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 RECEIVED 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 after the occurrence. (Gov. Code Sec.911.2) AUG 1 9 2025
3. Read entire claim before filing.
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 DEPARTMENT
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) TO: CITY OF VERNON CITY COUNCIL
Name of Claimant Age of Claimant (If natural person)
Angela Heras Ang
Hame Address of Chimant 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 on my way to work at approximately 2:45 a.m. when I drove through a dimly lit section of the road. My car struck a large screw in the roadway, which punctured my tire and caused it to burst.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
2:45 am on August 13, 2025
Where did DAMAGE orINJURY occur? Describefully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Fruitland Ave corner Soto Street
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:
Presence of a large screw in the roadway due to insufficient street cleaning or maintenance, which caused my tire to puncture and burst.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
One tire punctured and rendered unusable; replacement required.
What AMOUNT do you claim of each item of injury ordamage as of date of presentation of thisclaim, giving basis of computation:
$243.87 for new tire
Give ESTIMATED AMOUNT as farasknown you claim on account of each item of prospective injury ordamage, giving basis of computation:
$243.87
angelat
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, but tires are not covered by insurance.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) $243.87
Name and address of Witnesses, Doctors and Hospitals:
N/A
READCAREFULLY
of accident by "X" cidall by de and by placing house num dies or distances tires comeding North, East. South, and West: indicate place NOTE: If diagrams do not fit the situation, attach hereto a proper diagram signed by claimant.
FOR AUTOMOBILE ACCIDENTS
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71T71
FOR OTHER ACCIDENTS
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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:
ANGELA ANG relationship to Claimant: 08/14/25
angelet
NOTE: ALL CLAIMANTS MAY BE REQUESTED TO BE EXAMINED AS TO THEIR CLAIM UNDER OATH. PRESENTATION OF A FALSE CLAIM IS A FELONY (CAL EN. CODE SEC. 72). CLAIMS MUST BE FILEDWITH 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
To whom it may concern,
Good day!
Please find attached photographs of both the damaged tire and the screw that caused the puncture for your review and documentation.
Figure 1 Damaged Tire Figure 2 Screw that punctured the tire I would greatly appreciate your consideration of this matter and look forward to your response.
Thank you for your time and assistance.
Sincerely,
angelah
Angela Ang
Just Tires
Invoice 600 West Valley Boulevard Operator: Damian Sandoval Alhambra, CA 91803-3229 BAR/MVR: ARD224476
0000063851 626-289-5041 EPA ID: CAL000266059
Federal Tax Id 340253240
08/13/2025
Customer Infor Vehicle Info: Odom /O: /
fear: 202: Vehicle In: 08/13 05:08 PM
Make: TOYOTA Vehicle Out: 08/13 05:29 PM
Model: COROLLA NonSig: 904851
Color: DK Gray
Customer#: 4851011986
PRODUCT DESCRIPTION QTY PART LABOR TOTAL
109055366 225/40R18 92W XL EAGLE SPORT A/S VSBTL 1.00 174.99 0.00 174.99 (1) 1M75NKR1R1225
044555000 TIRE INSTALLATION PACKAGE W/TPMS 1.00 12.00 28.00 40.00 INCLUDES: MOUNTING & INSTALLATION, LIFETIME BALANCE,
LIFETIME ROTATIONS, TPMS REBUILD KIT, & FREE ALIGNMENT
CHECK.
VS1R STD RUBBER VALVE STEM 1.00
071000000 SCRAP TIRE DISPOSAL AUTO 1.00 7.50 0.00 7.50
046100000 LOOSE WHEEL 1.00 0.00 0.00 0.00
Parts Total* 194.49 State Tire Fee 1.75
Signature: Labor Total 28.00 Sub Total 224.24
Taxable Amount 186.99
Sales Tax (10.50%) 19.63
Cash: Check: Credit: 243.87 Debit: AR: Corp Ref:
Visa - Amount Remitted 243.87
Total Deposits on Order 0.00
Invoice Total 243.87
044555000, 046100000, 071000000, 109055366
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* SEE REVERSE SIDE FOR IMPORTANT SAFETY WARNING AND WARRANTY INFORMATION angelak