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HomeMy WebLinkAboutMINUTES - 08102004 - C9 CLAIM �• � BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 'BOARD ACTION:AUGUST 1.0, 20104`` 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 4,. Board of Supervisors. (Paragraph IV below), give JL € ¢ 3f.;)> Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $60.00 ;` CLAIMANT: DONALD DOUGLAS T 47345 ATTORNEY: UNKNOWN DATE RECEIVED: JULY 06, 2004 ADDRESS: SAN QUENTIN STATE PRISON BY DELIVERY TO CLERK ON:JULY Ob, 2004 SAN QUENTIN, CA 94974 BY MAIL POSTMARKED: JULY 02, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 06 2004 JOHN S WEE k Dated: By: Deputy II. MOM: County Counsel, TO: Clerk of the Board of Supervisors ( r}"This claim complies substantially with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: Dated t '' By:` G' s r Deputy County Couns III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). (IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: « JOHN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code secti n 913) 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 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 full prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. /I o JOHN SWEETEN, CLERK By Deputy Clef: to: ��CONTRA COSTA COUNTY in C 1 INSTRUCTIONS TO CLAIMANT 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 100'h day aver the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 fine 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 1Y 2 'P Against the County of Contra Costa or 064210104 *strict) R (til in name) 1 Xi d s i 3•' The undersigned�laimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of Sz } `_. and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) L (-X 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) T) ;,�1,, "`yc, C`-- C `=: � R ;r. ^, 1.`� r$` k Sty"fir. '- moi t�;' �.,, S •s s f 4. What particular act or omission on the part of county or district officers, servants, or employees caused the _ lnji32y or damagt? J- vi k Vv t � r IV. s�...:, 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.) Int 4 ?, 3 T 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) F' : ,�, vw } '. '..:' Std:`�c ^�)''. y ;'"�>t.� S _.�: t �. Y.f f;: is 'S � �..�s.J� wv& 4•'' ••� 1 k '4wt..,,. YL�`.+ f }� w,t "✓. s „ff.'s { ? qs.. •'- 1:)-Names and addresses of witnesses, doctors, and ho' pihais. 9. List the expenditures you made on account of this accident or injury. DATE TIiti1E AMOUNT _ ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney 1) j F i (Claimant's Signatire) F (Address) Telephone No. } Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county, city, or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,044), 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. R �, i - ti .F+' < 2: •c� ti,r} k- 4 ,, OR ,v4+`'�., C + WYWAI 7o f,s..c 4w .*,s,?.`le��si 'iw'rv,+:?^C'r •w..,$`,<.fi Afi°�� +a��w� <c,,. �`;. �tjhf' t+. z �'S '}' �Yf 2�`,' ^'�F<., �� <s A $ .},. '. ra•cas" k..:t,;, ;.,,'-.e:.-*b. 'iav 'sL,a .a„Ert�,ra. -' iwi! r M. 2 s r � �i�a :�}s � ,;u✓'�j�r X a` � ° t � T '48a�`� fr z ��� r R {I y Cn 4 k--,l.yv`t °r F. ! N 0.�' q ..C^.� `ry' Y b '�• 6+ C h ! { ,..>.,.cvr�.t•,.,,. ..9ss�..'.`ti''z.�e,�"�a.,,<-s�ca Sa na. .�E'' �`a',}',:,Sw. S., L. ,r, .F � ��r * �,*? � � �tra• i� 9' ,'F'., M:. C w ¢� �,. ,;� �s `. � f a r1�`. All r �. • meq# r f t. F,s � g., s t � �, ,.� • �sS<b S' �' �.,.; ,r ey w}I�l� f �" k.w t z `�": d ao' s f �l� fCUM s9 lepllo- `0'4? E�"x<`s a ,�✓ � : 'S ,, X- ? - �'ti .i do �,. ;b f �>r �1 rij-.+'� ��m.,^d ��?,.cecs,✓efi.&s.Esft.**r,..�..�`,�%.:w..�.$..Nr..:.s,�h:a.,�r.�rres•.ne�`rr5}r�:.�?���.,.,�..n .s::,,� Mr ,.c*; '� -"r � �k. ,'* ',..�:�.y;�, ..R s �r }IF ..: } .} : '; -? ft�., { rel�+, 14;� �'•+ i.� i4 e��y� ..fi..�`_,•#�;.; k,s t .; •,� a .-'r.: r $ 3: --�,, RAM b A -;,":» 3.r:`; _ �,< *<rtes .' :. ,�.i•. ,, s ,� r �,�.sar ';� 3. y s: f � ,, :�� }� sT�fi��fi : .F S � ba � =�y�`�` s�.,� zr r#}} t�;S� •' M o—IT-16V17VU1,17W a 31,. Imm +-" 4 I:_s�M.t,.#:.a 6 a.!'.'•t3 i ��., itEi1? .,t ;t f;:}.i ti"p� } +e v's5'+3 �' `�o4s `e {U .r A N 13 11 .rt,T.r.h+; f = -.:� q. `kfl shYia$.a•u�t�� * `:`r'�. <�t:'v; r`}���"� .,�Ff'=F�l.'"r i2' Contra Costa County Commissary Menu•Master+feral Population Canteen SAII. NO REFUNDS Ttftl cost of ardared Items will be deducted from your trust soaouunt, Sales taut va be Added to al Items with an p. We rste+srve me Oft to UmIt This oder is suite to pasted commissary(Viers, refIrain from plack p an order 24 hours prior to transfor date,as this delay flt►ari cash with��. ITEM A 112D Lamm 4.5a 9 0.9D A 4119 Chvw h n Rog 4oz 9 1.16 0 1106 BuftAnW 2;31 oz 9 076 T +4131 Slueban Muffin 40z 9 0.90 •-r + i :: `? y, i�i< y„0.r�}�*'sK �`>. '• 1169 6-mor"ftst /Our IABUz 9 0.71 Y 41111 DoWe+borne#e Chip Mrzf t 4tn 8 0.110 11077 IQ Kat [Cat 19+4oz ' � ., T$ 11.74 4145 Ghotrr Uoratt t3erna 3oz 9 0,90 1127 SnWors W Almonds 1 IOM $ 0.76 3106 Pork Crealdin's Het N Spicy 2oz :9 1.25 :r. ,,;y, w »v...', .,rrJ;;�:.i�'- •"� �m r., ,},� ,x. ::..L.;.. v IN I �, s v� ig '• wy� :,• ow a is, z ... .. .;,, •:x•.•.x•.L.x+ .�.. �i,?. n, r :,•'.u.n. .l`2 , e;. r•' ' ,' >:, ,•.•r.•!.r„ ..... a^.:0..-,.:':•:�:`.:.;:�:=:, 111}9 M 5 M Plaid 149oz $ 0.76 N 3115 Hot Crunchies 4.5oz 9 1.30 01->7, ....r.... ..... ..,�' �c .......r,fi••'�.'.>-':`:?;>"#1 fig,igg'-y�<? gr�„ r`.. "F,.... •r � • 1136 fifutrageous Ift 9 0.76 P 3114 Chem Cud&4.5oz 9 930 �...:?:� kyr �•L a! Rome's Pawl 9dtsr Ct*16oz 9 0.78 31 tS&Y TO chifis 575= a 1.35 ' w:fxr •, '4,¢ yc >;�.`x.2�,'ar..��'X rt + .. IiOl .},�'a�as....,n:.xSi'5:... d 1112 T'hw*jsMtftM 213oz 9 0.76 3110 R Pott Chi 5oz $ 150 „t s :ave'•` ,r'. ;•x �. �' Y ��its�•,,�v�,r,��,,µT •��^.�,,� 4 � 11 1 Whoppers(theme sin)27 9 1.10 3111 Whites Cheddar Pum 9 1.30 { { ,?N :: .: ,. .. .. .ca. ;.:.'�+M..•.�r^�'•r'`J,„.�.c:h'$+ .. ::;. ?F,� .�+'�`, Rs�.r:�.E:••✓!:} n. .... .... ...n..r,.,. r. Tyr 1140 unicr tints 1.6aa 9 0.76 3105 DorBas Nacho Chips 1,75oz 9 0.75 +.. rv...y,.•. •l,�;y$.wa,vn�J� • ,fiff..:: ''':t+ :,'{,,`':: '•v}+�:''.�i."}T+S.. r �. •'.:ri<�3:• 'T. IMrvxr''-;a>;"�!'uq'r ..-.i'•5{'.{:'y ''o .t T. f ra:hit'+`v. Fs 'r 1111 ttZti(tIs ea:, 0.76 C r 5111Oaurmw COOMBS 16oz j 9 2,5(3 r:. .... :ri.r:`!';M+r`•`•,•f'k>'•' r +,,yF+.w :>#! , a : 9c, e•.ty i m} a. .. v. . .. ... ,..`Yv a'r -' .....,.,i> ^;iv`::a'34^•'!_> .,�ys o ." �`i :'�.•�.�, Ila SAMWTAffy4oz a 1.65 0 5106 Cho Chip Cooiaes 1602 9 > 2.50 ;'ate• Xr `---i.�Y3, t Y -> i. �•S•air '�4. �. . :,*t yy��-.���,2 '2i. .+. kig $J vrtt`' ,.�{ 3• 1Cy ... •T.L •c:•:. :4... .<:.:Y,K:•:o>:x,�,c,'.k,r,L,:l2-:�'v.,�:a,;.,...d.>c`�.•i'�. ..cr,, :` i .r... •.:, t•'. ,.�. .F.r.,.c.9:s..h:i .::.,; 1199 Suffers colch Clime 9 1.16 1 5101 Grandmis Chocolate Chip Co"2.7502 9 010 vv :s.,} ...>:ht'�.. .. .T.`Y?{:''t.'t3,,.'t'r,,S,•, '. ;.,.,.,f ...% ..a. .,,. . r.: 'i0.';:`,x,•.:' 1124 Ste erfree Wild Fruit 2oz 9 1.20( ss 5104 +3rwwkMs Oatmeal Cr7WO 275= 9 tl 70 ti....,t { fie k :•' r. ;;}. w.t•;••,rwx s.�ac r sps3 tory sJ. h -•'», >•,';'•,+,g �•,.3"h• .,.�"`mf:+ 4~ .•� d® i �yj�� `+'y +��.,�,Y"y- al4 eh-L,e } ~h' pq,,., lXt � +...h + .< MOONRISE R:Y„r n.. J:. :,....-.v r�8.`�L.. i}.:iu'+;}r{ 1°�,.•r'Y+:->"''r` s .ftii't. $'-. 1119 Rarrdser Fire 4oz 9 1.20 6603 Coppu+ccine cookte+s 30z 9 0.80 ., •r. ��,e 41 1.1 $ 5114 C sac S Creates 20cz 9 2.86 �r ;i4:W•.'T>�'�;�„�n��� 5•t.;�.-J,{S: Gs.•�.e�� „s�•:;{r`• r -•.- ,a, ....x2.?,,,.rx,�.}`�:,*: r`.:. ','�/� j> 3� va n ...•.•. ,;. ,.r.......5-,.. ....., r..•... ..,....v < `.o`,�.•... - , $ 4110 Flour Ti's 10Vct 10trz 9 1.50 4413 Ramon,ChlOwn 3oz 0.92 y.,,y+ u' :•`;,-T:•;:c,::..r:.-.x;:s;u, .rr. •:•;i<•<•n• 'L+• s v° tt`ro• :a,o-;�Lati:x u� .Sv.Zv}'{"+j^w2*'"SY,r'-S:`-f:,+ry r$.e.•.•3f:rX•. :.. '.SL{, ++ z `. er, r .. ..Nr,v ,:9.N.lrT i'f�,�.Sri:•..:.--::. n ..n.X.?r.:• �i1,•:::+! r 4134 Nsoho Chi Clip 4oz 9 155 0 4415 Rome",ON 31" 9 92 11111101 d�..'•�•." a.,...JC..n-.r .!•d`+»•ts' ?:•, ..,... .. r rr.. t,,.., r .,. ...,s,.. ....:::.^.•...wT.•nt:,,..: ..xaa..xry ,+y.., .•..,,,xn.r...s .,,5,h•rn 'r K 4396 Micrumve Popcorn 3.5oz 1.25 n,Spicy Beef 0 .,.... . -::'. ,•?,".''irh`s•`:x:> "::•�..'•-:'<'``'' -s..;•,. ! $ le 4417 i4a 9'2 :.7>':.•:r"+v%<•E },;"''r'i4't�;ry�T,•Ta'A'�'`i` S 4112 n9i11Vtler 44.#eNy Sclu r 2oz 9 0.90 4422UwWwa Pouch 73a 9 210 .:v.'''+d�✓3���}';,-KC r°f�lluj,.v�?`:,':. ..r'.i 4101! Kostw[1111 Pie loz + 1l 1,•04 4410 Spm Rice wfC 8 J �„ 2.2oz- 9 1.00 Ne•• - w. .r r..•!r. +'}�`�'' �',vg;?Y�+ ', ,�. :.5•• .•, .viTw•d "x�r.; \,. s�•6fi•�osY Yi-a&;.• ��A. ?a,.::r:sW •yam .: ,. x •. .: ..v:,T,.,i::.•.r:?.v::id"t�...'•:n ,• .:,., er .. S .. 4 •... 4004 Ell Swed Low$00 2.50 4409 Refried S a-wt lata 8t tureen Choi 9 123 r { r ..'S: r WE' .•�:Cuw°n v�Ls` � v>', ss'• 4 >, .. ..:,Ka. �;hja,>,rr'•'.:;`�:,.�t�::��:-,'� ...�..';�'�..,s�.>� ,,x;'•,: •L•C"v:�:�>^'r�3`,'�kti'4..»�.h 2:.'' .::.r•�sr ..,r.•, . •f C. .+'4 r. 4114 Tuna Pouch 3oz 9 1.7$ 21134 Freen• Dded Core 302 9 3.810 T..r•'<}''�wo''/.r+.;r'• :s.'' w;5 '�# t.. , r - a,,.Kr�'„�,y y ��^�' L@�ka*k�„�s�e++.- ;�,ii:,",s •..� „• ti 'r .ti: '?vt:,v,•is:4.+ ��•:°'' � ..., ..�:'`� ..:,..'.t.:..�.,.::?::°i.v::"c.1,'�f} t 3 b !�� .+i. .h... ,.n.,.\.r.,ut'. S•:x•r:::}T. v:.,lri.:;=.:v. ? •:i. + -,.... .: ,•'. ..,. .. 4 .1:ti:...+..;r:..''3r....�:'}. 23 to t Ccxnnuts 3.4oz 9 {l 70 R 2198 Hbrallf"S oz 9 20 �}�{ ,. , ,r:. ':SC<'t :y,,,:+y.T .Y Y y : r& S. ✓irJ• Si :i�;:d••}>rt;a- b ;' "% 41 a .. •. .-, n. r, ...v.' , v...f :3. ;}, .. •.... -.. 5,w , .•. ,.{:CrS.'{... ...,...v.'. .ti ^i6.•J�.� � .. 4... ,y 4#4t) Ct a -1t 1.5o�c 9 0.70 N 21[39 load Tea Clank Aft&Z 9 1.65 't..-` .-'',�r�•r'tr-La'• r�•:n' Y•,'s , :v ti=,i:�>:?0.•A. ,xs. .v�v'••''•'.•s. ;�., K •'�.....r'.ra. h..,.?,..M 4ee.i - Xi 4141joispeno MKbo Slices 7oz 9 0 t3 2190 t�arrrarrurte Drink Mix Boz 9 1.60 ,r.•, :. ,:�. Imp t�i4 ...x.."L'. ..'y:y,, ..rx^%;}a+$*v�.t...�;}..s.•. .. . <.. h•. :.:T+�.. )s::: ..:�,�.:d<:;eT:;>�i r''iEi£.�cG:-^:�"rc�r h,.tw�.:2•.v. +41 s7 Msy4nnat" 195oz Capprmcft512= 9 1.70 .ni..... 4148 tartasl tJ1a a Il;Brown 5pk r F 5 CLAIM 84ARIJ OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:AUGUST.,10, 2004 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 ;# 3i n ..; r 915.4. Please note all "Warnings". H.."D . AMOUNT: UNKNOWN CLAIMANT: MIN QING DENG ATTORNEY: UNKNOWN DATE RECEIVED: JULY 07, 2004 ADDRESS: 3317 TARAVAL STREET, BY DELIVERY TO CLERK.ON: JULY 07, 2004 SAN FRANCISCO, CA 941.16 RECEIVED THROUGH BY MAIL POSTMARKED: INTER OFFICE MAIL FROM PENNY BAILEY FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 07 2004 JOHN SWEE E k Dated: By: Deputy II. FROM: County Counsel, TO: Clerk of the Board of Supe M_isors (This claim complies substantially with Sections 910 and 910.2. 4 ( ) This Claim FAILS to comply substantially with Sections 914 and 910.2, and we are so notifying claimant. The Board cannot act for IS 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 Couns 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). (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: fQ JOHN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code section 9135 Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposit+ in the mail to fila 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. 171 Dated: JOHN SWEETEN, CLERK By ALWDeputy Cler. Claim to: BOARD OF SUPERVISORS OF COMA COSTA C(YJ fY {� INSTRUCTIONS TO CLAUAANT i A. Claims relating to causes of action for death or for injury tc pers car o pr- sonal property or growing crops and which accrue on or before Decembe. - , must be presented not later than the 100th day after the accrualhe of action. Claims relating to causes of action for-death or for inj � err or to personal property or growing crops and which accrue on or after1' 1988, must be presented not later than six months after the accrual of the ius e 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 Roam 106, County Administration Building, 651 Pine Street, Va.rtinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the Country, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims ara:st bQ filed against each public entity. E. ' Fraud. See penalty for fraudulent claims, Penal Cade See. 72 at the end of this form, . RE: Claim By } Reserved for Clerk's filing stamp 167 v edd Against the County of Mn_tra Costa } or } U 0 7 H- ' District) i f u;S "ill, in n ) The undersigned claimant hereby makes claim against the County of Centra Costaa or the above-named District in the sum of $ and in support of this claim represents -as follows: 1. When did the damage or injurwy occur"? (Give exact date and hour) 61 2. Where did the damage or injury occur? (Include city and county) '�~;^;r�., y�"tw.kw.4£y„d�^..�... �•�aave• s�'�,��,�f�,�,i,� 3. How did the damage or injury occur? (Give full details; use extra paper if required) ,1,.. ,-s�'� �.�,� .::ter, �'i- .��� ��.���• `' ,�,,. ` - 4. 'What particular act or omission on the par�vof county or district officers, errvants or .employees caused. the. injury or dame? 5. Wriar. 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 in =ies or damages claimed. Attach twaca estimates for autos damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) B. *lames and addresses of Witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT A MOUNT , Gov. Code Sec. '9141:2 provides: "The claim must be signed by the claimant SM NOTICES TO: (Attorney) or some person on his.behalf." Name and Address of Attorney " W-la imant I 6-"'Signature) ignature) j Address M Telephone No. Telephone No. µ - : NOTICE Section 72 of the Penal, Code provides: "Every person who, with intent to defraud, presents for al.lo�ance or for payment to any state board or oafficer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one-year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine,-or by Imprisonment in the state prison, by a fine of not exceeding ten thousand ,dollars ($10,000, or by both such imprisonment and fine. 16232b E ;4W..S•.:= f `/-__• V4UDR .t µ :. :,4AKE f��..� ...5..1��`..—Al!C✓tL �_�....G�-^`St�_itG_ H,PHO:E i Ns.CG. — _AC'✓R=SS _ 7 T= _CSS Cf_v,i No. WPW S.kYJ?SCtt�.: >` p:} icy p..ffT3tl'S?TT+STL r y^�.{Y'^Y-`\ M��{{+� i}5—yv TS�C SQ i4 C< _ _ Y . {�+.'t RULf mmArswm 12 s � � imp r s - .:5 ....v ' y "' ." # z ...E .,.......__.... .,.. .....,.....�.__�_._. ......... ............�. Rv� --�-�.,�.. .,..�,.... tea._._. .. ..... t # .......... _i Q 1 4 _ t t S - g - 27 S £ TOTALS � rw #t aro t?G:3 1. dY -�u^�'3✓3c f2 #�' rrsi-�.,v <3a '� ti�RFs c�...r.'#3.3 5� 4i+A.a3: ?i"�'�b ::r� b f�#J�. ��'. i:✓t. �,. gtZ�\ -\.,.�hr,,,� � d:..,� �: : ies AUTO 280 ':8f2;iY_,,,�.,✓,-�Z3 f-..�c:-...1f�' ,:Q}'u_...�£i.:#+'tom?•,..:tzy..,f:f;?�t::f c,£.�J_. `• �,.� ':3� 4=1 j t San F : nd co, Californis, 2 ^sEJ�#�'1�.. .............. Phone ( .X A TAX un 80..-S33 926; ,. ;w cc 1024 06/22/2074 at 03: 44 PM Job Number. 76926 FRANKLIN AUTO BODY License Q AA225725 Federal ID # : 820561637 Location. 2 362 Fell Street 24 Franklin Street San Francisco, CA 94102 (415) 861-2355 Fax: (415) 861--2509 PRELIMINARY ESTIMATE Written By: Tae Kim. Adjuster: Insured: MIN Q. DENG Claim # Owner: MIN Q. DENG Policy # Address: Deductible: Date of Loss: Day: (415) 665-7348 Type of Loss: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2002 HOND ACCORD SE 4-2 . 3L-FI 4D SED Int: VIN: Lic: Prod nate: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Theft Deterrent/Alarm Body Side Moldings Dual Mirrors Electric Glass Sunroof Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 ON bumper assy 1 . 6 3** Repl RECOND Bumper cover USA built 1 214 . 00 Incl. 2. 8 4 Add for Clear Coat 1 . 1 5# HAZARDOUS WASTE 1 6. 00 X 6# COLOR TINT 1 0 . 5 7# FLEX ADDITIVE 1 8 .070 ------------------------------------------------------------------------------- Subtotals =_> 228 . 00 2. 1 3 . 9 1 06/22/2004 at 03 : 44 PM Job Number: 76926 PRELIMINARY ESTIMATE 2002 HOND ACCORD SE 4-2 . 3L-FI 4D SED Inv: Parts 222 . 00 Body Labor 2 . 1 hrs @ $ 79. 00/hr 165. 90 Paint Labor 3. 9 hrs @ $ 79. 00/hr 308 . 10 Paint Supplies 3. 9 hrs @ $ 38 . 00/hr 148 . 20 Sublet/Misc. 6. 00 ---------------------------------------------------- SUBTOTAL $ 850.20 Sales Tax $ 370 . 20 @ 8 . 5000% 31 , 47 GRAND TOTAL $ 881. 67 ADJUSTMENTS: Deductible 0 . 00 ------------------------------------------------------ CUSTOMER PAY $ 0. 00 INSURANCE PAY $ 881 . 67 Franklin Auto Body warranty for one year on workmanship and lifetime on refinish from the date of completion of repairs . Payment in full is required (including deductible) before the vehicle will be release. I have read and understand the above statement and I authorize repairs . X _ DATE / / (signature) 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=NINE NUMBER QTY=QUANTITY QUAL RELY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPT,=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. MQVP=MANUF'ACTURER"S QUALIFICATION AND VALIDATION PROGRAM. 2 06/22/2004 at 03 : 44 Phi Job Number: 76926 PRELIMNARY ESTIMA 8 2002 HOND ACCORD SE 4-2 . 3L-FI 4D SED Int. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARG4422 Database Date 04/2004, CCC Data Date 0-5/2004, and the warts 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 (ti) items indicate MOTOR Not-included Labor operations. Non--Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qua! Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Dart Numbers and prices are provided by National Aute Glass Specifications, Inc. Pound sign (#) items indicate manual entries. CCC Pathways W A product of CCC Information Services Inc. 3 06/22/20,04 at 03 : 44 PM Job Number: 76926 PRELIMINARY ESTIMATE 2002 HOND ACCORD SE 4-2 . 3L-FI 4D SED int: ALTERNATE PARTS SUPPLIERS 3 RECOND Bumper cover LSSA buy. Part No. HO1100184 Price $214 , 00 Faith Bumper Service (408) 986-1226 1085 DI OIULIO SANTA CLARA, CA 95050 4 CLAIM * BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 'BOARD ACTION: AUGUST 10, 2004 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 s Board.of Supervisors. (Paragraph IV below), giver ' L _< Pursuant to Government Code Section 913 and f 915.4. Please note all"Warnings" AMOUNT: $14,000.00 CLAIMANT: CHERYL HOYLE ATTORNEY: JAMES M. ROGERS DATE RECEIVED: JULY 07, 2004 ADDRESS: LAW OFFICES OF JAMES M. ROGERS BY DELIVERY TO CLERK ON:JULY 07, 2004 1941 JACKSON STREET, RECEIVED THROUGH OAKLAND, CA 94512 BY MAIL POSTMARKED: INTER OFFICE MAIL FROM PENNY BAILEY FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETFN, Dated: JULY 07, 2004 By: Deputy II. MOM: County Counsel. TO: Clerk of the Board of Supervisors ( * his claim complies substantially with Sections 910 and 910.2. { } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's night to apply for leave to present a late claim(Section 911.3). { ) Other: rp 3 Ir t 'Dated: ° . Deputy County Couns 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. OAR.D ORDER: By unanimous vote of the Supervisors present: { This Claim is rejected in full. { ) Other: f I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 14 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 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: OHN SWEETEN, CLERK.By Deputy Cler LAW OFFICES Page 1 JAMES M. ROGERS JAMES M.ROGERS 1941 Jackson Street Tel. (510)444-4464 JUDITH W MARSH Oakland, California 94612 Fax(510)444-4460 June 21, 2004 Nnny 8,#,y 24 Penny Bailey/Contra Costa County ury 2004 REPO- 2530 E 2530 Arnold Dr., Ste. 140 Penny Martinez, CA 94553 f` k4 'f Of 2:--,, 1 JUN 24 Re: My Client/Your Insured: Cheryl Hoyle/Mary Pickett Your Claim Number: 55568 Dear Ms. Bailey: Enclosed please find specials for my client as follows: 1. Drs. Medical Ctr. San Pablo $1,842.60 2. Dr. Robert Snyder $ 356.00 3. AMR. $ 891.43 TOTAL $3,090.03 The liability for this accident clearly rests with your insured, who backed out of a driveway and collided into my client. It is not surprising that my client was injured in this accident, as the damage to the car my client was in was significant. The police report noted that my client was injured. The collision was especially traumatic to my client who was near the point of impact, sitting in the driver's seat. My client was taken by ambulance to the hospital. The ambulance report noted: "redness at side." My client was seen in the Emergency Room at Drs. Medical Center with a diagnosis of"tender left upper chest," Objective injuries were noted as follows: permanent bruising and discoloration of left chest. Drugs were prescribed due to the pain my client was suffering. Due to ongoing pain from this accident, my client received treatment from Dr. Snyder. In light of the pain, inconvenience, and permanent discolorations along with the clear liability of your insured we are making a settlement demand of$14,000.00. Page 2 LAW OFFICES JAMES M. ROGER.S JAMES M.RoGERS 1941 Jackson Street Tel. (510)444-4464 JUDITH W.MARSH Oakland, California 94612 Fax(510)4444460 Our Tax.ID Number is 94-2905746. Please contact me after reviewing the enclo°sed documents. Sincerel , ROGERS Attorney at Law 510-867-5725 t .'^tient Ledger - Detailed Patient ID: 29418 CHERYL HOYLE i otat Charges: $350•oD Birthdate: 01/25/1945 1939 PABLO VISTA Total Payments: $80.00 Phone 1: (510)234-4053 Name SAN PABLO CA 94606 Tata!Adjustments: $296.00 Phone 2: Insurance Balance: $0.00 Patient Balance: $0.00 Visit DOS Visit DOE Company Doctor Facility Ticket Number Balance Procedure DOS DOE Code Modifiers Description Check#Units____Charge Payment Adjustment Insurance Patient 03/3012004 0313112004 Alliance Snyder MD,Robert E Pinole Medical 119286 Medical Group Group Current Insurance Carrier Affinity/Commercial 0313012004.0313012004 03131/2004 99213 Established Pt-Comp 1 i.00 $89.00 $0.00 $0.00 03/31/2004 Affinity/Commercial $0.00 ($74.00) 0410112004 HOYLE,CHERYL Payment ($15.00) $0.00 Visit TotaYBalance Due $88.00 ($15.00) ($74.00) $0.00 $0.00 0411312004 04/15/2004 Alliance Snyder MD,Robert E Pinole Medical 122139 Medical Group Group Current InsuranceCartiet AffinitylCommarcial 04/16/2004 Filed HCFA to Affinity/Commercial for$89.00 0411312004-0411312004 04115/2004 99213 Established Pt•Comp 1 1.00 $89.00 $0.00 $0.00 0411612004 Affinity/Commercial $0.00 ($74.00) 04/15/2004 HOYLE,CHERYL Payment ($i5.00) $0.00 Visit TotaYBalance Due $89.00 ($15.00) ($74.00) $0.00 $0.00 04/27/2004 04/3012004 Alliance Snyder MD,Robert E Pinole Medical 125923 Medical Group Group Currant Insurance Carrier Affinity(Commerclal 04/30/2004 Filed HCFA to Affinity/Commercial for$89.00 042712004.04127/2004 0413012004 99213 Established Pt-Comp 1 1.00 $89.00 $0.00 $0.00 04130/2004 Affinity/Commercial Affinity Cap $0.00 ($74.00) 04/3012004 HOYLE,CHERYL Payment ($15.00) $0.00 Visit TotaYBalance Due $89.00 ($15.00) ($74.00) $0.00 $0.011 05104/2004 05107/2004 Alliance Snyder MD,Robert E Pinole Medical 127727 Medical Group Group Current insurance Carrier AfffnitylCommerciaf 05/11/2004 Filed HCFA to Affinity/Commercial for$89.00 0510412004-0510412004 0510712004 99213 Established Pt•Comp 1 1.00 $89.00 $0.00 $0.00 05/0712004 Affinity/Commercial Affinity Cap $0.00 ($74.00) 0611012004 HOYLS,CHERYL Payment ($15.00) $0.00 Visit TotaYBalance Due $39,00 ($15.00) ($74.00) $0.00 $0.00 Selected Visit Totals $356.00 ($80.00) ($296.00) $0.00 $0.00 r' n 051271200411:19 am Page 1 of 1 Dni-#1-4--r).falI.A ` as j CIO/toP MAY 2,5 f004Attendrinh si cians .fie ort History: ' Physical Exam. ' Diagnosis: *complicating Factors: 0 CI Pt has prior history of similar condition. 'MS NO Plan: Prognosis: 0 Condition is completely resolved(d w ).Patient may return to usual job without restriction and no further follow- up is necessary for this condition. OR. Condition is permanent and stationary(date ). Work Restriction:D None 0 as Iisted OR *-Condition is:0-11M"proved 0 Stable CI Worsened Work Restriction:13 None Cl As listed I do 1 do not expect complete resolution of the problem (by DATE }• I dol do not expect return to CI Full duty CI Light Duty (by f)An _ }. (Light Duty Restrictions} }• 0 Patient needs Consultation/Equipment: G Next appointment with me: 0 Is treatment totally related to accident's :ao 77A M Date of Injury Case# ' PATIENT NAME Date of Birth (Tax I.D.#94-2811557) MAY 0 4 2004 Attendim Phvstcians Rgport History: t AX) Physical Exam: `� -- 4 Ike CL �. . r Diagnosis: "complicating Factor : has prior history of similar condition. YES tao Plan. -�-� Prognosis: 0 Condition is completer resolved(a� }.Patient may return to usual job without restriction and no further follow- up is necessary for this condition. OR 0 Condition is permanent and stationary(axe }. Work Restriction:Cl None D as listed OR Condition is:[Improved 0 Stable CI Worsened Work ==Restriction:0 None 0 As listed (TI'do/do not expect complete resolution of the problem (by DA-M J. I dot do not expect return to U Full duty Cl Light Duty (by DAYS ) (Light.Duty Restriction(s} � Q Patient needs Consultation/Equipment: 'Next appointment with me: Cl Is treatment totally related to accident? S h o s ' DATE r te of injury Case# PATIENT NAME Date of Birth -. (Tax 1. .It 94-2811657) -DATE PROBLEM ORIENTED RECORD l f / . WON PM r ra �r�►.{�►��.�a►r, a■ i.�.. APR 3 2004. ttending, Ph sicians REVort History:_ At Physical Exam: X t r Diagnosis: * ompl�ca g" tin Factors: 13 (rrPt has prier history of similar condition. YES NO Plan: . Prognosis: 0 Condition is completely resolved{a. ).Patient may return to usual job without restriction and no further follow- '" up is necessary for this condition. OR #� Condition is permanent and stationary(due }. Work Restriction:C]None 0 as listed OR lb-Condition is-O`lmproved 13 Stable 0 Worsened Work Restriction:C1 None 0 As listed I do do not expect complete resolution of the problem (by BAxE ''� � Zc tf I dol do not expect return to U Full duty C3 Light Duty (by t)A-M (Light Duty Restrictions) 0 Patient needs Consultation/Equipment: 4Next appointment with me: `' 7`0 Y CI Is treatment totally related to accident? - ` NO "a aatta DATE dateof Injury Case# 3 ` PATIENT NAME Date of Birth o , 1 C WeTZAI (Tax I. .#94- 11657) :( CIO Z,155 MAR 3 Q 2004 �`ti�'n d in P��'t C l��`Z ��' ort History: art. ` e'`' t„ t. r Physical Exam: Diagnosis: 5 ':omplica#ing Factors: L 0 Q'Pt has prior history of similar condition. YES NO Plan. , ,,✓ - ,.� ,Q__ Prognosis: X- tel_ - c Q Condition is completely resolved aaw }.Patient may return to usual job without restriction and no further follow- up is necessary for this condition. OR ❑ Condition is permanent and stationary(eau 1. Work Restriction:0 None n as listed OR Condition is:❑Improved 0 Stable IV Worsened Work Restriction:Cl None ©As listed I do /do not expect complete resolution of the problem (by DATE ). I do/do not expect return to d Full duty 0 Light Duty (by DATE }, (Light Duty Restrictions} 0 Patient needs Consultation/Equipment: 4Next appointment with me: 4,YVIJ 'Z J 0 Is treatment totally related to accident? ��' r NO 'im4pame 31A7E Efate of injury Case# PATI t NT NAME Date of Birth (Tax l.D.#94-2811657) STATE O(CALIFORNIA TRAFFIC COLLISION REPORT peP 5b' A e 1 (F se I-OL} OP1061 Page of .ONWTIONS 14MADER HIT a RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER atluREo FEL❑ ),{ RUN COUNTY BEAT Ti3' -y' HtWSER IaLEIs HITMREPORTING DISTRICT 1.4aOEMFAtiUR ❑ Can COLLISION OCCURRED ON MO. DAY YEAR TIME(240M NCIC M OFFICER/�I.D�.)�4 a 5 CJ 2 0 o?/3 0707 aSr f j MREPOST INFORMATION DAY OF VVEEK TOW AWAY - PHOTOGRAPHS BY: I.J7 NONE FEET)MILES OF S Ml W T F S E]YES 0 NO �f 0 AT IfVTERSECTION WITH STATE FMN REL J -�f OR: E .!MILES W OFN+� 44LV4C ❑YES ® NO PARTY DRI R'S LICENSE NUMBER STATE CUSS AIR BAG :SAFETY EQUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE CA ................. DRIVER NAME(FIRSt MIDDLE,LAST) ........ ............ MAW Al / _ OWNER'S NAME �`I SAME AS DRIVER . .DES• STREET ADDRESS !!! �tl�+ 1 {b cxAjAry TRtAN "6dt {�.F�L`i, gr OWNEWS ADDRESS ❑ �+r6 � ❑ SAME AS DRI ER VEHHIICLE ctTYrsurPntP A# Zq(P*7 '�fC,w,* ►C a�mer f� ❑ � �� / a DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICERPq DRIVER ❑OTHER SKY- SEX HAIR EYES HEIGHT WEIGHTSIRTHDDayATE RACE � '} � � f,�` o. CLIST ' 't' PRIgR MECHANICAL DEFECTS: Pq NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE B ItJESS PHONE _VEHICLE IDENTIFICATION NUMBER: ❑ 260— VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER LINK. ❑NONE ❑MINOR j MOD. ❑MAJOR❑ROLL-OVER w DIR OF TRAVEL ON STREET OR HIG INAY SPEED LIMIT r+" CA DOT CA _TC_ MC/MX PARTY 6RIVEWS LICENSE NUMBER STATECLASS AIR BAG SAFETY EQUIP. VEH.YEAR MAKENODELJCOLOR LICENSE NUMBER STATE __] C_ t4 9qi JESCO ..... . . ....... ORiV£It NAME(FIRST,MIDDLE,LAST) tt ONMERS NAME Lr� � � 6. �SAME AS DRIVER PLUS- STREETADDRESS JTRIAN ❑ PO 3 L O V i 5� U' OWNER'S ADDRESS SAME AS DRIVER PARKED CITYISTATEZIP VEHICLE } �` ,��r ❑ �n !�' { cel, gve !! 2 DISPOSITION Of VEHICLE ON ORDERS OF: ❑OFFICER®DRIVER ❑OTHER SICY' SEX HAIR 4 EYES HEIGHT WEIGHT 444������STIRTHDATE RACE L) LUST M. Day Yu r ❑ k j! /60 ( I w PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ Z31H ~ q 05 3 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑LINK. [:]NONE ❑MINOR 5A� .. ` 19 MOD. ❑MAJOR❑ROLL-OVER DIR OF TRAVEL ION STREET OR HIGHWAY SPEED LIMIT CA DOT �� ;r H Z5 CAL-T TCPJPSC MCIMX PARTY DRIVER'S LICENSE NUMBER STATE CUSS AIR BAG SAFETY EQUIP. VEH.YEAR MAKFJMOOEICOLOR LICENSE NUMBER STATE 3 DRIVER NAME{FIRST,IWOOLi LAST) ❑ OVMM S NAME ❑ SAME AS DRIVER PEDES- STREETADDRESS CONFIDENTIAL IV"itJf 111Yi If_#U Al M V ONMER'S ADDRESS ❑ SAME.AS DRIVER PARKED CITYlSF I VEHICLE p� ''T'' /� } RELEASED j A�+ H'1 ❑ NOT t TV I7 F7 �„ J�a7U DISPOSITION OF VEHICLE oN ORDERS OF: f�i OFFICER❑DRIVER ❑OTHER SICY- SEX M1AIR53NO' '9RO 1. BIRTHDATE JRACE LJ CttST T-!i V LJ L I�C�!v1...1 Mo. Day Vasr ❑ j- --'L L PRIOR MECHANICAL DEFECTS: HJONE APPARENT REFER TO NARRATIVE OTHER HOMEPHONE ......".0 VEHICLE IDENTIFICATION NUMBER: ❑ ;,CP t1a. /C'@Jec SI VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑LINK ❑NONE ❑MINOR _ ❑MOD. ❑MAJOR❑ROLL-OVER CA DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT tlOYc_ > CAI.P TCP/RSC MC/AJC PRE ER'S NAME DISPATCH NOTIFIED REV) AME DATE REVIE T D ❑YES ❑ NO ❑N/A _70— '*P49 Ie-% , _. —LISION CODING Aev.713 OR 066111,11, r Paga�oi�� 00. DAY Y" TI>: (24M) NCIC# taFFICER I.D. NUMH£Yt Cid d / Capt csrr d 7G! t{ } tt OV'diEfY8 NAM CatN}!ER'6 At]ISftE&B Nb71FIF1! �PERTY YEs NO LMAGE CSKSCRIP7I6N OF DAIMGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED m-(C vicyc,L E-HELMET A-CELLPHONE HANDHELD A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES O-RADIO ICO O-LAP BELT NOT USED E-SMOKING 2 3EHI 1-DRIVER E-SHOULDER HARNESS USED F-EATING Y TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RE TRAINT Fr(EGII U E ' G-CHILDREN 5 6 1.STATION WAGON REAR G-LAP/SHOULDER HARNESS USED O-IN VEHICLE USED D-NOT EJECTED H-ANIMALS 8.REAR OCC.TRK.OR VAN H-LAPIS"OULDER HARNESS NOT USED R-IN VEHICLE NOT USED i-FULLY EJECTED I-PERSONAL HYGIENE 9-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J.READING l i3-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 8-UNKNOWN K-OTHER U-NONE IN VEHICLE ITEMS MARKED I3ELtsw FOLLOWED IaY AN ASTERI5IC{`)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 2 g SPECIAL INFORMATION 112 '3 MOV EMEI�P I EI}INO NUMBER OF PARTY AT FAULT VoI CMoH14 AT10... cRw A CONTR OLS A HAZARDOUS MATERIAL A STOPPED YES S CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT OTHER IMPROPER DRIVING C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT I FACTOR 1)CELL PHONE NOT*1 USE D MAKING RIGHT TURN OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN UNKNOWN' A HEAD•ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN s SIDE SWIPE G 32 FT TRAILER COMBO G BACKING C REAR ENO H H SLOWING I STOPPING II;AATHER ARK f TO IITEMS D BROADSIDE I I PASSING OTHER VEHICLE CLEAR E HIT OBJECT .) J CHANGING LANES CLOUDY F OVERTURNED K K PARKING MANEUVER RAINING G VEHICLE I PEDESTRIAN L K L ENTERING TRAFFIC SNOWING H OTHER` M IM OTHER UNSAFE TURNING FOG I VISIBILITY FT. N N RING INTO OPPOSING LANE OTHER`: MOTOR VEHICLE INVOLVED WITH O 0 PARKED WIND A NON-COLLISION P MERGING UGHTIHG 8 PEDESTRIAN TRAVELING WRONG WAY DAYLIGHT C OTHER MOTOR VEHICLE 1 OTHER ASSOCIATED FACTOR(S) R O HER' DUSK-OAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK I TO 2ITEMS) DARK-STREET LIGHTS E PARKED MOTOR VEHICLE A vc`IlcU0NV ZKAllWYES DARK-NO STREET LIGHTS F TRAIN DARK-STREET LIGHTS NOT 0 BICYCLE B secrvaulzxc ° YES FUNCTIONING' H ANIMAL: NO RDAY SURFACE C w4do m"MAIxser. cllvs $ SOBRIETY•DRUG DRY I FIXED OBJECT: HNOYF 2 $ (M II PHYSICAL O TEMSI WET K tX A HAD NOT BEEN DRINKING SNOWY.ICY j OTHER OBJECT: ( VISION OBSCUREMENT: B HBO-UNDER INFLUENCE SLIPPERYUDDY O#LY ETC. F INATTENTION": C HOD-NOT UNDER INFLUENCE' ROADWAY CONDITION(S) G STOP&GO TRAFFIC I ID HBO-IMPARMENT UNKNOWN- (MARK i TO 2ITEMS) PEDESTRIAN'S ACTIONS 14 ENTERING(LEAVING RAMP E UNDER DRUG INFLUENCE- HOLES DEEP RUT` XL A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' LOOSE MATERIAL,ON ROADWAY* B CROSSING IN CROSSWALK- .I UNFAMILIAR WTTN ROAD G IMPAIRMENT NOT KNOWN OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEN.EQUIP.: CITED H NOT APPLICABLE CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT ©YES I SLEEPY 1 F TIC3UED" REDUCED ROADWAY WIDTH AT INTERSECTION umq FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE OTHER'. E IN ROAD-INCLUDES SHOULDER M OTHER`. �. � NO UNUSUAL CONDITIONS F NOT IN ROAD _ N NONE APPARENT G APPROACHING I LEAVING SCHOOL BUS 10 RUNAWA VEHICLE H MISCELLANEOUS INDWA TIi I�G r rw ,t1�►c.t. /Y TNESSES 1 ['"ASSE!`GEFlu r� PAGE T)M€T1406) NCICNUM0tA OFFICtRLD. NUMBER - y a Z l Iw� ,its PASS£NOER EXTENT OF INJURY( "X" ONE) INJURED WAS ("X" ONE ) PARTY BEAT SAFETY ALY ONLY AOE SIX - - NUMBER POS, EQUIP. EJECTED FATAL SEVERE OTHER VISIBLE COMPLAINT j�'^'''`� INJURY INJURY INJURY OF PAIN DRIVER P#}"`A'�S''S. PED. $ICYCUST OTHER I t D.O.S.I ADDRESS �y ,r} �.y TBLEP € 1! :' /7 I� LQ. varia- /aVc- dtiI +cr l� )RED Y)TRANSPORTED BY: TAKEN TO: AMlz :Riot INJURIES /i t/V VICTIM OF VIOLENT CRIME NOTIFIED 0 C: ❑ ❑ ❑ C1 D 0 ❑ 0 I I D.O.N.I ADDRESS TELEPHONE RED ONLY)TRANSPORTED BY, TAKEN TO: Rist INJURIES (' '� ❑ VICTIM OF VIOLENT CRIME NOTIFIED S,..S n 0 {ry`�!❑ 1. F /D.0.8./ADDRtSS TELEPHONE ED ONLY)TRANSPORTED BY: TAKEN TO: ISE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED 0 ❑ ❑ ❑ 0 C 10 1 F I D.O.s.I ADDRESS TELEPHONE.. :D ONLY)TRANSPORTED BY: TAKEN TO: ' tat INJURIES '} �} ("""'� 10, VICTIM OF VIOLENT CRIME NOTIFIED [``"� 0 0.0.6.t ADDRESS TELEPHONE iD ONLYI TRANSPORTED BY: TAKEN TO: BE INJURIES +-+•y , -tk )��-}(VICTIM OF VIOLENT CRIME NOTIFIED 00 10 10 �(--•�� D.D.S.I ADDRSSS TELEPHONE O ONLY)TRANSPORTED BY: TAKEN TO: If INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ER'S NAME I.D.NUMBERMO. DAY YEAR REVIEWER'S NAME MO, DAY YEA 1, leLf� 6/SUPPLEMENTAL .ev 7"90)Op{042 page 7dy, ,NCIDENT/OCCURRENCE TIME 9400) NC1C NUMBER OFFICER I.D.NUMBER NUMBER -23-0Oct 1 070 2419 1 /°G',1-1eJ'?2 ONE 'X"ONE TYPE SUPPLEMENTAL r X-APPLICABLE) Narrative 0 Collision report ❑BA update d Fatal ❑Hit and run update Supplemental 0 Oftr: ❑Hazardous materials ❑School bus El Other: 'Y/COUNTY/JUDICIAL DISTRICT,, REPORTING OISTRICT/BEAT CITATION NUMBER Wo 1! Z. s¢ / CATION/S JECT ISTATE HIGHWAY RELATED f ! --,47— �Yes �No NODPILADOnjb Ind I f 2 moylzs CA $04 42V;r1i 1/IY7-r -- ... 51: t' ! /" e-!j 111 'ry _ Tr Jtjar- , ' hc/` VckrJe- Incg f, .. r 2pear r7 Ver 00 , l l-. OE --She Ck P-r extT- rivraAlaal.1 or- Wo 7 ryen�. fen. her- rA n t e. n^1 e Tn V-1. 4- t h ; cz .PARER'S NAME AND W.NUMBER /� DATE REVIEWEFrS NAME DATE 0SUPPLEM1 NTAL tev 7-90)OPl 042 Page INCIDENTIOCCURRENCE TIME{2400) NCIC NUMBER OFl ICER 1.0.NUMBER NUMBER J3-2,3 --0 L/ 1 09/.3--- 0707 Fq CONE "X"ONE TYPE SUPPLEMENTAL r'X-APpL LE) x Narrative 91 Collision report E BA update ❑Fatal ❑Hit and run update El Supplemental 0 ether: El Hazardous materials 0 School bus E Other: :ITYICOUNTYJJUDICIAL DISTRICT REPORTING DISTRICTtB CION NUMBER OCATIONISUBJ T STATE HIWWAY RELATED OOCCW f7'F C,'7,1 'i7El Yes No 2. Slow speIe 5 fAj s avDr0 rti,e1`4 .r ,-� s. Gori en'ri 4. G.IG t m n ,Jr, 5. +4!+1 N --na r i 7 7. In er U f eeC 8. i/7 V-1 S 9. L e rN rr 1. 2. A l3. 4. 5. A ft r 6. 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No OSP se 16989 CASE #: 40730121 PAT.NAME: HOYi;*, CHERYL D.D.S.: 03/23/2004 Patient Care Report (PCR) Contra Costa County Event#: 4073012 Pt#: i of I Unit ID: 6028 Transport Date: 03/23/2004 DISPATCH INFORMATION Transferred- Incident Location: iV1C1 Dec.: tece€ved: 09:13:53 Transport: 09:30:00 CITY STREET Respon.Pr€: 3 )n Scene: 09:16:00 Arrive: 09:41:00 2131 PEAK.ST Change Pri: PINOLE,CA Responding With: 0 Pt.Side: 09:17.00 Available: 10:10:00 94564 LOCAL POLICE, FIRE Cancel: 10:10:00 FIRST RESPONDER kLS=TRAFFIC ACCIDENTS PATIENT DEMOts#tAf'MICS D.O.B: 01/25/1945 Age: 59 Months: Days: Vame: flOYLE,CHERYL Ethnicity: Sex: Female Weight: 180 LBS lddress: Physician: SNYDER,ROBE Triage Tag: 1939 PABLO VISTA Employer: 3AN PABLO,CA 94806 'gone: 510-234-4053 Responsible Party: 'SN: 547_62-7797 Responsible Phone: -- HISTORY OF PRESENT ILLNESS HEST PAIN :omplaints:PT WAS IN AN MVA AT A LOW RATE OF SPEED.PT WAS SELF-EXTRICATED AND AMBULATED INTO A TRAVEL AGENCY.PT C/O CHEST PAIN(LEF'r UPPER)THAT INCREASES W/PALPATION,PT HAS SOME MILD REDNESS TO kREA. PT STATES SHE DID HAVE SEATBELT ON,NO CREPITUS OR DEFORMITY NOTED.PT DENIES ANY OTHER PAIN.TX kS NOTED.NO CHANGES ON ARRIVAL.NO LOC,NO NECK/BACK PAIN,NO SOB,NO ABI)PN.PERTINENT POSITIVE:CHEST 'AIN.PERTINENT NEGATIVE:ABDOMINAL PAIN,BACK PAIN,NAUSEA,DOUBLE VISION,GENERAL WEAKNESS, 4EADACBE,SOB,DIAPHORESIS,NECK PAIN. 4echanism of injury: MOTOR VEHICLE CRASH VS MOTOR VEHICLE CRASH.Patient was Driver in a 10 mph Front fender impact >etween a Car and Car with Mild damage.Patient found SITTIN, IN STAORE. safety Equipment: :ontribut€ng Factors: Znvironmental Factors: +actors Affecting Delivery of Care: inset: Acute 'rovocation: Trauma 3ual€ty: TENDERNESS tadiat€on: NONE >everity: 5 rime on Set: 10 Minutes PAST MEDICAL HISTORY History:HYPERTENSION.ASTHMA. Allergies:PENICILLIN. Medications:ASPIRIN. CALCIUM,BECONASE,UNK CHOLESTEROL MED. CLINICAL IMPRESSION TRAUMA,MINOR CASE 21MU12 PA I A]It. ttr t'HI~ Ci3:Ct: U372, PATIENT FINOINGS L t, Cardiac Rhythm PTA: N Timet 09:23 By: FIRE,BLS EMS Rate: NIA Pt.Position: Sifting Pulse: Skin: ECG: N/A Stood Pressure: Rate: $6 Skin Color: Normal Ectopy: N/A 170/ 104 Temp: Warm Regularity: Regular Moisture: Dry Strength: Normal Cap Refill: Normal 12 Lead Interpretation: Location: Radial N/A N/A GCS Level of Consciousness ETCO2: +Dyes: 4 Conscious Respiratory: CO2 Value verbal: S Respond To: N/A Orientated to Time Rate: 16 CO2 Color Hatar: 6 Orientated to person Orientated to Event Effort: Non-labored Lung Sounds: Orientated to Place Depth: Normal Right Clear Cotal: 15 Pupils: PPRL CSM intact SA02: Left Clear tculty: Stable Comments: NARRATIVE Special Study: No TRAUMA TRIAGE CRAMS Score: Physiological Criteria: Anatomical Criteria: Mechanism: Trauma Disposition: Comments: REFUSE SERVICE 2efuse Service: PATIENT DISPOSITION Asposit#on.TRANSPORT TO ED Receiving llosp:DOCTORS SAN PALO Base Physician: 3st Time of Death: Other Hospital: Transport Priority:3 4fode of Transport:Ground by BLS Rendevouz Point: Change In Priority: kir by Request: First Respond: Mileage Scene:0.00 )estiBase Hospital: Mileage Hospital:5.30 IT/FAMILY REQUEST T/F Mtion Decision: Base Contact Time: g Total Mileage!5.30 �' 3osp Divert From: PATIENT MEDICAL INSURANCES Primary Insurance: Health Net nsurance-Health Net,Address-,,Policy#•R02662847,GROUP#-337IHA,Address- CASE#•. 4073bi2 PAT. NAME: HOJ CHERYL D.O.S.: 03/23/2004 Primary Attendant: 09508 Secondary Attendant: 01063 Primary Attendant Name: Munoz,Rick,AMR Secondary Attendant Name: Sponsler,Trenton,AMR 3rd Ptrson/Observer: r, ' + " CASE#: 4073012 PAT.NAMES HO '`'CHEPYL D.O.S.. 03/2312 4 ITREATMENT SE Time: Medic:. Procedure: 09:42 Munoz,Rick,AMR Vital Sign/ECG-Patient Semi-Fowlers.BP: 142 /88,Pulse at Radial 90 Regular Normal.Respirations: lb Non-labored Normal.Pulse Oximetry:on 02.Cardiac Rhythm:Sinus Rhythm at 90.Ectopy:None. PHYSICAL FINDINGS AIRWAY PATENT BREATHING NORMAL CIRCULATION RADIAL STRONG LOC A&OX4 HEAD NORMAL CEPHALIC FACE NO ABNORMALITY NECK NO ABNORMALITY/NO JVD LUNG SOUNDS CLEAR BILATERAL BACK NO ABNORMALITY/NON TENDER ABDOMEN NO ABNORMALITY/NON TENDER PELVIS NO ABNORMALITY/NON TENDER UPPER EXTREMITY INTACT-CMSTP LOWER EXTREMITY INTACT-CMSTP BLOOD LOSS NONE NOTED DRUGS/ETOH NIA LVL OF DISTRESS MILD CHEST TENDER r. O 4O O O � d N � Cfl � � 7 NM mm w N U U1 O l0 w t1 al 10 171 O W N N N N � m m m m6 e-1 ❑ 0000 m I[1 N W d F df St .-i N .i Ln O 4- v a v nn fry U M Q1 Gy Cd`:4 t] fn L] z r W (4f. � „ N H a7 � U VI w�i 0 ad 24 N U 7 t^ m tttt��i__ yk N to N L7 Yi O C• u7 000 0 ei Mif -0 V N QI wco a rmi N d M W W ONi C1i rNi m at to m R rt Ln :q to V O .1 ri Cs F N W vl E; O d � N d th 0 N N m d p n m1O1 S+ Od mm N y� m al d O O Ch s"1 O N cli N f1) r1 o O of 14 N H 0% N rt Y` 171 In V [� h rl O O N b `& M t]� m M 5 � 10H gn 14 fu M p " d � m .ter m 15 .�-1 a V W G cy s� m o Ooo H If ¢ W {{yy �l) N-1 r� N m v O (7 N M Cl ke rl ^.-t O O 0 0 0 O Cd tl1 W w PATIENT NAE ACCT.# CA EMER PHYS*DMC SAN PAS:,.. CMP CHERYL L HOYLE ;� ,` 000105753 PO BOX 582663 STE.D-38 MODESTO, CA 95358-0046 STATEMENT DATE PAY THIS AMOUNT PAST DUE DATE ADDRESS SERVICE REQUESTED 4/19/04 203.00 05/07/04 F SERVICES WERE RE,NDERED AT THE HOSPITAL,T11 IS BILL IS SEPARNrE FROM YOUR HOSPITAL.HILL. 1.0972 CHERYL L HOYLE MAKECHECK 1939 PABLO VISTAA AVE PAYA13LETO CA EMER PHYS*DMC SAN PABLO CMP SAN PABLO, CA 94806 PO BOX 582563 MODESTO, CA 95358-0045 ]Please Ml U address or insurance Information has changed. Make changes on reverse side. no all a a a a a a am a am a a am an as a am a a am a a am a wo all a, in am as is a am a a a a a a 11 a a a Hamm oa ■ a a a a a 11,11 r a # . ., * :. #. �.�. PLEASE MAKE COPY OF ENTtRe PAGE IF NEEr3EQ FOR INSURMCE T HERE IS A 5 10.00SERVICE CMA RGE F,OR ALL RETURNER CHECKS: 31LLING OFFICE HOURS; 8 AM-5 PM Phone o► coo 664-7660 fax ID.#*- 942494000 Para Espanol► 1-800-952-8351 4ttending Physician . GOLDIN, MARK M.D. Referring Doctor r. GOLDIN, MARK M.D. 4ccount Number t. 000105753 Service Provider r CEP BMC SAN PABLO CAMPUS patient Name I-- CHERYL L HOYLE Statement [late w- 4/19/04 DA'T'E POS DIAGNOSIS DESCRIPTION OF SERVICES AMOUNT 03/23704 4 78650 95283 LEVEL 3 EMERGENCY, PHYS CHARGE 1.80.00 03/23/04 4 78650 94760/26 PULSE OXIMETRY, SINGLE 23.00 Total for Claim: 203.00 r F PAYMEN C OF THIS ACCOUN IS YOUR RESPONSIBILITY. IF YOU HAVE. INSURANCE, PLEASE CONTACT THIS O FIC . THANK YOU a MUM EMPLOYER PRIMARY INJURY DACE ADMISSION DATE DISCHARGE DATE BALANCE DUE INSURANCE US TIRE SALES AND SE ** SELF PAY/NO INSUR 03/23/04 203.00 AMR (INVOICE American Medical Response AMERI �N� JIEDICAL RESPONSE WEST ACCT# PATIENT NAME 4 01 -4 40 73 012-0 0 002581557 DATE OF SERVICE C Hr RY L HOYLE AMOUNTDUE 03/ Z3/2004 DUE DATE ACCOUNT NUMPER: 002581557 891 . 43 04 /26/2004 REMIT PAYMENT TO: CHERYL HOYLE 1939 PA91-0 VISTA AVE RICHIIO;JD, CA 94 .106 AMERICAN MEDICAL RESPONSE FILE 7332.9 PO 9.3OX 60000 SAN FRANCISCO. CA, 941 60-33 29 SE CHARGE MY: O VISA O MASTERCARD )UNT EXPIRATION DATE ATURE PLEASE ENTER AMOUNT PAID: $ PLEASE DETACH AND RETURN THlS PORTION WITH YOUR PAYMENT PATIENT NAME ACCOUNT NO. TRIP NO. INVOICE DATE . iERYL HOYLE 002581557-0001 1401-4407301 ?-00 04/06/ 20104 _E OF SERVICE SERVICE FROM SERVICE TO i /23/ 2004 2131 PEAR ST DOCTORS MED CENTER, SAN PAILO IMPORTANT MESSAGES CODE DESCRIPTION UNITS UNIT CHARGE TOTAL CHARGE 3368 AL-S1 Lf4EPGENCY 1 801 .49 801 .49 ) 425 URBAN ALS MILEA3E 6 14 .99 39.94 ) 398 ALS DISF SUPPLIES 1 .00 .00 :1392 ALS DEF19- DISP. SUPP 1 .001 .00 J394 ALS DISP IV SUPPLY 1 .00 .00 TOTAL CHARGES DUE 4LL RCVD : 09 : 14 IAGNOSIS: 73659 7q62 E8120 SEE REVERSE SIDE FOR INSURANCE INFORMATION AND CUSTOMER SERVICE INFORMATION 3/24/04 DRS NTED CTR SAN PABLO*PIN REGISTRATION 22 : 22: 16 2000 VALE RD SAN PABLO CA 94806 RECORD-F01 ** * * PATIENT WITH ALLERGIES ** ** BLOODLESS ** PATIENT NO: 001921169 ADMIT DT/TIME: 3/23/04 09:51 M/R IJO: 000070900 NS/ROOM/BED: CLINICS: ER FILING MR#: 70900. BY: SHAS PATIENT NAME: HOYLE, CHERYL L TITLE: MAILING ADDR: 1939 PABLO VISTA ANTE SOCIAL SECURITY: 547627797 CITY/STATE: SAN PABLO CA 94806 2136 PHONE: (510) 234-4053 PHYSICAL ADR: NPP: 2.0 DATE: 12/08/03 CITY/STATE: PHONE: ( } OCCUPATION: HOMEMAKER LANGUAGE: EN FC: 80 POB: ADMT PHYS: 4296- GOLDIN MARK A HSV: 65 DOB: 1/25/1945 ADMT PHYS PHONE: (510) 970-5430 RLG: PR PAR.: AGE: 59 Y ATTEND PHYS: 4296- GOLDIN MARK A MS: M SEX: F REF PHY: 1810-SNYDER ROBERT E PHN: 510 724-3053 SMK: N RACE: 1 FATHER'S DOB: MOTHER'S DOB: PT: 3 REF SRC: FLAG: BLOODLESS VAL:N EMER CONTACT: JOE HOYLE REL: SPOUSE ADDRESS: 1939 PABLO VISTA AVE PHONE: (510) 234-4053 CITY/STATE: SAN PABLO CA 94806 2136 NEAREST RELT: REL: ADDRESS: PHONE: { } CITY/STATE: GUARANTOR: HOYLE, CHERYL L REL- SELF ADDRESS 1: 1939 PABLO VISTA AVE PHONE: (510) 234-4053 ADDRESS 2: SOCIAL SECURITY: 547627797 CTY/STE/ZIP: SAN PABLO CA 94806 2136 OCC:HOMEMAKER AF: PAYOR NAME 1: HEALTH NET INS. PLAN ID: 186A2 PLAN NAME: HEALTH NET/HEALTH NET-FHS/HMO/POS SRV/TYPE: ALLER BILL C/O NAME: HEALTH NET FHS AUTHORIZATION: BILL ADDRESS: P.O. BOX 14702 CERT-SSN-HIC-ID#t: 547627797 CTY/STE/CNTRY: LEXINGTON KY 40512 .BILL PHONE: (800) 634-7148 BILLING NAME: GP ##: INSURED: HOYLE, JOE SEX/REL: M SPOUSE EMPLOYER: US TIRE SALES & SERVIC MSP: N ADDRESS: 1915 NATIONAL AVENUE EMP PHONE: (510) 887-1282 CITY/STATE: HAYWARD CA 94545 ESC: 1 PAYOR NAME 2: INS. PLAN ID: PLAN NAME: IPA: 0001 AFFINITY BILL C/O NAME: AUTHORIZATION: BILL ADDRESS: CERT--SSN-HIC-ID#: CTY/STE/CNTRY: BILL PHONE: ( ) 000--0000 BILLING NAlAE: GP #: INSURED: SEX/REL: EMPLOYER: ADDRESS: EMP PHONE: ( ) 000-0000 CITY/STATE: ESC: SPAN CODE: PRIOR VISIT: 2/01/04- -__-__-- FROM/T0 DATE: PRIOR HOSPITAL: CONDITION CD CONDITION CD OCCURRENCE CD/DATE OCCURRENCE CD/DATE 01 3/23/04 CHIEF COMPLAINT DESCRIPTION: CHIEF COMPLAINT CODE: I-IVA COMMENTS: CAME BY AMBULANCE PRINTED BY: PAULA.HOWARD DATE 5/4/2004 Patient Name: HOYLE, CHERYL L MedRecNo: 000070900 Account No: 1921169 Page 1 Procedure: 4901020 XR CHEST PA,LAT Perform Date/Time: 03/23/2004 10:57 Result Date/Time: 03/23/2004 17 :06: 45 Ordering Dr: 04295 GOLDIN, HARK ------------------------------------------------------------------------------- Verified Reason: MVA Exams : DSP XR CHEST PA, LAT 2004/03/23 10: 57 PA AND LATERAL CHEST (71.020) , 3/23/04 : COMPARISON: 1/8/04 . Clinical History: Motor vehicle accident (959. 1.) Chest pain. (785.50) Findings: PA and lateral views were obtained. The lungs are normally aerated. There is minimal parenchymal scarring currently seen at the periphery of the left mid and lower lung. No mass, infiltrate or vascular congestion is present. Heart size is normal . No hilar or mediastinal enlargement is seen. No effusion is observed. Bony thorax is grossly intact. CONCLUSION: No evidence of acute pulmonary 4isease. No significant: change from 1/8/04 . DD: 3/23/04 Dictated By: TAO, KEITH E.M. Transcribed By: WILLIAMS 03/23/2004 12 : 45 Verified by: TAO, KEITH E.M. Verified on: 2004/03/23 17:05:34 . 00 RESULT ID / ADDENDUM: 1050374 / 0 Page 1 of 1 *** end of result **** n PRINTED BY: PAULA.HOWARD DATE 5/4/2004 t' .� Doctors Medical Ceretec Pt.Name: p C.RS AE D,-C � :�Att PAILO PI N CP Pr I ;Re-ASSess 0019211b9 000070900 ER ; 1�{?trLE � C� t.E �� l .. r Age: Priority I !I tit i PMS Q t; SKY-,AR ' OW/0 SOC)ther: GENERA U.RiC" SKYLAR SoiYQER ROBERT , C" CC: -/10 Peds(lU tided ss,byanr: Der tarsi No ® Ci 3 J p Wt• V.A. Other: 0— TOO— OD Head dry trth-t8ma) ti A/ Iltt =6 ®tow PMH: Q No scrims Ittnsss I ITN 0 D:tt (]Anglna/?%tl®CI lP d PTCA ci A•riNArrythntta❑CVAMA p t.tutu AsihmaJCUI'D ©DWyels Chat Cl S;eels O QVT OPE D Cather Immunization:❑UTO Ci Not UTD C]liner uni Into Gwen Tetanus: yrs. MEC)S: ONoneAAak O COUMADIN PSN: p CHOLE 1 APPY/LAF/C-SECT/HYSTER ALLERGIES:,o NKD,% C tr+ Abuse Scat No EvitWnee 0 Rett Criteria TO S<t en Mla stick 13 I'rceauittxts int. AIA - Allu interpreter: Fall WvLL214pne ®At Risk SOC: .tdrszg5 hies at: maXFAtone amity Si nature; RN FH: t3 CAD ! U11 ®Asthma t']Seintres n wasing Nome b CH sties. Ste HPI REVIEW OF SYSTEMS (circle Ahnnnnats) Neg. C HPI REVIEW OF SYSTEMS (Circle AMonnals) CONST: fiver-chith-wi.kiss-weaLnem-night sweats ENM.Pidvutia-Rtivdip a EYES:aruky change ENW- bead"t kis-tats be-nasal drainage use thenal GU/GYN:dyuln$-utgtncy-rmgacney-hcmatuda:VAt`1 toad.DIC nES? -Laugh-spmum-whettint MUSC`new bme at jnlnt pxln-two steams CY: tttstpaitr po-ttsitaiicmt-Pt3D-tvth+ysttea.esk+sta Y INTEL: sLinkxk+Mat-tah 1 ,. Csi:o ca-w 'ting-diarrhta- -uxk.-bmuttschetia NEURO: Syler:s"-focalweakneu-ttA-sclrure-dizrinea r ®All(XtW Systems W"ativs 13 Complete History Unobtsktable Out to: SN 11;;ad 8 agree i f Tr ee►b►f>!: Al9Ne a A&WIModifft 51 Vn ter+ r I qI dn v t ,r. mo� RK ti hrrnt . S C 9 97T KIM- C bt Time TuneTime Queered LAB!X-PLAY/EKG Entry dme Initial Ordered MEDS/TRE'ATMENTS Completed Initial J CSC Q MP(B/C)O Amyrase 3 NS Lock O Pox Q Q Monitor 3 CKMB O TRI O BND O EKG J th�� J PT SCI INR Q T&C&I 0 ASG 3 iv of,_tr S0Ivs_,--Rus+ ,o,,,,,10hr. J UA(d/L.)(CIS)O BLCU I.X_ J HHN 5mg alktut 0I Vii_.-.,.,. J DIG O SA 4 ASA 0 TYL Q UR-TOX J Continuous NES—mg over ter. UR/OUANF 0 TSRH J Conscious sED O See Nurses Nis. I i- CX . C:-SP D ASD SER J C / r• abd/ lva +/- O Contr J US ASO(pelvis ) r/o t 'a ACCU4 ' ! r PAIN/COMFORT 0 DENIES PAIN INTERVENTIONS i DIAGNOSTIC i PROCEDURES Time Init Assessment 0 Provider notified of patient arfivallstatus t.Complete table for complaint of pain Location Onset I Pattern g I Radlatlan me»sty OgOustlty ❑02 Urrdn via ❑ NC ❑ Mask 0 Monitor/R hm q.-. � K Y I -Intermittent C - Coneslant A-Acwfe Ct-Chronic ©I~Kt3 don® Radiation N -No Y -Yes,Ust sit® p 02 Sat 13 FtA % 002 `yo Description A - Aching g - Burning C-Cramping 0. Et P - Putiirg PR- essure S-Sharp Et Breathing treatment done by 0 AN 0 PIT SH• Shoots T /Throbbing 2.Patient stated goal for pain raiiei 0•t o ie 0 Labs drawn E3 Lab E3 Nurse E] Other S.What causes pain to Increase 0 Mas 4.What relieves pain s your pain affect ❑urine C t;,ofd 0 Med'"tion 0 Ability to eat Cl Safi image -ray p y��r Sttturned 13 Eating ❑Relaxation Technique O Activity 0 Sexuality o X M Exercise Ct Repositioning ❑EW»inatio» Cl Steep 0 pelvic exam by 0lieat C Rest t:3 Mood E3 Social Interactiarr aMatssage d Sleep ❑NG tube# © Lavage# E3 War 0 Foley Cath# 0 Inlout Cath r S.is there anything else you want to ton me about the pain?(use patient's own words) ❑ Return cc 13 DC 0 Glucometer PHYSICAL ASSESSMENT 13 Cooling measures IWA WNL ASN Comments 0 ice 0 Elevate r Near D 0 CI .w. d Elastic wrap Chest 0 0 0 � � _ p Immobilizedsiing Lungs C3 ❑ ® Cl Spl;r►t/Cast Abdomen U 0 C] I� sadvspine U C) Ct p Circ lsens WNL after placement Pelvis ❑ ❑ 0 42 ©Crutches dispensed ❑Training Done Gicu 0 13 13 Extremnies 0 ❑ D � E3 Irrigation 13 Ear 13 Eye Ct Wound ❑Other Nutrtt onat Status 13 Q 13 Wounds cleansed wl Functional status 0 Ct - ❑Sutured b r' Pressure Sore ®NIA Localk" y SIGNATURE _{ _ __ ..RN 0 Sutures removed NEUROL1jrx CAL C ECKS U NIA 0 Messing w1 ru WS Umbs GLA500W k*W Cl Spinal precautions cleared by MD _LT rrs LT AT 0 Spinal precautions removed by tea sm 5 R Alm tae Art+ Log L4 U E 1Aorrr Yero rt Tatar CT Scan ❑wMurse 3 Ia Returned 13 Ultrasound r Visual C3 WA ❑ Uncoffected R 2t}i L 201 ❑ Returned Acuity d Corrected R 201 L 20! E3 double Vision El Blurred Vislon © WA C3 Lumbar puncture by Other E3 MEDICATION I IV THERAPY POST INTERVENTION RESPONSE r r k,,) Time Medk;a6m/1VSokA1oss Dose/Rate Route Site Cath per' Initials Time Initials` f/ Size y N Y G fit �� i r- eRctorsts } wUSa tserrx P EMERGENCY MP'ARTMENT PATIENTT t � �6St3S�/LZJ1C ti�'1 CARE RECORD E1 380 Z3�911 5 tjV!Aa *S ')It 'n Page 2ot3 c, bY"A7tS r _ _ �_ r rnrT `?I. TfIn ., PREHOSPITAL CAVE REPORT CA-Contra Costa Case 9. 4073012 Pt 1 of 1 Unit 1b: 6028 bate: 3/23/2004 Recelved: 09:13 Transrerre Available: 10:10 incident Locatton: CITY STREET NfClt Dec.: On Scene: 09:18 Transport: 09:30 Cancel: 10:10 2131 PEAR ST.PiNOLE.CA 94584 Response Code: 3 At Pt.Side: 09:17 Arrive: 09:41 Change In Code Responding With: LOCAL POLICE, FIRE FIRST RESPONDER Natureof`Catl: ALS-TRAFFIC ACCIDENTS r. 0 Age Estimated Name: HOYLE,CHERYL D.O.B.: 01/25/1945 Age 59 year hlonths: flays: Address: 1939 PABLO VISTA, Ethnicity: Sex Femate 1N'tigh 180 LES +CIty.Statt,Zip: SAN PABLO,CA 94808 Physician: SNYDER,ROBERT Triage Tae t pbone: (510)234.4053 Employer: SSN: 547-63-7797 Rtspousibte Party: Phone: 111ILtAffilvilDI Chief Complaint: CHEST PAIN II Pi: PT WAS IN AN MVA AT A LOW RATE OF SPEED.PT WAS SELF-EXTRICATED AND AMBU1LATED INTO A TRAVEL AGENCY.PT C/O CHEST PAIN(LEFT UPPER)THAT INCREASES Wf PALPATION.PT HAS SOME MILD REDNESS TO AREA. PT STATES SHE DID HAVE SEATBELT ON.NO CREPITUS OR DEFORMITY NOTED.PT DENIES ANY OTHER PAIN.TX AS NOTED.NO CHANGES ON ARRIVAL.NO LOC,NO NECWBACKPAIN.No 509.NOABD PN.PERTINENT POSITIVE:CHEST PAIN.PERTINENT NEGATIVE:ABDOMINAL PAIN,BACK PAIN.DIAPHORESIS, DOUBLE VISION,GENERAL WEAKNESS,HEADACHE.NAUSEA.NECK PAIN.SOB. Onset: Acute provocation: "Trauma Quality: TENDERNESS Radiation: NONE Severity: 5 Time on Set: 10 Minutes b fechanivm of Injury: MOTOR VEHICLE CRASH VS MOTOR VEHICLE CRASH.Patient was Diver In a 10 mph Front fender Impact bet%ven a Car and Car with Mild damage.Patient found SITTING IN STAORE. Safety Equipment: Contributing Factors: Environmental Factors: i"attors Affecting delivery Of Care: s �• fiistoryt HYPERTENSION.ASTHMA. Allergies: PENICILLIN. Medications.- ASPIRIN. CALCIUM,BECONASE,UNKCHOLESTEROL MED. Primary Assessmtnt: TRAUMA.MINOR Secondary Assessment i Pate 1 o1`3 3442*004WS324AM CMOs 40730:1 tlsi S! ims T2074716 .t, h t or t Dry MAW" h NOYLP-CHERYL V206D i ZZGE01:0IM170 t a PRINTED BY: PAULA.HOWARD DATE 5/4/2004 ® rTA-. Tuns: 09.23 By: EIRE.SLS EMS Cardlat Rhythm Pt.Position.- Sitting Pulse Skin hate: WA .-hood Pressuret 170 1 104 Rate: 66 Color: Normal ECG- WA Regularity.- Regular Temps Wam7 Ectopy: WA Strength: Normal Moisture* Cary Location: Radial Cap Refills Normal 12Lead tnterpretarlon: WA CCS Level of Consciousness Respiratory ETCO2 Eyess 4 Conscious Rate: 16 CO2 Value: 1JIA Verbal 5 RespondTo.- WA Orientated to Time Effort: Non-labtxed C42 Color: NLA !Motor 6 Orientated to Petson Orientated to Event Dtpth: Normal Totals 15 Orientated to Place Lung Sounds Paapits: PERL CSM Intact SA02: WA Right: Clear Lela Clear Acuity; Stable Comments s AIRWAY PATENT BREATHING NORMAL CIRCULATION RADIAL STRONG LOC A&OX4 LVL OF DISTRESS MILD HEAD NORMAL CEPHALIC FACE NO ABNORMALITY NECK NO ABNORMALtTYINO JVD CII TEST TENDER L UPPER CHEST LtJNG SOUNDS CLEAR BILATERAL BACK NO ASNORMALCTYlNON TENDER i ARDC1tiEN NO ABNORMALITYINON TENDER PELVIS NO ABNORMALTTYINON TENDER IlP1'ER EXTREMM INTACT-CMSTP LONVER it XTREMITY INTACT-CAMSTP BLOOD LOSS NONE NOTED DRUCSIET011 WA -IT-1-TTIMM 1111111 0 Special Study J-jj* •� PTA 'Gime Medic Procedure i0 0942 Mutt=PJckAAMlt Vital S1gn1ECG-patient Semi+owlem.OP.142 186.Pulse at Radial 90 Regular N rmal. Respirations.10 Non4abored Normal.Pulse Oximetry:on 02.Cardiac Rhythm:Sinus Rhythm at 90.Ectopy:None. Page 2 of 3 30NM0:53:5 AM Cre 0 4077612 um to 6021 T207.1716 -L h 1 or 1 Daft 321+2004 h: laoyLf-CHERYL V2061) =000UOUX5170 f PRINTED BY: PAULA.HOWARD DATE 5/4/2004 1 B i ClIMM Store I Phydologicst Criteria: i Anatomic Criteria: Afechanism r Traums Disposition: Paramedic Judgment: Dispostion: TRANSPORT TO ED Receiving hospital: DOCTORS SAN PA13LO AID Consult: 13 lEst Tlme Dtaths 01htr hospital: Base Physcisn: Mode orTransport: Ground by BLS Rendezvous Point: Transport Prlaritys 3 Air Rtquest By: First Respond Assist: n Change in Priority: Reason For Air: Mase ttospitatr Mittage5ctne: 0 Dtstinatton Deris: PTIFAMtLY i2i=tylU> S Rase hosp Contact: 0 hiileage Hospital: 5.3 hosp Divert From: Base Contact Time: ietst h1#tester 6.30 i Physitlan Ordtrr Primary Insurance- Health Not Insurance-Health Net,Address-.,Policy#-R02662847,GROUP#-3371 HA,Address=, r' ist Attendant: Nfunoz,Ricic.AMR 2nd Attendant: 5ponsicr,Tmnion AMR 3rd Attendant: Hospital Signature: Number: 09308 Number: 01063 i Page 3 on sr2 ttoW 0.1327 AM CM*k 403413 t%k 1b sass T207.17t4 .L P4 t or t thea sasrd44 R Nt1Yt.8,MAYL V2460 22s;E0214127.ti70 PRINTED BY: PAULA.HOWARD DATE 5/4/2004 S*� �ylj'j t •. Doctors Medical Center San Pablo/Pinole tl� 2000 Vale Road Sart Pablo.CA 94gOG LRS KED CTR SAN P A B L tl PIN r (510)970-5431) ' C101q211b"I 000070900 ER ED NURSING NOTES "f rt E - C►+E R r.. L _ u, a f C+t $K l 114z" , te`►" t� iA��,tr���,�,R �ROBCRT DISCHARGE INSTRUCTIONS � � L^ �rCy�� .St e150.. 0-Y I t,!^ , � � �0 �2 3`701 11..:x-. llc . . i Este EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mg. Disp. Sig. Do not drive wNle Dea ` ; Patient Name and Address taking medication. CAI ?11 + i } - Do not substitute. PA/MCr Signalure" !f Transmittal Carder PAIMD Printer!Name' - 6111, b€u PLEASE NOTE:The examination and treatment that you have received In the Emergency Department has been given on an emergency basis only,and is not intended to be a substitute for complete medical care.It Is Important that you be checked again as lnstructed.If an x-ray or EKGhas been performed,!t has bean read bn>t preliminary basis only, and will be reviewed by a tadiologist or internist within 24 hours.You will be notified It additional findings are noted. Patient seen by JR O IA 0 RT 0 DCO LH O RD 0 KR O Return to our ER for re-check In: PA's: CR 0 CW Cl LT CI -GE E7 CM® 0 1 day Cl 2 days r other Work excuse,absence from work for: t Follow up with: In this many bays: Cl i day CJ 2 days 0 3 days d PMD t Cl '1 day CI other 0 RHO 0 ECC: Q 3 days ❑ Other _Ste_ CI 1 week Spanish El Can E7 Off ADDITIONAL INSTRUCTIONS- For the health t your chid follow up with your d toe to insure that your child is 11ulli Inrimnized. The law requires aft children under d years of age or So fbs.or less be placed In a car seat during transportation In a vehicle. IF YOUR SYMPTOM$ GET WORSE,OR YOU START HAVING ANY NEW PROBLEMS,RETURN TO THE EMERGENCY ' DEPARTMENT IMMEDIATELY. j I avdrecelved and understand the ins tions outlined above, Pe rent orlepreuentat' Stall v Deb WC Time YOUR DIAGNOSIS IS: ❑ CALL BACK uctrarwountture heart lnj ry Viral URI PneumoniatBror4ftis FP �ntroi oldie media Miscarriage,5pont. NO spr4ratrain Cbncasskrn sasimentedlis COP00ima otititJE lima Miscarriage.Thmien ovarian cyst r Buuftrasitm Nedi/Back Pain tilced6astritts Teasrcin HOW mollis,Viral Asthma lrregutu Vag.Bleed Curettage trtxstus€on Corral Abrasion Esepliagdis Hyperlenslon ryrrpdis,sirep Poisoning.Peds vaginitis Menstrual Pain Abse stove,Recurrent Bi o i Pox Febrile sebts: Cystitis,Fem. Kidney stent t Cast and Splint Care CMOs Abdominal Unknown CorilunctAls Arfergic Radian PyelwMptnitls GGchiamydia Suture Removal- Animal Bite Aldol Nim synd. Migtafne Headat:he Cioup .. slaushis scabies Deritaf Pain no Complications Diabetes Chest Psh-sari Cardiac Atopic Demtatifis ureteral stone Airanal Bile Dthydration conud vermat€t€s Other ron+uxruSS.fsttaroar PRINTED BY: PAIYAf`.AOA4"�� DATE 5/4/2004 LAW OFFICES JAMES M. ROGERS May 11,2004 JAMES M.ROGERS 1941 Jackson Street Tel. (510)444-4464 JUDITH W.MARSHCounty Administrator Oakland, California 94612 Fax(510)444-4460 C Risk Management Division 2530 Arnold Drive, Suite 140 Martinez, CA 94553 VIA CERTIFIED MAILryx 4AUl 0 ? tire)�r'wGf Si CLAIM AGAINST PUBLIC ENTITY f {` Name of Public Entity: County of Contra Costa Name and Address of Claimant: Cheryl Hoyle 1939 Pablo Vista Ave. San Pablo, CA 94806 Send Notices To: Attorney James M. Rogers, Moon Bang, Paralegal 1941 Jackson Street,Oakland, CA 94612, (510)444-4464. Place and Date of Occurrence: Pinole Circumstances of Occurrence: Collision with county vehicle Description of Damage and Loss: Serious personal injury, medical and other associated and incidental expenses, lost wages. Total Amount Claimed: In excess of$10,000;jurisdiction in Limited Court. Breakdown of Amount Claimed: General andpec' . amages. Dated: Signed: t t't- J s M Ro ' rs L OFFI 1 S OF JAMES M. ROGERS Attorney f Claimant ' RECEIVED JUL 0 7,20104 Cl/ A D t � BOARD OTF—,�DPER CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:AUGUST 10 2004'' 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 L 915.4. Please note all"Warnings". AMOUNT: $3,530.37 CLAIMANT: SHELLY D. RAY C,C.-,; 3N C,4 !NS ATTORNEY: UNKNO147N DATE RECEIVED: JULY 09, 2004 ADDRESS: P.O. BOX 880 BY DELIVERY TO CLERK ON: JULY 09, 2004 BRENTWOOD, CA 94513 .. EKED TFROUGH BY MAIL POSTMARKED: ���HARD COPY TO FOLLOW BY MAIL FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN erk Dated: JULY 09 2004 By: Deputy II. FROM: County Counsel, TO: Clerk of the Beard of Sup isors (`This claim complies substantially with Sections 910 and 910.2. { } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { ) Other: Dated: w ' , By: f 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/,BOARD ORDER: By unanimous vote of the Supervisors present: { jThis 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: /20 4J�C fZJOHN SWEETEN, CLERK, By AvAoL , 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 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 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 iJ 437 2288 _ 610 437 2289 1904,07-09 06:27 #77-0 P.01/02 Claim to: BOA," Of SU'ERVISQ.RS OF CON COSTA COU"l��' A Ciaians relating to causes ofaezion for death or for injury to person or to personal prvpezty or growing craps and whivh accrue on or before December 31, l98.7, must be presented not later than the. l Wh day after the accival of'the cause of action, Claims relating to causes ofactiom for death or for injury to - person or to personal property or Vowing craps and which accru: on or aflcr,�artu,anr 1, 1988, r. $- t be presented not later than six months after the acental of the cause of action. Claims relating xo arly othrr cause of action must be presented not later than one year after the accWal of the causc of acorn. (CMV't Code 911.2.) B- Claims must be filed with tht Clerk of the Board oil'Supervisors a$its offi;r in Roorr, 106, coy my Adre-Inistration Building, 651 1'irte Sheet, Mani nez, CA 94553- C. If claim is against a dtsi67t governed by the$oard of Supervisors, rather than the County, ihe.name of $lhe District should be tilted in. 17_ If the claim is against more than one public entity, se-parate claims must be filed against each public entity, E. Fraud, See }penalty for fraudule:tt claims, penal Code Sec. 72 at the end of this fOrrn. We**W***Vt+k4hsikl♦♦aa#**a*,p+eltW*fr'arar�s#w►M+►s�e�swre�sertrsrc raae�orsaw +r a:ass*�nrsa.y �s prov�rr RJE Claim By Deserved for Clerk's filing stamp 5 20,€.!# k t$gairt�t the County of Centra. Costa or � � {n� District) (Fill in name) The undersigned claimant hereby makes Claim against the County of Contra Costa of the above-named disttiC3 in the sum of s �7mid in support oftms claire represents as follows: 1. When did the damage or injury c!=r?(Give,exact date and hoar) 2. Wbere did the darnage or inury ocvr?(Include city and wunty) , 7� r "$/ 0(1 '61r-ma- 3. How dial the damage or injury occur? (Give hall del.ails; use extra paper if required) FROM :G S+`i_ T C-ONSTRUCT'ON 1 910 437 2289 11904,07-09 06: 10 #729 F'.02/0u, 4. What particular act or orussion on the Sart o county or district ocern, servants, or eMpioyeees caused t e injury or darnaSe' pea t /fit c %rr ct -z 17,9v , e, ,�.*t- 7 ke Beit" pAot e, 5. 'What are the names orwunry or district otlicars, servants, or employees causing the damage or injury? 6, What damage or iniuries do you claim resulted? (Crave full extent of injuries or dsrnages claimed. attach two estimates for auto damage,) ?_ Hov/was'the atnouatt claimed above co uted?(include the estimated amount of any prospective injury or darnage.) ' 8. Names and addresses ofWitnesSeS, donors, ant#110spitals. � 2 00 9. istt axrt atta a yta a cahrsnt- arirt` DAM AMt3UN"r 'iz�i�i��kfl.*4�VA�f�DMii�li�El+#*6#M#*i�l�i�i��Ct�6#�#�styili71�4ii6ttirL3�.MCFi�Cs�as�rA 4rti�Yiu�isucialbRi9l#a' Gov. Code Sec. 910.2 provides "The claim mast be signed by the claimant or by some person on his behalf SIS NOTIC..E TO-, (, vornev Name and AddreSS of Attorney aitrtant's Sig, red (Address`s.�. Te)ephtane No. Telephone No, .�..�.$N38bi4a6��0#*�Y'$+►Ri.�bOii�i»�.�...*.....���..*�..�litiY3tit��ikA4tLa3i9tii4�tit84i�ti�t��k N077t moo"72 of the Pest Grade pvvi : Event Perrno wLa,with intent 10 dchaad,ptWbtS for allowance of tbr,payn=1 to any stilt board or MScar.r, ar to amy Cou0ty, city,crdistrict board or offirxr,3vth�:zcd to allow or pair tht s$rtie i9'gt'Iauinc,atty Usc or fvudul=t rUirtt,b"a4otmit voucher,of w7idnl;,is punishablc cither by i=Kisoarntm in the county_ia.il fora pc iod rx not more xhaA atre year,by a Eme of W ratce0&nf one thousr Ad(S 1,0W),or by beth such ioaprism ocnt aM fine,orby i,ompris®ttmmi in tb?-gwe prison,by a fte of not excrtding teat thmtasa d doban(S 10,060),or by trots mtb im;wiwt tern and floe. PROM aP9* LE :T CCIhS TFUCTI Ik 1 SIO X437 2249 1904,0"7-09 06: 11 k 72`3 P. 4/0E; 0?/09,/20G4 at 03--05 PM Job Number: NIKVM EIZVEN BODY SHOP License 4:AE069902 GUARANTEED COLLISION REPAIR. 645 EAST 11TH STREET OAnAND, (",A 94606--3639 (5-10) 8335-2572 Fax: '510) 135-5949 VRRLXXTb"Y ESTIbMTE Written By: CHRIS DRUMMOND Adjuster: Insur&d : SHELLY RACY claam # Cl%mar: SHELLY RAY Policy # weak: PC BOX 880 Dadw--tible: BERSNTWOOD, CA 94513 Date of Xoxs: Day: If510) 43 7-2068 Type of Lose: Point of xaot- InaTect Locati*n- 1"virance C y- Lays to Repair 5 2001 GXC K1500 4X4 SIEPRA EXT 8-5.3L-rl 4D LONG RED Int: WN: GTF--K 9991&;1s773l Lia: 5X86526 CA Prod Date: tar: Tilt Wheel Intermittent Wipers Dual MxrMrs Clear Coat Paint Poorer Steering Power Brakes An-i--Lock Bxa)kes (4) Driver Air sag Passenger A-ir Bach 4 Whael Disc drakes Cloth Seats Split Bench Seats Rear Step Bumper Stymied Shell Wheels NUJ. OF. DESCR.IPTIWI QTY EXT. PRICE :f- OR PAINT -------------------------------------------------------------- 2 14.100D 2"' Rpr Hood Chevrolet w/o HD 0 0.00 _4 « �) .G 3 Add for Clear Coat 0 0.00 0.0 l..> 40 RePI BUG SH"IEU 1 79. 95 0_6 . CAB 6 R&I cowl grille 0 0-00 Incl, Rpt' Rate` panel 4 door 0 0,00 1..0 x Overlap Major Adj , Patnel. 0 0,00 +�,,7 5 --o Add for Clem Coat 0 0, 00 0. 6 10 R R.T Drip w1str� C1 { _ � 0 1 1R&I LT Dlrip w'strip 0 0.00 0-3 o, c 12 R&I RT Molding roof joint 0 0,00 0�2 3 R&1 IT Molding roof ,joint 0 14 R.&I RT Door l.s't rp front doo - 0 0..00 0-5 0,0 15 R&I L'+ Door w'strip front doox s 0: 00 0.3 0.0 '6 WINDSHIELD 17 R41 RT Wiper arm 0 01-00, -r:cl 0_0 ifs R11 1,T Viper a 0 0.00 Inc ],k C"),0 i 06 11 CONSTRUCT!C .' - 01/06/2004 at 0-2:05 Pm Job Number: 2001 GMC. K1500 4X4 STP"A. EXT 9-5.3L-PI PI 4D ,LONG RED Int: N'C_ CP. DESCRIPTION QTY EXT. P'SCE LABOR PAINT -------------------------------------------------------------------------- 19 Repl Windshield GM tinted 289.58 2. 0 0.0 20 Rept Windshield urethane kit I 52 , 63 0.0 0. 0 2? ELECT zea CAI, 22 R&I Antenna mast bracket 0 0k00 0.2 0.0 23 FENDER 24* Rpr RT Fender Chevrolet. 0 0 .00 0.5 2.2 25 ave--lap Major Adj . Paned 0 0.00 U- 0 -0.4 2:6 .Add for fear Coat 0 0..00 0. 0 0.4 7F Rpr Li Fender Chevrolet 0 0,00 0. 5 2..2 25 Overlap Major Aaij . Panel 0 ",..Ott 0.0 -0 4 29* Add for Clear Coat 0 0.00 0.0 O. 4 30 R&1 RT Flare paintedC 0. 0o O. 4 ' I i R&T LT glare painted. 0 0„00 0. 4 0. 0 32 GRILLE 33 R R&T. grille asst' 0 a_00 0 u 5 � s0 4# R. &I REAR ROOF LAAYIP 0 0..0t; J. 4 0, 0 35 FLACK GLASS R§1 Back glass tinted non heated a 0,00 1.5 090 37 FRONT DOOR :33' Pp: RT Door shell 0 0'.00 0.3 2. 4 39 Overlap Major Adj . Panel 0 0.00 5'. � -0. 4 40* Add for C14 r Coat 0 0.00 0:'Q 0.4 sl R&1 RT R&I trio. pane. 0 0. 00 0. 4 0.0 42 R.&I RT Handle, c;atside w/o luxury 0 0.00 O} 4 0.0 r;kg 44 MISGELLANZCUS tOVF,,.ATIt``1.NS 45 Repl Cover oar/ Sag 1 0.00 0.2- 0. 0 46## TINT COLOR 1 O.OD Ov V 0 PANELS 0# ?OLISH EXTERIOR SCUFFS O. OG 2 .0 O. C 4 NA2 MAT D15POSA1 5.00 X 0. 0 0„ ------------------------------------------------------------- r Subtotals -=> 42OP . 1.15 Parts Body Labor 21. 6 hr5 0 $ '?J. 00/hr 1512 . 00 Paint Labor 14 . 4 hrs @ 5 `70.00/hr 1008. 00 Paint Supplies 14 .. 4 hrF, @ $ 33. 00/h.r 4'75.20 sody Supplies 131 . 1 h-rs @ S 2 .00/hr 26.20 Sublet/Misc. 6.00 SUBTOTAL �55 8 :15500t �} s344P.� sa.Le Q' Tax 9.G,.� a .�. 8 6 � : 5500t 80'epi 2 ii r°Rort :f c+Ef_EC7 CONSTRUCTION 1 Sits 4S7 2289 1���,�7-tT� 06: 11 #^s�3 P. �Sf�� 07/09/2004 at 03:05 RM Jlob Nur ber-- 22690 M7aI C1MR C F.STrMTE 2001 WIC K1500 4X4 SIERRA EXT 8-5_3L--F! 4D LONG REQ: 110t: GRA.` D TOTAL ADJ'U5T.MENTS: Deductib.e 0.00 CUSTOMER PAY �.J (S. + !Y" G1 y, .+y 0 ALL REPAIRS ARE (3UAR.2A.N'T`EED A. 1MINTMtyj-1 GE �.,; YEAR PLEASE AS !OR A COPY OF OUR. WARR.A.NTY FOR YOUR, pFrTECT1ON CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON T PIIS; FORM: ANY PERSON WHO KNCY TNGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOP, THE PAYMENT Of A LOSS .iS GUIELTY OF A. CRIME AND Y- AY Sr; S BjEC`I TC F'-N 'S AND CONFINEMENT ITS STATE PRISON, THE FOLLOWING ,IS A :LIST GF AS8-REVIA':"IONS OR SYMBOLS TH-kT Y BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLAC-ED- MOTOR ,ABBP,E�17,ATI(it4S/SYYABO :S-- D=DISCONTINUED PARI" A=APPROXIIAATE PEKE LAJ:3OR TY[IS; E'-EGDY ,.t80.R �'y'=D. AI, INOS1IC E=RL CTR:CJ �'-FS. C—ISL'A,,.f` S M=MEC.r"fi.ANI4CAL 2""PAINT T...esBOR ,S=STRUCTUR L T=TA.2:ED M.ISCFLLANECQS X-NON TAXED ?`DISCr LLAT EODS P,�,I «t AYS ADJJ= D:TACENT P.,I,GNT A,.i.I(;?v BLND=BL'END CAPA--CFRTIFTZD AUTOMOTIVE PARTS ASSOCIA TON f&R-DISCONNECT .A9i RECONNECT EST=a,ET1, TE EXT. RR,ICE=Milli PRICE MULTIPLIED BY TffE QUANTITY JNCL=INCLUDE0 2?TSC=MISCE w. NFCUS 'NAGS-NATIONAL AUTO GLASS SPECIFICATIONS NON -ADJ=Nara, ADJACENT 0/11=W :RHAUL c:P-CPERkTION NO=LINE NUMBER QTY=QUANTITY QVIAL RECY QUALITY RECYCLED PARI QUAL REPL-QUALI."Y REPLkCMENT FART COIMP REPT, PARTS=CO PETITIVE REPIACEMEIN L PART REC0ND=PEC4N0'J TI0N R.gM=REFINTSF Rr P=R.F.P1 ACE R&I=REaMOVE: XV-4 wN'STA,`i..L nR=R 'f AND REPLACE RPR-REPAIR R.T=RIGHT SECT-SECT-10N SUV aST BLET ITI-. E I :0 WITHOUT' W/ =STH?f SYMSOL S: #�-MA UTAI: LINE ENTRY *==OTHER+�% i I'" M P w2 bIFGRTIC2X AS �_ _ . . CTC}? Am_ r CRA23GIT7� DA ALAS WITH A-r"TZL 1-1ARK `l NT--NC,TES A:.'T-AC:14 D TO I.I,n. `rI'=ti..l`+'Ti AC`x T .RAS DUALT ICCA�'ION' k4D VALIDATION PROGP-A.M. Z$tima.t* based on MOTOR CR"R ESTL`4AT1NGr GUIDE. Unless otherwise noted a3.1 items are der iVed fs^Ir, the Gu-*Ldp nRIGR99 Database nate 06jzoo4, CCC Data Date 06/2004, and the parts selacted are ,�EM--parts malitafactured by the vehicles or_:girai EqUipmenti Manu,facture?;, t r ask ; 1 or nouble Asterisk {*') indicates that the parts and/or labor infoY"tti at;:ion provided �}# mo-op may have been modified or may Lve carte from an alternate data ,source. T Ide sign t_ez' indicate Mt7'fbR NOt-Included Labor Operations. Nzn-C'sriginai Zquipment 3Kanufacturer aftermarket part4-. acre descriheb d �W AM; Qua! Repi Parts or Cosup Repl -ants which stands for compatiti.ve Repi.acement, Faits. 'Used r Partin are dept gibed as LLQ, Qual Recy Pars, RCC, or UsZD, Reconditioned parts are dencr.ibed a5 Recon. Tkocorad parwn azo described as Rotore. I-ML^rS Park Niers and Pnees are provided by ti warGlonal Auto GIass Specifications, nc- PCoA sign (#) Mems iadicate malzual ent:r'ez, Cis Pathways - A. prn, uct of Ccc T'nformat<-on Services iAc. 3 ................................................. . .............................................................. . ............................................................___. _.. ..._....... ..._..............._ __ L41wJ f } I trF August 25, 2004 Original pictures sent to Penny Bailey from Risk Management on August 25, 2004 through inter-office mail. _._:. a r.� �la Al t Y!f I: t � t •• i } :. t � , 4+ 1 'Pie Not'; 1 t Al Ak r \i Z 4' N a 11 1 .110 OR s Ar i r ,{ l i, i A 1 : f , < 7�1 7 , } s. � 1, ��" � ✓; 'R Yom. v` ��,�,�,��si�'.':. 1.. ratty'. 1 k f � r n u�. h S" vA 4 c 1 V Ao ,.s Y TRANSMIT REPORT 1904,07-09 06:27 1 S10 437 2299 GAS+ELECT CONSTRUCTION COM REMOTE STATION START TIME DURATION PRGES RESULT USER REMARKS 730 926 313 1913 07-09 06:261 00' 48 02/02 O 7541007350 -'`1,15 '24/2004 15:02 CONTPR COSTR (:CJUNT`r` CLERK OF THE � -R15104372193 NO.455 Pol Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS1ZV Q1105-1 QCLM�_� 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 Deownber 3l, )997, must be presented not later than the I00'h day after the accmal of the cause cifaction, Claims reJazing ur causes of action for death or for injury to -- per$on or to personal property or growing crops and which accrue on or s#tey lanuary 1, I999, must be presented not later than six months alter the accrual of the cause of action, Claims relating to any outer rause 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 fired with the Clerk of the Board of Supervisors at its office in ROOM 106, C0,4rry Administration Building, 651 fine Street,Martinez; CA 94553. C. 11claim is against a district govemtd by the Board of Supervisors, rather than the Counry, the/tame of the District should be fitted in. D. If the claim is against more than one public er►tity, separate claims must be filed against each public emity. . E. Fraud. See penalty for fraudulent claims,penal Code Sec. 72 at the end of this form. woevwoov*to$ 04*4#60 s# 00*$q#*4ts�tstss�rurrr�ltatsafM RE: Claim By Reserved for Clerk's filing stamp ) Against the Got�ttry ofCantra Costa or � } District) (Fill in name) ) The undersigned claimant hereby makes claim egeinst the County of Contra Costa or the above-named district in the sutra of Sland in support of Wo claim mpresents as follows: ` Contra John Sweeten 'rile Board of SupervisorsL Clerk of the Board �-�+ and dmi Counl),Adnih-dstratioll Building Costa County and 651 Pine Street,Room 106 County t��5}�� .1�a1 Martinez,California 94553-4068 John Glala,District I (4.0c D.tillkemst,1)ic160 11 +l h111EEe C.ivenherg,District III MarkUeSstelnkv,District IV Federal 1).Ulovei-, 1)istrict V TO: COUNTY COUNSEL RISK. MANAGEMENT FROM: Emy Sharp SUBJECT: Revised estimate on the damage truck CLAIMANT: Shelly Ray DATE: November 09, 2004 Enclosed are two (2) revised estimates received today from above Claimant per Penny Bailey's request and the tort claim which was denied on August 10, 2004. � D lNO2004 ;"LERK SOARD OF SUPERVISORS, ONTP4 CO? A.CO. 14 041, AjC�IexrJ:7 -74-ta .A—, /;i-e, 74 R y; ' s .......................... ......... .... ... . . 11/0.5/2004 at 02 : 47 PM Job Number: 22895 SAN RAMON BODY AND DETAIL SHOP Federal ID # : 942863297 10 BETA CT SAN RAMON, CA 94583 (925) 838--8380 Fax: (925) 838-6254 PRELIMINARY ESTIMATE Written By: Kevin Normoyle Adjuster: Insured: SHELLY RAY Claim # Owner: SHELLY RAY Policy # Address: P.O. BOX 880 Deductible: BRENTWOOD, CA 94513 Date of Loss: Evening: (925) 580-9387 Type of Loss: Business: (925) 437-2068 Point of Impact: Inspect Location: Insurance Company: Days to Repair 2001 CMC K1500 4X4 SIERRA EXT 8-5. 3L-FI 4D SHORT RED Int: VIN: 1GTEK19T91E117731 Lie: 5X86526 CA Prod Date: Odometer: 167910 Tilt Wheel Intermittent Wipers Dual Mirrors Clear Coat Paint Power Steering Power Brakes Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Split Bench Seats Rear Step Bumper Styled Steel Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 GRILLE 2 R&I R&I grille assy 0. 5 3 HOOD 4* Rpr Hood GMC US built 2 . 0 3. 0 5 FENDER 6 Refn RT Fender GMC US built 2 .2 7 Overlap Major Adj . Panel -0. 4 8 Refn LT Fender GMC US built 2 .2 9 Overlap Major Adj . Panel -0 . 4 10 R&I RT Flare black 0 . 4 11 R&I LT Flare black 0 . 4 12 ELECTRICAL 13 R&I Antenna mast 0 . 1 14 WINDSHIELD 15* Subl Windshield NAGS tinted +25% 1 412 . 50 X 16 CAB 17* Rpr Roof panel 4 door 0. 5 3 .2 18 Overlap Major Adj . Panel -0 . 4 19 Repl RT Molding roof joint 1 9. 50 0. 2 1 . 11/0.,5/2004 at 02 : 47 PM Job Number: 22895 PRELIMINARY ESTIMATE 2001 GMC K1500 4X4 SIERRA EXT 8-5. 3L-FI 4D SHORT RED Int: -------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -------------------------------------------------------------------------------- 20 Rep! LT Molding roof joint 1 9. 80 0. 2 21# R&I Rope back glass 0 . 4 22 PICK UP BOX 23 R&I R&I box assy 2 .5 24* Rpr RT Side panel 1 . 0 3. 1 25 Overlap Major Non-Adj . Panel -0.2 26* Rpr LT Side panel 1 . 0 3 . 1 27 Overlap Major Adj . Panel -0.4 28* Rpr Tail gate 0.5 2 . 1 29 Overlap Major Adj . Panel -0 . 4 30* Clear Coat 3 . 5 31 R&I R&I tailgate assy 0. 3 32 Rep! RT Body side mldg GMC chrome 1 41 . 50 0 . 3 33 Repl LT Body side mldg GMC chrome 1 41 . 50 0.3 34 R&I RT Flare 0 . 4 35 R&I LT Aare 0 . 4 36 Repl RT Decal "Z71" 1 1.0 . 67 0.3 37 Repl LT Decal "Z71" 1 10 . 67 0 . 3 38 Repl Nameplate "GMC" 1 9. 08 0 .2 39 Rep! Nameplate "SIERRA" 1 11 . 30 0 .2 40 R&I Upper molding 0 . 3 41 REAR LAMPS 42 R&I RT Combo lamp assy 1/2 & 3/4 0 . 4 ton 43 R&I LT Combo lamp assy 1/2 & 3/4 0. 4 ton 44 REAR BUMPER 45 R&I R&I bumper assy 1 . 0 46 MISCELLANEOUS OPERATIONS 47# Refn COLOR TINT BEFORE REFINISH 0 . 5 48* Rep! Cover car/bag 1 7 . 00 0.3 49# Sub! HAZARDOUS WASTE REMOVAL 1 5. 00 X 50# Rpr COLORSAND AND POLISH PER JOB 3. 0 51# Repl CORROSION PRO'J'ECTION 1 10. 00 T 0 . 3 52# Rpr POLISH SCRATCHES ON DOORS 2 . 0 ------------------------------------------------------------------------------- Subtotals =_> 578 . 52 20. 1 20.7 Parts 563 . 52 Body Labor 20. 1 hrs @ $ 70. 00/hr 1407 . 00 Paint Labor 20 .7 hrs @ $ 70. 00/hr 1449. 00 Paint Supplies 20 .7 hrs @ $ 30. 00/hr 621 . 00 Sublet/Misc. 15. 00 ---------------------------------------------------- SUBTOTAL $ 4055 . 52 Sales Tax $ 782 . 02 @ 8 .2500% 64 .52 2 11f05/2004 at 02: 47 PM Job Number: 22895 PRELIMINARY ESTIMATE 2001 CMC K1500 4X4 SIERRA EXT 6-5. 3L-FI 4D SHORT REE Int: GRAND TOTAL $ 4120. 04 FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. 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=ELEC`T'RICAL 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-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=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 Wf =WITH/ SYMBOLS: #=MANUAIJ LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE 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 DR1GH99 Database Date 09%2004, CCC Data Date 09/2004, and the parts selected are OEM--parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. 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, Qual Rep'_ Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as TKQ, 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 by National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries. Some parts that are described as Recon. may be OE Surplus parts or other OE parts offered at a special pricing discount. For further clarification please review the Suppliers List attached to this estimate, or consult the appraiser or estimator. CCC Pathways - A product of CCC Information Services Inc. 3