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. Claimsfor damages to real property must be filed not later than one (1) year ,a >'' `~ after the occurrence. (Gov. Code Sec.911.2) ~ `..~~ ~D
3. Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident AUG Z 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. 915x) CI I 1 C~.L~~hiS 0~1 ~C~ TO: CITY OF VERNON CITY COUNCIL
Name of Claimant ge o aimant natura person
Square-H Brands, Inc.
Home Address of Claimant City and State Home Telephone Number 2731 S Soto St. Vernon, CA 90058
Business Address of Claimant City and State Business Telephone Number 3615 E Vernon Ave Vernon, CA 90058 323-267-4600
Give address to which you desire notices or communications to be sent regarding this claim:
2731 S Soto St Vernon, CA 90058 (323) 267-4600 [email protected] How did DAMAGE or INJURY occur? Give full particulars.
City water began running as dark brown throughout the entire facility during sanitation. We were unable to clean the food plant properly and lost a full day of production. Some product was showered with the dirty water and had to be discarded.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Issue began approximately 11:30pm Wednesday 8/2/2023
Where did DAMAGE or INJURY occur? Describe fully, and locateon diagram on reverse side ofthissheet, where approximate, give street names and address and measurements from landmarks:
3615 E Vernon Ave. All water into facility was dark brown for several hours between 11:30pm and Gam the following day.
WhatparticularACTorOMISSION doyouclaimcausedthe injury ordamage? GivenamesofCityemployees, if any, causing the injury or damage, if known:
We were told by the city that damaged casing of a city well was the cause. City officials were on site promptly but unable to resolve the issue for several hours, despite purging hydrants in the street.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
3,600 pounds of product discarded. 61 people sent away from work, paid four hours report time, 4 employees worked all night attempting to clean, but unable. Overtime worked to compensate for lost production time.
WhatAMOUNT do you claim of each item of injury ordamage as of date of presentation ofthis claim, giving basis of computation:
Total costs of $14,120 comprised of: $5,000 for product damage, $4,880 for four hours report time for 61 people at $20 per hour. $640 for 4 employees during incident. $3,600 of overtime pay to catch up from lost production day.
Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basisof 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:
No Coverage.
Expenditures made on account of accident or Injury: (Date -Item) (Amount) See above.
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 corners.
If City Vehicle was Involved, designate by letter "A" location of City vehicle when you first saw it, and by "6" 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
FOR OTHER ACCIDENTS
31D~1NALK
Gu~e
cure
PAR KVItAY
~ D EIMALK
declare, under penalty of per'ur ,that the fore oin , including an Typed/Printed Name: Signature of Claimant or person filing relationship to CI ant: ~~ Noah Haskell ~ A .~' / ~
attachments, is true and correct.
his/her behalf, giving Date:
8/16/2023
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