CITY OF RIALTO
CITY CLERKS DATE STAMP
CITY OF RIALTO 2026 FEB -2 PM 4: 37
LIABILITY
RECEIVED
CLAIM FOR DAMAGES CITY CLERK
TO PERSON OR PROPERTY
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months afler the occurrence (Gov. Code 5971.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurence (Gov. Code $911.2).
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:
Valerie Campobasso
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: 1-31-2026 TIME: 8:37 DAMORM
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.
IT wks driving Nerth manhole cyler on thee, ore My passenger-side rear tire was punctured on the side wall..
3. HOW DID DAMAGE OR INJURY OCCUR?
, When suddenly the tire was immediately flat. There was exposed, raised manhole, with broken concrete debris stirrounding it. I could not see the concrete chunk's when driving I pulled ava right away and saw my
4. WERE POLICE AT THE SCENE? DYES DENO WERE PARAMEDICS AT THE SCENE? dyEs No Sideway rear tire had
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 manhole surrounded by sharp concrete debris.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ 218.02 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: - late rear pussenger-side tire Amount: $
American tire de pot near my house Amount: $
AMERICAN FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERICANTIREDEPOT.COM
Start Time: 1/31/2026 11:27:45 AM
Invoice#: 1163-8345500 Invoice Time: 1/31/2026 11:57:59 AM Customer Information Vehicle Information Store Location CAMPOBASSO, MIKE 2019 HONDA ODYSSEY EX-L RIALTO #1163
Cust#: ED-6190516 Engine: 3.5L V6 SOHC J35Y7 I-VTEC 185 E FOOTHILL BLVD Plate: RIALTO CA 92376
VIN Number: Phone: (909) 279-1567
Phone Miles: 1 Started By: AARON L. (AL317)
Email: Invoiced By: ROBERT (ROB) L. (RL105)
BAR#: ard301169
EPA#: CAL000470360
Brand Part Description Tech Salesperson Price Qty Total General Subtotal(No Tax): 203.99
NEX 14911N 235/60R18XL 107H N PRIZ A5 BSW NEX CR778 AL317 $191.99 $191.99 Tire Serial# 05YEHEM1525
* CONSUMER ADVISORY.* THID IS A 7/" RATE TIRE IT HAS A MAXIMUM SPEED OF 130 MPH. IT HAS " ENTED HANDLING CHARACTERISTO ONSULTYOUR OWNERS MANUAL FOR THE. PROPER SPEED FATING RECOAMENDED FOR YOUR VEHICLE CUSTOMERS ITALS —.....
CDF CDF TIRE RECYCLING CR778 AL317 $5.50 1 $5.50
_BR WBHS HIGH SPEED WHEEL BALANCE CR778 AL317 $21.25 1 $21.25 ...
SHP PREMIUM WHEEL WEIGHTS CR778 AL317 $4.50 1 $4.50
STF STF CALIF. STATE TIRE FEE CR778 AL317 $1.75 1 $1.75 DISCOUNT CUSTOMER DISCOUNT/REBATE CR778 AL317 $21.00 -1 $-21.00 -BR UCI LOOSE TIRE FOR LISTED VEHICLE CR778 AL317 $0.00 1 $0.00 Vehicle Tire Pressure - F: 35 R: 35
Page: 1 of 2
AMERICAN FIND STORE HOURS
AND LOCATIONS ONLINE
TIRE DEPOT AMERICANTIREDEPOT.COM
Start Time: 1/31/2026 11:27:45 AM
Invoice#: 1163-8345500 Invoice Time: 1/31/2026 11:57:59 AM Customer Information Vehicle Information Store Location CAMPOBASSO, MIKE 2019 HONDA ODYSSEY EX-L RIALTO #1163
Cust#: ED-6190516 Engine: 3.5L V6 SOHC J35Y7 I-VTEC 185 E FOOTHILL BLVD Plate: ¡ RIALTO CA 92376
VIN Number: Phone: (909) 279-1567
Shone: Miles: 1 Started By: AARON L. (AL317)
invoiced By: ROBERT (ROB) L. (RL105)
Email:
BAR#: ard301169
EPA#: CAL000470360
Invoiced Summary
Payment Invoice Totals
Type CCD2
669541129 Parts: $180.99
VISA CARDHOLDER
Debit4947
FET: $0.00
Amount $218.02
EMV: APPLABEL:US DEBIT|TVR: 0000000D00/IAD:06021203A00000/ Shop Fees: $0.00 ARQC:64914824D8422E19|ARC:00|CVM:N
NonTax: $23.00
Taxes: $14.03
acknowledge below and receipt of this invoice Total: $218.02 Customer Signature or Initials:
acknowledge notice and oral approval of an increase in the original estimated price.
Page: 2 of 2
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: 218.02 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 (altach additional pages, if necessary) NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: | ) TELEPHONE: |)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTOR(S) OR HOSPITAL(S) VISITED:
NAME: _ NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: ()
DATE: TIME: DATE: TIME: •AM 03 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.
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
PARKWAY
SIDEWALK
THOSE MATTERS MICH ARE EEN STATED UPON MY INFORMATION AND BLEE AND AS TO THOSE MATERS BEVE THEM TO BEDE EXCEPT AS TO / . ICERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OF AGENT
Valerie Campobasso 2/2/2026
TYPE OR PRINT NAME DATE
muself
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