 03 10 10
TVR 0000000000
IAD 458E001000820000
ARC
INVOICE 21221
signature
ACCOUNT CHASE VISA***********3710
ENTRY MODE Con actless Emv
CVM SIGN
AMOUNT USD$160.22
11/18/25 76.53.252.98
Cardmember acknowledges receipt of goods and/or services in the amount of thi TOTAL $160.22 otal shown hereon and agrees to perform the obligations set forth by the cardmember's agreement with the issuer.