CLAIM FOR DAMAGES RESERVE FOR FILING STAMP
TO PERSON OR PROPERTY CLAIM No.
RECEIVED
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 JUN 09 2025 after the occurrence. (Gov. Code Sec.911.2)
Read entire claim before filing.
4. See page 2 for diagram upon which to locate place of accident CITY CLERK DEPARTMENT LỔ CƠ This claim form must be signed on page 2 at bottom.
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)
AMERICO BLANCO 44
Home Address of Claimant City and State Home Telephone 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.
I WAS DRIVING SOUTH DIRECTION ON ALAMEDA ST, BETNEEN E ZS ST. AND E 3RTH SA WHEN I
RAN INTO A MANHOLE CONER THAT WAS ON THE MIDLE OF MAMEDA ST AND MAG NOT ABLE TO ANOID, THE CAR IN FRONT OF ME WAS ABLE BUT IT NAS TOO FAST, SOMEONE REMOVED THIs COVER AND LET IT THERE, IN CONSECUENCE, IT DMAGED 2 PRETIRES / RİM OF MY VEHiCLE AND I HAD TO CALL A TOW When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.: TOvaK.
DAMAGE OCCUR ON FRiDAY, APRIL 1OM @ AROUND 6:00 AM
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of thissheet, where approximate, give street names and address and measurements from landmarks:
S. ALAMEDA SAREET / BETNEEN E 25-T. AND E.38 AHCT.
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:
MANHOLE COUER WAS NOT PUT IN PLACE / LEFT ON THE ROAD
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
BROKE 2 TIRES / TRONT & REAR PASSANGER SiDE AND DAMAGE RIM TiRE AS WELL What AMOUNT do you claim of each item of injury or damage as of date of presentation ofthis claim, giving basis of computation:
$ 500.00 AMOUNT OF MY INSIRANCE DEDUCTIBLE I HAD TO PAY Give ESTIMATED AMOUNT as faras known you claim on account of each item of prospective injury or damage, giving basis of computation:
$ 500.00 AMOUNT OF MY INSURANCE SERUCTIBLE I HAD TO PAY BA THE TIME THE TOW TRUCK APRiVER, SOMEONE MOVED THE DOVER TO THE CiDE OF THE ROAD, SO OTHER PEOPLE WiLL NOT RUN iNTO LIKE ME, PREVENT ACCiDENT.
Anéis blaro
Were you insured at the time of the incident? If so, provide name of insurance company, policy numbers and amount of insurance payments received:
YES, GEICO INSURANCE /L
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 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
FOR OTHER ACCIDENTS
E.38HHCT.
SIDEWALK
- MAHOLE COVER LOCKiON
Ox m LET ON MISSLE OF THE ROAD
CURB/
• S. ALAMGDA 9T. 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 AMÉRICO BLANCO relationship to Claimant
Amer 5/29/25
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
Amena Blarno
**• +** CHARGE **
Subaru Santa Monica
1229 Santa Monica Blvd RECEIPT
Santa Monica, CA 90404
Customer Information: Invoice Details:
Americo Blanco Invoice Date: Saturday, April 26, 2025, 09:44 AM Repair Order/Ref #: 271497
XXXXXXX387
Description of Product/Services Amount
Service Performed $500.00
Payment Details: Vehicle Information:
Paid On: Saturday, April 26, 2025, 09:44 AM 2025 Subaru Impreza Payment Type: Chip Tag #
Creditcard: x8094 Exp: XX/XXXX License Plate:
Card Type: Visa VIN
Cardholder Name:
Approval Code: 03210C
Dealer Associate: Steve Moya
Cashier: Steve Moya
THANK YOU!
Customer Signature
Subaru Santa Monica Processed by myKaarma
SUBARU.
271497
CUSTOMER #: 41126 SANTA MONICA
* INVOICE*
1229 Santa Monica Blvd.
AVERTCO ALEXANDER BLANCO DUPLICATE 1 Santa Monica, CA 90404 (424) 622-1843
PAGE 1 www.subarusantamonica.com
EPA # CAL000409548
BAR# ARD281624
14481 STEVE MOYA
SERVICE ADVISOR: TAG
LICENSE MILEAGE IN/ OUT
VIN
1374/1376 T5282
PAYMENT INV. DATE
SUBARU IMPREZA RATE
25 PO NO.
WHC PROMISED
IN SVC. DATE PROD. DATE WARR. EXP. 25APR25
259.00 CASH
18:00 18APR25
22FEB25 DD SOLD-STK: S8208933 DR: 401814
DATE CUST. NOTIFIED OPTIONS:
R.O. OPENED ENG : 2. 0_Liter TRN: CVT
NET TOTAL
115:19 25APR25 LIST
10: 14 18APR25
LINE OPCODE TECH TYPE HOURS C/S: CUSTOMER STATES HE WENT OVER A POTHOLE AND BOTH RIGHT SIDE TIRES WENT INSTANTLY FLAT PLEASE ADVISE 0.00
PERFORMED ON DE F 0.00
0 WORK TOTAL LINE A: 0.00
4475 0.00 OTHER: 0.00
PARTS : 1374 TECH RPLACED TWO TIRES PERFORMED AN ALIGNMENT AND A NEW WHEEL 0.00 LABOR:
****
***
INSTALLED ******
*******************
B C/S: MULTI-POINT VEHICLE INSPECTION SI MULTI-POINT VEHICLE INSPECTION (N/C) TOTAL LINE B: 0.00
4475 ISP OTHER: 0.00
0.00 LABOR: 0.00
PARTS:
1374
FRONT TIRES: 10/10
REAR TIRES: 10/10
FRONT BRAKES: 10MM
REAR BRAKES: 8MM ************************
***************
C C/S: SET TIRE PRESSURES TO FRONT 33 PSI / REAR 32 PSI. SET TIRE PRESSURES TO FRONT 33 PSI / REAR 32 3332 (N/C)
TOTAL LINE C: 0.00
OTHER:
PARTS: 1374 TIRE PRESSURE SET TO 35 PSI ALL TIRE ********** ****************************
D** 4 WHEEL ALIGNMENT - CHECK & ADJUST TO FACTORY SPECIFICATIONS ALIGN 4 WHEEL ALIGNMENT - CHECK & ADJUST TO 183.52 183.52
FACTORY SPECIFICATIONS TOTAL LINE D: 183.52
4471 LABOR: wheel alignment AND FOUND VEHICLE
1374 technician performed
WORKING AS DESIGNED ***********
********** UPON INSPECTION, TOTALS
E** CUSTOMER FRONT RIGHT RIM WAS DAMAGED
REVISED ESTIMATE LABOR AMOUNT
(*•HAZARDOUS MATERIAL) Removal charge for al ORIGINAL ESTIMATE PARTS AMOUNT automobile $
hazardous materials removed from your $
that must be disposed of as a hazardous waste. GAS, OIL, LUBE
I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF AN INCREASE IN THE ORIGINAL SUBLET AMOUNT Licensed Smog ESTIMATED PRICE. HAZARDOUS WASTE CHARGES
you may choose another
law, needed repairs
perform any TOTAL CHARGES
facility
edjustments which the Smog Check test indicates are CUST. SIGN. X necessary. LESS INS./ADJ.
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE. CUSTOMER ACKNOWLEDGES ALL REPAIRS AS ITEMIZED AND A RECEIPT FOR VEHICLE SALES TAX
WE ARE STRIVING TO ENSURE YOUR PLEASE PAY
"COMPLETE SATISFACTION-
IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT X THIS AMOUNT OUR SERVICE PLEASE CALL IMMEDIATELY. OUR GOAL IS CUSTOMER ACKNOWLEDGEMENT "SERVICE EXCELLENCE.•
CUSTOMER COPY
ecomE INVOICE TYPE 2. SI2C. IMAGING
SUBARU.
271497
CUSTOMER #: 41126 SANTA MONICA
*INVOICE*
1229 Santa Monica Blvd.
AMERICO ALEXANDER BLANCO DUPLICATE 1 Santa Monica, CA 90404 PAGE 2 (424) 622-1843
www.subarusantamonica.com
BAR# ARD281624 EPA # CAL000409548
SERVICE ADVISOR: 14481 STEVE MOYA
MILEAGE IN/ OUT TAG
LICENSE
VIN
MAKE MODER
COLOR YEAR T5282
1374/1376
PAYMENT INV. DATE
25 SUBARU IMPREZA HARE
WHC PROMISED PO NO.
IN SVC. DATE PROD. DATE WARR. EXP.
259.00 CASH 25APR25
18: 00 18APR25 SOLD-STK: S8208933 DLR: 401814
22FEB25 DD DATE CUST. NOTIFIED OPTIONS:
R.O. OPENED ENG: 2. 0_Liter TRN: CVT
15:19 25APR25 NET TOTAL
10:14 18APR25 LIST
LINE OPCODE TECH TYPE HOURS RECOMMENDED A NEW WHEEL
0.00 0.00
PASSENGER FRONT RIM 660.02
660.02 660.02
28111FN040 DISC WHEEL AL 18 191.92 191.92 191.92
851.94
28103FL020 VALVE TPMS ASSY TOTAL LINE E:
1374 TECH INSTALLED NEW TIRE AND RIM ON THE FRONT RIGHT TIRE 851.94 ****************************************************
F** MOUNT AND BALANCE 2 TIRES DUE TO DAMAGED TIRES
79.98 79.98
MB2 MOUNT AND BALANCE 2 TIRES 423.90
211.95 211.95
24VR8S34P 225/40 18.0 AVID S34P YOK 5.00 10 - 00
4.99 9.98
CTF CALIFORNIA TIRE FEE
TOTAL LINE F: 523.86
WW WHEEL WEIGHTS 79.98 OTHER: 10.00
PARTS: 433.88 LABOR: NEW TIRES
1374 TECH MOUNT AND BALANCE TWO TIRES DUE TO DAMAGE.
**
INSTALLED **
***
*******
****
*************** 18APR25 10:14 SA: 14481
ESTIMATE: 0.00
CONTACT: * *
***********
#5282 CREATED 2025-04-18
10:11:58AM TAKEN BY STEVEN
MOYA
TOTALS
DESCRIPTION
263. 50
REVISED ESTIMATE LABOR AMOUNT
(**HAZARDOUS MATERIAL) Removal charge for all ORIGINAL ESTIMATE 1285.82 automobile PARTS AMOUNT
hazardous materials removed from your $ $ 0.00
that must be disposed of as a hazardous waste. GAS, OIL, LUBE I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF AN INCREASE IN THE ORIGINAL SUBLET AMOUNT 0.00 another Licensed Smog ESTIMATED PRICE. HAZARDOUS WASTE CHARGES 10.00 you may choose perform any needed repairs
By law tacity Check TOTAL CHARGES 1559.32
adjustments which the Smog Check test indicates are CUST. SIGN. X 0.00 necessary. LESS INS./ADJ.
NOTICE TO CONSUMER: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE. 138.23
WE ARE STRIVING TO ENSURE YOUR CUSTOMER ACKNOWLEDGES ALL REPAIRS AS ITEMIZED AND A RECEIPT FOR VEHICLE SALES TAX "COMPLETE SATISFACTION" PLEASE PAY
IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT THIS AMOUNT 1697.55 X
OUR SERVICE PLEASE CALL IMMEDIATELY. OUR GOAL IS CUSTOMER ACKNOWLEDGEMENT *SERVICE EXCELLENCE."
CUSTOMER COPY
Armiahe 2011 Cnk Globe. LLC SERVICE INVOICE TYPE 2 - SIC -MAGING Aménco Blanko
Amenta Bliko
ALAMEDA ST.
S34-
Amerio Blavo
ALAMEDA ST
MYVEHiCLE
Amárias Blaavo
Ангарію вило
Amária Blarco
LOS ANGELES CA 900
3 JUN 2025 PM9 L
Vernan Gity clark
4305 south Santa fe Avenue
Veron CA, 900586
90058-171405