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HomeMy WebLinkAboutMINUTES - 08071990 - 1.25 CLAIM / aJ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AUGUST 7 , 1990 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 Government Code Amount: $ 25,000 . 00 Section-"' and 915.4. Please note all "Warnings". • �BB�� Vag CLAIMANT: BROWN , Dovie JUL ATTORNEY: Law Offices of couwrr 19gn. Affinito and Morrison DaAteRTi���ki � ADDRESS: 2980 Railroad Ave . , Ste . E BY DELIVERY Td CLERK ON July 2 , 1990 Pittsburg, CA 94565 BY MAIL POSTMARKED: June 29 , 1990 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 10 , 1990 PpHHIL BATCHELOR, Clerk 8Y: Deputy I`]. FROM: County Counsel TO: Clerk of the Board of Supervisors (V ) 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: / it BY S, Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administ ator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ) 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 date. Dated: AUG 7 19Ju PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec n 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 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: -fj_ In BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator CLAIM TO; BOARD OF SUPERVISORS OF CONTRA CO§: 'Yapplicationto: iInstructions to C1aimi&C'erk of trie Board .O.Box 911 Martinez,Califomia 94553 • 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 six (6). months 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 , California 94553. 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 oTthis form. RE: Claim by ) Reserved for Clerk' s filing stamps DOME BROWN j iz� RECEIVED Against the COUNTY OF CONTRA COSTA) A - 2 NO fff HOUSING AUTHORITY [ ) CLERK BOARD OF SUPERVISORS (Fill in name ) CONTRA COSTA CO. HOUSING AUTUORITY OF The undersigned claimant hereby makes claim against the County ot Contra Costa or the above-named District in the sum of $25.000.00 and in support of this claim represents as follows : ----------:----------------T-z------------- -- =------------- --- --- 1. When did the damage or injury occur? (Give exact--- date and hour-]- January 19, 1990, at approximately 12:30 p.m. '�. Where did tFie damage or injury occur? Include city and county) Mailbox in front of Housing Authoritv Bldg. , 875 El Pueblo Avenue, Pittsburg, CA 9456.5, Contra Costa County 3. How did the damage or injury occur? (Give tuli details, use extra sheets if required) Went to mail letter in mailbox. turned around to walk away and stepped into a hole in the concrete sidewalk. This hole was 7-8" round and about 18" deep. - . t i Whapartcuiar act or omission on the part county- ty ordi '4strict officers , servants or employees caused the injury or damage? Hole existed for a long period of time. As a stopgap measure it had been covered with a wood board. The board no longer covered the hole. This was known by Housing Authority Personnel. (over) EIVED LAW OFFICES OF - REC AFFINITO AND MORRISON _ 2 XWO AFFINITO BUILDING 2980 Railroad Avenue,Suite E PITTSBURG, CA 94565-5271 C BBI re 415 ALFRED A.AFFINITO Pittsbur a 432-4731 JAMES D.MORRISON Concord Area 687-7780 Date : June 29, 1990 To : CLERK OF THE BOARD OF SUPERVIOSRS County, Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 Re DOVIE BROWN vs. HOUSING AUTHORITY OF CONTRA COSTA COUNTY M FlIe No. : 9M-5288 Documents Enclose CLAIM Please take the following action: Certify copies of enclosed documents . File the enclosed documents . Record the enclosed documents and return to this office . Check No. in the amount of $ is enclosed to cover your costs . XX pile the original document enclosed, and. return the endorsed , file-stamped. copies to this office . Sign and return the enclosed documents to this office . Keep the enclosed documents for your records and information . Other : Very truly yours , LAW OFFICES OF AT-FI ITO ,AND MOR:RTSON SANDRA J. HERSHKOWITZ SJH/cm z MoD H T 9 O Z � `2 D � C •n o U co O o n c n /b fl z 1 4 k-Ao J, d 9 H H � H Ln �O LTJ C!J by AHI--] O W O i--3 d Q Z O ^ ! -01, y L � / Al ,yt•�..•9 { . > CA LA *, CLAIM aJ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA {laim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AUGUST 7 , 1990 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 Government Code Amount: Undetermined Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CARMELICH, Jennie F . RereiyE® JUL 1 -1 1990 ATTORNEY: Scott W. Gordon, Esq . COUNiy Titchell , Maltzman, Mark, Date received MARTINEZ GuNsc� ADDRESS: Bass , Ohleyer $ Mishel BY DELIVERY TO CLERK ON Mly 9, 1990 (hand del ivered) 1990 North California Blvd. Suite 1020 BY MAIL POSTMARKED: Walnut Creek, CA 94596 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: July 10 , 1990 BY: Deputy 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: I )I 19I� BY:� Deputy County Counsel III. 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 ( ") 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 date. Dated: AUG 7 1990 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code s 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 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: R—Rj—9j BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator LAW OFFICES OF TITCHELL, MALTZMAN, MARK, BASS, OHLEYER 8e MISHEL A PROFESSIONAL CORPORATION HASKE LL TITCH ELL TELECO PIER STEVEN L.SWIG ' 29TH FLOOR (415)981-5027 ADVISORY COUNSEL 650 CALIFORNIA STREET RICHARD D. MALTZMAN SAN FRANCISCO, CALIFORNIA 94108 MELVYN I. MARK e PHILIP S. BASS TELEPHONE 392-5600 - AREA CODE 415 RECEIVE® 4(61 MICHAEL L.OHLEYER �/ n R. DAVID MISHEL bfLf-dam STEPHEN G.GOULD THOMAS M. BRUEN ,9 1 ROBERT TED PARKER CHARLES E.STEIDTMANN �� 30 FVM DONALD L. FEURZEIG GEOFFREY M. FAUST CLERK BOARD OF SUPERVl5c,.Y;, LEMOINE SKINNER III July 91 1990 CONTRA COSTA CC ALVIN L. FISHMAN JOHN M.YOUNGOUIST THOMAS A.ACKLEY PETER M.RADIN,JR. LILLIAN L.WONG SUZAN CANLI RICHARD C. INSALACO LISA R.SM IYH Clerk of the Board County Board of Supervisors 651 Pine Street, First Floor Martinez, California 94553 Re: Filing of Claim for Personal Injury Dear Clerk of the Board: Enclosed herewith please find an original and one copy of a "Claim for Personal Injury and Property Damage Against the City of San Pablo and the County of Contra Costa" for your filing and further handling. I would appreciate your date stamping the copy of the claim submitted and providing the messenger with the copy for my files. Thank you for your courtesy and cooperation in this request. Very t;W. y yours, SCOT GORDON Counsel for Claimant encls. swg/cg RECEIVED A 9N • /:3d PM CLERK BOARD OF SUPERVISOR, CONTRA COSTA CO. CLAIM FOR PERSONAL INJURY AND PROPERTY DAMAGE AGAINST THE CITY OF SAN PABLO AND THE COUNTY OF CONTRA COSTA [ Government Code section 910 et. seq. ] Pursuant to the requirements of Government Code section 910, claimant hereby submits the following information: A. The name and post office address of the claimant. Jennie F. Carmelich 6015 Jordan Ave. E1 Cerrito, California 94530 B. The post office address to which notices shall be sent. Scott W. Gordon, Esq. Titchell, Maltzman, Mark, Bass, Ohleyer & Mishel A Professional Corporation 1990 North California Blvd. , Suite 1020 Walnut Creek, California 94596 [415] 947 - 4555 Claimant is represented by counsel as set forth above, and all communications should be directed to counsel. C. The date, place and circumstances giving rise to the claim. On January 10, 1990, Claimant was seriously injured from a fall caused by uneven pavement surfaces on a public street claimant believes to be within the City of San Pablo. Claimant has filed this claim with the County of Contra Costa as well as the City of San Pablo in the event of any issue with repect to the location of the area on the street giving rise to the injury. Claimant tripped on the uneven pavement, falling on her shoulder and head, sustaining injury. The condition of the pavement and concrete structures on this street constitute a dangerous condition of public property, of which the City or County had actual or constructive notice. Other persons have been injured at this location to claimant's knowledge. The street is the 3200 block of Evans Avenue, which runs in a northwesterly direction between San Pablo Dam Road and San Pablo Avenue. The street surfaces are uneven at the joinder of concrete and asphalt near the curb, a condition which has been now altered due to construction along Evans Avenue. The street is, however, still in a state of disrepair as of the date of filing this claim. As a result of her fall, claimant sustained a compound fracture of the left arm, resulting in severe discomfort, pain, anxiety as well as several bruises about the face and upper body. D. General description of injury or damage. As noted above, claimant has suffered a compound fracture of the arm, bruises and abrasions about the head and upper body, and has undergone considerable pain and suffering. E. Names of public employees causing the injury. Claimant is not aware of the names of any public employees who may have caused her injury. F. Amount of claim; jurisdictional amount. In accordance with the requirements of Government Code section 910, jurisdiction over this claim shall rest in the Superior Court. Dated: J ly 91 1990 Scott W. Gordon Counsel for Claimant i.a� 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, ) NOTICE TO CLAIMANT AUGUST 7 , 1990 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 (P h IV below), given pursuant to Government Code Amount: Undetermined JSec�ti� "�i�Qand 915.4. Please note all "Warnings". CLAIMANT: GOLAB, Roger Kenneth bu% 1 -1 199 ATTORNEY: Arlene D . Kock ft4jer&�OuftR C'411,c Professional Law Corp . Date received ADDRESS: 24301 Southland Drive BY DELIVERY TO CLERK ON July 6 , 1990 Suite 308 Cert. P129 757 939 Hayward, CA 94545 BY MAIL POSTMARKED: July 5 , 1990 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: July 10 , 1990 BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup sors 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: -( '11190 BYI Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Admin strator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD. By unanimous vote of the Supervisors present ( ) 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 date. Dated:A U G 7 1996 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ion 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 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: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator ARLENE D. HOCK A Professional Law Corporation RECEIVED 24301 Southland Drive Suite 308 Hayward, California 94545 (415) 887.2856 'A - 6 CLAIM FOR PROPERTY DAMAGE CLERK BOAR OF SUPERVISORS ' CONTRA COSTA CO. TO THE COUNTY OF CONTRA COSTA: ROGER KENNETH GOLAB hereby makes -claim against the COUNTY OF CONTRA COSTA for an amount in excess of $25, 000. 00 and makes the following statement in support of the claim: 1. Claimant's post office address is 40157 Paseo Padre Parkway, Fremont, California 94538. 2 . Notices concerning the claim should be sent to the Law Office of Arlene D. Kock, 24301 Southland Drive, Suite 308, Hayward, California 94545. 3 . The date and place of the occurrence giving rise to this claim are as follows: Date: Place: LaMarinda Tow Company, Lafayette 4. The circumstances giving rise to this claim are as follows: Claimant was the owner of a 1937 Yamaha motorcycle, Florida license plate # 275129 now changed to California license plate # 11T8265. Said motorcycle was stolen by Scott Reimer. The motorcycle was listed as stolen by the Fremont Police Department on applicable stolen vehicle reports that were read by the Lafayette Police Department. The motorcycle was eventually retrieved by the Lafayette Police Department and Mr. Reimer was booked for stealing the motorcycle. However, the Lafayette Police Department did not contact claimants although police procedure required them to do so, and the motorcycle remained at the impound car lot, LaMarinda Tow Company. In April 1989, the motorcycle was sold to Police Sergeant John Funk, who was also the desk sergeant in charge of authorizing sale of the vehicle. Claimant alleges that the Lafayette Police Department, and particularly Sergeant John Funk failed to notify claimant, as required by internal police regulations that his motorcycle was retrieved so that Sergeant John Funk could purchase said motorcycle himself, all to claimants detriment. 5. Claimant's property damage is the value of the 1987 Yamaha motorcycle, valued at $2,500. 00. 6. The names of the public employees causing claimant's injuries and property damage are John C. Funk and unknown. 7. The basis of computation of the above amount is as follows: a. Value of 1987 Yamaha motorcycle $2,500. 00 b. Genera' damages Unknown C. Punitive damages Unknown all according to proof. Dated: June 15, 1990 LAW OFFICE OF ARLENE D. KOCK By: ELISSA URLIK Attorney for Claimant, Roger Golab 1 VERIFICATION 2 3 I , ROGER K. GOLAB declare: 4 I am the Plaintiff in the 5 above-entitled matter. 6 I have read the foregoing CLAIM FOR PROPERTY DAMAGE 7 and know the contents thereof . 8 The same is true of my own knowledge, except as to those 9 matters which are therein stated on information and belief, and, 10 as to those matters, I believe it to be true . //�� /1 11 EXECUTED on �>14e a) i 9,qp at L10151 aseo Padi'r- . 12rPinn(T� irNer�D— County, California. 13 14 I declare under penalty of perjury that the foregoing is 15 true and correct. 1617 z 18 ROGER K. GOLAB 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 • 35 36 a ASIZME_D. K= A Professional Law Corporation 24301 Southland Drive Suite 308 Hayward, California 94545 (415) 887-2856 VIA CERTIFIED MAIL DATE: JULY 4 , 1990 RECEIVED n _ 6 1990 TO: BOARD OF SUPERVISORS CLERK CLERKBOAROOFSUPERVIS COUNTY OF CONTRA COSTA CONTRA COSTA CO. 651 PINE MARTINEZ CA 94553 RE: CLAIM OF ROGER KENNETH -GOLAB FOR PROPERTY DAMAGES ENCL- . CLAIM FOR PROPERTY DAMAGES AGAINST THE COUNTY OF CONTRA COSTA REQUESTED ACTION: PLEASE RETURN STAMPED RECEIVED COPY IN THE ENVELOPE PROVIDED. THANK YOU. LAW OFFICES OF ARLENE D. KOCK BY: ELISSA URLIK , \ \%\? \ ` \ �do � ! JIL _ Ul § � \ sAlk's ow,/��«A�' S+® \ % �\ . , > , f ® � ®k @4 % © m « @ . o © � k� vo %f t & g/ \ � w « _ ) \ . k � 0 woo, . \ CLAIM aJ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AUGUST 7 . 1990 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Lodes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified 4 ition 913 and 915.4. Please note all "Warnings". Ep CLAIMANT: GREGORY, Stanley F . JJl( 2801 Bissell Avenue couN 1 _I 1990 ATTORNEY: Richmond, CA 94804 44ARTI), BYU,N7S�.received ADDRESS: BY &LIVERY TO CLERK ON July 6 , 1990 (Risk Mgmt) BY MAIL POSTMARKED: July 3 , 1990 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 10 , 1990 Jy1L BAATTCYELOR, Clerk epu I1. 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: 7 / II 150 BY: �• Deputy County Counsel II1. 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 ( 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 date. Dated: AUG 7 1990 PHIL BATCHELOR, Clerk. By Deputy Clerk WARNING (Gov. code sec 13) Subject to certain exceptions, you have only six (6) months from the date this notice was personalty 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 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: R e BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM T0: Sta ey F. Gregory 2801 Bissell Avenue Richmond, 'C 94804 Re: Claim of STAN. GREGORY Please Take Notice As Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910. 2, or is otherwise insufficient for the reasons checked below: _1 . The claim fails to state the name and post office address of the claimant. _2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. _3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. _4 . The claim fails to state the name(s) of the public employee(s ) causing the injury, damage, or loss, if known. x 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10, 000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ( $10, 000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. _6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WEST c , County Counsel By: Deputy Vunty Counse CERTIFICATE OF SERVICE BY MAIL C.C.P. 69 1012, 1013a, 2015 .5; Evid. C. 6S 641 , 664 My business address is the County Counsel' s Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69 , Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s ) addressed as shown above (which is/are place(s) having delivery service by U.S . Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S . Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: \��O\b , at Martinez, California. cc: Clerk of the Board of Supervisors ( iginal) V/ Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§S, 910, 910 . 21 920 .4 , 910 . 8) Claim to: 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 per- sonal property or growing crops and. which accrue on or before. December 31, 1987, must be presented not later than the 100th day .after the accrual of the cause of action. Claims relating to causes of action for ,de,ath or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months 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. . (Govt. Code §911:2.) 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• 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 the end of this form. .. RE: Claim By ) Reserved for Clerk's filing stamp RECEIVED via�.. -,e• rx,� Against the County of Contra Costa ) . 61M or District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO.. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as-follows: 4----------------------------------------------------------------------------- �l. When did the damage or injury occur? (Give exact date and hour) A-?$t - 13 - Laga — Ct•,3fl .Aa.M — ww► Le. 0 y Dory = _1l ------------- 2. Where did the damage or injury occur? (Include city and county)SL� �q,c�►+�G �La=Uf�ToVL — RtGtlt MAuH. STA4 bL uJ+� y �P 01•►J a STS Q Fey►^ � J�� _� t�A�.14�t__i►•l�1Q _�tt{2E.1��o �4st14.G_�LJ2 , TOM 3. 3. How did the damage or injury occur? (Give full details; use extra paper if required) ----------------------------------------------------------------------------------- 4. What particular act or omission on the part .of county or district officers, servants or employees caused the injury or damage? (over) 5. What are the names of county or district officers,- servants or employees causing the damage or injury? -----N a t - ----- ---------- -- ------------------------------- 5'. What damage-or injuries do "you claim resulted? (Give full extent of injuries or damages' claimed.` Attach 'Wo estimates for auto damage. " $ Ro.K�� i_ L 64. ,r oT3Y F�°►�i'►:^� G 'o w.� T'14 E do 10Ct4:ETE --- u-_- - __�rA t_�Lt�v A`9---------- - --------r---` ------------- Ems• ( 7 r How-was the amount=ciaimed above computed? -(Include"the-estimated amount of any prospective injury or damage.) 8. Names and addresses of- witnesses, doctors 'and' hospitals. MIc 14-AE-'Ll S -�-�n t3 n�c_ 00 >— Ni w tR T ► .. ------ 9. List the. expenditures you made on account of this accident or injury: DATE ITEM AMOUNT M�fl�GA �. S :.Tc� 1�r�G' =ra � E CS i= w► ds-� of C"r\E F3 � p►�-r�� sl-�oo LD ntcl� up ApoFa.T ►oa Qo•F3o�c. t234c � 12ALf— 93`rGS Jb I, Gov. Code Sec. 910:2 provides: "The claim must be signed7'by the claimant SEND NOTICES TO:-, (At;torney,), � ,., or by some person on his behalf." Name and Address rofi'Attorney.9s__ - - -- A13 AT/d,2/vE Y Clairqpt s Signatu � *3 15.4 (A *3 Telephone No. Telephone No. * * * * niC OSIS COURT'' N 0 T ,I C E RECEIVED JUL 5 1990. Section. 72 of the Penal Code provides.:' ; Risk Wna ment "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a_ period of not more than one year, by a fine of not exceeding one thousand ($1,000)-, or -by both- such -imprisonment and' fine, or by imprisonment in the state prison, by a fine of not exceeding 'ten thousand dollars ($10,000, or'by both such imprisonment and fine. Ald Su r TE / S /A.-) TEN1J 6:`,0 -- 1 '�1'� /1610 r sv G T Ir'L• cPo�.0 j-�&U.*% PCZ-O' UP 7-/16 S%�/9// .&-, T NoT CdViTA By /�-?end/C 4.4 6- t4 /44,6 7-A14 - 7--,�,r.g .�k ye ed -- AIA • S.F7 -r' 1 N ���i xa� z�'� QN91 N m . _. �'f�A m 'eco �f4< A O V - �` � �� a� � (� �� � � � � � � � C � �- vti � �, � �, � � � � . w � -� ,� � � y _ �`"� j r ,� Q �,J t� o �- .� .. �n � O � C n ' � � Y � � , � �.i '` ' P ` 't i. 49 }�' 1 � � �� �` � '' ^' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA I `A Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT AUGUST 7 . 1990 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 Government Code Amount: Unspecified Sectq�+Q't3aand 915.4. Please note all "Warnings". �V Q CLAIMANT: MITCHELL, Bobby J04 11 19 California Street CO&%y 7990 ATTORNEY: Rodeo , CA 94577 4t4Rr,'Af4?�'90UN Date Q'Ned ADDRESS: BY DELIVERY TO CLERK ON July 6 , 1990 (via Risk Mgmt) BY MAIL POSTMARKED: July 5 , 1990 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: July 10 , 1990 BY: Deputy I1. FROM: County Counsel TO: Clerk of the Board of Supervisors �1 ) 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: 11 BY: _ S, Deputy County- Counsel III. 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 ( 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 date. �!1 Dated: AUG 7 1990 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 an attorney, you should do so immediately. I t AFFIDAVIT OF MAILING I 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, i California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: .4Q BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim to: . 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 per- sonal property or growing crops and which accrue on or before December -31,. 1987, must be presented not later than-the 100th day after the accrual of the ,cause of action. Claims. relating to•:causes of action for death or for injury_ to ,person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months 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. (Govt,.` Code §911.2.) . 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• C. If claim is against a district governed by the Board of-Supervisors,. rather than the County, the name of the Distr.ict .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.the. end. of this form. RE: Claim By ) Reserved for Clerk's filing stamp RECEIVE® Against the County of Contra Costa :, or ) JUL 6 {990 District) CLERK BOARD OF SUPERVISORS . Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents-as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ti --- 1�L_Z� --ea-L !y----_ --- =i-,----------- 2. Where did the damage or injury occur? (Include city and county) ' - 1s % --L�cta . 3. How did th9_4 age or injury o cur? (Give full details u e extr paper if required) a ------------------------------------------------------------------V----------------- 4. - What particular act or omission on the -part of county ordistrict officers, servants or employees -caused the injury or damage? (over) t 5. What are the names of county or district officers, servants or employees causing the damage or injury? ---------==---- --------------------------------------_---,--------------------------- 5: • What damage~or -injur_ies do you claim 'eesulted? (Give full extent of ._injuries or d '.claimed'. - Attach,.two estimates for auto damage. n G� �:�C�c/lt�� C;v�gi.� �C!'�%:rte•�r'l��'i'�'� /- tit1.. � 7. How.was the,• unt .claimed above computed? -(Include the -estimated amount.of any v . prospective injury or damage.) 8. Names and addresses of witnesses doctors and hospitals-.. F•- -____ _______________ ____________________________________ _______ ... 9. List the expenditures you made on account of this accident or injury: .DATE _ ITEM . AMOUNT Gov'. Code Sec.__910.2 provides: "The claim must be signed ,by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of�Attorrieysa y�c; t• .. Claimant's Signature (Address) Telephone No. Telephone No. 74f-23 1'/ 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, city or district board or officer, authorized to.allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, 'or writing, is punishable either by imprisonment in the county jail for a•period- of .not more than one year, by•a fine of not exceeding one thousand ($1,000)•,• or -by both suchnimpr;R,,svnmftjratnd fine; or by imprisonment in the state prison, by a fine of not excee#D9p ri�thousand :dollars .($10,000, or by both such imprisonment and fine. JUL 6 1990 Risk management RECEIVED UNIQUE -� JUL 61990 AUTO PAINT AND BODY REPAIR " %/ "e' 232-7338 CLERK BOARD OF STA CCj Sf)i CONTRA COSTA CO u'j 107—_ 2311 Rheem Ave., Richmond, CA 94804 DATE: NAME CAR YR. & MAKE ADDRESS C, ODOMETER CITY—/2'j D ('-P PHONE PAINTING LABOR MATERI� TOTAL V BODY WORK LABOR MATERIAL TOTAL PARTS LABOR MATERIAL TOTAL NOT RESPONSIBLE FOR ARTICLES LEFT IN VEHICLE WHILE IN SHOP. i TAXABLES PLEASE. NO PERSONAL CHECKS. SIGNATURE TOTAL / ��� ,3� .� -!' w �.ir vl � � ,1 L? "` '�^ � .. e � � +; �^ � -� `, �� N A „� ., � -a Ca � �' � '. � � � � �� `a �, '.� ..(� � � 1� i� u, `� �, s �` meq„, � � �, � c s � � � �vs ' a � � �� ��� � � 4 ��� � �, ��� ,, �_ -_____- � _ , 5 � �� �� � A, n f ��i 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, ) NOTICE TO CLAIMANT AUGUST 7 199 �0 and Board Action. All Section references are to ) The copy of this document mailed to you is your ndtice o California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section j&j+A15.4. Please note all "Warnings". CLAIMANT: SAFEWAY STORES , INC . JUL 11 1990 (Gail Morris) couN ATTORNEY: 414RTW UNStl Jolie Krakauer, Esq . Date recMgyi ADDRESS: Martin, Ryan $ Andrada BY DELIVERY TO CLERK ON July 3, 1990 (Fed Exp) Orduy Building, Suite 2275 One Kaiser Plaza BY MAIL POSTMARKED: Oakland, CA 94612 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: July 10 , 1990 �aIL OepputyLOR, Clerk II. 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: �{{ '�U BY:� �, Deputy County Counsel �7 III. 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 ( 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 date. Dated: AUG 7 1990 PHIL BATCHELOR, Clerk, By 26Deputy 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 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: 8—R—RC7 BY: PHIL BATCHELORb Deputy Clerk CC: County Counsel County Administrator LAW OFFICES OF MARTIN, RYAN & ANDRADA GERALD P. MARTIN,JR. A PROFESSIONAL CORPORATION JOSEPH D. RYAN ORDWAY BUILDING,SUITE 2275 RECEIVED J. RANDALL ANDRADA JOLIE KRAKAUER ONE KAISER PLAZA _J,,,, JILL J. LIFTER OAKLAND,CALIFORNIA 94612 f`G�� KPn� KEITH I. CHRESTION50N STEPHEN F. RILEY TELEPHONE:(415)783-6510 p 3 GLENN GOULD FAX:(415)763-3921 I �- J ALISON ILEEN SCOTT JULIE ANN CANDOLI CLERK BOARD OF SUPERVISO CONTRA COSTA CO. July 2, 1990 FEDERAL EXPRESS MAIL TRANSMITTAL MEMO TO: Clerk of the Board of Supervisors 651 Pine Street, Room 106 Martinez, CA 94553 SUBJECT: SAFEWAY FIRE Gail Morris, et al. v. Safeway Stores, Inc. Our File No: S 831 ENCLOSURES: Original and a copy of a claim against Contra Costa County Health Department and a return envelope. REQUESTED ACTION: Please stamp the copy received and return the copy to this office in the envelope provided. YOUR COURTESY IS APPRECIATED Yours very truly MARTIN, RYAN & ANDRADA BY , ' Nancy F danesh, Secretary to JOLIE WKAUER -RECEIVED MARTIN, RYAN & ANDRADA .A1L 319M A Professional Corporation Ordway Building, Suite 2275 One Kaiser Plaza CLERK BOARD OFSUPERVISO Oakland, CA 94612 CONTRA COSTA CO. (415) 763-6510 Attorneys for Claimant SAFEWAY STORES, INC. CLAIM AGAINST BAY AREA AIR QUALITY MANAGEMENT DISTRICT, TO: CLERK OF THE BOARD OF SUPERVISORS , 651 Pine Street, Room 106, Martinez, CA 94553 : SAFEWAY STORES , INC. hereby makes a claim against the CONTRA COSTA COUNTY HEALTH DEPARTMENT and makes the following statement in support thereof: 1. Claimant' s post office address is: SAFEWAY STORES, INC. , 201 - 4th Street, Oakland, California 94607. 2. Notices concerning the claim should be sent to Gerald P. Martin, Jr . , Martin, Ryan & Andrada, One Kaiser Plaza, Suite 2275, Oakland, CA 94612. 3. The 'date and place of the occurrence giving rise to this claim are as follows: On or about January 4, 1990 SAFEWAY STORES ,. INC. was served with a complaint captioned Gail Morris as Guardian ad Litem for Duane Harris, et al. v. Safeway Stores, Inc. , et al. (Case No. 659682-6) . The .action was filed in the Superior Court of California, County of Alameda. 4. The circumstances giving rise to liability are as follows: SAFEWAY STORES , INC. owned and operated a distribution center warehouse at 2900 Hoffman Boulevard, City of Richmond, County of Contra Costa, State of California. On July 11, 1988 , there was a fire in the warehouse. The fire burned for a number of days. -1- The above-described lawsuit involves claims by plaintiffs for personal injury and property damage as a result of exposure to smoke from the July 11, 1988 fire at the Safeway distribution center warehouse in Richmond, California. Among other allegations, plaintiffs contend that the fire should have been extinguished immediately and that plaintiffs should have been evacuated. Safeway contends that the Contra Costa County Health Department was responsible for monitoring the air quality in the area of the fire, advising community residents with regard to air quality, evacuating the area if necessary, rendering advice to the Richmond Fire Department regarding the necessity for extinguishing the fire, and for issuing any health advisories necessitated by the fire. The Contra Costa County Health Department was also responsible for monitoring the presence of toxins, if any, and rendering health advisories, if any such advisories were necessary. As a result of the Contra Costa County Health Department ' s failure to properly manage the Safeway fire and its aftermath, claimant contends that it is entitled to indemnity for the damages sought in the above-described complaint. 5. General Description of Injury, Damage or Loss Incurred: Claimant is entitled to equitable or partial indemnity from the Bay Area Air Quality Management District pursuant to Greyhound Lines, Inc. v. County of Santa Clara (1986) 187 Cal.App. 3d 480. The indemnity to which claimant is entitled extends not only to the complaint set forth above, but to any subsequent complaints or cross-complaints brought against claimant based on the above-described occurrences. 6. Jurisdiction over this claim would rest in Superior Court. 7 . The names of the public employees causing claimant' s damages are unknown. 8. The amount of the claim and the basis for its computation have yet to be determined. DATED:-A-,O 1 Go MARTIN, RYAN & ANDRADA A Professional Corporation By 4� JOLIE KRAKAUER ) U -2- PROOF OF SERVICE BY MAIL - C.C.P. 5§1013a, 2015. 5 I , NANCY FARDANESH, certify that I am over the age of 18 years and not a party to the within action; that my business address is One Kaiser Plaza, Suite 2275, Oakland, California; and that on this date I placed a true copy of the foregoing document (s) entitled : CLAIM AGAINST CONTRA COSTA COUNTY HEALTH DEPARTMENT on the parties in this action by placing a true copy thereof in a sealed envelope addressed as follows: Clerk of the Board of Supervisors 651 Pine Street, Room 106 Martinez, CA 94553 XX (By Overnight Courier) I caused each envelope, with postage fully prepaid, to be sent by Federal Express . (By Mail) I caused each envelope with postage fully prepaid to be placed for collection and mailing following the ordinary business practices of Martin, Ryan & Andrada. (By Hand) I caused each envelope to be delivered by hand to the offices listed above. (By Telecopy) I caused each document to be sent by Automatic Telecopier to the following number : I declare under penalty of perjury that the foregoing is true and correct. Executed on `��a1Qt� at Oakland, California. A"a.FYJ� NAN Y FARDANESH -3- 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, ) NOTICE TO CLAIMANT AUGUST 7 1 9 9 Q and Board Action. All Section references are to ) The copy of this document mailed to you is your notice o California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $ 200 . 0 0 Sectio 11110 al15.4. Please note all "Warnings". CLAIMANT: TREUEL, Joseph F . JUL j 2191 Broadmore Avenue cou 11990 >Y ATTORNEY: San Pablo , CA 94806 414RN 00U Date rreCei96 ADDRESS: BY DELIVERY TO CLERK ON July 5 , 1990 BY MAIL POSTMARKED: July 3, 1990 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH IL BgATCHELOR, Clerk DATED: July 10 , 1990 gy; Deputy 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:1 ) • Deputy County Counsel III. 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 ( ✓) /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 date. Dated: Q U G 7 1990 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se 13) 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 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: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim to: 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 per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death,or for injury to person or to personal property or growing crops ,and which accrue on or after January 1, 1988, must be presented not later •than six months 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. (Govt. Code §911.2.) w. 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• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the riame"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 the end of .this form. RE: Claim By ) Reserved for Clerk's filing stamp . F ' -`'� �L- RECEIVED ) ) Against the County of Contra Costa ) v 5 or ) District) CLERK BOARD SUPERVIS Fill in name ) CONTRA COSTA CO. j The undersigned claimant hereby makes claim againse County of Contra Costa or the above-named District in the sum of Q and in support of this claim represents as follows: ` ------------------------------------------------------------------------------------- 1. When did the damage or injury.occur? (Give exact date and hour) ------------------------------------------------------------------------------------ 2. Where did the damage or i jury occur. (Include city and county) sw� � l� C . C _ C, ------------------------------------------------------------=---------------=------- 3. How did the damage or injur occur? (Give full details; use extra pa r if required) �rKe -5 v"9 ro"_OL w o �, ��, V,vee Je_ �Plc �.. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? �h SP rc-,-�') 1,V-, y � +ax-_ I K, �f\cey p�� (over) 5. What are the names of county or district officers, 'servants or employees causing the damage or injury? ----------------------r--------------------------------- --------------------------- 5. What damage or injuries-do you claim resulted? (Give full extent of injuries or damages• claimed., :Attach two estimates for auto damage. '. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 1 ----------------�---------- -----�------- --------- -------------------7------------ 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM T Q Q EE EE EF EF EE'' �f EF !F �F EE EE EF # Ef Et �F * EF iF iF EF EF # �F �F iF EF EF !F Gov: Code Sec. 910.2 provides: g "The claim must be signed by the claimant SEND NOTICES„TO:.%M(Attgrney,�)y; or same er on on his b half.” Name and Address of:Abtol ney. ,(Claimant's Signature 25/ 6 rOOv-� ddess) Telephone No. Telephone No. 4� I VEt EE EE EF EE EE EE EE $ 3F� �F EE Ef �F N O T I C E 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, city or,district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand- ($1,000) ,' or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. VALLEJO AUTO DETAIL 510 Pennsylvania Street VALLEJO, CALIFORNIA 94591 (707) 643-8335 NAME D TE OF DE to ADDRESS TE PROMISED. Nn 0a JO AME/LOC TION-4 07DD7 BY DEffS TIO O WORIy DA WORK CONTRACT EXTRA QTY. DESCRIPTION PRICE AMOUNT ---- --------------------- -fe w� =C��� - K 1 1_ - —_—---_--..-----.--I_--- I �1 I LABOR HOURS RATE AMOUNT TOTAL MATERIALS TOTALLABOR `- WORK ORDERED BY, TOTAL LABOR TAX DATECOMPLETED "Than 'You TOPL leo dOD �[r':]rIOO �d � 0'5 6'9. SIG RE(I dere fool, sstlslactory com e n of the above tleecAbetl work.) PRODUCT 621 0 VALLEJO AUTO DETAIL 510 Pennsylvania Street VALLEJO, CALIFORNIA 94591 (707) 643.8335 NAMED TEO DE i ADDRESS - P /�RS P O IS JOB NA /LO TON WCONTRACT Y R DESCRIP I F RK RK EXTRA OTY.— — DESCRIPTION PRICE AMOUNT LABOR HO,, RATE AMOUNT T LMATERIALS e TOTALLABOR i WORK ORDERED BY TOTAL LABOR TAX DATE COMPLETED lank GY9p TOTAL 0 O, r - 0570 SI ATURE here no ledge the setisf ry completion of the hove described work.) PRODUCT621 a :a°6 7-- U nrb7�rd� C> s�o:) o,�aae �d a