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) VERNON
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence. (Gov. Code Sec.911.2)
3. Read entire claim before filing 2026 JUN 16 P 4: 00
See page 2 for diagram upon which to locate place of accident
5. This claim form must be signed on page 2 at bottom.
Attach separate sheets, if necessary, to give full details. SIGN EACH SHEET. CITY CLERK DEPARTMENT
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)
Giovanna Silvestre 41
Home Address of Claimani Oliv 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.
While driving northbound on S Santa Fe Avenue near E 15th Street and the railroad crossing in Vernon, California, I struck a large pothole in the roadway. The impact damaged my vehicle' tire. The pothole was difficult to see at night and created a hazardous roadway condition.
When did DAMAGE or INJURY occur? Give full particulars, date, time of day, etc.:
May 30, 2026, at approximately 11:30 PM.
Where did DAMAGE or INJURY occur? Describe fully, and locate on diagram on reverse side of this sheet, where approximate, give street names and address and measurements from landmarks:
Northbound S Santa Fe Avenue near E 15th Street and the railroad crossing, Vernon, California.
Exact location is approximate based on my travel route and recollection of the incident.
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:
Failure to properly inspect, maintain, repair, or warn motorists of a hazardous pothole condition in the roadway.
What DAMAGE or INJURIES do you claim resulted? Give full extent of injuries or damages claimed:
Damage to one tire requiring replacement. No personal injuries are claimed.
What AMOUNT do you claim of each item of injury or damage as of date of presentation of this claim, giving basis of computation:
Tire replacement: $162.00
Tire mount and balance: $42.00
Iire disposal fee: $8. 00
Give ESTIMATED AMOUNT as far as known you claim on account of each item of prospective injury ordamage, giving basis of computation:
Tire replacement: $162.00
Tire mount and balance: $42.00
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. Automobile insurance was in effect at the time of the incident. No insurance payment has been received for this damage.
Expenditures made on account of accident or Injury: (Date - Item) (Amount) June 2nd, 2026 (actual repair date)/ Tire replacement and related charges $255 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 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 you 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
7^Г
FOR OTHER ACCIDENTS
SIDEWALK
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:
Giovanna Silvestre relationship to Claimant: 6/7/2026
Discenna
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)
INVOICE
PLAYA WEST AUTOMOTIVE
8145 W. Manchester Ave 106019
Playa Del Rey, CA. 90293 Org. Est. # 221741
Phone: 310-822-9115 Fax: 310-822-3129 B.A.R. REG#AF312354 •RF# 312354
INVOICE Printed Date: 06/02/2026 Work Completed: 06/02/2026 SILVESTRE, GIOVANNA 2007 BMW - Z4 - 3L, In-Line6 (183CI) VIN(3) Lic #: Odometer in: 144989
Odometer Out: 144989
cDC ass 5 122502
Cellular VIN#:
Ext
Part Description / Number Qty Sale Ext Labor Description 162.00 CHECK TIRES HIT A POTHOLE AND TIRE WENT n/c
TOYO EXTENSA TIRE 1.00 162.00
FLAT - VEHICLE TOWED IN
225/45R17 - 148030 195:00
1.00 CHECK AIR CONDITIONING SYSTEM FOR LEAKS &
Cabin Air Filter 45.52 SYSTEM PERFORMANCE # 221701
64 31 9 195 194 CHECKED A/C FOR OPERATION - NO COMPRESSOR WORKING A/C Refridgerant R-134 2.00 38.95 - NO FAULT CODES IN SYSTEM - FOUND VEHICLE IN TRANSITER
MODE - DISABLED TRANSIT MODE AND A/C COMPRESSOR
IN R134CE WORKING NOW - SYSTEM NEEDS A/C SERVICE AND CABIN AIR®
1.00 14.50
FILTER 1:37
• GIOVAN
TIRE MOUNT & BALANCE 142.00
V Shop Supplies 9.00
DISMOUNT & REMOUNT TIRE, INSTALL NEW VALVE STEM 49g) COMPUTER SPIN BALANCE TIRE.
HAZARDOUS WASTE DISPOSAL 8.00
TIRE DISPOSAL FEE COLL
CALIFORNIA TIRE FEE- $1.75 PER TIRE 1/75
CABIN AIR FILTER - Remove & Replace 125.30
161. TE
Air conditioning service
Service air conditioner. Check condition of all belts and ines aNG Evacuate and recharge with reclaimed R-134 Test syste Tart St* performance FECSUR
HAZARDOUS WASTE WICE AND CAONZIRC
[Recommendations ]
LOWER CONTROL ARM BUSHINGS (REARWARD) 186.95; TAX C
17.76, LABOR 379.23, TOTAL 583.94
*****
ALIGNMENT 99.95 3:00
****** LA
WIPERS 49.15, TAX 4.55, TOTAL 53.70
******
OIL COOLER GASKET $37.30, TAX $3.64, LABOR $162.53,
TOTAL $203.47
**..
FRONT STRUTS 381.50 FRONT STRUT BUMP STOPS 42.56
TAX 37.11 LABOR 433.40 TOTAL 894.57.
ALIGNMENT 89.95
REAR SHOCKS 294.00 TAX 25.73 LABOR 216.70 TOTAL
536.43
******
3 TIRES (225/45R17 BF GOODRICH G FORCE COMP 2 A/S
94W) 445.50 TAX 38.98 DISPOSAL 12.00 MOUNT AND
BALANCE 80.00 TOTAL 556.48
NIT INTERG MENTION ON ROO
PLAYA WEST AUTOMOTIVE INVOICE
8145 W. Manchester Ave. 106019
Playa Del Rey, CA. 90293
Playa West Org. Est. # 221741
Phone: 310-822-9115 Fax: 310-822-3129 B.A.R. REG#AF312354 Automotive 'RF# 312354
Printed Date: 06/02/2026 Work Completed: 06/02/2026
Playa West Automotive
8145W MANCHESTER AVE 2007 BMW -74 - 3l In-Line6 (183CI) VIN(3) PLAYA DEL REY. CA 90293 Lic # : Odometer In: 144989
10803921-0443 Odometer Out: 144989
Transaction VIN #
06/02/2026 • 04:30 PM Qty Sale Ext Labor Description Ext Dale Approved
Result 026310 1.00 162.00 162.00 CHECK TIRES HIT A POTHOLE AND TIRE WENT n/c i
FLAT - VEHICLE TOWED IN
Auth Code Dipped 195. 00.
Transaction Method 1.00 45.52 CHECK AIR CONDITIONING SYSTEM FOR LEAKS & Sale
SYSTEM PERFORMANCE.
Transaction Type SILVESTRE/GIOVANNA E CHECKED A/C FOR OPERATION - NO COMPRESSOR WORKING; Cardholder Name xxxx-xxxx-xxxx-6463 2.00 38.95 - NO FAULT CODES IN SYSTEM - FOUND VEHICLE IN TRANSITE Card VISA MODE - DISABLED TRANSIT MODE AND A/C COMPRESSOR Card Type WORKING NOW - SYSTEM NEEDS A/C SERVICE ANE CABIN AIRS
1.00 14.50
$879.19
1 x Quick Item TIRE MOUNT & BALANCE 142,00
9.00 COMPUTER SPIN BALANCE INSTALL NEW VALVESTEM, 3. COMPUTER SPIN BALANCE TIRE. $879.19
Subtotal HAZARDOUS WASTE DISPOSAL 8.00
$879.19 TIRE DISPOSAL FEE
Total
CALIFORNIA TIRE FEE- $1.75 PER TIRE 1,75
CABIN AIR FILTER - Remove & Replace 125.3G
Chip Read 161.V8
Method Air conditioning service
XXXXXXXX1588
MID 0002 Service air conditioner. Check condition of all belts and lines along Evacuate and recharge with reclaimed R-134. Test'system.
TID PIN performance
AYA ONO
CVM HAZARDOUS WASTE ANE: 4652A5 7:00
Please Sign [Recommendations ]
Here. LOWER CONTROL ARM BUSHINGS (REARWARD) 186.95,
17.76, LABOR 379.23, TOTAL 583.94
******
ALIGNMENT 99.95
******
WIPERS 49.15, TAX 4.55, TOTAL 53.70
.15
OIL COOLER GASKET $37.30, TAX $3.64, LABOR $162.53 30
TOTAL $203.47
FRONT STRUTS 381.50 FRONT STRUT BUMP STOPS 42.56
TAX 37.11 LABOR 433.40 TOTAL 894.57
ALIGNMENT 89.95
*********************•
REAR SHOCKS 294.00 TAX 25.73 LABOR 216.70 TOTAL
536.43 E/st 180.99
***
3 TIRES (225/45R17 BF GOODRICH G FORCE COMP 2 A/S
94W) 445.50 TAX 38.98 DISPOSAL 12.00 MOUNT AND
BALANCE 80.00 TOTAL 556.48
READ IMPORTANT INFORMATION ON REVERSE SIDE