CITY OF RIALTO
LIABILITY
CITY OF RIALTO
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY 2026 MAR 25 PM 2:59
RЕCки.
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurence (Gov. Code 59112) CITY CLERM
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:
Antoinette Riójas
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP J HOME TELEPHONE NO. 450 Auto Center Dr. Corona Ca. 1951) 737 5100
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: 2-22-2025 TIME: • AM • 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.
My home pool became full of dint due to the construction going on behind my home. The dirt was loose and never watered down. When the wind blews which it blows alot the dirt covered my pool.
3. HOW DID DAMAGE OR INJURY OCCUR?
4. WERE POLICE AT THE SCENE? DYES NO WERE PARAMEDICS AT THE SCENE? •YES NO
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.
N/A.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $1200.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: _ 3|17/26 Amount: $ 1200.00
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $1200,00 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) NAME: NAME:
ADDRESS: ADDRESS: —
TELEPHONE: L TELEPHONE: _)
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITALS) VISITED: 2026 CIT
NAME: NAME:
ADDRESS: 4. C
ADDRESS: 9
TELEPHONE: TELEPHONE: L)
DATE: TIME: DATE: TIME: ДАМ ШРМ
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
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE I CERTIEY OR NECTARFL LINNER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Antoinette Rio, as 3|25/26
YPE OR PRINT NAM DATE
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) DETIIDA I AIM TA. DIAI TAPITURI FOKE NEEINE_ 1ENG DAI MAVE DIAI TA SA 0227A From: Toni Riojas B
Subject:
Date: March 25, 2026 at 1:48PM
To: Nana
Javi's Pool Inc.
651 Wickford Ave. Invoice
La Puente, CA 91744
Date 3/17/2026
Invoice # 19083 2
MARI CITY
Bill To Ship To
Mrs. Toni
RIALTO
P.O. # ACID AND UP... Ship Date 3/17/2026
Terms Net 15 Due Date 4/1/2026
Other
Item Description Qty Price Amount
000000123 SERVICE CALL ACID WASH POOL. DRAINED POOL 1,200.00 1,200.00 | COMPLETELY THEN GAVE IT AND ACID WASH
NEUTRALIZE WATER AND DRAINED ALL ACID IN
¡POOL. AFTER GAVE POOL A LIGHT CHLORINE WAS
TO GET RID OF ALL BLACK ALGEA AND GREEN
| ALGEA. MADE SURE ALL WAS WELL WITH POOL
| AND SPA.
00000017 SERVICE CALL UPGRADE KIT ON JANDY SYSTEM. 1 1,600.00 1,600.00 | PROGRAMMED UNIT MADE SURE ALL WAS WELL
WITH NEW UPGRADE KIT HELP SET UP
APPLICATION ON PHONE
Subtotal $2,800.00
Sales Tax (0.0%) $0.00
Total $2,800.00
Javi's Pool Inc. Payments/Credits $0.00
Ralanca Mie 90 An an
From: Toni Riojas
Subject:
Date: March 20, 2026 at 11:15 AM
To: Nana I
2026 MA CIT
2076 MAR 25 CIT YOR
POPC MAR 25 PE CITY OFFIN