CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
2x
CLAIM FOR DAMAGES CITY OF RIAL
TO PERSON OR PROPERTY i NOV 24 AM/11:
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). TO
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:
Rate Cry Clerks Orice E
3, READ ENTIRE CLAIM FOR BEFORE FILING
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:
KEVIN HAKIM MUHAMMAO
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: 11/17/2025 TIME: 5:40 • AM 25 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.
ON CEDAR AVENUE SOUTHBOUND WHILE TURNING RIGHT ONTO VALLEY BLVD.
3. HOW DID DAMAGE OR INJURY OCCUR?
A POTHOLE THAT WAS COVERED BY WATER, PUNCTURED MY
DRINER-SIDE FRONT TIRE, ON THE DUTTER WALL OF THE TIRE.
I WAS TAKINO MY FATHER TO KAISER, WHERE HE WAS TAREN INTO ER.
4. WERE POLICE AT THE SCENE? • YESINO WERE PARAMEDICS AT THE SCENE? DYESINO
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.
RIALTO STREET VANEMENT MANAGEMENT PRIOR TO. ME APPEARS TO HAVE JAVED THE POTHOLE ON 1/18/2025,
RETURNING TO THE LOCATION TO TARE A PHOTO.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $279.76 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Hem/Date: TIRE SIZE 225/35 R2O 90W 11/18/2025 Amount: $ 1 39.88 Hem/Date: TIRE SIZE 225/35 220 90 W 11/18/2025 Amount: s 1 39.88 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 279.76 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: TIRE SIZE 225/35 R20 90W(2 TRES 1/18/20715 Amount: $ 274.76 Item/Date: 20 INCH LUXX RIm CHIPPED Amount: $340.00
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $619.76
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: KENIN ROBERT JOHNSON SR NAME:
ADDRESS: ADDRESS:
TELEPHONE: TELEPHONE: 2025 NOY 24 AM 11: 20 CITY OF RIALT (T)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS: _
TELEPHONE: L TELEPHONE: |)
DATE: TIME: • AM •PM DATE: TIME: • AM • 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 comers.
If 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 vehicle 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.
VAULEDURELND WESTROUND
PARKWAY
SIDEWALK
I CERTIPY IOR DEEL ARE LINDER PENALTY OF PER.ILIRY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLÁIMANT OR AGENT
KEVIN HAKIM MUHAMMAD 11/20/2025
TYPE OR PRINT NAME
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 357
11NTVINN
116624.
INVOICE DATE
RIMTYME 11/2/23
CUSTOMER'S
SALES ELEASE OWNERSHIP ORDER NO.
SOLD TO: SHIP TO:
KEVIN MUHAMMAD
GRAy
167,808 mies
SALES PERSON SHIPOED VIA TEFIMS
Dark IN SURF
OTY SHIPPED DESCRIFTION UNIT ALOUNT
OTY. ORDERED
4 LUXK 20" BM
225/37/20 FULLWAY (PACTAGE) 1799100
i us
4/ TPS 200
SuBs 1999.00
7Ax 149:92
TOTAL 2148 92
wheels- 74030011095, 096, 097, 098
CENTER CAR PARS# 9340L172 A
Wability Walver - RimTyme is not responsible for: (a) changes in vehicle's ride and handling, (b) modifications required to prevent "scrubbing", (c) damaged caused by not having wheels re-torqued 25 to 100 miles after installed, (d) wheels and/or tires removed from vehicle and left on our premises, (e) inaccurate and/or failure to make recommendations of service and/or repair needed on vehicle.
Warranty - All new merchandise sold by RimTyme is backed by a manufacturer's warranty. All pre-rented merchandise sold by RimTyme will have it's remaining manufacturer's warranty transferred to me. All warranty claims must be submitted to the manufacturer for approval. NOTE: The use of certain chemicals for cleaning/polishing can damage the wheel's finish and void the manufacturer's warranty.
< 357
Credit Card Receipt Nº 116624
RIMMINE INVOICE DATE
11/7/23
ED TON THEN NO MES
CUSTOMER'S
ORDER NO.
Magic Wheel & Tire 11.C
1560 Vesi Handekd Dirvo
permaide F32500 SHIP TO:
(850) 542 4650 "MAD
LE IS250
53 brAy
Receipt No: 25453
MILES
Maented u. 11 42 AM
implane• BROT MA 1 TERMS ¡F.OB.
Kevin Muhammad
DESCRIPTION UNIT AMOUNT
(830)2809733
20" BM
00 1/20 FULLWAY (PACKAGE) 1799
Cald ly/* VISA
"....
200 100
Amount: $2,148.92 SuB 149910
TAx 149:92
TOTAL 2148:92
U
«Cranner Copy»
CITY KECE 2025 NDY 24 CITY OF
Wheels- 74030011095, 096,047,098
CENTER CAR PARK 9340L172-A S VEL AM RIA
Liability Waiver - RimTyme is not responsible for: (a) changes in vehicle's ride and handling, (b) modifications required to prevent "scrubbing", (c) damaged caused by not having wheels re-torqued 25 to 100 miles after installed, (d) wheels and/or tires removed from vehicle and left on our premises, (e) inaccurate and/or failure to make recommendations of service and/or repair needed on Warranty - All new merchandise sold by RimTyme is backed by a manufacturer's warranty. All pre-rented merchandise sold by RimTyme will have it's remaining manufacturer's warranty transferred to me. All warranty claims must be submitted to the manufacturer for approval. NOTE: The use of certain chemicals for cleaning/polishing can damage the wheel's finish and void the manufacturer's warranty.
11/18/25
11:15 AM
SALES ORDER# 5053255234
ORDER TYPE: STORE-ORDER
KEVIN MUHAMMAD
COMPANY NAME:
13261 LILLIAN HWY APT 15
PENSACOLA FL 32506
M:
H: (850) 288-9753
2086 LEXUS CARRYOUT: N
IS250 AWD
O.E.: 225/45 R17 SL MILEAGE: 186227
O.E. INFLATION: F: 35 PSI R:37 PSI
5 - 114.30 MM
TORQUE: 080 FT-LBS
CAL 49 CA# ARD303795
17256 SLOVER AVE
FONTANA CA 92337-7583
989-328-6525
RACHEL M.
APPOINTMENT: 11-18-2025 14:15
---
ARTICLE# AXLE DESCRIPTION FET PRICE QTY AMOUNT
BESTHIS IS NOT A SALES HECEIPTA#*
ADJUSTMENT
39733 225 /35 R20 $164.00 -1 -$164.08
90W XL BSW
TOY EXTENSA
HP II
REASON: ROAD HAZARD
Recommended Tire Pressure: 0 psi
ORIGINAL TAX -$14.35
ADJUSTMENT TOTAL -$178.35
SALE
39733 225 /35 R20 $164.00 2 $328.00
90W XL BSW
TOY EXTENSA
HP II
TIRE MILEAGE WARRANTY: 45088
Recommended Tire Pressure: 0 pai
98188 B DIL DIL 1100K TQ40 $0.00 2 $0.00
Clamp-in
TPMS REK BASIC KIT
1100K
88017 B CERTIFICATES FOR $33.05 2
$66.10
REFUND, REPLACEMENT
For tire certificate details, see
www.americestire.com/customer - service/certificates
80224 WASTE TIRE $3.50
DISPOSAL FEE
80075 B STATE REQUIRED $1.75 2 $3.50
TIRE FEE
98937 B ADJUSTMENT/BAL & VAL $0.00 1
$0.00
LIFETIME
W/CERTS
91123 ฿ INSTALLATION & $28.00
528.00
LIFE OF TIRE
MAINTENANCE
COMMENTS: LF and RR. ew on rear. Ordering tires
When replacing less than four tires, America's Tire
recommends that the new tires will be placed on the rear axle of the vehicle.
The tire and/or wheel you have chosen is different from the original equipment provided with your vehicle and may
change its handling or stability characteristics. Further information is available from your America's Tire
For Returns/Exchanges, please visit any America's Tire
location with the items), receipt, and original form of payment. Additional Terms & Conditions can be viewed at https://www.americastire.com/customer-service.
SUB TOTAL $429.10
SALES TAXES $29.01
SALES TOTAL $279.76
TENDERED (DBT 2939) $279.76
BALANCE DUE 50.00
Date Time Store Reg Txn
11/18/25 11:15 AM 2248 719998 0206
11/18/2025
04:28 PM
TREADWELL: N
KEVIN MUHAMMAD
H:
2006 LEXUS MILEAGE: 186227
18250 AWD,
O.E. (F): 225/45 R17 SL
O.E. (A): 225/45 R17 SL
CONDITION: CARRY - OUT: N
COLOR: WHEEL LOCK: N
PLATE: LOCATION:
CAL 49 SALES ORDER #: 5053255234
17256 SLOVER AVE ORDER TYPE: STOREORDER
FONTANA, CA
92337-7583
909 - 320 - 6525
•
ARTURO G
ESTIMATED COMPLETION TIME: 05:36 PM
APPOINTMENT TIME: 02:15 PM
---- ------ ---
ARTICLE AXLE DESCRIPTION PRICE QTY AMOUNT
- - - ----------- -----------
39799 225/35 R20 90WXL $164.00 2 $328.00
BSW
TOY EXTENSA HP II
TIRE MILEAGE WARRANTY: 45000
98188 L DIL 1100K TO $0.00 2 $0.00
AMP-I
TPMS RBK BASIC KIT 1100K
80017 CERTIFICATES FOR $33.05 2 $66.10
REFUND, REPLACEMENT
80224 WASTE TIRE $3.50 1 $3.50
DISPOSAL FEE
80075 STATE REQUIRED $1.75 2 $3.50
TIRE FEE
98937 LIFETIMMENTIBAL & VAL $0.00 1 $0.00
W/CERTS
91123 INSTALLATION & $28.001 $28.00
LIFE OF TIRE MAINTENANCE
ADJUSTMENT
39733 036R0042L $164.00 - 1 S-164.00
TOY EXTENSA HP II
REASON: Road Hazard
TIRE MILEAGE WARRANTY: 45000
COMMENTS: LF AND RR. EW ON REAR. ORDERING TIRES IN.
SUBTOTAL: $265.10
SALES TAXE8: $29.01
Total Credit: 5-178.95
Total: $279.76
PAYMENT STATUS: PAID
-------
•---
SPECIAL INSTRUCTIONS: SPEC_Offset
SPECIAL INSTRUCTIONS: SPEC_MAXTIRE
TPMS INSTRUCTIONS: TPM$_TOY - 1
TPMS INSTRUCTIONS: TPMS_TOYOTA/LEXUS DTO'S
•
DOT: 0823 LF RF DOT: 1CX7X134D402
7 7
DOT: 02HLMAAH10823 LR AR DOT: NA
5 SP
BOLT PATTERN: 5-114.30 INFLATION: F:35 R:37
LUG NUT SIZE: 12.0X1.5 TORQUE LBS: 80.0
SALES ORDER #: 5053255234
KEVIN H MUHAMMAD
AUST BERNARDINO CA. 923
20 NOV 2025 PM7 L
RIALTO CITY CLERK'S OFFICE
CITY OF RIALTO 2025 NOV 24 AMII: 20 RECEIVED CITY CLERK 150 S. PALM AVE RIALTO CA 92376
923TE-àv0a