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) RECEIVED
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2) MAR 0 8 2023 Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident This claim form must be signed on page 2 at bottom. CITY CLERK'S OFFICE Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET.
7. Claim must be filed with City Clerk. (Gov.Code Sec. 915a) TO: CITY OF VERNON CITY. COUNCIL
Name of Claimant Age of Claimant (If natural person)
RUBI PEREZ 36
Home Address of Claimanti 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 full particulars.
Itthe South Bound entrance of the H10 Freewai
there was (IS) still a huge pot hole that caused
a flat hire on the passangers side ot mycar.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
January
approximate, give street names and address and measurements from landmarks:
Entranceof southband 710 Freeway
What particular ACT or OMISSION do you claim causedthe injury ordamage? Give namesof City employees, if any, monasano order the than de Mant.
Vhat DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed flat tire & damageto allignment of tire s
What AMOUNT do you claimof each item of injury ordamage as of date of presentation of this claim, giving basis of computation:
$ 302.02 wasthe cost torepare tire. Copyot rect attached Give ESTIMATED AMOUNT as faras knownyou claim on account of each item of prospective injury or damage, giving basis of computation:
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
AAA CAA IS
Expenditures made on account of accident or Injury: (Date - Item) (Amount) Name and address of Witnesses, Doctors and Hospitals:
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 comers NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
7^ Г
FOR OTHER ACCIDENTS
SIDEWALK
CURS/
CURB Y
PARKWAY
SIDEWALK
I declare, under penalty of perjury, that the foregoing, including any attachments, is true and correct.
Typed/Printed Name: Signature of Claimmat or person filing on his/her behalf, giving Date:
relationship to Claima
NOTE ALL CLAMANTS MAY BE REQUESTED TO BE EXAMINED AS TO JIR CLANDER CATH PRESENTATION OF A FISE CAN 5 03= 23 RUBIPEREZ beel toro PEN. CODE SEC. 72). CLAIMS MUST BE FILED WITH CITY CLERK (GOV.CODE SEQ. 915), 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
• •
Just Tires
Invoice 6162 S Atlantic Bivd Operator: Jovani Moreno
Maywood, CA 90270-3121 BAR/MVR: ARD8907
0000030230 323-560-0727 EPA ID: CAD981616220
Federal Tax Id 340253240
01/31/2023
Customer Info: Vehicle Info: Odom I/O: 28243/28243
Ruby Perez Year: 2017 Vehicle In: 01/31 01:36 PM.
Make: HONDA Vehicle Out: 01/31 02:51 PM
Model: ACCORD NonSig: 909267
Primary Ph: Color: LT Blue.
Customer #: 9267001482 License/Stated
PRODUCT DESCRIPTION QTY PART LABOR TOTAL
413021582 235/40R19 96V XL ASSURANCE COMFORTDRIVE 1.00 240.99 0.00 240.99 (1) 1m7 18jt1:2022
044554000 TIRE INSTALL PACKAGE W/TPMS 3 OR LESS 1.00 12.00 18.00 30.00 VS1R STD RUBBER VALVE STEM 1.00
071000000 SCRAP TIRE DISPOSAL AUTO 1.00 5.25 0.00 5.25
078000000 CHECK VEHICLE FOR ALIGNMENT 1.00 0.00 0.00 0.00 Parts Total* 258.24 State Tire Fee 1.75
Signature: Labor Total 18.00
Sub Total 277.99
Taxable Amount 252.99
Sales Tax (9.50%) 24.03
Cash: Check: Credit: 302.02 Debit:, AR: Corp Ref:
Visa - Amount Remitted 302.02
Total Deposits on Order 0.00
Invoice Total 302.02
Salesperson Technician Services
Jovani Moreno Jovani Moreno 044554000, 071000000, 078000000, 413021582 Goodyear, its successors and service providers may use your information; to send service updates and reminders; to request feedback; to communicate with you; for marketing promotional and commercial purposes; for data analysis; and as required by law.
Call 1-800-344-9859 to unsubscribe. Privacy Policy: https://www.goodyearautoservice.com/en-US/privacy-policy ** ALL PARTS ARE NEW UNLESS OTHERWISE SPECIFIED. **
* SEE REVERSE SIDE FOR IMPORTANT SAFETY WARNING AND WARRANTY INFORMATION SAFETY WARNING: SERIOUS INJURY MAY RESULT FROM
Tire failure due to under inflation / overloading - follow owner's manual or tire placard in vehicle.
Explosion of tire / rim assembly due to improper mounting - only specially trained persons should mount tires.
All custom wheel lug nuts must be retorqued after 25 miles and checked periodically.
JUST TIRES NATIONWIDE LIMITED WARRANTY
The Just Tires outlets warrant that the performed repairs will be free from defects in material or workmanship for either 24 months or 24,000 miles, whichever comes first, or the warranty periods for selected services as specifically outlined in the warranty brochure provided by the retailer at time of purchase These limited warranties apply only to parts and labor shown on your invoice - there may be other components in a system that are not covered.
ALIGNMENT WHEEL BALANCE
Parts: 6 months or 6,000 miles, whichever comes first. Standard Limited Warranty: 24 months or 24,000 miles, whichever comes Labor: 6 months or 6,000 miles, whichever comes first. first.
NOTE: Steering or suspension parts installed after the alignment voids *Lifetime Limited Warranty: Good for the life of the usable tire tread (2132") the limited warranty. balanced.
Not valid if tire is demounted.
-LIFETIME TIRE ROTATION TPMS reset procedure not included in lifetime limited warranty.
Lifetime Tire Rotation on new tire purchases of Goodyear, Dunlop, Kelly products at Just Tires locations. ROAD HAZARD WARRANTY SERVICE Ask provider for details Good for the life of the usable fire tread (2/32".)
Present this invoice at any Just Tires location for a free tire rotation every 6 months or 6,000 miles. 3 YEAR ALIGNMENT PROGRAM. Ask provider for details. (Vehicles requiring mounting or dismounting of tires to perform rotation All parts are new unless otherwise designated. Automotive repairs and parts, excluding tires, are warranted for a minimum of 24 Months or 24,000 Miles, whichever comes first unless otherwise designated. For the manufacturer's limited warranties for Goodyear, Dunlop and Kelly tire products visit https://www.goodyear.com/en- US/tire-warranty or contact the Goodyear Customer Assistance Center at 1-800-321-2136, email: [email protected] or write: Customer Assistance Center Dept 728 200 Innovation Way Akron, OH 44316-0001. FOR ALL TIRE PRODUCTS OTHER THAN GOODYEAR, DUNLOP AND KELLY PRODUCTS, JUST
TIRES HEREBY DISCLAIMS ANY AND ALL WARRANTIES AND REPRESENTATIONS, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION ANY
WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, AND NO WARRANTY OR REPRESENTATION OF ANY KIND IS MADE BY GOODYEAR OR SHALL BE IMPLIED BY LAW.
WHO MAKES THIS WARRANTY | WHO IS ELIGIBLE | EXCLUSIONS
This warranty is made and will be serviced by the Just Tires outlet who performed the repairs identified on the face of your invoice. This warranty will also be honored by any participating Just Tires or Goodyear Auto Service retailer nationwide*, if you require warranty service 25 or more miles from the location where the warranted original service was performed. This warranty extends only to you, the original purchaser, and the molor vehicle identified on the original repair invoice. It applies only during the warranty periods stated in the warranty brochure provided by the retailer at the time of purchase.
If you experience a warranty-related problem with the repaired vehicle as a result of a defect in either workmanship or material during the warranty period, this Just Tires outlet will perform the repairs again, including parts and labor, under the terms of the warranty as outlined. Warranty repairs do not extend original warranty periods. In addition, if a vehicle is more than 25 miles from the original repair facility and requires being towed, a towing benefit on "Approved Claims" up to $50.00 will be applied. The participating retailer must call 1-800-426-0733 to obtain warranty authorization from the Warranty Administrator prior to any warranty repair being performed. Warranty repair costs are covered up to the cost of the original repair. This warranty does not apply to vehicles used commercially.
IMPORTANT: Please keep any warranty brochure was provided by the retailer at time of purchase, along with your service invoice(s). These documents are required in order to exercise your warranty privileges.
This warranty is only for you and the vehicle serviced. It is not transferable. Just Tires is a division of The Goodyear Tire & Rubber Company "(Goodyear").
Goodyear will not be responsible for any consequential, incidental or indirect damage under this warranty. Implied warranties shall be limited to the duration of this warranty. This warranty gives you specific legal rights and you may have other rights which vary from state to state. Some states do not allow the exclusion or limitation of incidental or consequential damages, or allow limitations on how long an implied warranty lasts, so the above limitations may not apply to you (but in no event shall the inapplicability of such limitations or exclusions invalidate any other terms of this warranty). A buyer of Goodyear products or service has the right to have warranty service performed during the warranty period. The warranty period will be extended for the number of whole days that vehicle has been out of buyer's hands for warranty repairs. If a covered condition exists within warranty period, the warranty will not expire until the condition 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 buyer, or if the warranty repairs did not remedy the condition and buyer notifies the outlet which performed the warranted service of the failure of the repairs within 60 days after they were completed, If, after a reasonable number of attempts, the condition has not been fixed, buyer may return his/her vehicle for a replacement of parts, if applicable, or a refund, in either case, subject to deduction of a reasonable charge for usage. This time extension does not affect the protections or remedies buyer has under any law. *Not all services are provided by all locations.
PEREZ
PEREZ
.. •
Just Tires
Invoice 6162S Atlantic Bird Operator: Jovani Moreno
Maywood, CA 90270-3121 BAR/MVR: ARD8907
0000030230 323-560-0727 EPA ID: CAD981616220
Federal Tax Id 340253240
01/31/2023
MERCHANT# 000909267
PAYMENT VALUE: $302.02
TVR 8080008000
TSI 6800
AID#: A0000000031010
APPL LABEL: VISA CREDIT
DATA SOURCE: Chip
CARD#: Visa ******6421
Signature:
Tread Depth L/F 5/32 R/F 10/32
Tread Depth L/R 5/32 R/R 6/32
GUEST DECLINED RECCOMENDATIONS LISTED BELOW
PRODUCT DESCRIPTION QTY PART LABOR TOTAL
092209000 ROAD HAZARD PROTECTION (FREE 1.00 35.00 0.00 35.00
REPLACEMNT)
Total of Declined services this visit 35.00
PEREZ
ENTRANCE
SOUTH)
710
PEREZ
PEREZ
INTERSTATE
710 SOUTH
Long Beach
FREEMAY
ENTRANCE
(SOUTH
710
HIGHWAY PATROL