CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
INSTRUCTIONS RECEIVED
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 SEP 3 0 2024 after the occurrence. (Gov. Code Sec.911.2)
Read entire claim before filing
See page 2 for diagram upon which to locate place of accident CITY CLERK DEPARTMENT This claim form must be signed on page 2 at bottom.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET 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)
en EVAnS 60
Home Address of Claiman City and State
Business Address of Claimant City and State Business Telephone Number 4100 BAndini DIva Vernon-LinCASe
Give address to which you desire notices or communications to be sent regarding this claim:
How did DAMAGE or INJURY occur? Give full particulars.
Driving East on Bandini Blued
pothole in right lane
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
Thur, even ing Sapt 26th
Where did DAMAGE orINJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Bandini - just before Baker Commodities
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:
pothok in STreet
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
had to replace right front tire
What AMOUNT do you claim of each item of injury ordamage as of date of presentation ofthis claim, giving basis of computation:
$ 711.48 Sce Attached pictures a receipt
Give ESTIMATED AMOUNT as far as 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:
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 plac of accident by "X" and by showing house numbers or distances to street corners ehicle 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
LILL
7^T7.
FOR OTHER ACCIDENTS
///L
SIDEWALK
CURB/
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:
Ken
9/29/24
Evans
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) n. man
Ken Evans
From: Ken Evans
Sent: Monday, September 30, 2024 10:17 AM
To: Ken Evans
Subject: FW: Bandini Pothole
Attachments: Tire receipt.pdf
Ken Evans Lineage
VP, Regional Operations
Lineage, Inc. (Nasdaq: LINE) 4100 Bandini Boulevard. Vernon. CA 90058, United States onelineage.com
The information contained in this message and any accompanying documents is confidential, may be attorney-client privileged, and is intended only for the use of the intended recipient. It is the property of Lineage ("Lineage"). Unauthorized use, disclosure or copying of this message, or any part of it, is strictly prohibited and may be unlawful. If you hove received this message in error, please notify the sender immediately by replying to the message and destroying the message and all copies of it, including all attachments.
Electronic communication may be susceptible to data corruption, interception and unauthorized tampering and Lineage disclaims all liability of any kind for such actions or any consequences that may arise directly or indirectly there from.
From: Ken Evans
Sent: Monday, September 30, 2024 10:13 AM
Subject: Bandini Pothole
To Whom it may concern,
Thursday evening, September 26* | was driving East on Bandini Blvd. I was approaching our warehouse (4100 Bandini Blvd) in the right lane and hit a really bad pothole. The jolt punctured my right front tire.
I pulled to a side street (2680 Bonnie Beach) and waited for a tow. The car was towed to a tire dealership in my neighborhood. Luckily, the rim was ok and only the tire had to be replaced.
I am hoping to be reimbursed for the price of the tire - $711.48.
If you would be so kind, please send a check to:
Ken Evans
Thank you,
Ken Evans
From: Ken Evans
Sent: Monday, September 30, 2024 9:50 AM
To: Ken Evans
Subject: Pothole
COMMUNITY TIRE
PHD AUTO SERIE
INVOICE# 329033250
BAR# ARD 266950
EPA# CAL000437279
COMMUNITY TIRE & AUTO SERVICE
290 N BREA BLVD
PAGE:
BREA, CA 92821 TAME CE 133313
714/529-0393
NONSIG # : 000145796
CUSTOMER: KEN EVANS
0000001
AD SOURCE MADR WALK IN
BUSINESS:
1 VEHICLE: 2022 RuM MOROXI
SALESMAN: FISCHER, EVAN LICENSE: CA MILEAGE: 11630
EXT PHN 909/821-5358 1
VIN:
INVOICE DATE: 09/27/24 DUE: 09721724
PRODUCT MECHANIC QUANTITY PRICE LABOR EXTENSION
LF 42 RF 00 LR 44 RR 44 267 1 0.00
AP BEFORE
LF 42 RF 42 LR 44 RR 44 267 1 0.00
AP AFTER
LF 09 RF 09 LR 06 RR 06 267 1 0.00
TREAD DEPTH
245735R20 PERELLI PiRO MOE 10855-429-2791 See Store O%.eD For Details. 565.47 245/35R20 PIRELLI PZERO MOE ROF
390000001
DTS BALANCE AUTO 789 1 19.00 19.00
DTS DISPOSAL AUTO 267 1 4.70 4.70
CALIFORNIA STATE TIRE FEE 1 1.75 1.75
ROBE BROTECTiON FAN 522282126 Quantsey, 1
67.85 67.85
COMMUNITY TIRE & SVC - TIRE PROTECTION PLAN INCLUDES PRO-RATED TIRE REPLACEMEN T FOR THE LIFE OF THE ORIGINAL TREAD AND FREE FLAT REPAIRS. PLEASE CONTACT TH IS STORE AT 714-529-0393 FOR ASSISTANCE.
TPMS REBUILD W/HEX NUT OR STEM 789 1 8.25 8.25
040232
MERCHANDISE 573.72
LABOR 19.00
74.30 SALES TAX: 44.46
INVOICE TOTAL: 711.48
AMERICAN EXPRESS 711.48
Acct #: ****************1006 Auth: SALE: 819681:231944032: : 5398423 5626989401
SALE
Order# 329033250
Date/Time: 9/27/2024 3:48:40 PM
Trans Type: Sale
Amount: $711.48
Entry Method: EMV CONTACTLESS
Cardholder: VALUED CUSTOMER
Card Type: AMEX
Card Number: XXXXXXXXXXX1006
OrderID: 407014461
TransID: 539842363
AuthCode: 819681
RefCode : 539842363-819681
AMERICAN EXPRESS
0400008000
IAD: 06640103802000
ARge: C68944805387465
Signature Verified
APPROVED
x
Authorized Signature
COMMUNITY TIRE
MAD AUTO SERIES INVOICE # 329033250
COMMUNITY TIRE & AUTO SERVICE
PAGE: 2
CUSTOMER: KEN EVANS
PRODUCT MECHANIC QUANTITY PRICE LABOR EXTENSION
TENDERED BY 267
WE LOVE YOU!!!
COUNTER YOUR VEHICLE FOR OR BOSS ROTATO YOU I
Customer Signature :
Printed Name:
W ORIENTAL PRODUCE
Sent from my iPhone
Ken Evans
* Lineage
VP, Regional Operations
Lineage, Inc. (Nasdaq: LINE) 4100 Bandini Boulevard. Vernon. CA 90058, United States m:
onelineage.com
The information contained in this message and any accompanying documents is confidential, may be attorney-client privileged, and is intended only for the use of the intended recipient. It is the property of Lineage ("Lineage"). Unauthorized use, disclosure or copying of this message, or any part of it, is strictly prohibited and may be unlawful. If you have received this message in error, please notify the sender immediately by replying to the message and destroying the message and all copies of it, including all attachments Electronic communication may be susceptible to data corruption, interception and unauthorized tampering and Lineage disclaims all liability of any kind for such actions or any consequences that may arise directly or indirectly there from. 5