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Home My WebLink AboutMINUTES - 08122003 - C.35 SC ?AR OF 5UP RV SCLAIM _RS OF CONTRA COSTA COUNTY BC„�ARD ACTION•AOGt1ST 121. 2003 , 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), gives Pursuant to Government Code Section 913 and > 15.4.Please note all"Warnings". AMOUNT: $4,277-00 CLAIMANT. DONNIE RAY PERRY r A ATTORNEY: UNKNOWN DATE RECEIVED: JULY 03, 2003 ADDRESS: 214 PEBBLE BEACH ISI' BY DELIVERY TO CLERK.ON: JULY 03, 2003 pITrSBuRG, CA 94565 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETE 1 Dated: JULY 71 2003 By: Deputy II, FROM. County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 WX K. 10.2. ( ) 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. Deputy County Coun b 3 III. FROM: Clk of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD 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: /4 + JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913 Subject to certain exceptions,you Have only six(6) months from the date this ndtice was personally served or deposi 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 fu; prepaid a certified copy of this Board Carder and Notice to Claimant, addressed to the claimant as shown above. Dated: ZvJOI�iN SWEETEN, CLERK By Deputy Cle Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTR'I.,TCTIONS TO CLAWANT A. 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 before December 31, 1987, must be presented not later than the 10&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 91 I.2.)- B. Claims must be filed with the Clerk of the Board of Supervisors at its office-ire 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 f FLLE7HKSr,,��,ARD ECEIVED gainst the County of Contra Costa or ) 3 2UO3 District) F ,i+PRV�S HS (Fit in name) ) nA 00,ra co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sura of S, and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) 29.. Where.did the damage or injury o ?(Include city and county) C�qY 3. How did the damage or injury occur?(Give full details;use extra paper if required) t 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5. What are the names of county or district officers, servants,or 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 amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses, doctors, and hospitals. 1 ICU +31 9. List the expenditures you made on account of this accident or injury. DATE - t � AMOUNT *** `#44* ' } Gov.Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SEND NQIICES M: tt Name and Address of Attorney } } 4 } (CI rnan Signature) } (Address) Telephone No. }Telephone NO. r CE Section 72 of the Penal Code provides. Every person who,with intent to defraud,presents for allo,%Ince or the payment to any state board or officer,or to uy omen%city,or dis bict board or officer,authorized to allow or pay the same if genuine,any false or f=dulent claire,bill,account, voucher,or writing,is punishable either by i mprisonrnerrt in the countyjail for a period of not more than one year,by a fine o t'not exceeding one thousand($I,t)00)t or by both such imprisonment and fine,or by imprisonment in the state prison,by a fim of not exceeding tear thousand dollars(S10,000),or by both wh imprisonmew and fine. _ r1 D-# ,3 _ ......_.... )� ��r- C yam., ��j� {�•/[f °n cam ............................. f Wit" z i Ce t3 1-4 ...TVI. _ t). s� _ r tea_ da �:3t . . .. at R . ................._ .. .. ............................................. . v,n r } , l�Cr _ - _ r � fo y Cb 1 rs- .... a ... .. r ✓ ��Q .ice J. ��* �. ✓s � ` - L s 0j �'� r�"45...E`3 ��.- `�"'�.b��.�.�,'�...•'� '� -<` . .. # �`v?�..�".`�..` �..,.A...s .Y} , J J CLAIM BOARD OF SUPERYI5MS OF CONTRA COSTA COUNTY B ASB ACTIO ICY AUGUST 12, 2003 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 Cedes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and s 915.4. Please note all"Warnings", AMOUNT: $10,000,000. $, CLAIMANT: ROBERT SPENCE MARGARET SPENCE S ;Z ATTORNEY: UNKNOWN DATE RECEIVED: ,T= Us 2003 ADDRESS: 4497 ADELIA COURT BY DELIV'ER'Y TO CLERK.ON:JnY 07, 2003 CONCORD, CA 94521 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN', Cle Bated: JULY 07 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Supervisor lThis claim complies substantially with Sections 910 ac10.2. { ) This Claim FAILS to comply substantially with Sections 914 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: A By. Deputy County Counse III. FROM: CIA 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 tree and correct`copy of the Board's Order entered in its minutes for this date. Dated: ccsOI'CN SWF ETEN, 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 ofyour 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 1'8; 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: ' JOHN SWEETEN, CLERK By Deputy Clerk': RECEIVED Mr. and Mrs.Robert Spence 4497 Adefix Court J U L 0 7 2003 Concord,Ca 94521 (925)674-8951 �L�_ v' 15fi a Co. Contra Contra Costa County July 2, 2043 To Whom It May Concern.: On the behalf of minor child, Gordon Cameron Spence, we Robert and Margaret Spence, are filing a claim against Contra Costa County in the Wrong Death of Gordon Spence's mother, Heather Spence, in the amount of$10 million dollars for Medical Malpractice. On March 17"`, 2003 Heather was admitted into the Contra Costa. County Regional Medical Center to give birth to her first child, Gordon Cameron Spence. He was born on March 18th. and his healthy 31 year old mother, Heather Spence, due to negligence of Contra Costa Counter Regional Medical Center and staff, died March 26, 2043. Robert Spence IL - ; Margaret Spoi c CLAIM BOARD„OF SUPERVISt)RS OF CONTRA COSTA COUNTY BOARD ACTION•ADCUST12, 2003 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: $1,500,000-00 CLAIMANT: ROBERT SPENCE 4 MARGARET SPENCE ATTORNEY: UNKNOWN DATE RECEIVED: JTIT Y 07 2003 ADDRESS: 4497 ADELIA COURT BY DELIVERY TO CLERK ON: JULY 07 2003 CONCORD, CA 94521 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE Jerk Dated: JULY 07, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and6110.2. ( ) 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: f Dated: 1 By: €� Deputy County Counsf of the Board TO: County Counsel(1) County Administrator(2) III, FROM: Cle { ) 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 ,Deputy Clerk WARNING(Gov. code sectio 913) Subject to certain exceptions,you have only six (6)months from the date this adtice was personally served or deposits in the mail tofile a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of 'bur 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 full; prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Av w41�/, JOHN SWEETEN, CLERK.By Deputy Clerl Mr. and Mrs. Robert Spend IRI:u 4497 Ad+elia Court Concord,Ca 94521 �� (925)674-8951RS ctK60a? � C^vSiA �. Centra Costa County July 2, 2003 To Whom It May Concern: We, Robert and Margaret Spence, are filling a claim against Contra Costa County in the Wrong Death of our daughter, Heather Spence, in the amount of $1.5 million dollars for Medical Malpractice. 4n March 17'`, 2003 Heather was admitted into the Contra Costa. County Regional Medical Center to give birth to her first child, Cordon Cameron Spence. He was born on March 18" and our healthy 31 year old daughter, Heather Spence, due to negligence of Contra Costa County Regional Medical Center and staff, died March 26, 2003. Robert Spdnce Margaret S ence CLAIM POARD GF SUNLRVIE9.R OF C9NTRA COSTA COUNTY BQABD ACIION:, AUGUST 12 2003 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Beard 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 f 915.4. please note all"Warnings", AMOUNT: $952.78 r CLAIMANT: MIMI W. KP,NST z ATTORNEY: UNKNOWN BATE RECEIVED: JULY 0722003 ADDRESS: 140 BROOKSIDE PLACE BY DELIVERY TO CLERK.ON: JULY 07, 2003 DANWILL , CA 94526 BY MAIL POSTMARKED: JULY 03, 20013 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE 1 rk Hated: JULY 07, 20013 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup sors This claim complies substantially with Sections 910 arAA,941O.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 914.2., and we are so notifying claimant. The Beard cannot act for 15 days (Section 910.8). { ) Claim is not timely fled, The Clerk should return claim on ground that it was filed late and send warning of claimant'sright to apply for leave to present a late claim(Section 911.0. ( ) Other: Dated: 'A By: Deputy County Couns III. FROM: Cle of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: , (l, This Clain is rejected in full. ( ) tither: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: l JOHN SWEETEN, CLEF., By , Deputy Clerk WARNING(Gov. code section 9 3) Subject to certain exceptions,you have only six (6)months from the date this notice was personally served or deposit in the mail to.,file a court action on this claim. See Government Code Section 945.6. You may seep 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 full 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 Deputy Cler Clain to: BOARD OF SUPERVISORS OF C ON"TRA COSTA WJNT Y INSTRUCTIONS TO CZAIRAn A. Claims relating to causes of action for death or for in Jury 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 muses of action for.death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1968, 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 preented not later than one year after the accrcral 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, 661 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the rine of the District should be filled in. U. 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 a.. the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp AAs; 0J, RECFpIED AgaER the Cary of Contra Costa. } JUS � 2�� } CLE�x SJARo c s v s District) CONTRA COSTA CO, Fill in name } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum cif $ ��."7 g and in support of this claim represents as, foll.ows: 1. When did the dame or injury occur`? (Give exact date and hour) ._�..�......., ..... :.�. ...w...�� ...�. ......�......Y. �,..._ ..�..----—..—..,_—..__.. 2. 'Where did the damage or injury occur? (Include city and county) St. A-1 onscls U)gt4 3. How did the damage or injury occur? (Give full details, use extra paper if required) 1 do -rrvok -4- . Fiat particular act or omission on the part of county or district officers, servants or employees caused, the injury or damage? r to r 4.o -%e- G ad#r" a'i tib, V , . 5. Wnat are 'tne names of county or district officers, servants or employees causing the danage or injury? 2 nn e E'oc� o I W-1,4-SODS 6. What damage or injuries do you claim resulted? {Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 04 C GI.e-d 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 3. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury; DATE IZ M AMOUNT Won e * * .* * �t Gov. Code Sec. '910:2 provides; "The claim must be signed by the claimant. SEND NOTICES TO: (Attorney) or by someerson on his. bebalf." Name and Address of Attorney " . 7 Clai.mmnt's Signature a $roe, C�4. 191 (Address 3 Telephone No. Telephone No. * * UO3TI`CE Section 72 of the Penal Code provides: "Every person who, with. intent to defraud ...presents for allowanoe or for payment to any state board or officer, or to<any county, city or district beard or officer, authorized to allow or paythe 'same; if .genLtine, 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.' 06/30/2003 at 11:10 AM job Number: 26382 M2 AUTOEXCELLENCE Federal ID #:330577123 RELAX. WE'LL FIX IT. 2700 HOOPER DRIVE SAN RAMON, CA 94583 (925)831-1778 Fax: (925)831-8472 PRELIMINARY ESTIMATE written by: ANDRE BERNARD # Adjuster: Insured: GARY KENST Claim # owner: GARY KENST Policy # Address: 140 BROOKSIDE PL. Deductible: DANVILLE, CA 94526 Date of Loss: Day: (925)837-2808 Type of Loss: Point of Impact: 12. Front Inspect M2 AUTOEXCELLENCE Business: (925)831-1778 Location: 2700 HOOPER DRIVE SAN RAMON, CA 94583 Insurance Company: Days to Repair 2003 .JEEP GRAND CHEROKEE 4X4 LIMITED 8-4.7L--FI 4D UTV WHITE Int: VIN: 138Gw58N13C555965 Lic: POTS 04 CA Prod Date: odometer: 9176 Air conditioning Rear Defogger cruise control Intermittent wipers Climate Control Keyless Entry Theft Deterrent/Alarm Rear wiper Steering wheel Controls Dual Mirrors Privacy Glass Roof console Luggage/Roof Rack Fog Lamps clear coat Paint Power Steering Power Brakes Power windows Power Locks Power Driver Seat Power Passenger Seat Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 wheel Disc Brakes Leather Seats Bucket Seats Recline/Lounge Seats Automatic Transmission Aluminum/Alloy wheels 1 06/30/2003 at 11:10 AM Jab Number: 26382 PRELIMINARY ESTIMATE 2003 JEEP GRAND CHEROKEE 4X4 LIMITED 8-4.7L-FI 4D UTV WHITE Int: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2 Repl Bumper cover primed 1 432.00 1.9 2.8 3 Add for clear Coat 1.1 4# Repl FLEX AGENT 1 8.00 5# Subl HAZARDOUS WASTE DISPOSAL 1 3.00 X -------------------------------------------------------------------------------- Subtotals =_> 443.00 1.9 3.9 Parts 440.00 Body Labor 1.9 hrs @ $ 62.00/hr 117.80 Paint Labor 3.9 hrs @ $ 62.00/hr 241.80 Paint Supplies 3.9 hrs @ $ 26.00/hr 101.40 Body supplies 1.9 hrs @ $ 2.00/hr 3.80 Sublet/Misc. 3.00 ---------------------------------------------------- SUBTOTAL $ 907.80 Sales Tax $ 545.20 @ 8.2500% 44.98 ---------------------------------------------------- GRAND TOTAL $ 952.78 ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 952.78 2 06/30/2003 at 11:10 AM Sob Number: 26382 PRELIMINARY ESTIMATE 2003 JEEP GRAND CHEROKEE 4X4 LIMITED 8-4.7L-FI 4D UTV WHITE Int: under Calif. Code Of Regulations, Title 10 draper 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. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLVD=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-AD3=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RELY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/—=WITH/_ SYMBOLS: MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3WA99 Database Date S/2003 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Non-Original Equipment Manufacturer aftermarket parts are described as AM or Qual Repl 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. 3 06/30/2003 at I1.:10 AM Job Number: 26382 PRELIMINARY ESTIMATE 2003 JEEP GRAND CHEROKEE 4X4 LIMITED 8-4.7L-FI 4D UTV WHITE Int: Pathways - A product of CCC Information Services Inc. 4 CLAIM BOARD OF S P'ER'VISORS OF CONTRA COSTA COUNTY irrir�rirrr� �r�rrrr�rrr rr rr.n rriwr.. rnr -� BOARD ACTION:AUGUST 12, 2003 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), giver < t Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". ti AMOCJNT: $350.00 CLAIMANT: ARLEiTE LARSON . ATTORNEY: UNKNOWN DATE RECEIVED: ,DULY 09, 2003 ADDRESS: 3192 LUCAS CIRCLE BY DELIVERY TO CLERK.ON: JULY 09, 2003 LAFA=E, CA 94549 BY MAIL POSTMARKED: MIND DELIVERED FROM: Clark of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETW& Dated: JULY 091 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervi ars This claim complies substantially with Sections 910 an 10.2. ( ) 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: LV ZB AR Deputy County Counse III, FROM: CfJrk of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. PPARD 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. y Dated: / 3 JOHN SWEETEN,CLERK.,By A , Deputy Clerk WARNING(Gov. code sectio 913) Subject to certain exceptions,you have only six(6) months from the date this ndtice was personally served or deposits 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 fulf� prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Z1S -.er OI N SWEETEN, CLERK,By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CX}RM COSTA CO= 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, 1587, must be presented not later than the 100th day after the accrual of the cause of action. Claims gelating to causes of actio 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 ether cause of action must be presented not later than one year after tate 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 Rood 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 rye 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 ttz County of Centra Costa } JUL 0 9 2003 or CLERK BON RD 0E S' ER'VIS RS District Ra ocs Fill in name The undersigned claimant hereby crakes claim against the County of Contra Costa or the above-naffed District in the sure of $ �(� _ and in support of this claim represents as fellows: 1. When did the damage or injury occur? (Give exact date and 'nous) .~,tl..... 2. Where did the damage or in (Include city and county) ury oeeur? d-11_1411W-y M05S 9Z/ Z_ 577 3. How did the damage or injury occur? (Give Pull details; use extra paper if required) 69RA)e l-1 ROM F 1 L C.-15/.) .`- C_ 4. What particular act or omission an the part of county or district officers, servants or .employees caused. the injury or damage? 5 r what are the names of county or district officers, servants or employees causing "he damage or injury? 64'� 5. What damage or injuries do you claim resulted? (Give full, extent of injuries o.- damages rdamages claimed. Attach two estimates for auto damage. 771 7. How was the amount claimed above com;>uted? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of,`�witnesssees, doctors and hospitals. s 7~ lir 7- _ 1 .��,� ....._.. ...... .�.._....-...,._.�...�.�.�� 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Cade Sec. 91-0:2 provides: "The claim must be signed by the claimant SM NOTICES TO: (Attorney) or b same person on his. behalf." Dane and Address of Attorney (Claimant's Signature Address Telephone No. Telephone No. �L 1L/ '_az 1�� sf NOTICE Section 72 of the :'enal. Cade provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state bard 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 "berth such imprisonment and fines. or by imprisorment in the state prison, by a fine of not exceeding ten thousand dollars ($41.0,000, or by both such imprisorment and fine. ! R �f. R.1 �Ell 7, < A 'r�k " y�. t f <�f , �1��a rl,• �, >jS'b? . y; f INVOICE �R z HACIENDA AUTO GLASS 6219 South Front Fid., Livermore,CA 94550 (925) 447-9890 • Fax (925) 447-9893 Bill To: Insured: Phone: Phone: Policy: CIM ##: Ath/Ver: PO. /Ref. Loss Loc: Loss Cate/Cause: ;fief+ 5 � wMa w k $ r f a CUSTOMER SIGNATURE Release and authorization to pay other than insured or claimant. Parts Sub-Total The glass has been replaced to my complete satisfaction and l authorize the Libor Sub-Total to pay direct to hacienda Auto Glass the full amount due me under the terms of my policy Sub-Total covering the said Law and l understand for any reason my insurance company does not pay this claim l will be responsible for payment of same. Sales Tax IIVS3tREt1 In-Store: Address: — City. Windshield Repair Possible?Yes No Custoimer Initials:Accepted Declined CLAIM BOARD OF-SLPERVISORSOE CONTRA COSTA COUNTY BOARD ACTION: AUGUST 12, 2003, 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), giver f :Pursuant to Government Code Section 913 and <> 915.4. Please note all"Warnings". AMOUNT: $1,259.48 :f CLAIMANT: MARSHA DESCALA-FENNELL ATTORNEY: UNKNOWN DATE RECEIVED: JULY 09, 2003 ADDRESS: 164 ALAMO SQUARE BY DELIVERY TO CLERK.ON: JULY 09, 2003 ALAMO, CA 94507 BY MAIL POSTMARKED: HAM pgLTyFgm FROM: Clerk of the Board of Supe=rvisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JULY 09, 2003 JOHN SWP.E , rk By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup isors This claim complies substantially with Sections 910 and10.2. ( ) 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: ..i Deputy County Counse III, FROM: C of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 9113). IV, ARD 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 , Deputy Clerk WARNING{Gov. code secti n 9131 Subject to certain exceptions,you have only six (6)months from the date this ndtice was personally served or depositei in the mail too 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 immed:iatel . *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: "7 A3 a00JOHN SWEETEN,CLEF.By Deputy Clerk. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS M CL.AZMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause: of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the 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 y, y, f o m. RE: Claim By Reserved for Clerk's -filing stamp Marsha DeScalaY-Fennell RECEIVED Againstthe County of Contra Crista ) JUL 0 9 200? or COR a_R _OF SUPERVIs IRS District) CONTRACcs-MO. (Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above--named District in the sum of $ 1259.48 and in support of this claim represents as ,fellows: 1. When slid the damage or injury occur? (Give exact date and hour) June 20, 2003, 11-.48 AM 2. Where did the damage or injury occur? (Include city and county) West side of San Ramon Valley Boulevard, traveling in a south bound direction between Lavorns and Alphonse, Alamo, CA, Contra Costa County. 3. Row did the damage or injury occur? (Give full details; use extra paper if required) While passing a backhoe at 10 mph, the equipment operator lifted the scoop and a piece of cement or rock, fell from the scoop hitting the front right fender of my automobile. . What particular act or omission on the part of county or district officers, servants or .employees caused.the.injury or damage? There was no buffer zone between-the operat:Lng-.,heavy equipment and the traffic.- �. what are the names of county or district officers, servants or employees causing the damage or injury? Ghilotti Construction Company 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Right front fender damage. See attached two estimates. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) The two estimates were based on the MOTOR CRASH ESTIMATING GUIDE. .Names and addresses of witnesses, doctors and hospitals. There was a Hispanic laborer and a Caucasian construction worker as well as the backhoe operator. However, names were not exchanged. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 01(021431.5 hr. loss time from -work for $2$.50_ (3 hours @ $19/hr) obtaining estimate 07/03/03 1.5 hr. loss time from work for $28.50 Gov. Cade Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some arson on his. behalf." Name and Address of Attorney (Claimant's Signature 164 Alamo Square Address Alamo, CA 94507 Telephone No. Telephone No. 0: 925-943-6353/H: 925-820 -1860 I I T !F iF ik _iE �E iE #E NOTICE Section 72 of the renal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county Jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imorisohnmt 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. 07/02/2003 at 11 : 33 AM Job Number: 75706 COOKS ON MAIN License #:AJ'168568 Federal ID #:943344759 2198 N. MAIN ST WALNUT CREEK, CA 94596 (925) 944-1027 Fax: (925) 944-0970 PRELIMINARY ESTIMATE Written by: Damon Smith # Adjuster: Insured: MARSHA FENNELL Claim # Owner: MARSHA FENNELL Policy # Address: 164 ALAMO SQUARE Deductible: ALAMO, CA 94507 Date of Loss: Other: (925) 820-1860 Type of Loss: Cellular: (925) 963-7622 Point of Impact: 1 . Right Front Inspect COOKS ON MAIN Business: (925) 944-1027 Location: 2198 N. MAIN ST WALNUT CREEK, CA 94596 Insurance Company: 4 Days to Repair 1995 FORD MUSTANG GT 8-5 .0L-FI 2D YELLOW Int:BLACK VIN: 1FALP42T7SF234195 Lia: YLAPONY CA Prod Date: 04/1995 Odometer: 51643 Air Conditioning Tilt Wheel Intermittent Wipers Tinted Glass Dual Mirrors Fog Lamps Rear SQoiler Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Positraction Cloth Seats Bucket Seats Recline/Lounge Seats 5 Speed Transmission Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FENDER 2* Rpr RT Fender 3.0 2 . 1 3 Add for Clear Coat 0 . 8 4 Repl RT Nameplate "GT MUSTANG" 1 20.22 0.2 5 Repl Add for antenna 1 0.5 6 HOOD 7 R&I RT Scoop 0.3 8 R&I LT Scoop 0.3 9* Blnd Hood 1 . 3 10 rFRONT BUMPER 11 R&I R&I front bumper bumper assy 1 .5 12 FRONT LAMPS 13 R&I RT Headlamp assy w/o Cobra 0.3 14 R&I RT Park/marker lamp 0. 3 15 PILLARS, ROCKER & FLOOR 16 R&I RT Rocker molding 0. 6 174 Repl COVER CAR 1 5.00 T 0.3 18# Refn CORROSION PROTECTION 0.3 194 Refn COLOR TINT 0.5 204 HAZARDOUS WASTE REMOVAL 1 3.50 214 COLOR SAND & POLISH- FENDER & 1 1 .5 HOOD 22# TO MATCH 'OEM TEXTURE 1 ------------------------------------------------------------------------------- Subtotals =_> 28.72 9.6 4 . 2 1 07/02/2003 at 11 :33 AM Job Number: 75706 PRELIMINARY ESTIMATE 1995 FORD MUSTANG GT 8--5.OL-FI 2D YELLOW Int:BLACK Parts 23 .72 Body Labor 9. 6 hrs @ $ 75.00/hr 720. 00 Paint Labor 4 .2 hrs @ $ 75.00/hr 315. 00 Paint Supplies 4 .2 hrs @ $ 30.00/hr 126. 00 Sublet/Misc. 5 . 0C ---------------------------------------------------- SUBTOTAL $ 1189.72 Sales Tax $ 154 .72 @ 8 .2500% 12 . 1 ---------------------------------------------------- GRAND TOTAL $ 1202 . 48 THE ESTIMATE OF REPAIRS INCLUDES PARTS,LABOR,AND DIAGNOSIS. IF,ON FURTHUR INSPECTION,ADDITIONAL PARTS OR REPAIRS ARE NEEDED,YOU WILL BE CONTACTED FOR AUTHORIZATION .WE ARE NOT RESPONSIBLE FOR LOSS OR DAMAGE TO YOUR VEHICLE FROM FIRE,THEFT,ACCIDENTS,OR ANY CAUSE BEYOND OUR CONTROL.ALL TEST WILL BE MADE BY OUR EMPLOYEESS AT YOUR RISK AUTHORIZED SIGNATURE: DATE: THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME GWGLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNI"- PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER LIE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTE'S ATTACHED TO LINE. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2JC94 Database Date 4/2003 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that t":e parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Non--Original Equipment Manufacturer aftermarket parts are described as AM or Qual Repl 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 Manua' entries. Pathways - A product of CCC Information Services Inc. 2 Hate: 7/3103 01:20 PM Estimate ID: 7717 Estimate Version: 0 Preliminary Proms Iia: Mitchell LITHIA AUTO BODY 1260 Diamond Way Concord,CA 94520 (926)826-2441 Fax: (926)798-2161 Tax ID: 93-1223847 BAR#: AP-196293 EPA#: CAD 98251672 Damage Assessed By. KURT ARMSTRONG Deductible: UNKNOWN Insured: MARSHA FENNELL Mitchell Service: 913622 Description: 1996 Ford Mustang GT Vehicle Production Date: 4196 Body Style: 2DCps drive Train: 8.0L Inj 8 Cyl 6M VIN: 1FALP43T7SF234195 License: YLAPONY CA Mileage: 61,670 OEMIALT: O Search Code: 894627 Color: YELLOW "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEWL' ORIGINAL EQUIPMENT MANUFACTURE PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, REMANUFACTURED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALI'T'Y REPLACEMENT PART" ARE NON--ORIGINAL MANUFACTURE AFTERM RKET NEW PARTS. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units i 301960 REF BLEND HOOD OUTSIDE C 1.1 # 2 303660 BOY REPAIR R FENDER PANEL Existing 2.0*# 3 AUTO REF REFINISH R FENDER OUTSIDE C 2.0 4 300420 BOY REMOVOINSTALL R FENDER MOULDING 0.3 6 300300 BOY REMOVEMEPLACE R FENDER ADHESIVE NAMEPLATE F#ZZ 16228 AA 20.22 0.2 6 321704 BOY REMOVEANSTALL R FENDER ANTENNA MAST Existing 0.1* 7 300549 BOY REMOVEANSTALL R FENDER ANTENNA HOLE COVER Existing 0.0* a AUTO REF AOD'L OPR CLEAR COAT 1.1* 9 AUTO REF ADD'L OPR FINISH SAND AND BUFF 1.4 10 933018 REF ADD'L OPR MASK FOR OVERSPRAY 6.00* 0.3* 11 AUTO ADO'L COST PAINTIMATERIALS 117.60* * -Judgement Item #-Labor Note Applies C-Included In Clear Cost Calc ESTIMATE RECALL NUMBER: 713103 13:24:15 7717 UltraMate Is a Trademark of Mitchell international Mitchell Data Version: JUN V_A Copyright(C)1994-2002 Mitchell International Page i of 2 UttraMats Version: 4.8.012 All Rights Reserved Date: 713103 01:30 PM Estimate 113: 7717 Estimate Version: 0 Preliminary Profile 10: Mitchell Add'# Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body 2.6 66.00 0.00 0.00 160.00 Taxable Parts 20.22 Refinish 5.9 65.00 8.00 0.00 358.50 Safes Tax 8.260% 1.67 Non-Taxable tabor 657.50 Total Replacement Parts Amount 21.89 Labor Summary 8.5 657.50 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Casts 117.60 Customer Responsibility 0.00 Sales Tax Q 8.250% 9.70 Total Additional Costs 127.30 1. Total Lahr: 657.50 Il. Total Replacement Parts: 21.89 Ill. Total Additional Costs: 127.30 Gross Total: 706.68 IV. Total Adjustments: 0.00 Net Total: 706.68 This is a D ImInarq astlMata, AdAftionat qbantSs to the estftnaftfor the u i r ALL PARTS ON THIS ESTIMATE ARE OEM UNLESS DESIGNATED ON THE LINE ITEM TO BE SOMETHING DIFFERENT. WARNING: Accidental air bag deployment Is possible. Personal Injury may result. Avoid area now steering wheal and Instrument panel even it air bags have deployed. Ousi-stage air bag modules may be present that could contain an undeployed stage. When disposing of a deployed dust-stage air bag,always treat It as a"live"module. See appropriate MITCHELLO AIR:SAO SERVICE&REPAIR MANUAL,or OEM Information. ESTIMATE RECALL NUMBER: 713103 13:20:15 7717 UftraMsts is a Trademark of Mitchell international Mitchell Data Version: JUN 03_A Copyright(C)1994-2002 Mitchell fntemationai Page 2 of 2 UltraMate Version: 4.8.012 Ali!tights Reserved CLAIM OARD F PERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 1.2, 2003.' 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 Cedes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), giver Pursuant to Government Code Section 913 and 915.4. Please nate all"Warnings". s f }t AMOUNT: UNKNOWN CLAIMANT: SCOTT ELLIS ATTORNEY: UNKNOWN .DATE RECEIVED: JULY 09, 2003 ADDRESS: 1090 AMEND ST1zM, BY DELIVERY TO CLERK.ON: JULY 09, 2003 PINOLE, CA 94564 BY MAIL POSTMARKED: jay 08, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET rk Dated: JULY 09, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supe sons ( ) This claim complies substantially with Sections 910 and ;10.2. ( ) 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). ti rL Pesoe"�f+ 4ZD Other: C 4, fi ,` P- Dated By: Deputy County Couns( III. FROM: gerk 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: (v ' 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: E,e 20,0Z JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this ndtice was personally served or deposite, 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 AdditionalWarning 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: /. ! a2"3 JOHN SWEETEN,CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL SILVANO B. MARCHESI COUNTY OF CONTRA COSTA µ' '.� COUNTY COUNSEL Administration Building 651 Pine Street, 911 doorJ SHARON L. ANDERSON Martinez, California 94553-1229 f ; � _ CHIEF ASSISTANT (925) 335-1800 GREGORY C. HARVEY e a,�81`11� .q` ra. s`,�' VALERIE J. RANCHE (925) 646-10"78 (fax) � w � ° � R�� ASSISTANTS c� NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Scott Ellis 1090 Amend Street Pinole, CA 94564 Please Take Notice as Follows: In regards to the claim you submitted on July 9, 2003,portions of your claim are timely and portions are untimely. The portions of your claim prior to January 8, 2003 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2,because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 8, 2003 were not presented within the time allowed by law, no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. Your only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. SILVANO B. MARCHER COUNT{ COUNSEL %d Janet L. Holmes ' Deputy County Counsel Page 1 CONTRA COSTA HEALTH SERVICES OAYL BELFOR PATIEN- T RELATIONS 2500 ALHAMBRA ANTE D MARTINEZ CA 94553 .Tune 13, 2003 JUL 0 9 2003 CLERK BOA13D O� ca � aas PERMS ps SCOTT ELLIS 1090 AMEND ST PINOLE CA 94564 Dear Mr. Ellis I have received your letter regarding the West County Detention Facility. I regret that I cannot assist you as claims are to be filed with: Clerk of the Board Contra Costa Board of Supervisors 651 Pine Street I"Floor Martinez CA 94553 You may reach them at 925-335-1900 for additional information. Sincerely, M� Ka Re tons cc: Files . ....... .................................. f . w.v ,✓'. .. � _ ._....,_ •- ✓ :'tip.......,... .— r.*'r.,r � ....x:=s✓c > __. 1 f f- 1 � r » r , T ` — — -j PHARMACYw e, 4rttrtt esFtn artlt ON SA COSTA RECx# Ai MEDICAL CENTER k1hamt-ra AuenFsa Martinez.CA 94553 • 37-4-8244 NERIC EQUIVALENT'PERMi37'ED NO REFILLS, � � _�q Ln _ i cs 0 3C c it Vt 4 �L ub 4� rgcppt'm VZ `i k AY 7 s+ctx 'DRATORy a' i:::: ........ x t<-; CY DEPARTMENT IN �z -- — T DAYS/ DATE TFiti DATE T'#h 4 "0"(Patient Sign ••,"L'ODUUESTIONS ON OUR PATF#~NT SL,VES o E DELIVER R T .._.. v•<«V�5 i"O i3Ei_FVEF{TF r--t 4ei1,Fayasakera,M.D. #� ....t Herbert S#grrtond,M-i�. r"# chn P � Christian We#nr a; abers,M.C3. Afars Spain,M.Q. avid ReefjY'M.G. Mark Stinson,M,r�, .oti Schmid,M.G. C,? David Suchow,M.i7. e f .. f .' ---------------- f ... ,r... •• {' +i} 4 { 'v .. ..... ........ ..... .... :.......?::. ':ry :.};ffii: .. r.... ri:•: >tz:: fir;{ rel . { : : . site becomes reddened: wb ; : ulceration develops. < :..:r >::::<<:::>::<::. ::..... r` skin and muse a tissue dies and � . :.:. deal or'heals quite slovAy. f. ...:.. :.... :.........:... :.:... ✓r } x :. } } �f ry - q _ - } i ::: r 46 }` :: .. on't, risk it,gust owe bide from, Broivn Recluse Spider 1-,aAl cause- sualiy a bite<011 look like ars ant lite and not be particularly paivful. In serious cases, they progress to a blister with a dark center usually indicating that.necrosis will occur. oc�;asionally, l^ssra ara rad rings and/or streaks co Iing rrrn tine center ofthe trite similar to the Symptoms lime disease, rfi. ... ... ::. •}}}}ii}}. .•: `' •:•ilii... .}. ... ...... •i .:.}:•i}::.:. {p:•}:.}:•i}:is Jr±l :::. .. Necrosis .or%Ussue death. is present with more serious BRS titers. After several days, :pec~uc— tissue wili fall a.vay leaving a ;sir or open sore. Bites cAn ::gad to kidney faiiure, seizures, comic y:; d dea . immedia ely seek r:fedical after:tion if y;air 8r1 t-tten. Try, if possible, find the sQider tha bit you and take it with you to the medical facility. Photos of brown recluse spiders for spider identification { a <. r }£, J >..: v r f r '9' 3 i r'+ 3 'S Brqwn Recluse .A he brown recluse spiffier, oxosaeles rechisa Gsertsch, ca a so inflict r?vei y dangerous vice, .f,.e ini al pain associated with tffie bite is riot inknize, and is generally less ti'oubleserne than a bee sting. Within 8 to 12 how's the ix�in CCIN<#es quite e Md..,..i:.' an over c:. oeeriod of a.few days a large ulcerous som -omnis. This sore heals very Slowly and often leaves a larva, ugly disfiguring scar. + 1, ..v::r• i:• nY i:•i :. .�.�:.:.� vi':::..........v:::::::::::::;' > : . 4 ;t s CONTRA COSTA HEALTH SERVICES n CONTRA COSTA SUBSTANCE ABUSE CONTRA COSTA MENTAL HEALTH aCONTRA COSTA REGIONAL MEDICAL CENTERr R CONTRA COSTA HEALTH CENTERS AUTHORIZATION TO DISCLOSE HEALTH INFORMATI10 €PATIENTNAr49M.. I DATE OF BIRTH�— .RE aRC3 i -i-EER NAME) EE S:R. ET ADDRESS I am the -2-- PATIENT 0 GUARDIAN CONSERVATOR SIG and heraby authorize Contra Costa Health Services to disclose medical records for the above € amed patient TO-, u v(NAME OF Ki�-SON. RGIN'2A GN.AGE.C'l? I :REST ADDRESS _ — i PHONE -- -- PURPOSE FOR DISCLOSURE At the e--u t of the irdividuaf. the € VIS IT or DISCHARGE DATES or OTHER DATES £ FOR PURPOSE OF THIS INFORMATION REI_-ASE RESTRICTIONS: if you have authorized the disclosure Of your health infof oration to someone who is not legally required to keep it confidential, It may be re-disclosed and mal €;� l��e� �e protected, California law prohibits recipients of your health information from re-disclosing such information, except wt th your written authorization or as specifically required or permitted by law. INFORMATION TO BE RELEASE. This authorization is for full disclosure of all sem , including clinical Findings, Diagnoses, Treatment, Recommendations for Further fare Names of .Health Care Personnel, Dates of Hospitalizations and mbuiatony Visits Charges, and any information which may be related to Drug, Alcohoi, or Psychiatric conditioms or treatment and/or SexuallyTransmitted Disease, including AIDS and HIV Fest Result information, Such records will be disclosed unless you specify information you wish excluded. please initial 10,ploW information ,you do not giant released: O Exclusions Exclude., Exclude HIV test rest-tits fjN'M AL rnMrs,r_ Exclude Substance ,abuse information NMAL Exclude psychiatric information N€r<A Exclude other information DURATION- This authorization shall become effective imm6dlateiy and shall remain in effect for one year or until _ whichever- comes first. l imay revoke this authorization at any time. My revocation must be in writing and signed by me or on my behalf. My revocation will be effective upon receipt, but will not be effective to the extent that Contra Costa Health Services has acted in reliance upon this Authorization. RIGHT TO A. COPY OF AUTHORIZATION: i have a right.to receive a copy of this Authorization. I may refuse to sign this Authorization. Neither treatment, payment, enrollment or eligibility for benefits will be conditioned on nay providing or refusing to provide this Authorization. Date Ntient Signature s:cr�v� tt F sv; t S A.EF Rf CfiREfl Signature of Parent, Guardian, etc i Relations €i EMPLOYN 'AE !B.a- tr _ _Grii3'snar chard _ INTRA COSTA HATH SERVICE g{ aCONTRA CTA SUBSTANCE ABUSE xi COQ COSTA MENTAL HEALTH � �'%�� 7 ;la.70 CONTRA COSTA REGIONAL MEWCA;L CENTER a CONTRA COSTA H EALT H CENTERS AUTH0140ZATIONTO DISCLOSE i �!� STREET ADDRES� j�i�v I am the -�El PATIENT 0 GUARDIAN CONSERVATOR ' DESIGNEE and hereby authorize Cont-,e Costa Health Services to disclose medical records for the above named patient O i SET D TO m m.& mraa z n•:r,.Ac-ecyi iS'"RI ET ADDR SS PHC�E } PURPOSE FOR DI CLOSURE At the re uest of the individual. VISIT or DISCHARGE DATES or OTHER DATES :FOR PURPOSE O THIS INFORMATION RELEASE _ ___.. ._.._ __.. _ RESTRICTIONS-. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be re-disclosed and may no longer be protected. California law prohibits recipients of your health information from re-disclosing such information, except with your written ...authorization or as.specifically required or permitted bylaw. INFORMATION TO BE RELEASED.- This authorization is for f- II diselo r� of all 0gr s including-Clinical Findings, Diagnoses, Treatment, Recommendations for Farther Care,. Flames:of`flealth Care personnel, Tates of Hospitalizations and Ambulatory Visits, Charges, and any information which may be related to Drug,Alcohol, or Psychiatric conditions or treatment and/or Sexually Transmitted Disease, including AIDS and HIV Fest result Jpforrnation. Such records will be disclosed unless you specify information you wish excluded. please initial l� lqw information you do not aunt released, NO Exclusions Exclude, Exclude HIV test -esults iTi,�i INMAL A Exclude Substance Abuse information HTIAL Exclude psychiatric information ITIAt Exclude other information INITIAL PURATI €3 This authorization shall become effective immediately and shall remain in effect for one year or until _ whichever comes first. I may, revoke this authorization at any time. My revocation must be in:<writin9;and signed by me or on my behalf. My revocation will be effective upon receipt, but will not he effectiv6 to the extent that Contra Costa Health Services has acted in reliance upon this Authorization, RIGHT TO` O A COPY OF AUTHORIZATION.- 1 have a tight to receive a copy of this Authorization. I may refuse to sign this Authorization, Neither treatment payment enrollment or eligibility for benefits will be conditioned on my providing or refusing to provide this Authorization. Da to I atle t Signature s mA OF�cs�ra ST,-.FF mr--:�REQu;a€� _ ,. Signature of Parent, Guardian, etc. Relationship � s __ original Chart ui ORIN ALLEN JUVENILE HALL N AIN DETENTION FACILITY ONTRA COSTA COUNTY !El MARSH CREEK i WEST CGLIEVTY DETENTION ENTit1IV FACILITY SICKCALLTRIAGE DATE: uL�nw,,,.-� TIME: t" DOS: � MR#: MODULE: ALLERGIES- 13 CC&HPI: f 54V e ct NURSING DIAGNOSIS: PATIENT EDUCATION: SIGNATURE- RN SICK CALL FOLLOW-UP SCREENING DATA: SIGNATURE: RNILVN NURSENGIMEDICAL DIAGNOSIS: ADDITIONAL EDUCATION AND FOLLOW-UP-. SIGNATURE- ANJLVNIMDJFP n6^l('INAI -CHART/COPY-TRIAGE BOOK SICK CALL TRIAGE CONTRA COSTA DETENTION FACILITIES Medica! Chart Health Service#: 3804309 Health Status:Stable Clearances 114 day health screen ✓TB Testing Chronic Care Clinic Referral 7 Day Psych, (Vied Referral ✓'Clearance 1 Clearance 2 v'?Clearance 3 !-"4"harE Notes Entry Hate: 04-21-2003 1736 Entered By: 56803, DIENTE INMATE IS C/O REDNESS ANDPAIN ON THE RIGHT NARES .NOTED TO HAVE SLIGHT SWELLING ON THE RICHT NAREAREA AFEBRILE .PER MD RAEL KEFLEX 500 MG PO X 7 DAYS AND SC WITH PIZZO ON 4/22103.JDIENTE RN :hart }Notes Entry Gate: 04-039-2003 1447 Entered By: 41316, POOLE Hx small pea sized lump in R corner of lip, under moustache,for 2 days, slowly getting bigger; hx facial cellulitis and 3 courses of keflex for similar lesions since 12102. No open area, not draining, advised hot compresses 5 xlday. Sched with Dr Rael 4111/03 JP ihart Notes Entry Date: 033-24-2003 1016 Entered By: 41316, POOLE Pt c/o several episodes heartburn in past wk not responding to Maalox; states he was told he has Acid Reflux Disease, is avoiding spicy foods,takes a"purple capsule called Prilosec at home as needed, 30 pills last for 6 mos",does through a doctor in Pinole,? name, gets Rx's at Longs in Tarahills mail, last fill 6 mos ago. Sched SIC for Tomasulo 3128103 JP Chart Notes Entry Date: 03-23-2003 1557 Entered By: 54290, LONGSTRETH Inmate scheduled for FNPSC with Pizzo on 4122103 flu on chronic medication Maalox. F.L. RN Chart motes Entry Date: 03-23-2003 1552 Entered By: 54290, LONGSTRETH Inmate scheduled for FNPSC with Pizzo on 4122103 flu on chronic medication. F.L. RN Chart dotes Entry Date.: 02-28-2003 1105 Entered By: 26844, GIBLIN EVALUATE SPINDER POST RX-KEFLEX. SCHEDULE FOR S/C IF WORSE. AT TIME OF CHARTING THE BITE QUARTER SIZE RED BORDERS AND SCABS IN CENTER. GG RN Facility:945 Page 1 of 2 Printed*05-23-03 1326 CONTRA COSTA DETENTION FACILITIES Medical Chart hart Notes Entry Date: 02-27-2003 0912 Entered By: 26844, GIBLIN SPIDER BITE WAS ON KEPLIX BUT BITE IS NOT BETTER GG RN :hart Notes Entry Date: 02-23-2003 1623 Entered By: 123601 GUY 41 yo male c/o of facial tenderness secondary to spider bite 2 days ago; per innate says that he tried to pap the skin lesion resulting Into expression of drainage denies any fevers, nausea and vomiting per inmate had the same epidode last time, responded well to Keflex discussed with inmate that he will be started again on keflex versed on sick call vives and �acflity:945 Pace 2 of 2 Printed:05-23-03 1326 y- . • .. .y. :.:..... The case ou`�. emergency basis only.You`rnt�y.`` ` care after your release from here. If your condition worsens unexpectedly, retltrri here. If you feel your recovery is not proceeding as ! :k expected, contact your regular physician or call thev. Advise Nurse at 1-800-495-8885. € FROM: Si su condici6n empeora regrese aqui. Si siente I TO: $ que su recuperacion no avanza coma se expecta I I SIGNATURE: pongase en contacto con su doctor regular o Mame a E la enfermera de conseto 1-800-495-8885. (�.DATE: LL____—_.._—_.._..— _ OTHER 1�.GIVEN' WORKING.DIAGNOSIS: 'DCS NOT£3RWE 140ME FROM THr, PRINTED INSTRUCTIONS GIVEN: WSTRU HS On REVERW OF PAP wfJiJND CARE El SPRAIN t FRACTURE ;C;:voM}TfCFG DIARRHEA lr�-�urs ASTHMA I COPD E7 X-RAY C[sc�III ®�-�I HEAD WURY 0 CASTS I SPLINTS [1 I COLDS!FLU rlr��l•}EARLY PREGNANCY �!EAR INFECTION ION rr^�� AUMS �ftEY�Y€s CAit7 El EYE INJURY - ❑BACK I NECK INJURY L...1 FEVER CONTROL 0 VAGINAL BLEEDING 1...�ABDOMINAL PAIN 0 LAsoftATofiY L.._3 mutt PRe 17 o OTHER INSTRUCTIONS: G .zrez�, h FOLLOW-UP APPOINTMENT: CONTACT APPOINTMENTS FOR FAMILY PRACTICE APPOINTMENT IN DAYS I WEEKS lam_.'RETURN TO EMERGENCY DEPARTMENT IN D l�APPOINTMENT SLIP GIVEN. El SPECIALTY APPOINTMENTS: El MESSAGE LEFT AT APPOINTMENT UNIT YOU WILL BE CONTACTED ASOUTYOUR APPOINTMENT WITHIN TWO WORKING DAYS_IFYOU HAVE 'CLINIC' DAYS f WEEK NOT BEEN CONTACTED,GALL APPOINTMENT UNIT AT 800-495-8885. APPOINTMENT SCHEDULED NOSOTROS HEMOS DEJADO UN MENSAJE EN LA UNIDAD DE CITAS. CLINIC i PROVIDER SITE DATE TIME UD.SERA CONTACTADO DE. E 2 DtAS HABILES.SI NO IIA SIDO CONTACTADO,LLAMIN AC 84ft 495 5. CLINIC/PROVIDER SITE DATE TIME STAFF INITIAL SIGNA`f iEI UNDERSTAND THESE INSTRUCTIONS(Patient Signatur f ❑ YOU NEED TO PICK UP e REMAINDER OF DJF�jP _PAESCRIP_nON TI E DfSCHARGEO CONTRA COSTA REGIONAL MEDICAL CENTER EMERGENCY DEPARTMENT STRIVES TO DELIVER THE CARE POSSIBLE.YOUR COMMENTS AND SUGGESTIONS ON OUR PATIENT SURVEY ARE APPRECIAT YOUR PROVIDER TODAY WAS: E I� 0' josaph Barger,M.D. Gerard Bland,M.D. Neil Jayasekera, M.D_ !17 Herber:Sigmond,M.D. F1 Christian Weinman, E L_j Jon Beauchamp,M.D. © John 1.Ellis, M.D, 0 John Pabers,KD. !0 Alan Spain,M.D. Fred Beck,M.D. © Chris Farnitana, M.D. C3 David Reedy,M.D_ 0 Mark Stinson, M.D. 0 Ingrid Bellwood,M.D. David Goldstein,M.D. i✓ Scott Schmidt,M.D. M David Suchow,M.D. QCJ`I FtA COSTA COUNTY JUVENILE HALL � MAIN DETENTION FACILITY MARSH CREEK % WEST COUNTY DETENTION FACILITY SICK CALL �f �f TRIAGE DATE: NAME: i� ",10 R _... �_..�.._. ...__. .�. TIME: f DOS: A /, MRC O.+T MODULE- ALLERGIES: tl x Y NURSING DIAGNOSIS:d4et2 PATIENT EDUCATION. FaLLaw IJP: SIGNATURE: RN SICK CALL MLLOW-U +� SCREENING DATA. SIGNATURE:�. RN/LVN NURSING/MEDICAL DIAGNOSIS: ADDITIONAL EDUCATION AND FOLLOW-UP, SIGNATURE: �� RWLVNIMDIFP Y1E"3!liht F,t Y"'L.ln!"!Y!!"f".Yt\/Mr>>nr+r—rte.r.r.e CONTRA COSTA COUNTY HEALTH SERV€CSS DETENTION FACILITY OUTPATIENT NOTES f DATE v ` ',.h'.f:l r:... t,.t` �` i:�..; i i 1 { i i i f { GRIN;at CONTRA COSTA COUNTY JUVENILE I HALL MAIN DETENTION FACILITY MARSH CREEK I WEST COUNTY DETENTION FACILITY SICK CALLTRIAGE -." DATE: NAME: TIME: DOB-.1.1- r MR#: 'r' Fs } MODULE. ALLERGIES: CC HPf ��t'":"y.'"wd` ..�� .f'F,..L.r.,-�.C. .�.-C.-i" c'� �4✓ ./G....�".r,;-Y,f,.fi��,�' s„rl./ i".f r 333.3.c :. ,t NURSING DIAGNOSIS: ��U"� - t��:qtr��✓�� r PATIENT EDUCATION: J/ � 1 ^) r • t FOLLOW-UP: % _.—�_ SIGNATURE: SICK CALL s P SCREENING DATA fk SIGNATURE: NURSINcvmEDICAL DIAGNOSIS: AFJI3mONAL EDUCATION AND FOLLOW-UP.- SIGNATURE, OLLOW-FIR:SIGNATURE: RNILVN/MDIFF rintrssxrnr r�t_r�ri-r!nnnF-t-�rnr-.s^E.+^^st�lr ^AI I rmf A,-I CONTRA COSTA COUNTY HEALTH SERVICES � Ga� DETENTION FACILITY OUTPATIENT NOTES DATE Cie- i oto F Pa A f t WORWSCHOOL RELEASE CONTRA COSTA REGIONAL MEDICAL CENTER TIA4EOFF AUTHORIZED c EMERGENCE' DEPARTMENT � , � WORK L . ;� SCHO0 FOLLOW-UP INSTRUCTIONS ; r - 3 DUE TO: s - El ILL NESS The care you received here has been given on an � { FROM. emergency basis anlV. You may need further tests or v r°e after your release from here. � _ RESTRICTIONS: If your condition worsens unexpectedly., return 1 2`. here. if you feel your recovery Is not, proceeding as expected, contact your regular physician or cell the Advise Nurse at 1-800-495-8885. Si sU condici6n empeora regrese aqui, Si siente ' t que sly recUperadon no mwza cork se expecte s,c�3��: pcngase an contacto can su doctor regular o liame a la entermera de consejo '1-800-495-8885. WORKING DIAGNOSIS( <`�zs x � �'�` �. �•�, Lu £ � C# PRINTED INSTRUCTIONS GIVEN; WCit3NDC-k-RE 1_r SPRAIN IFRACTtFIE 0'",OT0,16f 7,ARRHEA0 Un. 0 hs-f3-4MA,C0P37 1� . . ..... {C{-��t,'•,�w?a _...... —FfEA Q 3NjAJPY }CASTS I Si^UNTS ©COLOS?FUJI 0EARLY PFV-- 'th'WY GEAR 3S3r ECT3O?ar £ S L-'Y3?WSURY aAC3i t 3 Y 3£3 if333Y 17J EEi+ER C1Xn I3:L 0 VAGINAL WLEEWIG #u.!AE'if3{kAe'FS IAL PAIN © ......,..... OTHER INSTRUCTIONS:UCTI€ NS: k -�ri� � � � �,u� •.. ,.�Mi� f�,�, k _�� f'Q el FOLLOW-UP APPOINTMENT. # Of-TAUT APPOINTMENTS FOP AMILY"FRA-- €CE.'PPOI3£MESENT 3N t. DAYS� �E3"� �EI:3s'F�F�3£�StE6iG E S �Ee'fSEi£�Ifr £kP�` "m£334Ps 5r�>`s;:fW'f'MENT.`'af_fP GIVEN. SPEUAI-TY APPUA"ENTS: L-1;AESNArE LEFT AT APPOINTMENT UNIT, YOU WIIJ-BE CONTAUEl, ABOOUTYCO$?APFI£)NTME-'NT'f 41)T-f33f TWO WORKING, f��, Of.££ffC`^ _ � _ _ DAYS tWEBQS+. NOT BEEN C€INTAC`#EC>CALL APPOIi—t-ENT UN -SW-4<9"NAPPOWTMEMT 't i..!NOSOT ROS E<£t�3 DEJADO UN MENSArIE EIS LA f NIDAL OE GITAS. C ll+£sC?PROVIDES,SCHEDULES#`E DATEE TIM-En ' UD.SERA CONT'ACTACLs 0ENT RO DE 2 oiAS I'fPkl3ll_r&Sl NO£dA Sift: CONTACTA00,`f AMFAL 8W-455-3.8335. i— I GUIlaC l PROVIDER SITE- STAFF ITESTAFF INfrIAL SIGNATURE _ PICK P I E2NDE Tarr'I H"E INSTRUCTIONS{Pad Bret you NEEP TO PICK fid' t o f3EIvIA#N's3ER OF � ti PRESCRIPTIONTUE CONTRA COSTA PEGIf)NAL MEDICAL CENTER EMERGENCY DEPARTMENT STRIVES TO DELIVER THE SES1 _ CARE POSSIBLE,YOUR COMMENTS AND SUGGESTIONS ON.OUR PATIENTSURVEY ARE APPRE-=TEL`S_ YOUR PROVIDER TODAY'WAS- Joseph&arra>,M.D. Gerard Ted,M.D. £#ell 3ayasekara,M-D, Hotbed Sor ond,M.D_ .' Ghfistian Wesrurlan,M.D- Jon . -.'an Beaucharnp, john L Ellis,M.D� john Paters,M.D, C3 Alan Spa'33i,M.D, EJ Fred Beak,M.D, L-3 Chris Farr£#ane,NkD. e Dlao•d Reedy:fsfi,C3. mark 541n-Son,M.U. rzgFid Rellworxf,.rCD. ---I, DasAd Goidstein,M.D. % : a ull achfn#Irl,M.D. 0 David S33O3ts-,v,M.D. 1-1 EIJOI =1000 OEII .. 0 T C ro > to z Ci 0 3 £ { CL < t tz w ow C� C3 i m tD zi z o $" � � 1 \t PATEN iMAW-. Af3MESS � �� DATE Sbo T Sid: f s'ss: _`_ n R zr f v w; Z ziTfT Cos toi Sfs3£a� Jf3w TRANSWiTTAL CSSRES S IATIF UC: NO, DEA t Fi IRMSt•KC— i CONTRA COSTA REGIONAL MEDICAL CENTER EMERGENCY DEPARTMENT GATE: TRfAf3ETibfE: AGE:.- SEX: : _ ARRIVAL bfA: <<^.J WALKING D WX D GUERNEY iO AMOULANCE M CARRIED ;:,POLICE [D5150 'TRANSwwFIJREFERRAL _L ADVICE NURSE VISITTYPE: !7 SCHEDULED RETURN UNSCY}EDLILED RETURN<46 HOi1R$ LOCATION- LOBBY ::RtY01�: CHART: NC YES TRIAGE STATUS: ❑ E f€ II1 `' €V CHIEF COMPLAINT!HPI, r PAST MEDICAL HISTORY. HTN , DiAS=TkS SEIZURE PAIN SCALE:ft# 2 2 4 5$TES 1C `i@ ASTHMA f COPD y.CVA � _ _ v CARDIAC(UST;: SN7E##PRE f ER. SIGNATURE: - OTHER: INTERVENTIONS: NIA MASK ICE DSG ^NPQ OTHER: _ LAB&- K-RAY: _ s MCC15: MEDICA'"ONS, C#I}fiNB ALLERGIES: L]NKA- DOMESTIC`.IOLEPiCE:w Y S 3 u CONTRACEPTION: LAST TETANUS TIME I INITIALS TY E B�' P R T;F -,R TYKE BF fl �SAT :WGT, KG �+P.CC}NAT}t7No �CE3RREfi T TIME IN RQcslai: IMTfAf_PHYSICIAN'S ORDERS/TIME MD ORDERED: j NOTED LAS: CSCD ❑ER BASIC E,COMPER 0 CRP ESR y PT/PTT TYPE SCREENICROSS X�- TIM SEEN BY MO: CARP LFP ,f LIPASE #--GL'UR SCX--._� ER PREG C,UA/C&S 0 PREGU 0 UTA TOX ASGS OTHER LAB: �. X-RAY: L PCXR ;;_'}CXR OTHER: TIME NURSe DIG: r_ CLINICAL S&S: EKG: fo CLINICAL S&S HISTORY&PHYSICAL EXAMMATION � TIME ORD. I PHYSICIAN'S ORDERS NOTED _ ? ,,3 MONITOR -SPO, CHEM,BG i OE Td BOOSTER Div: f STAFF NOTE; CONSULT f MD: I DISCHARGE DX: NURSES NOTES REVIEWED _ __-r4 SEEADDi',•OVAL NOTES NOTIMCATIOW ---�CORUK R ',POLICE CPS ORGAN-DONATION- Oft COQDMON:L IMPROVED --l,%ZCiRT&AMB E-I CRITICAL ::S EXPIRED OTHER: DISWL}Sf-YKSni: .__G✓flNTRA COSTA REGIONAL MEDICAL CENTER E.D.NURSING RECORD NEUROLOGIC PSYCHOLOGICAL CARDIOVASCULAR RESPIRATORY ABDOMEN I GU MUSCULOSKELETAL WATT VC 7 NIA TO CIC N/A TO CJC. c`v>.WA TO CIC �,N/A TO CX D MIA TO CX MENTAL STAIS BEHAVIOR SKIN SIGNS LUNG SOUNDS Ambulatory rA 1'.t# Awake Appropriate r B's,Present Abnorma,Gait Y RP t Formal Cacr ;r�ry= ;Maar B-S.Absent i C-spine p ecautio;� " fJriantad c alrn warm m ; Not �Coo � Wheezing L�R So f! �Swe##ink -:Ce�tenitr• AYousab#e to ;Restless L Anxtaas ;Cpanotic .aie _l_,, E or}manicat#on or Silm. Cr rin #nap resp #+For.-T nd„r Discoloration g+ p 7,C.ammv P#.1shed Rakes L—P. 0.No Response to S=ir:. 1 Uncontrolled p# o;1atFC � "" Rigid etfnass aph _ Rhonchi __L_ N yF E r4 Agitated :`Jaundiced [7acre8seG_ !--R ender Abrasior. �rharenP Combative PULSES Cough _ ? NP Distended µLaceration Emesis Rash nconers^i Paranoid a Bum HatP�cmatin i Strong J v D PATTERN Diarrhea Neufa-Vasc.alr Chack slurrec C tagu#er Rectal — Regular 0 Labored V8 Bleed boom,! :A s; Delusional GRIP STRENIGTF Nart_Verkaai ;.r eguiar Edo na Accessory Muscles wag DIC, Location Equal - T treatanin CAF REF#LL p"Masa#taring Unece a; NIA ,Pressured 8psech. # Norrnak Abnor maF Ury: C Strong �Weak PUPILS 7,PERRLA :mss NIA DESCRIBE ABNORMALITIES: CLASCOW 0 tWAA Scale -- Tremors PAIN WALE:01 2 3 4 5 8'7 8 9 10 110 VISUAL ACUITY L R CORRECTED I SIGNATURE: �: LVN RN 5" trtlTlA s :TYPE" B;P ? R T Other PAIN TIME REASSESSMENT/EVALUA d w_ 10 ! 10 t 10 E 147 147 i 10 _ ! i 10 � 10 TIME INT EI VENTIL?AIS i IN€T BELONGINGS-, � HOME �TO UNIT ��SEE.ADDITIONAL NOTES MEDICATIONS 1 Srr 0 Oe LITERS: VIA: TIME MED f SOLUTION DOSAGE "K OVTE INi f. EKG STAT<10- 0 ROLMNE � EE' NEBULIZER TX 0 RT t CARDIAC MONITOR RHYTHM XRAY: TYPE- r PCXR RETURN: IV#1 SITE: Ell SL TYPE: E] PARAMEDIC START �El- IV#2: SITE: l t SL TYPE: Q PARAMEDIC.START BLOOD SPECIMEN DRAWN L R T B BC � SITE: 13LAST D FIELD DRAW i �}} URINE SENT0 CC 0 CATH D.BAG INTAKE OUTPUT . NLA FOLEY fr: PO to f URINE. EMEsts 1 Nr.T OTHER NG TUBE fr: 13 LAVAGE IRRIGATION 0 Lac 0 Wound 0 E 0 Ear GEN PRC*E SENT DEye L"30u QIP-UA P3 _ t 0 LEUK8•.,,.,_.Q NFT 0 URC} 0 PPFt2„T,.,_ f - ADDITIONAL SIGNATURES INIT. s 10 coot— HOSPITAL.` ORKISCHOC33L NOTIFICATION :.FORM was seer;it"het€.rgent Care DepartrnenT on He/She shouid he able to return to work/school nn_ _ _ With the following reser€ctions: X NI-D. � _, �, _ - _ - _ _ - - w - - - _ - - - - - - - - - - - - - - - -- - - - - - - - - _ _ - - - - - - - - _ - - - - _ - _ _ _ - _ _ - - - Pt_EASE NOTE.The examinat{an and treatment that you have received fn the Urgent Care Department is net intended tobe a substitute for ort ete medical casco.It is important that you be checked main Es instructed.€f an x-ray or EKG has b3 en rleformed, it has been read on a preliminary basis only,and will be revie.ved b a radiologist or internist within 24 hours,You will 3e nvified i$ additional findings are noted. YOUR DIAGNOSIS IS: Lace G t F1 t�U,l kt'£k Hep €ftl'J j Anirnai Bit, tlfabetes i40 CUOM'PI c'i ic'ns clfl%k n>� Y Anergic Ra3aiQf G,rar�, n CnnetE�s en `• €�est ft!l lx_'ftf vnhy tratic�n Migraine Headade i rnr nt°',tts s c:tisitis s3a�t r fsi 8U., tFl7r f l ec<Ba k Pain, ( .tidal Ufa'. F:e r eFfia+ rti:e t* C est Fain :cn gat Qs �rcu rt of f a;. (ed Mies r gal P241 Ccn,wss_r sarfteai #rasif}n ; Gastrtterlwnz GGFI).As:`.... on,act Dc ter atitis :tt#pff eFi tatftf, L=gain;s one,Utz n a Cllr$ edGast itis Teinion. 4Wache FQ*;er CW.,rd Otic s.*V&Fa S`tfa Ram. l?a'?iui "asa#t s €f:i L'3£ees€U€Ell$ op.agi is ilVt3UFt?##stt3 t t f ! Fla?}f#bftf Viral }r s' alae a l)pi r gs�l3 itis ;to 4cnm 4t a° s ! do}tsln l U!-°knovr, 3f°-,Uc€:c Fhar,yng,;s,G'.ep yst€Ffne 5 abies PRINTED INSTRUCTIONS S PROVIDED AS INDICATED ABOVE Other: f The lmv requires all children under 6 years of age or 60 lbs,or less be placed in a cat'seat during transportation, In a vehicle. ADDITIONAL INSTRUCTIONS- YOUR URGENT CARE DEPARTMENT PHYSICIAN BIAS ISEEN ,%` if your symptoms are not getting better in__ hoursfdays:call your regular doctor or clinic,or return to the Emargercy t€Ftonare€�e�farttnertt€rrfntedlatelZt. # r l hafue received and understand the ins"Uons outlined above; _ Patiatit or Rwesentafiva � Matt Date £3,C Tw ie 72X-107A(n2) i Zi Y"j lit! .5 1 1Y 5 2:m G = oila - C: PNOLE C"pUS 2151 APPIAIV WAY PEVOLE, CA 94564 DERMATOLOGY REFERRAL LIST DR BEC .ER. MD DR.MCCAL ONT MD 6431 F'AIRMOt., NT AVE#3 EL CERR.ITO, CA 94530 5103/527-8865 DR CARL`I'ON MD 2023 VALE ROAD #7 r SAN PABLO, CA 94806 i 510/234-4875 r� I i if s EPTAG CONTRA COSTA HEALTH SERVICES E N< olmOFim 595 CENTER AVENUE, SUITE 300 MARTINEZ, CALIFORNIA 94553 EE� (925) 313-5500 RAMS�{T NAME PATIENT NUMBER SEX aC� AWAv SSIOD DATE i CSF$CHARGE DATE f DAYS AMOUNT ENCLOSED t INSURANCE COMPANY NAME GROUP No. POLICY NU SEER jw, SCOTT ELLIS PRIVATE PAY E 1090 AMEND STREET PLEASE RETURN TOP PORTION WITH YOUR PAYMENT Ow T DESCRSPTo,J OF SER'JRGE TWAL ES< OVERAGE # EST.COVERAGE ES,.CCrVE E # Pp 1:i' C.0 c HOSPITAL$EA1F#CES CODE `0HARGF S INS.^JJ.#SCJ.9 ( #NS.C G.t3fJ.? .NS CO,NO 3 AML ST t 0117,+.0 � j F vtl 03 t 1 BASIC C k'3,��` fr'�S O�..I C PML .fx,O6 8 i 339 12 4 . 0,C) # W 019710 f v v 01971078 TOTAL CLINICAL LAS 289. 00 8 9. 0 o' }�� 7 i EMERGENCY ROOM 45200027 9S'-' f 'wf0 1 C ;�• .,y 031 1 SR LIMITED VISIT 45324407 50. 00 TOTAL TAf. EME3?-..'lENCom.q< ROOM VISITS 1A.S .';` r. :UB Tn.TAL,< CHARGES 434. U0 t i t t E � i 3 j i c # 1 t E434. 00 1 rT2:'3= NUPABEP, PLEAS€R>:FEft TQ PATIEt=f� AFJDI't'tONAL PATIENT Sff.LINO MRY BE NECESSARY FQR ANY ` '.`lUtuW.rl ON ALL INCtt�fR1E5 C,ARGES NOT POS 7€II LYt#€N TF%18 FELL KAS PREFAREII_QR PLEASE.��+�r��+AMOUNT! �� -�- AND CO1fiRESt'ON 2ME, 'F INSURANCE CARRIERS 60 NOT PAY ANY PART OF THE - n WGUNQ WOW UNDER ESTIMATED iNSURA3QCE CCVERAGE. CONTRA COSTA HEALTH SERVICES Y DATE OF08.t 595 CENTER AVENUE, SUITE 300 N .. _6 1.10 ..3 MARTINEZ, CALIFORNIA 94553 (925) 313-6500 £#E v i NAM FA3 iEN7 t'!#3tdifiER SEX AGE i AMMS&ON DATE BiSCHARCxE i}RT� DAY i APhttUNi`ENCLE}SEt :y 1 •_Erio .. f 27 3 _4 K e�" .�.._.........._ INSURANCE COMPANY NAME GROUP NO, POLICY NUMtIER PAW-OR 5 fYib£.£..:s E s{. a�E lj PLEASE RETURN TOP PORTION WITH YOUR PAYMENT EDF DE&CttPROtOP TOTAL ES? COVERAGE EST COVERAGE EST.CnVERAtxE F'AllEtk# 140SPITA??L SERVICES CODE CHARGES INS.CO.NO.1 61+5.Cf1,tQt7.< IPtS.CO.NO.^a S+.>dfJi7NT , t'.:�,.,4,f 1 {? S.j.£C�f. s`'.�r'fr.. .3..Fa:,, 7 I��CkT%,;_.. ,._...,.`...Fi Y...xw� # t; st, r<"+x f *,r f # S f t j t 1} £ t i 3 f f 4 3 EwT N1rot. tt f PLEASE REFER TC PAtls'.T C7O£}"iONAL PA£ENT B£Llk1sG MAY BE NECESSARY FOR ANY ' y i NUMBER ON ALL WQUIRIES CHASGES NOT POSTED WHEN THIS BILL WAS PREPAREL},C1P AND CCJf;PESPONDE'�6 IF iNSURANCE CARRIERS 00 NOT PAY ANY PART CdF INE; PLEASE��THIS AMOUNT .�..,�....,,,.,.,„,._._.....�. AMOUNTS t©WN UNDFzR FS TIMATED INSURANCE CD'�fERACxi_: �._.. 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A�ll,�.+t' �'�t"�.t<t� .....•�.s•sw r',�"� .�•`�(`�� f.",If;r.��''n?"�.�.d.:../` "s,�-�-z�-s._-. �/ •'1",,.�,er`.'F ..r� f ...;:t'�" ,.,.�...�'✓"�`6'/�•..s�..+•8v`.�'sC�`'�� .•�1�'�.e''.:r"!.e'�.v'a y..rC`�.,,.:. ,.Tac:..;�'��d"�'M1.,.,t"'^c.'<:e.,�.-•' f�" �.,..F fa✓ t OFFICE OF THE COUNTY COUNSEL ZAL SILVANO B.MARCHESI COUNTY OF CONTRA COSTA �� - `�:�� COUNTY COUNSEL Administration Building .�s SHARON L.ANDERSON Pine Street,9t'Floor ; CHIEF ASSISTANT Martinez, California 94553-i 229 # ` (925) 335-1800 �; u { J _ GREGORY C.HARVEY 1l11 VALERIE J. RANCHE (925) 646-1078 (fax) ,. a a,`�.,:„� � ASStSTANTs V r�yl.W Vl�'y'Y NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO. Scott Ellis 1090 Amend street Pinole, CA 94564 Please Take Notice as Follows: In regards to the claim you submitted on July 9, 2003,portions of your claim are timely and portions are untimely. The portions of your claim prior to January 8,2003 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911,2,because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 8, 2003 were not presented within the time allowed by law,no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. Your only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney,you should do so immediately. SILVANO B. MARCHER COUNTY OUNT COUNSEL By. Janet L. Holmes Deputy County Counsel Page 1 CERTIFICATE OF SERVICE BY MAIL (C.C.P.§§ 1012,1013a,2015.5;Evidence Code§§641,664) 1 declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this NOTICE UP UNTIMELINESS AS TO A PORTION£7P THE CLAIM by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Executed in Martinez,California. Dated. July 10,2003 I kz Kathy©'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 CLAIM ARD QE SUPELVIJ2& OF CONTRA COSTA COUNTY � • BOARD ,ACT ON.AUGUST 12, 2003 Claim Against the County, or District Governed by ) the Beard 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), give rUP " Pursuant to Government Code Section 913 and 915.4. Please nate all"'Warnings" AMOUNT: $150.00 CLAIMANT: CHARANJEET S INCH ATTORNEY: UNKNOWN DATE RECEIVED. JULY 11, 2003 ADDRESS. 9059 WARM SPRING CIRCLE BY DELIVERY"TO CLERK ON: JULY 11, 2003 STOCKTON, CA 95210 BY MAIL POSTMARKED. JULY 09, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWJ�ET , 1 .Dated: JULY 11, 2003 By. Deputy_ II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 l 0,2. { ) 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 914.8). ( } 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 claire(Section 911.3). { } Other. t Dated. By Deputy County Counse t III. FROM: ClerkoftheBoard TO, County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911,3), IVB. BOARD ORDER: By unanimous vote of the Supervisors present; ( I' 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, 17ated. -2-60,�6 JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code sects n 913 Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or depositec 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:t States,over age 18; and that today I deposited in the United States Postai Service in Martinez, California,postage fulty prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. { Dated. /2 "J OHNSWEETEN,CLERK By Deputy Clerk Claire to: BOARD OF SUPERVISORS OF CONTRA COSTA tom.M INSTRUCTIONS TO CLADMAXT 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 clay 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. Gude §911.2.) B. Claim must be filed with the Clerk of the Board of Supervisors at its office in Room 108, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claire 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 REQ 1�JUL Against the County of Contra Costa. } 2003 or cLER BOAPD OF SUPERViS pS '0 ''TPA COSTA CC. District) Fill in name ) The undersigned claimant hereby crakes claim against the County of Contra Costa or the above--named District in the sum of $ and in support of this claim represents as follows: 1. When did t e r injury occur? (Give exact date and hour) 2. Where did thgK_ sir injury occur? (Include city and county) 3. How did the ge A� injurN occur? (Give full details; use extra Pape if rewire Oxm � WI-1 _01-YY fffiLle�_ I 4. What particular act or orron on the p6t of county rr� district officers, servants or .employees caused. the.injury or damage? . Wnat are the games of county or district officers, servants or employees causing the damage or injury? t L—to-A, i S. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. How was the amount claimed above compute? (Include the est3IISated amount of any prospective injury or damage-} �. -B. ones and addresses of` witnesses, doctors and hosp tats. r: 9. List�the=expenditures you trade on account of this accident or injury: OUNT DATE ITEM Gov. Code Sec. 91M provides: "The claim must be signed by the claimant SgND NtrTICF.S TO: (Attorne } orb 77" erson on his. behalf." , . Name and Address of Attorney �'� Claimant`s tore j r -- Address i yy � y Telephone No. Telephone No.� NOTICE Section 72 of the 'Penal Code provides: son who, with intent to defraud, presents for allowance or for Every per county, city or district beard. or payment to any state board or officer, or to any officer, authorized to allow or pay the same i punishable eitheany r by ImPriso�nttin claim, bill, account, voucher, or writing, ear, by a fins of not exceeding county jail-for a period of not more than one y one thousand {$l,00())1 or by both such Imprisonment and fine,` or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars (WtOOO, or by bath such Imprisonment and fine. LA 'F�JL 'e,."i', S ... .. CLAIM BOARD oF§,yPE,RvTS,oxs,oF CDNTr,� COSTA coin BOARD ACTION: AUGUST 12, 2003. 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), giver Pursuant to Government Code Section 913 and { 915.4. Please note all"Warnings". r ` AMOUNT: UNKNNN CLAIMANT: LESLIE ASBER1tI (Minor) ATTORNEY: TERRY D. BULLER DATE RECEIVED: JULY 11, 2003 ADDRESS: PROFESSIONAL CORPORATION BY DELIVERY TO CLERK ON: 11jLy 11-, 2M-3 1418 LAKESIDE DRIVE OAKLAND, CA 94613 BY MAIL POSTMARKED: JULY 09, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET , Dated: JULY 11, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup isors This claim complies substantially with Sections 910 an&Q 10.2. ( ) 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 fled. The Clerk should return claim on ground that it was fled late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: 1 Dated: By: "fl eputy County Couns III. FROM: CYerk of the Board TO: County Counsel(1) County Administrator(.2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV ARD 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 Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or deposit( in the mail to.,file a court actionon 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 full; prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:IL4 JOHN SWEETEN,CLERK By Deputy Clerl LAW OFFICES Tm, izi� Y D . Bur. T, t+, tz PROFESSIONAL CORPORATION THE CAMRON-STANFORD HOUSE HAROLD L.STROM 1418 LAKESIDE DRIVE BARBARA K.BOOTH RETIRED OAKLAND,CALIFORNIA 94612 DENEEN M.CONSAGRA (510)832.4245 PARALEGALS FAX(510)832-4364 RECEIVED July 9, 2003 JUL 1 1 2003 CLERK BOARD Of SUPERVISORS CERTIFIED MAIL _ CONTRA COSTA M RETURN RECEIPT REQUESTED Contra Costa County Clerk - Board of Supervisors 651 Pine Street Martinez, CA 94553 RE: Claim for Damages by Leslie Asberry(Minor) Date of Accident: January 15, 2043 Dear Sir or Madan: Enclosed please find the original and two copies of a Claim for personal injuries against the City of Concord by our client, Leslie Asberry(a minor). Please date received stamp one copy and return it to this office in the envelope provided. Thank you for your cooperation in this matter. Sincerely, Terry D. Buller TDB/dmc Enclosures CLAIM AGAINST THE COUNTY OF CONTRA COSTA CLAIMANT'S NAME: Leslie Asberry(a Minor) CLAIMANT'S ADDRESS: 2800 Broadmoor Avenue, #B Concord, CA 94520 ATTORNEY FOR CLAIMANT: TERRY D. BULLER Professional Corporation 1418 Lakeside Drive Oakland, CA 94612 510/832-4295 DATE OF OCCURRENCE: January 15, 2003 PLACE OF OCCURRENCE: Eastbound Olivera Road on-ramp to State Route 242 southbound; or 23 feet south of Olivera Road, Concord, California SAID CLAIM AROSE FROM THE FOLLOWING CIRCUMSTANCES: Claimant Leslie Asberry(a Minor)was a pedestrian injured when struck by a vehicle while in the City crosswalk as well as the carelessness and negligence of the COUNTY OF CONTRA COSTA which allowed the crosswalk to be and remain in an unsafe and dangerous condition as the roadway lacked adequate markings and warnings of the unsafe and dangerous condition. The COUNTY OF CONTRA COSTA was negligent and careless in allowing an unsafe condition to exist with no warnings or other barricades to warn pedestrians of the unsafe condition. Said condition was the proximate cause of the injuries sustained by Claimant herein. ITEMS, NATURE AND EXTENT OF DAMAGES OR INJURIES: Claimant Leslie Asberry(a Minor) suffered injuries to her body, health, strength and activities and extreme general shock and emotional distress to her nervous system, the exact nature of which is unknown to Claimant at this time. JURISDICTION OVER THIS CLAIM RESTS IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA. DATED: July 9, 2003 TERRY D. BULLER Professional Corporation By: Attorney for Claimant 0 v a > m � ° � � � p rr �t o z n O m 0 z W rn Z b Xo D m = D r 0 81+1 m 6 Z N .wrrwr«wrrir�s � �rrFrrw� to Wcr i� � Mwrr M M w Mrwr� .�' arrirwiMrrr�w�� "° ru ` } w O arwirrwr.— c.n t1� w ON ., k r s, ,s � r x4� i9 a '`�+s 4w •aa.ss CLAIM . BC3 F PERM C) S 2F CONTRA COSTA COUNTY BOAR, ION- AUGUST 12, 2003, 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), give Pursuant to Government Code Section 913 and , 3 915.4. Please note all"Warnings". AMOUNT; UNKNOWN CLAIMANT: EMILY CHAMBERS (a Mince) ATTORNEY: TERRY D. BULLER DATE RECEIVED: JULY 11 2003 ADDRESS: PROFESSIONAL CORPORATION BY DELIVERY TO CLERK ON: JULY 11, 2003 141:8 LAKESIDE DRIVE OAKLAND, CA 94612 BY MAIL POSTMARKED: JULY 09, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOAN SWEET , Dated: ,JAY 11,, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervi ors This claim complies substantially with Sections 910 an&,tQ,10.2. ( ) 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: VU� Deputy County Counst III. FROM: gerkoftheBoard TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with novice to claimant(Section 911.3). IVA. OARD ORDER: By unanimous vete of the Supervisors present: (V5 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: 1Zg±gXOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov, code section 913) Subject to certain exceptions;you have only six(6)months from the date this ndtice was personally served or deposftec 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: 0_3 JOHN SWEETEN, CLERK By Deputy Clerk Law OFFICES TP1� I2Y D . Bui Li IP, iz PROFESSIONAL CORPORATION THE CAMRON-STANFORD HOUSE HAROLD L.STROM 1418 LAKESIDE DRIVE BARBARA K.BOOTH RETIRED OAKLAND,CALIFORNIA 94612 DENEEN M.CONSAGRA (510)832.4245 PARALEGALS FAX 1510)832.4364 RECEIVED July 9, 2003 JUL 1 1 2003 CLERK BOARD OF SUPERVISORS CERTIFIED MAIL - CONTRA COSTA CO. RETURN RECEIPT REQUESTED Contra Costa County Clerk -Board of Supervisors 651 Pine Street Martinez, CA 94553 RE: Claim for Damages by Emily Chambers (a Minor) Date of Accident: January 15, 2003 Dear Sir or Madam: Enclosed please find the original and two copies of a Claim for personal injuries against the City of Concord by our client, Emily Chambers (a minor). Please date received stamp one copy and return it to this office in the envelope provided. Thank you for your cooperation in this matter. Sincerely, Terry D. Buller TDBldmc Enclosures CLAIM AGAINST THE COUNTY OF CONTRA COSTA CLAIMANT'S NAME: Emily Chambers (a Minor) CLAIMANT'S ADDRESS: 1651 Detroit Avenue, #204 Concord, CA 94520 ATTORNEY FOR CLAIMANT: TERRY D. BULLER Professional Corporation 1418 Lakeside Drive Oakland, CA 94612 510/832-4295 DATE OF OCCURRENCE: January 15, 2003 PLACE OF OCCURRENCE: Eastbound Olivera Road on-ramp to State Route 242 southbound; or 23 feet south of Olivera Road, Concord, California SAID CLAIM AROSE FROM THE FOLLOWING CIRCUMSTANCES: Claimant Emily Chambers (a Minor)was a pedestrian injured when struck by a vehicle while in the City crosswalk as well as the carelessness and negligence of the COUNTY OF CONTRA COSTA which allowed the crosswalk to be and remain in an unsafe and dangerous condition as the roadway lacked adequate markings and warnings of the unsafe and dangerous condition. The COUNTY OF CONTRA COSTA was negligent and careless in allowing an unsafe condition to exist with no warnings or other barricades to warn pedestrians of the unsafe condition. Said condition was the proximate cause of the injuries sustained by Claimant herein. ITEMS, NATURE AND EXTENT OF DAMAGES OR INJURIES: Claimant Emily Chambers (a Minor) suffered injuries to her body,health, strength and activities and extreme general shock and emotional distress to her nervous system, the exact nature of which is unknown to Claimant at this time. JURISDICTION OVER THIS CLAIM RESTS IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA. DATED: July 9, 2003 TERRY D. BULLER Professional Corporation -- ? Attorney for Claimant 0 x z y D n Z D D z z r J, 0 0 oz p n z < ? o D q t-4 N 6 tj z �-,q Cl C3 \ W C w r 0 C 0 o CLAIM CtF P RVI RS {3F CONTRA COSTA COLNTY BOARD-ACTION: AUGUST 12, 2003 Crim 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 Cedes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), giver „ { Pursuant to Government Code Section 913 and y > ' 915.4. Please note all"Warnings". AMOLTNT: $822.87 { j3 CLAIIV/AN . CHRS1Oyy�TTRB s HARRISON ATTORNEY. UNKNowN DATE RECEIVED. JULY Il, 2003 ADDRESS: 143 ROXA NE COURT #2 BY DELIVERY TO CLERK.ON:JULY 111 2003 WALNUT CREEK, GA 94596 BY MAID POSTMARKED: JULY 09, 2003 FROM: Clem of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim JOHN SWEETS , k Bated. JULY 11, 2003 By. Deputy II, FROM: County Counsel TO: Clerk of the Board of Supervis rs This claim complies substantially with Sections 910 ani10.2. { ) 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: r Dated: �� ...... By. A &=A4kf1 --Depyty--DeputyCounty Counse 111, FRO I 4: Cl k of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. '?ARD ORDER: By unanimous vote of the Supervisors present: ( This Clain 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 , Deputy Clerk WARNING(Gov. code section 913 � Subject to certain exceptions;you have only six(6)months from the date this ndtice was personally served or depositea 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 ybur 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 fulty prepaid a certified copy of this.Board Order and Notice to Claimant, addresses)to the claimant as shown above. Dated: JOHN SWEETEN, CLERK.By Deputy Clerk', Claim to: BOARD OF SUPERVISOM OF C ONMA CITY INSMCTTOM TO CunikYM A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the: accrual of the cause of action. Claims relating to causes of action for.de ath or for injury to person or to personal property or growing *raps and which aocrue on or after January 1, 1988, must be presented not later than sic Months after the accrual of the cause Of action. Claims relating to any other oa=e of action tffust be presented not later than one year after the accrual of the cause of action. (Govt. Cade §911.2.) S. Claims mast be filed with the Meft of the Board of Supervi3ors at its office in 7 Room 106 County Administration Building, 651 Pine Street, Martinez, Ci 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the C.mnty, the nares of the District should to filled in. D. If the claim is against more than one public entity, separate claim must be filed against each public entity. E.' Fraud. See penalty for fraudulent claims, Penal. Code ,Sec. 72 at the end of this a * RE: Claim May Raserved for Clark's filing stamp n � !` ,"y{� ,14r c sa;; "'RECEIVED tR Costa ? JUL 1 12003 or } # U?ERIKSOARD OF SUPERVISORS Uistriot) CnNTRA nAR A CO. Tire undemigped_o1alwat hereby makes dim inst the County of Cara Costa: or the: arc-zed District in the sum of -ZZ- 7 � , and in support of this claim represents .as follows: I. Vhen did the damage or iznjur occur? (sive exact dates and hour) 2. Where did the damage or injury cacscur'. (Include oi'tp and ownty) 3. How did the doge or injury occur? (Give fall, details, use extra paper if required) i) v- 1� � �^,es-,ct� �tz� i;�� frrr: � �v��3,�W'.a a r3fs 3 x ,l- a(,•.afi 3— Gsavb2z Grua Ali Lar 3 9 t ^ .t� �u.,: 4�r4- ML Yr ��t�++y;} - ,:•a^t� ��. .N7'r(i:i+ s..�:4 2 Iri r`i'+C. "ty;. „}"'i�-£ ;�sf,4�&2.��"• '�" ,�}"" i,;y��„sxw�„1 �✓;a,, .t. f r��:�,.,!” E - s,�-^ �:i`< 4 t_+Z F'+ .+ Y" +kt+'j`i. 1 t'w w r� •w '+w.9't-fi d fir.. 4. What partioular act or omission on the part of county or district offices, servants or.employees caused,the.injury cr ? Told TZb T 9212 SK 6 lNawo"w )G I N 30D BS:V T 2002-60-tJ r W,d IJ10i what are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim re3ulted? (Give full extent of injuries or dames claimed. Attiob two estimates Par auto damage. } 7• How was the a=mt claimed above a mputed? (Include the estim�a,ted amount of any prospective injury or damage.) f.w'a'� ,w," w..r C�z _tn `°� �'•£�.�w.r' ,'.,a+ -�.+� - 8. tis and addresses of witnesses, doctors and 1110spitals,. r' - �,,3�r,', +�r'.rwiWn.rrr.ir�rr !��'+'�'�""re.�.rrrw+++�+��•��rw.r....r+r�ww+�...++.++rwrr.wsw.rw.e.,Mr�w+wrr.a. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AL IT � 9i �lcai� * i! * �F .lF � � !l � 1a � �a � •� l�.� �l � �' �, �' � '� # # i � ii. .MiEN # �' � +kpiklt Goof. Code Sec. 91 M provides i "The claim must be signed by the claimant SEND =aS TOO (Attorrie or s ex on on his.behalf." Fame AdCreSS of Attorney tts � ure A ss olophone No. Telepbone No +� NOTICE Section 72 of the Feral Code pr'oridesz "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 eL1nw or pay the assn* if .genui.net any false or fraudulent c3aalm, bill, account, voucher, or writing, is punishable either by inprisoriMt, in thea county jail.'for a perked of not moo ttw one,year t by a fine of not exceed Ing one thousand ($1,000), or by-bath such iz*rlactment 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. E0'd T b t 5E2 6 iN3WOtJWW >iS 1 d 69:tl 2002-60-wx ........ ......... .............-___ ......... ......... ........ ......... ............................. ti ,-`•, •'�+ A �� Kra jt t �e.,n, � t.e „ 'k n��.� r ��`{ y j s.. i;.z L fY a:.c_.'t' .,✓, ,: i..- a .. }.. .+, = 7 <.i s a � s.,. ,,.'.. u ra�t 5........4-.-�' y ..........`"' "..'c.✓ -..__ 2 _ .._._..._........... ........ .......... a , ;+r, y i �✓ Fr t y .. t�✓s.f'f" ry:.!}�f s .r:...'... a ...;i `��,,,�,z<�.-_ ..f.��!/c tr ---'.... ... � . �.; •.'rs,;-"' `� `w h;�5 •'a-% <'�..,r Yr,; :s£r?4'k�s''+..• �''�'6,;,:,i `tet-" "`'^� ';� a +.., �a.t�:) ` firg u l ;r ...: r`?:' �r� _ C fr 'a�. #.1.<'.. r'... .......................... j _ ................ .......... _._._...... ...................... . ... _._ _ . ........ ....... ................... _...... ......... .._...._.._........._. __ . ..._....._............... _.._ .................... _ __........ _ ..._...._ ......................... _. _..... ....._._._............. ......... _......... :-11-2003 12:39 AM, AMERICA'S TIRE PRICE QUOTE PAGE 1 QUOTE 4 5955 CUSTOMER INFORMATION VEHICLE INFORMATION STORE LOCATION ------------------------------------------------------------------------------------------------ CHRIS R HARRISON 1999 EAGLE CAN 21 143 R€XANNE CT 2 TALON 1350 PINE ST. ALL DL/ES/ESI WALNUT CREEK CA 4526 WALNUT CREEK CA 94596 PHONE: 925-933-2833 925-274-9238 PLATE # UNKNOWN MILEAGE; UNKNOWN 568 CHRIS DALTON CODE CC QTY SIZE DESCRIPTION F.E.T. PRICE AMOUNT --------------------------------------------------------------------------------- 356&E NRM 2 225/45R-17 90V MICHELIN SX-GT BLACK .00 205.00 410.00 WARRANTY: WORKMANSH I A;€SATE R I ALS-L I FET I.ME B0075 NRM 2 STATE REQUI RED ENVIRONMENTAL FEE 100 1.00 2.00 80224 'SRN 2 WASTE TIRE DISPOSAL FEE .010 2.50 5�00 80219 NRM 2 FREE FLAT REPAIRS, AIR CHEC.kS & ROTATION .00 .00 .00 80402 NRM 2 LIFETIME" BALANCING & RUB ER-<VALVE .00 .00 .00 64179 NRM _? 17X7 5-100/112 400 ENKE I DR9 29477006SP .00 05.00 250.00 WARRANTY: N R ANSHI /MATERIP-S-L.IFETE TA& 54.86 TOTAL: 721.86 FREE CUSTOMER FLAT REPAIR AND ROTATION This quote is pped for 30 days THANK YOU FOR SHOPPING AMEPICA'E TIRE CS,,,.`' ................................................................................... .... ....... ....................... .................................................................................. ............................ .......... ............... 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' fi�C'i'•.' �' fF �f F a� f 4 a f •` xf ✓., t a � r� p S k - � ry s CLAIM OE SUE.Eg)L1SQRS Of CONTRA COSTA COt1NTY r BC)ARD AC'I'SQN: AUGUST 12, 2003 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}, giver K " Pursuant to Government Corse Section 913 and 915.4. Please note all"Warnings". AMOUNT: $612.56 , CLAIMANT: PLACER COUNTY SHERIFF CORONER-MARSHAL FOR: RICHARD NAVARRO ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2003 ADDRESS: P.O. BOX 6990 BY DELIVERY TO CLERK ON: JULY 14, 2003 A(JBWTRN, CA. 95604 BY MAIL POSTMARKED: JULY 11, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 14 2003 JOHN 57, , erk Dated.: By: Deputy II. FROM. County Counsel TO: Clerk of the Board of Supefvisois This claim complies substantially with Sections 910 an& ; 0.2. { } 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 uty County Counse III, FROM. Cl �of the Board TO: County Counsel{1} County Administrator{2} { } Claim was returned as untimely with notice to claimant{Section 911.3}. IV� ARD ORDER: By unanimous vote of the Supervisors present: t { This Claim is rejected in full. { } Cather: I certify that this is a true and correct copy of the Board's Order entered in its.minutes for this date. e Dated: OHN SWEETEN, CLERK, By Deputy Clerk 21 WARNING{Gov. code section 913} Subject to certain exceptions,you have only six {6}months from the date this ndtice was personally served or deposftea in the mail tofile 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. ' f 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`1, 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: 0400HN SWEETEN,CLERK.By Deputy Clerk _ PLACER COUNTY �r ID T xi SHEX FF �.4 MA`�:OFF;C :AHOESUBc NON " 4 RO.sox S990 ^HAVrEFS710 m 11 AiSURN-1,0A95604 TAHOE C;Y,CA96145 ES<: 1851 `a� �� #'�1.30)38978x3 FAX:;630j889.7899 PH:(530;591.6300 FAX:(530)581.6377 EDWARD N.BONNER STEPHEN L.DIARCY CLAIM AGAINST THE COUNTY OF CONTRA COSTA Board of Supervisors "` County of Contra Costa fl�jU 651 Pine St. 1 4 Martinez,CA 94553 ZER Re: Case Number SO-02-20611 co Re: The Placer County Sheriff's Department files this claim of$612.56 for reimbursement under Government Code 26614.5 for Search and Rescue expenses. Victim: Navarro,Richard 1370€1 San Pablo Ave##2117 San Pablo,CA 94806 How search occurred:Became lost while snowboarding. Expenses: $712.56 100.00 Deduction pursuant to G.C.26614.5 $612.56 Report and expense sheets are attached. Please make the check payable to County of Placer County Sheriff's Department, Attn:Accounting Department,P.O.Box 6990,Auburn,CA 95604. Sincerely, Edward N.Bonner It's brand fax transmsitai memo 76�1 Sheriff—Coroner-Marshal Poet- From Yo cn. Co. �l hone# �' Det X# e Fax 9 Search for Navarro, Richard Contra Costa County SCS 02 20611 Food & Beverage: Jiffy's Pizza $ 76.31 Fuel: N/A Officers Wages: Deputy Perriraz 9.5 ST $456.00 3.5 OT $180.25 Mileage: N/A Total $712.56 y PLACER COUNTY SHERIFF'S DEPARTMENT 4) RECORD TYPE MISSING PERSON REPORTING FORM (ChOcktypowhich best describes) L. Runaway Juvenile D Voluntary Missing Adult 1) C/7eckt7ne: ADULT C1 JUVENILE 0 Parental/Family Abduction D Non-Family Abduction Reporting Agency 1 ?!y :r 3) ORI d.:./40f, t !,0Z_ D Stranger Abduction D Dependent adult Case# c- - / U Last ✓ 0 Catastrophe 6) DOJ# t`� '- x est`/' 7) NCIC# D Unknown Circumstances 8) CATEGORY: 'W At Risk D Prior Missing O Sexual Exploitation Suspected 9) Neale NAVA t 7ZcC + Date/Time Missing _" -d 10) Alias 'I Alias 2 11) 12) 13) 14) 15) EYE 16) HAIR 17) DATE OF GENDER RACE HGT, WGT. COLOR COLOR/LENGTH BIRTH i Male D W D C D BLK D HAi 2 BLK D RED 59 y}'=tk MBLU 0 MAR © BLN 0 SDY D Female B D F ) ,, 54 BRO D PNK D BRO D WHT 1 D Unknown D 1 D 0 D GRY CJ MUL C GRY D XXX 0 X D GRN D XXX Length 18) Residence Address .14.. '_ .�� i +% ' Ci1C AIV J�ARAI 14 tY 19) Location Last Seen e 'f 44 J' -- Ae"bable ton 20) Known Associates 4&lve 21) Mental Condition 22) SS# .1d'r dy Cil# t``��' ' _ FBI# 1*,vAL_ DL# + ' r2e)7 2 ) Photo Available: 1.3 Yes ij;� No Age in Photo_ Photo/X-Ray Waiver Release Signed: 0 Yes IP No (Attach Pham) 24) Scars/Marksfrattoos (locate/describe) -T&I , 25) Skeletal X-Rays Available: D Yes No; Broken Bones/Missing Organs: L �j LXj c)�h 26) dental X-Rays Available: D Yes iV No; (Attach Chart and X-Rays) Dentures: D Upper D Lower El Full D Partial 27) Visible Dental Work B Dentist's Name el y F r Phone ;- 29) Glasses ❑ Contact Lens, Cl Clothing Description/Size ` 30) Jewelry Description - ' r c � ) If Vehicle Involved: CS M MP Lic,# Make _ Lit r,4 Model Year If abduction,did abduction involve movement of missing person in the commission of a crime? D Yes 0 No 33) Suspect Name DCB 34) Relationship to Victim Warrant# 35) Reporting Party � � '-rh'`� Ph 36) Relationship to Missing Person Date Reported 37)Additional Information —' � . x-1)4 4�_ .5 -4 38 Reporting Officer/AgencyOfficer/Agency Contact Phones' s�s GEO. ODE PLACER COUNTY SHERI'FF'S DEPARTMENT REPORT NUMBER ALPINE MEar OWS � � � REPORT � , � � S002-20611 CONNECTED REPORTS {XI ORIGINAL REPORT { ] SUPPLEMENTARY { FOLLOW-UP GRIME TYPE: VICTIM: INCIDENT REPORT MISSING PERSON �EVARO, RICHARD DATE 12/20/02 TIME 1638 HRS ORIGIN: I was dispatched to Alpine Meadows Ski Area for a reported snowboarder who was missing. l arrived and spoke with the R/P-Apollo Kahl. R/P-Kahl told me the following in summary: RIP-Kahl and M/P-Richard Nevaro are roommates and live in San Pablo, Cly. They arrived at Alpine Meadows at approximately 1030 HRS. R/P-Kahl said the last time he saw M/P-Nevaro was at 1100 HRS in lime to use chair lift number six. R/P-Kahl has known M/P-Nevaro for nine years now and said it is not like him to not meet him at the car at the end of the ski day. DATE 12/20/02 TIME 1720 HRS Deputy Perriraz arrived and initiated a Search and rescue. l filled out a Missing Person Reporting Form and a Search and Rescue Form. l was unable to obtain any medical information or a picture of'M/P-Nevaro. I turned the scene over to Deputy Perriraz. NOTHING FURTHER: Reporting Deputy: R. PIRTLE #143 December 21, 2002 Approved: Page of . GEO.CODE PLACER COUNTY SHERIFF'S DEPARTMENT REPORT NUMBER Alpine Meadows � drelijim Aa* „ 5002-20611 CONNECTED REPORTS [ � ORIGINAL REPORT IXJ SUPPLEMENTARY [ ] €oLr.aw-uP CRIME TYPE: VICTIM: Search anti Rescue NAVARRO, RICHARD 12-20-02 1 was directed to respond to the Ski Patrol Office at Alpine Meadows ski area in order to 1643 Hrs. evaluate the missing person report being taken by Dep. Pirtle for the potential of initiating a Search and Rescue. i arrived at the Ski Patrol Office at 1720 hrs. where 1 met with Dep. Pirtle and the reporting party. 1 monitored the information given to Dep. Pirtle for his missing person's report and immediately made the decision to begin a search. (See Dep. Pirtle's Missing Persons Report for additional information.) l directed dispatch to call out the Tahoe Nordic Team and arrange for the communications van to respond. Dep. Pirtle also requested that a Chaplaincy member respond to stand by with the RIP. I spoke with Ray Belli who is the patrol manager for Alpine Meadows and learned that a final patrol sweep of the mountain had already been completed with nothing found out of the ordinary. Belli also told me that he would provide transportation for the searchers to the top of the mountain. 1 spore further with the R/P(KAHL) who told me that the last time he had seen the M/P(NAVARRO) was about 11:00 A.M. after they got off the Summit Chair lift and were headed towards the Three Sisters area. When the RIP arrived at Three .Sisters, he did not see his friend. The conditions at the top of the ridge were strong winds and blowing snow, which made for very poor visibility. l determined that the priority areas for the search would be off the backside of the Summit Chair Lift in an area known as Wolverine Saddle. Tahoe Nordic team members began arriving and prepared to deploy. (See attached sign in/ sign out sheet.) At 1915 hours, 1 gave a briefing to the searchers, which covered all of the information on the lost Person Questionnaire. Team assignments were made as follows. Nordic 1: Joe Pace and Jonathon Laine. Nordic 2: Steve Twomey, Paul Honeywell, and Jeff Reiger. Nordic 3: Bill Wise and Tony Bochene Nordic 4: Mark Johnson and Mike Kennett Teams 1,2, & 3 were detailed to search the three drainage's from the top of the summit chair West to Big Springs then North to the Five lakes area. Team 4 staged at the top of the summit chair i n case they were needed somewhere else. The communications van arrived and assumed Reporting Officer J. P'erriraz #18 December 21, 2402 Approved;A'1 . Page 1 of 5 GEO.CODE PLACER COUNTY SHERIFF'S DEPARTMENT REPORT NUMBER Atpine Meadows i ,, S002-20611 , CONTINUATIONCONNECTED REPORTS [ ] ORIGINAL REPORT [X] SUPPLEMENTARY [ ] FOLLOW-UP r - CRIME TYPE: VICTIM: Search and Rescue t+iAVARRCI, RICHARD responsibility for all radio traffic from the search teams. The primary channel used was the Ward Peak repeater. The Alpine Meadows snow cat arrived at 1930 hours and transported the teams to the top of the summit chair. The three primary search teams were dropped off and began searching at approx. 1950 hours. The command center was set up in the ski patrol office. I assumed the role of Incident Commander and was assisted by Daren Honeywell who acted as TNSAR liason and Operations Commander. Eilene Mulligan of the Law Enforcement Chaplaincy arrived and stayed with the R/P in a support role. At approx. 2220 hours, Team 2 advised that they were following a faint track, which appeared to be headingNorth from the Big Springs area. Shortly after, team 1 joined with team 2 and confirmed a track heading North. They described the tracks as "post holing" in the snow. At 2335 hours, Team 1 advised that the missing person had been located and was in good condition. They further advised that he was wet and cold and slightly hypothermic. They dried him off and gave him dry clothes to warm up. Team 3 joined the others. After some discussion, it was decided to have the teams and the victim hike to the K.T. saddle in Squaw Valley where a snow cat could pick them up and transport them to the Squaw Valley Tram Building. The teams anticipated about a two-hour walk to the pick up site. At 0245 hours, dispatch called Squaw Valley and directed that the snow cat respond to the saddle and link up with the search teams. I transported the R/P to Squaw Valley where we met with the search teams and victim. The victim had been medically checked by Jonathon Laine of team 1, who is a medical doctor and was not in need of any other medical assistance. I transported the Victim and the R/P back to Alpine Meadows where we met with all of the returning searchers. Once all of the searchers where in and accounted for, Tahoe Nordic was cleared of the search and left. The search was terminated at 0404 hours. I interviewed the victim in the ski patrol office and he told me the following in summary. Victim and his friend, the R/P, were snowboarding at Alpine Meadows, and had already made one run down the mountain from the top of the Summit Chair. At about 1100 hours, they were preparing to make the same run and got off of the Summit Chair lift together and started North before going down the mountain. Victim lost.sight of his friend due to the poor visibility from the blowing snow and Reporting Officer 3. Porriraz #18 -,l'� � December 21, 2002 7Approved:; Page - of oEt RODE PLACER COUNTY SHERIFF'S DEPARTMENT REPORT NUM$ER Alpine MeadowsSgt-21f'!"I • CONNECTED REPORTS ORIGINAL REPORT [X] SUPPLEMENTARY [ } FOLLOW-UP CRIME TYPE: VICTIM: Search and Rescue NAVARRO, RICHARD apparently walked too far to his left and dropped off the wrong side of the mountain. He felt that he realized his mistake quickly and tried to move to his right to regain the correct side of the mountain. The Victim soon became disoriented and began heading down hill. After some time, he tried to build a snow cave to stay in and warm up. While constructing the cave, he became very wet and cold and decided to start moving again to warm up. Victim came to an area where he needed to rest and climbed into a low tree to get out of the snow. He wasn't there long when the searchers carne upon him. After getting some food and dry cloths, the Victim was able to walk out with the search teams to the pick up area. The Victim told me that he never saw any boundary sighs and had no intentions of getting off of the beaten track. Victim and R/P were very appreciative of all the help they received. Officer's Notes: As a result of my investigation and observations, I felt that the actions of victim did not violate the provisions of Penal Code 602(q) in that I could establish no intent to ski out of bounds. Further, Alpine Meadows does not have an out of bounds policy in that the area outside of their property is considered open. The final coordinates of where victim was found was 735761 mE 4337712mN. I During the search, I had food purchased for the search participants. This consisted of three pizzas and three 5-packs of soda from Jiffy's Pizza in Tahoe City. Jiffy's did not accept credit cards, however, they still supplied the food and gave us a bill in the amount of$76.31. (attached) No injuries to any searchers and no equipment damage reported. No infringement on the U.S.P.S. Wilderness Area was made by any motorized vehicle. Reporting Officer J. Perriraz #18 � r December 21, 20(2 ,' Approved: . Wage of 3 PLACER COUNTY SHERIFF'S SEARCH AND RESCUE LOST PERSON QUESTIONNAIRE / SHORT FORM Case # SUBJECT INFORMATION: -- - Name Q UA 1Z€ � � .�CA4v4 DOB Oc Sex— Age .33Race t4 Height s Weight W Hair 4-LV Eyes 'Z;tzz Build oA Bair Style 'if6d-T- Facial Hair stet;.,-4,s D.L.#� Scars/Marks ,j�.s- - At& rhe Physical Condition 1,,6,e.P Handicaps - Emotional State Outdoor Experience Responds T %' 4 a ' , Fears or Phobias tero N-kZ Vehicle/Year 10Make s Madelg-kvA,4&zColor °% License-- - CLOTHING DESCRIPTION j DETAILED & SPECIFIC: Shirt ,LY- Coat I` Pants Hat/Type .. _ Cloves 1 ► Glasses . Shoe Type, ne s: Sole Print &Lpx ; - Other " A:�— � QL AENT & SUPPLIES f SPECIFIC BRANDS & COLORS IF KNOWN: Smoke r Candy/Gum -6,--- Food/Snacks - &i*g6:6, Pack Tent btii Sleeping Bag ,-10 Skis *c� Poles Alb Other ve A,•-Qz_ i Gun nife ,tc Compass Maps MirrorA '6_„� VICTIM LAST SEEN: By Whom 4) _g4 DateJ Z'O-->Z- Time 1 r.` ,-- Where-, ,o�At Dentination� _ r Situation REPORTING PERSON: Named hzeej L<'d#6 Age 2- Relationship A:(; Local Phone PHOTO Staying at el- Other Important Info Form Completed By: White W Plans/Report Yellow = Operations Pink = Comm ALPINE MEADOWS SIO PATROL MISSING PERSON REPORT DATE €E-PORTED: TIME DEPORTED: REPORTED MISSING BY: R.ELA'I"IONSHIP: VV'1` ADDRESS/PHONE iF REPORTING PARTY: PERMANENT: LOCAL: NAME OIC` MISSING PERSON: SEX-- H AGE: IIEIGI-I'F: 1 0 WEIGHT: 1 --wHAIR_.. JACKET: l PANTS: o,C _ I.IA"I": �t� f-1 �;,,Qlo V* SKIING ABILITY: SIMS: _ _ ._ SNC3'ytTBOAR.D:V I HEAL"€ll, MEDS, L7IZUGS: { _ TIMI;: - LOCATION LAST SEEN: TOO .. r LIFTS LIKELYTO USE: AGREED UPON MEETING PLACI"s: 1 TIME: Ia AMILIAR TY W/ALPINE: � � �¢ -� 4`,� _11 TIMES SKIED AM: RENTAL SKIS? � .( t� � SEASONAI3 LOCKER?. MISSING PERSON'S HOME AI)DRES/I'II.OM ; Make calls _ – _ .._.,—... FOCAL FRIENDS LOCAL NUMBERS: OR RELATIVES: MAKE/YR OF-CAR: L I C E N:�I1 COLOR: CAR'S LOCATION: HAS IT BEEN MOVED?: C:) BARS: River Ranch: 4 !�€ z ie Doti: 583-6896 Squaw Bar I: 583-1777_ CALL TRANSPORTATION:TATION: SWEE€-' PARKING LOT: CALL FIRST AID ROOM AND CHECK LOG.- OT 1-1 E, OCI.- OT1-1E LFOUNIJIBY- _ _ WI-IERE?: TIME: 2/l/00 PLACER COUNTY SHERIFFOS DEPARTMENT SEARCH & RESCUE SIGN IN LOG S.A.R. UNIT. '� a. ca v: O.E.S. NO: A --- DATE: OPS PERIOD TIMES: - to INCIDENT NAME: LOCATION: SEARCH & RESCUE .'IiRAXITYNG WMXN. [ ] MA.INT. EVIDENCE � TIME IN STARTS ON FATE LISTED ABOVE t exceed 24 hours perpage) ID # NAME (Last,Fi rst M. ) UNIT TIME IN TIME OUT HOURS 2 0o kcah tJ " 9 - C C 1t 1 10 j �, to 11 '" 'G 1/ L 00 C 12 .til t0 t106 lo � 13 L- 1910 o Vo 0 14 1 rr j /t3 oybo 957 1 `` l 2,01 16 1 Flo 17 18 19 20 TOTAL HOURS THIS PAGE: Reporting Officer supervisor White = Recorder/Report Yellow = Finance Pink Plans �/'� r .. PLACER ►�YsxcF�F.S DEPARTMENT Case. �_ .�- . C�� a6 SACH AND RESCUE STATS SKEET VICTIM � NAME f� ,/ GSE DISPOSITION (.circl-e) #1 ) 1L'. t .! 1 ti ICS` �V DE NF ME #2) SV DE NF ME. #3) SV DE NF ME #4) SV DE NF ME TYPE OF ACTIVITY [ l Aircraft (downed) [ ] Climbing [ ) Motorcycling/ATV [ ) Backpacking [ ) Fishing C 7 Rafting [ ) Bicycling [ I Hiking Skiing [ ) Boating/Water skiing [ ] Hunting ) Snow sports [ Camping [ ) Mines/caving, Other MAN HOURS rNVC) VED . 1 . Civilian Volunteers: _ SAR Unit # People Hours SAR Unit # I�eOP16Hours 2. Compensated Deputies: Name/rank Reg.hrs. O.T.hrs. Total wages (KEY_.:,-.SV=survived DE=deceased NF=not found ME=medical:.'evacuation) f 3 .' Outside Agency Assistance: Unit Name # People Hours Cost . EXPENSES Meals: Location # Served: Cost i 5 J 2 - Fuel Location # Fueled Cost Damaged Equipment Unit membe Item Damage Cost 4 - Other Expenses JIFFY'S PIZ?P Phorfe no. Date 12/20/1,12 Time 00S PM TICKET 0 S1 (11) SEWER Y Ertacia F. LARGE TH I CK 16.7 IS PEPPERONI LARGE THICK 21.15 JIFFPECL LARGE THIN 18.�;t� 1#USMOO S E`EE'F'EF�O�I OLIVES. 6PK COKE Subtotal 71.1a If C.16 To to 1, 76. 3 881-6330 KELLY KIM TIC 1.U--`x- INCIDENT HISTORY DETAIL: P021208611 INITIATE: :1.5 : 38 : 07 12/20/02 CALL NUMBER: P8611 ENTRY: 16 : 38 : 10 '� " CURRENT STATUS: CLEARED DISPATCH: 16 : 40 : 55 PRIMARY UNIT: 3TT ONSCENE: 1.7 : 08 : 08 CASE NUMBER: 50020.0020611 CLOSE : DISPOSITION: CXC LOCATION: ALPINE MEADOWS SKI AREA ,TC (2600 ALPINE MEADOWS RD) LOCATION COMMENTS : DAREA: STI BEAT: BT85 OLD TYPE: MP FINAL: SAR SEARCH GZONE : 25 PRIORITY: 2 ST CODE: 0726H5 HAZARD 15 : 38 : 10 TC01 ENTRY COMP:JEANNETTE \PH:5818230 \TEXT:MISSING 33 YOA MALE SNOWBOADER, MISSING MOST OF THE .DAY. MEET AT THE PATROL ROOM. VICTIM/NAVARRO,R.ICK FROM SAN PABLO, NO FARTHER DETAILS . 16 : 38 : 1.0 TC01 MAP PAGE -------- ------ ------ BLK C 16 :38 : 10 TC01 PRIOR. PP T 12/15/0.2 @ 15 : 06 :28 .(98 MORE) 16 :40 : 55 TCO2 DISPATCH 3NN 1.5 : 43 : 39 TCO2 ADD-ER 3NN 3TT 1.6 :43 : 39 TCO2 ID 3TT <S20700>PERRIRAZ,JON 16 :45 : 43 TCO2 ENROUTE 3NN 17 : 08 : 08 TCO2 ARRIVED 3NN 1.7 :20 : 26 TCO2 ARRIVED 3TT 17 :21. : 49 TCO2 MISC 3TT, SAR, NORDIC, COM VAN NEEDED 1.7 :26 : 09 TCO2 MISC 3TT, PAGED 3SS, NO RESPONSE 1.7 : 27 : 07 TC01 MISC . 8611, AUBURN DISPATCH NOTIFIED OF NEED OF CHAPLAIN 1.7 :28 : 19 AC01 MISC . 8611, 10-39 CHAPLAIN ANS SERVICE FOR CALLOUT 1,7 :29 : 39 TCO2 MISC 3TT, TO COORDINATE 17 :30 : 16 AC01 MISC . 8611., 10-39 CHAPLAIN WOODWARD XFRD TO TAHOE DISPATCH 17 : 30 : 31. TC01 MISC 3NN, PHARRIS PAGED TO COME IN EARLY 17 : 31 : 34 TC03 MISC 3TT, LT11 AWARE OF THIS IS AVL FOR RELIEF 17 : 31 : 51 TC01 MISC 3NN, CHAPLAIN WOODAR.D, ON CALL SUPERVISOR; WILL TRY TO GET EILENE TO SIT WITH FAMILY 17 : 33 : 34 TC01 MISC 3NN, PHARISS WILL COME IN AT 2000HOURS FOR PATROL COVERAGE 17 : 34 : 32 TC01 MISC 3N-N, BILL HEALY PAGED AND MSG LEFT 17 : 35 : 1-3 TCO2 QUERY 3NN @NAM/NAVARRO/RICHARD @DOB/19690911 @SEX/M 17 :35 : 32 TCO2 QUERY 3NN @NAM/KAHL/APOLLO @DOB/19680819 @SEX/M 17 : 35 : 36 TCO2 CASE 3NN 500200020611 Assigned 17 : 35 : 51. TC03 MISC 3TT, STEVE TWOMEY NORDIC TEAM COORDINATOR CALLING 3TT 17 : 35 : 53 TC01 MISC 3NN, LARRY CLARK. . PAGED AND MSG LFT 17 : 36 : 00 TCO2 MISC 3NN, KAHL I5 RP 17 : 37 : 04 TC01 MISC 3NN, RANDY WILLIAMS . . .NO ANS AND PAGED 17 : 38 :28 TC01 MISC 3NN, CHAPLAIN EILENE. . .WILL BE RESPONDING TO IC 17 :42 : 39 TC01 MISC 3NN, JOHN WEAVER UNAVAIL 17 : 45 : 51. TC01 MISC 3NN, STEVE HARRIS, MSG LFT AT HOME AND CELL PHONE 17 : 47 : 33 TC01 MISC 3NN, KATHY KING, NOT AVAIL 17 : 50 :24 TC01 MISC 3NN, PAM EMMERICH, MIGHT BE ABLE TO ASSIST IF NO ONE ELSE CAN DO IT 17 : 53 : 19 TC01 MISC 3NN, CHAPLAIN WOODDARD PAGER 916-951.-8871 1.7 : 55 : 19 TC01 MISC 3NN, JIM SMITH, MSG LEFT AT HOME 17 : 56 : 07 TC04 MISC 3NN, CHAPLANES PHONE NUMBERS ARE 587-47210 (H) INCIDENT HISTORY DETAIL: P021208611 320-1333 (0) IN CASE YOU NEED TO REACH HER. 17 : 56 : 57 TC01 MISC 3NN, ED LECKEY,MSG LEFT 18 : 04 : 59 "�C01 MISC 3NN, BILL HEALY NOT AVAIL. . .AND WILL BE OUT OF TOWN FOR A WEEK , BACK ON 29TH. 28 : 06 :20 TC01 MISC 3NN, REPAGED LARRY CLARK AND RANDY WILLIAMS 1.8 :22 : 16 TC01 MISC 3NN, ROLANDO GARCIA IS ENROUTE TO WORK THE COMVAN 28: 38 : 10 TC03 MISC . 8611., STEVE HARRIS NOT AVL, WILL BE AVL IF THIS CONTINUES IN THE MORNING 18 : 43 : 57 TC01 MISC 3TT, PER 3SS, PLAN FOR 0500 RELIEF FOR 3TT. 1.9 : 07 : 35 TC01 MISC 3TT, CODE 4 1.9 : 07 : 59 TC01 ADD-ER 3NN TCMVAN 19 : 09 : 38 TC01 MISC 3TT, PAUL MOYER WILL BE IN AT 0500 TO RELIEVE FOR COORDINATOR. . . .CALL IF NOT NEEDED 19 : 10 : 09 TC01 MISC 3TT, STEVE HARRIS CAN WORK COMVAN FROM 0500-0900 . . . .C- ALL AT 0400 IF NEEDED 19 : 15 : 38 TC01 MISC 3NN, LEANNE S'T'RONG ADVISED SHE MAY NEED TO HOLD OVER FOR ROLANDO' S DAY SHIFT 19 : 24 :25 TC03 MISC 3TT, Cl ADVISED OF THIS 19 : 26 :20 TCO2 ARRIVED TCMVAN 29 : 39 : 53 TC03 MISC . 8611, LARRY CLARK NOT AVL 19 :45 : 08 TCO2 INSRVICE 3NN 19 : 49 : 20 TC03 MISC . 8611, LARRY CLARK ENROUTE TO HANDLE THE COMM VANN 20 : 03 : 35 TCO2 FNLTYPE FINALTYPE:MP-->SAR PRI : 1P-->2 20 : 05 : 06 TC01 ADD-AR TCMVAN 617 20 : 05 : 06 TC01 ID 617 <S76950>GARCIA,ROLANDO 20 :40 : 58 TC01 MISC TCMVAN, MESSAGE SENT BY M051/S76950 TO: TDI. LARRY CLARK IS 97 AT THE COMM VAN [12/20/02204058001] F 20 :43 : 10 M051 CODE-4 3TT 20 :43 : 1.0 M051 CODE-4 TCMVAN 20 :43 : 10 M051 CODE--4 617 21. :22 : 09 TC01 INSRVICE 617 22 :28 : 23 TCO2 MISC 3TT, SEARCHERS FOLLOWING FAINT TRACK 23 : 04 : 05 TC01 MISC 3TT, JIM SMITH CAN BE CALLED AT 4A TO BE AT THE COMVANT BY 5AM IF NEEDED. . . .ALSO WILL BE AVAIL TO RELIEVE LARRY CLARK IF HE NEEDS A BREAK FROM MIDNITE ON 23 : 05 : 21 TCO2 MISC 3TT, 4NTSO OO .UM MPS ENTRY MISSING PERSON DATE:2002-12-20 TIME:23 : 04 : 05 RE:EMP FCN/3990235400412 NAM/NAVARRO,RICHARD JOHN MISSING PERSON INFORMATION TYP/L-LOST NAM/NAVARRO,RICHARD JOHN SEX./M RAC/W HOT/510 WGT/175 HAI/BRO EYE/BRO DOB/19690911 DLC/20021220 DXR/N MIS/LAST SEEN ALPINE MEADOWS SKI RESORT SNOWBOARDINGIF CONTACTED PLE ASE NOTIFY THIS AGENCYAUTH PLACER COUNTY SHERIFF ADMINISTRATION INFORMATION URI/CA0310002 OCA/0310002 APN/ (530) 581-6330 FCN/3990235400412 *** ENTRY MESSAGE SENT TO NCIC *** ********** END OF MPS MESSAGE ********** [12/- 20/02230511-00111 23 : 44 :46 TC01 MISC 3TT, FOUND THE MP. . .AT 2336 HOURS . . . . NORDIC IS WITH THE MP, JUST NORTH OF WDHISKEY CREEK CAMP, NEAR FIVE LAKES DRAINTAGE. . . . IN GOOD CONDITION. COLD AND WET. . .WILL ADVISE HOW THEY ARE GONNA GET HIM OUT 23 : 46 : 03 TC01 MISC 3TT, PAUL MOYER ADVISED TO 10-22 THE 0500 RESPONSE 23 : 47 :48 TCO2 MISC 3TT, 4NTSO OO .UM MPS CANCEL MISSING PERSON DATE: 2002-12-20 TIME:23 :47 :35 RE:XMP FCN/3990235400412 NAM/NAVARRO,RICHARD JOHN RIC/R DTI/20021220 *** CLEAR INCIDENT HISTORY .DETAIL: x'021208611 MESSAGE SENT TO NCIC *** ********** END OF MPS MESSAGE ********** [12/20/02234748001] S 23 :49 : 53 TC03 MISC 3TT, MP IN GOOD SHAPE, GOING TO TRY TO HIKE ON INTO THE 5 LAKES SADDLE AREA AND TRY TO ARRANGE FOR A SNOWCAT TO COME IN FROM THE SV SIDE 23 : 57 : 14 TC04 NOTIFIED 3TT, CDF GV ECC FOR USFS DUTY CHIEF - BOB MOORE TO CONTACT PCSO FISP 23 :58 :42 TCO2 MISC 3TT, PERMISSION FROM FOREST SERVICE WILL NOT BE NECESSARY 12/21/02 00 : 09 : 12 TCO2 MISC m] m +4 m( 00 : 09 : 15 TCO2 CLEAR 3TT CXC OPERATOR. ASSIGNMENTS : TC01 SXTRAI FICTITIOUS PERSON 1 TCO2 580741 ZUCCARO, CHERYL AS OF 17 : 27 : 07 : TC01 585930 YAMAMOTO,GALE SUPV AC01 5621.00 EDRIS,DANICE SUPV AS OF 17 :29 : 39 : TCO2 502520 MELTON,M. SUZANNE TC03 598230 NORWOOD,LINDA TC04 SXTRA4 FICTITIOUS PERSON 4 M051 576950 GARCIA,ROLANDO AS OF 23 : 57 : 14 : TC04 592530 YORK,BRIAN NCJIS Reply Placer County Sheriff 1ASHZ 00 .AUB0 .AUB TEXT TO: OPERATIONS CAPTAIN PCSO TAHOE IS CURRENTLY ENGAGED IN A SAR AT ALPINE MEADOWS SKI AREA. THE MISSING SKIER WAS. LAST SEEN DURING THE AM HOURS TODAY. THE MISSING SKIERS NAME IS NAVARRO, RICHARD DOB/9/11/69, LINK CLOTHING DESCRIPTION TAHOE NORDIC SAR HAS BEEN DISPATCHED SAR COORDINATIOR IS DEPUTY PERRIRAZ CASE #SO02-20611 PLACER COUNTY SHERIFF - NORTH TAHOE STATION EDWARD N DONNER - SHERIFF - CORONER - MARSHAL POB 1710 - 2501 NOR'T'H LAKE BLVD _ TAHOE CITY, CA 96145 530-581-6330 NTSO 1-2/20/02 2321 HOURS DISPATCH/LN CLAIM B F SUPERVISOB§ OF CC} RA CO TA,C ��"1"Y BOALD ACIIt N:AUGUST 2, 20103 . WII11Y�.N4�iW�wYV M .til 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), giver Pursuant to Government Code Section 913 and f 915.4. Please note all `Warnings", AMOUNT: UNKNOWN' CLAIMANT. VARUN RAI .t AIL- IL- ATTORNEY; ANDREGI R. GILLIN DATE RECEIVED: JULY 142 2003 ADDRESS: GILLIN, JACOBSON, E .LIS & LARSEN BY DELIVERY TO CLERK ON: JULY 14, 2003 2 THEATRE SQUARE, #230 ORINDA, CA 94563 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE Jerk Dated: July 14, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup isors This claim complies substantially with Sections 914 a &410.2. { } 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: gi— ZI Dated. By, uty County Counse III. FROM: Cler f the Board TO: County Counsel{1} County Administrator{2} ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER. By unanimous vote of the Supervisors present: (t4 This Claim is rejected in full. { ) Other. I certify Haat this is a true and correct'copy of the Board's Order entered in its minutes for this date. Bated: 14, OHN SWEETEN, CLERK'., By , Deputy Clerk 61 WARNING(Gov. code se tion 913) Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or deposit& 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, ' i 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: OHN SWEETEN, CLERK By Deputy Clerk' CLAIM FOR.PERSONAL INJURIES � � � 1 , (GOVERNMENT CODE, SECTION 910) N eolo? TO THE GOVERNING BODY OF: County of Contra Costa (hereafter, Publi Entity) OUR CLIENTS & CLAIMANT: Varun Rai (hereafter, Claimant), spouse and heir of Parmbaldeep Rai, decedent (hereafter, Decedent) ADDRESS: 16010 Candalero Drive, Walnut Creek, California, 94598 DATE OF DEATH: February 5, 2003 PLACE OF DEATH: Richmond, California DESCRIPTION OF INCIDENT: (1) On the above-noted date, Decedent exited District's bus (upon which she was a paying customer) at the bus stop located across the street from the apartment buildings located at 3400 Richmond Parkway, City of Richmond, California. These apartment buildings are the primary and perhaps only reasonable destination for patrons disembarking at this stop. (2) After exiting the bus, she began to cross the street towards said apartment buildings. In doing so, she chose to cross the street immediately at the point she exited the bus, rather than traverse the approximately two hundred foot distance necessary to cross said street through the marked crosswalk, which is located in an easterly direction from the bus stop. At her crossing point, there was no crosswalk. (3) As she crossed the median strip and entered into the eastbound direction of traffic, she was struck by a vehicle operated by one Vinoth Ram Krishnasamy, said impact causing her death. (4) At said time and place herein alleged, the roadway at said location (and the adjacent sidewalks and pedestrian areas), which were all owned and maintained by Public Entity, constituted a dangerous condition of public property, as that term is described in Government Code Section 830, in that, among other things: (a) the Public Entity permitted said bus stop to be placed in a location which it knew, or should have known, was unduly dangerous and/or hazardous to bus patrons, who were unreasonably required either to cross at that location or to walk two hundred feet (in the wrong direction for most or many of them whose destination was the west sidewalk of the apartment complex) to reach the nearest crosswalk, and then walk back in the same direction after crossing; (b) the Public Entity permitted said crosswalk to be placed in a location which it knew, or should have known, was unduly dangerous and/or hazardous to bus patrons, who were unreasonably required either to cross at the location the bus stopped, or to walk two hundred feet (in the wrong direction for most or many of them) to reach the nearest crosswalk, and then walk back in the same direction after crossing -- the Public Entity should have instead relocated said crosswalk so it was at the bus stop itself, or created a second crosswalk at that location, (c) the absence of signs or markings to alert eastbound drivers on Richmond Parkway of upcoming pedestrian crossing areas, both at the bus stop and at the crosswalk two hundred feet away, created a hidden hazard and "trap" that, in the absence of such suitable warning signs or markings, endangered pedestrians at said location; (d) the Public Entity permitted the speed limit to be dangerously high, in light of the traffic conditions and patterns of pedestrian crossing; and (e) the absence of regulatory traffic control signals, to alert and/or control eastbound drivers on Richmond Parkway of upcoming pedestrian crossing areas (both at the bus stop and at the crosswalk two hundred feet away) -- coupled with the dangerous conditions created by the failures noted in subsections (a), (b), (c) and (d) hereof, and otherwise - created a condition which was unduly dangerous and/or hazardous, in that drivers were unlikely to slow properly for crossing pedestrians due to the absence of such warning signals and notice. (5) The death of Decedent, as alleged herein, was proximately caused by the dangerous conditions herein alleged. (6) The dangerous condition of the roadway and adjacent areas above-described created a reasonably foreseeable risk of the kind of injury which was incurred and. (a) A negligent or wrongful act or omission of an employee of Public Entity within the scope of his or her employment created the dangerous condition; and/or (b) Public Entity had actual or constructive notice of the dangerous condition a sufficient time prior to the injury to have taken measures to protect against the dangerous condition. (7) Claimant is informed and believes, and thereupon alleges, that Public Entity had actual knowledge of the existence of the condition herein alleged through prior accident history, prior citizen complaint, prior employee inspection, and otherwise, and that Public Entity knew or should have known of the dangerous character of the condition of public property as herein alleged. (S) Claimant is informed and believes, and thereupon alleges, that the above-described dangerous condition had existed for a substantial period of time and was of such an obvious nature that Public Entity, in the exercise of due care, should have discovered the condition and its dangerous character. ! ! 1 NATURE OF DAMAGES: Death of decedent, resulting in economic and noneconomic damages to Claimant including, among other things, loss of income, financial support, and loss of emotional support, care, comfort and society. AMOUNT OF CLAIM: An amount within the jurisdiction of the Superior Court, unlimited jurisdiction. ATTORNEYS TO WHOM NOTICES GILLIN, JACOBSON, ELLIS & SHOULD BE ADDRESSED: LARSEN 2 Theatre Square, #230 Orinda, Ca. 94563 (925) 253-5800 DATED: July 10 2003 '� t endrew R. Gillin ATTORNEY FOR CLAIMANT __ 1 PROOF OF SERVICE 2 I am a citizen of the United States. My business address is 2 Theatre Square,Suite 230,Orinda, 3 California 94563. I am employed in the County of Contra.Costa,where this mailing occurs. I am over the age of 17 years, and not a party to the within cause. On the date set forth below, I served the 4 foregoing document(s)described as: 5 CLAIM FOR PERSONAL INJURIES (Government Code,Section 910) 6 on the following person(s) in this action by placing a true copy thereof enclosed in a sealed envelope addressed as follows: 7 County of Contra Costa 8 Office of the Clerk of the Board 651 Pine Street 9 Martinez, California 94553-1229 10 11 [] (BY MAIL)I am readily familiar with my firm's practice for collection and processing of correspondence for mailing with the United States Postal Service, to-wit, that 12 correspondence will be deposited with the United States Postal Service this same day in the ordinary course of business. I sealed said envelope and placed it for collection and 13 mailing on ,following ordinary business practices. 14 jX (BY PERSONAL SERVICE) I delivered such envelope(s) by hand this date to the offices of the addressee(s). 15 [ (BY FEDERAL,EXPRESS)I delivered such envelope to Federal Express for overnight 16 courier service to the office(s) of the addressee(s). 17 [ } (BY FACSIMILE) I transmitted such document by Facsimile machine to the number indicated after the address(es)noted above. 18 I declare under penalty of perjury under the laws of the State of California that the foregoing 19 is true and correct and that this declaration was executed on July 14,2003, at Orinda, California. 20 21 22 Santiago Laya i 23 24 25 26 27 28 Proof of Service Rat, Varun v. County of Contra Costa CLAIM LBOAR OF PE VISORS OF CONTRA CESTA COUNTY • BOARD N: AUGUST 1.2, 2003' Claim Against the County, or District Governed by } the Beard 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 :: 'ursuant to Government Code Section 913 and ' 15.4. Please note all"Warnings' UNKNOWN AMOUNT: _ .. . _ CLAIMANT: JET W. 'ERICSON .. ATTORNEY: UNKNOWN DATE RECEIVED: .IDLY 08, 2003 ADDRESS: P.O. BOX. 1535 BY DELIVERY TO CLERK.ON: JULY 08, 2003 BRENTWOOD, CA 9451.3-3535 BY MAIL POSTMARKED: JULY 07, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOIN S VVEET N Dated: JULY 07, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supe ors ( } This claim:complies substantially with Sections 914 arAmQ,10.2. { ) 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: t� 7 Dated: By: Deputy County Counse 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. GIRDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. { } tither: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: OHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code secti n 9131 Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposfia 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: /,3, ZovJOHN SWEETEN, CLERK By Deputy Clerk`. OFFICE OF THE COUNTY COUNSELSILVANO B. MARCHESI COUNTY OF CONTRA COSTA �� x COUNTY COUNSEL Administration Building ;' = `,4 SHARON L. ANDERSON 651 Pine Street,9" Floor CHIEF ASSISTANT Martinez, California 94553-1229 f F 43 GREGORY C. HARVEY (925) 335-1800 (925) 646-1078 (fax) � + r°y VALERIE J. RANCHE '_ ASSISTANTS r NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Jeffrey W. Ericson P.O. Box 1535 Brentwood, CA 94513-3535 Please Take Notice as Follows: In regards to the claim you submitted on July 8, 2003,portions of your claim are timely and portions are untimely. The portions of your claim prior to January 7, 2003 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 7, 2003 were not presented within the time allowed by law, no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. Your only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. SILVANO B. MARCHESI CO Y COUNSEL e By: fill Janet L. Holmes Deputy County Counsel Page 1 CERTIFICATE OF SERVICE BY MAI (C.C.P. §§ 1012, 1013a,2015.5;Evidence Code§§641,664) 1 declare that my business address is the County Counsel's Office of Contra Costa County,651 fine Street,Martinez,California 94553,1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a parry to this action. I served a true copy of this NOTICE OF UNTIMELINESS AS TO A POR'T'ION OF THE CLAIM by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Executed in Martinez,California. Dated: July 8,2003 A! K thy b" nn�l cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA;COUNTY lWs'S'l'Q110NS TO CL,AI3�ZAlti'T 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 tater than the 10&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 Tater 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. ErAvj. See penalty for taudulent claims,Penal Cade Sec.72 at the and of this form. RE: Claire By Reserved for Clerk's filing stamp Ericson, Jeffrey W. } RECEIVED Against the County of Contra Costa or J U L 8 8 2003 District) CLERK BOARD OF SUPERVISORS Gill in name) CONTRACO STA CO. The undersigned claimant hereby makes claim against the County of Centra Costa or the above-named district in the sum of S and in support of this claim represents as follows: Unlimited Civil Case 1. When did the damage or injury occur?(Give exact state and hour) On or About F'ebruary 5, 2003 2. Where did the damage or injury occur. (Include city and county) Contra Costa Health Plan Authorization nit 595 Center Avenue, Suite 1.00 Martinez, CA 94553 3. How did the damage or injury occur?(Give furl details,use extra paper ifregu xed) The CCHP Authorization Unity. abruptly ter i.rnatee� efits (medications) to treat my disabilities can 2/5/03, even though they had provided coverage for my medications sine 1998. The Unit also placed substantial "barriers' that impede my ability to participate in and benefit from having equal access to health care services. The Auth/Unit did so in such a manner that provided less benefits to me--an individual with disabilities--than they provide to their ether clients. I have been without medication for treatment of my disabilities sine late-December 2002 as a result of the Autb./Unit, and this has limited my ability to live more indPpPndentl.v, enrage in employment, continue with my education, as well as participate in community and family life. 4. What particular act or ornission on the part of county or district officers,servants, or employees cause'the in, or damage? Violation of the ADA, Section 504 , Unruh Civil P.i.ghts Act, AB974 & AB88. Discrimination on the basis of disability , medical malpractice, negligence, intentional infliction of emotional distress, retaliation. s. What are the names of county or district officers,servants,or employees Causing the damage or injury? Dr. William Walker, Dr. James Tysel7 , milt Ca<mhi, Pauline Jones, Flcrence Chan, Dr. Karen Burt, Dr. David Hearst, Dr. Barry Miller, Dr. Chervl Bryan, Dr. Stephen Kalkstein, Dr. . Michael McFadden, Dr. Eiland, Evalyn Rinzler 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed.Attach two estimates for auto damage.) Unlimited Civil Case Que=stion #5 Continued: Gayle Belfor, Donna Wigand, Dr. Suzanne Tavano, .Victor Mona.toya Janet Wilson, Kann Pratt, ?. How was the amount claimed above computed?(include the estimated amount of any prospective injury or damage.) Unlimited Civil Case 8. Dames and addresses of witnesses, doctors, and hospitals- Brentwood Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCRMC Family Practice, Martinez, CA 94553 9. List the expenditures you made on account of this accident or injury. DATE TXh NOUN Unlimited Civil Cas: } Gov. Code See. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SMNOTICESM: -(A-AWAY Name and Address of Attorney 6 } III claimant's Signature) j} P.O. Box 1535 (Address) } Br nttwood, CA 94513-3535 } ZTeI hone No. (925) 757-8006 Telephone No. LT Nana Swoon 92 of the penal Code prMdes. Evac pcoon wbo,writh kum to dehaA prescnts for atlm=m or dze povient to any state board or officer,Of to any county.city,or disaiet board or otfisxr,wAbwizOd to allow or pay the slm if gam,wW faire or fraudvient cWra,bili,ac=wt, voucber,or writing,is puniAMNO either by i p6scument in the coumlyjaR tor a period of so ns=tests case yew,by a fire erf not ezceoding out thousand(SI PM,or by troth sleds impisoaraw ard Aw.at by haat in the&we prism by a fiat of not meeding teas tbo nd ddlam(S10,O00),or by botb such imgrisonmrit and fiat. CLAIM BQ&RD OF ' RVI (7 _ OF ONTRA COSTA COUNTY BOA" ACTION: AUGUST 12, 2003; Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, } NOTICE TO CLAIMANT and Beard 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}, gives R Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT; UNKNOWN CLAIMANT: JEF'F'REY W. ERICSON r. ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK.ON: JULY 14, 2003 BREN`1WOODI CA 94513-35.35 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Beard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE rk Dated: JUDY 14,, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisor XThis claim complies substantially with Sections 910 arh%l0.2. f ( } 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: IT 171 Dated:i, By: ��u W/UUT Deputy County Counse ISI. FROM: Cler ofthe Board TO: County Counsel(1) County Administrator(2) { } Claire was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: (4 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 , Deputy Clerk WARNING{Gov, code se tion 913} Subject to certain exceptions, you have only six(6)months from the date this ndtice was personally served or deposftea in the mail to.file a court action.on this claim. See Government Code Section 945.6. You may seep the advice of an attorney of yourchoice in connection with this matter. If you want to consult an attorney, you should do so irnmediatel . *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: JOIN SWEETEN, CLERK By Deputy Clerk'; Chaim to: BOARD 4F SUf'RR'iriSURS OF CONTRA COSTA,COUNTY t.SMCUMS sn C DIAM A. Claims relating to awm of a+a*m ft death or for ir&y to person or to personO Ply or growing crops and vAich salsa on or bcfbre Decomber 31, 1987,viast be Pvmftd amx tater than the 10e day afterthe B=ud oftbe Cam ofsction.Claims rdaft to mum ofautim for death or for injury to parson or to pers"M proputy orvowig crops sand wtaich accrog on or&ft January 1, 19'88;must be pxpit Pated ascan 1aaa:r than a x r* air tho�arfthr� of as a[a.CW�relating a u any othar came of action must be pmsented not halm'don raft YM sfbw tine moat of dae cause of cti0& (Gov't Codas 911.2.). B. Claims must be filed with the Clerk of the Board of SuperViS rs.at its OMW in Rooaai 106,CoWIY Administration Building,651 Ping Strook MIrd.rm7,.CA 94553. C. if'claim is against a district governed by the Board of SupwAso ,rather than the County,the name of the District should be filled in. D. Mthe claim is against more than one public soft,separate claims must be filed against each public entity. . E. Fmd. See penalty for AWdulent rJaims,Renal Coda:Sec 72 at the end Ofthis form. RE: Cla hn By Reserved liri'Clerk's filing stamp Ericson, Jeffrey W. RECEI Against the County of Contra Costa or �y JUL 14 2003 3 CLE lK 80AgL)CF Dila) co�NrPA(,' RS Rs (Fill in name) ) The undersigned claimant hereby analm claim against the County of Contra Costa or the above-named district in the sum of wid in support vfthis claim represws as,Wows: Non-limited Civil Casa 1. When did the danaaage or ivjury o ?(Give exact data and hour) On and After January 24 , 2003 2. Where.did the damage or injury ocuO Wit&city and county) Brentwood Health Center Brentwood, CA 94513 Contra Costa. County 3. ]Flow did that dame or i*Wy ocaMI(Give full details,use extra paper ifm* red# Dr. . Karen Burt-Imira failed to provide adequate: medical care for treatment of my disabilities. Her negligence resulted ire-the denial 9f medical services and benefits to whi.ch I am entitied, "And did so �n violation of my federal and State civil rights.. ', 4, *bat particular acct or cunissitm on the part ofcom ty or&Wid offk4M Wrvat1%or employees caused ft in CLAIM BO F P 12VI CARS OF CONTR COSTA COUNTY i B.QARR ACTION: AUGUST 12,> 2003 Claim Against the County, or District Governed by ) the Beard 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 Cedes. } notice of the action taken on your claim by the Board of Supervisors, (Paragraph IV below), give y Pursuant to Government Code Section 913 and 915x4. Please note all"Warnings" AMOUNT: UNKNOWN CLAIMANT: JEFFREY W. IRICSON _h� ATTORNEY: UNKNOWN DATE RECEIVED: JULY 149 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK ON: JULY 14, 2003 BRENIW00D, CA 9451.3-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 14 2003 JOHN SWL E lerk Dated: 7 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup 'isors This claim complies substantially with Sections 914 an&�%10.2. ( } This Claim FAILS to comply substantially with Sections 910 and 914.2, 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: Dat B : D uty County Counse III. FROM: k of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 9113). (IV. ARD 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. b Dated: - JOHN SWEETEN, CLERIC,By Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions;you have only six(6)months from the date this notice was personally served or deposfte� 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. *Far 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 r 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: ! c—�4ZOHN SWEETEN,CLERIC By Deputy Clerk 3 Claim to: BomW OF SUPERVISORS OF CONTRA COSTA COUNTY A. Claims relatinS to causes of action for dem or for Wwryr to pew or to �tic or�ng day crops a wlridr asp on be e b r 31,1987►,rmut be for demb or for injuty to after thectf'tl ea rltd .�rd din&to e�afat8iion p "tea IFS pvperty orgtowin&aop ark wl acmW on or after Iammy 1, 1988;must.be Wese~mW not Imt r than srk a;�after** of dieewe of actim Claims rebating to any otba cause of Wfioft Haat be presertedont arra rw&Aer the acmd ttf C&M ofactiom (Gov't Code 9!1.�.�. B. Cwms'�ust frac fiW"h the Clerk offt Board of Supervisors at its office in Room 106,Counter All nitus ra n Jluildin&651 fines Street,Maatit=,'CA 94553. C. ! Ir a laisu is against a district Saves W by ft Board,of Supervisors,ratW than the C6urrty,the name of the Dignric t slwuld be filled in. D. If the claim is against more than one public enft separate dames must be filed against each public entity. . E. See penalty lbr ftWulwd claims,POW Coda Sec.72 at the aid oftIds form. RE: Claim BY Raerved for CleWa filing stamp Ericson, Jeffrey W. a St 1he couray ofCagras Cel or '�` cc 4 Z Fill m name) � „ �- 7ber undersigned claim**hereby euaka claim sonEst the County of Corns Costa or the rsamed district in the sum of 5 �,and in esaapport ofthis claim represents as Ibllows. Nonce limited Civil ease 1. Wbem did the:damage or ildwy e3aw?(ohm Wma date anal liar) on and After February 4, 2003 2.. Wbett.diel the damage+err isdwy o a 0hebi city'surd e;,ounty} costa Csta health Flan Authorization Unit/utilization Review 595 Center Avenue, Suite 100 Martinez, CA 94553 3. How did the damage or i4wy c»r't(Give fidl details;use extra paper ifrequired) Dr. James Tysell denied mental health services and benefits. to which I am entitled, and in violation of federal and State civil rights laws and California State laws SB974 and AB88. Dr. Tysell als'o-placed gubstanti.al "barrier " that impede-- ability to participate in, , and benefits from, havi nia� equal eelual to' 'health care. benefits and services, and failed to ensure that there are providers qualified and 14iiiing to provide mental health services-to treat ii�y disabi'liti.es to which I am entitled. 4. What particular act or orniWon on the part OfOOMAY or district offiicers,servants,ar employes caused the injury of damage? Intentional Infliction of Emotional Distress; Benail of Mental Health Services/Benefits; Viol ktion of the ABA, Section 504, Unruh Civil Rights Act., Disability Discrimination; Medical Malpractice Negligence; Breach of Contract, Retaliation. 5. 'what are the comes of county or dWrrict of cem ser+mnt4 or employees tatuatrtg the damage or injury) James R. Tysell, M,D. Medical Director, Contra Costa Health ,Plat=:, Authorization Unit Contra Costa Health Service C. What damage or injuries do you clahn tnesu�ted?(Give full extent ofinjuries or+images claimed.A ch two estimates for auto damage.) Notre-1imited Civil Case 7. Now was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) Non-Aimited Civil Case Loss of Employment/Educational/Vocational & Lifetime t p—ortuniti�:s; Pain and Suffering, Emotional Distress B. .Names and addresses ofwrhness�docoxx and hosfiitWs. Brentwood Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCRMC Martinez Family Practice, Martinez, CA 94553 9. hist the expenditures you made on account ofthis accident or injury. DAA Non-limited Civil Case Gov.Code Spec.910.2 provides"The claim must be } signed by-Che claimant or by some person on his behalf'• Name and Address ofAttorney ) } 1{Claizttaries Sipature) Pd Bax 1535 } (Address) Brentwood, CA 94513-3535 Telephone Aro. 'Tdepluije No. 025} 757-8006 w«:*+�*s:*.,►as*s***�#*#�+sss�*a**trt*rsa*#�**�►*�►***+«s**ger#+esssarsa�ar*�s**�*�**�*ss:*s**�s**«*: N017CE Secdw 72 of the PoW Cub pt'owrkkx. rperaarr36twawtaor�. i�rr�cr�epaaa►aa�s�cboaardararta t eoanty,city.ac&Wks bawd wdkMm 0,, m rdimr store e s r c„ r ear aet e ,�. �`.��.is� �;rkrrp�+urw�aie3+urape�iad�'�tr�a+ara� ,arj:�:� s�OC +orlcr'�rlit �rrsMta�rr!#�;+ra`�pr`i��intartpta�b,�ssaf�a+t CLAIM OA F P R f3 OF-CONTRAOF-CONTRA COSTA CQUNTY BOARD ACTION: AUGUST 12, 2003 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), give; Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings" AMOUNT: UNKNOWN CLAMANT: JEFFREY W. .ERICSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK ON: JULY 14, 2003 BRENTWOOD, CA 94513-3535 BY MAH POSTMARKED: HAND DELIVERED FROM: Cleric of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 14 2003 JOHN S Clerk Dated: By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Sup6rvifors el This claim complies substantially with Sections 910 an10.2. { } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for l5 clays(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: 4 . By: �Mk Deputy County Counse IIT. FROM: C k of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). iV� OARD ORDER: By unanimous vote of the Supervisors present: s ( 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 , Deputy Clerk WARNING(Gov. code se tion 913) Subject to certain exceptions, you have only six (6)months from the date this ndtice was personally served or deposftee 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 ofporjury 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 fulfy prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. , Dated: / " -:NA�&JOHN SWEETEN,CLEF,By Deputy Clerk Claire to: BOARD OF Stip)MVIaSORS OF CONTIU CC)STA COUNTY A. Clah ns relating t*CUUM of action fhr death ort hiffy to person or to pnwxW property or 8Mw09 a0ps&nd,vdA&&OMM on or bdwe Deoexaber 31, 1987,mom.be pc+aurm +ed eeot later than the I0&day alter the atc-r of of teff.Chims Vdaft to cmuft ofd ft death err 1988 to 198S.-must be parsim or tea�pity car aexn + or �' not hiff than sk re+orrft after the accrual ofthe cause ofactim Ciaims f dshmg to arty otlw cam+of sctimn met be;#arw SM bw tfm saw Year Aw the amt ofaw Cain Ofact'CML (GOA Codec 911.1) B. Claims mcg be filed with the Clark orgm Board of dors.at its oft ice in Rom IOC,County Aftiniostion Badjn&65I bias Sue:et,Mattis CA 94553. C. if claim is against a district governed by the Board ofSupeMsoM rather don the County,the name of the District should be filled in D. 7f the`lair is against MOM than am public a itft SePW96 claims mum be filed against ach public entity. . E. ZMd. Sex penalty for AwduleM claims,panel Code Sec.72 at the end of this form. ��,��.*.�,esu:��:*.:e��s�s��**err..*«�:«��#+�:sse:.s:*.**+►:::�*�*�rrsr�r*s+rs►**►s•*w*tsar**�� RE: Claitr By Rsseived for Clerk's feting stamp Ericson, Jeffrey W. } Against the Cotmty of Cornua Costa or District) ULERK �, ;.: (Fin in name) � co'v r SG'P6'#V S 3 v 'Z-r �s The undersigned claitment hereby maka Claim againt the County Of Contra Costa or the above-named district in the sura of aced in support ofthia claim mpvswts as fbiiows: Non-limited Civil. Case I. when did the damage:or injury oc cur7(Give exact date and hour) on and After January 15, • 2003 2 Wbm.did the d aamw or ityeery obi 0 b*j&city and owmty) Contra Costa Regional Medical Center—Martinez Martinez Family Practice 2500 Alhambra Avenue Martinez, CA 94553 Contra Costa County 3. How did the ori Deme?(0i" ts„use cache pVar if't fired) Dr. Barry Miller failed to conduct an. a.deguat . medical evaluation to determineeffective treatment for my disabilities. This ..ne►cli cxoric_ resulted in the denial of medical services and be ne3fits. to-which I am entitled, and in violation of ,my federal and-State.-civil rights. 4 4. 1 h' at particular act or omission on the part ofcouM►Of&VAd tfficerk swvm%or employees used the iniury ordamage? Intentional Infliction- of Emotional Distress; Deni.al of Mental Health Services/Benefits; Violation of, the ADA, Section 504 , Unruh Civil Rights Act; Discrimination on the basis of disabilities; medical Malpractice; Breach of Contract; Negligence; Ret 1i tion. :5. What am the;neutmes of missy or district�servWAs„m'esnployc�s ding Im�am a or in�wy+'t Barry Miller, M.D. Psychiatric LJ.aison Martinez Family Practice 6. What damage or inju nes do you clam resulted?(Give full extent of injuries or damages claim.Attach two estimates for auto damage.) Non-limited Civil. Case 7. How was the amount claimed above computed?(iuelude.tics estimated amount of any prospective injury or Non limited Civil Case Loss of Etn_ploymentjtducational/Vocational. & Lifetime ol-1portuniti.es „ Pain and Suffering; Emotional Distress S. Names and addresses ofwkne se%doctora,and hospitals. Contra Crista. Regional Medical Center - Martinez Family Practice~: 2500 Alhambra Avenue Martin.Az, CA 94553- 9. List the expenditures you made on account of this accident or injury. 1A'I Non-limited Civil Case ilcyt#*tik;kkk#�Y##k#kk*+tk#�cittRt+►#*#3R#**a1rc1�#+FkiF#+RR*#*##�!i**/t+tk#�i�►##kk*#R*#+Rte+t**int##c�M�k�k�klt*�t+k�l+R�icri�k Gdv.Code Sec.93 of probes"The claim must be signed by-tlte ehumw t or by Borne person on his behalf.' SM NQUM IQ: LAW=- Name and Address of Attorne } � � 'mane's Sigt►attzre) j P.O, Box 1535 _ } (Addmu) Brentwood, CA 94513 Telephone No. )Td*h No. (925) 757-8006 #**�*t***fyrs*#***+►w#�***+�*s+�:�r*+►s#its**�esssss�ts***a**#s*,r*r�ssss***she*#�r�t****s****s***s*e** N=CE Semon 72 oftba P=W Code pwvWa: Eyersoswdacmdmdipesar�ear�rea aao�raaaler my .*y.cratviabwdare 1 ffi tMr�pg cS c3 . vauchm,errs.is- jil-Iondarnr�aniliee #adatmaecawebr arcaf lana +�,A +arb�r �eilEs��t�„oc•�►iiatA� p�oo.�jrai�acd`� CLAIM BOAU OF UPE VI Q&S OF CONTRA COSTA CO NTY BOAT, ,— CIT N:,A0(30STr12, 2003 Claire 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 ofthc�action taken on your claim by the Board of Supervisors. (Paragraph IV below), give Pursuant to Government Code Section 913 and ` 915.4. Please nate all"Warnings". AMOUNT: UNKNOWN CLAIMANT: JEFFREY W. 'E21CSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 13, 2403 ADDRESS: P.U. BOX 1535 BY DELIVERY TO CLERK ON:,= 18. 2003 BRENTWOOD, CA 94513-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JULY 18, 2003 By: Deputy JOHN SWEET k II. FROM: County Counsel TO: Clerk of the Board of Supervisors XThis claim,complies substantially with Sections 914 at&10.2. ( ) This Claim FAILS to comply substantially with Sections 914 and 914.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 914.8). ( } 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: Al .moi{ Dated: '` $ - Deputy County Couns+ ISI, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was retied as untimely with notice to claimant(Section 911.3). TV,BOAIi.D ORDER: By unanimous vote of the Supervisors present: , ( This Clain is rejected in AW. { } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 4 JOHN SWEETEN, CLERK, By � , ,Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions;you have only six (6)months from the date this ndtice was personally served or deposit-e( 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 imrnediatel . *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: �A-* JOHN SWEETEN,CLERK B Deputy Clerk's Claim to., BOA"OF SUPERVISORS OF CbNIX4 COSTA COUNTY A. Claim reWaStc ON005 Of 8Gfi=for dea*ur fir i*wY t*peraan OF to Persoaa PVPcrtyQrwDwft crops ww vAicb aomw on at befibm De mbar 31. 19V, be p Sot law them the.10&day after the a��of of" • to Caen ofa ftdeah or for in,�xrry to l�or to lw �'h'`arming�and wN&accrue to of MOW YNNOWY 1,19 -MS be PS*WUW art letter 1bW sus=00ft Stier AM MCMW Gfd*cause.OfaCfiM Ch'=Mahng to MY oto Carse ofadke Wig b6prOMOW not lir the we ym afer the a ccmd of tie r ofac". (GWt Code 911.2..). B_ Claims mun be fired with the Clerk ofthe Hoard ofSupetviwrsat its oftix in ROOM 106,County Administradon,Bodin,651 Pine►Streek rtirre,,CA 94553. C. Lf claim is agaliM a dish gc+ve ruW by type Board of SupervisoM ram than the County,the name of the District should be filled in. D. H the claim is og&hW som than am public eaft squrate claims smut be fel against+rack public entity. . E. E Seen penalty for flew c Www,Panel Code Sec 72 at tit+e eld Oftf ki$farm. *�**�s�***.•r*�.��#r.**res�s.*e*t�►s*s��ar�er��s�e+r�+r#*�s**s�r*+��t*,e��*ss�s*►*s�r***»rrrt,e RE: Claim By Reserved for Clerk*s Ding stamp Ericson, Jeffrey W. � r. Against the CftW1Y Of QWft Ctu11 tr (fill in named 1 The underaped rhihaam bwvby water claim the Ctmaty cj Comm ODA&or the abo+ve+-named dim in the sum of$ and in affort ofAis daim rgmasents as fhnows: Non-rlimited Civil Case L When diel the dareaP or Wury occas?(Ghv exact darter mg her) June 11 , 2043 2_ Where did the dan"e,or i*eiry ocm?Thede city and cm") Pittsburg Health Center 554 School. Street Pittsburg, CA 94565 Contra Costa. County 3. How did the:damage os injury orae(Give fWl details;usG extra paper if fid) Fir. McFadden failed to perform an adequate medical evaluation to determine, and to provide, effective treatment for my disabilities. His negligence resulted in the continued _deni.al of medical services end benefits to which l am entitled-t- and did. so in.violati cin of my federal. and Mate civil rights. 4: partiCUI r aa or omissaoa ort the part ofcotvay or&StrW tffre rs,srrMts,or employees caused the injury ord&MAge? Intentional Infliction of Emotional Distress; Dermal cf Health Services/'Benefits; Violation of. the ADA, section 504, Unruh Civil Rights Act, AB974 & AB88;Di.sability Discrimination; M. edical Malpract.icn; Negligence,- Bruch of Contract; Retaliation. the damage+�r injury? .j. What sure the names of couay or�oft swiw4s,or "S cam Michael McFadden, M.B. Pittsburg Health Center Contra Costa Health Services 6. What damagemage or iniwies do you claim resulted?(Give full ext"t OfiniW ies or dwages claimed.Attach two estimates for atm damage.) Non--limited Civil Case 'r. 14ow was the amount claimed above coned?(include the estimated amount Marty prospective i*ry or age Non-limited Civil Case Loss of Employment/Educational/Vocational & Lifetime. Opportunities; Pain and Sufferinc; Emotional Distress; Physical Injury 8. Names and addresses ofwfir;esses,docW4 and hospitals. Pittsburg Health Center 550 School. Street Pittsburg, CA 94565 9. List the expenditures you made on account of'tlis aCddent or injury. M 3= AMP= Nan-limited Civil Case ��et*r**�t�r�******sir*t��t*�t�,�*a+�s��*sv��**��:*�►r�*��ess*�*s�**+t****�t��*�*�*�e��c**�*s*�►�****** fix.code Ser,91tl.2 provides"The claim must be signed bytbe oWynam or by some pert on has behalf" Nance and Address ofA.ttoxmeyT it (T,3itnaw j a PO Box 1535 (Addms) Brentwood, CA 94513-3535 Tea NDS eNo. (9.25) 757-8006 *�**� ��*s***�s*�#+�*�*+*��e*,ry�r�ts�wrs�rsss#t�s�*�t«r,e�ss�e��**�**s*�r�r�►►*a**s�+w:�s�:**** NcyncE Sacdon 72 of**P+W Code provideL lr �,t�dYt somacm�„prf�t'�:�#�r�r�tla�as�sha�deror .�erlerrwa� OwW .city. abuaadnr lbs r+d�t t s r w+5, 1i►t ur .� i � d�atrrtirtaa�■ rifrra��aFaratrsiwareac# rt �19rra�+��awr'l4grbsd► 3h�'arttaa�i6�. M CLAIM B0AU_QFSLPERVI§0RSOFC0NTRA COSTA COUNTY • BO Rt} ACTION UST 12, 2003 .. Claim Against the County, or District Governed by } the ward 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), giver Pursuant to Government Code Section 913 and v 915.4. Please note all"Warnings". AMOUNT: UNKNOWN v CLAIMANT: JEFFREY W. 'ERICSON ATTORNEY: UNKNOWN DATE RECEIVED: ,JULY 18, 2003 ADDRESS: 1'.O. BOX 1535 BY DELIVERY TO CLERK ON:JULY 18 2 BR.EN'I'w ,ow, CA 94513-33.35 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET Dated: .JULY 18, 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Supervisors (�This claim complies substantially with Sections 910 ar-n1.0.2. { } 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: - } "ZtO�� B . tectmDeputy County Counse III, FROM: C erk ofthe Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER.: By unanimous vote of the Supervisors present: t (%4 This Claim is rejected in full. ( } Other. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ,Q �50HN SWEETEN, CLERK, By ,Deputy Clerk WARNING(Gov. code wetion 913) � Subject to certain exceptions;you have only six(6)months from the date this notice was personally served or deposfiec 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. *Far 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: _zJOHN SWEETEN, CLERIC By Deputy Clerk'` Claim to: BOA"OF SUPERMOR9 OF CONTRA COSTA COUNTY M—AMANT A. Claims relata ic Causes aracomforamb tier fir wry to pasm o r to persasw rapav ar gTow-mg c and�*own on nor��31,Irl, bre�i h*w ttmn�1 afterthe aCVMd offt eme a'at � m"XM+af ac6m for doth or for i�a,�tiry to l�ar lo��'to = txops Mdv seem=ver afkarlawmy It 1 be Pfuenftd ass leer am sk MXAZ after At acaftw ofdo oracfim cuims 140fing to any add cause+af adion mist be prese a*bear then one yew aBar the acrud oftbe com ofactio m (t3ov"t Cie 911.2.). B. Claims annual be AW with the Ck%rk ofthe Surd of&*wv wa at its af&*in Rom IK Cotraty A.dmitistratitw Odin,651 Pine Savr,Matfi=2,CA 94553. C. Ifclaim is song a district gov timed by dw Scrsrd of Supw viswsy,nuher than the County,the name of the I'9Wct should be filled in. D. If the claim is agimi st afore then one pubft eaft sqwde dims most be filled asst wdt public entity. . E. Emd. Sae peulty for$audulem claims Panel Code Sec.72 at the tend of this form. E. Cutin By Reel for CAWS filing stamp Ericson, Jeffrey W. � s Against the County ofQu*a Gosta or r ,Fill in named *u,,d" d ramt bw*y m*w d4an againstthe Courcy*f Cc►r M Cast-,,r the eve.,n med&strus in the sum of$ and in support aftWs claim reprums as follows: Non-limited Civil Casa L Wha did the&mage Or iaq WY 00=7(OWD mad due sad horn) On. About, and After May '19, 2003 _ ' ''lx ra,did the duna$e or injury occw?(hwju&city,and caunty) Pittsburg Health Center 550 School Street Pittsburg, CA 94565 Contra Costa County 3. How did the daump or boy*ccW?(Give#A ddgb,.use Apra paW ifae phod) Dr. Cheryl Bryan denied health services and benefits to whish Y am entitled, and in violation of federal and State civil rights laws and California State laws AB974 & AB88. Dr. Bryan also placed substantial "barriers" that impede my ability t0-Participate. ins- and benefit from„ having equal access to healteh ,care benefits and services, and failed to ensure that there are providers qualified and willing to provide mental health services to frost mAr disabilities to' which r am entitled. Dr. . Bryan's "bad with" effort and intentional negligence resulted in the continued denial of medical services and benefits to which 1 am ^htit;led, and she dial so with full knowledge that her actions were it violation of. Federal and Stag civil rights laws and C'al.ifornla State laws AB974 and AB88, 4. 'What particular act or omission on the pan of miry or dstrwt offkas,servants,or employees caul the injury or damage? Intentional Infliction of Emotional Distress; Denial of Health Services/Benefits; Violation of the ADA, Section 504, Unruh Civil Rights Act, AB974 & AB88; Disability Discrimination; -Medical Malpractice Negligence; Breach of. Contract; retaliation. 5. What arc die crone of wUMY or distrid affiews,Vis,or employees cmuing the:damage or injury? Cheryl Bryan; Ph.D. Victor Monatova' Pittsburg Health Center (Supervisor) Pittsburg Health Center (Ma.nager) Contra Costa Health Services Contra. Costa Hes„Zth`Services 6. What damage or fiMlwies do you claim resulted' (Give fog extent ofinjuries or damages c1a: Attach two estimates for auto damage.) Non-limited Civil. Case 7. How was the amount claimed above computed?(wlude the estimated amount of any grospec+trve injury or damage-) Non -limited Civil Case Loss of Employment/Educational/Vocational & Lifetime Opportunities; Pain and Sufferinc; Emotional Distress; Physical Injury 8- Names and addresses of'witnesses,doctors,and hospitals. Pittsburg Health Center 550 School Street Pittsburg, CA 94565 9. List the expenditures you made on account ofthis accident or injury. PAIL Non-limited ed Civil Case ) Gov.Code Sec,910.2 provides"The claim must be ) signed by.the Claim or by some person on his behalf" T Name and Address of Attorney ) � o ) (+Glai�narat's Signature) PO Box 1.535 } (Address) Brentwood, CA 9457.3-3535 Telephone No )TdVhoWNo. (9 2 5) 757-8006 #4#«#####aa►K KKKat>t########*#aR###nR##at####'#######>♦r##########wnt>R«!###t#####*####ale######7c#atK>lc+t## NICE Swim 72 of the Pori Coft p: r �q,1��'�[lOi� �� aalraliN6bOrn$�o �� t�vm r,c�ty.ar lures= ar► aarwr lhesem# o9t �►aacLetfea`�arlile'ie�.ialss�or}r itie��ratpa�i�d�':aetmaraiiroers�arbya:�'�e.at`30at aoc �,�rL,�Ta�sadr` .ai�pri� ia}�s�p� igrsfinea��t egg� d �Q.d6Q�j;+aritg t+edr a� a+aaa�. ..................................................... CLAIM B ARI} P VI It F CONTRA COSTA COUNTY • BOARD ACTION..AUGUIT 12, 2003: 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), give. Pursuant to Government Code Section 913 and t 915.4. Please note all"Warnings". :... AMOUNT: UNKNOWN CLAIMANT: JEMEY W. 'ERICSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLEF.ON:JULY 18, 2003 BRENTWOOD, CSA 94513-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. if Dated: JULY 18, 2003 JOHN SWEETS By: Deputy 11, FROM: County Counsel TO: Clerk of the Board of Supervisors (This claim complies substantially with Sections 910 anc14.2. { ) 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). { ) Other: Dated: By: Deputy County Courts 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). IVV OARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in W. ( ) 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 , Deputy Clerk WARNING(Gov, code se ion 91 ) t Subject to certain exceptions,i you Have only six (6)months from the date this ndtice was personally served or deposftf 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 attomey, you should do so immediately. *For Additional Warning Sec 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 full, prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: =4,4 HN SWEETEN, CLERK By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY A. Clams reWmg to+mases of action for dem or ibr i�to person or to pOH�or' B coops WW wMch accrtm on or beibm 11wember 31, 1981,UnUt be preset am later than the I M?"stay aft ar the ac^.Md of ftOMMof&Com ClaimVeI#ftto cguses ofaWon for death or for injury to person or to pal VMpaty at VOWM' s cop NO vbich WM*an or after Jwwwy 1,198k inust be s ted wA tbm six alb the�ofan ora .Claims rads to any otter c4 use ofacdon must be presented am id than aim 1m ams the acanW of de CMW ofactiom (Gov'tt Cie 911.2.). B. Claims must be filed with the Clerk ofthe Bayard of Supervisors at its office in ROOM 106,Coum3r AdminisUation Building,631 pine Stmt,Nlvrti rez,.C..,A►94353. C. V 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 tgamt more than ane pu bft aatit ,sqm*e dams must be filed against each public entity. . E. Fraud. See penalty for fiaudvknt claims,Penal Code Sec 72 at the end of this farm. RE: Clam By Reserved for Clerk's filing stamp Ericson, Jeffrey W. ) Against tM CWinty of Corina Costa or ) District} (pill in name) } IU undersigned clainaM booby makes ar WUXt tlm County of COntra Costa or the above-named distric* in the sum of and in support ofthis claim represents as follows: Non- limited Civil Case 1. When did the damage or itiury ocmO(GW*exp date ad hoot) On, About, and After February 4 , 2'603 2. Wbere.did the damage or hjury occW(Iacltade citT and cowty} Contra Costa Health Flan Authorization Unit/utilization Review 595 Center Avenue, Suite 100 Martinez, CA 94553 3. How did the damage or injury ocm?(Give MI details;use extra paper irnuplired) Dr. William Walker denied mental health services and benefits to which T am entitled,, and in violation of Federal and Stag Civil Rights laws and California Stag laws AB974 and AB88. Dr. Walker failed to ensure nondiscrimination in the CCHP .programs, a barrier-free environment, equal access to health care and benefits, as well as ensuring there aro providers qualified and willing to provide health services for the continued treatment of my disabilities. His negligence caused the denial of medical services and benefits to which T., am entitled. 4. What particular act or ornimion on the part of county or district o#fi oersa sesvayrnts,or employees caused the injuryordamage? Intentional Infliction of Emotional Distress; Denial of ealt~h Services/Benefits; Violation of. the ADA, Section 504, Unruh Civil Rights Act, AB974 , & AB88; Disability Discrimination; Medical Malpractice:; Negligence; Broach of. Contract; Retaliation. 5. 'what are the names of county or d Wid o$icers,servants,or employees causing the damage or injury? William B. Walker, M.D. Health Services Director Conga Costa Health Services 6. What damage or injuries do you claim resulted?(Give Rill extent r finjuries or damages claimed.Attach two estimates for auto damage.) Non-limited Civil Case 7. How was the amount claimed above compuW?(Include the estimated amount of any prospective injury or damage Non-limited Civil Case Loss of. Employments/Educational/Vocational & Lifetime Opportunities; Pain and Suffaring; Emotional Distress; Physical Injury. 8. Names and addresses ofwitnesses,doctors,and hospitals. Brentc47ood Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCRMC Martinez Family Practice, Martinez, CA 94553 9. List the expenditures you made can account ofthas accident or injury- RAM njury.R � Non-limited Civil Case } Gov.Code Sec. 910.2 provides"The claim must be } signed by. be claimant or by sonic person on his WWI SM NMCES IQ: Name and Address of Attorney ) Claimant's Signature) } PO Box 1535 (Address) } Brentwood, CA 94513-3535 Telephone Nat._ )Telephone No. (9 2 5) 757-8006 N rJICB Swtkm 72 of the Pmal Ccxk pwWde : Yp �o.e�t3iwaattn>sti'oc aa:a�p��at�sa�ramwa6oa:atd oto Qatar aay amW.city.erdsaaialn,i arall er,�matt�rerll� am}ft tieac „ .�� '��oanrejr}"�t f�ratpeetad e�9�ot>artaae af�s e.G�bt►aflame dntn sx�aaeJDt►�. Li�aatay arbpr. 3rtcsta�cpr : caF�nat a®oeedin�s9ea,�a�wrogand l;�fQOt�,,,wt�r Oen s� �. CLAIM F F RV1 F CONLRA COSTA COUNTY i s NARD ACTION:AUGUST m12, 2003 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), give Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings", $5 AMOUNT: UNKNOWN CLAIMANT: JEFFREY W. 'ERICSON Ty ATTORNEY: UNKNOWN BATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK ON:JULY 18 2003 BRRN=D, GA 9451.3-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Beard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JOHN SWEETE JULY 18, 2003 By: Deputy H. FROM: County Counsel TO: Clark of the Board of Supervisors This claim complies substantially with Sections 910 ane 10.2. ( } 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: t B D uty County Count' III, FROM: LrkoftheBoard 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: s (v3 This Claim is rejected in full. { } Other: I certify that this is a true and correct`copy of the Board's Carder entered in its minutes for this date. Dated: JOHN SWEETEN,CLERK, By Deputy Clerk / " WARNING(Gov. codes tion 9 3} Subject to certain exceptions;you have only six (6)months from the date this ndtice was personally served or deposfte( 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 immediatcl *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: JOHN SWEETEN,CLERIC.B Deputy Clerk': Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �,�1"RtJCTIf3NS�c�An A. Claims relating to caonows oraction for 4emb erfori*vt to person or to pWWAW PvV"or gro 109 aWs ww which accrue on or bei bzr 31, 1967,nml be moat law thAn the 10&clay atter the a+cMeal of'the cm ofa fq1gtWg so OMM+rage for death or for injury to person car to pw"M Wqpwty or rowitog apps apd wbk&acarus on ca after Jammy 1, 198$;l awst be Wt Ida dm abc sombs after the Men ofthe Cat aracdm Clailm r"ng to any other ct um cfaction macer be pxsented a*bw dw 9M Year SAW the e=ud ofdocam ofacdom (GWt Code 911.2.). B_ Claims mesas:be fled with the Clerk ofthe Board of Supervisors.at its office in Room 106,County Admire n Build,651 PiDe Suver,Mfffinez,.CA 94553. C. If'claim is against a district govemed by the Board of SuperAsars„rather than the County,the name of the District should be filled in, D. If the claim is Wiest ratan than am pubft amity,sepolte€5sises must be fled against each public entity. . E. Zmt See penaltyy ffpr Merit claims,Fuel Code Sec.72 at the end.Of this form. RE: Claim By for Clerk's fling stamp Ericson, Jeffrey W. } Against the County of Contra COM or ) - � j _District) (fill in name) ) The undersigned claims*hereby awkes darn afprinaat date Coulaty of COOM Costa or the above-name!district in the sum of 5 wid in stffort ofthis claim represents as follows: Non limited Civil Case 1. Wham did the damage or hdury oem?(Give exBa date and.hour) On, Ablaut, and After February 4, 2001 2. Whom.did the dattrtaEa a or itrjury accut?(BaClcute city and oxmty) Contra Costa Health Plan 595 Center Avenue, Suite 100 Martinez, CA 94553 3. How did the damage.or injury r7(Give hall details,un owl paper if required) Pauline Jones, Florence Chan, Karen Pratt engaged in a "bAd faith" effort to deny mental health services and benefits to which I am entitled, and in violation of Federal and State Civil Rights laws and California Stag laws AB974 &..P.H88. They also placed substantial "barriers" that impeded my ability to participate in; and benefit from, having equal access to health care benefits and services, and failed to ensure that there are providers qualified and willing to provide mental health services and dispense benefits to treat my disabilities to which I am entitled. CLAIM B F JUE&EMSOM F QNMRA COSTA C U TY • 7 BOAU ACTION*AUGUST 12, 2003 wrri.w 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 Govemznent Codes. } notice of the-action taken on your claim by the Board of Supervisors, (Paragraph IV below), give. Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN CLAIMANT: JEFFREY W. 'ERICS ATTORNEY: UNKNOWN DATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK,ON:JULY 18 2 BRENIVOOD, CA 94513-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clark of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN Dated: JULY 18, 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Supervisors This claire complies substantially with Sections 910 ana�Q10.2, This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant, The Board cannot act for 15 clays(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 claire(Section 9113). Other: Dated: B : Deputy County Couns: III, FROM: Ctirk ofthe Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in M. ( } Other: I certify that this is a true and correct'copy of the Board's Order entered in its minutes for this date. Dated: 5 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se on 913) Subject to certain exceptions;you have only six(6)months from the date this notice was personally served or deposfte+ 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 irnE!e hd atel *For Additional Warring See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per ury 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 fulf y prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: VOHN SWEETEN,CLERIC By Deputy Clerk' claim to: 'BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CL 04AM Maims mlatrug to peesas of action for dealb or for injuryto person or to persemst Property or V;"ng A crops and wldch acs ora or bei�btr 31, 1987,Vont be��not tow than the ltd day to after the acxual Of the c,� ` n»Cbd=t"g m��ft depth or for injury8.- us person car to penal property cur Vowmg and ch accrue cru Or 8 teer lautuary 1988,imust be Presented not lamr than sips mxmft after the a mull of the cause ofacdom Claims relating to any other cause of action mast be later than est ym after the wxpW of the came of action. (Gov't Code 911.2.). B. Claims squat be filed with the Clerk of the Berard of'Supeavisors.at its dice in Room lob,County Administrati►n Buildh46 651 Pine Street,?+r.'cardtm x,,CA 94553. C. N claire is against a district governed by the Board of SupwvxscrM ram don the Ginty',the name of the DWrt shcneld be filled d in D. If the clahn isMpingmare than ewe public soft separate claims must be fled against each public entity. . E. ft . See penahy for flwMe ni claims,P=W Code Sm 72 at the eyed ofthis farm. +c:s��»***�r�r*+►*��rt,�.�rrwr*yrs+c*�*�►rr.�r��«.r,Asa►�.*,as*+**•*�w��t�*�+r��e�s�*�s�r*r�*r**��►.�::tom RE: Claim By Reeaved for Clerk's filing stamp Ericson, Jeffrey W= Against the:County of Contra C46U or Oistrict� --•- - (Fill in name) no a Mgned claimant bw*y c W=x0list*e County of Comm Costa or the above-rnamed distrix in the scum of S�, „OW in support of"claim mpresemms as follows: Non-limited Civil Case 1. When did the damage or Wary o=O(Give enact date and hou t) on, About, and After June 18 , 2003 2. Whe m did the datnop or injury 0e0 UnrdudO city and County) Mental Health Consumer Concerns, Inc. 1420 Willow Pass Road, suite 120 Concord, CA 94520 Contra Costa County 3. How did the dam9e,or injury Occur?(Griv*fall dettails;00 6xft paper if required) Janet Wilson enSacred in a "bad faith" effort, and failed to advocate for my "special reeds" as well as investigate they Contra Costa Health Plan' s illegal policies, procedures, and practices and inadequate medical evaluations. Janet Wilson failed to ensure nondiscriminat n i-,, the CCHE pgrograms, a barri.er,,�:free environment, equal access to health care services and benefits, as well as ensuring there are providers qualified and willing to dispense health service's for continued treatment of my disabilities. Her negligence contributed to the continued, illegal denial of medical services and benefits to which I am entitled, and she did so with full knowledge that her actions were in violation of Federal and State civil rights Laws and California State laws AB974 & AB88. 4. What particular act or omisg(M on the part ofcourlty or district off"Gers,servants,or employees caused the injuryordamage? Intentional Infliction of. Emotional Distress ; Denial of Health Services/Benefits; Violation of the ADA, Section 504, Unruh Civil Rights Act; AB974 , & AB88; Disability Discrimination; Medical Mappractice; Negligence; Bruch of Contract; RetQLli t'on. S. what are the names of county or district+kers,servants,or employees comng the damage or injury? Janet .Marshall Wilson, Program Director Centra Costa Pateints ' Rights Mental Health Consumer Concerns * Ic. 6. What damage or injuries do you claim resulted?(Gave f11 extent of injuries or damages claimed.Attach two estimates for actio damage.) Non-limited Civil Case 7. How was the amount claimed above computed?(1pe zde the estimated amount of any prospective injury or damage.) Non- limited Civil Cass Lass of. Employment/Educati.onal/Vocational & Lifetime Opportunities Pain and Suffe ifig; Em �-ional iSt ess; Physical Injury. 8. Names and addresses orfvvttg;Sses,r oetors,and nosprtals. Brpntwocd Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCPMC Martinez Family Practice, Martinez, CA 94553 9. List the expenditures you made on acct of this accident or injury. PAM A Non--limited Civil Case f�***�t�t*i�kkiMi��Y###*##�*####�t�M�M#�I*##+Yi�k*�+�#it�4##�R*�t#ik#*+i*+Mi�it►i######ati#+Itik�i#�tik�ls*##*#!�*#ati+k } Gov.Code Sea 910.2 provides"The claim must be signed by-the claimant or by some person on his behalf" Name and Address ofAttorney ) } ) } iarmant's Stgns�turej PO Box 1535 (Address) Brentwood, CA 9457.3-3535 Telephone No. 1'Te lephonse No. (9 2 5) 757-8006 ♦t+MM�#+f+tt+*####yt#�tia#i#ilei**###i####�t�Ri#i*#*iM####�ti+«wc+M�kytls#�ttl�+��ks##�#�►#*i*#�k#irf�*#�R#**##iki# NCE Section 72 of the P=W Cbde pravkl s: � 1►peers gat�rlio,vr" t ioaGot te►ddra peesea br a mree G rea pgawat to my st a irwd ar dfiam wig my .�Y+illt�if['e�4Cfs�b�[/1PilC1�IG51� ► QC ��as exs ooe � +� � taail�.��kerirep �stt��tp�rar,.i�tst�sar��rnt eatooadg slrrs�c�and tlio�aa L+orb trar�#arm iat �re CLAIM PO.AM OF PERV _1§!2R5 OF CQNTRA COSTA C Ulti'TY BOAU ACTION: 12, 2003 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 Cosies. ) notice ofthe•action taken on your claim by the Board of Supervisors. (Paragraph IV below), give 4.a Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOW CLAIMANT: JEFFREY W. ERIC80N ATTORNEY: uNoow DATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK ON.JULY,18 _2QQJ BRENTWOOD, CA 94513-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN 1 Dated: JULY 18, 2003 By: Deputy H. FROM: County Counsel TO: Clark of the Hoard of Supervisors ( This claim complies substantially with Sections 910 arA 10.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for I5 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. Z, County Counsi III. FROM: Cle k 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 Claire 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. s Dated; .f JOPIN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions;you have only six(6)months from the date this ndtice was personally served or deposfte, 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 ofyour choice in connection with this matter. If you want to consult an attorney, you should do so imrnediatel . *For Additional'Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty ofperjury that I am now, and at all tunes 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 fulty prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. ; Dated, JOHN SWEETEN,CLERK By Deputy Clerk Claire to' BOARD OF SUPERVISORS#3B CONTRA COSTA COUNTY WSMUCTICYN110 G"l.A IAM A. Claims ralaang to causee;Gractionfordtath air AwiaVury toperson ortoPersona!pmPaty g !Fops ndrW h�on or 32, 1 ,>2tbe eat t# I�a y a#tar the anal ofthe am efa to caum ofd for doh or for injury to parson or to pM80001 PCOPUty OF VOWift trop$and WMCh SCUM 00 ar add-Tatmairy 1, 198kinust be not lftr tb"six xmxft&*a do a=ual ofd o cause ofactim Claims Faafi%to any other rye cfaction nag be presested a*but thele me year after*a a ccnW Of&t Cause ofaction, ( Code 911.2.). B_ Claims must be filed with the Clink of the Board of at its of a in Room 1K County. Administration Buildh%,651 True Street,Maurtimm CA 94553. C. Irclaim is aeOnst a Amrict governed by dwRoard ofSupervi ,raid rr dere the County,the name of the District should be filled in. D. If the c!aim is more thele we public eaft sqwrate claims mint be filed against each public entity. . E. EmLct See penaky fur mem claims,I"cool Codi Sw,.72 at the caul o this farm, s# *wept*revue*�weeefsee�rs+trove�tr+�reeeee*�,�#ree:wseee*w#*er*er+tw+�r*s*r:*sww*er*www�ew*swe,t#,� RE: Claim By Reserved for Cork's fling stamp } Ericson, jegf;'e W., } Against the Comity of Contra Costa or � ( !il in name) � 71*uWersiped claimsm hffft Mdws claim VISTA"tom:Cay OfCamta Caoatat or the almme xamed district in the scum of$ and in sa"rat of o&dim is as vs: Non-.limited Civil Case L When did the damage or Wury ocao(Give exa a date atnd howr) On, About, and After February 23, 2.003 Z_ Wlmft-did tote or%mit city aced county) Patient ons _ 2500 Alhambra Avenue Martinez, CA 94553 Contra Costa County 3. How did the danup t r ur3+omve{Give full detsi s'use OM psp�ar if Gayl Belfor engaged in a "bad faith" effort, an�diled to advocate for my "special needs as well as investigate the Contra Costa Health Man' s illegal policies, practices, and procedures, and the inept medical evaluations. Gayl Belfor failed to ensure nondiscrimination in the CCPH programs, a barrier-free--environment, equal access to health care services and benefits, as well as ensuring there are providers qualified and willing to dispense: health services for continued treatment of my disabilities. Her negligence contributed to ' the continued, iller..al denial of medical services and benefits to which I am entitled,, and she did so with full knowledge that her actions were in violation of Federal and State civil rights laws and California State Laws AB974 and ARM 4 What particular act or omissa m on the part ofcxmty or district offwwrs,servants,or employees caused the inluryordamage7Intentional Infliction of Emotional Distress; Denial of Health Services/Benefits; Violation of the ADA, Section 504, Unruh Civil Rights Act, AB974 & AB88; Disability Discrimination; .Medical Malpractice; Negligence; Breach of Contract; Retaliation. S. What are the names of rmarny or district offioui,servants,or employees anWng the damp or injuy? Gayl Belfor, Patient Relations Coordinator Contra. Costa Health Flan Contra Costa Health Services 6. What damage or Nunes do you claim resulted?(Give fu l extent of injuries or damages caroted.Attach two estimates for auto damage.) Non-limited Civil Case 7. How was the amount claimed above meted?(Include the estimated amount of any prospeWve injury or damage.) Nor-limited Civil Case Loss of. EmpJ-oyrtient/Ed.ucati.onal/Vocationa.l & Lifetime Opportunities; Pain and Suffering; Emotional Distress; Phsyi.cal In-iury. 8. Names and addresses ofwltnesses,doers,and hospitals. Brentwood Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCRMC Martinez Family Practice, Martinez, CA 94553 9. List the expenditures you made on account ofthis accident or injury. P—AM 3= Non--limited Civil Case ) Gov. Cade Seo:.9213.2 pw%ides"The claim must be ) signed by-the claimam or by some person on his behalf$), Name and Address ofAttonzey ) } aimant's Signature) P© Box 1535 m� (Address) Brentwood, CA 94513-3535 } (925) 757-8006 Te�ep3mneAM._ �'I�depbcmeNo.. i#+�tK####iiiiiiiii+K�►+k#�kii�iiMi�Riiit#1i�tiftR�t�tst�R#i#i�►#iit#iiiiRtt#yRtlii�isaRi#####ik##i#4r+Rl3RaR�e#r►#sir##� N=C SoWm 72 with P=W Cwk p wider. �l �,rrihir�ttoF ,p�fwr�aE�e lorae� hops+d nr_ ,+ar1e�* anam clr.ardCa al '. $M adl5oe ar8r media albw+acpaP stparrr r+ a aE dabkW�, or is i�i�e �ri�raal��ia��t�ej�Ltra► �aot �a�c �1,pD�f.e�'b�' ��ta�„a�r�r�Itirti�st „'�atiiat;a�fsto! e�soee�fea��arsanddai�rs�ar�6o�a�t'aepde�e siid.e. ....._...__......_...__......_.............................._....................................................................................................... CLAIM BOABR OF VI F NRA COST-A C UNT'Y F OARD ACTION. AUGUST 12 2003 , 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), give Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN CLAIMANT: .JEFFREY W. 'ER CSON ATTORNEY: UNKNOWN DATE RECEIVED. JULY 18, 2003 ADDRESS: P.O. PDX 1535 BY DELIVERY TO CLERK ON:JULY 18 2 BRENTWOOD, CA 94513-3535 BY MAIL POSTMARKED: HASID DELIVERED PROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JULY 18, 2003 JOHN SWEETEN By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Supervis rs This claim complies substantially with Sections 910 an&ij0.2. { } 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: 7J ED uty County Counsi, M. FROM: Clerk ofthe Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: (VI This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. . 1 Dated: g±o JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this ndtice was personally served or deposfte, 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 immediate) . *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. JOHN SWEETEN, CLERK By Deputy Clerk, Claim tri: BOARD OF SUPEtIVIStIRS OF CONTRA COSTA COUNTY N SMCTIONS 1Q MAWANI A. Claims rdati to cows of awe fear+tom or for i jr to pawn arto p�� t see :i� crops and wbkh ae on cw befbm l��3 t: M7, be . ager the somial of dw CWM Gf&c&GL CWM . ra mues ofav im fw death or for injury to pVnW or tai pwmmd pmpmy*rVvWfti crops aeed wbic*accla e ate or aRv JIMMY 1,199$;img baa reuod Wt hi"tbas sioe was"afar AW wome afew a of ash.C�ims t+e3a ca�o mmefaction wAstbepresenuda*bUrthn aftIMSAWthe MQW000 cam or"c" (GWt Code Rl C3ahns=W be Tact with the Clerk aftiee Bard of gupftvixn at its oOce in Rwm 106,County Adminigra a BWdin ,6S Pi"Vii,Mardne4CA 94353. C. If claims is agoing a district governed by the Dw d of Supetvisms.ralber than the COMM th8 ire of the District*-Md be filled in. D. If the ads is agairin mw than eWity. a CWMS rano be AW each public entity. . E. Fd. See et d flet amines,PaW Code 5w.72 at the end ofthis form RE- C#eiire By Rasarved for Cm's filing stamp Ericson, Jeffrey W. � Againat the Cowty of Caifta Costa or � Disuict) (Fila in name) ) Tho und"sigaed rheimant busby mskes cWrn agmieeo the County of'Comm Costa or the above-named distriot in the sum ofS clad in a 4VW oftis claim W"Ots as follows: Non-.limited Civil Case 1. Win did the damage or iojury ocuo?(ON*exua data aced j war) Can, About, and After June ll, 2003 2- Whae.did dw daumv orite,�r off! city and away) Mental Health Care Manages tent 1340 Arnold Drive, Suite 200 Martinez, CA 94553 Contra. Costa County 3. Hvw died the damp or boy oe m?{G'j"fiefi deWLt,cess extra paper ifaxpitoo Dr. Suzanne: Tavano and Donna Wigand trailed to respond to my requests for assistance or investigate in a timely fashion the Contra. Costa Health Plan' s illegal policies, practices, and, procedures . as well as the inept medical . evaluations by uneuali.fied CCHF providers and the continU4d, i.11 ec°,al denial of health services and benefits by Dr. James Tysell-, Medical Director, and Dr. Cheryl, Bryan, Supervisor Pittsburg Health Center, Their ne- ligence has contributed to the continued, illegal denial cf medical services and benefits to which I am entitled, and did so in violation. of my Federal and State Civil Rights. 4. What perticWar act or omission on the part ofcs y or district officers,servants,t�employees caseduthe injuryordamage? Intentional Infliction of Emotional Distress; Denial of Health Services/Benefits; Violation o.f the ADA, Section _504, Unruh Civil Rights Act:, AB974, & AB88; Disability Discrimination; Medical Malpra.cti.c Negligence; Bruch of Contract; Retaliation. S. What are.*e:names of CQUMY or&Mid Offiicws.seavants�or emplOyees causing the dammag-or i*ry Dr. Suzanne Ta.vano Donna. M. Wigand, LCSW Mental Health Care Management Mental Health Care Management Contra Costa Health Services Contra Costa. Health Services b- what damage or itm3wies do you claim r+asulted?(Give fun extent ofWcries or damages claimed.Ana& twa estimates for alto damage.) Non-limited Civil Gast 7. How was the amount claimed above computed?elude the agimated amount Of arty pxosp€Wive h*ry or damage.) Non--limited Civil Case Lass of E. r-,lc,ymp.nt/Educational/Vocatio al & Li fetimp, Opportunities; Pain and Suf.ferinq; Emotional Distress; Phv'sical Inlurv. 8. lames and addresses ofw =%doc Wm and hospi[W& { Brentwood Health Center, Brentwood, CA 95413 Pittsburg Health Center, Pittsburg, CA 94555 CCRMC Martinez Fatrtily Practice, Martinez, Cha 94553 9. List the expenditum you made on acmwd ofthia accident of injwY. Non-limited Cavil Case } Gro Code Sec 910.2 provides"The claim must be signed by.-the claimant or by some perste on his behalf's SMM E Name and Address ofAttorney ) � } Y I OClaimanes S1gnature) PO Box 1535 (Ad ) } Brentwood,. CA 94513-3535 wephtme wo. l't'a3eph eNo. ( 2 5) 757-8006 �t*s*��+�++*saes*+►s*s*s��e+��ary►ss��rsw.ssr�ss�t�s�t +�s� �*��+srr+rrw.s�ss�es�v��ss�:*sa��«�� N=CF' 72 of the P=O Code provides: E�rerrpcascra�p,a�iM�tiud �ranieai�fpf arabe�o�eaeatMarg�t�oarsdotoii�ccs,orttr� vx=ay,aly.4wdaft bmdase soft nift&%w at pq Gt=Aft` bbb OrSawkINA dn"%W . roaaci�er.or .iartr��aeiwr�iaieaarsltpj�i>b��a�'�oEaraactiiwaaCjn�b)raf�edaot e�adr�a�,any�raas�rd�,�'fwri�ae�ti�oaswa�t�i .�'��itt�e8si�„i9r a► a€ caaeetestbo�d �,airir,�ioa�► ��ard�rrs. CLAIM F P B R QF C NT8A COSTA COUNTY • r' MORD ACTION:'AUGUST 12, 2003 Clan Against the County,or District Governed by } the)3oard 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), give Pursuant to Government Code Section 913 and 915.4.Please note all"'W'arnings". AMOUNT. UNKNOWN CLAIMANT: J nEY W. ERICSON 'Y� ATTORNEY: UNKNOWN DATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK.ON:JULY 18 2 BRENTWOOD, CA 94513-3535 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS Dated: JULY 18, 2003 By: Deputy 0-4� II. FROM: County Counsel TO. Clerk of the Board of Sup ervi rs AThis claim complies substantially with Sections 910 a &j O.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: D ut Coun Courts Dated: By: y tY Cou III. FROM: Clerk fthe Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as!Ttimel with notice to claimant{Section 9113}, IV. OARD ORDER: By unanimous vote of the Supervisors present: � ( This Claim is rejected in W. { } Other: I certify that this is a true and correct copy of the Beard's Order entered in its minutes for this date. Dated: JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sectio 13) Subject to certain exceptions;you have only six{6}months from the date this ndtice was personally served or depositet 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"our choice in connection with this matter. If you want to consult an attorney, you should do so irntnediatel . *For Additional Warnin 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: ✓ OHN SWEETEN, CLERK.By Deputy Clerk`; Crim to., BOA"OF SUNMVISORS OF CCfl/rN�TAAR�r�,COSTA COUNTY A. Clstims relating ttl o fir der t� to Pusan Or toPascualProperty orgrowling snips and w4"accrue ort ar b Dwetober 31,1"7,mast be UMtbbn tlW IW"day after the accrualofft ofs cdm to ca m c raction death or for m,�y to Person or to Property or�+ �� on oraftrx�lr l irms<be not how tbox aierc=Dabs after she acamd oft# afar.Claims mahng to any o tber +4un of action asist be scot W*r resat Wt yW afbel'the W=W]Of dw Ca6se aractim (Govt Colt 911a). B. Claims rivet be fled with the Clerk aftha Board of Supexvis=at its pct in Rom 106,County Administration Building,651 pim Savq ', ufim:4 CA 94353. C. Xfclaim is against a district governed by theBoard of'Sapervimo ratW than the Counts+,the name of the District should be filled in. D. u the claim is againg mom tim one iblic eaft,separate swims must be wed against each public. entity. . E. FMA See penalty for*M&& +damns,POW Code SM 72 at the end Oftlda form. #iit4##k***a#♦#'#M*�l*****�*i#*lttt#til**##*alt#t4fc**ilf ttkit***ikb*al:*+�t#�k*ttkt►ys;f�tyt#�►#iF+t###iF#k##dctR:�t RE: Cla im By Reserved far Cluk's filing stamp Ericson, Jeffrey W. Against the Comity of Cornua Costa or } - quiet) (Fill in name) Tho undersigned chin »t harby Mkn claim against the County of Coma Costa or the above-narned district in the suns cf$_, ---- _„ark in snort ofthis daim roprasents as ibliow r.: Noes-.limited Civil Case 1. When dial the damp or Wury 00=7(tae cuo date and hour) On and After March 10, 2003 I Wluw.did the damop or is#wy oem?(hes hale city and a oty) Contra Costa Health Services, Ombudsman Program 2020 North Broadway, Suite 247A Walnut Creek, CA 94595 Contra Costa County 3. Howe did the damage or bjwy os:curo?(Give fiA dctsits;use+extra paper ifrequited) Evelyn Rinzl.er engaged in a "bad faith" effort and ailed to advocate for my special needs as well as investigate the. Contra. Costa Health Plan's illegal policy practices and inadequate medical evaluations. Evel.vn Rinzler failed- to ensure nondiscrimination in, the CCHP programs, a barrier-free environment, equal access to health dare and benefits, as well, as ensuring there are providers qualified and willing to provide health services for the continued treatment of my disabilities. Her negligence resulted in the continued and illegal denial . of medical services and benefits to which I am entitled. 4. What particular acct or orissitm on the part ofoxmq or&Mict oftm-4,setvau%Or stnptoyees caused the injury or damage?'Intentional Infliction of Emotional Distress;; Denial of li4alth. Services/Benefits; Violation of the ADA, Section 504, Unruh Civil Rights Act, :AB974 & AB88; Disability Discrimination; Medical Malpractice; Negligence; Bruch of Contract; Retaliation. 5. W"t are dire games of ooumy or XaUid aficxs,savastts,or e mploy M muft the damage or injury? Evelyn Rinzler Program Ombudsman Contra Costa Health Services Attwk & what damage or injuries do you daim mmulted?(Give fall e;ctertt Ofimt1unts or datna�s claimed. two estimates for auto damns.) Non-limited Civil Case 7. How vwas the amount claimed above computed?QwJude the estimated amount of any prospective injury or damage.) Non-limited Civil Case Loss of. Emcloyment/Ed.ucational/Vocational & Lifetime Opportunities; Pain and Suffering ; Emotional Distress; Physical Injury 8. Names and addresses of'wknssm docwm ad hespittais• Brentwood Health Center, Brentwood, CA 94513 Pittsburg Health Center, Pittsburg, CA 94565 CCRM, C Martinez Family Practice, Martinez, CA 94553 9. List the expenditum you made on accowd of flus accident or iajtrry. RAM Non-limited Civil Case *##**####rbc####*#*tM*##*yi�t!*#i#**###�R�t##1�4•#3f##**##iRM**+i##it4t►#iR##�k###ii**I�+��F#sR**rt��t#�R#�I+t#� Gov.Code Sec.910.2 provides"The clam must.be } signed by-rhe claimant or by some person on his behalf.' SEM NOMM IQ: (AIMMU ?+Trine and Address of Attorney ) � laimanes,SignaWre) } PO pox 1.535 (A"ess) Brentwood, CA 94513-3535 } (925) 757-8006 Telephone No. Z Telephone No. Sactim 72 of tho Parol ODde pmvides: E'er pc==v4WvA1k*41w%dekw4j Swagnuteas6t1uarwsfilabowderafficMas1D.my d4'.+aci�oa�orod� ii�t�cnr+otp�ii�stpear�grrwir�.ault +o��t .b�,;eacrum�, smocks.WW41k&15PWhh#&+e�rdr '� ie r i�rr �all`arot ti irrrrraejnes ibl► afrwt aW14P , nude samok+ �r��e1130MlCrir; anlsc��dt �1a*=god A 0 �a ............................................................................................................................................................................................................................................................................................................................ CLAIM F B OF CONTRA COSTA C!2jJNTY • BOARD ANION:AUGUST 12, 2003 Clan Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Beard 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), sive Pursuant to Government Code Section 913 and F 915.4. Please note all"Warnings", { 4...... J y'. AMOUNT. UNKNOWN w CLAIMANT. JEFFREY W. ERICSON ATTORNEY: Umow DATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1.535 BY DELIVERY TO CLERK ON:JULY 18. 2003 _ - BRFN'1"1WD, CA 94513-35.35 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOIN SWEETS , Dated: JULY 18, 2003 By: Deputy II, FROM: County Counsel TO: Clerk of the Beard of Sup ervi ors KThis claim complies substantially with Sections 910 ant10.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we.are so notifying claimant. The Board cannot act for 15 clays(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: lax: DeputyDepHty County Couns, IIT. FROM: Clerk ofthe Beard TO: County Counsel(1) County Administrator(2) ( } Clam was returned as untimely with notice to claimant(Section 911.3). IV. ARD ORDER: By unanimous vote of the Supervisors present: {v?' 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: 2�"OHN SWEETEN, CLERK, By , Deputy Clerk WADING(Gov. code section 9f3) Subject to certain exceptions;you have only six{6}months from the date this adtice was personally served or deposfte 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 yr►ur 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 � 40<_"3 JOIN SWEETEN,CLERK By Deputy Clerk. Claire to: noA-RD OF su'PEtYrARS of CUNrRA STA C©'URT �xS'fRt1C'f� ��t1 t .AIIE A. Clairaax relating tc caaa af' for taa`f�irj►u> or toil► c mps and wNch acwn an tsar b Dece=bcr 31,19 7►,a be "W titer dean the 1t&day sV.wthe&=udofdWc&UftGf`9cd0WCW= ao r c facdiottt fox dath car for itaaajM to - rNum c+r to paxed pn*wtyr arip aui h atc+rme oat cur sfk r r 1,19K- bae not Lear than aix=0066 saw tfae Me"offt CRIft ofaction.Claims sawn*to any a illi cam ofactioaa nut be pueowd amthow than am ym afterthe acensd ofdo close of _ B. Claims mug be filed with the Clerk of the Board of Suparvigors at its office in Rom 100 County Admurisfratkm aiding,631 Pine Strom Mardna,,CA 94353. C. If claim is agaimst a district governed by the Board of Supe visoM rather tta n the County,the name of the District mould be filled in D. If'the dlaim is against more than one public+amity►,sqmnate claims must be fled aaVWst each public entity. . F. Frasrd. See penalty for Awdulent claims,Pwal Cate Sec.72 at the and of fts form. RE: Claim By Reserved for Clark's ming stamp Ericson, Jeffrey W* } 3 Against the CODUtyi,of COrAM Costa or � District) (Fill in aamn+e) - <. 3 M*undersigned claim nt hWVbY m8k0s claim 0028t the Cwnty of C W Wa Costa or the above-named disttjot in the Sam of S and in art afWs claim rests as Ibllows: Non-limited Cavil Case 1. ltaen did the damage or injury oc '1(Crive+exact date anti hour) On and After May 19 , 2063 2. Whew did tits dates or injury oacw?(hw4uds city and wunty) Pittrsburcr Health Center 550 School. Street: Pittsburg, CP_ 94565 Conga Crista County 3. How did the"MP or Wury Dew?(Give fhli details;tree exft paper if required) Dr. Murray Ei.land failed to perform an adequate medical evaluation to determine, and to provide, effective treatment for my disabilities. This na gligence resulted in the continued denial of medical services and benefits to which I am entitled;- and did sea in violation of my Federal and State civil rights. 4_ What particular actt or ornisdon on the pan ofCounty or&XtrW offices,servants,or employees caused the irrjuryordamage? Intentional Infliction of Emotional Distress; Denial of Health Services/Benefits; Violation of the ADA, Section 504, Unruh Civil Rights Act, AB974 & AB88; Disability Discrimination; Pledical Malpractice; Negligence; Broach of Contract; Retaliation. damage or injury? 5. What me tine names ofcoumy or district o rs,se its,or employees caosing the da ? Murray Liland, M.D. Pittsburg Health Center Contra Costa Health Services 6. What damage or injuries do you claim resulted?(Clive full extent ofinjuries or damages claimed.Attach two estimates for auto damage.) Non-,limited Civil Case 7. How was the amount claimed above computed?(Includes the estimated amount of any prospective injury or damage.) Non-limited Civil Case Lass of Employment/Educati.onal/Vocational & Lifetime Opportuni_tie-s; Pain and Suffering ; Emotional Distress; Physical Injury 8. Names and addresses of witnesses,doctors,and hospitals. Pittsburg Health Center 550 School Street Pittsburg, CA 94565 9. List the expenditures you made on account of this accident or homy. PM Non—limited Civil Case *##*MAS**i►�yc##�##+i****#+k#at«�##ti*#4##+t�k*+k#**�t*�4##�t�tat*#Mt#*#�R+k#!�R#+�+�i�**iR�lt*�tr�##*t�#*##*+A#�k«�k**�t�r* } Gov_Code Sec.910.2 provides"The claim must be signed by.-the:claimant or by some pawn on his behalf" MM NSMCES 19: L&SUM Name and Address of.Flttoraey } aflt'S Signage:) PQ Box 1535 (Addteas) Brentwood, CA 94513-3535 TelepbDoeNo. )T No. (925) 757-8006 «s*s**«*«*«««s+�«+*#*«+girt«««ss«s«gas*ssa►**s*ss�s+�««tie**«sa�...�esss:«��s�r#�r«t«*«*�ras�r»«#*«� NcyncB Smc�a'tZ Atha P+onat tie peca►t�: rpe�or thireaect�i ,p ii�r ar ep tier #�abmedarlcmwlany ooeagr,city.uar+t�axtbo�ed oec�.aouat+ar�dtu a�ror��s�+acit+�eeaurS��er. r�i�i„b�l1, t, ' �'' `.� e�'ty_r i�it�a�gpiiorspe�odr�'�etaoarzii�aee�„t�a� t�'n�ot oe�e �,+ocbrb�aar�iEaadtb�rrr'�r�.ia�,t p �r a Smw�at�ntt exoeodin��d�oasimdd .WOil,drbyt�ard+►�aadtawa. --- __.. ............................................................................................................................................................................................................................................................................................................................ A CLAIM Q P VI F CONTRA COSTA COUNTY i -BQAU ACTLQN,AUGUST 12, 2003 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), give Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN � CLAIMANT: JEFFREY W. 'ERICSON , ATTORNEY. UNKNow-N BATE RECEIVED: JULY 18, 2003 ADDRESS: P.O. BOX 1535 BY DELIVERY TO CLERK ON:JULY 18, 2003 BRENTWOOD, CA 94513-35.35 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JULY 18, 2003 JOHN S W B! rk By: Deputy, 11, FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 914 aAJ10.2. ( ) This Claim FAILS to comply substantially with Sections 914 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. D!Tuty County Counse 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. DOARD ORDER: By unanimous vote of the Supervisors present: { This Claim is rejected in ill. ( ) Other: I certify that this is a true and correct copy of the Board's Carder entered in its minutes for this date. Dated: JOHN SWEETEN, CLERK,By .Deputy Clerk WARNING G(Gov. code secFon-913 Subject to certain exceptions;you have only six (6)months from the date this adtice was personally served or deposfiec 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 tunes 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: JOHN SWEETEN,CLERK.BX Deputy Clerk''' Claim to: BOARD OF SUPERVISORS OF CONTR.4 COSTA COUNTY TN3MCn0NSTO A. Claims relating to cuum ofoctionfor dcrrir e r far no"ry to peter or to pen al Property or RMWIMS crops s and d"aomm an ar beftrre Dece=bcr 31,1 7, be pmoesited not bterthmthe 100&&y after the avmW of do mn c `actiOw Cbjw rokft to caum aacdon br death or for inijuty to or I* PI*My O r rowinS CM0 md which acOm oo or alar J==7 1, 198k iomst be pftsemd not lawden s"k xonft atter the atm+card*cattle+aractim Claims relshm to my ad= Dallas�'�trttr�t�ln'�rad hr�art�t t>n� r ailartthe�ttd'tie of actt . {Gov't Ctrs 911.3,). B_ Claims wAM be AW with the Clot ofthe Dowd of&*ervi rs;at it office in Wit»106.Cir Admitt ti aSuildin&651 Rine Sttaet jtr x,C.A94353. C. If'claim is sgalnst a district Bovet ted by the Board of Supervisors.rather than the County,the name of tha District should be filled in. A If alts ddom is POWtyre ttWn we ptift wift N*wde daims moo be wed againa eub pu, entity. . F- See:parMalty fOr*XAJlem claims,POW Code Sm 73 at the end of'this fonn. �:*�*�::*•**�*��.►*�,��«.�:yrs,�t�v�*.fs*sw►*�:s� :.ssa**ssr�s*�c�wr�:�esUs,rare:*t�ts�*s*�+�*r+**.�*ss,► RE. Clam By Rammed fiv Clues fifin sump Ericson, Jeffrey W. } 3 ,Apitnst the County of conmCoja TJ�strict3 . (Fill in named The umler vc d 4MM*bW'*y ttrtal=claim 84 the C*UrAy Of Contra Costa or the above-named med district in the sum of$ in,rapport oftthis dam Mwam"s as*now$: Non-limited Civil Case I. Whm did lite damap or W"00=7 =wt dmft mW bm3 On and After March 10, 2003 I W w e,did the damage or Wuly occur?t WU&try and coudy3 CCRMC Martinez Family Practice 2500 Alhambra Avenue Martinez, CA 94.553 Contra Costa. County I How did do dares cut iu M ain't pm%X11&t gh,lase art paper if ,.d) Dr. Stephen Kalkstein failed to "perform an adequate medical evaluation to determine, and to provide, effective treatment for my disabilities. His negligence resulted in the continued and illegal denial of medical services and benefits to which I am .enti.tled, and did so in violation of my Federal and State civil. tights. 4. 'What particular act or omissaon on the part Of county or&strict afficers,servants,or employees caused tha injuryordamage? Intentional Infliction of Emotional Distress Denial of Health Services/Benefits; Violation of they ADA, Section 504, Unruh Civil Rights Act, AB074, & AB88; Disability Discrimination; Medical Malpracticet Negligence; Bruch of Contract; Retalia i.on. ©rWjury? S. "What are the names of tawny or district Officers.ffiervutts,or employees caUft Stephen Kalkstein, M.D. CCR-MC Martinez Family Practice Contra Costa. Health Services 6. What damage or injuries do you claim resulted?(Give fog extent ofinjuries or damages claimed.Attach two estimates for auto damage.) Non-limited Civil Case 7. :How was the amount claimed above computed?Qncludc the►estimated amowt of any Prospective injury or damage j Non—limited Civil Case Loss of Emplc•yme<nt/Educational/Vocational & Lifetimes Opportunities; Pain and Suf'ferino; Emotional Distress; Physical In ury9 S. Names and addresses ofwltnesses,doCW3.and hospitals. CCRMC Martinez Family Practice 2500 Alhambra Avenue Martinez, CA 94553' 9. List the expenditures you made onwx t of this accident or injury. . .... �� Non-limite-d Civil Casey *****+�+�+�***�#�s�*******�tsee**ass*****s*tib+t�Ri*#+k**�k*s***�M*r*+r**#A�***s**sir*ws**�►***+R*****,k** Gw Code Sec.910.2 provides"The claire must be signed by-the claitnant tsr by some person on Ws bela f." Name and Address ofAvorney �v 1 PO Box 1535 {Addres} Brentwood; CA 94513-3535 Telephone Net. `1T (9 5) 757-8006 #*#s�R**�*�Ir*##CRY�RM��k+F�##+i M'�►rF##�R##+t#ItRMnrit�R#*+f#�k�i+tl+F�###+t#�M3t*�t�sM��R�1'f#*s#��##+Y+R�k##ak*#****�c4�k#�t��# NCE Sectiou 72 ofthe PmW Cade proWdes: C ,r poaC wog, farsa�ce aria paossrc to air stove 600d" sr WY mod a �s� r � efint 1=61 �,,� CLAIM BO&U01F$.VP RVISORS OF CONTRA COSTA COUNTY BO _AUGUST 12, 2003 . 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), give, Pursuant to Government Code Section 913 and 915.4.Please note all'Warnings", AMOUNT: UNKNOWN CLAIMANT: SUSAN DIRKSEN ATTORNEY: UNKNOWN DATE RECEIVED: JULY 15, 2003 ADDRESS: 10042 FOXBORO CIRCLE BY DELIVERY TO CLERK ON: JULY 15) 2003 SAN RAMON, CA 94583-2627 BY MAIL POSTMARKED: JULY 14, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 15, 2003 JOHN SWEE Dated: By: Deputy FROM: County Counsel" TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 an&QJ0.2, 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 Deputy County Counse 111, FROM: Jerk of the Board TO: County Counsel(1) County Administrator(2) Claim was returned as untimely with notice to claimant(Section 911.3). (This ARD ORDER: By unanimous vote of the Supervisors present: 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 Deputy Clerk WARNING(Gov. code,sectio rf 913) Subject to certain exceptions,you have only six(6)months from the date this n6tice was personally served or deposfte� 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 poury 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, Califon"postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ��_/U -&p IS JOHN SWEETEN, CLERK By Deputy Clerk" Clam for BOARD OF SUPERVISORS OF CONTRA COSTA C(UN-r'Y INSTRUCTIONS To CLAIMANT A. Clam relating to causes of action for death or for injury to person or to per- sonalproperty 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 groaning 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 Rods 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If clan 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 Susan Dirksen 10042 Foxboro Cir. San Ramon,CA 94583-2827 RECEIVED} i R the County of Contra Costa JUL 1 5 2003 or CLERK 88ARO OF SUPERVISORS District) CONT, COSTA Co. 7111—In name } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents -as follows: 1. When 'did the die or injury occur? (Give exact date and hour) AM 2. Where did the damage or injury occur? (Include city and county) 5� 3. How did, the damage or injury occur? (Give full etails; use extra paper if required) � t S17fd WJ�- 4. What particular act or omission on the part of county or district officers, servants or ,employes caused. the injury or damage'.' � 0, ` ' '- 27-14 5. 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 autos damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 3. Names and addresses of witnesses, doctors and hospitals. Z �q ; 9. List the expenditures you made on account of this acci HTnt or injury: DATE y ITEM € : Gov. Code Sec. 910;2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorne } or by some person on hi . behalf." Name and Add.^ess of Attorney Claimant's Signature Address Telephone No. Telephone No. t ' 2. A N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill., account, voucher, or writing, is punishable either by imprisonment in the county jail-for a period of not more than one year, by a fine of not exceeding one thousand ($1,400), 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. ..................................................................... ..... .................................................................................................................................................................................. ............................................................... F7 r A Ty Q4.. a f 3 Ns eF Ms.Susan Dirks®n 1£1042 Foxboro Cir. San.Ramon,CA94583 CLAIM BOAER OESUPERVISOM-QF CONTRA COSTA COUNTY � • Bo&U Ag�O_N:AUGUST 12, 2003 �..�rw.r�rrwro �r w � 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), give: Pursuant to Government Code Section 913 and 915,4, Please note all"Warnings" I 3 + v � 5 AMOUNT: $227.11 CLAIMANT: BARBARA HEA,LLY ATTORNEY: UNKNOWN DATE RECEIVED: JULY 159 2003 ADDRESS: 3689 SAILBOAT DRIVE BY DELIVERY TO CLERK ON; JULY 15, 2003 UISCOVtRY`BAY, CA 94514 BY MAIL POSTMARKED: JULY 14, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 15, 2003 JOIN SWEP, rk Dated: By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Supe isors oo This claim complies substantially with Sections 910 an&qJ0.2. ( ) 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). { ) tither: F Dated: By: eputy County Counse III, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returners as untimely with notice to claimant(Section 911.3). IV/B OARD{ORDER: By unanimous vote of the Supervisors present; ( This Claim is rejected in full, ( ) tither. I certify that this is a true and correct copy of the.Board's Order enterers in its minutes for this date. Dated: *94e•GOHN SWEETEN, CLEF., By , De uty Clerk WARNING(Gov.code se ion 913) Subject to certain exceptions;you have only six(6)months from the date this ndtice 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'I 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 ISN SWEETEN,CLERIC,By Deputy Clerk claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLALMWr 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, 1587, 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, 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. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the`Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims =st 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 g �... i,. .Ai ...fixY t 4. c_; _ ,k, } RECEIVED Against the County of Contra. Costa } JUL 1 2003 orC L EE[R E�0�) qD OARD 0- District) c0N'TR.AC,. +.�. Fill in i2—w5) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ <D�—1, \ and in support of this claim represents as follows: 1. When did the dame or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) t _ 3. How dial the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or .employe'es caused. the.injury or damage? what are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resdted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (include the estimated amount of any prospective injury or damage.) CX 8. Names and addresses of witnesses, doctors and hospitals. .,, •g .'www{r�..�"�L.w..rrrrr...�rr rrrwM�...r�.�a.awr,..�YMIMn....F+. MelaMr....rw�.r+lw.rwaY+rrrY++ew.r r+Me..sw 9. List the expenditures you made on account of this accident or injury% LATE ITEM AMOUNT A CiF iF iE iE !E f iE #E ik i 1 ,iE Gov. Cade Sec. 1U:2 provides: "The claim roust be signed by the claimant SEND NOTICES TO: (Attorney) or b some erson on his.behalf." Mame and Address of Attorney a. Claimant's Siture Address F > Telephone No. Telephone No. � j V � 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 ary 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 ($100000V or by both such imprisonment and fine. '� try d L{'[ mf �G=-t f ✓` k r✓'� -.,4 f + rr ,r •_:.� rte`. t., ,�" 1. ✓ ..«,�....,.-, <, r fr,.!dr L� �:"� " °� �C--_ C... P° r lit, r t"��r.� �,�� f f, j rN`�• 1-.• a i o " ., 4: ..� y ,y��r � r �J; rr'� >.. s ftil.: t. i_ ,_. � "l f -. �M h.-•- !'4....� / �. .. '� i ,e�y yr_.ya ....� �•'.Y !< f ., Y :•'2 .. � �r..-"� �j y F"� ' ��rg( r; t' _�..- rf k: �.r �,r wx � ...-�'",�"�,.., 7 .e 'f -.... !{� 91 J��^�,e,.i�✓�....s�� Ir ..�� .-�r''�� t� �''�"r elf F • r r'A,,. Sr F� ''� 't f�•�-�- �^ ,°'r�'��'.'� £! i., } -"`5" ✓s�N yam, � <..,..�%.°`,•,t �,•£ �- /y fi } jr r ! J F � x s L.^. or f - •„�.. C- r r` ,3 J ti ° jw... �...�_. s'j .•:g_, tj i .„.J i j��A t r �,,y �7 y�-.,,_°+.- < �-- r ,.,. { ry .! £ '� �..C..r 4•,¢'� J{ \.. ._.J i'w F:;.� '••� �,-.,: b`� r' r 3 STATE OF CA11FOgMA—BUS NESSTgAN6J!QRWJQ9 D HOUSINrIA nRAY nAVIS. ve DEPARTMENT OF TRANSPORTATION 111 GRAND AVENUE P. 0. BOX 23660 OAKLAND, CA 94623-0660 .flex your power! PHONE(510) 286-5807 Be energy efficient! FAX(510)286-4638 TW(800) 735-2929 .dune 30, 2003 BARBARA A. REALLY 3689 SILBOAT DR. DISCOVERY BAY, CA. 94514 Dear Ms, M- y ni , Claim No D030445 The Department of Transportation has rejected your claim. After a very thorough investigation it has been determined that Caltrans was not responsible for the damage incurred. Our investigation indicates the site of the alleged incident was not owned, controlled or maintained by Caltrans. Therefore another agency or entity is responsible for the maintenance of this area. Wherein the County of Contra Costa should be contacted directly concerning the handling and investigation of this claim. County of Contra Costa Attn: Public Works Dept. 255 Glacier Dr. Martinez, Ca. 94553-4897 (925) 33 51080 Sincerely, District Claims Officer "Caltrans improves mobility across California" STATE OF CALIFORNIA DEPARTMENT OF TRANSPORTATION CLAIM AGAINST DEPARTMENT OF TRANSPORTATION FOR AMOUNTS $5,000 OR LESS LD-0274(REV 4!2003) PERSONAL INFORMATION NOTICE Pursuant to the Federal Privacy Act(P.L.93-579)and the Information Practices Act of 1977(Civil Code Sections 1798,ct seq.),notice is hereby given for the request of personal information by this form. the requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article b.Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification.to inspect all personal'information in any record maintained on the individual by an identifying particular. Direct any inquires on information maintenance to your IPA Officer. This form is to be used when filing a claim against the Department of Transportation as provided in Government Code Section 935.7. PLEASE:$ print or use a typewriter when filling out farm. $ sign and date claim form. (UNSIGNED AND UNDATED FORMS WILL NOT BE ACCEPTED) v: -STATE USE ONLY 4.NAME: LAST rt FIR, MIDDLE F E UM$ER Fz.,.� X�• ��3 S��t � 7 a15-•�.N r°"N d'� lil�flr • � ___—. HOME ADDRESS BUSINESS PHONE NOME PHONE y (;TY STATE ZIP CODE ;TIME OF INCIDENT AM DATE OF INCIDENT 2.PUT A SPECIFIC TIME AND DATE WHEN THE DAMAGE FIRST OCCURED 1 PM (14RY .202n0- 3. 02 0- 3.STATE THE LOCATION OF THE INCIDENT WITHIN ONE-HALF MILE(CITY,COUNTY,HIGHWAY,NEAREST OFF-RAMP,CROSSSTREETOR,POSTMILE). Ai A t , 4.EXPLAIN HOW THE INJURY OR DAMAGE OCCURRED ` LL a2 xr"`. ; PUz IA.S' i4i2 .^ -K• �..� '�'. l.r_f=..StA-.. ;:..p., 2-, � '"� £ _ 1 .x' WHAT PARTICULAR ACTOR OMISSION ON THE FART OF CALTRANS OR ITS CONTRACTOR CAUSED THE INJURY OR DAMAGE? '77H L /9 ht` c WHAT INJURY OR DAMAGE DO YOU CLAIM RESULTED? i °�, '. { 7 A "J ".:'a.."`.4-r'_Y 3G./s ,F � F ;F '• L.Fj.....^' f•.J &LI 'd tL'` �4'at' ✓'e5 t\%tv,.i WHAT IS THE DOLLAR AMOUNT OF YOUR CLAIM FOR DAMAGES? (SUBMIT TWO ESTIMATES OR PAID RECEIPTS) NAME OF SURER 5.INSURANCE INFORMATION IS REQUIRED 4 ARE YOU THE REGISTERED OWNER? I YES NO HAVE YOU SUBMITTED A CLAIM TO YES NO YOUR INSURANCE CARR/ER? IN YES, WERE YOU PAID? -I YES NO FOR WHAT AMOUNT? VEHICLE INFORMATION MAKE OF VEHICLE e YEAR ,_ LICENSE NO. ej I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE FOREGOING,FACTS ARE T RUE AND CORRECT TO THE!s`ST OF MY KNOWLEDGE AND BELIEF. SIGNS ARE; CLAIMAN - DA E - REVERSE SIDE FOR STATE USE AND FILING INFORMATION ON CLAIMS �� P J � " A GROPERS .. ONE < P€ r�3T3S zT '€ S E ` R?ssusAP y ...... .. 1 .1 '�•� J" I/�:�/ (r y�,y",.d'r, er q S fir'".j v ,r>, iq� y,: e 3�1" Co , ..... .......................... . _ ___ � ��a�, .1 '� -. �H �� ,� ts�^milt r �•9. .., i 3. A� Wz . _. � � Z "�I � 1 t4 7 d f r., i �21 .,�, R ,. f p C T^"�F :� �J a'� ;4 •fit 3*01S r r KIN NOT N r 4 4 { >ep r, r # -ON ° i; � r r t , X >. r r J W4 ,$ -f 'p a x An v �- axb � r 001, AT All OWNS Saul WNW x a t v a s i 3 : s m"lax g � mo INTO cam out TOW,$ ........................................................_._.................................. .............................................................................................................................. . ............................................................................................................. ................................... _. _..._ Lu uj ul to C ¢ L n.J :y R� a ry k r - 3 t t t r �y r CLAIMA OF PERVI ORS OF CONTRA COSTA COUNTY BOARD ACTION.- AUGUST 12, 2043 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), giver r Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: Exceed $10,000. "` t CLAIMANT: DAVID LEIGH' COOK >;.,.A. ATTORNEY: UNKNOWN DATE RECEIVED: JULY 16, 2403 ADDRESS: MARTINEZ DETENTION FACILITY BY DELIVERY TO CLERK ON: JULY 16, 2003 A #14 901 COURTSTREET, MARTINEZ, CA 9553 BY FAIL POSTMARKED: JULY 15, 2003 , FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Dated: JULY 16, 2003 By: JOHN SWEE k Deputy II. FROM: County Counsel TO: Clerk of Board of Supe Ysors f This claim complies substantially with Sections 910 an l0.2. +{ ) 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. Al. DatedAB J/1Deputy County Counse ISI, FROM: 4c,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 Clain 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 , Deputy Clerk WARMING(Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this ndtice was personally served or deposftec 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 age18; 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: /3 JOHN SWEETEN, CLERK By Deputy Clerk' Clain to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS=TIQNS TO Q ATMAN'T A. 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 before December 31, 1987, must be presented not later than the 10&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 rause 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 died 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. ?x at the end of this form. RE: Claim By Reserved for Clerk's filing stamp 7LRECEIVEOAgainst the County of Contra Costa or6' 2003 District) E Fill in name) ) CLERK BOARD '1"'��tV1S�7�s CONTRA CCuTA Co, The undersigned claimant Weby makes claim against the County of Contra Costa or the above-named district in the sum of S {; end in support of this claim represents as follow 1. When did the damage or injury occur?(Give exact date and hour) n 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, or employees caused the injury or damage? 5 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 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 amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) S. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TIME AMClUNT Gov. Code See. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SEND-NOTICES T &t Name and Address of Attorney ) (Claimant's Signature — x (Address) ea t k f )) ){ 22 4 S Telephone No. )Telephone No. s ` NOTICE Section 72 of the penal Code provides: Every person alio,with intent to defraud,pmts for allowance or the payment to my 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,bili, voucher,or writing,is punishable either by imprisonmerst in the oxmty jail for a period of not more than one year,by a fine of not exceeding one thousand(St,000) or by both such impfimment and fuse,,or by imprisonment in the state prison,by a fine of rot exceeding tens thousand dollars($10,0013),or by both such imprisonment and fine. 3 e � �� tia.✓E` ° h. y �``$ �.k i 3, t C,>�z �}.k.�f�.�..... y.. �y�,� £an��+,:.. ''.,�+''` ��+.'..$��.. �' �':,^�•.. .?F;:..• s � ,,,�'�"' 2. 4 � ,�.3 `L• S Ro.:�C.� L•�..,:.M ,..:•._.,(y.?iJ S ..f.,J n .,.4\-�A.:.. 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Y� -{ 1 i'i`i. c ys. �r 'E..+ I'� ' Qat R g& '"S d Routed 7b: ANSWER: ( )APPROVE® ( ) DENIED-(state reason) By:Al Date: .a __J03 Rink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1/2/91 { .. "ng' 'ate'-.,�.. "` .:ewe: a _..._ c: .7,'..",: :a•:•;. + `- w.�„ .. � ':" "a.._:- ZON DETE1'�'T'ION FACILI'T'Y { } INMATE REQUEST FOR INFO M .TION { MEDICAL REQUEST To: Sa From: Housing Assignment: Check One: { j Request { Grievance ( }Appeal { j Other Request: .' ¢ to l t t 1 � " '�,.��.. :"1 � 1 ."sc. �1°A,�`?4.fb.: f-'�•X•' �'A"'4 j ta':! t l V� E _... ( s Y } 1 I 15gg i Cate Rec'jw l l I - Rec!dBvm ZC .I& Routed To: --- ANSWE Ft: { )APPROVED { j DENIED-(state reason) By ;`" � Date:_ J 1 'Y Pink:Kept by inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1!2/91 t 4 Rte' yi b y.z g ONOF � y2y,... 3 „cel x� .�"�W`r•� 4 fj'..33a�� ry`x.. ..x4,�y ��r}". �-�v - . Z DETER 16H fACILtTY PHARMAJYgt #7107/03 DU MARTINEZ °° 7004 INE Sheet.Martinez,CA 94553 925 646-7642 RX.mzu FOR- DAVID ? 87107103 DR. Brooks,Keanetli R. INSERTRECTALLY i SUPPMI'TORY s AT BEDTIKE FOR 7 DAYS. � 4 HBIlERROIDAL SUP? Y/HC i SUP? FQRI.MLSERT RC LEFT.0 Q7"1: 7 SUPS �,� ,4•r+� « ftD{! BUT USE AFTER Patient Name DOS MR# Contra Costa County detention Facilities (Utl1 tSTRATIC?N ALLU ANC PERMISSIOR TQ CARRY MEGs ATIC)N 1. You are responsible for keeping your medication secured at each facility. 2. You are to take the medications as written on the medication package. Med/schedule Med/schedule 3. Do not trade or sell your pills to other people.This can cause permanent damage or death. 4. if you have any problems with or questions about your medicine, notify the Deputy or nurse or put in a sick call slip. 5. If the FNP 1 MD changes your medication, you will need to turn in your old pills before receiving the new. 6. If you are rebased before you finish your pills, take them with you and continue to take them as directed until they are gone. is if you go to court, you may keep the pills in your pocket with this permission paper. 8 If you do not follow these rules, you will be referred to custody. 6: There will be periodic spot checks by medical and custody. 14. If you want your medication renewed, put in a Sick Call slip 3-4 days before you need more_ medication. Allergies I have read and nde tand these rules an Instructions. r F Pat:crit Signature Date ¢ Reviewed side effects snd ca traIndications. f Nurse's signature ' ,t '''' Da /}< { to It authorizes you to carry the medicines listed until /JJ/j ✓(Ji :�+�"' }}• �yf }{ '' DI fS.BV dill\ a1...+Et 4a.vf 6 Rik`w.GY1Y/14. • bfs{44$4-y�{ S m�;k Patient Name - CD .W11 DOBA-- 2- 6.9V mR# � Contra Costa County Detention Facilities SELF-ADMI ISTRAIION RIJI�E A:ND _PERIV_I_l_;SSION TQ CARRATION 1. You are responsible for keeping your medication secured at each facility. 2. You are to take the medications as written on the medication package. Med/schedule (,l Med/schedule cLed 3. Do not trade or sell your pills to other people.This can cause permanent damage or dgwb. 4. If you have any problems with or questions about your medicine, notify the Deputy or nurse or put in a sick call slip. 5. If the FNP 1 MD changes your medication, you will need to turn in4our old pills before receiving the new. 6. If you are released before you finish your pills, take them with you and continue to take them as f . directed until they are gone. If you go to court, you may keep the pills in your pocket with this permission paper. S. If you do not follow these rules, you will be referred to custody. 9. There will be periodic spot checks by medical and custody.. 10. If you want your medication renewed, put in a Sick Call slip 3-4 days before you need more medication. Allergies I have read and u erstand these rules and Instructions. . Patient Signature g Date Reviewed side effects and, contraindications. Nurse's Signature Date -)�-g-03 WETHISPAPER l� It authorizes you iv carry the medicines listed until J }S h 4 t f3fi$7'i�tBUTEtjN' 1Efit,11 PINK M$bDC.iL # Y 4<< . i ARIA{ CLAIM P RVi O OF ONTRACOSTA COUNTY BOARia ACTION: AUGUST 1.2, 2001 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), give; Pursuant to Government Code Section 913 and . 915.4. Please note all"Warnings". AMOUNT. UNKNOWN CLAIMANT: LAWRENCE .J.' STILES ATTORNEY: UNKNOWN DATE RECEIVED: JULY 16, 2003 ADDRESS: 1.837 ATHENS DANE BY DELIVERY TO CLERK ON: ,JULY 1.6, 2003 ANTIOCH, CA 94509 BY MAIL POSTMARKED: 114ND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS Bated: JULY 16, 2003 By: Deputy.. II. FROM: County Counsel TO: Clerk of the Sward of Supervisofs This claim complies substantially with Sections 910 ares -10.2. { ) 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). i ( } 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). { } Cather: Date A M Deputy County Counse y III. FROM: C rk of the Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IV. B ORDER: By unanimous vote of the Supervisors present: { This Claim is rejected in full. { } ether: I certify that this is a true and correct copy of the Board's Carder entered in its minutes for this date. Dated: �- 4 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sec on 913) t Subject to certain exceptions,you have only six(6)months from the date this adtice was personally served or depos4ec in the mail to.Dile a court action on this claim. See Government Code Section 945.6. You may seek the advice of an ' attorney ofyour choice in connection with this matter. If you want to consult an attorney, you should do so immediate!x. *.For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty ofperjury that I am now, and at all times herein mentioned,have been a citizen of the United'! States, over age IS; 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. OHN SWEETEN, CLERK.By Deputy Clerk's Cla im to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS'TRUC'TIONS TO CL.ATMANI' A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the 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 or ) .. 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 $ and in support of this claire represents as follows: 1. WY ,en did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How dial the damage or injury occur? (Cave full details; use extra paper if required) r k)/tS rlj -7 � T" c7"- -r a�r4' %r-,,,5P.O10,I� Z�� 4. What particular act or omission on the part of county or district officers, servants or .employees caused. the.injury or damage? WASIJ '7' Z_0.1a/W 4 7 1-,4,04 `- ,i'a-7— S&Z> c_J 5Z-0,k,>14)4� (over) 5. wnat are the names of county or district officers, servants or employees causing the damage or injury? s` `j� f I!- 6. p 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for -a todamage. 7. How was the amount claimed above computed? (include the estimated amount of any prospective injury or damage.) - - ' --------_...__-__.___------..�...._._....__.........�__ _..........�.. ......__....___.._.r.__--_ 9. Names and addresses of witnesses, doctors and hospitals. E- ---- - -_.._—----- List the expenditures -_Listtheexpenditures youmadeon account of this accident or injury: DATE Date: 7115108 01:52 PM Estimate ID: 6713 Estimate Verson: 0 Preliminary Profile ID: Mitchell SIMPLY SUPERIOR AUTO BODY 2110 Market Street Concord,CA 94520 (925)$80-6946 Fax: (925)680-6961 Tax ID: 94-2909061 BAR#: AB107867 EPA#: CADS81368590 Damage Assessed By: Lezcano Rich Deductible: UNKNOWN Owner LARRY STILES Address: 1837 ATHENS LN ANTIOCH,CA 94509 Telephone: Home Phone: (925)706-9417 Mitchell Service: 915495 Description: 2001 GMC Pickup Sierra 02500 HD SL Body Style: 40 PkupXCb 8`Bed 157'WS Drive Train: 8.1L Inj 8 Cyl 2WD VIN: 1 GTHC29G01 E335630 Mileage: 23,231 ***SPECIAL PARTS NOTICE: All crash parts on this estimate are "neva" original equipment manufacturer parts, unless otherwise specified. Parts described as rechromed, recored, remanufactured, or reconditioned are considered "rebuilt" parts. Crash parts described as "quality replacement part" are non--original equipment manufacturer aftermarket new parts. "**** Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 503614 BDY REMOVEIREPLACE TRAILER HITCH 12497988 GM PART 194.29 0.5 2 AUTO BDY OVERHAUL REAR BUMPER ASSY 1.2 3 501885 BDY REMOVE/REPLACE REAR BUMPER FACE BAR ORDER FROM DEALER 392.56 INC ESTIMATE RECALL NUMBER: 7115/03 13:52:35 6713 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_03_A Copyright(C)1984-2002 Mitchell International Page 1 of 2 UltraMate Version: 4.8.012 All Rights Reserved Date: 7/15/03 01:52 PM Estimate 10: 6713 Estimate Version: 0 Preliminary Profile ID: Mitchell Add1 Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body 1.7 72.00 0.00 0.00122.40— Taxable Parts 566.95 Sales Tax @ 6.250% 48.42 Non-Taxable Labor 122.40 Total Replacement Parts Amount 635.37 Labor Summary 1.7 122.40 Ill. Additional Costs Amount IV. Adjustments Amount Total Additional Costs _., 0.00 Customer Responsibility 0.00 1. Total Labor: 122.40 Il. Total replacement Parts: 635.37 lit. Total Additional Costs: 0.00 Gross Total: 757.77 1V. Total Adjustments: 0.00 Net Total: 757.77 This is a preliminary estimate. Additional charges to the estimate may be required for the actualre-pal WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could contain an undeployed stage. When disposing of a deployed dual-stage air bag,always treat it as a"live"module. See appropriate MITCHELLID AIR BAG SERVICE&REPAIR MANUAL,or OEM information. ESTIMATE RECALL NUMBER: 7115/03 13:52:35 6713 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_03_A Copyright(C)1954-2002 Mitchell International Page 2 of 2 UltraMate Version: 4.6.012 All Rights Reserved v", 1 ., l // ��,c�'1✓; s3.3`i.� s"!' "tYs^rr�/ .J faS' I''�"`�.iE'' / `-- � .�� /::..a`..f'"'�f s">�`E ye`�i•'�....M y+,d'�.,...� � ,,.,.._f G{'�f -:>,, �_s'��- 6�i �f �bl� : Date: 711510312:57 PM Estimate ID: 22960 Estimate Verson: 0 Preliminary Profile ID: Mitchell JIM'S CALIF. AUTO BODY, INC. 1615 W.10TH STREET Antioch,CA 94509 (925)754-7600 Fax: (925)754-3614 Tax ID: 94.2227228 BAR#: AHI 34092 EPA#: CAD983607524 Damage Assessed By: James Maitble JUL Deductible: UNKNOWN Insured: LARRY STILES CONT g GC,1 Address. 1637 ATHENS LANE ANTIOCH,CA 94509 Telephone: Home Phone: (925)706-9417 Mitchell Service: 915495 Description: 2001 GMC Pickup Sierra 02500 HD SLE Vehicle Production Date: 6101 Body Style: 40 PkupXCb V Bed 157"WS Drive Traln: 8.1 L lnj B Cy#2WD VIN: 1 GTHC29G01 E335530 License: 6589688 CA Mileage: 23,211 OEMIALT: O Search Code: None Color: PEWTER "ALL, CRASH PARTS ON THIS ESTIMATE ARE NEW-OEM(ORIGINAL EQUIPMENT MANUFACTURER) UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, OR REMANUFACTURED ARE EITHER RECONDITOINED OR REBUILT. PARTS THAT ARE DESCRIBED AS QUAL REPL PART, AND QRP CAPA, ARE NON-OEM CRASH PARTS. Line Entry Labor Line Item Part Typel Dollar Labor #tem NumbType Operation Description Part Number Amount Units Number _ 1 503614 SOY REMOVEIREPLACE TRAILER HITCH 12497988 GM PART 194.29 0.5 2 AUTO BOY OVERHAUL REAR BUMPER ASSY 1.2 3 501884 BOY REMOVE/REPLACE REAR ADD WITRAILER HITCH INC # 4 501885 BOY REMOVE/REPLACE REAR BUMPER FACE BAR GIRDER FROM DEALER 392.66 INC #-Labor Note Applies Add'l Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals #I. Part Replacement Summary Amount Body 1.7 63.00 0.00 0.00 107.10 Taxable Parts �586.95 Sales Tax @ 8350°10 48.42 Non-Taxable Labor 107.10 Total Replacement Parts Amount 635.37 Labor Summary 1.7 107.10 ESTIMATE RECALL NUMBER: 711510312:57:03 22960 UltraMate Is a Trademark of Mitchell International Mitchell Data Version: JUN_03_A Copyright(C)1994-2002 Mitchell International Page 1 of 2 UltraMate Version: 4.8.012 All Rights Reserved Date: 7/15103 12:57 PM Estimate ID: 22960 Estimate Version: 0 Preliminary Profile ID: Mitchell Ili. Additional Costs Amount IV. Adjustments Amount Total Additional Costs 0.00 Customer Responsibility 0.00 1. Total Labor: 107.10 it. Total Replacement Parts: 635.37 Ill. Total Additional Costs: 0.00 Gross Total: 742.47 IV. Total Adjustments: 0.00 Net Total: 742.47 This is a creiiminary estimate. AUTHORIZED AND ACCEPTED. You are hereby authorized to make the above specified repairs, I understand that payment in full will be due upon release of vehicle, including additional supplemental damage charges, and hereby grant you and/or your employees, permission to operate the car, truck or vehicle herein described on street, highways or elsewhere for the purpose of testing and/or inspection. An expressed mechanic's lien is acknowledged on above car, truck or vehicle equal to the amount of repairs thereto, You will not be responsible for loss or damage to vehicle or articles lost in vehicle in case of fire, theft, accident or any other cause beyond your control. ALL OLD/DAMAGED PARTS REMOVED FROM VEHICLE WILL BE DISPOSED OF UNLESS REQUEST OTHERWISE PRIOR TO REPAIRS. ******* NO CREDIT CARDS ACCEPTED ***** REPAIRS AUTHORIZED BY DATE WARNING: Accidental air bag deployment is possible. Personal injury may result. Avoid area near steering wheel and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could contain an undeployed stage. When disposing of a deployed dual-stage air bag,always treat It as a"live"module. See appropriate MITCHELLS AIR BAG SERVICE&REPAIR MANUAL,or OEM Information. ESTIMATE RECALL NUMBER: 7/1510312:57:03 22960 UitraMate is a Trademark of Mitchell International Mitchell Data Version: JUN 03_A Copyright(C)1994-2002 Mitchell International page 2 of 2 UltraMate Version: 4.8.012 All Rights Reserved CLAIM OFCOTS,-TBA C© T C} NT"Y Claim Against the County, or District Governed by ) the Hoard 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 Hoard of Supervisors, (Paragraph IV below), gig Pursuant to Government Code Section 913 and p=, 915.4. Please note all"'turnings". AMOUNT: UNKNOWN { CLAIMANT: SHANNON E. REA/JOSEPH N. PATTON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 16, 2003 ADDRESS: 752 SHELL AVENUE #5 BY DELIVERY TO CLERK.ON: JULY 16, 2003 MARTINEZ, CA 94553 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOIN' SWEETE , IL.,,.— Dated: JULY 16, 2003 By: Deputy II. FROM: County Counsel TO: Clem of the Board of Supervisors This claim complies substantially with Sections 910 an 10.2. { } 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 fled. 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: r Dat'd: B' D uty County Coun III. FROM: �JkofthoBoard 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 fhll. { } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOIN SEETEN, CLERK,lay , De pu!yClerk WARNING(Gov. code section 913. Subject to certain exceptions;you have only six(6)months from the date this ndtice was personally served or deposit+ 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 full; prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN SWEETEN,CLERK,By De uty Clerk Clain to: BARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAI}4ANT 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 Bch 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 5911.2.) 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 roust 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 } j orKI /k ) .._: Ell. in name) District The undersigned claimant hereby manes claim against the County of Contra Costa or the above-named District in the sum of $ t�' ;, ,rE and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Whe4 did the damage or injury occur? (Include city and county) -{.f+Y.:iii� ;. ..��-- � 4 3. How dial the damag4 or injury occur? (Give full details; use extra paper if r required) 4.' What particular act or omission 'on ihe part of county or district officers, servants or.employees caused. the injury or damage? (over) Wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or i uries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on accouA o this accident or injury: DATE ITEM AMCUIrL f ^'JL6 "" '� ^v` 0.«.d YJ�f...r. +'*�..4. "4.- � 9 ✓f Py..."� .J�,✓j24 Go"d. Code Sec. 91M provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or• some 2erson on his. behalf." Name and Address of Attorney (ClaimantYs s Signature) � Address 2 j (34553 3 Telephone No. '>.' ` .1,° fi i Telephone No r e ��.,,_ N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than ane-year, by a fine of not exceeding one thousand ($1,000), or by bath 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. " IY- a 1 . ITI An _ t c _ t-lu _ _ � ; -V"ICcf voce.: _ F . e, ( 'Owl 4 Aj Do r O'A .x' ��t__ ckiv a� 3✓� y ' < h .... .. ... .....:... ...... ....... ....... ....... ...... ..... .. _• -s5 •. f Or O� f . yam µ el c a 06 ts bbb •, ....... ................. ...: . ........................................... .. . CLAIM F SUP RYI QRS OF CONTRA COSTA COUNTY E0ARD AC'T1_QN: AUGU-'T 12, 2003= 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), gives Pursuant to Government Code Section 913 and r r =,94 5.4. Please note all"Warnings" t AMOTJNT: Excess of $25,000.00 CLAIMANT: SHALNL A iANEE HAMBLIN "`N�1" ATTORNEY: STEVEN R. FAIRES DATE RECEIVED: DULY 11a,, 2003 ADDRESS: LAW OFFICES OF STEVEN R. FAIRES BY DELIVERY TO CLERK ON: JULY 18, 2003 2175 N. CALIFORNIA BOULEVARD, S`1'E.575 WAL,NUr GREEK, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN,- Dated: JULY 18, 2003 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Super•vis- This claim complies substantially with Sections 910 an&Q 10.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated: 7 `fn B : Deputy Count Counse 111, FROM: Cle of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). (IV. ARD 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: ZOOJOHN SWEETEN, CLERK, By , De uty Clerk WARNING(Gov. code secti n 9131 Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depositec 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 ofperjury 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: JOHN SWEETEN,CLERK By Deputy Clerk i I Steven R. Faires (SBN 99639) LAW OFFICES OF STEVEN R. FAIRES 2 2175 N. California Boulevard, Suite 575 :"" Walnut Creek, CA 94596 3 Tel: (925) 937-0600 �� Fax: (925) 937-0601 �1� 4 Attorney for Claimant SHAUNA JANEE HAMBLINSUFVtS(� S 5 G1.�4�KB0A P��STA��• 6 I 7 Claim of 8 SHAUNA JANEE HAMBLIN CLAIM FOR PERSONAL INJURIES 9 (Government Code § 910) VS. 10 COUNTY OF CONTRA COSTA 11 12 1.3 TO THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY: 14 NOTICE IS HEREBY GIVEN, pursuant to Government Code § 910, that the following person 15 claims damages for personal injuries caused by the County of Contra Costa: I 16 Claimant: 17 Shauna Janee Hamblin 853 Dolphin Drive 18 Danville, CA 94526 19 Notice Address: 20 All notices and other communications should be directed to the following address: I 21 j Steven R. Faires j Law Offices of Steven R. Faires 22 i 2175 N. California Boulevard. Suite 575 23 Walnut Creek, CA 94596 24 Circumstances of Accident: i 25 On January 23, 2003, the claimant slipped and fell on a public sidewalk adjacent to the residence j 26 at 865 El Cerro Boulevard, Danville, California. A drainage pipe on the property emptied directly onto the 27 sidewalk, creating a dangerous condition for pedestrians. The claimant is informed and believes that the 28 sidewalk and/or the drainage pipe was under the ownership or control of the County of Contra Costa. 1 CLAIM FOR PERSONAL INJURIES [GOVERNMENT CODE § 9101 I Injuries Sustained. 2 The claimant sustained a fracture of the ankle and other injuries to her body in the accident. She I has suffered physical pain and suffering, impairment of function, emotional distress, mental anguish, 4 loss of earning capacity, and,other general damages. She has incurred medical expenses, loss of income, !i 5 '? and other special damages. �i 6 'lames of Responsible Employee(s): 7 Unknown. 8 `E Amount of Claim: i 9 ? Claimant seeks monetary damages in excess of$25,000.00. This claim would be an unlimited 10 civil case. ll � 12 H DATED: Julyl8, 2003 8, 2003 LAW OFFICES OF STEVEN R. FAIRES ! ! ! 13 `i 14 _ '_ .✓ ✓ STEVEN R. FAIRES 1 Attorney for Claimant 16 SHAUNA JANET~ HAMBLIN 17 j ie I8 r 19 20 21 22 i. 23 :i i! 24 1 I 3 ; 25 i 26 27 i 28 3 !3 2 CLAIM FOR PERSONAL INJURIES [GOVERNMENT CODE § 910] 1 CLAIM B RD OF SUPER ISORS Of CONTRA COSTA COUNTY BOARD ACTION:AU UST 12, 2003 , Maim 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), gives Pursuant to Government Code Section 913 and 915,4. Please note all"Warnings". AMOUNT: $402.91 MICHAEL KHAN CLAIMANT: ATTORNEY: UNKNOWN DATE RECEIVED: JULY 21, 2003 ADDRESS: 388£ VALLEY LANE BY DELIVERY TO CLERK.ON: JULY 21, 2003 EL SOBRANTE, CA 9480.3 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 21 200.3 JOHN SWEET Fk -1 Dated: By: Deputy II. FROM: County Counsel TO Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 10.2. y ( } 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 tate and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: r r Date By: H--h Deputy County Counse III. FROM: JJerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: s 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 -5 JOHN SWEETEN, CLERK., By , Deputy Clerk WING(Gov, code section 913) Subject to certain exceptions, you have only sic(6)months from the date this ndtice 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 per ury 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: 09 JOIN SWEETEN,CLERK.By Deputy Clerk''. 07/21/2003 08:21 FAX 510 233 5544 NEWPORT KEN LAE 0 004 Clain to: BOARD OF SUPERVISORS OF CONTRA COSTA CMM INSTRUCTIONS TO CLAIFCAUT 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 perzSonal property or growing craps 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 =3t be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 551 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. Sae penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp ) ...�._..: M . . a Against the County of Contra Costa )) District) " ' Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the stag of $ yc�Z,qJ and in support of this claim represents -as follows:. 1. When did the damage or injury occur? (Give exact date and hour) ------____-.-__- 2. Where did the damage or injury occur': (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) LrrlIt LtJ©il ��?�:� G� -e us, 4. What Particular act or omission on-the part of county or district officers, servants or .emPloyees caused, the.injury or. damage? 07/21/2003 08:20 FAX 510 233 5544 NEWPORT KEN LAB 12003 » Wnat are the nares of county or district officers, servants or employees causing the damage or injury? » What damage,car injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach .two estimates for auto damage. IT f ` . Naw was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) . 3. Names and addresses of.witnesses, doctors and hospitals. List the expenditures you made on account of this accident or injuryt DATI:'� ITEM AMOUNT y ft YC) r Q Gov. Cade Sec. 910;2 provIdes: "The claim must be signed by the claimant SEND NOTICES TO: (Attorne ) or by some gerson on his.behalf." Name WE Address of Attorney ai mant s s Sigr�ture . Address =L /AO/7 aleV-3 Telephone No. Telephone No.I If ITT IV IF IT � .N0T .1. CE ' Section 72 of the Penal. Code provides: "Every person who, with intent to defraud ,,presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized.to allow or pay the same if .genuine, any false or fraudulent claim, 'bill., account, toucher, 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 imoriscriment and fine; `or by imprisoment in the state prison, by a fine of not exceeding ten thousand dollars ($1},000, or by . both such imprisorment and fine. 07/21/2003 08:19 FAX 510 233 5544 NEWPORT KEN LAB IM002 ROSA Aii�. �� DATE: SANTA 1R OS^ CA 95407 INVOICE #: � PH:(70 ) 52&6700 PAM(M7)528.5722 CUSTOMER TAX 10 N UMBER INSTALL DATE; t j INSTALLED SYS 901.0 TO: 81LL TOs J INSURANCE INFORMATION AAENTs DISPATCH Ss POLICY 09 CLAIM#t; CAUSE OF LOSSs DATE OF LOSS; DEDUCTIBLE: VEHICLE INFORMATION MAIOp; MODEL: yoNC / tt YEAWMf BODY; �' ' ODOMETER: gob LICENSE: � f •� i,� , , � VMS AutolnobHe glass igs warranted against dejects In the glass and worlemanshlp for ars tong as you own or lease the vehicle ltt was Installed In. Back stung gimm Is warranted against defeats and worlunanshlp for two]►e L � Total Parts Total Kh 'fatal Labra Tax Customer Signature TOTAL INVOICE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 6.0 '. BOARD AC'T'ION: AUGUST 12, 2003 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". �:;a 3 1•a3` AMOUNT. UNKNOWN Y CLAIMANT: HEIDI ELLINGSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 21, 2003 ADDRESS: 555 BROOKWOOD COURT BY DELIVERY TO CLERK ON:JULY 21, 2003 BRE MOOD, CA 94513 BY MAIL POSTMARKED: JULY 181 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS 1 Dated: JULY 21, 2003 By: Deputy L4,4a_ II. FROM: County Counsel TO: Clerk of the Board of Supervis rs ),IThis claim complies substantially with Sections 914 and10.2. ( ) This Claim FAILS to comply substantially with Sections 914 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 914.8). ( ) 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: a Dated: ' By: ' Deputy County Course iI III. FROM: Cl 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: WK 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: 24a_:5 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se ion 913) ? Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposfte� in the mail toile a court action on this claim. See Government Code Section 945.5. You may seek the advice of an attorney of ybur 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: sz3JOHN SWEETEN, CLERK By Deputy Clerk Clain to; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSl"1'lUCTICNS M CLATMWr 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 ouch 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 'Beard of Supervisors at its office in Room lC?6, County Administration Building, 651 fine 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 roust 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 { wRECEIVED ) ,Against the County of Contra. Costa ) JUL � Z Os or } OARDJF s, PERViSof,-�_N C0S-,A CO. 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 and in support of this claim represents as follows: 1. When did the damage or inj 5. wnaL 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. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) $. Names and addresses of witnesses, doctors and hospitals. 9. Listtheexpenditures you made on account of this accident or injury: DATE ITEM AIVJNT Gov. Code Sec. 910:2 provides: "The claim must be signlqd by the claimant SEND NOTICES TO: (Attorney) or b me son h'�- f." Name and Address of Attorney t Signature) Lwoc)(J- V " Address Telephone No. Telephone�No.� '3V__ * * * �t F It N 0 T I G E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one.yeart by a fine ,of not, exceeding one thousand ($1,000), or by both such imprisonment and fine;- or by imprisonment in the :Mate prison, by a fine of not exceeding ten thousand dollars ($10,0009 or by both such imprisonment and fine. Heidi Ellingson 555 Brookwood Ct Brentwood, CA 94513 925-634-3379 On Friday July I i, 2003 at 4;30 pm I was traveling from Pittsburgh to Concord on Kirker Pass Rd. There was signs of construction posted that the left lane was closed. l was traveling in the right hand lane, there was a street sweeper vehicle in the left hand lane sweeping the road as I was coming up the hill a rock from the vehicle (Street sweeper)hit my windshield and cracked it. I saw a work vehicle up a head in the lane that was closed and pulled up behind him and got out of my vehicle and approached him. I told him of the incident andasked who was in charge of the construction and he stated that he was an independent contractor and I would have to call the city Monday morning. I asked him for a business card and he claimed he did not have one and reassured me that every thing would be covered by the city and that he was not at fault. I at this time would just like to have my windshield fixed and paid for. If you have any further questions please feel free to give me a call. Heidi Ellingson 925-634-3379 1WHANA 4 DBA LOW { cum 6ALS; AUTO GLASS , 6355 SCARLETT r £ she DUOLIN, CA 04566 ------------- FATE ED 105 34-1077560 my MIKE ELLINGS5N 555 RROOKWOOD CT CA r # 43 e p0my AMORY sun i W All— UST $$Mcrl TOIA# v rY Caifforwa BAR4 AK215355 s i��'�� J'„`,.�tY -7 s�ry� � S`:�v� -.✓,��,}�. ''55yry�"'k,`i Yµw,4 r 55 t,✓ �S:�i t�;.r`S�.fv{..� t�L�'Ur. ._.,...,�,.��._.e�_...._..�.,..-.w.,.,.� _.a... WSPECT YOU?:fs"`"3£L✓LE B}d`.F OiRr N,Ei4.fiOT:AT NO MWty3«wM :fit'... R SFI DNSS B...s.,rI R A �� ,✓"A b e�� k`" ,fi•'.S Ct'' �€"�'._..r�;� ;�.�. ,Lx�=h:-��.�? Gt''dF',,:;fir ,A,'AR .:N 3`Y ON xl � � NO'vVASH aS HOURS, REvOvE E . TAPE N 48 HOUPzS, .MihiEvT4 }0W C RT ✓KEEs FO`4 48 "O': S„ CHP RENO ORs, LID,L'a) '»4 A'ND AR"YE Ntx.DT A �_"+v`£i i�EN.. S' "§ >4� iYt�s;i�,�i`-rn.•--{;."':.,.-..k-.•r-�---^? H...-+ry•-+- y —i.v». Fi L.tv'�1��£#"d`...,:5' 3\J-1.a"t }Z3.�F`:_fA�..' 'xi7L.,}`d 3. . ._.... ...t: 5 t li Omni iE Et £ iS "o ftl esd fur credit, re-lumid, or excrIP—ge restisaWs cwdton, a. ;-.ortzo: got aCo^.x%r ai"Sff3C'�:✓y ...Ia •'f ay::•+3 5u;;;t3f`.E£C}#"£8"L3Ci{ �"C•�:.i't.r of:}'�ii5 C"zf3 Sp;2aiat i;i"li?f£F&S??�3, ' Y credit r;:,3r 5.:3.2 c 3. y. TOTAL P.EGVED 3Y. :» ,.a+;e Cc^�paNv'o c v `A�evo ra:;•sd.R r :r I 0.054",away fos One CLAIM BC?ARD OF SUPEBYI§ORS OF CONTRA COSTA COUNTY BO AR. AC'T'ION- AUGUST '12, 2003, Claim Against the County, or District Governed by ) the Beard 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), givex 4, Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $9,600.00 plus 3� CLAIMANT: ANTHONY E. 'WEARY ATTORNEY: UNKNOWN DATE RECEIVED: JULY 23, 2003 ADDRESS: 41.4 DIMM STREET BY DELIVERY TO CLERK ON: JULY 23, 2003 RICHMOND, CA 94805 BY MAIL POSTMARKED: JULY 18, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETS e Dated: JULY 231_2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Superviso s (i� This claim complies substantially with Sections 910 and*6�;1O.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). 0-)( Other: . t---'---'"y�1' _ � ..- w.�. i•�-{�, �w vi1.4r ��+�,'i,.� '"� 'r.,y-,::w - �ve' i4.~ `'lSdCs.ie�. 's•z�'' � "` R.Y�.c�a'.�� .��.�`�'�':�+ Dated: By: / - County Counse III, FROM: Clerk of the Board TO: County Counsel 1) County Adminit4tor(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV, OARD ORDER: By unanimous vote of the supervisors present: This Claire 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:C �Sg JOHN SWEETEN, CLERK., By , Deputy Clerk WARNING(Gov. code section 913) ' Subject to certain exceptions, you have only six (6)months from the date this ndtice 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. Bated: JOHN SWEETEN, CLERK By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS JO C 'A. 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 before December 31, 1987, must be presented not later than the I Oe 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 ca `of action. (Gov't Code 911.1) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Cnonty 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 21 is M rvVe-ti�_q6 Against the County of Contra Costa or 3 tyi cf,L t-District) Q 003 �(Fill in name) two tI ac. M The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district inthe sum ofSq,6M..G:) and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) ZZ-v '2- 2-6 t 2. Where did the damage or injury occur? (Include city and county) 44 1 Lt + is Q Cit t7r,h,-k-cL C-f;,-5*3-Cc�(t�-t 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? " s tZ i aL,kY "' ( S. What are tie names f county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) L "`3's e L o otic -i -4 i o,0C� X ke,i",CS. " 1„0 L ide- Pej ,tb �;ct ... ply+e�" 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ^...s+.{::.e 11 i,.. 44-,e- t"�i � f C'-£"-i''~ *S : `L. s-r,`' Cx c- C4iw' � 's''�:T iC'i' !:tlr•s_ t .. F-tby'8-f C j}z?,:.. 8. Names and addresses of witnesses,doctors, and hospitals. 0 e-to co-- L.ec-- N eA W c: =(-y 01 rr\re 6+ -- A<Jk,sem)�-k ct; - . 9. List the expenditures you made on account of this accident or injury. DATE T E AMOM Gov. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SEND NC}TICE�TO: (Atter Name and Address of Attorney ) } V (ClaimantYs SignatureV ¢(Add s) P tki 44 C V1 5 Telephone No. }Telephone No.,),-- NO'nCE Section 72 of the Petnal 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(S 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(S 10,000),or by both such imprisonment and fine. s bn"';'`E L {r ... et 5F S f.J. i�i:.r L F L .A�C�:1,+3 d A Z tf. +1 •{..A.i y 4✓ f..+l.a.F .. �� { �'S�.,C'.�.�t�•L t "�`f �i".�., �,�•i'{.�i 4 1Y1 "�"�v s �'��`�C`"•j t1 �" ^-i� s`��t...� C.'i�-�?.-�(tib.�t`"':�. �s S�.% C'."�`'�'�. 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CLAIM BOARD OF SUPE VI ORS OF CONTRA COSTA COUNTY BOARD ACT N: AUGUST -12,---200 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". Y t AMOUNT: $1,493.70 F CLAIMANT: NEl3 ERTARI ROYSTON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 24, 2003 ADDRESS: 419 E. 12th STREET BY DELIVERY TO CLERK ON: JULY 24, 2003 PITTSBURO, OA, 94565 BY MAIL POSTMARKED: JULY 23, 2003 FROM: Clem of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEJerk Dated: JULY 24, 2003 By: Deputy II. FROM: County Counsel TO: Clem of the Board of Supe isors {4This claim complies substantially with Sections 910 andm%l0.2. { } 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: s� Dated ! l r ,>>,. Byr - ✓ r. -Daper`rty County Counse 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. ARD ORDER: By unanimous vote of the Supervisors present: (k� This Claim is rejected in full. { } other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: , q JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING{Gov. code section 913} Subject to certain exceptions, you have only six {6} months from.the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 9456. You may seek the advice of an attorney of yiaur 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: JOHN SWEETEN, CLERK By Deputy Clerk'. Clain to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAD-IAN'T 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 craps 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 fine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the Warne 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 pe i lty 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 � LR ECE 2 2003 District) A �3i^10. `ill In t'ERe_ The undersigned claimant hereby makes claim pgai t the County of Contra Costa or the above-named District in the sum of $ grid in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Y i icy if ice. ^ f3 w Y 2. Where`idid the '� e or injury occur. (Include city and county) u.s......n+.+. � 4.+w`w++wswr ' .res + +..�....r.�.�,...a...w.....�....w....,.. 3. Howe did the` damage or injury occur? (Give Puli details, use extra paper if required) 4. What particular act or omission !fin the part of county or district officers, servants or .employees caused. the.injury or damage? (over) 5. wnat are the names of county or district officers, servants or employees causing the damage or injury? .r�..�.....� +.r_.r__..�.��.raw... _.....�..,_r_._...r....`.+r_...r o,..nr_�...ir.....wrrw.w ...��...r......._....._.,. 5, What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. n r'T ..x 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) l 8. Names and addresses of ,'itnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injuryz DATE ITEM A"MINT Gov. Code Sec. '910.-2 provides: "The cl im must be signed by the claimant SEND NOTICES TO: (Attorney) or erson o. is behalf." Mane and Address of Attorneyh' - r` (ClaiOdntIs Signature Address > f L.) Telephone No. Telephone No. f � �# . N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one-year, by a fine of not exceeding one thousand ($1,1100), 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. 07/22/2003 at 06:58 AM rile ID: 3066 43738 ROCHA.T & SMITH APPRAISAL Alamo Office PO BOX 836 Alamo, CA 94507 (925)820-5319 Fax: (925)820-8455 Written by: Rich Myers #43738 07/22/2003 06:58 AM For: CONTRA COSTRA COUNTY RISK MANAGEMENT - Adjuster: PENNY BAILEY # ESTIMATE OF RECORD Insured; CONTRA COSTA COUNTY Claim #53717P Owner. NEFERTARI ROYSTON Policy #2003-1147 Address; 415 E. 12TH ST. Date of Loss: 07/07/2003 PITTSBURG, CA 94565 Type of Loss: Collision Evening: (925)435-3080 Point of Impact: 12. Front Inspect 415 E. 12TH. ST. Evening: (925)439-3080 Location. PITTSBURG, CA 94565 :TOME Repair NO SHOP CHOICE Days to Repair Facility; License # 1994 SATU SL2 4-1.9L-FI 4D SET} WHITE PRL Int:GRAY VIN, lG8ZK5570RZ353152 Lic: 5BDT865 CA Prod Date: Odometer: 72944 Air Conditioning Rear Defogger Tilt wheel Intermittent Wipers Tinted Glass Body Side Moldings Dual Mirrors Clear Coat Paint Power Steering Power Brakes Power Windows Power Lacks AM Radio FM Radia Stereo Driver Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats Automatic Transmission Overdrive Aluminum/Alloy Wheels -------------------------------------------------.--_------_----__--__--_--_--- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ----------------..--_----__-__-_----..__--_-__--__--_--_---_-----_---__-_---_--_- 1 FRONT BUMPER 2 Refinish Components 3.6 3 Repl Upper cover 1 150.08 1.5 Incl. 4 Repl Lower cover SL2, SW2 1 192.45 Incl. incl. 5 Repl License bracket SL2, SW2 1 16.61 0.3 6 Repl Emblem 1 7.97 0.2 7# COLOR. MATCH 1 0.5 8# FLEX ADDITIVE 1 8.00 9# HZRD WST 1 3.00 ------------------------------------------------------------------------------- Subtotals =_> 378.11 2.5 3.6 1 07/22/2003 at 06:58 AM File ID: 3065 43738 ESTIMATE OF RECORD 1994 SATU SL2 4-1.9L-FI 4D SED WHITE PRL Int:GRAY Parts 378.11 Body Labor 2.5 hrs @ $ 65.00/hr 162.50 Paint Labor 3 .6 hrs @ $ 65.00/hr 234.00 Paint Supplies 3.5 hrs @ $ 28.00/hr 100.80 ---------------------------------------------------- SUBTOTAL $ 875.41 Sales Tac $ 478.91 @ 8.2500% 39.51 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 914.92 ADJUSTMENTS: Deductible 0.00 TOTAL ADJUSTMENTS $ 0.00 NET COST OF REPAIRS $ 914.92 THIS IS NOT A REPAIR ESTIMATE. OWNER MUST AUTHORIZE REPAIRS. NO SUPPLEMENT WITHOUT PRIOR AUTHORIZATION. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT, PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RELY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/_ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE ;.,INE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DE8IB91 Database Date 5/2003 and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-original Equipment Manufacturer aftermarket parts are described as AM, Qua! Repl Parts or Comp Repl Parts which stands for Competitive Replacement 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 W items indicate manual entries. Pathways - A product of CCC Information Services Inc. 2 _ .. ....._ ........ .. .......... _. .... _ ........ ........ ........ ......... .__ UNITED AUTO BODY Federal Tax 10: 68-0181576 430 E. 10TH STREET Customer No: 450 Estimate Pittsburg, CA 94565 Report No: 447 7/9/2003 Phone#: (925)427-6609 Claim* Fax* (925)427-4373 Assign No: --__ E-Mail: UNtTEDAS430@AOL.COM Vehicle Information Owner-Mefertarl Rayaton Accident Location 1994 Saturn Sedan (SL) 419 E 12 th st. Style: 4d Touring Sdn Sit Pittsburg, CA 94565 Color: Home Phone: (925)439-3080 Color Code: Work Phone: (925) - Phone#1: - Production Date: /0 Fax* (925) - Phone#2: - License: State: CA Insured - Claimant- VIN: 1 G8ZK5570 RZ353152 Miles In: 0 Miles Out: 0 Home Phone: (925) - Home Phone: (925) - Condition: Work Phone: (925) - Work Phone: (925) - Estimator: TIM Fax* (925) - Fax* (925) - Date Assigned: 719/2003 Date of Loss: 7/9/2003 Date of Inspection: 7/9/2003 Description of Work Part Number Price Labor Paint Other FRONT BUMPER-BUMPER&COMPONENTS Overhaul bumper asst' 2.4 body Replace Front Bumper Upper cover 21080801 $144.31 Included 2.0 +Clearcoat(0.8) 0.8 Replace Front Bumper Lower cover, SL2, SW2 21095608 $185.05 included 2.3 +Clearcoat(0.9) 0.9 Replace Front Absorber 21094985 $57.53 Included Replace Front License bracket, SL2, SW2 21095944 $15.97 0.3 body Replace Front Emblem 21111139 $7.66 Included FRONT LAMPS-HEADLAMP COMPONENTS Right Front Headlamp assy 21110140 $168.84 0.3 body R&I Right Front Headlamp assy 0.3 body Other omraffons ' Hazardous Waste Disposal $5.00*taxed ' Cover car for paint Sub Tof;ls . $5.00*taxed . **IN BUSINESS SINCE'96** **STATE LICENSE#AM219400** Hours Rate Total Body Labor 3.3hrs $60.00/hr $198.00 t THANK YOU FOR LETTING US SERVE YOU AT UNITED AUTO Paint Labor 4.3hrs $60.00/hr $258.00 t BODY WHERE THE QUALITY IS STANDARD, AND MINUTES Clearcoat Labor 1.7hrs $60.00/hr $102.00 t COUNT. OEM Parts $579.36 t Body Supplies 3.3hrs $25.00/hr $82.50 t Paint Supplies 4.3hrs $25.00/hr $107.50 t Clearcoat 1.7hrs $25.00/hr $42.50 t Misc Taxed $10.00 t Tax $1379.80 8.2500% $113.84 Grand Total $1,493.70 Estimate based on MOTOR CRASH GUIDE(DEBIB911. 3102 Indicates Estimators Judament #Indicates Taxed Item The above is an estimate based on our inspection and does not cover any additional parts or labor which may be required after the work has been opened up. Occasionally after work has started,worn or damaged parts are discovered,which are not evident on the first inspection. Because of this the above prices are not guaranteed, and are for immediate acceptance. Page f of 9 Date: 711710312:46 PM Estimate ID: 22977 Estimate Version: 0 Preliminary Profile ID: Mitchell JIM'S CALIF. AUTO O BODY, INC. 1615 WAOTH STREET Antioch,CA 94509 (925)754-7600 Fax: (925)754-3614 Tax ID: 94.2227228 BAR M AH134092 EPA#: CAD983607624 Damage Assessed By: James Maitbie Deductible: UNKNOWN Insured: NEFERTARi ROYSTON Address: 419 EA2TH STREET PITTSBURG,CA 94565 Telephone: Home Phone: (925)439-3080 Mitchell Service: 912101 Description: 1994 Saturn SL2 Body Style: 4D Sed Drive Train: 1.9L Inj 4 Cyl AT VIN: 1GSZK557ORZ353162 License: 5BOT865 CA Mileage: 72,646 OEMIALT: O Search Code: None Color: PEARL WHITE "ALL CRASH PARTS ON THIS ESTIMATE ARE NEW—OEM(ORIGINAL EQUIPMENT MANUFACTURER) UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, OR REMANUFACTURED ARE EITHER RECONDITOINED OR REBUILT. PARTS THAT ARE DESCRIBED AS QUAL REPL PART, AND QRP CAPA, ARE NON—OEM CRASH PARTS. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description _ Part Number Amount Units 1 — AUTO REF REFINISH FRT BUMPER COVER COMPLETE C 3.0 2 201060 BOY REMOVEIREPLACE FRT UPR BUMPER COVER 21080801 144.31 1.6 # 3 201096 BOY REMOVE/REPLACE FRT LWR BUMPER COVER 21895508 185.05 INC # 4 201279 BOY REMOVEIREPLACE FRT BUMPER LICENSE BRACKET 21095944 15.97 INC 5 200039 BOY REMOVEIREPLACE FRT BUMPER EMBLEM 21111190 7.66 INC # 6 201610 BOY CHECKIADJUST HEADLAMPS 0.4 7 202074 BOY REPAIR HOOD PANEL Existing 0.2* 8 AUTO REF REFINISH HOOD OUTSIDE C 2.8 9 900500 BDY* REMOVE/REPLACE FLEX ADDITIVE **Qua]Repl Part 8.00* 0.0* 10 900500 BDY* ADO'L LABOR OP CHECK&ADVISE NOISE IN FRONT END Existing 0.4* 11 933003 REF ADO'L OPR TINT COLOR 0.5* 12 AUTO REF ADUL OPR THREE STAGE 3.2 13 933018 REF ADO'L OPR MASK FOR OVERSPRAY 0.4* 14 AUTO ADD'L COST PAINT/MATERIALS 256.50 15 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 7.00 ESTIMATE RECALL NUMBER: 711710312:46:30 22977 UltraMate Is a Trademark of Mitchell International Mitchell Data Version: JUN 03–A Copyright(C)1994-2002 Mitchell International Page 1 of 3 UltraMate Version: 4.8.012 All Rights Reserved Date: 7/17/03 12:46 PM Estimate ID., 22977 Estimate Version: 0 Preliminary Profile ID: Mitchell * -Judgement Item #-Labor Note Applies C -Included in Three Stage Calc Add'I Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 2.6 63.00 0.00 0.00 163.80 Taxable Parts 360.99 Refinish 9.9 63.00 0.00 0.00 623.70 Sales Tax @ 8.250% 29.78 Non-Taxable Labor 787.50 Total Replacement Parts Amount 390.77 Labor Summary 12.5 787.50 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 256.50 Customer Responsibility 0.00 Sales Tax @ 8.250% 21.16 Non-Taxable Costs 7.00 Total Additional Costs 284.66 1. Total Labor: 787.50 II. Total Replacement Parts: 390.77 Ill. Total Additional Costs: 284.66 Gross Total: 1,462.93 IV. Total Adjustments: 0.00 Net Total: 1,462.93 This isa preliminary estimate. AUTHORIZED AND ACCEPTED: You are hereby authorized to make the above specified repairs, I understand that payment in full will be due upon release of vehicle, including additional supplemental damage charges, and hereby grant you and/or your employees, permission to operate the carr, truck or vehicle herein described on street, highways or elsewhere for the purpose of testing and/or inspection. An expressed mechanic's lien is acknowledged on above car, truck or vehicle equal to the amount of repairs thereto, You will not be responsible for loss or damage to vehicle or articles lost in vehicle in case of fire, theft, accident or any other cause beyond your control. ALL OLD/DAMAGED PARTS REMOVED FROM VEHICLE WILL BE DISPOSED OF UNLESS REQUEST OTHERWISE PRIOR TO REPAIRS. ******* NO CREDIT CARDS ACCEPTED ***** ESTIMATE RECALL NUMBER: 7/1710312:46:30 22977 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUN 03 A Copyright(C)1994-2002 Mitchell International Page 2 of 3 UltraMate Version: 4.8.012_ All Rights Reserved CLAIM BOARD OF SUPERVISORS OF C2NTRA COSTA COUNTY BQARD ACTION AUGUST 1,2. 2003 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 F `° 915.4. Please note all"Warnings" •J Y � t• t„d ° -moi AMOTNT 150,000.00 r CLAIMANT: NICHOLS RIOS ATTORNEY: UNKNOWN DATE RECEIVED: JULY 24, 2003 ADDRESS: M.D.F. #2002025280 BY DELIVERY TO CLERK ON: JULY 24, 2403 B - MODULE, ROOM #2 901 COURT STREET` BY MAIL POSTMARKED: JULY 22, 2003 MARTINEZ, CA 94553 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE rk Dated: JULY 24, 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors 4 This claim complies substantially with Sections 910 arAQ, 10.2. ( } 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 claire 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: A Dated: -j > By '? .. - County Counse ! 5 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. CARD ORDER: By unanimous vote of the Supervisors present: ( y 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: OHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions,you have only six (6)months from the date this notice was personally served or deposftec 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. F Dated: — JOHN SWEETEN, CLERK By Deputy Clerk' Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUN INSTRUCTIONS TQ CL 'jU f A. Claims relating to causes of action for death or for injury to person or to pars iftl cif � 1 t7uvin crops and which accrue on or before December 31, 1987, must be presented not after the accrual of the cause of action. Claims relating to causes of action for death or for inlu 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 146, 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: Claire By Reserved for Clerk's filing stamp Against the County of Contra Costa or ) 4 lV:� * &I r, Alf/ District) (Fill in name) e } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sur: of V5_0 � and ire support ofthis claire represents as follows: 1. When d the dar age or injury occur? (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) �A Car ' ', 7� CP ck 3 d' �. i$ ., ol�t .: y'�, ,5 ', SQi'..f.,• fP dp 4,. 4 $ •yam _.._ y d es 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? r: '' <; �� eo 4 , 5. What are the Warnes of county or district officers, servants, or employees causing the damage or injury. �. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach epeel" two estimates for auto damage.) , .. a Vol r ke Ike /NZI e { 7. How was a am unt claimed above corn used. elude tl estimated amount of any prospective injury or damage.) .� 00 " , 8. Names and addresses ofwtt asses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or i jury. DATE d AMMOf Y ,<. All, ' AJC Cy n Gov. Code Sec. 9101.2 provides "The claim must be ,< } signed by the claimant or by some person on his behalf.,' SENDNOTICES TO:, (Alto-my, Name and Address of Attorney ) (Clai inik :s Signature) )J (Address Telephone No. Telephone No. l+OIICE Section 72 of the penal Cade 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 bath 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. x v a� T� ik all o r. G: t .. �ii6'•:� � .... .. ® ,;:`k .....�� G.:' �: l �MY A, �r�'F'f"✓:YY+r � �r� -� .{) •.gyp'- ' k �,r. r... k.. • g ,r ;fi f; r 6 f� Two h � }� 'fy�> ,Y -s°'�� '��f,1�>ti'"� �r Y�';,,�'?' l£w� �f �.L+'l. �::�.G..�."r/� 3��,/?r'`S••� F ....... �+ ^ .r l: /Y�� 2.. ........ { of{v.. C �.�. y... ��. GF3 YGs� <{.}` '' f ;:-Y�•'•� .. - .:F f � a ✓ �vi...'J� i..f ,r Ft�� ✓ y f 4 . t4�.4�. f^ '��.�� '.�~•f: *{• 4.y • +Y'+ a � f Cyt' ){ {. ::�. }:f xG Y t b a{ k ..P�3 �' z... �. {�' .,,.f� .,,�",✓ L�` 3�Y •.,{:. "n::: M >r:..---. a �/<S, .; � �, �fi y % £.aa° r.:kc•-��: •L'.e+^'�'` :.�•�� s : F r { J � yr1 { A; W "PAR f yy � cF y{'•sf•'Y�'•'-a f „,-„. .}��,`. �f f �`,F y' &W +Y” �'..✓ .�%'.....'ow Y R`^ fid.... .•r �S:x.. tu. Y �j 1.0 ,.-•{fes/' .. f} .< t m CLAIM BOARD OF WPER VISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 12, 200.3. 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 CLAIMANT: RELIANT CLAIMS SERVICE, INC. ATTORNEY: UNKNOWN DATE RECEIVED: JULY 25, 2003 ADDRESS: 5237 COLLEGE AVENUE, BY DELIVERY TO CLERK ON: JULY 25, 2003 OAKLAND, CA 94618 BY MAIL POSTMARKED: JULY 18, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 25 2003 JOHN SWEET N Irk Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Superv'sors (),)"This claim complies substantially with Sections 910 and 110.2. { ) 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 � � ��- .,..,�,..f. y: .. _ y County Course r ;F 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: (t<< 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: 62444OHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions,you have only six (6)months from the date this notice was personally served or deposfte( 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 Waming 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: °O"JOHN SWEETEN, CLERK.By Deputy Clerk r i f y tt1 -R.. 's 1:A RELIANT CLAIMS SERVICE, INC. Insurance Adjusting&Claims Services 5237 College Ave.,Oakland CA 94618 Telephone(5110 420-1053 Facsimile(510)420-1176 E-mail:mail@reliantclaims.com EBOARD 03 July 18,2003 VISORS. County ofContra Costa Public Works Department 255 Glacier Drive Martinez,CA 94553 Re: Notice of Claim for Damages Loss Location: Olympic Blvd., 569 feet east of Pleasant Hill Road Date of Loss: March 20, 2003 Insured: Breashears, Barbara CSAA Claim No.: 380517 Dear Madam or Sir: On behalf of Oregon Mutual Insurance Company ("Oregon Mutual"), the subrogated insurer in the above captioned claim,we hereby place you on written notice of Oregon Mutual's claim for damages in an amount as yet to be determined. This claim is for damages relating to a car accident at the above captioned location. The accident involved a tree which we understand is located on Contra Costa County property and which had been marked for removal. (Enclosed please find a map indicating the specific location of said accident). The accident was a direct result of a fallen tree limb blocking the roadway. The tree limb had fallen from a tree previously marked for removal as it, and several other trees in the vicinity, had been deemed hazardous by Contra Costa County. Please note that the insurance claim is still open; therefore the total value of this claim has yet to be determined. This claim will be forwarded to legal counsel in the near future for further pursuit of Oregon Mutual's subrogation rights. However,prior to that transfer, I am authorized to discuss and if possible,resolve this matter. To that end I ask that you please forward this claim to the attention of the appropriate representative of your company, so that we may discuss the claim in further detail. Thank you for your attention and response in these regards. Very truly yours, RELIANT CLAIMS SERVICE, INC. f ohn D.Ratto President/General Adjuster Enclosure: Map indicating accident location cc: City of Walnut Creek Oregon Mutual Insurance Company S r cif t it 'alwid. Vill �� t��Si• r l I 't (j. h 1 r1 S a ,.y i## 1A bi r. t a + �' I t r ?tet - fit S+ t-At •. o tl+ jw all 1i 1 AI.r rel v rl i ` tt ii + t?1 f to tl 1�•Nf 5 4 g x#f.n a r a it fl L,rA' G;i,,, r t t a,t`it`ll I 14 ;,111 "• 1 fl f.i $ ii, , f t 11�. • rs 3 ut{ }+ t ! r yA., w t i S I t s ti i a r ,t..,l' ,,„}i„ t1a r r' u• ,4 9t t i t �5}'11? 1 s .f a '' t I t j,. ,4,1 t 1n'"tk .5 A; 1, t' 1 • t e '6 ` x 7 L� yy q 1 tt is ,6f i i �a i r t '!�I r •�i1.<i�t t•: t I `� I,filii iyi lits. ,iia. I �1 `i v''if�t i 1� �� fi , t fttr X � t?i 3 •'i1h � N �� t a $ � ! ,•r '�' i } t 1 t si'ni' �,�•", t{I t - �x t 4 y i i t !I t x i It}u i`s it thy, y r,tl` !,y i+ f+a t , +sirt�x a' ,�4't•a f h'' 'adi� 1 {` I 1 tsl Vtijlsl#hllt# ( tt z 1 I ri tf iliiSil Ii I r i Ihi Irt SIS {u,$ y iItf }iI t o j r 1+r t t �rilU'trJ!r It9��xi illl r! ` if }} t- s t t x rtqq tyf,Yt t tiT p t I.f +I`` Si5 t I t ray 1 i i'1. 1 t i'#Sy+ -nl t o i i I ,f•„ ,, f Y.fFS �>qt fl.:' ? - .r.0 a f rr „ s ' 4ts a �h y s � t �1ti t tN'S,tl•+r ,Y I fi�'an�!kt i ei r z n + 1ghN, lk ,i, j t.,tiln ;.1, , , f. .1 'ri�'Jl,}, '�'1„ '1+' l,i• •Ii „ ''.hl t 6,f.'i,r�,tii tto,.l ,!t• ,fa' ,�'• I I`S,u�:+ s., ..,�i6 a . � si- �f r Hvi�r" ,�`, ,, {a I� l��i 1t st'AI�•1f ",li�+>.` 1rt r� ` tt,1 t•h,.u.i }L° tr:7M@�",SIYdO?i +S �L fii;kv iiL r;lir Wei, X000 roots SWIVID zvalaw Nooaxo s z 9 o SYg s-oT col f T/r APPLICA110t TO FILE LATE CLAIM „ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA AUGUST 12,, 2003 BOARDACTION 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.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the"WARNING"below. L Claimant: MICHELLE MELLERS { Attorney: MARTIN GLICKFELD n . Address: LAW OFFICES OF MARTIN GLICKFELD 2133 LOMBARD STREET, SAN FRANCISCO, CA 94123 JULY 23, 2003 Amount: $1,000,000.00 By delivery to Clerk on: 1 Bate Received: JULY 23:,.. 2003 By mail,postmarked on: HAND DELIVERED I. FILUM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim.. BATED: JULY 23, 2003 BORN SWEETEN,Clerk,By: DEPUTY 11. FROM: County Counsel TO: Clerk o theBoard of 5upervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) AND MINDED APPLICA TON ( The.Board should deny this Application to File Late Claim(Section 911.6). t DATED: ls B ."� : ?$EPUTSILVANO B.MARCHESI Count Counse III. BOARI,)ORDER By unanimous vote of Super s,oriresent (Check one only) pp fo ( ) This ApplicWt n� �edf 5eJR6). AND AMENDED APPLICATION ( This ApplicationAto File Late Claim is denied(Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE: ' wJOIIN SWEETEN,Clerk,By: DEPUTY 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 Cade Section 945.4 (claims presentation requirement).See Government Code Section 946.5.Such petition must be filed with the court within six(6) months from the date your apl cation for leave to present a late claim was denied. 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. 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. JOHN SWEETEN,Clerk,By: DEPUTY V. FROM: (1)County Counsel (2)County Administrator TO: Clefk 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 .Jul 22 03 12: 25P Clerk of the Beard 925 335 191 RECI TI . Claim to: BOARD OF SUPERVISORS OF CONTRACOSTA COUN JUL 2 3 2003 INSTRUCTIQNS TO CLAIMANT CLERK BOARD OF.t PEWSO 9 CONTRA COSTA CEJ, A. 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 before December 31, 198?, 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 alter January 1, 1988, must be presented not later than six month 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.to Roam 106,County Administration Building, 651 fine 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 } MICHELLE MELLERS ) } Against the County of Contra Costa or } 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 S 1 Million and in support of this claim represents as follows: 1. When did the damage or injury odor?(Give exact date and hour) July 31, 2002, at approximately 9: 00 a.m. 2. Where.did the damage or injury occur?(Include city and county) on Danville Boulevard, approximately 54 feet north of Finley Lane, in an unincorporated area of Contra Costa County .. 3. Haw did the damage or injury occur?(Give full details;use extra paper if required) See "Exhibit A" attached hereto J; Jul 2203 I2z25p Clerk of the Board 925 335 1913 p. 2 d. What particular act or omission on the part of county or district officers,, servants, or employees caused the injury or damage? See "Exhibit A" attached hereto 5. What are the names of county or district officers, servants, of employees causing the damage or injury? Unknown at this time 6. What damage or injuries do you claim resulted?(#".,`rive full extent of injuries or damages claimed. Attach two estimates for auto damage.) Traumatic brain injury 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Traumatic brain injury 8. Nantes and addresses of witnesses, doctors, and hospitals. Discovery is continuing 9. List the expenditures you made on account of this accident or injury. DATE 'TIMEMO 'I Discovery is continuing Gov. Code Sec. 9W provides""The claim must be } signed by thee, ant or by some person on his behalf_" LIM NQMES IQ: Attorn Name and Address of Attorney ) MARTIN GLICKFELD, ESQ. LAW OFFICES OF MARTIN GLICKFELD 2133 Lombard Street } wmant's Signature) San Francisco, CA 94123 } By; Martin Glickfeld, on behalf of Tel: 415-441-7491 } Claimant MICHELLE MELLERS Fax: 415-441-7493 } (Address) } } } Telephone No. )Telephone No. N077CE Smtion fit of the Penal Code pmvides: Every person who,with intern to defraud,presents for allovmnce or the payment to any state board or aflicer,or to any county,city,or district board or officer,authorized to allow or pay the sante if genuine,any false or fi=dWent claim,bili,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(S 1,00),or by both such unprisonrnent and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars CS 10.000),or by both such imprisonment and Race. I MARTIN GLICKFELD, ESE . ' - ` = State Bar Number 95346 R E � ECI 2 LAW OFFICES OF MARTIN GLICKFELD y 2133 Lombard Street y JUL 2 3 2003 3 San Francisco, California 94123 Telephone: 415-441-7491 CLF�#K 4 Facsimile: 415-441-7493;' t. ?. '. ly 5 Attorney for Claimant MICHELLE MELLERS 6 7 8 IN THE MATTER OF THE CLAIM OF } APPLICATION FOR PERMISSION TO MICHELLE MELLERS, } PRESENT LATE CLAIM 9 ) (GOVERNMENT CODE § 911.2) AGAINST, 10 } TO: CONTRA COSTA COUNTY CONTRA COSTA COUNTY } 11 12 I, Martin Glickfeld, declare as follows: 13 1. I am an attorney at law,licensed to practice before the courts of this state and am the 14 attorney of record for the claimant. 15 2. Application is hereby made for permission to present the attached claim after 16 expiration of the time limit provided in Government Code § 911.2. 17 3. The reasons for the failure to present the claim within the time provided in 18 Government Code § 911.2 are as follows: On July 31, 2002,just shy of her eighteenth birthday 19 (August 9), claimant was seriously injured while riding; her bicycle on Danville Boulevard in an 20 unincorporated area of Contra Costa County. Despite due care, she collided with a garbage can 21 negligently placed in the designated bicycle lane in which she was riding. Claimant contends that 22 the County may be liable, for the reasons set forth in the attached Claim. As a result of her fall, 23 claimant suffered a fractured skull and sustained a traumatic brain injury, diagnosed by a Dr. Adey 24 in Walnut Creek. Claimant is still under doctors'care for this injury. This injury has had a profound 25 effect upon claimant,both physically and mentally. Prior to the incident.claimant had been accepted 26 as a student at Cornell University. She attempted to attend school, but because of her mental 27 incapacities, she could not successfully do so and had to leave Cornell and return home. 28 1!1 APPLICATION FOR PERMISSION TO PRESENT LATE CLAIM(GOV'T.CODE§911.2) Page 1 of 2 1 For these reasons,it is requested that claimant be given permission to present this late claim. 2 1 declare under penalty of per ury under the laws of the State of California that the foregoing 3 is true and correct,and that as to those matters set forth on information and belief,I am informed and 4 believe them to be true, and this declaration was executed this 22nd day of July, 2003. 5 7 MAVIN GLICKFELD 8 Attorney for Claimant 9 10 C:\CLIFNTS',MFLLERS\Pieadings\App for Percrossion to File Lace Claimmpd 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 APPLICATION FOR PERMISSION TO PRESENT LATE CLAIM(GOWT.CODE§911.2) Page 2 of 2 "EXHIBIT A"TO CLAIM OF MICHELLE MELLERS AGAINST CONTRA COSTA COUNTY Claimant was riding in a designated bicycle lane with a group of other cyclists on Danville Boulevard. A garbage can was negligently placed in the bicycle lane. Claimant collided with the garbage can and fell and suffered a traumatic brain injury. According to the Police Report, the location ofthe incident was approximately 54 feet north of Finley Lane on Danville Boulevard. This is an unincorporated area of Contra Costa County,and Danville Boulevard is identified as a"county road". The bicycle lane is adjacent to a culvert, which claimant believes may also be County property, The bicycle lane constitutes a dangerous condition of public property. Because it is configured immediately adjacent to the culvert, among other things,there is insufficient or limited ability to take evasive action from foreseeable hazards in the bicycle lane. Accordingly, there is a dangerous condition of property as defined under the applicable Government Code sections relating to dangerous condition of property and such other Government Code sections as may apply to this factual context. Further, claimant is informed and believes that at least one similar accident has occurred and that the County had actual and/or constructive notice of the dangerous condition of its property and/or this particular hazard and,further,that the County has now undertaken steps to pave- over the culvert. In addition, the absence of a sidewalk and/or having had a paved-over culvert increased the probability of garbage cans being placed in the bicycle lane. 07/24/2003 15:00 4154417493 MARTIN GLICKFEL6 PAGE 01 t MARTIN GLICKFELD AYTORNEY AT LAM' A333 4aM$ARa AT FILL-MORE SAN FRAmci=C,CALIFORNIA 94193 YES,irHONE (41tSi{{i-'dp1 PAC®tMtL6 (+etS)441-749S t I t July 24, 2003 I VL ]FACS II LE-; -1913 Clerk of the Board of 411upervisors Contra Costa County Attention: Emy 651 Sine Street Martinez,California 91553 RE: Applic tion for Permission to Present Late Claim.of Michelle Mellers Lodged July 23,2003 Dear Emy: This is to confi our telephone conversation of this date in which you confirmed with me that you received the c rrected first page to the Application for Permission to Pile late Claim which was lodged in this mater yesterday; that it has been made part of that Application; and that no further action is neces ary on my part. I understand tht the,Application has already been set for determination on.August 12,2003 and that you will advi a me thereafter as to whether the Application has been accepted. Thank you ver much for your courtesy. Very truly urs, i 1 t M Glickfeld f MG/ticd Enclosure: As noted a ove CACLYJ6NT3k,VELLMk,YbvaWde*c.A CoCawttyBdo(SupattrQ7.2a.03.wo W1141 L.'Uvj 11:11 41b44114y3 MATIN GLICKFELD PAGE 01 MARTIN G LICKFELD A'1'WORN[Y AY"W It i►LOMDARD AS MI—MORIC DAN IRANCISCO,CAL{MCRNtA*4184 1'BLICPN0Nt; (4i9)441.949/ FACBtM{L& (410)44t.7498 July 24,2003 F J Y 915-335-1911 Clerk of the Board of upervisors Contra Costa County 1 Attention: Erny 651 Pine Street Martinez,California 9 4553 RE: Applicition for Permission to Present.Late Claim of Michelle Mcllers Lodge I July 23,2003 Dear Erny., Yesterday I to ged an Application for Permission to.present Late Claim with your office. Inadvertently, we SWled the caption: as "Application for Permission to Preset Late Claire (Government Code ",when it should say"Application for Permission to Present Late Claim (Government Code )". I imagine that this is not a problem;however,I ane faxing a corrected cover page, I need,to get 1 his takers care of at your early convenience, I am leaving for vacation on Saturday,July 26,ant,will not return to the office until Monday August 4, so I would appreciate it if you could immedia ely confirm for me that all is correct with this Application, Thank you ve much for your courtesy in this regard. Very trul urs, artin Glickfeld MGlticd Enclosure: As noted above C:lcz r�lt+TsA19tL8ttslCa[.wwld. *CoCwwy Dd of$u"s L1.7.24=69-od B7t/t4lLnny 11:11 41�4i1/4y� MAKIIN 1JL1UKPtLV NAUt n'1 1 , 1 i I MARTIN GLI K.FELD, ESQ. State Bar Num et95346 2 LAW OFFIC OF MARTIN GLICKFELD 2133 Lombard treet 3 San.Francisco, alifomia 94123 Telephone: 411-441-7491 4 Facsaxnile: 4154441-7493 5 Attorney for Caimant MICHELLE LLERS 6 � , 7 8 IN THE MATtER OF THE CLAIM OF ) APPLICATION FOR.PERMISSION TO MICHELLE TLLERSI ) PRESENT LATE CLAIM 9 ) (GOVERNMENT CODE § 911.4) AC ST, 10ATO: CONTRA COSTA COUNTY CONTRA COT COUNTY ) 11 12 I,M n Glickfeld,declare as follows: 13 1. I I am an attorney at law,licensed to practice before the courts of this state and am the 14 attorney of rejord for the claimant. 1 15 2. Application is hereby made for permission to present the attached claim after 16 expiration of i he time limit provided in Government Code§ 911.2. 17 3. The reasons for the failure to present the claim within the time provided in 18 Government Code § 911.2 are as follows: On July 31, 2002,just shy of her eighteenth birthday 19 (August 9), c aimant was seriously injured while riding her bicycle on Danville Boulevard in an 20 unincorporated area of Contra Costa County. Respite due care, she collided with a garbage can 21 negligently p ced in the designated bicycle lane in which she was riding. Claimant contends that , 22 the County y be liable, for the reasons set forth in the attached Claim. As a result of her fall, 23 claimant suffered a fractured skull and sustained a traumatic brain injury,diagnosed by a Dr.Adey 24 in.W alnut Cr lt. Claimant is still under doctors'care for this injury. This injury has had a profound 25 effect upon e1 `ment,both physically and mentally. Prior to the incident,claimant had been accepted 1 26 as a student lat Cornell University. She attempted to attend school, but because of her mental r 27 incapacities, he could not successfully do so and had to leave Comell and return home. 28 //I APPLICATION F PERMISSION TO PMENT LATE CLAIM(GOWT.CODE 1411.4) Page I of 2 Jul 03 l 2 a 25p Clerk or the Berard 925 335 1913 P. 1 Claim to: BOARD OF SUPERVISORS OF CONTRAS COSTA COUNTY >INSTRUCIMNI-S TO CL o A. 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 before December 31, 1997, must be presented not later than the 100'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 ofthe cause of action. Claims relating to any other cause of action must be presented not later than one:year after the accrual of the c=ause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its offica in loom 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. Itt�� a**ter.*��r***.*��*******�►** ►**e�*��*�*��::**�#��*��**.��*x�►*�*3« FtE: C arra y Reserved .for Clerk's filing stamp ,hit_ CEELLE MELLERS Against the County of Contra Costa or Jut 9 District) c<i7j"4 y 2003 (Fill in name) -Sr4 cd The undersigned Claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of S 1 Million and in support of this claim represents as follows: I. When did the damage or injury occur?Give enact date and hour) July 31, 2002 , at approximately 9: 00 a.n1. 2. Where.did the damage or injury occur?(Include city and county) on Danville Boulevard, approximately 54 feet north of Finley Lane, in an unincorporated area of Contra Costa County .. 3. How did the damage or injury occur?(Give full details;use extra paper if required) See "Exhibit A" attached hereto J Jul 2q '(33 12:25 Clark sof' th o Bcar�d 325 336 Lerta p.3 4. What particular act or omission on the part of county or district officers;,.servants, or employees caused the injury or damage? See "Exhibit A" attached hereto 5. What are the names of county or district officers,servants, or employees causing the damage or injury? Unknown at this time 6. What damage or injuries dry you claim resulted?(Give full extent ofinjuries or damages claimed.Attach two estimates for auto damage.) Traumatic brain injury 7. How was the amount claimed above computed?(Include the estimated amotutt ofany prospective injury or damage.) Traumatic brain injury S. Names and addresses of witnesses,doctors, and hospitals- Discovery is continuing 9. List the expenditures you made on account ofthis accident:orinjuty: Discovery is continuing ) Gov.Code Ser. 9 IPA provides"The claim must be signed by tlYec, 7 by some;p n on his behalf." SEND NOTICES TO: Attomgy � W Name and Address ofAttotney } MARTIN GLICKFELD, ESQ. LAW OFFICES OF MARTIN GLICKFELD 2.133 Lombard Street ) sitmanCs ipaturee) San Francisco, CA 94123 ). By: Martin Glickfeld, on behf of Tel: 415-441-7491 - Claimant MICHELLE MELLER Fax: 415-441-7493 ) - (Ad&ess) Telephone No. Telep}tone No. NOnCE Section 72 of the Penal Code p vv+s`dw. Every pemn wbo,with intent to defraud,premnts for allowance or the payment to any state board or deer,or to uy county.city,or dais ct board or officer,authorized to allow or pray the:=cc if genuine,any raise or fraudulent claire,bill,ac=mt, voucbcTr or writing,is punishable either by imprisonmcxt its the county,Pjl for a period of not snom than one year,by a f=' of not exceeding ding one tho sand(S 1,000).or by both such imprisonmew and fore;or by imprisonment in the state pr isoa,by a fte of not cxcec d ng ten thousand dollars(S I S?.000)�or by both such imprisonment and fine, 1 MARTIN GLICKFELD, ESQUIRE State Ear No. 95346 2 LAW OFFICES OF MARTIN GLICKFELD 2133 Lombard at Fillmore =' 3 San Francisco, CA 94123 Telephone: (415)441-7491 c Y 4 Attorney forClaimant 4�ns MICHELLE MELLERS 6 7 8 IN THE MATTER OF THE CLAIM OF } AMENDED APPLICATION FOR MICHELLE MELLERS, } PERMISSION TO PRESENT LATE 9 ) CLAIM(GOVERNMENT COBE AGAINST ) SECTION 911.4) 10 ) CONTRA COSTA COUNTY ) TO: CONTRA COSTA COUNTY" 11 } 12 ) 13 ) 14 15 1, Martin Glickfeld, declare as follows: 16 1. 1 am an attorney at law, licensed to practice before the courts of this state and am the 17 attorney of record for the claimant. 18 2. Application is hereby made for permission to present the attached claim after expiration 19 of the time limit provided in Government Code section 91.1.2 20 3. This is an Amended Application.The original Application was lodged on or about July 23, 21 2003. We subsequently lodged a correction to the first page of that application. Upon further 22 consideration we wish to amend Exhibit A attached to the proposed claim submitted with the 23 original application. Accordingly, this Amended application has as an attachment the Amended 24 claim proposed to be filed. 25 4.The reasons for the failure to present the claim within the time provided in Government Code 26 sec 91.1.2 are the same as identified in the original Application,to wit,: On July 31,2003,just shy 27 of her eighteenth birthday(August 9), claimant was seriously injured while riding her bicycle on 28 1 I Danville Boulevard in an unincorporated area of Centra. Costa County. Despite due care, she 2 collided with a garbage can negligently placed in the designated bicycle lane in which she was 3 riding. Claimant contends that the County may be liable, for the reasons set forth in the attached 4 Amended Claim.. As a result of her fall, claimant suffered a fractured skull and sustained a 5 traumatic brain injury,diagnosed by a Dr.Adey in Walnut Creek.Claimant is still under doctors' 6 care for this injury. This injury has had a profound effect upon claimant, both physically and 7 mentally.Prior to the incident,claimant had been accepted as a student at Cornell University. She 8 attempted to attend school, but because of her mental incapacities, she could not successfully do 9 so and had to leave Cornell and return home. 10 For these reasons, it is requested that claimant be given permission to present her amended 11 late claim. 12 I declare under penalty of perjury under the laws of the State of California that the foregoing 13 is true and correct, and that as to those matters set forth on information and belief,I am informed 14 and believe them to be true, and this declaration was executed this 25th day of July 2003 at San 15 Francisco, California. 16 Dated: July 25, 2003 Respectfully su itted, 17 18 By: M TIN GLICKFELD 19 A tom ey for Claimant 20 21 22 23 24 25 Marshall"F-D.BRIEF 26 27 28 2 "EXHIBIT A"TO AMENDED CLAIM OF MICHELLE MELLERS AGAINST CONTRA COSTA COUNTY Claimant was riding in a designated bicycle lane with a group of other cyclists on Danville Boulevard.. A garbage can was negligently placed in the bicycle lane. Claimant collided with the garbage can and fell and suffered a traumatic brain injury. According to the Police Report, the location of the incident was approximately 54 feet north of Finley Lane on Danville Boulevard. This is an.unincorporated area of Contra Costa County,and Danville Boulevard is identified as a"county road". The bicycle lane is adjacent to a culvert, which claimant believes may also be County property. The bicycle lane constitutes a dangerous condition of public property. Because it is configured immediately adjacent to the culvert, among other things,there is insufficient or limited ability to take evasive action from foreseeable hazards in the bicycle lane. Accordingly, there is a dangerous condition of property as defined under the applicable Government Code sections relating to dangerous condition of property and such other Government Code sections as:may apply to this factual context. Further, claimant is informed and believes that at least one similar accident has occurred and that the County had actual and/or constructive notice of the dangerous condition of its property and/or this particular hazard and,further,that the County has now undertaken steps to pave- over the culvert. In addition, the absence of a sidewalk and/or having had a paved-over culvert increased the probability of garbage cans being placed in the bicycle lane.Claimant is informed and believes that the County had actual and/or constructive notice that garbage cans were being placed in the bicycle lane on Danville Boulevard presenting a hazard to cyclists. The County had a duty under these circumstances to protect users of the bicycle lane from injury caused by such hazards associated with the use of its property and bicycle lane including but not limited to taking measures to instruct property owners or the garbage company or otherwise ensure that cans would not be placed in the bicycle lane and/or to provide adequate protections or warnings to users of the bicycle lane.