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CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS
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 Sec. 9112)
2. Claims for damages to real property must be filed not later than one (1) year RECEIVED after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing.
See page 2 for diagram upon which to locate place of accident JAN 3 0 2023 This claim form must be signed on page 2 at bottom.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. CITY CLERK'S OFFICE
7. Claim must be filed with City Clerk. (Gov. Code Sec. 915a) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (li natural person)
James Brian Talbert 50
Home Address of Claimant City and State Home Telephone Number Business Address of Claimant City and State Business Telephone Number 1700 S. Soto st. LosAngeles C
Give address to which you desire notices or communications to be sent regarding this claim:
1700 S. Soto St. Les Angelas (A.
How did DAMAGE or INJURY occur? Give full particulars.
Monday Jan 9th 7:30pm. West bound Washinton Blrd.
Rained for Several days. Could not see hole, Front
Driver tire hit hole and blew tire out. No Rim Damage.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Mondan Jan 9th 7:30 pm
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Directly across from 4260 Washinten Blrd. Cross street
I5. Ash st.
at As ToroMISSION 0 Frame stare frontive nameso Cly employes, it any. causing the injury or damage, if known:
City of Vernon GA failed to properly inform Public.
of hole in the ground.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Front Driver Tire damaged beyond repair. Alignment was
damased. 1 Tire and Alignment.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation: From Receipt: 1 Tire $ $265.99, Fees $ 6.15, Services $13.49 1 Wheel Alignment $ 215.11
Total: $500.74
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
Amount shown on Receiet.
2of5
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received: Limited Liability. Accident not covered.
Progressive Inseurence.# #0
Expenditures made on account of accident or Injury: (Date - Item) (Amount) N/A
Name and address of Witnesses, Doctors and Hospitals:
N/A
READCAREFULLY
For all accident claims place on following diagram names of streets, including North, East. South, and West: indicate place of accident by "X" and by showing house numbers or distances to street corners If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "B" location of yourself or your vehicle when you first saw City vehicle; location of City vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of accident by "8 1" and the point of Impact by "X." NOTE:If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
норе
west bound
Washington Bird.
7117, 4260
Machine
Shor
FOR OTHER ACCIDENTS
SIDEWALK
CURB/
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimant or person filing on his/her behalf, giving Date:
relationship to Claimant: 2023
James B. Talbert Jan 30°
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEC.915a). STATE LAW PROVIDES THAT IF YOU ARE NOT NOTIFIED OF ANY ACTION BY THE CITY OF THIS CLAIM WITHIN 45 DAYS OF FILING THEN THE CLAIM IS DEEMED DENIED (SEE GOV. CODE SEC. 911.6 & 912.4) 30f 5
BAR#299542/EPA#CAL000461001
5233 CLARK AVE PAGE 1
LAKEWOOD,CA 90712
MOUNTAIN TEW (562)531-7570
TIRE & AUTOVSERVICE
Guest ID: 1721012958 Year: 2009 Date/Time: 01/10/23 15:27:52 Name: JAMES TALBERT Make: MERCEDES-BENZ Estimate #: 435512 Address: Model: E550 Invoice #: 427832
Address 2: Lic No: PO Number:
City, State, Zip: VIN: Unit Number:
Home Phone: Color: SILVER Email Address: na
Work Phone: 0 - Engine: 5.5L GAS DOHC Fleet/Wholesale: N Other Phone: 0- Mileage In: 273422 Est Created On: 01/10/23 09:57:27 Tax Exempt #: Mileage Out: 273422
Manager: MANNY TORRES Inspect Due:
Services Requested:
ORDER 2/TIRES CONNT
Car
Qty. Part # Loc Description Part Labor Amount
Tire Pressure Spec: Not Available Wheel Torque: Not Available Tire Pressure IN Tire Pressure OUT Tread Depth Brake Pads 35 psi 35 psi 35 psi 36 psi 10/32 10/32 132 132
35 psi 36 psi 36 psi 36 psi 7 /32 7/32 132 132
INCLUDED WITH EVERY VISIT
1 CI COURTESY INSPECTION NO CHARGE
1 TPO TIRE PRESSURE CHECK & INFLATE NO CHARGE
TIRE
2 OUTTIRE F CNT PRO CONTACT 265.99 0.00 531.98
Tire Size: 245/40R18 Speed Rating: V Ply: XL
Load Range: B Sidewall: BSW Load Index: 97
Mileage Warranty: 40000
DOT Numbers:
HW2PM1H63822 Mfg. Date: 38th week of 2022
HW2PM1H63822 Mfg. Date: 38th week of 2022
TIRE RECYCLING FEE 4.40 8.80
2 TRZ F 1.75
CATT CA TIRE FEE 3.50
TOTAL TIRE: 544.28
TIRE SERVICE
1 ALIGNMEN WHEEL ALIGNMENT 129.99 129.99
•LTI F Lifetime Install Package Includes: Mounting Balancing Standard Valve 30.99 61.98 Stem TPMS Inspection&Reset if applicable Alignment Check Wheel Torque PLUS: Lifetime Balancing Lifetime Rotation Lifetime Tire Repair 2 1040K F TPMS KIT 10.49 6.00 32.98
TOTAL TIRE SERVICE: 224.95
*** Customer Wishes To Discard Old Parts ***
1-30.23
These parts were declined by the customer:
2 RHW-MV MV RHAZARD COVERAGE 42.56 0.00 85.12
1 ALIGNMENT WHEEL ALIGNMENT 0.00 129.99 129.99
Subtotal of declined parts (tax not included): 85.12 129.99 215.11
SEE NEXT PAGE
INVOICE INVOICE BAR#299542/EPA#CAL000461001 INVOICE
CUSTOMER COPY
LIMITED WARRANTY
Thank you for your business! We are committed to earning your trust by providing the expertise, convenience and value you expect, every time you visit us. If you have any questions regarding the service, you received or our limited warranty, please contact Customer Service at 800-876-6676 x3500 or visit our website at www.monro.com.
WHAT IS WARRANTEED AND FOR HOW LONG
Most parts and service purchased at the Company are covered by a minimum of twelve (12) months or 12,000 miles, whichever comes first, with some parts and service carrying a different warranty. This warranty is valid for replacement performed at any Company location. Please visit www.monro.com to find our locations.
Some exclusions may apply; please see details below. Auto parts which prove to be unserviceable during the warranty period will be replaced for free of any additional charge for parts or labor, except as noted under "Exclusions", below.
SERVICE PARTS LABOR
Batteries' Covered by battery manufacturer N/A
Brake Pads Varies on brake pad level? Varies on brake pad level? Calipers Lifetime 12 months/12,000 miles
Catalytic Converters 60 months/50,000 miles 60 months/50,000 miles Flat Repair Lifetime/Fix Flat Only Lifetime/Fix Flat Only Mufflers Lifetime 12 months/12,000 miles
Rotors 12 months/12,000 miles 12 months/12,000 miles
Shocks and Struts Lifetime 12 months/12,000 miles
Steering and Suspension Lifetime 12 months/12,000 miles Tire Alignment N/A 3 months/4,000 miles
Tire Balance* N/A 3 months/4,000 miles
ALL LIFETIME WARRANTIES ARE VALID ONLY FOR AS LONG AS THE ORIGINAL CUSTOMER OWNS THE VEHICLE 'Batteries are covered by a separate performance warranty from the manufacturer. (This is on the back already) Brake Pad Framework Part Warranty Labor Warranty
Silver Limited Lifetime *Manufacturer Defects Only None Gold Limited Lifetime *Manufacturer Defects Only 12 months/12,000 miles Plalinum Lifetime 24 months/24,000 miles
Specialty Limited Lifetime *Manufacturer Defects Only None "If parts are required to restore vehicle to manufacture's alignment specifications, then those parts and the labor required to install them are not covered. *Lifetime balance is only warrantied so long as originally balanced tire remains on wheel. If needed, additional charge may apply for resetting the Tire Pressure Monitoring System (TPMS).
Other Exclusions: Replacement of anti-freeze or clamps is not included in the warranty on belts/radiator hoses. Cost of refrigerant and recharging of the air conditioning system is not included with the warranty on air conditioner parts or air conditioner compressors. Cost of additional brake system components, including rotors and drums and/or labor to restore brake system to its safe and proper operation is not included with the warranty on brake shoes, disc pads, calipers and/or wheel cylinders and all other hardware. Batteries are covered by a separate warranty by manufacturer.
TIRE WARRANTY
We are so confident of our top-quality tires, if you are not pleased with your purchase in the first 30 days or 500 miles, whichever comes first, you may return your undamaged tires and exchange them for any others of equal value or receive a full refund.
Tires purchased at the Company are covered by a manufacturer's limited warranty. Tire warranty information will be provided separately at the time of purchase.
For the following purchases: Falken, Pirelli, Achilles, Black Lion, Gallant, Landsail, Hankook, Yokohama, Laufenn, Ohtsu, Pantera and Vee Rubber Congratulations on your tire purchase. As an added benefit we are offering complimentary tire change service with your purchase. This "Free Emergency Roadside Assistance" tire change service is available 24 hours a day, 365 days a year, anywhere in the U'nited States and Canada for 2 years from date of purchase. Please refer to our Roadside Assistance brochure for complete details.
GENERAL PROVISIONS (APPLICABLE TO ALL WARRANTIES)
This warranty is valid only at Company locations: if the vehicle is serviced by anyone other than the Company, this warranty is void of that service.
No Company representative has authorization to alter or enlarge the warranties and their terms and conditions The original invoice from the store at which the original service was performed must be presented when making a warranty claim.
This warranty covers only the original purchaser of the services and/or the installed parts and the original vehicle; this warranty is not transferable This warranty does not apply to products or vehicles used for commercial, racing, or off-road purposes, or to damage caused by abuse or accident.
This warranty gives you specific legal rights, and you may also have rights which vary from state to state.
Any implied warranty of merchantability or fitness for a particular purpose is limited to the duration of the limited warranties stated herein
THE COMPANY WILL NOT BE LIABLE FOR INCIDENTAL OR CONCEQUANTIAL DAMAGES (SOME STATES DO NOT ALLOW THE
EXCLUSION OR THE LIMITATION OF INCEDENTAL OR CONSQUENTIAL DAMAGES SO THE ABOVE LIMITATION MAY NOT APPLY
TO YOU)
This warranty is given by: Monro, Inc (The "Company"), 200 Holleder Parkway, Rochester, NY 14615 • •
Commercial vehicles excluded, (vehicles weighing 10,001 libs or more and commercial tires 17.5 or larger) 4 of 5
BAR#299542/EPA#CAL000461001
5233 CLARK AVE PAGE 2
LAKEWOOD,CA 90712
AOUNTAIN TEW (562)531-7570
TIRE & AUTO SERVICE
Guest ID: 1721012958 Year: 2009 ate/Time 01/10/23 15:27:52 Name: JAMES TALBERT Make: MERCEDES-BENZ 437832
Address: Model: E550
Address 2: Lic No:
City, State, Zip: VIN:
Home Phone: Color: SILVER na
Work Phone: 0 Engine: 5.5L GAS DOHC leet/Wholesale:
Other Phone: 0- Mileage In: 273422 st Created On: 01/10/23 09:57:2 Tax Exempt #: Mileage Out: 273422
Manager: MANNY TORRES Inspect Due:
Services Requested
ORDER 2/TIRES CONNT
Car
Qty. Part # Loc Description Part Labor Amount
PAY TYPE: VISA 826.81 Date: 1/10/2023 APPROVAL #: 010308 ENTRY: CONTACTLESS CREDIT CARD #: XXXX-XXXX-XXXX-8376
Transaction ID: 128230106645527823
Application ID: A0000000031010 Terminal ID: 1
1-30•23
INVOICE INVOICE BAR#299542/EPA#CAL000461001 INVOICE
SUB TOTAL 769.23
TECH: 105964-0.00 D. ALONSO SALES TAX 57.58
GRAND TOTAL 826.81
All parts are new unless otherwise specified. Please see reverse for warranty details. this Invoice. If there was an increase in the original estimated price, I acknowledge notice and oral approval of an increase in the original estimated price. X Guest Signature
I certify that all repairs were properly completed. _
Company Authorized Representative
CAUTION: Owners of Mag, Custom, Alloy, or Dual Wheels must have lug-nuts retorqued after 25 miles or 24 hours! The Company will gladly retorque these lug-nuts once after the first 25 miles at no charge.
Guest Initials
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PAY AMT
CREDIT 826.81 1/10/2023
PAYMENT COLLECTED BY: M. TORRES
CUSTOMER COPY
5 of 5
1/30/23, 9:31 AM Account Transactions
Transaction Post Transaction Description Transaction
Date Date Amount
1/10/2023 1/12/2023 MOUNTAIN VIEW 00017210 LAKEWOOD $826.81 Additional Information: MOUNTAIN VIEW 00017210 LAKEWOOD CA Reference Number: 24164070B6RZZ7DE7
Merchant Type: Automotive Service Shops
1-30-23
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