CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY CITY OF RIALTO
CLAIM FOR DAMAGES 2026 JAN 14 AM 9:55
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
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:
Arleen Cynthia Sanchez
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
Adamson Ahdoot 1122 S. La Cienega
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Los Angeles, Ca 90035
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 07/21/2025 TIME: 2:30 • AM CXPM
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.
The location of the incident was Mid Valley Landfill located at 2390 Alder Ave, Rialto, Ca 92377
3. HOW DID DAMAGE OR INJURY OCCUR?
The claimant was discarding trash from the trunk of her personal automobile, when a CAT Machine, being operated by an employee of the landfill, struck the claimants auto, causing the rear of the vehcile to strike the claimants body, knocking her to the ground
4. WERE POLICE AT THE SCENE? [YESE}NO WERE PARAMEDICS AT THE SCENE? DYES ENO
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 employee of the Mid Valley Landfill, negligently operated the CAT machine, causing bodily injury to the claimant
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $_5.000,000.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Medical Treatment to date Amount: $ 31,809.91 Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 5,000.000.00 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: 07/21/2025 Bodily Injury Amount: $5,000.000.00 Item/Date: Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ 5,000,000.00
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: TBD NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: _).
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: West Point Medical Center NAME: Anil Date, MD
ADDRESS: 7774 Cherry Ave Fontana, Ca 92336 ADDRESS: 27141 Hidaway Ave Canyon County Ca TELEPHONE: L TELEPHONE: L
DATE: 07/22/2025 TIME: DAM OP DATE: 07/24/2025 TIME: • AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate plac f accident by "X" and by showing house numbers or distances to street corners 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.
CURB CITY CLERK RECENCE 2026 JAN 14 AM CITY OF RIALTO
PARKWAY
7/F SIDEWALK
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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.
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Chistopher Bates Adamson 01/12/2026
TYPE OR PRINT NAME DATE
Attorney
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 TRK# INV:
(909) 820-2519 UNITED STATES US LOS ANGELES, CA 90035 APS LA CIENEGA BEVD ERIKA LOPEZ ORIGIN BABA WM RIVA [02011 8878 4592 7973 RIALTO CA 92376 290 W. RIALTO AVE TO RIALTO CITY CLERK'S OFFICE (310) 888-0024
DEPT: REF: ARLEEN CYNTHIA SANCHEZ
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CA- US PRIORITY OVERNIGHT
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