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 RECENED after the occurrence. (Gov. Code Sec 911.2)
3. Read entire claim before filing
4. See page 2 for diagram upon which to locate place of accident MAR 0 7 2023
5. This claim form must be signed on page 2 at bottom.
6. Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET
7. Claim must be filed with City Clerk. (Gov Code Sec. 915a) CITY CLERK'S OFFICE TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Saul Lagunas Arellano 25
Home Address of Claimant City and State Home Telenhone Number Business Address of Claimant City and State Business Telephone Number Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give fuil particulars.
I was healing south lown soto st. before passin, 26"* st when I hit a pot hole es that popped my front passenger fire and made my right rear tire dereloped tire shop to replace both
right toront we and rear tire, the right rear tire had to be changed beause of ball it harshich male the rear tire eat ant coull later pea
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
03/01/2023 2:50pm
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:
On my front right tire and my fear vas popper and right rear life hat a ball front tire
What particular ACT or OMISSION do you claim causedthe injury ordamage? Give names of City employees, if any. causing the injury or damage, if known:
Not repairing the Streets.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
for the tho her tires I had to buy from this accident resulting in Br20 Lollars.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation
Filo dollars per tire
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis or computation:
$220 with receipt
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
I was insuranced but dil not callmy insurance
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
READ CAREFULLY
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 yoursell 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
7AT71
FOR OTHER ACCIDENTS
//IL
SIDEWALK
CURB/ Soto st. about 200ft
south
to corner 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
Saul Lagunas Arellano 03/07/2623
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) Rev. 8/4/16
PACIFIC COAST MICHELIN GOOD/TEAR IRIDGESTONE Firestone BFGoodrich KELLYKSTIRES IRONMAN MUMIROYALE ALIGNMENT SERVICES AVAILABLE! WE SPECIALIZE IN TPM SENSORS • 24 Hour Road Service • Airing Programs • Fleet Inspections Date Work Order# PCT 3-1-23
3056 E. Bandini Blvd. Vernon, CA 90058 099457
Tel: (323)264-2366 Cell: (323)614-6533 Fax: (323) 264-2262 All new & retread tires Purchased from Pacific Coast Tire Ine. are warranted from the
TIRES INC Email: [email protected] • WWW.PACIFICCOASTTIRESINC.COM manufacturer against defects in worksmanship and materials for the life of the original tread
BILL TO LOCATION DELIVER TO LOCATION
Name Name
Saul laginas Pct
Address Address
City, State & Zip City, State & Zip
Name Originator Telephone Mileage Start Start Time
Drivers Name Drivers Cell# Mileage Finish Time Finish
Drivers Badge or ID# Location Code Reference # Time Call Received Unit# Vehicle Make Purchase Order #
Ble Honda
License and Stati Mileage Vin# Serviceman Name
Nod Jou
OTY STOCK# TIRE SIZE DESCRIPTION UNIT PRICE F.E.T. TOTAL manta Domant
Wheel Balance
Tire Disposal
2 a1555kil0
Prox Hiaky
CRE
LABOR
After a wheel has been installed it is recommended that the wheels be retorqued between 50 and 100 miles of operation. FET
Serial# New Serial# New Reason Replaced
SALES TAX
Serial# Old Serial# Old Remaining 32nds off Casing Bran TOTAL
220,00
Pass / Lt Truck RF V_ LF RR LR V Duals RFI RFO LFI LEO F-Flat R-Replace S-Switch Medium Truck RF LF RFI RFO LFI LFO RRI RRO LRI LRO
Reason For Replacement
Worn Out Run Flat. Cut Through Tread Cut Through Sidewall_ Tread Separation Sidewall Separation __ Casing Failure Retread Failure_ _ Valve Problem Please Send Payment to: Pacific Coast Tire., 3056 E. Bandini Blvd. Vernon, CA 90058 Limited Warranty on all Retread Tires - No Warranty on Used Tires Pacific Coast Tire is not responsible for Customer Tires or Casings left over 30 Days
BY SIGNING BELOW SECURITY AGREEMENT
(hereby certify that i have received a written copy of this estimate of service, repairs or parts needed on the Buyer grants to the seller a security interest in the above merchandise until the indebtedness is paid in full. Until vehicle stated and hereby authorize service, repairs or parts required by this estimate and hereby grant you payment in full has been made, Buyer agrees that: (1) Seller shall retain title of said merchandise: (2, Buyer will have and/or vour employees permission to operate the vehicle herein described on the streets, highways or the risk of loss or damage; (3) Buyer will not sell, transfer possession or remove or encumber above merchandise elsewhere for the purpose of testing and/or inspection. An express mechanics lien is hereby acknowledged without Seller's written consent: (4) If Buyer defaults in the payment of any installment, Seller may declare the entire in above vehicle to secure the amount of repairs thereto which I have authorized and are not covered by m balance due and payable and Seller may at its option take back the merchandise or affirm the sale and hold Buyer varranty, we will not be held responsible for loss or damage to vehicle or articles left in vehicle in case of fire liable for the unpaid balance, including any reasonable attorney fees or collection charges permitted by law: (5) The theft, accident or any other cause beyond our control. Seller shall have all the rights, options and duties under the Uniform Commercial Code of this state. Security interest in the goods herein described shall terminate as the unpaid balance for them are paid.
PRINT NAME / ESCRIBA SU NOMBRE SIGNATURE / FIRMA EMPLOYEE DATE SIGNED
VERNON CITY OF
DELI
Just a tittle bit. Better
ABF