CITY CLERK'S DATE STAMP
CITY OF RIALTO
SALINO CANE CITY OF RIALTO
LIABILITY
CLAIM FOR DAMAGES 1026 SEP -3 PM12:56
TO PERSON OR PROPERTY RECEIVED
CITY CLERK
1. Claims for death, injury to person, or to personal propery must be filed not later than six (6) months after the occurence (Gov. Code 59112).
2. Clalms 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 Mall: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Evelin Janeth Escalarte
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO. 2425 W Via Bello Dr
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): Rialto CA 92377
1. WHEN DID DAMAGE OR NURY OCCUR? DATE: 24 JULY 2026 TIME: 7:00 PM DAMLPM
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 was on Riverside Ave and Linden Ave North. That
area was a long Strip ot roadwork on riverside Are.
3. HOW DID DAMAGE OR INJURY OCCUR?
Due to the roadwork that was hard and rough F
gut bubbles on my tires, air leaking, damages to all
4 rims.
4. WERE POLICE AT THE SCENE? •YES NO WERE PARAMEDICS AT THE SCENE? •YES ANO
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.
Roadwork caused by City of Rialto.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $$3,578.00 HOW WAS THE ABOVE AMOUNT COMPUTED? Be speciflc, Ilst doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Front left rim & tire damage Amount: $
Item/Date: Eront right rim & tire damage Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $.
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
ack left rim &tire damage Amount: $
Item/Date:
Item/Date: Back right tire & rim damage Amount: $
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
NAME: Brad castro Smith
ADDRESS: ADDRESS:
=a -
TELEPHONE: 1e-41 TELEPHONE: Is y up
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: L)
DATE: TIME: •AM • PM DATE: TIME: • AM LI PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident clalms, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accldent by "X" and by showing house numbers or distances to street corners.
If a clty/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 vehlcle when you first saw City/Town vehicle; location of City/Town vehicle at time of accldent 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.
N Riverside AV EuRB
PARKWAY
SIDEWALK
N Cedar Ave
Ave
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 CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Evelin do Esculante 09/03/26
TYPE OR PRINT NAME DATE
Self
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 Correction Wheel - Rear - RH Labor Hours Price Adjustment Subtotal (Remove & Replace) - Remove and
Replace
0.30 84.00 0.00 84.00
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
WHEEL, 20X9.0J ET34, 1.00 875.13 875.13 0.00 875.13
UBERTURBINE(1234267-
00-A)
Parts Subtotal 875.13
*Labor Hours included in other correction Pay Type: Customer Pay Total Parts Amount 2,819.13
Total Labor Amount 487.20
Labor Hours 1.74
Concern: Check tire pressure and condition
Repair Notes:
Correction Automated Tire Pressure Check
Pay Type: Goodwill
0.00 Concern: Windshield Protection Plan Inspection
Repair Notes:
Correction Windshield Protection Labor Hours Price Adjustment Subtotal Plan Inspection
0.05 0.00 0.00 0.00
Pay Type: Customer Pay
Total Parts Amount 0.00
Total Labor Amount 0.00
Labor Hours 0.05 0.00
Service Center hourly rate: USD 280
Notes: To assess your vehicle's Tire Wear and Condition, please see the Tire Care and Maintenance section from the digital Owner's Manual in your car.
Parts Taxable
All parts are new unless otherwise specified. 2,819.13
Amount (USD)
Accepted Payment Methods:Major Credit Cards (Visa, Mastercard, AMEX, etc.), Labor Taxable 487.20 Debit Card, Cashier's Check Amount (USD)
You agree that: You are entitled to a price estimate for the repairs you have authorized. Discount 0.00 The repair price may be less than the estimate provided, but shall not exceed the Total Taxable Amount (USD) 3,306.33
estimate without your consent unless 1) the repair price increases by no more than 10% and 2) no additional consent is required by law. Additional repairs may not be performed Tax Amount 272.53 without vour consent. This estimated price for authorized repairs will behonored if your vehicle is delivered to Tesla's facility within the time period agreed to by you and Tesla. Total Amount (USD) 3,578.86 You may waive vour right to a written estimate and require that you be notified if the price exceeds an amount you have specified. All personal items should be removed from the vehicle prior to repairs as Tesla is not responsible for any personal items left in your 2 of t
Tesia, Inc Service Estimate Invoice date Invoice number 1932 E GARVEY AVE S 3000-009-
West Covina, CA,US 91791-1910 SERVICE DEPARTMENT HOURS 03-Sep-2026 0038704796 Mon-Fri 7:00 a.m. - 6:00 p.m
Ph.: (626) 646-1117 Sat-Sun Sat;Sun:8am-6pm Service#
TESLA
SVO2E21B0E
Due Date PO Number
B.A.R. #ARD00309771
03-Sep-2026
Date/Time Received Date/Time Promised
14-Sep-2026
-11:15:00
Odometer In Odometer out
Miles • Miles
Ready Date
Service Advisor
Michael Sanchez
Bill To Mobile Phone Additional Phone Vehicle Identification Number Brad Castro
Year Model License Plate Number Colour
12023 MODEL 3 Red Multi-Coat
Job Description Of Work Amount (USD)
1 Concern: Customer states: Other - I want an estimate on my four tires and four rims of my Tesla 3,306.33 model three for damages that was done due to roadwork bubbles on the tires and rim scrapes Repair Notes:
Correction Tires - Vehicle - Set Labor Hours Price Adjustment Subtotal
0.00* 0.00 0.00 0.00
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
235/35R20 92Y XL - 4.00 420.00 1,680.00 0.00 1,680.00
PIRELLI - P ZERO 4 PZ4
SUMMER(1044257-00-
TIRE DISPOSAL 4.00 6.00 24.00 0.00 24.00
FEE(1025331-00-A)
Parts Subtotal 1,704.00
Correction Wheel Sensors - TPMS - Labor Hours Price Adjustment Subtotal Vehicle Set (Remove & Replace) -
Remove and Replace
1.44 403.20 0.00 403.201
Parts Replaced or Added
Part Quantity Unit Price Price Adjustment Subtotal
TIRE PRESSURE 4.00 60.00 240.00 0.00 240.00
MONITORING SENSOR
- BLUETOOTH -
BLACK(1490701-01-E)
Parts Subtotal 240.00
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vehicle; Tesla and its employees may access and operate your vehicle including on streets, highways, or public roadways for the sole purpose of testing and/or inspection of epairs: Tesla may update your vehicle's software in the course of a repair or as part of he standard vehicle maintenance process per your owner's manual and New Vehicle Limited Warranty; Tesla and its employees may access, download and use the information stored on your vehicle's data recorder to service and diagnose issues with your vehicle, Tesla may share limited information about you and your vehicle with manufacturers to submit warranty claims and Tesla may store and aggregate such data for its own purposes; an express mechanic's lien is hereby acknowledged on your vehicle to secure the amount of repairs, storage and other applicable fees; the vehicle owner's insurance provides exclusive coverage for the vehicle while it is in Tesla's possession; and you may be charged storage fees of $35/day from the fourth working day after you are notified that repairs on your vehicle are complete and that the vehicle is ready for pick up.
Tesla disclaims all express or implied warranties with respect to any repairs or products used in repairs, except as may be set forth in your Tesla-issued New or Used Vehicle Limited Warranty, Tesla Parts, Body, and Paint Repair Limited Warranty or other extended service agreement. Tesla is not responsible for repairs not performed by, or components not installed by, Tesla. Any parts (including tires/wheels) removed or replaced by Tesla during vehicle service will become the property of Tesla. However, at the time you authorize repairs, you may request to receive (subject to any applicable core charge, which you agree to pay) or inspect replaced parts (excluding inflatable restraint system components), except body shop repair parts and parts required to be returned to the manufacturer or a third party under a warranty, trade-in or exchange agreement, which will only be presented to you for examination and not returned.
MODIFICATIONS TO THE VEHICLE: Tesla will service the Vehicle in accordance with Tesla's vehicle specifications and standards for service and repair, and Tesla reserves the right to refuse at any time performing vehicle service or repair in the interest of safety either during, or as a consequence of, the service or repair. You acknowledge Tesla is not responsible for any damage caused to the vehicle or any non-tesla modifications to the vehicle as a result of service performed on the vehicle. Tesla may remove any third-party equipment or modifications, including but not limited to non-Tesla software or firmware, during the course of service or diagnosis and repair. Tesla is not responsible for replacing any third-party equipment or modifications. You will remain liable for any additional costs incurred in servicing of a Tesla vehicle with any third-party modification.
GNITION INTERLOCK DEVICES: If your vehicle is equipped with an ignition interlock device that requires additional handling by authorized Tesla Service Center personnel to enable the performance ofrepairs or services, you will be charged a flat fee of $200 per individual service visit, applicable for the entire duration of that specific visit. This fee is assessed per visit such handling is required and covers the administrative and technical efforts necessary to safely handle the device in strict compliance with all applicable federal, state, and local laws, as well as manufacturer guidelines. Such efforts include, but are not limited to, administrative coordination with the device provider, implementation of technician safety protocols, management of vehicle warm-up cycles, and mitigation of any device-related interruptions. You must be physically present on-site with the vehicle at the time of your appointment to personally authorize and facilitate the handling process, and failure to do so may result in service delays or refusal, for which Tesla shall bear no liability. To ensure seamless handling and prevent any disruptions, please notify our service advisors in advance if your vehicle is equipped with such a device. Tesla disclaims all liability for any consequences arising from the presence, malfunction, or regulatory requirements of the ignition interlock device, including but not limited to delays, additional costs, or compliance issues not directly attributable to Tesla's actions.
I authorize the repair work, including parts, materials and labor, on my vehicle to be done pursuant to the terms and conditions as set forth in this service agreement document.
Signature: Date:
Waring: Motor vehicles contain chemicals known to the State of California to cause cancer and birth defects or other reproductive ham.
FullName:
A buyer of this product in California has the right to have this product serviced or repaired during the warranty period. The warranty period will be extended for the number of whole days that the product has been out of the buyer's hands for warranty repairs. If a defect exists within the warranty period, the warranty will not expire until the defect has been fixed. The warranty period will also be extended if the warranty repairs have not been performed due to delays caused by circumstances beyond the control of the buyer, or if the warranty repairs did not remedy the defect and the buyer notifies the manufacturer or seller of the failure of the repairs within 60 days after they were completed. If, after a reasonable number of attempts, the defect has not been fixed, the buyer may return this product for a replacement or a refund subject, in either case, to deduction of a reasonable charge for usage. This time extension does not affect the protections or remedies the buyer has under other laws. 3 of t
You further agree and acknowledge that:
• Estimates are good for 30 days from invoice date.
• You have the right to inspect your vehicle on Tesla premises priorto payment • To the extent permissible by law, Tesla is not responsible for loss or damage to the vehicle or any articles left in the vehicle in case of fire, theft, hail, wind, or any other causes beyond its control; • Tesla personnel will turn off any photo or video capturing devices, such as dashboard cameras, once they receive the vehicle in preparation for service and your vehicle's Tesia dash cam will be enabled when you pick up your Tesla from this Service visit; • Labor charges are not based solely on actual service personnel's time but are aggregate prices for specific services or repairs, which may include flat rates based on industry manuals and vehicle condition; • Waste storage and disposal fees are charged separately when applicable to specific services or repairs, and represent costs and profits to Tesla which are calculated based on average annualized costs across Tesla service facilities; • Items purchased over the counter or online directly from Tesla may be returned within 30 days with a proof of purchase and must be in their original and uninstalled condition with factory labeling attached and in factory packaging (if supplied); • Tesla-branded parts purchased directly from Tesla over-the-counter, online or purchased and installed by Tesia Service are covered under the Tesla Parts, Body, and Paint Repair Limited Warranty for a period of 12 months subject to the applicable terms, conditions and exclusions and available at https://www.tesla.com/support/vehicle-warranty • All charges for repairs, including labor, parts and materials furnished, are due and payable simultaneously with the return of your vehicle or prior to return upon the expiration of three (3) working days after notice has been sent by Tesla that the vehicle is ready; • If applicable, you have the right to choose the licensed repair shop where the damage to your vehicle will be repaired; • All crash parts supplied meet the standards used in manufacturing the original equipment replaced; • If any repair, storage and other applicable fees remain unpaid for thirty (30) days after a request for payment, Tesla may pursue collection and you will be responsible for paying all reasonable attorney's fees and costs for such collection; • If provided a loaner or rental vehicle, the vehicle must be returned within 24 hours of such notification or a daily usage rate of up to $100 USD and applicable fees will be charged until the return of such loaner vehicle • The repair work may not be completed prior to the date and time noted under Date/Time Promised and Tesla may adjust the estimated completion date upon notification to you and is not responsible for any delays caused by the unavailability of parts or parts shipments; and
• Tesla (and any of its subsidiaries) may contact you via emails, calls, SMS or other messages including through the Tesla app (collectively, "messages) to obtain authorization and provide updates regarding this Service visit and your vehicle. Standard SMS message and data rates may apply. You can withdraw your consent to receive automated SMS messages at any time by replying "STOP"or providing written notification to Tesla's customer representative. • This dealer is required by law to charge a nonrefundable $2 California battery fee and a refundable deposit for each lead-acid battery purchased. A credit of the same amount as the refundable deposit will be issued if a used lead-acid battery is returned at the time of purchase or up to 45 days later along with this dealer's receipt. 4 of 4