CITY CLERKS DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2025 MAR 25 AMII: 46
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to persan, or to personal property must be fled not later than six (6) months affer 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 (Gav. Code 59112). 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: 150S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Beshay Foods, Inc dba Jack in the Box #0162
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO. 316 W. Foothill Blvd, Rialto, CA 92367
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE Attention Risk & Compliance 41760 Ivy St, Ste 201,
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM,
(if different from home address provided above): Muriefa, Ca 92562
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 11/09/2025 TIME: 4:57
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locale on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
At Jack in the Box, 316 W. Foothill Blvd, Rialto, CA 92367, Sgt. Cordova who appeared to be in pursuit of a suspect, drove onto the property and struck a retaining wall/planter located on-site.
3. HOW DID DAMAGE OR INJURY OCCUR?
The impact damaged the low brick wall surrounding the planter box. The damaged section of the wall required reconstruction.
4. WERE POLICE AT THE SCENE? EYES DINO WERE PARAMEDICS AT THE SCENE? DYES CKNO
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.
Sgt. Cordova who appeared to be in pursuit of a suspect, drove onto the property and struck a retaining wall/planter located on-site.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ $2.420.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bils, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Retaining Wall Estimate • Amount: $_ $2,420.00 Item/Date: Amount: $_
$2,420.00
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
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: _ > TELEPHONE: | )
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME:_ N/A NAME: N/A
ADDRESS: ADDRESS:
TELEPHONE: | 1 TELEPHONE: | 1
DATE: _ TIME: DATE: . TIME: DAM OPM
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 citytown 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 → NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
SIDEWALK CITY OF RIAL
THOSE MATES MORE ARE ON INFORMAND BEE AND AS TO THOSE MATERS BOLEVE THEM TO BE TRUE GENT AS TO
THOSE MATTERS WHICH ARE HEREIN STATED UPON
I CERTIEV IOR DECI ARE LINDER DENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Dawood Beshay 3|26|2026
TYPE OR PRINT NAME DATE
President •
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 Gavino's Lawn Service, Inc.
PO Box 33410 CITY OF RIALTO
Riverside, CA 92519
+19516606084 2126 MAR 26 AMI: 45
[email protected]
ACCLIVED
CITY CLERA
Estimate
ADDRESS ESTIMATE # 6556
BFI DATE 11/17/2025
Store #J162
316 W Foothill Bivd
Rialto, CA 92367
CSLB NO. C27-1027974
DATE ACTIVITY DESCRIPTION QTY RATE AMOUNT
Landscape Work Fix Retaining Wall that was 2,420.00 2,420.00 impacted and damaged by car
Remove broken bricks.
Clean-up dirt and debris.
Install approximately 400 bricks.
Install Mortar Type 'S Mason Mix.
TOTAL $2,420.00
Accepted By Accepted Date