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in Seal of the City
City clerk's date stamp
of Rialto, California, City of
including the words
Rialto
'City of Rialto,
California' and 026
Liability
'Incorporated Nov. CITY OF
17, 1911. Claim for =
Damages 7. 0 LT.
to Person 50
Property
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).
3. Read entire claim form before filing
4. Attach separate sheets, if necessary, to give full details Return to:
Rialto City Clerk's Office
Mail: 150 S. Palm Ave., Rialto, CA 92376
Address: 290 W. Rialto Ave., Rialto, CA 92376
Claimant Information
Full name
Jennifer Petinaud
Date of birth
Home address including city, state & zip
1075
Home telephone no.
SHAY 11 CITY OF RIALTO
Business address including city, state & zip Fil
LERA
Business telephone no.
Address at which claimant desires to receive notices or communications regarding this claim (if different from home address provided above):
Mailing Address:
2058 N. Mills Avenue #505
Claremont, CA 91711
1. When did damage or injury occur?
• Time period—
Date: Time: 0 AM DIPM
April 7, 2026 12:30
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.
Southbound Locust Avenue, past Bohnert Avenue and before the right-turn lane for westbound Casmalia Street, Rialto, CA.
3. How did damage or injury occur?
See attached Incident Statement and supporting exhibits.
4. Were police at the scene? — Were paramedics at the scene?— • Yes 2 No • 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.
See attached cover letter and supporting exhibits.
6. Give total amount of claim Include estimate of amount of any prospective injury or damage
2003
$ CITY
2,724.30 933
How was the above amount computed? Be specific, list doctor bills, repair estimates, etc.
Please attach 2 estimates.
Damages incurred to date:
Item/Date:
Vehicle repair invoice - HTW Auto Center 04/14/2026
Amount: $
2,724.30
Item/Date:
AAA tow service verification attached - 04/07/2026. No out-of-pocket charge Amount: $
0.00
Additional content from previous item:
Total amount claimed as of presentation of this claim: $ 2,724.30
Estimated prospective damages, as far as known:
Item/Date:
None known at this time
Amount: $
0.00 Item/Date:
Amount: $
Total estimated amount prospective damages: $ 0
2005 MAY 11
7. CITY OF RIALTO
Witnesses to Damage or Injury
List all persons known to have information (attach additional pages, if necessary) en Name:
Marva A Jackson
Address:
Telephone:
Name:
None known at this time
Address:
Telephone:
8. If Injured, Provide Name, Contact Information and
Date/Time Doctor(s) or Hospital(s) Visited
Name:
Not applicable - no bodily injury claim being made.
Address:
Telephone:
Date:
Time:
O AM O PM
Name:
No medical treatment sought.
Address: CITY CLLAR RECENTLE 2970 MAY I1 Pi 1: 50 CITY OF RIALTO Telephone:
Date:
Time:
O AM O 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.
i Blank vehicle accident diagram template. A central street edge is labeled Curb. Inside the central area are two horizontal sections labeled Parkway and Sidewalk. Partial curb or corner outlines appear around the outside, creating a blank intersection-style layout where the claimant can add street names, directions, positions, and the point of impact.
Diagram labels: Curb, Parkway, Sidewalk.
Certification and Signature
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. 10 =
Signature of claimant or agent ..
OLT:
Type or print name
'Jennifer Petinaud
Date
I May 8, 2026
Relationship to claimant
Self
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 Claimant: Mrs. Jennifer Petinaud
Date of Incident: April 7, 2026
2075 MAY I 1 CITY OF RIALTO
2%:
ATTACHMENT TO QUESTION #6
The claimed amount of $2,724.30 is based upon the attached repair invoice and supporting repair statement from HTW Auto Center following inspection of the vehicle after the roadway incident.
The damages include replacement of four discontinued rims, replacement of two damaged tires, control arm replacement, labor, alignment, and associated taxes resulting from the pothole impact.
Only one repair estimate/invoice is available because the vehicle was not safely operable following the incident and required immediate towing and repair.
Supporting documentation attached includes:
• Repair Invoice
• Repair Shop Statement
• AAA Tow Verification
• Photographic Evidence of Roadway Condition and Vehicle Damage Submitted in support of claimant's Government Claim.
Mrs. Jennifer Petinayd / •/.
Attachment to Question #9
Roadway Hazard Location Diagram
CITY CLERA RECEIVED 7025 MAY 11 PM 4:50 CITY OF RIALTO
NORTH
Bohnert Ave
--------------------AAAAAOMMO
I* Jennifer traveling
I southbound
I (Pothole)
Right turn lane to westbound Casmalia St
SOUTH
Submitted by:
Mrs. Jennifer Petinaud,. r
CLAIM PACKAGE - ROADWAY HAZARD DAMAGE CLAIM
Claimant: Mrs. Jennifer Petinaud
Incident Date: April 7, 2026
Location: Locust Avenue, Rialto, California
207E HAY I1
22°
To:
City of Rialto - City Clerk / Claims Division CITY OF RIALTO Re: Claim for Damages - Roadway Hazard Incident
Dear Claims Examiner:
Please accept this correspondence and attached documentation as a formal claim for damages resulting from a hazardous roadway condition located on Locust Avenue in Rialto, California.
On April 7, 2026, Mrs.,
The roadway condition, as documented in the attached photographic evidence, reflects substantial deterioration and presents a clear hazard to motorists. The damage incurred required towing and extensive repair, as supported by the attached repair statement and invoice.
The hazardous condition remained present on April 10, 2026. Following rainfall on April 11, 2026, the roadway was subsequently repaired by April 13, 2026, indicating the condition existed long enough to have been identified and addressed prior to the incident.
Tow services were rendered through AAA membership roadside assistance benefits. Although no direct out-of-pocket towing charge was assessed at the time of service, the tow verification confirms the vehicle was not safely operable following the roadway incident and required transport to a repair facility.
We respectfully request review and reimbursement for damages incurred as a direct result of this unsafe roadway condition.
Sincerelv
Mrs. Jennifer Petinaud
Exhibit Index
Exhibit A: Pothole - Wide View
Exhibit B: Pothole - Close-Up
Exhibit C1: Damaged Tire Mounted on Vehicle
Exhibit C2: Bent Rim Damage
2078 MAX 11 PM 4:51 CITY OF RIALTO
Exhibit C3: Side View of Damaged Tire RECEIVED
CITY CLERX
Exhibit C4: Cracked and Bent Rim
Exhibit D: Signed Repair Shop Statement
Exhibit E: Repair Invoice - HTW Auto Center ($2,724.30) Exhibit F: AAA Tow Verification
Exhibit A - Pothole Wide View
2925 MAY 11 CITY OF RIALTO
PH 4: 51
Exhibit B - Pothole Close-Up
2026 MAY 11 PM 4: 51 CITY OF RIALTO
Exhibit C1 - Damaged Tire Mounted on Vehicle
2026 MAY 11 Pii 4: 51 CITY OF RIALTO
Exhibit C2 - Bent Rim Damage
2025 MAY ! | PM 4: 51 CITY OF RIALTO
Exhibit C3 - Side View of Damaged Tire
2028 MAY 11 PM 4: 51 CITY OF RIALTO
265/50
Exhibit C4 - Cracked and Bent Rim
ciTY 2026 MAY |1 PM 4: 5! CITY OFRIALTO
Hy Performance Tire & Wheel, Inc. Exhibit D - Signed Repair Statement DBA HTW Auto Center
356 E. Foothill Bivd. - Upland, CA 91756
Tel: (909) 946-3338 - Fax: (909) 946-2453
4/14/2020
a pothole.
damage to the rim, bre and suspension components. Due to the the vehicle was not safety operable and required towing to out nd try the
and espiscement of two tires is also necesary due
negrity resulting from the impact.
* with the force
controt arm is regu ed by an
tore properve
In our professionat opinion, the dam identified is not const mat wear and tear but rather the insutt of a sudden and forcefut impact with a medway hazand/pothole:
Scott Strango
HTW Motorsports
TO ALD
Exhibit E - Repair Invoice
-HIV- AUTO GRATER
01706-3838
LT.... CITY CLERN KECEIYLI 7085 MAY 11 PM 4: 5/ CITY OF RIALTO Tet uL Ft
рако
Tati
DATE DAT SHIFPZD RSTAStD": DePOSI•
4 alge
20xa Magher 250 BAcO:
a S.ki 185-
20 350 390
AL SS 120 200E 300E
IED= (CD)
TO COENA
MILESI 164 30
TOTAL 2129 30
Thesk Uro
Exhibit F - AAA Tow Verification
AAA Verification Page 1
Automobile Club of Southern California AAA.com
May 06, 2026
JENNIFER PETINAUD Member No. 004-92040534
2075 MAY !!
Dear Jennifer Petinaud: CITY OF RIALTO
As you have requested, a synopsis of the calls) you placed for Emergency Roadside Assistance are located on the next pages).
The SERVICE CHARGE (YES/NO) field:
NO = the call counted as part of your service call entitlements. 51 YES = you were charged for this service call.
The SERVICE CHARGE AMOUNT is the monetary value of the service. hould you have any questions, or if I may be of further assistance, please do no esitate to call me at the number below or Toll Free: 888-222-944 Sincerely,
Jennifer Gomez
714-850-5261
ERS Administrative Services
Ara CA02799-3001 Apaduater: 260h$ 10-01001 Am CADY 374
We're attaye with you."
AAA Verification Page 2
Automobile Club of Southern Colllainic AAA.cOm
Call: 1 Date: 04/07/2026 Time: 1:25 PM
Location: Service Type: Tow
3356 N Carnation Dr Tow Dest: 356 E Foothill Bivd
Rialto, CA Upland, CA 2025 MAY I I
Vehicle: 2005 Chevrolet Express Cargo CITY CITY OF
Service Charge: No Service Charge Amount:
Service Status: Completed MECEIVEL
Provider: ANGELO'S TOWING & RECOVERY CLERK
PM 4: 5! RIALTO
402300 s00
We're ahways with you."
VENNIFEA
2058 N. 1 Retail U.S. POSTAGE PAID
FCM LG ENV
CLAREMONT, CA 91711 RANCHO CUCAMONGA
CA 91701
MAY 08, 2026
92378 $12.14
9589 0710 5270 2415 0803 91 RDC 99 S2324W500693-16
RECEIPT
ESTED
CITY DE RIALTA 207 HAT 19 PM 4: 50 CITY CLERA 150 So. Pem AvE PALTo, CA 92376
VERNMENT Cimm