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Home My WebLink AboutMINUTES - 08132002 - C38 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTACOUNTY BOARD ACTION: AU 13, 2402 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given E!41HPursuant to Government Code Section 913 and UL 2 4 72 �D� 915.4. Please note all "Warnings". AMOUNT: $2,219.36 COUNTY COUNSEL CLAIMANT: Suzanne Craig MARTINEZ CALIF ATTORNEY: DATE RECEIVED: July 24, 2002 ADDRESS: 443 Lincoln Ave BY DELIVERY TO CLERK ON: July 24. 2002 Alameda, CA 94501 BY MAIL POSTMARKED: July 22. 2002. I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS. ler s € 4 ifs Dated: July 24, 2002 By: Deputy i 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). p { Cher: _ 14,f "�foCes _` 1&5' o7- f6 17 d, ,E ay. A ',e Dated: ` y` J 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 1 ��f° �:.�.,� � .�, L,�� ^"'f•n�. �^ t=, JOHN SWEETEN, CLERK, By ' € r z s >,� _ , Deputy Clerk 4 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. *For Additional Warning See Reverse Side of This Notice. 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 �:.; r i s ' j ., JOHN SWEETEN, CLERK.By' - .; r Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA 0 UN'TY 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 bine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the C'Ounty, the nar,-,e 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 Against t<1Ze County of Contra Costa ) or ) JUL 2 4 2002 PODi3 riot) CLERK BOAR of SUPERVISORS Fill in t� ) CONTriA COST CO, The undersigned claimant hereby makes Claimagainst the County of Contra Costa or the above-named District in the sum of $ ,' '"'� and in support of this claim represents as follows: 7-0-02- 1. 2-- 1. Wien did the doge or injury occ=? (Give exact date and hour) 2. Where did the damage or injury occur? (Include City and County) 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 the injury caused. or.emplo � c� y � �� Vie.? �jC��.�- �'�' �c` (over) wnat are the names of county or district officers, servants or employees causing the damage or injury? -. k; What dawge or injuries do you claim resulted? Give full extent of injuries or damages a claimed. Attach two estimates for auto damage. 6C,_F_ t •7TC-kA :} f -ns> kyc,61g 7. How was the amount claimed above computed? (Include the estimated, amount of any prospective in)uz y or damage.) Y'�� t��_ � d �� t �. )kJOAJ fC 8. Names and addresses of witnesses, doctors and hospitals. Lam, (�T�,j C,`>S C, Cryt�'��i�� c> ? ha,*—, J 9. List the expenditures you made on account of this accident or injury: DATE iT�I _ .f -Cce e , Gov. Code Sec. 91M provides; "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) 2erson on his behalf." Name and Address of Attorney � Claimant's Signat Telephone No. Telephone No. IL rt - f it' W * W N O T I C E Section 72 of the Penal Code provides.- "Every rovides."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 sane 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 ($1t000), 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. 443 Lincoln Ave. Alameda, CA 945031 July 08, 2002 Ironho€ se Sanitation District, 450 Walnut Meadows Drive P.O. BOX flims Oakley, California 94561 Gentleman: On June 15, 2002 at approximately I2.45pm, I was traveling North on Jersey Island Kavas Rd. toward Webb '17rack.' Bradford Island Ferry landing. At approXirnately 1.1 miles from the beginning of the levee road I shack a large'section of asphalt that protruded eight inches upward. I drove over a damaged section of road that contained a large piece of protruding asphalt. The result was a hard blow to the underside e of ray 1998 V90 Volvo Station 'Fagot.. I contacted i ray husband who care out and took i tures of the road, which I have enclosed. (see photos I and ) You have been doing work on this road by widening it. You have no construction signs, or hazard signs on this public road. You hauled your trucks over this road and after the work was completed or suspended you left the road surface in a broken condition that can easily caws damage to ordinary cars or vans. I have listed costs that I have already incurred and or paid for out of my pocket, itemization of bass: Non payment by insurance $ 1,341.96 Loss of Pay 20hrs X $33.77 hr 40 5.24 Loss of On Call Pay 14hrs % S13.00 186.20 Photo Copying/Photo reprints 20.00 Total as of 7/11/02 1,953.40 My car is due, to go back in for further repair the week of July 22, 2002, addendum will follow. cc, Clerk of the Boars of Supervisors County Administration Building Room 106 651 Pine, Street Martinez, CA 94553 Suzann Hamilton Craig t All- J �� hmi F u j�W it>; h OTARGET 07/17/02 6:1b PM RETURN BEFORE 10/15/02 4, GIVING A GIFT? Include a sift receipt' 3 � A rece;Pt dated within 90 days is required for all returns a exchanges, `J 001 056090200 1 HOUR PHOTO T 5.99 r: 002 056090200 1 HOUR PHOTO T 5.99 }: SUBTOTAL 11 .98 T= 8.250% TAX 99 TOTAL 12 97 CASH PAYMENT i3.Ofl CHANGE 03 RECEIPT ID# 2-2198-1208-0069-2738-6 VCD# 11006345 CSH# 952 2 ITEMS . Save ALL Receipts `.' s Give Gift Receipts & GiftCards Ask about Receipt Lookup Y .;ate:• .. ` ,� ... <� ;.�n:..?Ss.,<,y3 k{; v.� y 4} y< xav �s ,( y' y EI r-10 ,� .._._.. y T 0 > Z; rn {%v _ > rn h 00 O L7 L7 NIJ 3 1A -8 Zi IWO ..1 W>Z- 0 rn z-n �< u'a � 1*-1 3 I F—I F-1 '� � �' x� r= to tn-4 CA r Lei .. El r ti Viz+ CL ei x r jiJ t it Y to i to ! y y3Cr�y °° no r z a wo t �y t 1. 1' 5 a P I <c 60 CL CIO I( 'e .�"� ? 11 ^`.."- �Y � __!F✓� f � � 1� �5` f„ � �.{y ,..y � CJjw,�1�, w++ o i ! ! i✓"' � f �is w a! ! ! 1{ t fi `+-.... ! ♦ � 111 � 7 i ...��' .` Q i t \ PROM : LIBERTY MUTUAL P?X NO. : 9690324 Jan. 28 2002 '2:09PM P2 1998 VOLVO =V90 STD 4 DR WAGON 06-20-02 10:44 AM CLAIM # 002439926-01 L0 1155 —1 S1. 06-26-02 7 :00 AM E ASSORTED WASHERS & BCL REPLACE OEM 5. 00* S;, I SB X—MEMBER STAYS SUBLET 45. 00* -4.20 S1, >>NZ i -Mk BSR DID NOT COME WITH ATTACHED STAYS, ?-A1? TO R&I CLD STAYS. I PULL STEERING CCLUNM REPAIR Si 1.0*2k >>H.AD TO PULL OLD CO LUNM BACK INTO POSSITION FOR R&R, 1.6 ITEMS MC MESSAGE 01 CALL DEALER FOR EXACT PARI 4 / PRICE FINAL CALCULATIONS & ENTRIES PARTS GROSS PARTS $ 2,246. 066 OTHER PARTS $ 8.00 PAINT MATERIAL AD,TJSTMENTS DISCOUNT MARKUP PARTS TOTAL $ 2, 254 .66 TAX ON PARTS & MATERIAL 8.250% $ 186.01. LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL $ 60. 00 2-MECH/ELHC $ 95. 00 7. 9 4.5 $ 111?8. 00 3-FRAME $ 60.00 4-REFINISH. $ 60 .00 5-PAINT $ 25.00 LABOR TOTAL $ 1, 178 .00 TAX ON LABOR a SUBLET RZI ,AJRS $ 119.00 TOWING STORAGE GROSS TOTAL $ 3, 737 . 67 LESS: DEDUCTIBLE $ 1, 000.00- LESS: BETTERMENT & TAX $ 34t.:9:6- NET TOTAL $ 2, 395.71 LESS: PREVIOUS NET TOTAL $ / , 962.97�r y NET SUPPLEMENT 'TOTAL $ 432.74 'U"NRELATED PRIOR DAMAGE OP GIBE DESCRIPTION MFR.PART NO. PRICE HOURS R ----- ----- - UP 0239 PNL,REAR DOOR. OUTER LT UNRELATED PRIOR 1 .00* 1 UP 0566 COVER, REAR StNPER UNRELATED PRIOR 1.00* 1 UP ENGINE OIL LEAK UNRELATED PRIC7R 1.00* 1 -2- FRO!" z L I'DERTY MUTUi L FAX NO. 9890324 Tun. 28 2002 12:09PMf .P 1 E'RELIMINARY INSPECTIC7N REPORT CU LOG NO 115_5 06-20-02 10,:44 AM SUPPLEMENT 51 06-26-02 7:00 AM CLAIM # 002439926-01 POLICY # PD631 OWNER NAME CRAIG',SUZANNE: APPRAISER NAME STEVEN ROSE VEHICLE 1998 VOLVO V90 STD 4 DR WAGON 6CYL GASOLINE 2.9 OPTIONS TWO-STAGE - EXTERIOR SURFACES TWO?-STAGE - INTERIOR SURFACES KEYLESS ENTRY SYSTEM LUGGAGE RACE{ REMARKS: r. COPY OF EST. WAS MAILED TO OWNER, CP_. SILL OF RIGHTS PROVIDED TO CONSUMER. WHERE SEEN SEE ABOVE,WHEN 6-27-02 By S.ROSE,MILEAGE SAIME ADDITIONAL RENTAL DAYS NEEDED TO COMPLETE SUPP. (2) EST. WAS FAXED TO SHOP ON 6-28-02 EST, WAS FAKED TO SHOP ON 6-28-02 BETTERMENT TAKEN DUE TO 91, 000 MILEAGE ON CAR. OP CODES: * = USER—ENTERED VALUE E = REPLACE OEM TVG REPLACE NAGS EC = QUALITY REPL. PART UC = RECONDITIONED PRT `M = REMAN/RESUILT PRT EU = LIKE KIND & QUALITY EP = QUALITY RE?L. PART PC = PXN RECONDITIONED FM = PXN FF"MAN/REBU11,17 TE w PARTL REPL PRICE ET = PARTL R8FL LABOR IT = PARTIAL REPAIR I = REPAIR L Rn-FINISH BR = BLEND REFINISH TT = TWO-TONE CG = CHIPGUARD SB - SUBLET N w ADDITIONAL LABOR RI = R&I ASSEMBLY P = CHECK AA = APPEAR ALLOWANCE RP - RELATED PRIOR UP = UNRELATED PRIOR OP GDE MC ?ESCRIPTION MFR.PART NO. PRICE AJ% By HOURS R 0655 C:RSMBR, FRONT SUSP 91408526 _ _ 420.C0 —_— —_ -- .7 2 E 0789 S3-IIELD,ENGINE I`OWER 94477270 91. co INC 2 E 04 MUNTENGTNE LT 3536226 94.n0 r 0.8 2 E 03785 MOUNT ENGINE62 � 94.00 0.6 2 SETTE E # ? 7 £3I SEAR ASSY,STEE I:stG 50:0.3 0:8 514 . 00* 81 INC 2 E 0710 'C'OLUMN ASSEMBLY,STRG 9157.1360 1 , 015.00 7. 71�*C N 0710 STEERING COLIJW O/H ADDITIONAL LABOR 81 3.5 2 RI 0663 SEZEL, INSTRU ENT PN RT R&I ASSEMBLY S1 0.2 2* RI 0726 IO,AM/FM W/CASSETT R&I ASSEMBLY 51 0.6 2* SB 51RONT WHEvL ALIGN SUBLET 65. 00* 1 EC P/STEERING FLUID QUALITY REPL. PAR 8. 00* 1 E ASSORTED NUTS & BOLTS REPLACE OEM 10.00* 1 E C O Lt.IMN SOOT REPLACE CSEM 3. 66* —1— { FR.G'! L Y EEPTY ice'T UAL FAX NC. : 8890324 Jun. 28 2002 12:10PM -P4 a .t PRELIMINARY SU?PLF.MEN''i RECONCILIATION CD LOG NO 1155 -1 SUPPLEMENT SI C1.P11' I # 002439926-01 FOLICY # PD631 OWNER CRAIG, SUZANNE APPRAISER STEVEN ROSE VEHICLE 1998 VOLVO V90 STD 4 DR WAGON ADDED LINES CDE PART OPERATION PRICE AJ% B% LABOR. RATE 0710 Steering Column C/H Additional Labor S1 3.5 ME 0726 Radio,AM/FM W/Cassette R&I Assembly $1 0.6 ME* 0863 Bexei, Instrument Pn1 RT R&I Assembly S1 0.2 MEQ' Steering Column Boot Replace OEM 81 3. 66* !NC* ME* Assorted washers & bolts Replace: OEM S1 5.00* X--Member Stays Sublet S1 45. 00* +20 PDLL STEERING C©LUNM Repair S1 1.0* ME* CHANGED LINES � . GDE PART OPERATION PRICE AJ% St1LABOR RATE 0707 Gear Assy,Steering Replace OEM S1 514.00* 4 J INC ME 484 .00 415V INC ME 0710 Column Assembly, Strg Replace OEM S1 1015.00 INC ME 1015. 00 1.6 ME C UL 'L ON>CFANGES FROM TO DIFFERENCE GROSS PARTS 2,208 .00 2,246,66 38. 66+ TAX ON PARTS & MATERIAL 8.250% 182. 82 8.250 186.01 3.19+ ME W MECH/ELEC 95. 00 826. 50 95.00 1, 178.00 351.50+ SUBLET REPAIRS 65. 00 119.00 54.00+ EETTER M & TAX 327.35- 341. 96- 14 6 tlmm� Supp 1 NET TOTAL, 432 74t i 11 SUMMARY NET TOTAL DATE TIME APPRAISER crag Est 1, 962.57 06- 20-02 10:44 AM STEVEN ROSE Supp 1 432.74 06-26-02 7000 AM STEVEN ROSE _1, .. --, Vw f ,77 f Wit,, f f� i pi� f } t _ ' �Q� t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Aue 13,2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 91H7111) 915.4. Please note all "Warnings". AMOUNT: $150,500 lUL 2 4 2002 COUNTY COUNSEL CLAIMANT: Maria Enrique MARTINEZ CALIF, ATTORNEY: Philip Nchekwube DATE RECEIVED: July 23,2002 ADDRESS: 2006 A St#212 BY DELIVERY TO CLERK ON: July 23, 2002 Antioch, CA 94509 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS ;Clr € . f Dated: July 24,2002 By: Deputy ' t % II. FROM: County Counsel TO: Clerk of the Board of Supervisors (t,,' his 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: -.n+ i t �°�r- o o i 5� _ s 'I sy 4_ yy z jr LL 9 t 4 Dated: '' By: ;' rt 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. ; ,sty Dated: JOHN SWEETEN, CLERK, By t ' `, . ; f � , Deputy Clerk t 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. *For Additional Warning See Reverse Side of This Notice. 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 UIQ JOHN SWEETEN, CLERK By s� � tt 't :%� Deputy Clerk :)J—N 21-2002 11:07 CCC RISK MANRG ENT 925 335 1421 x'.02 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA CX'MY MMMONS TO CLADiW 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 acme an or after January 1., 1988, must be presented not later-than._sig months after the accrual of the cause of action. Claims relating; to any other cau-s-6 of action must be presented not later than one year atter the accrual of the cause of action. (Gov't. Cade §911.2.) >6. Claims must be filed with the Merk of the Hoard or Supervisors at its .office in Rotor 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Hoard of Supervisors, rather thAn the County, the rye of the District should be filled in. D. If the claim is against more than one public entity, separate claims must bee filed against each public entity. E. ' Fraud. See penalty for fraudulent claims, Penal, Code Sec. 72 at the end of tris form. ' � � * � a �• � e a e e a * � rt � � � � a � s tx �r �t � rt a et a � a � a � � � � � � � � � RE: Claim 9y } Reserved for Clerk's filing sump RECEIVED Against the cit Contra Costaor � JUL j jL � � �Qtl2 - �+�-• "sA3 tr"iCt CLERK ABOARD OF SUPERVISORS ` 2n name CONTRA COSTA Co, The undersigned claimant hereby maid clams against the County of Contra Costa or the above"-rid District in the s= of &Wj;0r and in support of this cit represents,as follows: Ylr.i..w�w+ilMwN.iM YIM 1. When did the damage or injury occur? (Give exact date and hour) M. � . ., v � .� : rte , s 2. Where dial the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) V,- �' � � qi�C 4`� 4A� � CAi iE {� !�� y� act ,��y (y, j y{y� ]qyy }q�i y�y+'.��y�q}�/� �7y,�}ay y#p 1p' �•'`/��,}.y1..__. _ 'T. �Or Pa ti�1 act o ,son on their �t o 4t4+e nt-y or �.tisL ict officers, s, .s erv=ts Car.employees caused, the.injury or, Vie? t� SUN-21�2�02 11:08 CCC RISK MANAGMENT 925 335 1421 P.03 wnat are the names of county or district officers', servants ar employees causing the damage or injury? c?- 6. 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 am mt claimed above computed? (Include the estimated amount of any prospective injury or damage.) y }� r ^cR vtr,_ '�~xc.''.�� a�% � Asx 6 ��L'".�;1 .�°"� �q '-•1 i� . !dames and addresses of witnesses, doctors and hospitals. S ms's "e iz`s•d ML a� r' g. List the expenditures you made on account of this accident or injurry% DATE ITEM -r- ---- fy\'` 41. - A . � � � � �t � �tt� � .� � � * r� �t �t �t � •� �.e �t � �t � e � � � �t � �t �t � e �e �t � � r�,� � Gov. Code Sec. 910:2 provides: fmThe claim must be signed by the claimant SEND NOTICES TO: (Attarne or by some Rersonon his-behalf." Name and Address of Attorney s Signature) UN SQj Address ' 1 e_ 4 Li 1621 Telephone No. _ Telephone No. * asap 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 beard or ,officer, t autrized to allow or pay the same if .genuine, any false or fraudulent claim, bill.., account, voucher, or writing, is punishable either by imprisoriment in the county jail.-for a period of not more than we-year, by a, fine of not exceeding one thousand ($19 000), or by both sushi itvOrLionment and fine i' or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10i0009 or by. Moth such imprisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Auz 13,2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action, All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 799 915.4. Please note all"Warnings". EllAMOUNT: Unknown �I U 15 2002 CLAIMANT: Heather Waters COUNTY COUNSELMARTIN Z CALIF ATTORNEY: Horace Siino DATE RECEIVED: July 12: 2002 ADDRESS: 7960 Brentwood Blvd BY DELIVERY TO CLERK ON: July_1.2_,2002 Brentwood, CA 94513 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETM, , Dated: July 15 2002 By: Deputy '' a `" II. FROM: County Counsel TO: Clerk of the Board of Supervisors (,KThis 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: 1 14-h r `2±�r Dated: `� By: Deputy County Counsel 111. 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: # !f M1"'� 1.. r..4.i F t:'.:f },.,,r"" ��.�,x.4� . ; ., ,_, _A JOHN SWEETEN,CLERK., $y f �,��.. S �---- ,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. *For Additional Warning See Reverse Side of This Notice. 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. . x % ✓ f f s. K By Deputy Clerk SWEETEN, CLERDated: TO: BOARD OF SUPERVISORS, CONTRA COSTA COUNTY EASTERN CONTRA COSTA TRANSIT AUTHORITY; TRI-DELTA TRANSIT; and LAIDLAWTRANSI7 i 801 Wilbur Avenue, Antioch, CA CLAIM PRESENTED BY: HEATHER WATERS ' :,"A Cf 1. Claimant's address : Ms. Heather Waters 4960 Kushner Way Antioch, CA 94509 2. (Notices concerning the claim should be sent to: SIINO ANIS KELLNER 7960 Brentwood Boulevard Brentwood, CA 84513 (925}513-0119 FAX: (925)513-0145 3. Claim involves an accident between a Tri Delta bus and pedestrian on January 18, 2002. 4. On January 18, 2002, a Tri Delta Transitbus operated by Roy Clark Cole, in a northerly direction along Brentwood Boulevard, in the City of Brentwood, County of Contra Costa. At said time and place, claimant was in a crosswalk traveling west across Brentwood Boulevard and was struck by the Tri Delta Transit bus operated by Roy Clark Cole. 5. Claimant's injuries are as follows: Injuries to left arm and shoulder, bruising, and injury to her body. 6. The name of the public employee causing the claimant's injuries is: Roy Clark Cole. 7. The claim as of this date is in an amount that would place it within the jurisdiction of the Superior Court(unlimited). The claim is based on the injuries, damages, and/or loss in an amount to be proven at a later time. DATED: July 11, 2002 Bye. HORACE J. SIINO Attorney for Claimant, HEATHER WATERS CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNT' BOARD ACTION: Aug 13.2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and . A, 915.4. Please note all "Warnings". R!UL � T 1 , i AMOUNT: Unknown ' CLAIMANT: Jacob Elmore COUNTY COUNSEL NlAl TINEZ CALtF ATTORNEY: Horace Siino DATE RECEIVED: July 12, 2002 ADDRESS: 7960 Brentwood Blvd BY DELIVERY TO CLERK ON: _ July 12, 2002 Brentwood, CA 94513 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ; JOHN SWE , leek - , Dated: __July 15. 2002 By: Deputy ` (4 II. FROM: County Counsel TO: Clerk of the Board of Supervisors (;A�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.$). { } 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). y r a Dated: 17 7-6 2-- 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. r-, Dated: 'A_,s Jr� S' " '_ JOHN SWEETEN, CLERK, By �f rev . , DeputyClerk 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. *For Additional Warning See Reverse Side of This Notice. 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. � 9 Dated:! 14 ;:,; x" , . -':) JOHN SWEETEN, CLERK By f� - ' ; '%-.- Deputy Clerk TO. BOARD OF SUPERVISORS, CONTRA COSTA COUNTY EASTERN CONTRA COSTA TRANSIT AUTHORITY; 7fR1TRI-DELTA TRANSIT; and UL 1. 2 Zai? t LAIDLAW TRANSIT 8011 Wilbur Avenue, Antioch, CA C '.:RACOS";af CLAIM PRESENTED BY: JACOB ELMORE, a minor, born 5/25/95, by and through his Guardian ad Litem, DIANNE ELMORE 1. Claimant's address : Ms. Dianne Elmore, Guardian ad Litem 30 Broderick Drive, #8 Brentwood, CA 94513 2. Notices concerning the claim should be sent to: SIINO AND KELLNER 7960 Brentwood Boulevard Brentwood, CA 94513 (925)513-0111 FAX: (925)513-0145 3. Claim involves an accident between a Tri Delta bus and pedestrian on January 18, 2002. 4. On January 18, 2002, a Tri Delta Transit bus operated by Roy Clark Cole, in a northerly direction along Brentwood Boulevard, in the City of Brentwood, County of Contra Costa. At said time and place, claimant was in a crosswalk traveling west across Brentwood Boulevard and was struck by the Tri Delta Transit bus operated by Roy Clark Cole. 5. Claimant's injuries are as follows: Lacerations to the head and abrasions, bruising, and injury to the body. 6. The name of the public employee causing the claimant's injuries is: Roy Clark Cole. 7. The claim as of this date is in an amount that would place it within the jurisdiction of the Superior Court(unlimited). The claim is based on the injuries, damages, and/or loss in an amount to be proven at a later time. DATED: July 11, 2002 HORACE J. SIINO Attorney for Claimant, JACOB ELMORE, by and Through his Guardian ad Litem, Dianne Elmore CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Aup 13. 2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given r Pursuant to Government Code Section 913 and R!UL � � 915.4. Please note all "Warnings". AMOUNT: Unknown 15 200Z COUNTY COUNSEL CLAIMANT: James Elmore MARTINEZ CALIF ATTORNEY: Horace Siino DATE RECEIVED: July_12, 2.002 ADDRESS: 7960 Brentwood Blvd BY DELIVERY TO CLERK.ON: July 12.2002 Brentwood, CA 94513 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN { SWEET_Ed Dated: _ July 15,2002 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( x, his 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). ? (i.,)'"-Other: /4- d` 4 h r f e— YC '/' ry O re— Dated: ByCw ? - ; de-—t.. 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: ='f� iL '�; � - JOHN SWEETEN, CLERK, By' �� s ' ��i'' _ � �'' Deputy Clerk P Y 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. *For Additional Warning See Reverse Side of This Notice. 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: T ,.. JOHN SWEETEN, CLERK By,; r . , ;' , < y: Deputy Clerk TO: BOARD OF SUPERVISORS, CONTRA COSTA COUNTY r7F Tr l ( # L � 1n EASTERN CONTRA COSTA TRANSIT AUTHORITY, f `'� TRI-DELTA TRANSIT, and i s ;° l LAICILAIN TRANSIT (30-M c�spa 0, 801 Wilbur Avenue, Antioch, CA CLAIM PRESENTED BY: JAMES ELMORE, a miner, born 11/15/93, by and through his Guardian ad Litem, DIANNE ELMORE 1. Claimant's address : Ms. Dianne Elmore, Guardian ad Litem 30 Broderick Drive, #8 Brentwood, CA 94513 2. Notices concerning the claim should be sent to: SIINO AND KELLNER 7960 Brentwood Boulevard Brentwood, CA 94513 (925)513-0111 FAX: (925)513-0145 3. Claim involves an accident between a Tri Delta bus and pedestrian on January 18, 2002. 4. On January 18, 2002, a Tri Delta Transit bus operated by Roy Clark Cole, in a northerly direction along Brentwood Boulevard, in the City of Brentwood, County of Contra Costa. At said time and place, claimant was in a crosswalk traveling west across Brentwood Boulevard and was struck by the Tri Delta Transit bus operated by Roy Clark Cole. 5. Claimant's injuries are as follows: Abrasions about the face and chin, and bruising and injuries to the body. 6. The name of the public employee causing the claimant's injuries is: Roy Clark Cole. 7. The claim as of this date is in an amount that would place it within the jurisdiction of the Superior Court(unlimited). The claim is based on the injuries, damages, and/or loss in an amount to be proven at a later time. DATED: July 11, 2002 By---;�a ,_ HORACE J. SIINO Attorney for Claimant, JAMES ELMORE, by and Through his Guardian ad Litem, Dianne Elmore CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: An 13,2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given: Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $484.00 UL .12 ell{ COUNTY COUNSEL CLAIMANT: Weldon Wiggins JR. MARTINEZ GAUP ATTORNEY: DATE RECEIVED: July 12,_2002 ADDRESS: 901 Court St BY DELIVERY TO CLERK.ON: July 12. 2002 Martinez, CA 94553 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, y JOHN SWV Dated: July 12 2002 By: Deputy 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 Beard 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: a 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: 0j`.' izt JOHN SWEETEN, CLERK, By JJ .v i# ', r `' , Deputy Clerk 4 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. *For Additional Warning See Reverse Side of This Notice. 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 .,;}`1{ " Lt` - JOHN SWEETEN, CI ERIC By r ' ` 't °��s Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS' UCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing craps and which accrue on or before December 31, 1987, must be presented not later than the I Ofl h 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. (Gov't 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 Against the County of Contra.Costa d ,.. ) RECEIVED f ) 1 2 2002 District) JUL (Fill in name) f ) CLERK BOARD 0,S:J3�RRViSC3 co TRA COST-41 CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sun of'$, y ,`,..and in support of this claim represents as follows: I. When did the damage or injury occur?(Give,exact date and hour) ..... ^ .. ;: 0.v..... 2. Where did the damage or injury occur?qnclude city and county) A. J, 3 3. Hove did the damage or injury occur? (Give full details,use extra paper if required) r r t k 4. What particular act or omission on thepart of county or district officers, servants, or employees caused the injury or,damage?s t F 5. What are the names of county or district office s, servants, or employees causing the damage sir injury? _ t> t a 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 1 < 7. How was the amount claimed above computed? (Include the estimated amount of any prospective`injury or k y damage.) 8. Names and-addresses 6f witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT' s J } Gov. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornex Name and Address of Attorney ) : (Claimant's ' ature} } 0 } (Address) } Telephone No. _ )Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the 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. / S t r COSTA C 'Y IOTENTIOFACILITY ( )1N ATE REQ EST FOR ILM AT40N ( )MEDICAL REQUEST To: i Bkg# From: looe> Housing Assignment: Date:: ' Other ,Check One: ( )Request ( }Grl Vance ( )Appeal ( t Request: --�- ;t f t f RoutedTo: ( ) APPROVED ( )DENIED-(state reason) AN : ER: ... t DBY: ate hite:To Booking Pink:Kept by Inmate Yellow.Reply to inmate DET 024:FRM 1/2/91 - D T COUNTY ZNTION FACILITY INMATE REQUEST FOR INFORMATION { )MEDICAL REQUEST To: From:.. cfl�J HouS9rrg Assignment: Date:�1 ,• Ch k ne. { ) Request { ) Grievance ,rAl at { )Other Req y t a y,; s r H f 1Aj IF 6/ + QYeAtL'�av- Do Ran& Routed To: / { )APPROVED { ) DEMED-{state reason} Date:��--.----� i By: LVt*e:To Booking Pink:Kept by Inmate Yei1T:Reply to inmate r DET 024:FRM 112/91 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: An 13,2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the r Board of Supervisors. (Paragraph IV below), given ` Pursuant to Government Code Section 913 and JUL, 19 2112 915.4. Please note all "Warnings". AMOUNT: $8,522 COUNTY COUNSEL MARTINEZ CALIF CLAIMANT: Newtron Inc, C/O Fara ATTORNEY: DATE RECEIVED: July 18, 2002 ADDRESS: 2525 Cherry Avenue#350 BY DELIVERY TO CLERK.ON: July 18,2002 Signal ill, CA 90755 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE. Dated: July 19,2002 By: Deputy, ' ~ II. FROM: County Counsel TO: Clerk of the Board of Supervisors ` { his 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: C 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:`` Ih. ; £ y JOHN SWEETEN, CLERK., By :'' '` Deputy Clerk WARNING (Gov. code section 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. *For Additional Warning See Reverse Side of This Notice. 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: 1 € ;, ,, JOHN SWEETEN, CLERK By ;: #i �r` xI - Deputy Clerk Phon Tools a Cq •' Phone: 5102227732 Fax: 5102223984 Message Ms. Bailey, Here is the claim form regarding the Newtron truck damage. The truck was operated by Mr. Doug Nelson at the time of the accident. He did not suffer any personal injuries. The supporting invoices will be my next fax to you. Please have the check, if approved, payable to Newtron, Inc. and sent to 1=ARA, 2525 Cherry Avenue, Suite 350, Signal Hill, CA 903755 Thank You, Stan Hazlak Phone: (925) 383-2678 From: Stan Hlak To: Penny Bailey Contra Costa County Risk Mgmt. Page(s): 3 0"1/02/1996 21:37 5102223984 3 1 1 > 1 i j 1 Chief to: MM CF SAMM=pe MEM CMTA =Wn I A. Claims raiitXnS to a&"*$ of action rw death or for tftjury to pw-30n or to Parr Genal PAY car &MwtnB crops end ►hath aeft-%e an or befors December 31, 1987, + Must be predated tart later freers the 100th day at'w Un mil of the muse of actiaa. MAdm r*lattft to c aims of actica fere dnth or rccr Sr;,Wry to pswam ; or to Pw'wml WvWty w gmwing arqw Nod *lob am an or attar Jamesry 1, 19", =Mt be ➢MM&Ad Mt lattr th'tCi six Mohan ArtV (tie accrual, of the name ` Of *ctlm- Claim re1atI4 to anY other >mum of MtUn mesh be pmswted not later than out year stow tto atsaMsaj or ft go" at SGUM. (Cant. code 5911.2.) B. MAIN eemlt be lilad leith the Clift Of the 11- CC bJPWVlftM at ate cfficsd 1A <. Rom U6. Csmmty►AftiatLetratIon Buildi4, 651 Pine Street, WptLraz, d 94553• C. If Clain IN WI,Ut s diatriat Srnrned by the Hoerr of 3uparviaws, rather thLn y; the C mty, the new of the p sEriat shenld be fillmd In. D- If the Claim is aaainrrt 9w Ulan one public entity, sipNrate claim =At be ; +: filed mL sst each public entity. B.' Fraud. Sae P@nkl,tl fes` fraudulent alALM. penal,CAdr Sect. 72 at the end of this eeDeDeriaaterceeererr • errralres # eeeaerrsera • r AE: Claim $Y T ) MrA EJUL gL . j `. Y CLERK BOARD OF SUPERVISORS CONTRA COSTA CO, ; . The w4l"1021d etlatmetect hare" =4M clain sgainet the Cbwnty of Contra Costa or t w a District in V110 Base of gsz-- and in stt vdet of th13 tetaim mp+u Cts as i allaw e i z. Yheges cid the or ismer? vveuf'! (Give met datm end hour) � 2. Mm did tbu dmosp or ies$vy eeaasr't Ctm3.tsde titer ted aqueet,Y) 744T'Bea4weVrlo a 0 SAW 944LO *Jenvc '40411 iLtL40,601 flitltltull►�y �lLlittaO+Jt�, !: 3. (torr did the demap cr injury occur? (Mve full dotatui rase extra paper If ' Pmgixtt'�d) -b-ovsk"Pw- -Jo's IVa ►,4pAe F*Aa,'MG t4rfr Le.lrF!r'rvA* 4V%-V) ✓l4rr 11440 da R1Gk�iw{h�i�i �{1Q14ri►11r►}. Si� tM`IC 1U1L+�fib fi3O.4r •n'R's SON f"" 0,00rJV6 ,tAc++Z+o'�#`i-r*V' +Y pC�jgClrt2T 3 L I SM1 ®rwfr4i..et" -b :, A D� Epy T1QpF►G. V.!lilt.l..L Ctlt.i 16 � *at owuoa w mot ar onimmtaa an On pert of=Mty ON dixtr'tat officers, erar"rmti ar.44dayaei cause;-he i0wy tr dinwed plcC kenrsab P41-%G r RLw'$A #jbL'b ff"b 14#,v `'ksfV#dJLT-.., ISAVRI MA-b Aio L*-1L-Av3a --5t_ p%pQ C»SSfjF -Nau wrm 11t yWAttw mCr (POP, w ctlaell� ! ' n��^�00A mn V71 r)99?'AQAd 07/17/2002 12: 40 PM Paqe 1 01/02/1996 21,'37 510222398441 t$ a= Y t13 t S. *At am tno itafts of CoMty or district aft'iom, is1iN'333MS or oyees CRUSIPA the dam e& or injury? 'NSC cis 744r 'M vS e 6. *at dwoo or Injuries d0 you *IAL* risnitod7 tilt" f41 oxteat of inion or r dsmrt i" ate. Attt:u h two asttftt*s for wto 4000. t`aa # a►a �rf1 .� eQ ,t .r� y ., k" 'vAr , ria gr .ura- iF +rr, CC= +. �rl�t�csrw.sr rtstL+ ht' cilEb 4 �a Ww wta tAt ma mt bj.0.imd above anuted't (Unl3ft the eatimutid 6Esmt of wy pmspwtl" inj%xy or amp.) ►� A t i#9 ii. R !s C" t►a!i+�ti1 I c L G #.Y381 LEPg �1ML HEI 1# h � � tt ►1 14L i I rt 9. Naoei stsd adtiit cUm s of sritxss#"s, 400tOm #mid 20ipMU# Y o�► 9. List thelai�€sdit ryca mMe, an %*wmtt at tt& SW6mt or iftlurrt PM i JJ i/tf gG $ rt4 a 0166 # # 00iil66106610.ai,00 # # 6i1iee1e160 . 0 # aILA 0 Oui. Code 3w, peov'.idimt oft clals be wv" by the c3auwt SM ICM 'TOT t tc rrr •'� Nam am` ftrsm or Ittt1 mm A41-1. tMalawls 31"U") i.4 Telcptseise tio. Trlepb 1110. q 5 3t3 7.t,'lIr 00 # • iii R * 11111 • 6i ,,^�; 10TICr Suction 72 of to ftal Cale proviftsy a+� Olvaer t3ersais %bo, with inteat to dbfr%Ws prwlestst fcr et11wAn" or for paywent to st w state botH or offloor, am* to my ate. olty ap district board ar Offices, autbmixed to s3.337ts at My the SIits if aw falm or fr-&Aent x clslm, bill, Bra t. t+atlC'ltw, it sritU%a U #M"r by imrioori =st in � i'er um JALI' pwicd of rtat OCM 6z aw,yort by tt ru* of wt exoccdl% a% ttsacrewusd ($I, ). or by bistXs wj* "jx� mW tboei or by isp lsornwt ist U the Ettte Wisp , by a ftt* Of rot mm#sdiri4 ton tmnwld dnll„AM 4410,000, Or by bans strati istp Lv*marit Am flue. vT>rw r", TO 51 02223984 07/17/2002 12. 40 PM Pace 2 Ph neTool $ xs{yPhone: 5102227732 wra s� �} Fax. 5 (q 02223904 Mess,"',.,vre Ms. Bailey, Here are the invoices, estimates and appraisal documents concerning the Newtron, Inc. claim. Stan Hazlak Phone: 925-383-2578 From: Stan Hazlak To: Penny Bailey Centra Costra County Risk Mgmt. Page(s): 17 7-17-Us;10:..2 nla;n.A. A,A. if a/ is Damage& Evaluation Appraising of Automobiles, Truoks, Heavy Equipment, Farm Machinery& Boats q f WESTERN APPkAISERS V V OF OAKLANDs�""r'g: ALAMEDA AND CONTRA COSTA �{ P.O.BOX 70278 A Counties POINTRiCHMOND,CA 94807 2525 (5101)234-0191 FAX(510)234-0192 �Date :11311200!2 Total Lass Appraisers Report our case� _ 0142-154 IN&Co. F.A. R.A !IwusrER Eddie Sakai I7/L 01/22/2W2 tnsurvd: Douglas Nelson 1 Newtron claimant CLAAWORPOUCY MBS458449 Appraiser: Eric SaMsberg NSE.. . ®;Ail:Cii 1996 FORD F-150 { Vltl{iTiv 2t TEF15N6TCAD4727 NC1NE DATE REC11, CONTACTED,. INSPECTtab CC?AN 09/29/2002 01/29/2002 09/30/2002 1/39/2002 APPROXIMATE ACV TQAIISTORAGE PER JAY DRIVABLE: APPROX.DAYS 7O REPAIR r-- 0 (D T. L 7987 t $#3.00 $ S�y.C YES: NO: EGUIPMENT_ CL)Nb1774tYPftt4�t Tt7L4SS jYP€OC L6.S5 f Of V HM.t u 00NE TRANSMt$SION: LE AINI: AM IECTRIC }} ca.usak IS RAW.FAC71 nY 4 C`0L O Aura. Q WINDOWS O * O 0 Fxc�+�vr I D "aoaErm 4 a�scc s CYL © 3 SPEED CZ LOCKS G1 GOOD O O GOOD 'I OAMAOE a n © d a CYL 4 SPEED SEATS 0 A'YERAG6 a * AVERAGE Cow. WSINEss i DIESER. O 5 SPEED 0 MIRRORS 0 0 p 0 0 POOR POOH i VANDAUSM: TOWFAC,tmr AIR GOND. Igl TILT ® cRutsE O d LE 'r1& M B($ OTHM OTHER AMIFM ST. 1@ CASS.i CD ❑ CUS,WHEELS p 9132 12132 10132 13132 � in Richmond PWR STRG IS POWER 9RK IM REAR DEFOG. (3 SIZE: , ?735175 I s-- i lL�e..itasp�t�t..��..ir��arsci's_ttc�rl�.;�#..iha.,dim.£3s�s�.B.�z�L�r..Shcs�t..i�z.Ricfrrncnd..gtrx..t�`1.t3l�IlJ�.�nci.fctrand ;I moderate right front damages which included the bumper components, grille, hood,fender, f f .�t��i►�t�,........._..........__......._,......___....._._.._.._......... _v........�_....._._.......... I were made for condition and equipment, as listed on the Total-Loss evaluation form. CPR FARA -17-Q2;10 23AM;F.A. R.A. �b5d�'s643a8 Ot 4/ 18 WESTERN APPRAISERS Vehicle Evaluation o(Oakland - —, —_ — 0102-154 Based On Local Market A Point Richmond,Ca. 04WI INS.CO, F.A.R.A. CLAIM OR POLICY Cats of Loss MBS458449 01J221211142 insured Clairmont Date Of Inspection Location oftnspectien DOUGLAS NELSON I 611=2002 JIM ROSE BODY SHOP,RICHMOND,CA. Year and Ma is Madel Oody siyle Mileage Ueenso Serial 4 1996 FOf�O F-156 DECK-UP TRUCK(LB) 94869 NONE. 2FTEF15N6TCA04727 Kelly Blue Book Values prior Dttterencas Condition G F P Description DED ADit Yue No Whlss Rated Report Base 6325. 19175. eurrpers X :ultra -8507. 1 -850. Gee C Engine 4 s is INC INC; tiaad f��L Gas t Diesel INC INC Fendam DIS D Fual Infected INC INC Doors DOE] } Cr Tta2smtssixs A M i INC INC Rockers 0 LE i Fain wheat Drive Quarters ❑C9 L`sI AtrConditiordnit INC INC Rcof DZ D � �' Power steseing INC INC Dectdid D LX D �' '°' Paver YV ndows IRear Busty DED j t Power Dow Loats Gins f" -rat stealing whom j 1001. 135. tint D D d Bed-side, Primer-spoty 450-001 `t crutsecaftl 50. 65, Trirrr DDLD 113ench-seat, Tom. ' -85.00 Am1Fm c .1cD I INC j INC mechantcat D ❑ uto Trans. (50%) I+240.00 Power seam Make Reedy O IS D ITilt 1 Cruise/Liner(100,6) +100.t}0 Custom Ttim TIRES: UE Ld� SEE SIZE* P235175R15 9132 12f32 1GV32 12M +75.04 Vdnyt Top Tu-Tona Pain Brand Total Differences C,: A&ovWhoels 7847.00Averaa Market Value S �-' wtre vow cvm € . 140.00 Condlfiott Ad'us.ment $ 11 r_ re srsuoot Recommended ACV 7987.00 i �'' i W Uther 1M 135. Deductible i Total Book Value 3 5725 � 8650 Projected Salvage 750.00 Average Book $ 7'192.50i Net Loss 7237.00 Salves Bids-Co. Bidder Bid ALVYNS AUTO:?SALVAGE JAIME f 51 D-65193161 450.00 - MAC ANDYS AUTO SALVAGE E MIKE 1 415-89.2-0993 $ 750.00 C'CRfl-hi 21102 I l Savage Maven To�Cttarae S ae�l � r ony 35.00 From Addvvence Chg PENDING Appraisers S€gneturDate 113112002 i J 7-17-02;J0:22A4n>n.A. P.A. ;11,6242648 AS n 5i 7J Page l of l Ailtd./ r w 1996 Ford 112 Ton Pick Up F160$7700 Ysur tsar is w Altlna. Araifibh at: Stage Coach Auto Sales Vallejo,CA 94590 cordWt Dennis Phone.7075624662 This Car's Details Price $7700 Mileage 83000 ExUrior White Color Interior Color Grey Body Style Truck Doors Two Door Engine 8 Cylinder L Trans. Automatic Stem AM1FM Stereo Tape Fuel Type Unknown Drives Type Unknown KIN 1FTEF16NXTLB22141 � Back to Car Dwtnffs rw.Us,Uwe*ro%Parlatourm Aua.OwW Dooms~roe,Flms a C6naaa 4akdm rm tc rtws tad aaata1.m.F.""aainbrw to Yts AU%MtOemtrt* 2 aas i"IMA m 9Qa■YMki§X JhWiQbW*.Pk*3t»M t.au[ftbl Ap"Mx tftr Ntsw k*tM.1m art ve Mir ciao, OV Wa¢tltta aaevlat,Yattat Capt"WM at%K tSsr,,�.sa&*. A PsW WOW Of txt&m utas atn 9 m>mea w. Caroti AftTtatlar twe I.L.C. p.o.rwr- P�Vjpkp L d httpJlaotsN,c.autotrader.cornlindecer/printablc jtmpl?car id=76385013&dealer id=31087'-.. 01/31/2002 7-17-02;1 A. P.A. :1$s2A•::64;�+18 # 6i 1$ Page 1 oft ut'vTrader 1999 Ford 112 Ton Pick Up$7995 r Your car is Waiting. Av lWo Ot I Aft Auto Warehouse Fremont,CA 94536 Cam Auto Warehouse Phone:510.790.1937 CommentsThis Carrs Details Anince iaYbody O A.&:it with www.sutowarohous exat'tor Price $7995 irrwerrbxyi Mileage 103294 Futures Driver Side Air&V;FuU"re Two;Air Conedtinning;ABoy 1N mW; Duni Air Bag Restraints;PwAt Door Looks;Power Mirrors;Power Exterior Color Green ' mm,Power Meering;Tat 5teeimg w l;D&w Shia Air Beg; RA Spare Tire;Air CcxrOonbW Aiby Wheals;Dual Air Bag R ft;Po+,vers)ocrLodm;Powerr rom;Pbwwvfnaaws; interior Calor Brown Powersiebring;rdi t kering Nuheet; Body Style Truck Downs Two Door Engine 8 Cylinder Gasoline Trans. 5 speed Manuel Stereo AWFM Stereo`cape Fuel Type Gasoline Drive Type Unknown k Stock No. 4289 VIN 1FTEFi5Y7TLB89481 Back to Car Dotriiezj 3t4w Irn,TI*tk6r"Vft,R*Wt 1 I*f,f",0#.kr Gewm#rjW7#44.FYIN C"Mex;l91+IkA Tooftf Pass I?W C.ORlriIbme Foci•Nr atditmi b rtG WW*dW grX0. Avid ishr""It s tM4 Nr rsw W J04 saw W kualrcnuuw.Pmw6ri r6W 10 OW Yittlr ALrtt M"R tura r O Wo mim w,Volim MIA $ruarirkrm�co,roU"M9Ktrra.4W6tburY eatirc h-A e'.=VsorCantron* A@u tgagLt_w@¢QSLr. t rano t.trw r.t r"• C http:iiaoIsve.autotrader.com/fmdacar/printable jttnpl?car id-84062620&dealer id=55589,... 01131/2002 'I-1'-02;tO:12AM;F.A. A. A. :tb62b`26J3$h8 n 7t ,g Jan 31,2002 Y X Wholesale/Retail Breakdown Kelley Blue Boob Jan-Feb 2002 1996 Ford FISO Long Bed........».................»...............................56,325/$4,175 VIN:2FTEF15N6TCA04727 V85.0 Liter............................................»...b....»»......Included Automatic..........,.....»........................ ........................Included 2 Wheel Drive.».......».»»».....»..».»..»..................»....».Included **:Equipment**« Air Conditioning..»......................»...........Included Power Steering................»...»..»»...»...........Included r Tilt Wheel................................................... 100/135 Cruise Cr►n#rnR.....»....»...»............»».... ..... 50165 AM/FM Included Bed Liner.»._.».....».........».....»...... ........... 100/135 Total Value without Mileage........................................56,575/59,510 Mileage adjustment(90,809)miles........................... <8=54> ***Total V'4'holesaleMetall Value».........»................................»...$5,725/$89660 WESTERN APPRAISERS FA iii^i►...r .inn-Feb 2002 Kegey Blue Beak KARPOWER values for California Values art subjective opinions. Kelley!Blue Book asames so re"nsibility for errors or oailssions 0 Copyright Kelley Blue Bank 2002,all rigbtx reserved 7-17-02;10:22,AI,A;P,A. P.A. ;ISSL4"2648449 ;t 8i 18 q Data: 1/31/02 04:14 PPI r' rttlnu to 10. 0101-154 Estimate Version: 0 Committed 'rofila 10:IO: CLl5TOMIZED WESTERN APPRAISERS , P.O.BOX 70275 POINT RICHMOND,Cao MW7 (510)234-0191 Fax: (SID)MU-1192 j SERVING ALAMZDA & CONTRA COSTAL COtWTIES, MARIN AND VALLZ.70 Darnwe A>neased BY: ERIC SALVI5tlERG Ccwrds`tion Cede: fair Type of Larne: Wisian Date of Lasa: 1122102 Dedactilr s: UNKNOWN Fele Number: 0102-154 Claim Number.' MBS458449 Insured. DOUGLAS NELSON Mltcbw Service: 911621 Desariptitn0 1"6 Ford Pickup F150 XL Vabide Prodwction Date: /96 Body Styts 2D Pkup$'Red 1.331 Via Drive Train: SAL Inj E Cyt ZVVD VIM: 2FTEFI5N6TCA04727 Llconsa NONE 6111-v S 90,500 Calor. WHITE i Line Entry Labor 1.1"a Item Part Type/ Dauber Labor i Item Number Type Operation Description Part Norrebw" Amount Unit � 2 AUTO 6DY OVERHAUL FRF BUMPER ASSY 1.S 2 20114+0 $DY REMOVE/RSPLACE "M DUMPER PACE DAR Remaeufactraed 182.00 r INC f 3 AUTO BOY REMOVEIREPLACE FRTADDWIDUMPERPAD LS 4 101200 ODY REMOVEIREPLACE FRTDUMPERL.ICENBE DRAOW F2TZ 17A38S A 3.0.02 INC 5 1012220 MY REMOVE/REPLACE IR4T DUMPER VALANCE PANEL ORDER FROM DEALER 46.00 INC s 101750 DDY REMOVE/REPLACI: R FKT DUMPER MOUNTING ARMC F2TZ 17752 A 27.10 INC 7 101290 DDY REMOVE/REPLACE L FRT DUMPER MOUNTING ARM F2TZ 17752 B 37.60 INC � 8 100003 ODY REMOVEIREPLACE GRILLF FSU OW AAA 114AC INC 9 101570 BUY REMOVE/RI PLACE GRILLE NAMEPLATE F97Z 9042528 CA 17.87 INC el` 10 101590 BOY REMOVE/REPLACE GRILLE STOW DEFLEC MR. F2TZ 17779 A 155.50 INC d 11 AUTO REP REFINISH UPR STONE DEFLECTOR C 1.4 12 101610 DDY REMOVE/REPLACE R GRILLE F1UXR TO DUMPER FZTZ 17A861 A 12x9 INC els 13 101650+ EDY REMOVEIREPLACE GRILLE OPENING REINFORCEMENT FM SA2D4 AC 167-0 INC i4 101910 RDY REMOV€/REPLACE R H/LAMP DOOR FM 19064 A 42.90 IHC� 1S 1014110 BOY REMOVE/REPLACE R HILAMP ASffMOLY FZTZ 1.3008 A 144.00 INC 5 16 1008" BOY REMOVE/REPLACE R PARIt1AMP AsSEMBLj FSTZ 1322 AD 72.80 Inc 17 103350 DDY REMOVE/REPLACE R MARM LAMP ASSEMBLY F2TZ ISA201 C 23.22 INC 18 101580 BOY REMOVE/REPLACE HOOD PANEL F=16612 A 400.00 10 4 !,c 19 HOODOUTSIDEpf2A P HOD UNDERSIDE sec ep C 1.3 ESTIMATE RECALL NUMBEIt: 113110216:14:27 0102-154 UltreMate is a Traaatemm*of"khan InterneticrAl � Mitchatt Data Version: JAN 02-1 Capyftkt CCI 1994"2000 Mitheil International Page 2 of 3 tlttraMata Varsion: 4.7.007 A6 Rights Reserved � 1 y.✓ 7-17-02;1 :;;2nI.M1: .4. P.A. :7v+si2df!6d8n8 i1 3! +.8 Date. 1131/02 04:i4 FM Estimate 18: 0102-354 Fstimabarld'eerlio,,�reJ O Cwprnitbed Prolft ID: CUSTOMIZED 21 0 RE t 1RJEPLACE R HOOT?HINGE F27116796 A 16.29 0.2 d 22 TBH RHINGE 0.1 23 02710 M0 MARPLACE HOOD PRIMARY LATCH FZU 16700 A 28.13 INC 24 20 6i Y ` OVEIRIIPLACE HOOD PRIMARY LATCH BRACKET F47Z 16RS4 A 40.38 INC 25 102 REMOVEIREPLACE W/AIR C'OND -M 0.3 d 26 1001 5 MCH REMOVEIREPLACE WIAIRBAG -M 0.2 27 102979 MCH REMOVEIREPLACE W/OIL COOLER -M 0.4 28 100101 DDY CHECKIAD]UST HEADLAMPS 0.4 29 100025 MCH REMOVEIREPLACE EVACUATE&RECHARGE AIC -M 2.4 30 100026 MCH REMOVE/REPLACE AICREFRIGERANTRECOVERY -M 0.3 31 10301a HDY REMOVEIREPLACE COKM.ING RADIATOR SUPPORT F4TY 16138 8 288.60 4.4 d 32 AUTO REP REFINISH RADIATOR SUPPORT COMPLETE 1.5 33 100132 MCH REMOVEIREPLACE TRANS OIL COOLER IM ORDER FROM DEALER 98.07 0.7 34 106130 BOY R WE/INSTALL LFENDER ASSY 1.3 aF 35 106170 BDY REMOVE/REPLACE R MIDER PANEL FXTZ 16005 A 26250 Z3 36 AUTO REF REFINISH K fTMER OUTSIDE C 2.2 37 AUTO RIP REPINISH R FENCER ECoG'@ IL INSIDE C 1.1 j as 104250 BOY RaMOVEIREPLACE R P ER LINER F4TZ 16054 A 52..80 0.8 9 39 100911 MCH REMOVEIREPLACE DISABLE R ENABLE AIR BAG SYSTEM 44 0.2 40 104912 MCN REMOVEIREPLACE AIR BAG SYSTEM DL461MIS -M 0S 41 IM214 MCH RE74OYE/REPLAC;E AIR BAG MODULE-DRIVER SIDE -M F&U 15043813 A 550.00 0.5 42 108230 MCH ALIGN FRONT SUSPENSION iN 2.3* 43 900300 "" ALIGN FRT UNIBODY STRUCTURE Extstinp 3.011 44 900500 MCW REMOVEIREPLACE P.FRT TIRE New 95.00' 0.3* 45 900500 MCH* REPAIR R FRT TIRE/MOUNT to BALANCE Sublet 15.00*INC• 46 936001 ADWL COST COOLANT JIM e 47 936012 ADWL COST HAZARDOUS WASTE DISPOSAL 3„00 r 499 AUTO REF ADD'L OPR CLEAR COAT 2,7 49 933003 REF AJDD'LOPR TINT COLOR b.5s 50 233004 BOY ADO LOPR UNDEPMOATING 8..00* 0.2* � 51 933006 "t M ADIO'L OPR SAME/RACK SET UP 1.50 52 9331118 REF ADWL OPR MASK FOR OVERSPRAY 5.000 0.20 53 AUTO AOD1.COST PAINT/MATERIALS 380.70 o.3udgement Item -Labor Note Applies I C•Included in Clear Coat Calc IK Pdar Damage LEFT SW-53Dt:,POOR QUALYfY REPAIR. Add'i Labor Sublet t. Labor Subtotals Units Rate Anmmt Amount Totals II. Part Replacement Sam murr Amount f Body 1.2.2 62.00s.06 0.00 7"40 T Taxable Paris 2,878.43 i Ratkish 14.3 62.00 5.00 0.00 891.60 T SaksTax 0 1.2w% 23747 France 4.5 62A0 0.00 0.00 179.00 T t Madlsanical &1 62.00 0.00 moo 399.20 T Total Ra Mcennat Pwft Amount 3,115.90 Taxable Labor 2,328.20 Labor Summary 37.1 2,328.20 ESTIMATE RECALL NUMBER: 1/3110216:14;27 0102-554 UltraMate is a Trademark of Mitchell International FFA 4 2002 Mitcham Data Version: ]AN GZ_A CepYright(C)1994-2D00 MkenW International Page Y of 3 WtraMata Verxmn: 4J.007 A8 Righb Reserved i 7-1`-02;10c'2AM; A. R.A. ;186:'4264&48 0 1D/ 18 D®te: 1131)02 04:14 PM Esthn.eft Its: CMOZ-iso Estimate VatsIotm 0 Cuma►ritted Pr*fU*IO: CUSMMIZED III. Amount IV. Adiustnusts AMOKMt cats Custsmer Raspomwiity 0.00 Tax 6.250%0 32.40 T r, 3.00 To Additional Costs 429.10 1. Total Labor: 2,32x.20 Il. fatal ReptacaMent Patter 3,115.90 Ill. TStal Additional Costs: 42LIO arose Total: 3,872.20 IV. Total Adjustments: O.00 Net Total: 5,372.20 point(s)or Impact 1 Right Front Corner(P) Insurance Cot FA.R.A. Inspection Sits: REPAIR FACILITY. Inspe tiwr Bets: 1131102 Body Shop; 8038 AUTO BODY Address: 129222 SAN PABLO AVE. RICHMOND,CA 94605 TakVhone. (510)2176399 Pax Phone: (SLC)237-6460 Federal I.D.# 94-2728676 THIS IS NOT ANi3 A10THORIZATION TO REPAIR AUTHORIZATION MUST BE OBTAXNED SROM THE OWM7 R THIS DOES NOT VERIFY COVERAGE NOR I3 AN AGREMCHT TO PAY FOR REPAIRS ****NOTE: NO SUPPLEMENTS WITHOUT PRIOR APPROVAL**** BY SED. TAX ID# ESTIMATE RECALL MUM ER: 113110226:14,27 0102-154 tilftv"ats is a Tradetisitk of Mitchel International Mitcheii Data Version. JAt4_02._A Copyright(C)1994-2000 Mitchell Iabc matlorwi Page 3 of 3 UltraMate Version: 4.7.007 A9 Rights Reserved Vq OUR FILE NO Aw wr Az w ti a *A A �! «, :° op a ytfj 7--9.-U2;10:22AtA,A. R,A. :1652426 48 # r2i to CLAIM NUMBER: MBS458449 OUR FILE NO. DATE' 011S#?12002 j' PHOTOGRAPHER: V e stem Appraisers I CLAIM NUMBER: i MBS458449 OUR FILE NO. 0102-154 DATE: 01/30/2002 PHOTOGRAPHER: i 1 G:LlALA;F.A. R.A. iE'.6£-i�Ei-0�A8 VF 53/ 18 CLAIM NUMBER: MBS458449 OUR PILE NO. Y. q I 0102-154 4 ! 01/3=002 MATE. �j�� ~` PHOTOGRAPHER: 'tl i. .. lYfC ,..... ...... .V_....... ...... _ .. .. ,.. ... i Western 8Mraisers CLAIM NUMBER; MBS458449 OUR PILE NO. DATE: 01/3012002 y PHOTOGRAPHER. 'i-17-02:tOP.A. P.A. # idi t$ CLAIM NUMBER. ' MBS468449 Y OUR FILE NO. 0102-154 DATE. 01/30/2002 k PHOTOGRAPHER: ss `M i J Westem Appraisers CLAIM NUMBER. MB545W9 �!!! OUR FILE NO. 0102-154 - >�DATE: 01=12002 l PHOTOGRAPHER: 7-17-02;10:21 ALR;F.A.A.A. 1$ .+..r.vv wsYVrCMe lwi Ytvww...�..WU t/.r\.V4 \rl/wt Va/v yrtsarvV. MAC ANDY AUTO PARTS, INC. 6 317 P.0.BOX 953 310 DE�#t M�L4ND 111NE tI VATb,GA 04st48 h a C� -tIBE is PAY—A& TO TME cRDER "'__ d�}�.�A�S . r14'••s•'� � q' u'OClE,3 �7►+" -�: ��i,i74 �,66 �E:CJ58856�978Et" � r� ��a rid / 'gyp is 77■ 1 ..U.-'rt��w'�ASJ+i C•'�,.?.l"A" - Yt; R5 rn rl p 'g s �gBp 'rS3'.y 2 '� ,'rt v� +a' y, .�.' �, 2 .r ,.`•,, t�] `� r+ i� }ty}}'✓� � � 'E r { is W y�' �. �y ``µ ••i S; «{j 1^L555: 'S dr��yy t. �j � iy � L �:1 '� ^.y �r i �, ii✓✓Va"`�t �.e��', . kitSO al ml ILL S• E5 3�,'� 4i '4 �' J ��`• � e~ � \ "*.. Y {Ii MSw�' ��`' Y. is r 4 lF � : 7-17-02;10:22AM; A. F7.A. :15524264848 FILE No. 477 02/04 '02 14:13 ID:NEWTRIN INC. 510 242 5937 PACE 3 H514T.Z iUIPMENT RENTAL REMIT. ou HERTZ IMUIRMENT RENT yrt 5251 INDUSTRIAL WAYC;'_0. LL) �Jw;�J I a $ 1VICIFa CA 94510 ROHNERT PFARY', CA t 707 S 747-4444 cONTRAGT nNYo:CE M R-i-ON7'RAC:TEbNil'17601 P'61. TME.IN NEWTRIDN INE:1 39 40 DATE AND TO; r..f]. BOX 4605q TIME OLT 01 i':`Ip i GwiZ,0 P 14s'50 ! BATON ACILIGE, LA 7 0 li'l 5 ' 1; "a Rb NC wl-fl0l'4 INC'. 134ti'rjob BATtUN RDUGE, LA 7009 13M1I 's TEN BY CHEMED IN 8Y ACOW J08 n10. { AA +a6`ihtta- UR JOHN 6fi. 7tit7NC L1NiVt I 6tCEt 6E Nltlh9ER Pb,NO.OR I MTKJATE iL_ AflT Nsl t �t�atJrr. . 1 3 at711 �'r 'titt.lt,".i<�w, '4T t}l1 9,00/4H 1.1.00 b'x.*x t iF at9r 1Y x iF#9•i!••A#i!'p.is M'b•tli 7f 11•tF t•#'•k.y..y.y..rt x•iF iF.y A•il•M#K.}}i4 x••A iF•a rt� x CUSTOMPri R(rS=+C1hSIBLE 1=`t)Ft TIRE WE AV AND C1Ht+1AtiF* �*a rr•r++t t+t•r##.p.•a�•m'�+r x•rr#it•L'-r��•+tx��•�t,F•k�.r..Y,.sa.�t oeaa�it•M•#•�1-�••r•K a• y' MILEG CA @I. 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PAEK3H#': NET 30 Cl OTNE04 0 ALLowco 13 PREPAY A ADD C1 OTHER 0 rT �xtuA N. _ uv#T aesewlrnar# urar wnu:#c um � It) ,eau; tan, NBWTRON,INC, PuMnes#naAgent W`03'PUKrNAZNC/VEL cOW-101UK "KPAY 9#4C APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA BOARD ACTION Aug 13, 2002 Application to File Late Claim ) NOTICE TO APPLICANT Against the County,Routing ) The copy of this document mailed to you is your Endorsements, and Board Action. ) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.). iven pursuant to Government Code Sections 911.8 and 15.4. Please note the "WARNING"below. Claimant: Perlita Trinidad a!UL 1 9 2002 Attorney: Raymond Bengert COUNTY COUNSEL. MARTINEZ CALIF Address: 329 S. Mayfair Ave#373 Daly City, CA 94415-1404 Amount: in excess of$25,000 By delivery to Clerk on . July 19, 2002 Date Received July 19, 2442 By mail, postmarked on July 18, 2002 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Lat DATED: July 19.2002 JOHN SWEETEN, Clerk,By. � � �� j '<� ' � deputy Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). til . The Board should deny this Application to File Late Claim (Section 911.6). DATED: �' r r SILVANO MARCHER, County Counsel, B Deputy IIT. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). ( ) This Application to File Late Claim is denied(Section 911.6) I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 9 DATE r � � ,. JOHNSWEETEN, Clerk, By f - ' . Deputy Clerk L' WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six(6)months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: (1) County.Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED r ��, �,`^�'= OHNSWEETEN, Clerk, By Deputy Clerk V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA.COSTA COUNTY CALIFORNIA BOARD ACTION Aug 13, 2002 Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing } The copy of this document mailed to you is your Endorsements, and Board Action. } notice of the action taken on your application by (All Section References are to .; the Board of Supervisors (Paragraph III, below), California Government Code. V #€�94 Miven pursuant to Government Code Sections 911.8 and { 15.4. Please note the"WARNING"below. JUL. 19 2002 Claimant: Josephine Ramirez COUNTY COUNSEL Attorney: Raymond Bengert MARTINEZ CALIF. Address: 329 S. Mayfair Ave#373 Daly City, CA 94015-1404 Amount: in excess of$25,000 By delivery to Clerk on July 19. 2002 Date Received July 19, 2002 By mail,postmarked on July 18, 2002 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Lat�im. . f DATED: July 19, 2002 JOHN SWEETEN, Clerk, By Deputy Clerk II, FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim(Section 911.6). { . The Board should deny this Application to File Late Claim(Section 911.6). f � � DATED: f 'i� SILVANO MARCHESI,County Counsel, By - e Deputy III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). ( } This Application to File Late Claim is denied(Section 911.6) 1 certify that this is a true and correct copy of the Board's Orcr entered in its minutes for this date. DATE t _ , �s s - JOHNSWEETEN, Clerk., By ra`r te 1;' } ?` � Deputy Clerk WARNING(Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6)months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. IV. FROM: Clerk of the Board TO: (1) County Counsel (2)County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED }' '< �" ` /,u"`,'jbHNSWEETEN, Clerk, By Deputy Clerk z�- V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM BENGERT LAW OFFICES 329 S. MAYFAIR AVE.,#373 DALY CITY, CA, 94015-1404 RECEIVED July , 2002 CLERK..OF THE BOARD OF SUPERVISORS J U L COUNTY ADMINISTRATION BUILDING LURK WMI)aF SUPER tso�s 651 PINE STREET,ROOM 106 ' MARTINEZ,CA. 94553 RE: APPLICATION FOR.LEAVE TO PRESENT A LATE CLAIM Dear Beard of Supervisors: Perlita Trinidad swears that she filed the attached Claire Form with the Board of Supervisors in August 2001. Ms.Perlita Trinidad believed through her conversations with the Contra Costa.County Assistant Risk Manager for Liability,Ms. Sharon Hymes-Offord,that the claim that she filed would protect both herself and her sister Josephine Ramirez. When my Law Office took over the handling ofthe claim in late August 2001,Ms.Trinidad presented us with this copy of the Claim Form which she stated that she filed with the Board of Supervisors of Contra Costa County. On May 15, 2002, my Law Office was surprised to receive a letter from the Assistant Risk Manager,Ms. Sharon Hymes-Offord, stating that my clients never filed a Claim Form with the Contra Costa County Board of Supervisors to protect the six-month Statute. Therefore, Ms. Hymes-Offord wrote that she could not accept our offices demand package for payment consideration.This was especially shocking because Ms. Trinidad told us that after she sent in the claim, she called Sharon Hymes-Offord and Ms. Hymes-Offord confirmed that it had been received and filed. Ms. Trinidad is now besides herself with grief, frustration,anger and despair. We are hereby submitting this application for you to grant leave for Ms. Perlita Trinidad and Josephine Ramirez to present a late clain-L We note that Government Code Section 991.6 states"(b) The Court shall grant the application where one or more of the following is applicable: (1)The failure to present the claim was through mistake, inadvertence, surprise or excusable neglect and the public entity was not prejudiced in its defense of the claim by the failure to present the claire within the time specified in Section 11.2". In this case Ms.Perlita Trinidad is quite surprised that her application,which she swears under oath, that she mailed to the Board of Supervisors(See Declaration ofPerhta Trinidad,Exhibit A attached). was not received by them. The fact that the Board did not receive the application which was mailed by Ms. Trinidad prior to the representation of this Law Office, had to be through mistake, inadvertence, surprise or excusable neglect by some party. Certainly,the County is not prejudiced in their defense of this claim because liability for this automobile accident was already investigated by Contra Mosta County and Ms. Sharon Hymes-Offord, Assistant Risk Manager, already paid Ms. Trinidad$2,197.20 for herr property damage. In addition, our client's medical bills incurred as a result of the injuries suffered in the impact are modest. At this time my clients are stable and have reached their pre accident condition. We are resubmitting the demand letter that was sent on 5/10/02 to Ms. Sharon Hymes-Offord which was received by her on 5/15/02 and returned to our office. If the Board of Supervisors decides to grant Application to Accept this Late Claim,we will send the additional documentation such as Wage Loss Verification and medical bills,which we originally submitted with the demand package to Ms. Hymes-OfIord and which she returned to us. We await your decision. Very truly yours, RA, �NGER' , ESQ. I,PFRLITA TRINIDAD, declare as follows: I. I was working with Assistant Risk Manager Sharon Hymes-Offard to settle my accident claim that occurred on 7122/01. Ms. Hyams-Offard assigned the Claim##: 48267 to my case. 2. Ms. Hymes-4ffard declared that liability rested with Contra Costa County and paid me for my property damage. 3. Ms. Hymes-Offard also sent me claire forms which I was to fill out and submit to the Clerk ofthe Board of Supervisors at its office in Room 106,County Administration Building,651 Pirie Street,Martinez, CA. 94553. After I received these forms I filled them out and sena them to the Clerk of the Beard of Supervisors, County Administration.Building, 6.51 Pine Street,Room 106,Martinez,CA. 94553. I believe from my conversations with Ms.Hymes- Offard that this Application would protect both me and my„sis ,JOFp 'ne Ramirez. 4. Ms. Josephine Ramirez lives in the Philippines and actually signed a cume t granting me Special Power of Attorney to conclude her claim. 5. After I submitted the Claim Form to the Board of Supervisors I called Ms.Hymes-QffiLrd and asked if the claim form I sent in made it to her yet. She said that she had it! However, Ms. Hymes-DRord is such a difficult person to deal with,and she gave me such a hard time even just getting my property damage,that I decided to just hire a lawyer to finish my claim 6. When I hired Mr. Bengert I advised the Law office that I had submitted a claim and gave them a copy ofthe claim that I mailed.. I told them that Sharon Hymes-Offord confirmed that the claim had been received. I have reviewed a copy of that claim which is attached to my declaration and it is, in fact, a copy of the claim that I sent to the Contra Costa Board of Supervisors as stated above. 7. I declare under penalty of perjury under the State of California that the foregoing is true and correct. This document is being executed on iv in Richmond, California. PE ITA TRINIDAD `�__ June 3, 2002 Raymond Bengert 329 S. Mayfair Ave. #373, Daly City, CA 94015-1404 Re: Confirming that I had submitted a Declaration Dear Mr, $engert, This is concerning your letter to me that the case I am Ming against Contra Costa County Risk Management Division had been rejected by the company for the reason that they had misfiled,misspelled my name or file number, date they got or have not gotten my mail. This are all unacceptable reasons because before I got your service, I got a blank copy of the declaration they sent me and they are giving me a hard time settling this case. The mere fact that Mr. Jeff Parks who was the driver of their van had already admitted that it was his fault,Miss Sharon Offord still gave me a hard time for an out of court settlement. I answered all the questions on the Declaration paper they had sent me and made a copy of it that I gave to you through Mr. Levi Baranda when I got your service and I sent it back to them. It was sent in July,2001. I even called them back to ask if they gnat it, and Miss Offord say she did. Since we did not agree on what I want to happen on that accident I told her just to talk to my lawyer and that was the time which was August 2001 you got to the scene through Dr, Maria Escalada ,any physician's recommendation. So all the records I got are now in your hands. I hope things will be settled soon because I was almost a year now that this accident occurred. Hoping you'll do everything to put an end to this case as soon as possible. Any questions,just call me at(510)236-6964 or at my cell phone no. (510)734-7453. Yours truly, t �- P �RLITA A. TRINIDAD 0 29`x'. St., Richmond, CA 94804 _ _ _ _ Claim to, BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUC"1`IflNS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or t4 personal property or owing crops and which accrue on or before December 31, 198'7, must be presented not later than the 100`" 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 browing 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. (Gov-t. Code §3911.2. ) _ B. Claims crust 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. l;raud. See penalty for fraudulent claims. Penal Code Sec. 72 at the end of this form. RE: Claim by . ) Reserved for Clerk's Filing Stamp 3 RECEIVED: Against the County of Contra Costa JUL 9 2002 or Ct.EFtK L30AFttl flI� JPERVtu�RS CONTRA C{1S7J1 C£7. Czz� T_ District) (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sutra of S -25_,_000..-and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact Date and Hour) CIn 2. Where did the damage or injury occur.? (Inciude City and County) 5A-L) pht 'a AA 3. How did the damabe or injury occur? (Give full details:use extra paper if required) w C�S' trot cs- S CE '-C` Y-` `t 1C S A C'r ------------------------------------------------------------------------------- ------ 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? -__ --- �r_ _----- -----+,__�'�'t!t�_� ._Vko�_ ------ ------ 5. What damages or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) • - ------------------------- ------- -- --- -- ----- ----__.__. ------___. ----- How was the above claimed amount computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses, doctors, and hospitals. 1 TO ) t - I COV, PC 0,e t , r in P vo , Gia -'�4 9 V,,4 Ave 9. - stretuvo m utoint�Sr njnr e 'a�+� i' D.�TE ITEr4 aniot'ti?' t4s .00 'i, iPsa:a tl.�-O) ''Z 1� 7.0 it AA ��`k x Ys 5t tr t 5t 'it,�rt�:� -- Code 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 Attorney g 0cK t & C_, ' ( Claimant's Sig azure) 1L11PN S,3 Addrtss ) Telephone ivo _17 7( 51Telephone Nod xxxexx � x ,� x � xxx � xxxx � x � � x � � � � x � x ,� � xx ,� X * xx � x � x � � * x � xx � x � � NOTICE Section 72 of the Penal Code proN ides: "Every person who, with intent to defraud,,presents for allowance or for payment to any state board or officer, or to any county, cit` 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 dollars ( 51,000 ), or by both such imprisonment and fine. or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ( 510,000 ), or by both such imprisonment and fine. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAMAN:[ Maims relating to causes of action for death or for injury to person or to personal property or growing, crops and which accrue an or before December 31, 1987, must be presented not later than the 100" 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 Buildings 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 mast he filed against each public entity. E. .Fraud. See penalty for fraudulent claims, Penal Code Sec. "w at the end of this form. * * * * * * X * * * x * x * * * * * * * * * * * * 7t * * * * * * * * * * * * * * * * ,t * * * * * * * * * * * * RE: Claim by ) Reserved for Clerk's Filing Stamp RE EI ED l -�.gainst the County of Contra CostaJUL 9 2002 or CLERK SOARD OF SUPEROSM CflMRA C OSTA otfl. District) (Fill in `name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of$2L and in support of this claim represents as follows: 1. When did the damage or in,)tlrti' OCCtIr:` (Give exact}date and Hour) { >t , u +1C A It 2. Wbere did the dama{„e or injure occur? (include City and Counn ZA 3. How Olid the damage or injury occur? (Give full details: use extra paper if required')7. µ ' 'i,s, 0WTIj �'t ". jp {;y�r.+j .♦i,.(.) #,) y� ( +.5.:..tt qk ( ,Gfty.�r 'nJ u Yj fd"�.l",y...�u./� ] {.4.✓Z\pj 0y",a"# & 4-V •Os.Ye": i. 'f 't`"d:�`°� ✓'.�.L: b..f+. Y.+" '•` 5 2u x.. {_,y u,• ,'4 3. =`A b..- `�e t..i�Y$at'b�..m..R,,. ------------------------------------------- --- 4. What particular act or omission on the part of county or district officers, sen-ants, or employees caused the iuja-y or damage? Over) S. What are the names of county or district officers,servants,or employees causing the damage or injury? { £i�F^ r a_^ . .... �_ '0.•T Z L •-.;yu.ewd l '^"` b j Sim lh� ,--- +w.�---- . \ ..` ! "• > f. What damages or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach cwo estimates for auto damage.} 1,21 5 `$" --------- --- ---- ---------- --- --- jet's' was the above claimed amount computed" (Include the estimated amount of ant prospective injure or damage. ) �."�j��..,:t..F4�^'`v •'✓ � y,�.s' 4� ��v"E.y�'•�.''. ''a....� ,. `o'_ ..`4 8. Names and addresses of witnesses. doctors, and hospitals. �; _ �..�.�`�``�•� �'.>i � '� �' � i� �=-�C' ��"rte ��'�= ��t ��d�..�:�,i,,,,�;-`' : C'.. . 7 { s"" e ., T/4P c'I � r" __! ',t dLp. A 4 - ----------------------- ------- ------------------ __ _ ----_ -- --- - - . . 9. List the expenditures you made on account of this accident or injun. DA—F NIO "NT r� Gov. Code Sec 910.1- provides: "The claim must be signed by the claimant SEND NOTICES T0; (Attorney) or by some person on his behalf." 'Name and Address of Attorney r � ""l :j .f - of ' { Claimanty Signature j .,_ i ( Address ) 3 Telephone Nafw € l Telephone Na. NOTICE Section i2 of the Penal Code prop ides: "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 benuine, 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 dollars ( SI,OOtl ), or by both such imprisonment and fine. or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars { S10.000 ), or by both such imprisonment and finer BENGERT LAW OFFICES May 10,2002 Contra Costa County JIA IZ``0` Risk Management Division 2534 Arnold give,Ste. 144 Martinez,C.A. 94553 Attention Sharon Ilvmes-Of1`ord Re: Our Clientis Perlita A.Trinidad and Josephine Ramirez Your Insured Contra Costa County Probation (Jeff Parks) Date of Accident 7/2212001 Claim Number 48267 Dear Ms. Hymes-O1Tord: As you know, this office represents Perlita A. Trinidad and Josephine Ramirez for injuries they sustained in an accident on July 22, 2001. We have substantially completed our discovery procedure pursuant to this action and authorized to settle this matter for our client based on the following: 1. FACTUAL SUMMARY On or about July 22, 2001, my clients were stopped on the Wall Greens parking lot in San Pablo Ave. corner Church Lane, behind a van driven by Mr. Jeff Parrs. Mr. Parrs was waiting on the San Pablo on ramp, when suddenly this van moved backwards towards her vehicle. Ms. Trinidad did not have time to put her car on reverse, instead started homing at the driver, as the van rolled down from a ramp. Your insured, Mr. Jeff Parks, was in violation of California Vehicle Code Section 22106, unsafe backing. Upon sudden impact, my clients was vigorously jolted forward sustaining back pain, headaches, and neck pain. Your insured caused this accident and is responsible for my client's injuries. Ms. Trinidad and Ms. Ramirez saw Dr. Escalada, M.D., in Hercules. They were under observation and a series of tests taken. Although no focal abnormality, fractures, dislocation were found, Ms. Trinidad suffered from headaches,difficulty sleeping,right neck pain, and tight law-back while Ms Ramirez suffered from headaches, right shoulder, and neck pain, low-back pain and mid-back pain. After a few weeks of continued disconifoM they were prescribed therapy. They sought physical therapy with Hercules Chiropractic Center. Treatments consist of specific spinal adjustment, moist heat, low-voltage electrical stimulation, massage, rest and stretching and strengthening exercises. Mailing Address:329 S.Mayfair Ave.#373,Daly City,CA 94015-1404 Tel.(650)755-7999 Contra Costa County Attention: Sharon Hymes-Offord May 10,2002 Page 2 ii. LIABILITY Mr. Parks was blatantly negligent. He jeopardized the safety of those in the immediate area. This is a conclusive presumption of negligence in the part of your insured. It is clear and apparent that this was in fact,the actual and proximate cause on my client's injuries. A careful review of the attached medical report will reflect the injuries sustained as a direct result of your insured's negligence. III. BILLS INCURRED Perlita Trinidad Sycamore Medical Group $ 145.00 Hercules Chiropractic Center $2197.00 Josephine Ramirez Sycamore Medical Group S 215.00 Hercules Chiropractic Center $2215.47 IV. WAGE LOSS Perlita Trinidad Contra Costa Dental Clinic $ 331.50 V. CONCLUSION Since liability is reasonably clear, we are hereby demanding $12,000 for Perlita Trinidad's bodily injury claim and $331.50 for her wage loss, and $12000 for Josephine Ramirez' bodily injury claim. Please be further advised that if this claim is denied or if you offer a compromise settlement, we are requesting that you provide us with a written, reasonable explanation and the exact basis relied upon in relation to the facts of applicable law in making such denial or offer on compromise. To assist in the evaluation of this matter, I have enclosed copies of all supporting documents. I would appreciate an advance call regarding receipt of this demand at your convenience. Thank you in advance for your prompt attention towards this matter. Sincerely yours, KNYMOM BEN{ T, Q. Enclosed: medical bills,records BEN ERT LAW OFFICES WAGE LOSS VERIFICATION Re: Our Client/Your Employee : Perlita Trinidad Bate of Accident July 22, 2001 To the Employer: This is for the benefit of your employee in his claim arising out of an accident that is in no way connected with his employment at your company. It will be in his/her advantage if this form is filled out completely. V Name of Employer: I w Address: 4eb a ffc 3` ' CA Gate Employed: (approximate date) Currently Employed: $ ayl ` Actual number of days/hours lost from work at a hourly, weekly,. monthly (circle the appropriate time) rate of$ • � � Dates of time Inst: from: € "" '' to: � inclusive. (Date) (gate) Total Salary Lost $ .eoonus, Commissions or Overtime last, if any, $ ` ea Please explain: '?' s Employee's regular duties. � t Comments, d 8 i J Print Name jSidnature DATE �z t Title: eWU - _.,,. Telephone: % ' xt. ( � s 3150 Hilltop Mai{Rd.,Richmond,CA 94806,TEL:(510)970-7$56 FAX:(510)222-t 7 E Mailing Address:P.0.BOX 5715,HERCULES,CA 94547 Contra CostDental A Professional Corporation `RW EST FOR TIME OFF Todays Date: J WO) Employee's Name: Dates Requested: Reason: Covered By: 1 i--0 ) VA YI Ut'.'2- Signature of Person Covering: Request must be signed by person covering prior to submitting for approval. Approved By: < Disapproved: Total number of days off YTD: 14270 San Fable Avenue • Richmond.California 94806 (510) 234-1414 Fax (5 10) 234-4707 ContraCosta Dental 4 A Professional Corporation REQUEST FOR.TIME OFF Todays Date: � ' Employee's Name: - " " i i P A V To: s t-� A Dates Requested: J `) ., Reason: Covered By: ` 'i. oak V1 Signature of Person Covering: Request must be signed by person covering prior to submitting for approval. Approved By: Disapproved: Total number of days off YTD: 1#270 San Pablo Avenue • Richmond, California 94806 (510) 234-1414 Fax (510) 234-4707 Coricra Cost. D A rc�fessional C©rporatic�n RE(WEST QUIZ'�'T_11+ w ` Todays Date: L`ro SJ t Employee's Name: k90 V-A Dates Requested: +' e a ►. Reason: Covered Ey: ' 4�,\A k,G �-k Signature of Person Covering: Request must be signed by person covering prior to submitting for approval. Approved By: i Disapproved: Total number of days off YTD: 14270 San Pablo Avenue Richmond, California 94806 {510} 234-1414 Fax(510) 234-4707 SYCAMORE MEDICAL GROUP PRINTED 03:55:27pM 10 May 2002 1581 SYCAMORE AVE SUITE 6 BY: 2052 SMG-AR XA HERCULES, CA 94547 PAGE 1 510-799-2100 TAX ID# 343300697 PMITA TRINIDAD (3375ACC) 640 29TH ST RICHMOND, CA 94804 NOTICE, THIS Its LISTED} FROM MOST RECENT TO THE OLDEST Date. . . . Name. . . Cede. . . . Desoaription. . . . . . Link. . . Dr. . Fcl Amount. . . . Dx ---------------------------------<10/31/01>--------------------------------- BALANCE _-_.._..,.-_.._..____....,....,.-.....,-__ -..--<10X31/01>..-....___-............----_-___.._....___-_- BA.LANCE 0.00 10/09/01 PERLITA 35 PAYMENT IN OFFICE 100901 ME 1 -70.00 401.3 10/03/01 PERLITA. 33213 OFFICE VISIT #3 1.00901 ME 1 70.00 754.0 ---------------------------------.X08/31/01>___.._.,__..______________-______ -- BALANCE Q.-00 08/22/01 PERLITA 35 PAYMENT IN OFFICE 082261 ME 1 -75.00 08/22/01 PERLITA 99211 OFFICE VISIT #3 082201 PIE 1 75.00 353.2 ......__--___-___-___..-__-..__....___-_-__A_--__......_..___-_..-___--___--___..-_---_., DOCTOR. . . . . . . . . . . . . . . . . . . . . . TA.X_ID. . . . . . FINANCIAL CLASS ME MARIA C E CAL DA, MD 943300697 1 NO INS/PENBED _____ ..w.._-_-.,__.»_.._--....____---- .-__..___..,.____.._________....__.._-__-....__----- PA.TIENT# 3375ACC PERLITA TRINIDAD DOB:10/11/1960 SEX*.F 340--96-7661 Insurance Compain Group I'd Number Insured NO INSURANCE CARRI 340-96--7661 PERLITA TRINIDAD PATIENT# DOB; SEX: —------ No. 7 4 7�7.7 jKT 1 _.::; b / 1vY No,, 747726 ILI :C S °3 Ste, _ YU 3 1C• Ain MOM `# :y V er cul s hi +eater MEDICAL REPORT April 15,2002 PERSONAL DATA Patient lame: Perlita Trinidad Date of Birth: 10/11;'1960 Address: 640--29th Street Richmond,CA 94804 Date of Accident: 07/22/2001 Date of First Visit: 09/01/2001 Occupation: Dental Assistant HISTORY AND EXAMINA'T'ION History of Accident Patient was driving,wearing her seatbelt,and was struck by a van hacking up. Patient Complaints Patient complained of heartaches,difficulty sleeping,right neck pain,tight low-back. Examination Findings • On cervical motion study,decreased range of motion with mild pain on flexion,left rotation;decreased range of motion on extension,right rotation,left/right lateral flexion. • On Dorso-Lumbar motion study,decreased range of motion with mild pain on extension, right lateral flexion,decreased range of motion on flexion,left/right rotation,left lateral flexion. • The following orthopedic signs and tests were positive: Left/right Kemps. • Upon the spinal examination,pain and tenderness were noted at: Occiput-C1,c7-T6,left/right Ilium. • Associated muscle spasms were noted at: Right trapezius,suboccipitals,paravertebral cervical,thoracic. X-RAYS Date Taken: 09/01/2001 By Whom: Dr. Denise I. Walther 'dews: Cervical Davis Series Findings: Decrease in flexion. Retrolisthesis of C3 in the neutral and extended positions. (510) 799-0900 1581 Sycamore Avenue, Suite 4, Hercules, Californias 94547 Fax (510)799-1370 Medical Report Page 2 of 2 Trinidad,PerIita E IBOSPITALIZATION HISTORY Following the accident,Ms.Trinidad was treated on July 25,2001 by Maria Escalada,M.D. A muscle relaxant and headache medication was prescribed. DIAGNOSIS Upon examination: On September 01,2001,the diagnosis was headaches,cervical sprain/strain, and lumbar sprain/strain. As of February 11,2002,the diagnosis of cervical and thoracic sprain/strain was resolved in addition to resolved headaches. TREATMENT The treatment in this case has been of a conservative nature,including specific spinal adjustment, moist heat,low-voltage electrical stimulation,massage,rest,and stretching&strengthening exercises to relieve the patient from the effects of this injury. PROGNOSIS Upon evaluation of the subjective history,consultation,and review of the physical examination and x-rays,l have found this injury to be consistent with the type of accident reported by the patient. Ms.Trinidad is employed as a dental assistant which involves standing and leaning for extended periods of time. The biomechanical stress from this type of activity is centered in the lumbar spine where her injury occurred. At this time however,Ms.Trinidad is asymptomatic. She has recovered completely from the injuries she sustained in the automobile accident ad 1 do not expect her to need any further treatment. She has no residuals arising from her injuries. Should you have any questions or need any additional information,please do not hesitate to contact me at my office. SinceJr/ely,, K-alani S.Walther.D.C. Enc. KSW/bag I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER:CONTRA COSTA DENTAL PATIENT: BIRTHDAY: INSURED: PERLITA A TRINIDAD 3190 PI LIE 10 11 60 640 29TH STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS ACC DATE: 07 22 2001 FIRST TREATMENT: 08-31-2001 DIAGNOSIS: E812 0 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE DRIVER ORIG DX: 784 0 847 0 847 2 RESOLVED: 847 0 847 2 784 0 DATE DESCRIPTION PROC CODE AMOUNT 09-01-2001 EXAMINATION 99203 70. 00 09-012001 DAVIS SERIES X-RAY 76140 150 . 00 09-04-2001 SPINAL MANIPULATION 98940 38 . 00 09-04-2001 HOT PACK 97010 12 . 00 0904-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-082001 SPINAL MANIPULATION 98940 38 . 00 09-082001 HOT PACK 97010 12 . 00 09-08-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-11-2003 NEUROMUSCULAR THERAPY 97112 35. 00 09-11-2001 SPINAL MANIPULATION 98940 38 . 00 09-11-2001 HOT PACK 97010 12 . 00 09-112001 ELECTRICAL STIMULATION 97014 12 . 00 09-13-2001 SPINAL MANIPULATION 98940 38 . 00 09-13-2001 HOT PACK 97010 12 . 00 09-13-2001 ELECTRICAL STIMULATION 97014 12. 00 09-18-2001 NEUROMUSCULAR THERAPY 97112 35. 00 09-18-2001 SPINAL MANIPULATION 98940 38 . 00 09-18-2001 HOT PACK 97010 12. 00 Continued. . . Drs . Walther 04 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3190 510-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI EARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P O BOX 5775 HERCULES CA 94547 EMPLOYER:CONTRA COSTA DENTAL PATIENT: BIRTHDAY: INSURED: PERLITA A TRINIDAD 3190 PI LIE 10 11 60 640 29TH STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS/ACC DATE: 07 22 2001 FIRST TREATMENT: 08-31-2001 DIAGNOSIS: E812 0 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE DRIVER ORIG DX: 784 0 847 0 847 2 RESOLVED: 847 0 847 2 784 0 DATE DESCRIPTION PROC CODE AMOUNT 09-18-2001 ELECTRICAL STIMULATION 97014 12. 00 09-20-2001 SPINAL MANIPULATION 98940 38 .00 09-20-2001 HOT PACK 97010 12 . 00 0920-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-25-2001 RE-EXAMINATION 99213 25 67 . 00 09-25-2001 SPINAL MANIPULATION 98940 38 . 00 09-25-2001 HOT PACK 97010 12 . 00 09-25-2001 ELECTRICAL STIMULATION 97014 1-2 . 00 10-02-2001 SPINAL MANIPULATION 98940 38 . 00 10-02-2001 HOT PACK 97010 12 . 00 10-02-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-09-2001 SPINAL MANIPULATION 98940 38 . 00 10-09-2001 HOT PACK 97010 12 . 00 10-09-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-16-2001 SPINAL MANIPULATION 98940 38 . 00 10-16-2001 HOT PACK 97010 12. 00 10-16-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-23-2001 SPINAL MANIPULATION 98940 38 . 00 Continued. . . Drs. Walther 04 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3190 510-7990900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER:CONTRA COSTA DENTAL PATIENT: BIRTHDAY: INSURED: PERLITA A TRINIDAD 3190 PI LIE 10 11 60 640 29TH STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: CROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS/ACC DATE: 07 22 2001 FIRST TREATMENT: 08-31-2001 DIAGNOSIS : E812 0 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE DRIVER ORIG DX: 784 0 847 0 847 2 RESOLVED: 847 0 847 2 784 0 DATE DESCRIPTION PROC CODE AMOUNT 10-23-2001 HOT PACK 97010 12 . 00 10-23-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-31-2001 SPINAL MANIPULATION 98940 38 . 00 10-31-2001 HOT PACK 97010 12 . 00 10-31-2001 ELECTRICAL STIMULATION 97014 12 . 00 11-08-2001 SPINAL MANIPULATION 98940 38 . 00 11-08-2001 HOT PACK 97010 12 . 00 11-08-2001 ELECTRICAL STIMULATION 97014 12 . 00 11-19-2001 SPINAL MANIPULATION 98940 38 . 00 11-19-2001 HOT PACK 97010 12 . 00 11-19-2001 ELECTRICAL STIMULATION 97014 12. 00 11-20-2001 OUTSIDE RADIOLOGY CONSULT 1 VIEW 76140 60 . 00 12-03-2001 SPINAL MANIPULATION 98940 38 . 00 12-03-2001 HOT PACK 97010 12 . 00 12-03-2001 ELECTRICAL STIMULATION 97014 12 . 00 12-12-2001 SPINAL MANIPULATION 98940 38 . 00 12-12-2001 HOT PACK 97010 12 . 00 12-12-2001 ELECTRICAL STIMULATION 97014 12 . 00 Continued. . . Drs. Walther 04 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3190 510-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER:CONTRA COSTA DENTAL PATIENT: BIRTHDAY: INSURED: PERLITA A TRINIDAD 3190 PI LIE 10 11 60 640 29TH STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS/ACC DATE: 07 22 2001 FIRST TREATMENT: 08-31-2001 DIAGNOSIS: E812 0 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE DRIVER ORIG DX: 784 0 847 0 847 2 RESOLVED: 847 0 847 2 784 0 DATE DESCRIPTION PROC CODE AMOUNT 12-19-2001 SPINAL MANIPULATION 98940 38 . 00 12-19-2001 HOT PACK 97010 12. 00 12-19-2001 ELECTRICAL STIMULATION 97014 12. 00 01-07-2002 SPINAL MANIPULATION 98940 38 . 00 01-07-2002 HOT PACK 97010 12 . 00 O1-07-2002 ELECTRICAL STIMULATION 97014 12. 00 01-14-2002 RE-EXAMINATION 99213 25 67 . 00 01-14-2002 SPINAL MANIPULATION 98940 38 . 00 01-14-2002 HOT PACK 97010 12 . 00 01-14-2002 ELECTRICAL STIMULATION 97014 12 . 00 01-21-2002 Office Visit Prob Exp 99213 25 67 . 00 01-21-2002 Therapeutic Acitivies 97530 32 . 00 01-21-2002 Neuromuscular Re-Ed 97112 36. 00 01-21-2002 Electrical Stimulation 97014 32 . 00 01-21-2002 Ice/Heat 97010 20 . 00 01-28-2002 Adjustment 98941 52 . 00 01-28-2002 Neuromuscular Re-Ed 97112 38 . 00 01-28-2002 Electrical Stimulation 97014 32 . 00 Continued. . . Drs . Walther 04 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3190 510-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER:CONTRA COSTA DENTAL PATIENT: BIRTHDAY: INSURED: PERLITA A TRINIDAD 3190 PI LIE 10 11 60 640 29TH STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE IT DATE: 07 22 2001 FIRST TREATMENT: 08--312001 DIAGNOSIS: E812 0 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE DRIVER ORIG DX: 784 0 847 0 847 2 RESOLVED: 847 0 847 2 784 0 DATE DESCRIPTION PROC CODE AMOUNT 01--28-2002 Ice/Heat 97010 20. 00 02w-04-2002 Adjustment 98941 52 . 00 02-04-2002 Passive/Active ROM 97530 35. 00 02-04-2002 Electrical Stimulation 97014 32 . 00 02-04-2002 Ice/Heat 97010 20 . 00 02-11-2002 Office Visit Prob Exp 99213 25 67 .00 TOTAL 2197 . 00 DATE: 04 15 02 Employer ID No Drs. Walther 68-0099246 1581 Sycamore Ave #4 Social Sec No Hercules CA 94547 510-799-0900 Drs . Walther REPORT: 02 11 2002 SYCAMORE MEDICAL GROUP PRINTED 03:55:45pm 10 May 2002 1581 SYCAMORE AVE SUITE 6 BY: 2052 SMG.AR KA HERCULES, CA 94547 IMAGE 1 510--799-2100 TAX ID* 943300697 JOSEPHINE L RAMIREZ (5135) 2903 HOWARD ST RICMOND, CA 94804 NOTICE, THIS IS LISTED FROM MOST RECENT TO THE OLDEST Date. . . . Name. . . Code. . . . Description. . . . . . Link. . . Dr. . Fcl Aamount. . . . Dx BALANCE 0.00 10/09/01 JOSEPHI 35 PAYMENT IN OFrICE 1.00901 ME 1 -70.00 724.2 10/09/01. JOSEPHS 99213 OFFICE VISIT #3 100901 ME 1 70.00 847.0 ---------------------------------<07/31/01>--------------------------------- iILS♦CE 0.00 07/26/01 JOSEPHI 35 PAYMENT IN OFFICE 072601 LSE ' 1 -145.00 724.2 07/26/01 JOSEPHI 99203 NP LEVEL 3 072601 ASE 1 145.00 $47.0 TOR . . . . . . . . . . . . . . . . . . . TAX-ID. . . . . . FINANCIAL CLASS ME MARIA C ESCALADA, MD 943300697 1 NO INSIPENDED --------------------------------------------------------------------------- PA'T`IENT# 5135 JOSEPHINE L RAMIREZ DOB:03/12/1963 SEX.F 999-99--9999 Insurance Cnmpan Group Id. Number Insured NO INSURANCE CARRI 999--99-9999 JOSEPHINE L RAMIREZ PATIENT# DOB: SES d qq4 ;I k J P 3 3 i i i i ( - No. T' 7727 75 *r s �s r—)CASH - �ldpli �_✓_1f1C. _3 CHECK 2.7 E DATE z No. 30OL93 RECEIVED FRO 0FCR RENT r} , ---------._...._DOLLARS ACCOUNT z �CASh PAYMEN7 =ROM, a CHECK BAL. DUE L MONEY E 8Y `27fl: er rrr�c enter MEDICAL REPORT Report Date: January 7,2002 PERSONAL DATA Patient Name: Josephine Ramirez Date of Birth: 03-12-1963 Address: 2903 Howard Street Richmond,CA 94804 Occupation: N/A Employer: N/A Date of Accident: July 22,2010'1 Date of first visit: August 30,2001 HISTORY AND EXAM History of Accident Patient was a passenger,wearing her seatbelt,in a vehicle that was stuck from the front by a van backing up. Patient was not expecting the impact. Patient Complaints Patient complained of headaches,right shoulder and neck pain,low-back pain,mid-back pain. Examination Findings *On Dorso-Lumbar motion study,decreased range of motion with mild pain on Flexion, Extension, left and right rotation,left and right lateral.flexion. *On Cervical motion study,decreased remge of motion with moderate pain on flexion;decreased range of mcstioa•A ith mild pain on extension,left rotation,left and.right 1_eteral flexion;decreased ranae of Motion on 6rht rotafio1'1. 4.1,C'!».:yz�,_a.. IL uht I'c,r atri:'r� E.UIYt.3ressio2l Left ar d rig ht:4houlder Depressor Right Braggard's l*i,►it Psoas Right Yeoman's Right Ely's "On Spinal Examination,pain and tenderness were noted at: Right Occiput-C1,Right C7-T3,T6- T8,L4 to left/right Ilium. X-RAYS Date Taken: 08-30-2001 By Whom: D.r. Denise 3. Willticer 'Views: Cervical Davis Series and AP/LAT Lumbar Findings: Cervicztl spino: decrease in extension. i umbar spine: Left unnorninate is inferior with respect to the right;left to right scoliosis;facet arthrosis 1-5/Sl-. (510) 799-0900 1581 Sycamore Avenue, Suite 4, Hercules, California 94547 Fax(510)799-1370 MEDICAL.REPORT JOSEPHINE RAMIREZ FAGS.2 EIVHOSPITALIZATION HISTORY Following the accident,Ms.Josephine Ramirez was treated by Dr.Escalada. DIAGNOSIS Upon examination: 784.0 Headaches 847.0 Cervical Sprain/Strain 847.1. Thoracic Sprain/Strain 847.2 Lumbar Sprain/Strain 739.8 Thoracic Rib Segment Dysfunction 839.01 Cervical Subluxation 839.20 Lumbar Subluxation TREATMENT The treatment in this case has been of a conservative nature,including specific spinal adjustment, moist heat,low-voltage electrical stimulation,massage,rest and stretching and strengthening exercises to relieve the patient from the effects of this injury. PROGNOSIS Upon evaluation of the subjective history,consultation and review of the physical examination and x-rays,I have found this injury to be consistent with the type of accident reported by the patient. She was released from our care on December 19,2001 with no residuals. Should you have any questions,or need any additional information,please do not hesitate to contact my office. Sincerely, VVIKalani S.Walther,D.C. Hercules Chiropractic Center xsw/bag I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER: PATIENT: BIRTHDAY: INSURED: JOSEPHINE L RAMIREZ 3182 PI LI 03 12 63 2903 HOWARD STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS ACC DATE: 07 22 2001 FIRST TREATMENT: 08-30a-2001 DIAGNOSIS: 847 0 CERVICAL SPRAIN/STRAIN 847 1 THORACIC SPRAIN/STRAIN 847 2 LUMBAR SPRAIN/STRAIN 739 8 THORACIC RIB SEG DYSF 839 0 CERVICAL SUBLUX 839 20 LUMBAR SUBLUX E812 1 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE PASS ORIG DX: 784 0 847 0 847 1 847 2 739 8 839 0 839 20 ALL RESOLVED DATE DESCRIPTION PROC CODE AMOUNT 10-11-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-16-2001 SPINAL MANIPULATION 98940 38 . 00 10-16-2001 HOT PACK 97010 12 . 00 10--16-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-23-2001 NEUROMUSCULAR THERAPY 97112 33.21 10-23-2001 MANUAL THERAPY TECHNIQUE 97250 44 .28 10-23-2001 SPINAL MANIPULATION 98940 38 . 00 10-23-2001 HOT PACK 97010 12. 00 10-23-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-30-2001 MANUAL THERAPY 97140 44 .28 10-30-2001 NEUROMUSCULAR THERAPY 97112 33. 21 10-30-2001 SPINAL MANIPULATION 98940 38 . 00 10-30-2001 HOT PACK 97010 12 . 00 10--30-2001 ELECTRICAL STIMULATION 97014 12 . 00 11-08-2001 RE-EXAMINATION 99213 25 67 . 00 11-08-2001 SPINAL MANIPULATION 98940 38 . 00 11-08-2001 HOT PACK 97020 12 . 00 11-08-2001 ELECTRICAL STIMULATION 97014 12 . 00 Continued. . . Drs. Walther 01 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3182 520-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER: PATIENT: BIRTHDAY: INSURED: JOSEPHINE L RAMIREZ 3182 PI LI 03 12 63 2903 HOWARD STREET SEX.: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS/ACC DATE: 07 22 2001 FIRST TREATMENT: 08-30-2001 DIAGNOSIS: 847 0 CERVICAL SPRAIN/STRAIN 847 1 THORACIC SPRAIN/STRAIN 847 2 LUMBAR SPRAIN/STRAIN 739 8 THORACIC RIB SEG DYSF 839 0 CERVICAL SUBLUX 839 20 LUMBAR SUBLUX E812 1 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE PASS ORIG DX: 784 0 847 0 847 1 847 2 739 8 839 0 839 20 ALL RESOLVED DATE DESCRIPTION PROC CODE AMOUNT 09-27-2001 SPINAL MANIPULATION 98940 38 . 00 09-27-2001 HOT PACK 97010 12 . 00 09-27-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-02-2001 RE-EXAMINATION 99213 25 67 . 00 10-02-2001 SPINAL MANIPULATION 98940 38 . 00 10-02-2001 HOT PACK 97010 12 . 00 10-02-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-04-2001 NEUROMUSCULAR THERAPY 97112 35. 00 10-04-2001 SPINAL MANIPULATION 98940 38 . 00 10-04-2001 HOT PACK 97010 12 . 00 10-04--2001 ELECTRICAL STIMULATION 97014 12 . 00 10-09-2001 SPINAL MANIPULATION 98940 38 . 00 10-09-2001 HOT PACK 97010 12 . 00 10-09-2001 ELECTRICAL STIMULATION 97014 12 . 00 10-11--2001 NEUROMUSCULAR THERAPY 97112 33 .21 10-11-2001 MANUAL THERAPY TECHNIQUE 97250 44 . 28 10-11-2001 SPINAL MANIPULATION 98940 38 . 00 10-11-2001 HOT PACK 97010 12 . 00 Continued. . . Drs. Walther 01 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3182 510-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER: PATIENT: BIRTHDAY: INSURED: JOSEPHINE. L RAMIREZ 3182 PI LI 03 12 63 2903 HOWARD STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS ACC DATE: 07 22 2001 FIRST TREATMENT: 08-30-2001 DIAGNOSIS: 847 0 CERVICAL SPRAIN/STRAIN 847 1 THORACIC SPRAIN/STRAIN 847 2 LUMBAR SPRAIN/STRAIN 739 8 THORACIC RIB SEG DYSF 839 0 CERVICAL SUBLUX 839 20 LUMBAR SUBLUX E812 1 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE PASS ORIG DX: 784 0 847 0 847 1 847 2 739 8 839 0 839 20 ALL RESOLVED DATE DESCRIPTION PROC CODE AMOUNT 09-06-2001 CERVICAL D-CORE PILLOW E0943 45 . 00 09-11-2001 SPINAL MANIPULATION 98940 38 . 00 09-11-2001 HOT PACK 97010 12 . 00 09-11-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-13-2001 SPINAL MANIPULATION 98940 38 . 00 09-13-2001 HOT PACK 97010 12 . 00 09-13-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-18-2001 SPINAL MANIPULATION 98940 38 . 00 09-18-2001 HOT PACK 97010 12 . 00 09-18-2001 ELECTRICAL STIMULATION 97024 12 . 00 09-20-2001. NEUROMUSCULAR THERAPY 97112 35. 00 09-20-2001 SPINAL MANIPULATION 98940 38. 00 09-20-2001 HOT PACK 9701.0 12 . 00 09-20-2001 ELECTRICAL STIMULATION 97014 12. 00 09-25-2001 SPINAL MANIPULATION 98940 38 . 00 09-25-2001 HOT PACK 97010 12 . 00 09--25-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-27-2001 NEUROMUSCULAR THERAPY 97112 35. 00 Continued. . . Drs. Walther 01 15 02 1581 Sycamore Ave #4 Hercules CA 94547 Acct No 3182 51.0--799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER: PATIENT: BIRTHDAY: INSURED: JOSEPHINE L RAMIREZ 3182 PI LI 03 12 63 2903 HOWARD STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP. OTHER INSURANCE: WORK INJURY. NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS ACC DATE: 07 22 2001 FIRST TREATMENT: 08-30-2001 DIAGNOSIS: 847 0 CERVICAL SPRAIN/STRAIN 847 1 THORACIC SPRAIN/STRAIN 847 2 LUMBAR SPRAIN/STRAIN 739 8 THORACIC RIB SEG DYSF 839 0 CERVICAL SUBLUX 839 20 LUMBAR SUBLUX E812 1 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE PASS ORIG DX: 784 0 847 0 847 1 847 2 739 8 839 0 839 20 ALL RESOLVED DATE DESCRIPTION PROC CODE AMOUNT 08-30-2001 EXAMINATION 99203 70 . 00 08-30-2001 DAVIS SERIES X-RAY 76140 150 . 00 08-30-2001 LUMBAR X-RAY 72100 60. 00 08-30-2001 CERVICAL ORTHO PILLOW W/ CASE E0943 30. 00 08-30-2001 ICE PACK CHIRO ALL-TEMP E0230 10 . 00 08-30--2001 ICE PACS{ CHIRO ALL-TEMP E0230 10. 00 08--31-2001 SPINAL MANIPULATION 98940 38 . 00 08-31-2001 HOT PACK 97010 12 . 00 08-31-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-01-2001 SPINAL MANIPULATION 98940 38 . 00 09-01-2001 HOT PACK 97010 12 . 00 09-01-2001 ELECTRICAL STIMULATION 97014 12. 00 09-04-2001 SPINAL, MANIPULATION 98940 38 . 00 09-04-2001 HOT PACK 97010 12. 00 09-04-2001 ELECTRICAL STIMULATION 97014 12 . 00 09-06-2001 SPINAL MANIPULATION 98940 38 . 00 09-06-2001 HOT PACK 97010 12 . 00 09-06-2001 ELECTRICAL STIMULATION 97014 12 . 00 Continued. . . Drs. Walther 01 15 02 1581 Sycamore Aire #4 Hercules CA 94547 Acct No 3182 510-799-0900 I T E M I Z E D S T A T E M E N T MR LEVI BARANDA CLAIM NO: LAW OFFICES OF RAYMOND BENGERT ADJUSTER: P 0 BOX 5775 HERCULES CA 94547 EMPLOYER: PATIENT: BIRTHDAY: INSURED: JOSEPHINE L RAMIREZ 3182 PI LI 03 12 63 2903 HOWARD STREET SEX: F I . D. # RICHMOND CA 94804 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDENT: YES RELEASE OF INFO ff)1 T_I0N:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS ACC DATE: 07 22 2001 FIRST TREATMENT: 08-30-2001 DIAGNOSIS: 847 0 CERVICAL SPRAIN/STRAIN 847 1 THORACIC SPRAIN/STRAIN 847 2 LUMBAR SPRAIN/STRAIN 739 8 THORACIC RIB SEG DYSF 839 0 CERVICAL SUBLUX 839 20 LUMBAR SUBLUX E812 1 MOTOR VEHICLE COLLISION WITH ANOTHER VEHICLE PASS ORIG DX: 784 0 847 0 847 1 847 2 739 8 839 0 839 20 ALL RESOLVED DATE DESCRIPTION PROC CODE AMOUNT 11-15-2001 SPINAL MANIPULATION 98940 38 . 00 11-15--2001 HOT PACK 97010 12 . 00 11-15-2001 ELECTRICAL STIMULATION 97014 12 . 00 11-19-2001 SPINAL MANIPULATION 98940 38 . 00 11--19-2001 HOT PACK 97010 12 . 00 11-19-2001 ELECTRICAL STIMULATION 97014 12 . 00 12-19-2001 RE-EXAMINATION 99213 25 67 . 00 12-19-2001 SPINAL MANIPULATION 98940 38 . 00 12-19-2001 HOT PACK 97010 12 . 00 12-19--2001 ELECTRICAL STIMULATION 97014 12 . 00 TOTAL 2215. 47 DATE: 01 15 02 Employer ID No Drs. Walther 68-0099246 1581 Sycamore Ave #4 Social Sec No Hercules CA 94547 5101-799-0900 Drs . Walther REPORT: 12 19 2001 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Aug 13. 2002 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given `; d Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". r§' hi UL 14, 1009 f..eri•+K7 4•.. AMOUNT: $33,000 COUNTY COUNSEL CLAIMANT: Laura Burns ?MARTINEZ CALIF ATTORNEY: Birnberg&Assoc DATE RECEIVED: July-19,2002 ADDRESS: 703 Market St#600 BY DELIVERY TO CLERK.ON: July 19, 2002 San Francisco, CA 94103 BY MAIL POSTMARKED: July 18, 2002 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET e; Dated: _ July 19, 2002 By: Deputy 11, FROM: County Counsel TO: Clerk of the Board of Supervisors (0 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: 'V �` f By: L Deputy County Counsel III. FROM: Clerk ofthe 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: "- ;, JOHN SWEETEN, CLERK, By f i `> r ,4 , Deputy Clerk f 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. *For Additional Warning See Reverse Side of This Notice. 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 ay(certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: f .b: r > =F , ° JOITrrT SWEETEN, CLERK By { r / 4• Deputy Clerk uF BIRNBERG&ASSOCIATES Cory A.Birnberg,P.C. ATTORNEYS AT LAW 703 MARKET STREET,SUITE 600 TEL (415)398-1040 SAN FRANCISCO,CALIFORNIA 94103 FAX (415)348-2001 Henry D.Dkum E-MAIL -tsi z'tb�i c Of counsel July 18 2002 VIA CERTIFIED MAIL Clerk of the Beard of Supervisors County Administration Building 651fine Street Martinez, CA q4553 Re: Burns v. County. Our File No. 1923 Gentlemen: Enclosed please the original of our claim in this matter. Sincerely yours, BIRNBERG &ASSOCIATES Cory Birnberg CAB/vb Enclosures \\13irnbag nt\documents\Client\Burns-1929\L,ctters\County_claim.doc zoo f2i [ 96T9 •om oor i st.sr am zooziszrso Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSI'RUMONS TO C[AMT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing craps 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 gimps and which accrue on or after January 1, 1988, roust 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. (Crim. Code §911.2.) B. Claims must be tiled with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pian` Street, Martinez, C".A 9#553. 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 Seo. 72 at the end of this form. RE: Claim By ) 'Reserved for Clerk's filing stamp LA ) F REG IVED7 Aga nst the Ca Ey or Contra Costa � JUL 1 9 2002 or District) CLrq+;"'�"^"r• rr t��;��IS�?FS �{ 1 + YY�H�riYiwYaY�Yy.Y�+i�Ylii The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ °�,� C)CD 0 and in support of this dim represents-as follows: 1. When did the damage or injury occur? (Give exact date and hoar) 2. Where dirt the damage or injury occur? (Include city and county) 3. Howdid the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or mission an the part of =mty or district officers, servants or.employees caused.the.injury or damage? ZO'd T Zt7T SEE GE6 1N3WOUNHW ASIN :)Do 217 a R T ZOOZ-9E—Nnr too i1 C Re•rs -ox gor i 5t:U GU 90OZl9Zl90 20'd -IUMi �a wnat are the names of County or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 1 0 0 0 I �*' � -(-'e-C., Q u_k r c s—s 7• How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Dames and addresses of witnesses, doctors and hospitals. List the expenditures you made on aocount of this accident or injury: DATE ITEM AMCIM StLo� X00 0. O j Gov. Cade Sec. •910;2 prw4des: "The el a. must be signed by the claimant SEND NOTICES TO: (Attdr ne ) on his.behalf.* Name and Address of Attorney C-O" r'A I"', i, - i .1 0 _ la t sSignatureT Telephone No. t, '�3 'w Telephone No. 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 beard 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, mount, voucher, or writing, is punishable either by i prisonmen.t in the county Jaii;l•for a period of not more than one•year, by a fine of not exceeding one thousand ($1,000),, or by •bath such imprisonment and fines•�or by imprisonment in the :Mate prison, by a fine of not exceeding ten thousand .dollars ($1.4,000, or by both such imprisonment and fine. 201d TEPT S22 Sig _LNSWDUNdW ASIN X30 217:CT ZOOZ- -Nnf BIRNBERG&ASSOCIATES Cary A.Birnberg,RC ATTORNEYS AT LAW 703 MARKET STREET,SUITE 600 TEL {415}39&1040 SAN FRANaSOD,CALIFORMA 94103 FAX (415)398-2001 Henry D.Dim= E-MAIL birrrbaobimbergcom Of Counsel ATTACHMENT TO CLAIM OF BURNS To Whom It May Concern: With respect to the civil actions taken in a civil case by Teri Mockler,one of your Public Defenders. Her actions cost my client thousands of extra dollars. I was not aware of the jail policy not to transport prisoners for civil matters until June 7, 2002 when I appeared on the continued hearing on the prisoners(Olivas')restraining order and even the court could was unable to have him transported. Upon further, investigation,Teri Mockler arranged his transportation against the rules on April 19, 2002. I checked independently with the jail and the rules apparently prohibit the transportation of prisoners for civil matters. I aryl the civil attorney for Ms. Burns. Please be advised that I represented Ms. Burns at the civil restraining order(brought by Mr. Olivas in Pittsburgh)hearing on April 19,2002 and I personally saw Teri Mockler at this civil hearing. I personally observed her hand documents,including a tape recorder and tapes,to Mr. Olivas to use for the hearing. She told me and then the judge that she would not represent him civilly,but came to bring him the"stuff'for his hearing.We appeared and the judge. Mockler told the judge she intended only to observe and not to represent Mr. Olivas.We adjourned for a time. I exited the courtroom and conversed with Mockler for a short while about the case. I appeared for the continued hearing on June 7,2002 in Mr.Oliva's Application for a Restraining Order. Apparently,despite Judge Dan O'Malley's order and request the Sheriff department refused to transport him for a civil case. Again,apparently the rule is that prisoners are not to be transported for civil cases. Beth,Judge O'Malley's clerk,called me on Wednesday,June 5,2002 and wanted to know how I was able to have Mr. Olivas transported for the first hearing on April 19,2002. I informed her that I did not have him transported and thought he had simply asked to be transported. I had one of my staff call the sheriff one-hour before that hearing on April 1.9, 2002 and we were informed that Olivas was not on transport list. On June 7,2002 after our hearing,Beth informed us that apparently Teri Mockler had arranged in part for her criminal case for the April 19,2002 hearing. Mockler attended that April 19 hearing with evidence,including,inter alis, a tape,documents and a tape recorder to play,but told Judge Hammer she was not appearing on Olivas' behalf and was merely there as an observer. When confronted with all the"new evidence"I continued the April 19,hearing. Clearly Mockler was seeking to obtain a different decision in the civil matter as res 'udlcta in the criminal—or at least as persuasive authority. Further, since prisoners cannot be transported in a civil case,how did Olivas obtain transportation for this one? Teri Mockler,I believe,exceeded her powers in her role as a Laura Burns- facts for claim Page 2 of 2 18 July 2002 public defender in arranging this transportation and participating in a civil matter. This was totally inappropriate. As far as my client is concerned,I am in San Francisco and the travel time,preparation,&etc. was very costly for me and my client. Secondly, after the April 19 hearing I interviewed seven witnesses,prepared extensive briefing and made various motions,all of which would have been unnecessary had we known on April 19 that Mr. Olivas could not be transported and could not appear on June 7,2002. Surprisingly,none of Olivas' witnesses for whom we adjusted the date for attended including Officer Tom Furhman. The problem from our perspective is that if the hearing dict not go forward on April 19,2002,Laura would not have taken the deposition of Tom Furhman,she would not have had to hire an attorney and spend a significant amount of money to defeat the restraining order----all resulting from Mockler's abuse of power in transporting a criminal or prisoner for a civil matter which was in fact prohibited and not the proper policy. Thank you for your consideration. Sincerely yours, B .... RG &ASSOCIATES f Cory Birnberg 11Bir�ntkdcuments\Client\Bums-1929U..euessstfaM FOR CLAN.doc CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Aug 13. 2002 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: unknown COUNTY COUNSEL. MARTINEZ CALIF. CLAIMANT: Brian&Alison Haux ATTORNEY: DATE RECEIVED: July 25. 2002 ADDRESS: 153 MacAlvey Dr BY DELIVERY TO CLERK ON: July 25. 2002 Martinez, CA 94553 BY MAIL POSTMARKED: July 24, 2002 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEFfTE ,HCl " ' c Dated: July 25, 2002 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). O Other: ,� ., r `' r Deputy County Counsel Dated By: 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. { - s JOHN SWEETEN, CLERK., By � As� f s beputy 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 945.5. 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. *For Additional Warning See Reverse Side of This Notice. 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,4sidressed to the claimant as shown above. .J '.�:.FiR r 'F,, ''i" I� �i S �S k „`vY JOHN SWEETEN, CLERK By ; �i ,., , , Deputy Clerk Dated. Brian Haux Alison Haux ix RECEIVE` 153 MacAlvey Dr. � r Martinez, CA 94553 'JUL 2 5 200? (925) 372-3348 CLERK BOARD r In propria persona CONT" CLAIM AGAINST THE COUNTY OF CONTRA COSTA TO: The Board of Supervisors County of Contra Costa 651 Pine St., Room 106 Martinez, CA 94553 PRESENTED BY: BRIAN HAUX and ALISON HAUX, Claimants CLAIM FOR PERSONAL INJURIES, WRONGFUL DEATH You are hereby notified that Brian Haux and Alison Haux (hereinafter described as 44 claimants"), whose address is 153 MacAlvey Dr., Martinez, CA, 94553, telephone number (925) 372-3348, claim damages from the County of Contra Costa. This claim is based on personal injuries sustained by claimants as the result of the wrongful death of their son, :KEITH HAUX, hereinafter G4decedent", on or about January 29, 2002, at the Diablo Valley Ranch for Contra Costa County. At said time and place, and on or about said date, decedent KEITH HAUX, while residing at the Diablo Valley Ranch, hung himself until he died. At all times herein relevant, decedent was suffering from mental disorders and had self destructive tendencies, which disorders and tendencies required immediate medical care and treatment. At all times herein relevant, decedent was a resident of Diablo Valley Ranch, and was seen as a mental health patient at the Contra Costa Regional Medical Center on or about January 28, 2002. Various Contra Costa County employees, whose names and identities are unknown to Claimants, including employees of the Contra Costa Regional Medical Center, and the Diablo Valley Ranch, were aware of, or in the exercise of reasonable diligence, should have been aware of the medical disorders, including the self-destructive tendencies, of decedent, and his need for immediate medical care and treatment. The aforementioned Contra Costa County employees, among other things, negligently and carelessly failed to supervise, oversee, take the necessary precautions to ensure that the decedent would not injure himself and/or take his life, and failed to diagnose, treat and obtain the appropriate medical care and treatment for decedent. As a direct and proximate result of the negligence of the County of Contra Costa employees and their failure to obtain immediate medical care and treatment for decedent, decedent, on or about January 29, 2002, hung himself and died. The damages sustained by Claimants as far as known as of the date of presentation of this claim are as follows: the loss of love, comfort, care, society, support and companionship of their son, KEITH HAUX. Jurisdiction over this claim would rest in the Superior Court. All notices or other communications with regard to this claim should be sent to: Brian Haux Alison Haux 153 MacAlvey Dr. Martinez, CA 94553 (925) 372-3348 DATED: 't - 2-Y- b 2- BRIAN HAUX � ALISON HAUX CLAIM (? BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION; Aug 13,2042 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT- $648.29 CLAIMANT: Zenith Insurance Co ATTORNEY: Mark Klein DATE RECEIVED: July 12,2002 ADDRESS: 4309 Hacienda Dr#200 BY DELIVERY TO CLERK ON: July 12, 2002 Pleasanton, CA 94588-2730 BY MAIL POSTMARKED: July 11, 2002 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. i JOHN SWEETE ';�i Dated: July 12,2002 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors (y)"'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: %`�'�' -� _..�`�. B '`.��'-,` � y: l — 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. , h, - >? . Dated.i 1 .; ' JOHN SWEETEN, CLERK., By Hff ;f Deputy Clerk WARNNG (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. *For Additional Warning See Reverse Side of This Notice. 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: i , x `'` ' > - JOHN SWEETEN, CLERK By s f' � "y � '' � Deputy Clerk I MARK S. KLEIN (SBN 71512) CHERNOW AND LIEB 2 Attorneys at Law 4309 Hacienda Drive, Suite 240 3 Pleasanton, California 94588-2730 Telephone: (925)416-5380 e RECE , 4 Facsimile: (925)463-3868 - iUL 12 20 } 5 Attorneys for Claimant € f ZENITH INSURANCE COMPANY, � r, 6 r a corporation c�s, ri,�lS. ;.ac 7 8 9 10 Claim of ZENITH INSURANCE COMPANY CLAIM FOR WORKERS' COMPENSATION SUBROGATION 11 vs. 12 CONTRA COSTA COUNTY FIRE DISTRICT, 13 Defendants. 14 15 TO: CONTRA COSTA COUNTY FIRE DISTRICT: 16 1. Claimant, Zenith Insurance Company, whose address is 4309 Hacienda Drive, Suite 17 200, Pleasanton, California, 94588, claims damages from Contra Costa County Fire District in 18 the amount of$648.29 and continuing for worker's compensation subrogation damages as a 19 result of injuries to insured employee, Christopher Simpson. The claimant insured the employer 20 Spencer Star Coffee Service, Inc. 21 2. Jurisdiction over this claim in Superior Court, Limited Jurisdiction. 22 3. This claim is based upon the following circumstances: 23 A. On January 15, 2002, Contra Costa County Fire District employee, Kody Kerwin, 24 was operating a Contra Costa County ford truck, when that track collided with and rear-ended a 25 vehicle by Anthony Crimmins, also an employee of Spencer Star Coffee Service, Inc. 26 B. This accident occurred on I-80 eastbound, 450 feet east of Gilman Street, in Albany, 27 Alameda County, California, as more fully set forth in the attached police report 01-218, 28 attached hereto as Exhibit A. CLAIM FOR WORKERS'COMPENSATION SUBROGATION(Simpson) I C. Pursuant to Labor Code §3850, et al, and a policy of workers compensation 2 insurance with the employer Spencer Star Coffee Service, Inc., Zenith Insurance Company has 3 provided worker's compensation benefits to or on behalf of Christopher Simpson, and those 4 benefits are continuing. 5 4. Kody William Kerwin is the public employee of the Contra Costa County Fire 6 District whose negligence was the proximate cause of Christopher Simpson's personal injuries and 7 Zenith Insurance Company's damages as set forth herein. 8 5. The damages of Zenith Insurance Company are $648.29 in medical and nothing has 9 been paid as of this in indemnity. 10 6. The damages are expected to include future medical and fixture indemnity as 11 provided by the Labor Code. 12 7. All notices and communications concerning this claim should be sent Mark S. 13 Klein, Esq., Chernow and Lieb,4309 Hacienda Drive, Suite 200, Pleasanton, California, 94588, 14 telephone number(925)461-5250; facsimile(925)4633868. 15 Dated: J �` c 16 D Stoval, Claims Adjuster Z KITH INSURANCE COMPANY 17 18 1.9 20 21 22 23 24 25 26 27 28 _2_ CLAIM FOR WORKERS'COMPENSATION SUBROGATION CASE NO.: 1' f Yt ------- EXHIBIT A k; C G' c: C { {I 555 } { k. { k. #f: 3 �� r E; t 5 h b F444,, L' L Y k i } }{$}{ x 'r {{{� f E 3 STATE OF CALIFORM A TRAFFIC:COLLISION REPORT 1 CHP�: i "7 OPI042 Pagis 1 at � SPHC3AL I� E WACITY • .ri.AStCtA:,DiSTR1CT ',LOC.AL REQORT tlfJAl9ER ,�..._._��.... i kvmw oS fo M 4 n* I COUNTY RP-PORTT14G DtmtCT SEAT Y d2 nt Cry I i OOWSiCN Q=mwen ON MO. DAY TEAR I TIME(2440) NCtC t t OFFICER F D. j ,,;, tMIED'b$T lli0(R1i/. DAY OF VW-K g TOW AWAYPHOTOGRAPHS By: YORE i Ll 50 FEfT - � So* is MOW T F S i u YES NO j _! Ei [hT R(tPffl WcTION UMTtt STATE HWY REk i ! DR r� Tn�wra DF i l Ik E k r/ fid € YES € NO #*A1ZTY.DIRNER'i LLLIJSE'NG4BEA j STATE Ck458 SAFETY V€H.YEAR ,MAKEAWOOEVOOLOR Ltcvm NUMBER r STATE 16 0( 1 D c,¢ EQUIP, o x NAME#Wgr,,4004 LAST) � $ { � i f ✓_ OWNER'S NAME i SAME AS DRIVER t" 0 (J'LAj ( PLG4 o�NE/Pyt S ADDRESS �j €( SAME AS DRIVER /� 5 r� #h fi}I�ICITYISTATEMP T t 'T-fZ�„ L.-t n &7V 40-M•J A ' 7 tl,5 F (i CA % DIaPi>SiTlONDP v6angaE C)tt 8 ots: { [3 OFFICER WAR L.OTHER lop. ox imp tt mia"Tcm W�IlT $iRTNDATE RACE t d , / e* Ma. Day Yaar ) DEFECTS. NONEWMW RSFR TO tiMPW 0.`-1 ByiNERj HOME FFgNE ,SUSMESS PHONE VEHICLE IDENTIFCCA"Ni NUMBER: i CHP USE ONLY f DESCRme vewAE oAmAC@ SHADE IN DAMAGED AREA loft vica CARR POLICY NUMBER VEMCLE T pf UNK NONE MINOR CQ ")' ro ro v - ,5 �L r j t 4- [�}neoa. MAJOR ROLL-av,R ONR OF TRAVIEL DN STREET OR HK;*wY SPEED E.;MfT CA DOT_._. ... 1 CAk•T T'CP7PEC , PARTY f7R1VFRSIJCEIVRIC hkkAtlYT}L STATE CI.ASa SAFETY VEH.YEAR MAKEIMODELL OLOR LICENSE NUMBER STAT€ 2Qw+ d L i CSL + Er �4flnl rf 11fG _ _ 5,96),1 +` 1 NAM �n�xsr�,twa�,a( usrs _ r t i.—i-iQ€ W!W 1 j jf f GwFtER S tyt SAME As DRILLER � S _ STREET ADDRESS G v'JQm G�� ♦V e 1-11-1 C Dr CVVER'a ADDRESS SAME AS DRIVER+ !f�'�`"s CffY1a(T`'AT'BIYiR ,�y-, .__a"+_ rt /� r EAS/� t 'f iG •f r ) l� 1 (t 1 C A _ q �'F F3 0 c DISPOSITION OF YEHt=ON ORDERS OP: � CIFFICER DRI3iER O7#iER '• 9'X mm R S t -TONT WEIGHT W RTHDATE RACE !. ctuT _ P Y r r Mo, Y A W PtEtGF M-CHAN CAL DETECTS: f N{NtE AAPARENT' RMR 7D NARRATtW— eTII+ / `l F�♦ i�PHOW t �Wjmwss PFIONE VEHICLE IDENTfF#CATION NI R: CHP USE ONLY DESCfIIBE VEHICLE DAAfAQR aHAS,>E IN DA1tACtED A.R✓t VEHICLE TYPE t; GARJtiMt POLICY NUMBER F�LINK []NONE MINOR ` j%7 Lr—F"7 6 7-14&v �MOD. �DYtA it3R�ROLL-OVER LtMiT Y d�T4RA'�t,dVIKTR@7ET DR kNOhNSIAY ,SPEED E CA DoT ..- I CAL^T TC.�RMDC MC1M)L I PARTY I.ICBtA9@ NWMB R STATE •CIASB SAFETY YEN.YEAR .AOR LkeeNBE NUAESI R t STATE i R I EAUIP. y i t 6MYRR NAME"ST,WMA i.A8i) Y i - - - !{ _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ ( i OVOOMNAME � SAME AS ORtVER E aTREETADDRESa j 1 DVYNER•B ADDRESS t�'3 SAME AS OMER `. ►rtle� EE'Y78TATEltIP L...1 ` DISPOSITION OF VEHICLE ON ORDERS OF: El OFFMA E]DRIVER �OTHER I L.._t a" HAW, EYES !HMW VmwiT i INRTYOATE iRAOE i ... YNMoDy i PR MECHANICAL zEcTs:PNONE APPARENT REFER TO WAPATIVE � oEaKII NOW PHC*& � BLISKaEBe PHONE VEHICLE tbENi FICATION NUMBER: � s CHP Usa QALY "WE V&ilCk.l€"WOE SHADE tN MWAOED AREA , sNSURANCE CARWER POLICY NUMBER VEHICLSFUNK TE ' t FINK O NONE []MIW-A II El MOD. L]MAJOR 0 ROLL-OVER OF TR,tVEi.ON STREET OR HKHMVAY SPEED LIMIT CA DOT CAS.-T 'CF'NSC asRePaReR'S NAMEDISPATCH NOTTWOREVIEWER'S NAME EEDATE REVIEVWD STATE OF CALIFORNIA TRAFFIC.COLLISION CODINL �- ' DATE 001 COU00H 0H 040 *AY Y1tAIL1 t TREE a4m 4=f•...��•J••• -»» �orf:'mast 4.4` oi - of 218 f PROPE YES L__j_1 NO DAMAGE RIP rON OF OAMAGE 1_7SEATING P08tC`IONSAFETY EQUIPMENT EJECTED FROM VEHICLE OC PAl L-AIR SAG DEPLOYED M f C BICYCLE-HELMET VEHICLE M-AIR SAG NOT DEPLOYED u-NGT EJECTED {B-UNKNOWN N-OTHER DRIVER t•-FULLY EJECTED {: w-LAP BELT USED P_40T REOUIREG V-NO 2-PARTIALLY EJECT:D i D-LAP OELT NOT USED W-YES 3•UNKNOWN { # 2 3f-DR E-SHOULOER HARNESS USED 2 rO 8-PASSENGERS F•SHOULDER HARNESS NOT USED CHiiD R@ TRATNT PASSENGER 4 5 S 7-STATION WAGON REAR G-LAPI$HODUWR HARNESS USED ��`�D X-ND t $•REAR OCC.TRK,OR VAN H,L kArSHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 9-POSITION UNKNOWNK,PASSIVE RESTRAINT NOT-PASSIVE RESTRAINTDUSED T-N VEHIC E IMPROPES-IN VEHICLE USE R USE { �{ 0.OTHER U-NONE I%VEHICLE # ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK I')SHOULD BE EXPLAINED IN THE NARRATIVE. { E MOVEMENT PRECEDING PRFWFACMTRXFG CONTROL eCEB # 2 $ TY"OF VEHICLE 12 3 ;L87I ! t A c a tacssa .a trEo cit u Gt7kTRCFLO_UNCT 7tVN4�s A PA$$E3iCsER CAR r STATION WAGON I A 5TC?PPED C£ONTI�3f..3,�NOT FUNCTIONING* �PA$s�TtGER CAK LV r Ti lJtlL£f2 8 Pi 2pg ING STFLA GHT QTHER IMPROPER ORIVIN+3* CONT ROLS "CUREt3 C MqT RCYCI.E t SCOOTER C OFF RtT,40 NO t'R1 tiT A F/kCTOR• 1 PIC.(fLlt'OR PANEL tGHT T RN OTS9ER THAN'I RMA* 7 y Of VOL. fOt P1�KUP t PAM:TRUCK Wl T4tAtLER E MWONG LEFT TURN UNKNOWN" HEACO ON F TRUCK OR TRUCK TRACTOR P` MAKING U TURN E FELL ASLEEP* $ 3iI E SWIPE G TRUCK f TRUCK TRACTOR Wf MR, G BACKING -- �`REA fi END H SCHooL Bus 1H SLOWING f STOPPING WFATImm&AM I rO 2Imi3 I D BROADSIDE i I {OTHER SUS I PASSING OTHER VEHICLE - A CLEAR E HtT OBJECT J EMERGENCY VEHICLE J CHANGINGLANES _._._ $ CLOUDYI4 OV!RTtJRNED aK HIGHWAY CONST.EQUIPMENT _ K PARKING MANEUVER–__ C RAINING i CtVEHICLE i PE)ESTRWN i t. BICYCLE # ENTERING TRAFFIC — NOWIHG i H OTHER': M-OTHER VEHICLE %M OTHiER UNSAFE TURNING FOG r VISIBILITY FT N PEDESTRIAN --_ Y N RING INTO OLAN AN FOTHER*: — TiFOTCTR 1tE!#CLE 3N1fQLV€33 WSTH 0 MOPED _ d PARKED A NON-COLLISION � � P MERGING LAt3"NG 8 PEDESTRIAN TRAVELING WRONG WAY_-._ tlr A DAYLIGHT C OTHER MOTOR VEHICLE T Z ; OTHER ASSOCIATED FACTOR(S} � R OTHER 18 QUSK-DANM MOTOR VEHICLE ON OTHER ROADWAY (MARK f TO 2 rTt MS} i— C DARK-STREET LIGHTS I E PARKED MOTOR VEiICLE A c saCttwty ocxt m ciraa�YES i D DARK-NO STREET LI0HT$ F TRAIN No,.,,__ iE DARK-STREET LIGHTS NOT BICYCLE csccror��auna+• aet€Q YEa tFUICTo"o- iH ANIMAL: SOBRIETY•OR U3 !em—* 84FAM �. cl. YeS 1 2 { PYCAL FIXED OBJECT: (MARK frf2fTEMS ) 7-11 DRY VST A HAD NOT BEEN DRINKING C SNOWY-iCY :J {OTHER OBJECT VISION OB$CURr1FEw: B HSD-UNDER INFLUENCE to SUPPERY Y 013:Y:ETC.` I P INATTENTION*: C HBO-NOT UNDER INFLUENCE ROADWAY OOND('"OWS) i STOP 6 GO T R 1FFIC D HOD-IMPAIRMENT UNKNOWN -t {MARK f TO 2 ITEmsj }{ ENTERING t LEAVING RAMP E UNDER DRW INFLU€NCE t K]I ES DEEP RUT" NoPEKtE57 itli�AM2S IMfCN VE0 PREVIOUS COLGt3ION F tMPAtRMENT-PHYSiCAL' .- -! B LOOSE MATERIAL ON ROADWAY* a CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN — C OBSTRUCTION ON ROADWAY* AT INTERSECTKSN ± K DEFECTIVE VEH EOUiP.: CITED + H NCOT APPLiCAOLE _.J t CONSTWUCTtfON_REPAIR ZONE C CROSSING IN CROSSWALK-NOT YEX i f RED D ROADWAY WIDTH AT INTERSECTION F t*Lootft* 0 CROSSING.NOT IN CROSSWALK tJNiNYOLVE0 VEHICLEA Kg RDLTUS MATERIAL OTHER': I E IN ROAD-INCLUDES SHOULDERO'TtiEtt`. t I H NO UNUSUAL CONDITIONS i~ NOT IN ROAD NONE APPARENT C' IQ APPROACHING I LEAVING SCHOOL.BUS RUNAWAY VEHICLE vAi ' L Lff ( H +2`- +2f 1 A 1'2f1 t S MISCELLANEOUS t1 CA i NNNE 1404 H F-A r OF6fkoAv V/c' � { I { c,,A f3Arwn v I�-ss w18 -rrtA>✓z,rt � � 4trC.WYkkTk� { i?FI.I+T IYtA/4 Gl�.1l�lrrJ ST :��.. c��ca€ cl=�.•Tr� /ry � �-t4 ,SFti11AA'Af1C £1.j1 A$PrtArLr 1 STATE Cf CALWORNIA INJURED I VATNESS I PASSENGERt* P4942 -r� FfP v, 7 #gla _ DATE O'COf.lf$it)N(Mf}. DAY 0*1 v�txKEs ( P�asErto Acftl( sex EXTENT OF INJURY("X"ONE) INJURED WAS("VONE) PARTY � SEAT aaFEtw v _ i 0.4f.Y # C#d.Y t t FATAL 6€XERE Olwot VWRLE COMPkANT fJRtYLR PA$1Se i t+Et3, t fifGYCi3ffiS OSltE€4# XutdEER } PO3. EOufP. u� # ..... 3N,7(iftY ffV1tMY tti7E}itY OF YAIk. . 71D I evi- ItNittAMONLY;TJ2dMWOR:TED BY, , <v'ESGZ�BE iN.Si1R;$S ! � vtC�vtM CF),lzxENr CRiMENcrrt:;ED r , Li a F C`J-B.i ADDRESS .F.-EPHOONE� ! I::tdMEO ONLr TRANVORTED BY TAKEN TO E DESCRIBE twt"Ates OF VncLE I CRIME NOTIFIED Li I, I NAW!G.O 8.!ADDRESS TELEP'riONE (!Nt URED ONLYy TRANVORTED 8Y TAKEN TO I 6ESCR!$@ W.UR!ES OF vlotX14T CRIME NOTEFtEC � .....__..... t NAME f 05 0 B.AA.ot�k-�Es.B TELEPHONE ONLY;TRANSPORTED$Y: � �.. TAKEN TO' �. V4TIM OF VOtENT CRON NOTIFIED El 0 MAW 10,0.$.r ADORE" TELE#SFFONE } IS%,11;€fEO Z)Nt.Y}TRAN3Pt YTEii BYTAKEN TO !II �t�.SCRiHE3NJ{dRf@S MTtM OFVIOLEN7 CRME.NoInFIED NAME 10.0.B.f ADORE" Tf'i&PNf�NE }I(iNJ3lRE0 ONLY)TRANSPORTE69Y; TAKEN TO: �' ^--------...--- __ i CEsmsE SN.tUREES i 1 ` VtCTfM OF VlOt.ENT,CRIME NOTMW 1 PREPARER'S NAME t.0.NUMEER MO. DAY MOM REVIE'WEWS NAME IMO. DAY YEAR t STATE OF CALIFORNIA �f NARRATIVE ENTAL PAGE '5ATL OF tNC IDEN'T TWE N7fC?ii KIM-#. OFFICER I.D3 NUMBER 01-15 -02 1125 9370 14191 1-218 I FACTS: 2 3 NOTIFICATION: I advised Golden Gate Dispatch of a non-injury collision at 112£ hours 1- 4 80 EIB east of the Gilman Street U/C. All tunes, speeds and measurements in this 5 investigation are approximate. Measurements Were taken by estimation,except Where 6 otherwise indicated. 7 8 SCENE: At the scene of this collision, 1-80 is an eastbound freeway consisting of five lanes. 9 The roadway is straight and level. The surface is composed primarily of asphalt. 10 I I PARTIES: 12 13 Pa y`# l(Kerwin)was located sitting his vehicle. Party Kerwin was identified by a valid 14 California driver's license. Kerwin Was placed as a party by the following items: 15 16 - personal statements I7 - being in possession of the vehicle's keys 18 19 Ford Pickup (V-l), Driver# 1's vehicle, Was located on its wheels on the right hand shoulder 20 of I-80 E/13 east of the Gilman Street U/C. 'V-1 had minor damage to the front end. 21 22 Party# 2 (Crimmin was located standing next to his vehicle. Party Crimmins was 23 identified by a valid California driver's license. Crimmins was placed as a party by the 24 following items- 25 26 - personal statements 27 - being in possession of the vehicle's keys 28 29 F€�n,O�:„2,},Driver# 2's vehicle, was located on its wheels on the right hand shoulder of 30 1-80 E/13 east of the Gilman Street U/C. V-2 had minor damage to the rear enol area. 31 32 PHYSICAL EVIDENCE: Physical evidence consisted of damage to V-1 and V-2. 3 34 STATEMENTS: 35 36 Party# 1 (Kerwin) related that: I was driving on 1-80 EB in lane#4 at about 50-55 mph. I 37 notice that the vehicle ahead of me was slowing down. I attempted to stop but Was unable to 38 stop in time and hit the slowing vehicle. 39 PREPARER'S NAME T.D. NUMBER DATE. REVIEW'ER'S NAME BA'T'E P.CRt Z 14191 01-15-42 STA-"r bF CALIFORNIA NARRATIVEISUPPLEMENTAL PAGE DATE OF INCIDENT TIME NCIC NUM13FR OFFICER I.D. NUMBER 01-15 -02 1125 9370 14191 1-218 rte,,# 'Crimmins related that: I was driving on I-80 EIB into # 4 at about 25-30 mph 2 due to some strap and go traffic. The stop and go traffic was due to some debris in the 3 roadway. I was suddenly rearended by the vehicle behind nae. 4 5 OPINIONS AND CONCLUSIONS 6 7 SUMMAU: P-l(Kerwin) was driving V-1(Ford PicFeup)on 1-80 EB in lane #4 at about 8 50-55 mph. P-2(Crimmins) was driving V-2(Ford Van)on 1-80 E/B in lane#4 at about 25-30 9 mph in stop and go traffic due to some debris in the roadway. P-1(Kerwin) driving V-1(Ford 10 Pick-up) saw slave traffic ahead. P-1(Kerwin) attempted to stop but was unable to stop in time 11 and hit V-2(Ford Van). 12 13 AREA OF IMPACT: A01# 1 was located 454 feet east of the Gilman Street U/C and 18 14 feet mirth of the south roadway edge of 1-80 EB. Statements from parties involved 15 determined area of impact. 15 1? CAUSE: P•l(Kerwin) was the cause of this collision by being in violation of 2.2350 VC — 18 unsafe speed— no person shall drive a vehicle upon a highway at a speed greater than is 19 reasonable or prudent having due regard for weather, visibility, the traffic on, and the surface 20 and width of, the highway, and in no event at a speed which endangers the safety of persons or 21 property. Statements and damage to vehicles involved determined cause. 22 23 RECQMN ENBATIONS 24 25 None. 26 PREPARER'S NAME I.Da NUMBER DATE REVIEWER'S NAME DATE P.CRUZ 14191 01-15-02 CHERNOW AND I.JIEB Attorneys at Lary SANDRA B.ARNOLD DANIEL T.MAr.EELLA 43139 Hacienda Drive,suite 200 ®200 WASHINGTON STREET,SUITE 105 NORMAN BEEGUN BARSARA A.MENDENHALL REPLY TO: F.O.BOX 7520 DUANE IL CHERNOW ROBERT MYERS Pleasanton,California 94588-2734 SANTA CRUZ,CALIFORNIA 95061 JOSEPH P.FLANAGAN MARK E.OLMtI PAULA N.HARRIS CHERT EATON PAVONE TELEPHONE NO.(831)429.2747 EDWINA J.HEINE CATHRYN R.PINE Tele hone: (925)460-13600 FACSIMILE NO.(831)421-0581 COREY A-INGDER STEVEN M.POPKO RICHARD W.JOHNSTON TOMAS C.RMSPIC Facsimile: (9255)463-3868 WRITER'S DIRECT DIAL NUMBER VIDYA M.KALE P.JOSEPH SCHNEIDER MARKS.KLEIN WARD D.SKINNER (925}416-5250 JACK M.LESTER L RAY STANEK JEROME LEVIN JUDITH L STEHR TEMA A.LEVINE ALAN L STEINHARDT PHILIP L.MACH ALEX S.CREILNOW(1926-1985) DONALD C.LIED(1928-1991) July 9, 2002 JUL 12 nu Clerk of the Board of Supervisors 3 r County Administration Building 651 Pine Street, Room 106 Martinez, California 94553 Re: My Client - Zenith Insurance Company Claim Number - 100005 Injured Worker - Christopher Simpson Employer - Spencer Star Coffee Service, Inc. Date of Loss - January 15, 2002 Dear Gentleperson: Enclosed please find the original and two copies of the Claim for Workers' Compensation Subrogation. Please file and return a conformed copy in the enclosed envelope. Very truly yours, Mark S. Klein MSK:dmd APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY,CALIFORNIA BOARD ACTION Aug 13, 2002 Application to File Late Claim } NOTICE TO APPLICANT Against the County,',Routing } The copy of this document mailed to you is your Endorsements, and Board Action. } notice of the action taken on your application by (All Section References are to ,- } M the Board of Supervisors (Paragraph III,below), California Government Code % given pursuant to Government Code Sections 911.8 and Ll AUG 5 Z00'. 915.4. Please note the"WARINING"below. Claimant: Nancy NetoCOUNT, COUNSEL Attorney: MARTINEZ CALIF. Address: 1290 B St#112 Hayward, CA 94541 Amount: $339.10 By delivery to Clerk on July 26, 2002 Date Received July 26, 2002 By mail, postmarked on I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Latm ` ` / DATED: July 26, 2002 JOHN SWEETEN,Clerk, By # G � Deputy Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). *✓J The Board should deny this Application to File Late Claim(Section 911.6). DATED: 6-21-- SILVANO MARCHESI, Count Counsel, B "` ' - y y Deputy lII. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). (° } This Application to File Late Claim is denied(Section 911.6) t I certify that this is a true and correct copy of the Board's Or entergd in its rpinutes for this date. DATE: ;#ice. Y ` r ---JOHNSWEETEN, Clerk, By t `� � Deputy Clerk WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6)months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your choice in connection with this matter. If you waist to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED:I� �s` JOHNSWEETEN, Clerk,By. � � R. Deputy Clerk V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM 06/,21/2002 15:42 5105378582 NET PACE 01 Grou of Coni a.ies Neta Insurance Agency 1290 B Street. #112, Hayward , Ca. 94541 (510) 537-3500 Fax: (510) 537-8582 Toll Free 877-838-9118 Date: June 21, 2002, 2:22pm Number of pees including co r!h=t: To: PENNY Fax number: 1-925-335-1421 From: NANCY Re: 48577 HELLO FENNY, IT WAS A MINOR.REPAIR BUT I COULD NOT TAKE CARE OF THE REPAIR FOR PERSONAL REASONS: MY HUSBAND HAS BEEN SERIOUSLY ILL. I COULD NOT TAKE ANY TIME OFF AND I ASSUMED THAT I HAVE STATUTORY LIMIT OF ONE YEAR FROM THE BATE OF THE ACCIDENT, I WAS NOT INFORMED WHEN I HAVE SPOKEN WITH PENNY INITIALLY ABOUT THE 6 MONTH STATUTORY LIMIT FOR THE CITY. PLEASE, )YORK WITH ME ON THE LIMIT. NANCY NETO 06/21/2002 15:42 5105373582 NET PACE 02 Claim to: BOAM OF SUPEW SM OF Cf,1nU COSTA C00M 1N.TMCTIM TO CLAI.?ME 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. Cla.iw relating to causes of action fors.death or for injury to person or to personal property or growing crops and uhich accrue can 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 gather Cause of action must be presented not later than we year after the accrual of the Cause of action. (Govt. Code B. Claims must be tiled with the Clerk of the Board of Supervisors at its office Rocc 106, County Administration Building, 651. Fire Street, Martinez, CA 94553. C. if' claim is against a district governed by the Hoard of Supervisors, rather thar: 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. B. Fraud. See penalty for fraudulent claims, Penal Cade Sec. 72 at the end of this farm. RE: Claim By Reserved for Clerk's Filing stamp RECECIRVE Against theGtr ty i of Contra costa � JUL or District) CLERK R-OArf,9 OF SUPERV,,�u, ) �1 CCST�t Co." The imdersigned claimant hereby makes claim against the County of Contra. Costa or the a.bOve-named Dist in the Sint sof y'�r�2 .i'?-- aid in supportof this cla.ir, represents as ,fc howl: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or ijury occur? (Include city and county) 3. How did the damage or injury occur' (Give full details; use extra paper if required.) t" ornoae an un%Le 4. What Particular act Cr omission can the part of county or district officers, servants car .employees ca=ed the.injury or damage? SCJ'ci T �H S Sr 5 iN3W9dNtJW >IS I,a O T:e T EOOZ-T�!-N,1 .. 06/21!2002 15: 42 5105378582 NET PAGE 03 20'd Idiol wnat are the names of county or district officers, servants Or employees causing the damage or injury? 6. What doge or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Hoer was tw c t claim above crziputed? (Include the estimated ammmt of any prospective injury or damage.) -UL 8. Names and addresses of witnesses, doctors and hospitals. 9• List the expenditures you made on account of this accident or injury: A'iE ITEM AWWNT Gov. Code Sec• 910;2 provides: Me claim must be signed by the clairwt SM TICS TO: (Attome ) or is .n Name and Address of Attorney C3 i s Si, tW,i lI (Address) Telephone No. Telephone No.� N 0 T I C E Section 72 of the Perm.? 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 mwe than one year, by a time of not exceeding one thousand (�1,000), or by both such im orisorbent and fine i. or by imprisonment in the state prison, by a tine of not exceeding ten thousand dollars {$1(7,000, or by bath S h imprisonment and fine. ' TF17` Ge6 1 N:;W!1HNH(xt �- 0G/21!2832 15:42 5105378582 NET PAGE 94 1.0/11/2001 at 04:12 PP1 Sob Number: 26382 M2 AUTOEXCELLENCE Federal ID #:330577123 RELAX. WE'LL FIX IT. 2700 HOOPER DRIVE SAN RAMON, CA 04583 (925)831-1778 Fax: (925)831-8472 PRELIMINARY ESTIMATE written by: THOMAS CARVA.IAL # Adjuster. CLEM RABELO # Insured: KRISTIE VETO Claim # Owner: KRISTIE NETO Policy # 1 Address: 2 TALUS CT Deductible: SAN RAMON, CA 94583 Date of Loss: ,Evening: (925)479-9224 Type of Loss: Collision Business: (510)537-3501 Point of Impact: 6. Rear Inspect M2 AUTOEXCELLENCE Business: (925)831-1778 Location: 2700 HOOPER DRIVE SAN RAMON, CA 94583 insurance FARMERS Business: (925)724-8342 company: 1.1.533 Dublin Carryon Road Days to Repair Pleasanton, CA 94588 1990 TOMO 4RUNNER 4X4 5R5 6-3.OL-FI 4D UTV GREEN Int,GREY VIN: )T3VN39w6L8003334 Lac: 3HXA199 CA prod Date: 03/1.990 odometer: 167897 Rear Defogger Tilt wheel Intermittent wipers Tinted Class Dual Mirrors Clear Coat Paint Metallic Paint Power steering Power Brakes AM Radio FM Radio Stereo Search/Seek Anti-Luck Brakes (2) doth seats Bucket seats Recline/Lounge Seats Automatic Transmission Styled Steel wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -------------------------------------------------------------------------------- 1 REAR BUMPER 2** Repl Qual Repl Parts LT Extension c 1 1.22.03 0.3 3 QUARTER PANEL 1 06/21/2002 15: 42 5105310502 NET PAGE 05 10/11/2001 at 04:12 Pm Job Number: 26382 PRELIMINARY ESTIMATE 1990 TOMO 4RUNNER 04 SR5 6-3,OL-PS 4D UTv GREEN Int:GREY ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT, PRICE LABOR PAINT ------------------------------------------------------------------------------- 4 Repl LT Mud guard 4W€3 w/o ground of 1 64. 56 0.3 5 Rept LT Wheel opng mldg narrow 1 53.64 0.3 ------------------------------------------------------------------------------- subtotals ==> 240.23 0.9 0.0 Parts 240.23 Parts Discount $ 1.1.8.20 -2.0% -2.36 Body Labor 0.9 hrs @ $ 58.00/hr 52.20 ---------------------------------------------------- SUBTOTAL $ 290.07 Sales Tax $ 237.87 @ 8.0000% 19.03 ---------------------------------------------------- GRAND TOTAL $ 309.10 ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 309.1.0 under Calif. Code Of Regulations, Title 10 Chaper 5, Subchapter 8 section 2635,8,d,2,c, We are advising you that you have the right to have your insurance company reasonably adjust any written estimates prepared by the repair shop of your choice. if you choose to use a repair facility suggested by your insurance company, they will guarantee the damaged vehicle to be estored to its pre-loss condition at no cost to you other than as stated in the policy (i .e. policy limits or deductible) or allowable depreciation. This estimate has been prepared based on the use of crash parts supplied by a source other than the manaufacturer of your motor vehicle. Any warranties applicable to these replacement parts are provided by the manufacturer- or the distributor of the parts, rather than by the original manufacturer of your vehicle. 2 OS121f2002 15: 42 5105378562 NET PAGE 06 1011112001 at 04:12 PM Sob Number: 26382 PRELIXIIIARY ESTIMATE 1990 TOYO 4RUNNER 4X4 SR5 6-3.0L-FI 4D UTV GREEN Int:GREY THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL, MANUFACTURER OF YOUR VEHICLE, Estimate based on MOTOR CRASH ESTIMATING GUIDE. unless otherwise noted all items are derived from the Guide ARM8409 Database Date 5/2001 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer, Asterisk (*) or Double Asterisk (*'1) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. pion-Original Equipment Manufacturer aftermarket parts are described as AM or Qual Rep!. Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Prices are provided from National Auto Glass specifications, Inc. Pound sign (#) items indicate Manual entries. 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