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HomeMy WebLinkAboutMINUTES - 08041987 - 1.18 (2) TRAFFIC COLLISION CODING PAGE PATE C aSON TIME(2400) NCIC NUMBER 7 OF R I.D. NUMBET� — MO DA ��O- /yV\� PROPERTY DAMAGE DESCRIPTION OF DAMAGE OWNER'S NAMEIAODRESS - NOTIFIED p YES ❑NO VIOLATION(S) PARTY I PARTY 2 PARTY S PARTY 0 CHARGED PRIMARY COLLISION FACTOR 1 2 J 4 1 .MOVEMENT PRECEDING 1ST NUMBER F OF PARTY AT FAULT CONTROLS FUNCTIONING A PASSENGER CAR/STA.WAGON COLLISION A VC�GCTIO VIOL ) K3� B CONTROLS NOT FUNCTIONING B PASSENGER CAR WRRAILER TOPPED '`/ SCJ` C CONTROLS OBSCURED C MOTORCYCLEISCOOTER B PROCEEDING STRAIGHT A B OTHER IMPROPER DRMNO' D NO CONTROLS PRESENT O PICKUP OR PANEL TRUCK C RAN OFF ROAD E PICKUPIPANEL TRK W?RLP D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN 0 UNIWO' A HEAD-ON D TRKrTRK TRACTOR W/TRLR F MAKING U TURN FATHER(MARK 1 to Z ITEMS) B SIDESWIPE H SCHOOL BUS O BACKING ' A CLEAR C R. 1 OTHER BUS H SLOWING—STOPPING B CLOUDY BROADSIDE J EMERGENCY VEHICLE I PASSING OTHER VEHICLE C RAINING E HR OBJECT K HWY CONST.EQUIPMENT J CHANGING LANES D SNOWING F OVERTURNED L BICICLE K PARKING MANEUVER E FOG G AUTOIPEDESTRIAN M OTHER VEHICLE ENTERING TRAFFIC FROM F OTHER': H OTHER': N PEDESTRIAN SHOULDER,MEDIAN, G WIND O MOPED L PARKING STRIP OR LIGHTING MOTOR VEHICLE INVOLVED WITH PRIVATE DRIVE A D HT A NON-COLLISION 1 2 D A OTHER ASSOCIATED FACTOR M OTHER UNSAFE TURNING US DAWN B PEDE AN (MARK 1 to 3ITEMS) N KING INTO OPPOSING UNE C DARK—STREET LIGHTS TMER MOTOR VEHICLE A VC SECTION VIOLATION: O PARKED D DARK—NO STREET LIGHTS D MOTOR VEH.ON OTHER ROADWAY P MERGING E DARK—STREET LIGHTS NOT E PARKED MOTOR VEHICLE B VC SECTION VIOLATION: O TRAVELING WRONG WAY' FUNCTIONING' F TRAIN R OTHER': G BICYCLE C VC SECTION VIOLATION: lw�OADWAY SURFACE H ANIMAL: 1 2 D A SOBRIETY—ORUG— DRY D VC SECTION VIOLATION: PHYSICAL B WET i FIXED OBJECT: (MARK 1 to 2 ITEMS( C SNOWY—ICY E VISION OBSCUREMENTS: A HAD NOT BEEN DRINKING D SLIPPERY(MUDDY,OILY,ETC.) J OTHER OBJECT: 0 H8D—UNDER INFLUENCE F INATTENTION C MBD—NOT UNDER INFLU.' ROADWAY CONDITIONS G STOP&GO TRAFFIC O HBO—IMPAIRMENT UNKN.- (MARK t to 2 ITEMS) PEDESTRIAN'S ACTION H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A HOLES.DEEP RUTS' PEDESTRIAN INVOLVED I PREVIOUS COLLISION F IMPAIRMENT—PHYSICAL' B LOOSE MATERIAL ON ROADWAY' 0 CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NO KNOWN C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP.: H NOT APPLICABLE D CONSTRVCTION-REPAIR ZONEC CROSSING IN CROSSWALK—NOT 1 SLEEPYIFATIGUED E REDUCED ROADWAY WIDTH AT INTERSECTION JUNINVOLVED VEHICLE F FLOOPEO' 0 CROSSING—NOT IN CROSSWALK MOTHER': 1 2 0 A SPECIAL INFORMATION NER': E IN ROAD—INCLUDES SHOULDER N NONE APPARENT A HAZARDOUS MATERIALS' H NO UUS NUAL CONDITIONS F NOT IN ROAD O RUNAWAY VEHICLE B FIRE INVOLVED' 0 APPROACHING/LEAVING SCHOOL BUS C TIRE OEFECTIFAILURE' SKETCH ) I MISCELLANEOUS . NOORTH N �7 tt r PHYSICAL DESCRIPTION OF PARTY NUMBER HAIR EYES HEIGHT WEIGHT PREP AM `�I � I�NUMBER I •MO. I •REVIE R'S N I IR l OMO,� DAY v q *Ezpfairt in nam1 ive I i.ALL 101®rm A%gis/i� • 5A WMW WMIi r , Iliad; m.��_•=—Y�,..� % /,[__ ✓ I �' I � Stu • , , ��.� v � i 1 Pwaa I cNacw oN cnecN one NARRATIVE/SUPPLEMENTAL �TIVe ❑ SUPPLEMENTAL ❑ COLLISION REPORT ❑ OTHER: ;} Dw/T/ef�'/SOF ovula twwt DANT n C) Ncic Nu • J Plcew Lo. nu�a lye _— M. Dwr r . CITY/COON /JUD16CIAL D11T w6eO wTINa DI Tw IC /• T CITATION NyMwew tA C VL .. 7. 0. l'1 r, CS C ro. is. ,9. 20. 2,. 22. 22 14, 25, Pw [ Nw Me 1, yM•ew p0 D wavla Waw'.Nw Ma MO. DwT T CHP 556 (Rev 4 )OPI 049 Use previous editions until depleted. - IWVREDNITNESSES/PASSENGERS _ I .IID ++`1{' OwT r <OLNfIo Nme N '•-. Op Lw. N�w^l ��� ••••�--JJJ i M Ow Y 1 ( EXTENT OF NJURY (Check Onf) I JUReD WAS (cheek one) S WITNESS IA98HfiOHR Iw OH fH% STORTK WOUND OTNaw VIf1aL[ COMpLA1NT 1 ONLY ONLY wTwl lNlUwV pwlV{w pw/l. p[O. •ItV CLIfT OTNaw NUI l DIfTOwTID MaM{{w IMJywla• Or pA1N. ❑ ❑ 1 ❑ 1 ❑ ❑ NAM f TAKEN TO jIft7UR9O ONLY) A DRlf1 . TaLSINONE ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ D. I NAM[ - TAKEN TO IINIUR{O ONLY ADDRESS TRL[INON[ ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ 1 ❑ ❑ NAM[ - TAKEN TO )INJUNap ONLY) j AOOIIEff - TEL[rNONa 1 - 1 I . ❑ ❑ ❑ :. ❑ ❑ ❑ ❑ ❑ ❑ ❑ CD-7- NAME NAM[ TAKEN TO )INJURED ONLY) ADDRESS TOLapMON[ ❑ ❑ ❑ . ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAM[ 1. TAKEN TO )INJU.KC ONLY) • ADDwEif T[L[.NONa ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME TAKEN TO (INJURSO ONLY) ADONEf[ T[LEpKONa ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAM[ TAKEN TO (INJURED ONLY) AOOwEf• TRLEINONa ❑ a ❑ ❑ ❑ ❑ ❑ I ❑ a I ❑ ❑ NAME TAKEN TO(INJURRO ONLY) ADORES{ 0 O TaLEINONE ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAM[ TAKEN TO (INIUw EO ONLY) ADONEf[ TELEINOM{ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ I ❑ ❑ NAM[ TANEM TO (INJyNEp ONLY) ADDRESS TaL[IMOM[ EXTENT OF INJURY /Check One) INJURED WAS(Check One) WITNESS ►ASSENGER / PAF AGE SHE [EyERa NOUN. OTNEN Vlllata COM ILAINi NUM ON ONLY pwTwL IN1YRY ..w.. pwf S. IED. EICVCLIST oTNER DniowT[p Ma MaEw INIuwIEs or IwIN p R NAMI NyMEEw '/n/x/11 Na V1ENi N { a MO. .A�' CHP 555—Page (Rev 6.82)OPI 042 -� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of supervisors, Routing Endorsements, ) NO'(''ICE TO CLAIMANT August 4, 1987 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Govern nt Coe Amount: $4,812. 00+ Section 913 and 915.4. Please note all "Warni knt Code Counsel CLAIMANT: 14ARYANN VANWEMMER JUL 4355 Oakdale Place 151987 ATTORNEY: Pittsburg, CA 94865 fvlartine Date received 2, CA 94553 ADDRESS: BY DELIVERY TO CLERK ON July 6, 1987 hand del . BY MAIL POSTMARKED: IIO envelope 1. FROM: Clerk of the hoard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JbIL gATCHELOR, Clerk 4� DATED:— July 13 , 1987 : Deputy L. Hall 11, FROM: County Counsel TO: Clerk of the Board of Supervisors (< This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: Ag y County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (x This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this dat_��u^ 4 W7 � Dated: - PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult l an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: AUG 5 1987 BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator CLAIM 'iO:, BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant A. Claims relating to causes of action for death or for injury to . person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. . 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, ,CA) _ C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps ) Against the COUNTY OF CONTRA COSTA) (y�PJZCoun I or DISTRICT) (Fill in name) ) The undersigned claimant hereby makes claim against Contra Costa orthe above-named District in the sum of $ 4p.17�qcp t oactot►�ti ENEpt and in support of this claim represents as follows: T— ']Wys 1. When did the damage or injury occur? ) (Give exact date and hour ! l rU Sr7 PAL E at --- - -- ------------- count- ---- 2, Where-aia the-d-amage------or- inj-ur----occur?--------(Include city anndd county) �� G�PtW. &D 1. f aAt GJ dJ&vJ 8114-, -------------------------------------- -- -------- ----------- 3, How did the damage or injury ccur=. �Give ful det� use extra st� if erequired) JQ�w � �QCx Bl c�n -4% d4 wa-a, e c H p 4-o arre d e� ------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? Gia fn4�at t-f/ (over) 5. What are the names of- county or district officers, 'ser-vants• r=4 _1. - . . employees causing the damage or injury? � jl� mom" ------------------------------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto dama e�QL'� Q� �a;C�-�¢/✓'� ,�, 611140T741V ___How-- - ----- -- ----- ---- ----------- - - -- 7. was the amount claimed above computed?. (In-cl-ud-e-th-e-estimate--------=d amount of any prospective injury or damage. ) 50= kmkcriep steer; ------------------------------------------------------------------------- 8. N��aJJmes and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury. ITEM AMOUNT URVRVD0 A6 ocXkel> sk, OJ 41:FJ:1 Uil Nr3:1 Govt. Code Sec. 910.2 provides : "The claim s ' ned/by the claimant SEND, NOTICES ' TO: (Attorney) 'or some rsoW on his ):)ehalf. " Name and Address of Attorney , Claima s lr ss �nat ;e / / 5/ Telephone No. Telephone No. � /05D ************************************************************************** NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " f I i. i; - --- — I��-- 3Soo-•co-- '1�Llg.� - 3355•x. . -__ ---- !'_IO�o._�ow_M1,�2A6c__ So,oa 10. Uvo %—__353.aa _-- { aTlr�PtT P_LACCiM�IT_—Vll�� 00 _SES►-�ox�. --� za S_o_m°t'_. _ !i S .OD - !i , 11 VEHICLE DAMAGE REPORT-ESTIMATE ERIC'S BODY SHOP - NAME � 1124 ERICKSON ROAD CONCORD, CALIFORNIA 94520 ADDRE�;S C' 3 5 S O 0 b dajQ (415) e82-3250 — CITY "Specialists in Uni-body repair" Home featuring Phone Ins,Co. CAR BENCH—the Ultimate Unibody Repair System uc. 22 Pour Wheel Alignment&Precision Color Matching Business Phone Adjuster Engine Other Claim N Trans. Date of loss W.B. Paint Code Odometer 'a�-�o" ��irSM►NS sem.,,oreae.-.x.-.,.s>.-e.,. rya res se'e's �y� Trim Code Year Make Model VIN W w W DESCRIPTION PARTS ¢ ¢ aa Sx dx ad Ir�t'..�1(� l•O 15140 V Ii t/ �/� n 7 u t t // 67 ,501,S-- 2S 78O1, 1 i �1-SCC .S 5rc 16 31 I This damage report Is based upon our detailed inspection COLUMN TOTALS of your vehicle and does not Include repairs other than Itemized above.Occasionally additional damage will be PARTS discovered once the work Is opened up,and additional repairs BODY HTS. Sub BCt t0 Invoice will be required. TOTAL Our parts prices are from Mitchell's Manuals.Any rise in PAINT Hrs..@ LABOR cost must be supplemented to us by owner or Insurance company. FRAME Hrs. ® CHARGES SUBLET Repairs will be made for you as owner. If you do not Intend to pay with your own funds, please make certain the insurance company can deliver their check to you in time to MECH. Hrs. ® SUBTOTAL pick up your vehicle.All repairs must be paid yn full before the vehicle will be released. SUBLET SALES TAX If a lienholder Is named on the Insurance check,their endorsement must be obtained. PAINT & We are proud of our technicians and their superior quality MATERIALS craftsmanship.Thank you for letting us serve you. WRITTEN BY TOTAL THE CASUALTY WARD PHONE: AUTO' BODY REPAIR 825-3200 FIRST AID OR MAJOR SURGERY 1116 ERICKSON RD. CONCORD,CA 94520 B.A.R.IAR107720 / R.O. NO. DATE NAMEX11'2 r� ADDRESS �/3s r O �►,t-o- /f P� , CITY I S/�LJ HONE HOME BUS. E INS. CO. ADJUSTOR PHONE YEAR MAKE MODEL MILEAGE LICENSE STATE -7 ,-"'sczr q , �/ I Ia4�ff /(- 4a4 0 /1- BODY PROD. DATE COLOR TRIM MLDG. NO. SERIAL NO. E REPAIR LABOR PARTS REFINISH PAINT,MAT. STRTN REPL PART NO. PART NAME HOURS @ LIST HOURS 6 NET ITEMS - 2 3 a aS O 6 Atov-f .: V �1.�c/-r 6 C✓ov1 �1 �xc �P � Vii e g 10 12 13 14 16 16 17 18 19 - SUB TOTALS THIS ESTIMATE IS BASED ON OUR INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR WHICH MAY BE REQUIRED AFTER THE TOTAL WORK HAS BEEN STARTED. PARTS PRICES SUBJECT TO INVOICE. LABOR HRS AT e VEHICLES NOT PICKED UP WITHIN 48 HOURS OF COMPLETION WILL TOTAL BE SUBJECT TO A DAILY STORAGE CHARGE. REF. HRS. AT$ TOTAL PARTS LESS % PAINT MATERIAL 1 AUTHORIZE THE ABOVE REPAIRS SUBLET AND NET TAX DATE THANK INSPECTED YOU GRAND TOTAL BY DATE 788-12814 NORICK OKLAHOMA CITY (r^tE o1 I'.}evow.0 I 'SUN 2 2 S87 TR.1fFIC COLLISI.ON REPORT .AGE e,3 _ SPECIAL CONDITIONS No.INJ Yw[O M R CITY JUDICIAL DIBTNICT NYMfaR C FELONY : O ❑ 0AJ1AJC1WA01Z ATC nJGvti rl / I�21 R .0..ILLSO rlm CCU"" MUIONTIMI DISTRICT NEAT 6* / s O ❑ 2a Co STA ya3 VVV /NN+ COLLISION OCCVRRED ON r0. Owr •w. nME (Yoo) -Cie MUMaSR OFFICER la. _ :/� : Tao 9320 90rio 0 F MILEPOST IMIORMATIOM/�1 Jj � IMJYNT,'AT"00 TOW AWAY STATE HIGHWAY RELAT(D ` VC, PEaT 4`Ae /{� DI MILEPOST / 1:1 was U(NC f5Ta{ ❑Ne LJ AT INTCRSUCTIOH WITH dow MOTOQN, 1N e.: .a.,/.L- A57 OI :A/4"w 8 S /2vAld [:]1.. 39.e PARTY NAME (FIRST,MIDDLE,LA{T) OWNER'S RAMS NAME As OwIVaq .1�I BAR YA M" _ I :VAN. wry STOWST AVOWS#* Hort Fn eNa Ow"a"..mass SAME AS DRIVERy35 S DA F AZA y3 2410 c4r "Ross- CITY/STATS/RIP *usimass MONK DIS"SITION M vE". ow ORDERS or TRU. P1 TTSauaG -CA - AA LJ OFIICSR ®*RIVER ❑OTHER PA..KD DRIVER'$LICSHSS NN UUUMMBB�ER STATE j7NIRTHOATE {ax NAA C[/ DI.a CT10MOF ON/�HIGHWAY) &Pa000LLIMIT vaH. j ��V ! �� I .,•ewv TIF._ IV AusTNAVEL VV DICT- Va....IR(N)jwAc).4tScj%le- s)/MODEL(5)/COLOR(6) LICENEK MO.(S1 {TATK(s) CHP USE VEHICLE DAM AGS—a STE NT/LOCATION .LIST TV 9� 2 C A.M vcM1�S tY ❑ARCAj9MODcwwra ❑MUON TOTAL OTHRa 7sb0& - O "142EA2 PARTY NAME (IINNT,MIooLE,LAST) DWHE.'S=K LiSAME As DRIVEN 2 vAIN A 2T/N �o Jv'r2.� W 1m a JV J m.V ST.afT ADORRSN NOME P.MK OWNKK,s ADDRESS Li SAME AS OWIVaN "f DN a- utY/s,wTl/z� � �� Nuu.aas MONK OI�1✓� H e❑eF Hca wFBA a J ❑oT�E•.: ff oss 0,UK7 La el $� l IL ORIVlw i •gRrCO ON\NIB'S L,c...9 NYM99. �Ja STATS SIRTNOAT! se ggCE DIw3 Cyla.OF OMI N16HW{Y) Lf6C0 YNR. I C4 'I yY �AYT SICU- Va".vo({) NAM a(s)/MceSL($)/COLOR(s) LICSNSS .o.(s) STATI(s) CHP USE VEHICLE O^MAGe—c xtcNt/LOc wTIbM CueT �)�A `�.I��� CA ONLY . �Y'.`f.i . . 474�nNC(/• .7. ` fr. - . . . . . . va.ICL!TTP 19MIMOR ❑MOer AATE E1 MAJen ❑TOTAL i oT.SR ' N MIQnl� MERMENNEW PARTY N^ME(P-IRST,MIDDLE,LAST) ow.R.'s wAME NAME As Dwly&" 3 DRIVE. ST.SNT^Dana's HOME PHONE OWNER**ADOPES• Ll SAME AS DRIVER PaOas- CITY/{TATE/RI♦ NUNINIfS MONS OINPONITIOM OI NEN- ON ORDERS OF TRU. ❑OFFICER ❑ONIVUR ❑OTHER PAq MID DOWUP•S LICE.{E NUMBER {TATA OIRTMDAT6 {a% NAC6 DIRECTION OF Oq/^C.ISS (s TREAT OR HIGHWAY) BKEO LIMIT VEN. MO. DAY VR. :TRAVEL *ICY- VE..YR(s) MAKw(S)/MOOKL(S)/COLOR(S) LICE *a .0.(S) {TATU(S) CNP USE VEHICLE DAM^6E—SAYS NY/LOCATION .LIST ONLY . VEHICLE TIM ❑MIND" ❑MOOI.ATI ❑MAJOR ❑TOTAL oTMlw PARTY NAME (PI*ST,MIDDLE,LAST) *..am's NAM. SAMI AS DRIVE* DRIVER STREET ADORSE{ Noma MONK OWNER'S ADOwass Li SANK As DRIVER � 'SOWS- CITY/{TATKIRIP *u{IHaSS MONK DIN.OSITIO.M VEN. OM ORDER{OI TwI^N — ❑OPPICaw ❑D.IVmw ❑OT... PANNED ONIVKW'S LICENSE 1IYM*ER STATS *IRtNDATEEEx RACE DUSCTION OF aI/ACNOSN (STREET OR NIGMwAV) SEND LIMIT Va.. YO. DAY VR. TRAVEL I WICY- vw..YR(S) MAKE IeI/MOORL1511COLORIST LICm.an NO.(*) STAYS(8) CMP USE VEHICLE DAMAGE—axTENTILOCATION 41et ONLY • EMICLa TV ❑MINOR ❑"**CRATE ❑MAJOR ❑TOTAL *THBR • • • . . • • . - . • • • • • . • • . • • • • . . . . . . . . . CHP 655—Page 1 (Rev 8$4)OPI 042 OB Ml ' sTArs e. CALtWONNIA . TRAFFIC COLUS601"011 CODING ►.Dw'_Z . ,DATA OI COLLISION rTIME (M{SI nctc Numsaf OFFICER I.O. NYMaaR MO. DAY /41 10.46 /'` 7.A.) 9040 (ter 22 1 `^ PROPERTY DAMAGE Da{c*Imo.a DAMAGE . . ly 1A OWNER'S NAME/AYOWKNS NOrinao OYat o.. bYIOLATION(S) ►ARTY I ►ARTY 2 PARTY 2 PARTY A CHARGED PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICE{ / 2 ) 4 TYPE OF VEHICLE 1 2 2 s MOVEMENT►RECEDING (LIaT NUMax*(w IOF PARTY AT FAULT) A CONTw OLt IYNCTIONINO A IAtt[MCaw CAA/S� COLLISION a A tt CT10N VIOLATED: B CONTROL{NOT FUNCTIONING' B ►ARSKNGaw CAR r/TRAILER A[TOPI[D C CONTROL{OESCUNaD• C MOTORCYCLE/SCOOTER B PROCEEDING STRAIGHT « B OTHER IMPROPER DRIVING. CONTEOLS NOT PREt[MTIIAGTOR D� PANEL TRUCK I C MAN OFI ROAD E PICKUP/PANEL TRK w/rRLR 1 D MAKING RIGHT TURN C OTNEw THAN DRIVER- TYPE OF COLLISION I F TRUCK ON TRUCK TNACTON I E MANING LRVT TURN D YNKNOwN• A Ha AD�M 1 G TRK/TRK TRACTOR W/TRLM I F MAKING V TURN WEATHER MARK I TO a IY[M{) B {IDgr1IE H SCHOOL MUS I G NACKING A CLEAN C we AR END I OTHER Bus I H{LOWING—OTOPPING B CLOUDY D EMOADOODE J EMwROwMCY Va.lcLa I PASSING OTHER V[NICLE c RAINING E MIT OwJECT K Hwy CONST.SQU1PMENT J CHANGING LANES p SNOWING F OVERTYa MEO L a1CYCLE K PARKING MANEUVER E Poo G VENICLS/PEDurRIAN M*THE.VEHICLE L aNTawING TRAFFIC F OTHEN•: H OTNEM•: N I[DasTR1AN M OTHER UNSAFE TURNING G W/ND O M0060 N XING INTO 011091.0 LANE LIGHTING MOTOR VEHICLE INVOLVED WITH O PAR.RG A DAYLIONT A NON-COLLISION 1 2 2 A THER ASSOCIATED FACTOR ►'MERGING DUSK—DAWN B FEDESTRIAN (MARK 1 TO a Taws) O TR4VELINO WRONG WAY• DARK—STMERT LIGHTS C OTHER MOTO.VE.ICLf A VC SECTION VIOLATION: R Orman-: p DARK—NO STREET LIGHTS D MOTOR Va..ON OTHRf ROADWAY {TRa ET LIGHTS NOT E PARKED MOTOR VEHICLE B Vc{a CT10M VIOLATION: E DAwN— IUMCTIONINO• F TRAIN — G a1CVCLE C VC SECTION VIOLATION: —_ ROADWAY SURFACE H ANIMAL: - 1 2 2 A SOBRIETY-ORtIO— A On, Vr.SECTIO.VIOLATION: IHYSICA.. B W[T._ I FIXED OSJECT: (MARK I TO I ITOMt) C SNOWY—ICY C VISION CoACURKrENTS: A NAD NOT OKI.DRINKING p{LIPIK*l (MUDDY,OILY,ETC.)- J OTHER Oafs CT: B MaO—UNDER INILULNCE' F INATTENTION C HaO—.OT UNOEw INILU." ROADWAY CONDITIONS G aTOI 8 60 TRAFFIC DHaD—PMIS Iw MCNT Y.H6- MA wK 1 TO a RENS PEDESTRIAN'S ACTION H ENTER'NO RE AV ING*AMR E UNDER DRUG 1Nr LYENCK'I A HOLE K.DEEP OUTS• A.O 1ROE SYRIAN INVOLVED I PREVIOUS COLLISION FIMPAIRMENT—PHYSICAL' E LOOKS MATERIAL ON ROADWAY• CRO{s..0 IN CROSSWALK J UNFAMILIAR WITH ROAD G IMIAlf HENT NOT KNO-. B c Oat TR UGTIO.ON ROADWAY• AT I.TfR KE CTION K OE FE CTIV{V[N.EQUIP.: N NOT APILICAa LE D C0.9160UCT10N-MRPAIN 20M9 Cw CAKING IN CROSSWALK—NOT I 1OLEE1Y/1ATIGUED C E wsoUClO ROADWAY WIDTH AT INTER{[CTION L UNINVOLVED VEHICLE F PLOODCO• D CROSS1.G--NOT IN CROSSWALK M OTHER.: 1 2 2 • SPECIAL INFORMATION G OT.aw•: E IN WOAD—INCLUCCO KHOYLOER N NOME APPARENT A NAEI.R000S MATERIAL(• H NO UNUSUAL CONDITIONS F NOT 1.w040 O RUNAWAY VEHICLE B "no IHv06Vs0- G APPROACH ING/LEAVI.O EC.00L BU{ C TIRE DalseT/IAIwwE• SKETCH MISCELLANEOUS IMOICATS �r1O D 5 R 1-I L A WT .M V V AJL> _ PHYSICAL DESCRIPTION OF PARTY MYraaR NAIw arms Na1DHT WRIGHT Pwar ER'S NAME LD.NUMas* 00. DAT Va. 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Shook k''.. . 1700 Contra Costa Blvd. Karen Krieger, M.D. IRS #942873255 Concord, Calt forma 94523 825-2000 Russell Everest, M.D. Provider #Zu 91375Z PATIENT PATIENT I.D. FEE TICKET NO. DATE VAN WEMME?, MARYANN 32,639 63567 06/18/87 D.0:6. : 07/29 56 KS n: > > TREATMENT RVS AMT TREATMENT RVS AMT TREATMENT RVS AMT INITIAL OFFICE VISIT - SURGICAL PROCEDURES I F MEDICATIONS(IM,IV,SUB-0,INHALATION) 'I Office Visit,Brief 81 1 6 D Subcutaneous Ab.- 10060-58 400 Allergy Injection 90730 2 Office Visit,Limited 90010 (, 84 Remove F.B.Subcut. 10120-58 402 Epinephrine/Susphrine 90730 - 3 1 Office Visit,Intermed. 5 86 1 1 8 D Thrombosed Hemorroid 46320-58 146 Respiratory Therapy 94664 4 1 Office Visit.Comp. 90020 87 1 Debridement of Wound 11000-58 ESTABLISHED PATIENTS-OFFICE VISITS 88 1 Burn,Small Debride d Dress 16020-58 9 OFlice Visit.Brief 90040 89 Burn,Medium Debride d Dress 16025-58 SUPPLIES. ll Office Visit,Limited 90050 90 Injection of Trigger Point 20550-58 201 Cervical Collar 99070 11 Office Visit,Intermed. 90060 91 Wart Removal 11050-58 202 Shoulder Immobilizer 99070 -EXAMINATIONS 92 Removal F.B.Conjunctiva 65210-58 203 Cradle Sling 99070 15 Periodic Exam Gyn 90088 95Removal F.B.Comea 65220-58 233 Sling 99070 Periodic Exam(age_) 907_ 93 Excision,Benign to 0.5 cm 11400-58 204 Elastic Bandages_inch 99070 17 Pro-Employment 90005 94 Excision,Benign 0.5 to 1 cm 11401-58 2D5 Knee Splint(Small,Med.,Lg.) 99070 18 Spots P.E. 90000 206 Splints,Finger 99070- 19 9070-19 DMV Physical 90005 207 Splint,Wrist 99070 ORTHOPEDICS 208 Air Cast Ankle Splint 99070 121 Radial Head Subluxation 24640 209 Rib Bell 99070 LACERATIONS—SIMPLE REPAIR 122 Fx Metatarsal,Simple 28470 210 Suture Tray 99070 25 To 2.5 cm,Scalp,Extrem. 12001-58 124 Fx,Finger(Proximal or Middle) 26720 211 Suture 99070 28 2.5 to 7.5 cm,Scalp.Extrem. 12002-58 125 Fx,Finger(Distal) 26750 212 Steri Strip 99070 27 To 2.5 cm,Face,etc. 12011-58 128 Fx,Great Toe 28490 213 Dressing,Small 99070 129 Fx Toe,Other 28510 214 Dressing,Intermediate 99070 LACERATIONS—INTERMEDIATE REPAIR 99 FX Toe,Manipulation 28515 . 232 Dressing,Large: -99070 35 To 2.5 cm,Scalp,Extrem. 12031-58 215 Eye Tray 99070 36 2.5 to 7.5 cm,Scalp,Extrem. 12032-58 1 229 Air Cast Short Leg Walker 99070 40 To 2.5 cm.Neck,Hands,etc. 12641-58 SPLINTS/CASTS UP TO 10iYRS.-c.. 226 1 Ent Tray 99070 45 To 2.5 cm,Pew,etc. 12051-58 330 Long Arm Splint 29100 230 Cast Material(Plaster) 99070 332 Short Arm Splint 29120 231 Cast Material(Fiberglass) 99070 334 on Leg Splint 29510 221 Crutch 99070 X-RAY 338 Short Arm Cast 29070 228 Crutch Rental 50 Chest,2 V'lews 71020 51 Chest.3 Views 71021 SPLINTS/CASTS 10 YRS AND OVER 52 1 Ankle 73610 331 1 Long Arm Splint 29105 LABORATORY 53 Foot 73630 333 Short Arm Splint -29125 301 Collection 8 Handling 99008 54 Knee 73570 335 Short Leg Splint 29515 302 Executive 11 8499990 55 Toes 73660 339 1 Short Arm Cast 29075 303 Culture,Throat 87060 56 Elbow 73080 1 304 Culture,G.C. 87070 57 Finger 73140 MEDICAL PROCEDURES-DIAGNOSTIC 305 Culture,Urine 87086 58 Hand 73130 141 Audiogram 92551 306 VDRL 86592.90 ' 59 Shoulder 73030 142 ECG with Interpretation 93000 307 Rubella Titer 86171-90 60 Wrist 73110 143 ECG Rhythm Strip 93040 308 Pap Smear 88150.90 61 Cervical Spine 72050 144 Pulmonary Function 94001 309 KOH Prep 8 Wet Mount 67210 62 Lumbosacral Spine 72110 145 Tonometry 92100 310 Gram Stain 87205 311 Urinalysis,Dipstick 81015 312 Urinalysis,Complete 8/000 PHYSICAL THERAPY X 3270 IMMUNIZATIONS 313 Pregnancy Test,Serum 82998.90 180 Musculo-Skeletal Eval. 97720 161 Adult dT,Ped.DT,T.T. 90720 314 Pregnancy Test,Urine 86006 181 One Modalilly 97000 162 DPT 90720 315 Mono Spot 86300 102 Two Modality 97050 163 M-M-R 90723 316 Occult Blood,Stool 89205' 183 30 Min Procedure 97100 164 Polio 99720 317 CBC 85022-90 184 Ea.Add 15 Min. 97101 1 166 TB Skin Test 86580 318 1 Hematocrit 85014 185 Any Comb.Mod.8 Proc. 97200 1 167 Gamma Globulin 99070 328 WBC 85048 186 Ea.Add 15 Min. 97201 327 Tissue Pathology 88304 ORAL MEDICATIONS - MISCELLANEOUS PHARMACY 99070 99070 99070 -- -----^ 99070 DIAGNOSIS n 1 TODAY'S FEES N RSE'S SIGNATURE RECEPT,� TIME OUT P Credit Card / Cash $ CC AM A \ Y PHYSICIAN'S SIGNATOR E ( lr N.._. 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