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MINUTES - 08172004 - C27
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD AC`I'ION;AUGUST 17, 2004 Claim Against the County, or District Governed by } the Board of Supervisors,flouting 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 U1- 13 915.4. Please note all"Warnings". AMOUNT: MORE THAN $10,000.00 ILLI HP,,;C N SESEAL CLAIMANT: LESLIE SCHOENFELD, Individually and as Successor in Interest for ATTORNEY: Decedent Samuel Ragent DATE RECEIVED: JULY 13, 2004 ANDREW R. GILLIN, ESQ. GILLIN JACOBSON ELLIS & LARSEN ADDRESS: #2 THUffi SQUARi, SUITE 230 BY DELIVERY TO CLERK ON: JULY 13, 2004 ORINDA, CA. 94563 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 13 2004 JOHN SWEETEN, 1 rk Dated: By: Deputy II. MOM: County Counsel TO: Clerk of the Board of Sup isors (:.This claim complies substantially with Sections 910 and 910.2. 1 ( ) 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: s= t By: ? : r 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. OARD ORDER.: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: OHN SWEETEN, CLERK, By ,Deputy Clerk WARNING(Gov. code recti 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. *Fair 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: °1j' ,�OHN SWEETEN, CLERK By Deputy Clerk Claim to. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY t A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which argue on or before December 31, 1987,must be presented not later than the 10&day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.). B. Claims must be Filed with the Clerk of the Board of Supervisors at its office-in Room 146, County Administration Building, 651 Pine.Street,Martinez, CA 94553. C. If'claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. ErAuA. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp LESLIE SCHOENFELD, Individually and ) as Successor in interest for . ...... ... DecEE[enf gamuelRagent ) - - E Against the County of Contra Costa or f { District) (Fill in name) ) The undersigned claimant hereby mares claim against the County of Contra Costa or the above-named district in the sum of S and in support of this claim represents as follows: More than $10, 0 0 0. o o 1. When did the damage or injury occur?(Give exact date and hour) January 25, 2004 at 11:36 a.m. 2. Where did the damage or injury occur?(Include city and county) see Exhibit A attached 3. How dict the damage or injury occur?(Give full details;use extra paper if required) See Exhibit A attached 4. *hat particular act or onussion on the part of county or district officers, servants, or employees caused the injury or damage? t See Exhibit A attached 5. What are the names of county or district officers, servants, or employees causing the damage or injury? Unknown 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) See Exhibit A attached 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) See Exhibit A attached 8. Names and addresses of witnesses, doctors, and hospitals. Witness - Nathan Gans, 232 Creekside Drive, Walnut Creek, California Hospital - John Muir Medical Center, Walnut Creek, California 9. List the expenditures you made on account of this accident or injury. PATE AM- February, 2004 $6,000 - funeral Gov. Cade Sec. 910.2 provides"The claim must be signed by the claimant or by some person on his behalf." ENI)NOTICES T tt me Name and Address of Attorney '-' M1 It Andrew R. Gillin, Esq. GILLIN, JACOBSON, ELLIS & LARSEN ) - 2 Theatre Square, Suite 230 ) (Claimant's Signature) Orinda, California 94563 ) Andrew R. Gillin, Attorney for Claiman- 2 Theatre Square, Suite 230 (Address) Orinda, California 94563 ) Telephone No. (925) 253-5800STtIephone"I o. t 925) 253--5800 NOTICE Suction 72 of the Venal 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 of i=,authored to allow or pay the same if genuine,any false or fraudulent claire,bill,acwunt, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000).or by both such imprisonment and fine,or by imprisonment in the State prison,by a fine of not exceeding ten thousand dollars(S 14,000),or by both such imprisonment and fine. CLAIM FOR PERSONAL INJURIES LGOVERNMENT CODE,SECTION 9101 TO THE GOVERNING BODY OF: County of Contra Costa(hereafter public entity) OUR CLIENTS &CLAIMANT: Leslie Schoenfeld, individually and as successor in interest for decedent Samuel Ragent(hereafter Claimant) ADDRESS: 3368 Robinson Drive Oakland,California 94602 DATE OF DEATH: January 25, 2004 PLACE OF DEATH: South Main Street, near its intersection with Castle Hill Road DESCRIPTION OF INCIDENT: (1) Decedent Samuel Ragent, survived by his wife Leslie Schoenfeld, died when his bicycle was struck from the rear at said location, in the furthest right lane of traffic, by a vehicle being operated by Nathan Louis Cans, Jr. (2) At said time and place herein alleged, said roadway, designed, owned, operated and maintained by the County of Contra Costa, constituted a dangerous condition of public property, as that term is described in Government Code Section 830, in that: (A)the southbound lanes of traffic were of inadequate width, given any and/or all of the following: the large flow of vehicular and bicycle traffic thereupon; the presence of the left turn "storage area"; and the presence at said location of a drainage grating, the avoidance of which tended to push bicycle traffic (including decedent) further to the left than was reasonable, prudent, and appropriate but for the hazard presented by the grating; (B) vehicular site distance was unduly unsafe and obstructed, due to road conditions, known shadows and sunlight, and obstructions caused by adjacent vegetation, placed both by the City and by neighboring owners of private property; (C) other impairment of driver vision, the cause of which has as yet been ascertained; (D)inadequate signing to warn motorists of the presence of bicycles on South Main Street, which signs were necessary to warn of a concealed trap; and(E) other impairment of driver vision, the cause of which has as yet not been ascertained. (3)The loss of decedent sustained by Claimant, as alleged herein, was proximately caused by the dangerous condition of the roadway above-described. (4)The dangerous conditions of the roadway above-described created a reasonably foreseeable risk of the kind of injury which was incurred, and: (a) A negligent or wrongful act or omission of an employee of the public entity within the scope of his employment created the dangerous conditions described above, and/or (b)The public entity had actual notice of the dangerous conditions, due to prior incidents, periodic review and inspection by staff, numerous complaints that had been submitted by bicyclists and other members of the public, a sufficient time prior to the injury to have taken measures to protect against the dangerous condition; and/or the public entity had constructive knowledge thereof as hereafter alleged, a sufficient time prior to the injury to have taken measures to protect against the dangerous condition. 5) Claimant is informed and believes, and thereupon alleges, that the public entity had actual knowledge of the existence of the condition herein alleged through prior accident history, prior citizen complaint, prior employee inspection and periodic review, and otherwise, and that the public entity knew or should have known of the dangerous character of the condition of public property as herein alleged. 6) Claimant is informed and believes, and thereupon alleges, public entity's constructive knowledge of the dangerous conditions, in that the above-described dangerous conditions had existed for a substantial period of time and were of such an obvious nature that the public entity in the exercise of due care, should have discovered the conditions and their dangerous character, and in fact the public entity should have known of the dangerous conditions due to prior incidents, numerous complaints that had been submitted by bicyclists and other members of the public, and periodic inspection and review by staff. NATURE OF DAMAGES: Economic damages and non-economic damages arising from the wrongful death of decedent; and medical, funeral and burial expenses. AMOUNT OF CLAIM: An amount within the jurisdiction of the Superior Court. ATTORNEYS TO WHOM NOTICES GILLIN, JACOBSON, ELLIS & LARSEN SHOULD BE ADDRESSED: 2 Theatre Square, Suite#230 Orinda, California 94563 (925) 253-5$ DATED: July 6, 2004 Andkv . lin ATTORNEYS FOR CLAIMANT CLAIM BOARll OF SLPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION.,_AUOUST 17, 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. "tom 6 " t s, r : notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and g A- 915.4, Please note all"Warnings". AMOUNT: °T€NEZ CALIF CLAIMANT: ANTOINETTE STEVENSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2004 ADDRESS: 2975 DESEIEI' DRIVE BY DELIVERY TO CLERK ON: JULY 141 2004 EL SOBRANTE, CA 94803 BY MAIL POSTMARKED: JULY 13, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETrk Dated: JULY 14, 2004 By: Deputy II. Fit OM: County Counsel_ _ TO: Clerk of the Board of Supervisors s { ) This claim complies substantially with Sections 910 and 910.2. I (=,.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 wap . w By: Deputy County Counse. III, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: {v This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: OHN SWEETEN, CLERK, By It Deputyierk "WARNING(Gov. code se lon 915) 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: Ae SWEETEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL �� SILVANO B.MARCHES! COUNTY OF CONTRA COSTA ,�� � ' � � ��N�. COUNTY COUNSEL Administration Building 651 Pine Street, 911, Floor / y _rt oi4 SHARON L. ANDERSON Martinez, California 94553-1229 £ k ' C141EFAsSISTANT x € GREGORY C, HARVEY (925) 335-1800 r Al VALERIE J. RANCHE (925) 646-1078 (fax) «`t. 4' F' AssIsTANTs NOTICE OF INSUFFICIENCY AND IZOR NON-ACCEPTANCE OF CLAIM TO: Antoinette Stevenson 2975 Deseret Drive El Sobrante, CA 94803 RE: CLAIM OF: ANTOINETTE STEVENSON Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] L The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. Page 1 Antoinette Stevenson Re: Claim Page Two [X] 8. Other: You did not state the address where you fell. It is unclear why the County would be liable. SILVANO B. MARCHESI COUNTY COUNSEL �f r. By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ.Prow, §§ 1012, 1013a, 2015.5; Evid.Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years,and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On July 16, 2004, 1 served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on July 16, 2004, at M�ttinez, California. �; fj Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:AUGUST 17, 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 Cade Section 913 and 915.4. Please note all"Warnings". AMOUNT: $7,331.10 CLAIMANT: ANTOINETTE STEMSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 14, 2004 ADDRESS: 2975 DESERET DRIVE BY DELIVERY TO CLERK ON: JULY 14, 2004 EL SOBRANTE, CA 94$03 BY MAIL POSTMARKED JULY 13, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET rk Dated: JULY 14, 2004 By: Deputy 11. FROM: County Counsel. TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: 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). IV. BOARD GIRDER: By unanimous vote of the Supervisors present: ( ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this 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 ofperjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in theUnited States Postal Service in Martinez, California,postage full: prepaid a certified copy of this Beard Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN SWEETEN, CLERK.By Deputy Clerl Claire to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the muse 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 roust be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims mast be filed with the Clerk of the Board of Supervisors at its .office in Room 106, County Administration Building, 651 Pine Stmt, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. ' Fraud. See penalty for fraudulent claims, Penal.. Cade Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp Against the County of Contra Costa or ) . District) Fill in name The undersigned claimant hereby sakes clai inst the Countyof Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows. 1. hien did the damage or injury occur? (Give exact date and hour) .� vA 2. Where did the damage or injury occur? (Include city and county) 17(_2,, 3. How did the damage or injury occur? (Give full details; use ex' ra paper if required) � � i � ii a �' ' '� � d `` k "7a S s 4. What particular act or omission on the part of county or district officers, servants or .employees caused. the.injury or damage? (over) �. wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries o damages claimed. Attach two estimates for auto damage; ? 7 Haws the mount claimed abo-Vecomputed? (Include the estimated amount of any prOsp80tive injury or damage. `:. --w'i--__--_and ,a.�dd,•'4reetss•./e�es of witnesses,-`"� 1F �.doC3cto; a..ni..5d.4'lh..io,cs'pvit...a."..ls. £10 Names . f skv i;V". �"L '^i��,,��,.r�%+.t C. +7'-1��if4 ..��♦�..� . �../r`ap..'.!.^„r_.^...�J��A �,� ''�...-.. :.e E.� +. 9. List the expenditures you made on account of this accident or injury. DAM ITEM AMOUNT Gov. Code sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorne ) nr by some person on his. behalf." Name and Address of Attorney Cla' s Signature k Address _K_ Telephone No, Telephone No. el * � e N 0 T I C E Section 72 of the Penal Cade provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county* jail- for a period 0f 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. DOCTORS MEDICAL CENTER-SAN PABLO 2000 Vale Road, San Pablo CA 94806 (590)970-5940 Discharge Instructions RAY €�AWKINS ML3 ANS ONIETTE STEVENSON CONTUSION: UPPER EXTREMITY You have a CONTUSION of your UPPER extremity(arm,wrist, hand or fingers). This causes local pain, swelling and sometimes bruising. There are no broken bones.This injury takes a few days to a few weeks to heal. HOME ARE: 111 Keep your arra elevated to reduce pain and swelling.This is very important during the first 48 hours. 2)Make an ice pack(ice cubes in a plastic bag,wrapped in a towel)and apply for 20 minutes every 9-2 hours the first day. Continue this 3-4 times a day until the swelling goes dawn. 3)You may take Tylenol or ibuprofen (Advil, Motrin)for pain, unless another pain medicine was prescribed. Ef3LLC}W UPUP with your doctor or this facility if you are not starting to improve within the next THREE days. [NOTE: If X-rays were taken,they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care.) RETURN PROMPTLY or contact your doctor if any of the fallowing occur: - Pain or swelling increases -- Redness,warmth or drainage -- Nand or fingers becomes cold, blue, numb or tingly 6111/2004 (22:50) EMERGENCY DEPARTMENT Paae 2 of 5 Discharge Instructions{cont.} TRAY DAWKINS MD ANTONIETTE STEVENSON CONTUSION: LOWER EXTREMITY You have a CONTUSION of your LOWER extremity(leg, knee, ankle, foot, or toes). This causes local pain, swelling and sometimes bruising. There are no broken bones. This injury may take from a few days to a few weeks to heal. HOME CARE: 1)Keep your LEO elevated to reduce pain and swelling. This is very important during the first 48 hours. If walking causes pain, stay off the injured leg until you can walk without gain. 2) If CRUTCHES have been advised, do not bear full weight on the injured leg until you can do so without pain. You may return to sports when you are able to hop and run on the injured leg without pain. 3) Make an ice pack (ice cubes in a plastic bag,wrapped in a towel)and apply for 20 minutes every 1-2 hours the first day. Continue this 3-4 times a day until the swelling goes drawn. 4)You may take Tylenol or Ibuprofen (Advil, Motrin)for pain, unless another pain medicine was prescribed. FOL!©W UF'U€'with your doctor or this facility if you are not starting to improve within the next THREE days. [NOTE: If X-rays were taken,they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care.] RETURN PROMPTLY or contact your doctor if any of the following occur: -- Fain or swelling increases -- Toes become cold, blue, numb or tingly -� Redness, warmth or drainage from the skin 6/11/2004 (22:60) EMERGENCY DEPARTMENT Page 3 of 5 Discharge Instructions(cont.) RAY DAWKINS MD ANTONIETTE STEVENSON MEDICATION: SUPROFEN [Adult] lbuprofen (brand name: Motrin)is an anti-inflammatory drug. It is also available aver-the-counter in a iower strength as Advil, Nuprin, Motrin IB and other brand names. It is very useful for pain,fever and inflammation. DIRECTIONS FOR USE: You may take this medicine with food or milk to reduce stomach upset. WHAT TO WATCH FOR: l gaMLE SIDE EFFECTS: Nausea, upper abdominal pain,dizziness--> (Contact your doctor if these symptoms persist or became severe). Bleeding from the stomach, which may appear as blood in vomit or stool (red or black color); rapid weight gain, leg swelling or easy bruising-->(Contact your doctor or return to this facility promptly). ALLERGIC REACTION: Rash, itching, swelling, trouble breathing or swallowing--> (Contact your doctor or return to this facility promptly). MEDICAL CONDITIONS: Before starting this medicine, be sure your doctor knows if you have any of the following conditions: -- Stomach ulcer(active or in the past), history of vomiting blood or bloody stool -- Chronic alcoholism or if you consume more than three alcoholic drinks every day -- Allergic reaction to aspirin or other anti-inflammatory medicines -- Asthma, nasal polyps or angioedema; pregnancy or breast feeding -- Liver or kidney disease; bleeding disorder [DRUG INTERACTION: Before starting this medicine, be sure your doctor knows if you are taking any of the following drugs: e_ Coumadin (warfarin), Lasix(furosemide)Lithium, blood pressure medicine, Dyazide(triamterene), diabetes pills, prednisone, aspirin or other anti-inflammatory drugs, Lanoxin (digoxin), methotrexate, cyclosporine WARNINGS: -- Do not take with prednisone,other anti-inflammatory drugs or ALCOHOL since this increases the risk of getting a bleeding ulcer. This drug may cause dizziness. DO NOT DRIVE, ride a bicycle or operate dangerous equipment while taking this medicine until you know how it will affect you. [NOTE:This infom7ation topic.may not include aN directions,precautions,medical conditions,drug/food interactions and warnings for this drug. Check with your doctor,nurse or pharmacist for any questions that you may have.] 6/1112004 (22:50) EMERGENCY DEPARTMENT Page 4 of 5 Drs.fftd.cal etx.-San Pablo {418) TeneT 933 STOL7I3"D ROAD Mcss9etata CA 95356 tRSO: 75-2918969 G v4Y3ritltbttt3Flf i Patient Natne: ANTONIETTE STEVENSON Return Service Requested Account#: 00190137 Account Balance: 1,079.30 StatetuentDate: 06/251200 1111 M yfflit$11g!111k1¢jjiltff1]1fi¢ift[1z11t{{h filt14p{11fjj111d klessage4: Pk l ANTO NIETTE 3'PEVtytlt9ON 3535 DEMUT DR Questions cin Your Statement? EL 34RR.ANTB CA 94903-2328 t;ontact Customer Service at: (800)346-0775 Our records indicate that no insurance information was provided. Please contact our Customer Service Department to provide insurance information or remit payment. Services rendered. 06/20/2004 through 0612012004. Account Summary: 1,079.30 1,079.30 1,079.30 nrliw. PWai .skw wv rw,di F{ 4.4•.1-nori'i?t T,i2u€�'{31t, ty td }};;tt i £' �#:.`Ti� To pay by,credit carni please complete this section. Amount to Charge CARD NI It"+riBEK-ALL DIGITS PLEASE i lYti� -r- EXPIRATION DATE. Lv' VISA �v' MASTERCARD I�€O N-111 YL'.AR Print cardholder's natr . 1 AMEXIM} # DISCtVER F-71_7� t_v..� 1 Cardholder's signatulc _._ . Please include.you r account number on your check or money order, payable to: Drs.Medical Ctr.-Sats Pablo (4111) Account Number..... 0011 9f3{t3�l�3 7 Y y 11 1t3tlillfllllt til lil ttllffli!#311 i1tll til ltf{}Itt#1 Responsible Pattyr... AItiI"I(,NII•:TTE STEVENSON Drs.Medical Ctr.-San Pablo Patient dame.,........ ANTONiI;.I TE.STEVENSON FIL # 57433 Account Balance..... 1,07930 Payment Amount LCIS ANGELES CA 90074-7433 Hease tttnke sate the ntsove acldress sho-,s 3 in the undo-,v'of tate envelope 1"vided. its azot _ �� il►rs.Medical Ctr.-�San Pablo (418) (800)346-0775TeneT Account information forSTEVENSON�NTONIEVIT STEVENSO Account#: 001900137 Page Y# 2 Services rendered. 06120/2004 through 06!2012004. Summary o1 Charges: Emergency Room 831.50 Supply Casts/Splints �`�� �� Total 1,079.30 ne k, - .Street-Address Address_-_._�_ City,Stag amt Lip Code - �....._ Telephone l+tuznl7er Please include your account number on yourANY CHECK SENT AS PAYME.NT M FULL IN RELATION check or money order and send payments to: TO A BILLING DISPUTE-MUST BE SENT TO: liiitli�tlf�.tfttllf ll�iltf��f it��litl�ttl�ltf llifflilftfl�iftt t��t/1l�tlt�ilft��t tllltlil�f if��ltt�itt1�11f lt�fflfltii#ifllf Dra.Medical Ctr. -San Pablo Drs.Medical Ctr.°-San Pablo FII«EIt 57433 Pit BOX 66050 LOS ANGELES CA 90074-7433 ANAHEIM CA 92816-6054 PFSBKOI Drs.Metllcsl Cir.-San Pablo (4153 TeneT 5933 STODDF4RD ROAD Modesto CA 95356 iRS�,: 75-2919961,J- Patient Narue: 1' NT()Nirm STEVENSON Return Service Requested AccoU11#; 002168774 Account Balance: 1,617.80 Statement Date: 06/1812()(9 ftt tfi #tlltllillt111l11t41i!#tlltdiltllttliliiilifiltliltil i�E ssaigeM PE"1 2975 DESUXT DR f uesfioki4 on r,)Ur statellient? HL 90BR.ANT$ CA 94803-2328 Contact Customer Service at: (800)346-0775 Our records indicate that no insurance information was provided. Please contact our Customer Service Department to provide insurance information or remit payment, Services rendered: 06/1112004 through 0611112004. Account Summary: ---_Char ------------.--Pisc-ount --_ .._N. l_��i����_____.._.1ris_1'.a 1,617.80 1,617.80 1,617.80 VeMeft Ilea c;see reverse Sid o�c�rtt�t�t�c�2xy�gY. [_ }� t) ypy y71S { 4i :t .� � '!�� .,�'y.` ,xr.f:/ .. .. Jv', i�`} ,.¢:v✓.�#',h.f'."..'r':-'r�C Svi _,r; To pay Erb-credit card,please complete this wc:tion. Amount is Charge CARES NUMBER SALE.,DIGITS PLEASE EXPIRATION DATE L_ DESA (i MASTERCARD MOKI'tI -YEA R Print cardlioEder's uante: __- - - i AMEX 11 DISCOVEEl � � _. i.__ -� I::._I_.. Cardholder's signature. Please include your account number on your check or money order, payable to: Drs.Medical C;tr.-San Pablo (418) Account Number-- 002668774 I1Iti/111ttlltttlItttl11#11111JIM 111111ItIII MlIII ilIto$1 Responsible Party... AN ONIETTL STEVENSON Patient Name.......... ANT'()!' TETTE STEVENSON Drs.Medical Ctr.-Sart PabloAccountfialancc..... I,fi1 7�0. FILE# 57433 Payment Amount LOS ANGELES OA 90074-7433 � Please nxake sure the atxve address shows ill the Window of the envelope prmri(w. Prse2z a Drs.MedW41 Cts, w.Pal iu RA {S00)346-0775 ccotaztt info t a rsr fc 32 1t 1 IT STEVENSON Actount#F: 002168774 � n e T ['age# Services rendered: 0611112004 through 0611112004. Stunwary of Charges. AMDt Diagnostic Radiology 633.20 lihamiacy Oral Solite 31,90 Emergency Room 831,80 Dressing/Bandages 33,60 Supply Orthopacs 87.30 ssusa:zzsss<�nsasaag�amam axass�xea cm.azx........... ....... .....zssrcam..x00..`..r= Total 1,617.80 Street Address City,:hate and Zip Co& Telephone Nurnbxr Please include your account number on your ANY CHECK SDJT AS PAYMENT W FULL IN RELAMN check or money order and send payments to: Ii�tfllflii3�-##E��titE i/tint#E��if#!{!til}li##�##E!�#tFilEJfi ���##tll#tt#�t##1#ti#�tittlElJ t41JtF�t tif##i#tl�t#FI�IFf I�It#t Ilrs.Medical Ctr.-San Pablo Drs.Medical Ctr.-Sart Pablo FILE# 57433 PO BOX 66050 LCIS ANGELES CA 34074-7433 ANAHEIM CA 92826-6050 p�satt�? .,. k", a. a . ^�•' ;; ...•hn PATENT NAME ACC Y',# CA EMER P YS*DMC SAN PABLO CACP ANTONIETTE STEVENSON 0300114855 PC BOX 582663 E D-38 MODESTO, CA 95358--0046 STATEAENT DATE PA`!THIS AMOUNT PAST DUE DATE ADDRESS SERVICE REQUESTED 6/28/04 313.00 0-1/116/04 XF SERVIC&S WERE.RENOEWi D AT THE MOS- MAI,TEAS BILL IS SEPARATE FROM YOUR HOSPIXAL BILL. •• .. '`�.. '+"' ,?§i •A:.iCr: .u, {. ' ...;: 2: rg^y.. .c .,;.. :•a ,'�; :x A r r ;.v.�, ae 12422 ANTrONIETEE STEVENSON 2975 DESERET DR � , }� CA EMER PMYS*DMC SAN PASLO CMP EL SOBL2ANTE, CA 94803 ?�'� PO BOX 582663 MODESTO, CA 95358-0046 OPlease 0 if address or inswa infra-matin has char . M*e,changes c n reveme Wde.. - !. ;+;�d� :;+;:, � 4.s�•" ijt k€ "'� '�s rG � :rf, .£ �'a,�•s`'»i ,qE'. {o.��.'�}"v 31. ,s �"R� x Y z -Ar#>„�; � PLEASE MAKE COPY OF ENTIRE PAGE II^NSWW INSURANCE THERE,IS A$I0 00 SERVICE CHARGE FOR ALL RETURN,ED CHECKS, BILLING OFFICE HOURS: 8 AM-5 PM Tax ltd.# 9424940 Phone w 800 664-7660 Para EspAol> 1.8ofl 9524i3sj Attending Physician w DAWKINS, ROGE •-To M.:). Referring Doctor ► DAWKINS, ROGELIO M.D. Account Number► O00114855 Service Provider ► CEP DMC SAN P ABLO CAMPUS Patient IVaCtte I► A1T NIETTE STEVENSON Statement date . 6/28/04 DATE POS DIAGNOSI DESCRIPTION OF SERVICES---- AMOUNT O6/11-17o4 4 71,9343 ; 99283/25 LEVEL 3 EMERGENCY, PHYS CHARGE i80.00 06/11/04 4 r '71943 ' 291.25 SHORT ARM SPLINT £7.00 06/11./04 4 i 71943 j 73110/26 X-RAY WRIST 3; JiE67 46>030 Total for Clam ? 313.00 i � f i j 7 tti 1 PAYME2v OF IT IS ACCOUNt IS YOUR RE`SPONSISIL.ITY. iP YOU HAVE INSURANCE, PIETAS CONTACT F ls, 1CS. T;AIDE YO r ' ? ..;a y.5,:, �< "'F.� �''ttFid Yf i�” �Fk3 _r 1. �v 4:- a�"�-r,'�y}t a} �4..:• i El 13YE ( P{i Y Il�Jl1RY DATE AC3#YI#SSfC� I I� tTI i ISI CHA4 GE DATE � BALANCE DU ° NCE C PENNY Y *� SELF PAS Ir rNau v5;wri/04 ; 3i3aVv PATIENT STATEMENT 00149-95566,17 05 25 Q4 kmr.•. v'"'"'�2,, "• �` ', ? ..r`4F;G r-fv?CE:P� ..'�.�� C.a,r"i "£"{ter 3 510/243-0799 09/09/79 rib^' UM ;^` >' ±fix.`#s a °•,� AP,-NUMBER Exp.OTIC TRUE SELF PAY i" PH (925) 296-7156 007 02906 BAY IMAGING CONSULTANTS MED GROUP 1111111111111111111131111/IfIII$ 1111fit 1113111111111111111111 PO SOX 31455 STEVENSON , ANTONIETTE WALNUT CREEK CA 94!598 2975 Deseret Dr 11111131111111 111111#IS111111111111111111111111111111111111111 El Sobrante, CA 94803--2328 M-TA k HERE AM WJ#1Ek'109 M4afu9'WTH t'f UR MMENT MM,THE RETURN L":#`d UME E ,t,'u'SFD^ V :a_ME CHECK Sox ADIRESS is 101CGMECT A11# 1833! $�CEiA�ftxES?�f£S'"t. sx+^� .,• ""��. ."T.t R� ��i�s•,€ ,- :; - 14.t .� '�� Y; � � r°��J^ r,•a-��i- A��-'rt�n.-�"!. (��/3.1,j44 E : 7311.0 26 WR�51", �3 C3R MC3RE VIEWS '� ' 7'29.5 35.(30 y� ` f i PENDING �NSU�ANCE PAYMENT: .00 E f f j kat•a;�'r`riek�:YraY#irYc:c4r�iraY�xir'.:�aYykkir�c�4raYsYaYir'uata'riYnY•A•sY'x�Yak#sYsYsY�r#aYik•krYiraY'.r#aY#i�lrsYYrir - F" r questions, to update your insurance inform4tion, or foo! a * N6tice of Privacy Practices, phone us at (925)1, 296-7156, falx f u at (92 S 296 -7174 or e ai l us at bi l l�i ng@bmimi .net. P l else * * ilhclude your account number in the email or onl; the check. j } ���tYs�YrsY�'.raYzY#3r ielr=esk>Yxr�kYesYx�sY�ruiss0s'r�iztt�rYeirsYdetY+lrit9raYsY�a'r3ritit4ryh•fiir��s4ic'.raYtiaYaYiyiririsP: �.,?vPTF^v?..,,.. �.FIV r.,E i����k, .µ .<..�.Y..: ��S•�sx.s,. � 4�w �. tiD�CTuPi� ML�",tJJ.CiSiL L;I�1TLR -' �r�ii`� PAI3LOi ;21X10 VALE ROt�3 948(X SARONOFSKY, I i 036/25/04 _.-- _sA„....,...�.�,�.._"..,..>... ..''�,.�r.,.�3:.�„a.�,�;.rr�• s Jt;a'.w :s.:as,:.�',,.;:.0...,,� '�.:,. h.y."."��"ra='..•.fi�;a£:-fig ..f �, ss.�.Y"'.'��.,,,'���., • ,�r.f�.t4 INCOMPLETE INSURANCE INFORMATION, PLEASE SEND A COPY OF YOUR INSURANCE BAY IMAGING CONSULTANTS MED GROUP `CARD FRONT AND BACK. PEI BOX 31455 WALNUT CREEK CA 94598 IRS#94-2965646 PHONE 925!296-7156 PHONE HOURS:8:00 am,to 4:00 pm. ENT Hyncr,RA:_ �O_QW'?ATONT•10SP-W. F' OFFKK E M-F ASE-RG'Ncy Rook" — CU vi�st v..+3S....S an'-!III.,1'..1 v EE3:Stt tit"ytk,F?Saln'rRSuf8Rt8 bvmafi:n,pi'aSe c0^tpiete:;Sts rofm al.s`(3111(3;it m.;,.F Offica.Faiturt t0 rolurn tnf;aon m aU On-'attmPy r?2kE5 y3.i for in{: ft 2, you need u:.i.frt...fi F..Er 303 a SaconG'Msij.:a re c"pi nv[ wease ma?e a 01"olwor, 0".I,:S S alf'i2ent'then cow'c?E:e One t.r,7,fior w2C^:'5i:ta^•c&'mrr^e'.REti3!'f a4 T42i`m 14 ow offic@. y .'.5e Sure 3J Sig""Ime Svw,0.'-We at tool a.'o S,u;o'A for n-_„ ,C7:;n S 1;-.Y'_u. r' Ati F#R!47-A t# !HEREBY ,HORO..NE aROV;V4 S ON TmiS r'RM,L'RELEASE ASE F f,5' a.•> 0 F 2?;' —_.----__— fA .S„R-WIE ,;•U, ._!r h MEG a;_iNt,.IRPA i Poky N0.:--..^—.--_--_---------.—___-_-...____.. ci'0t�3 Q0.' Ade"TMAA.M-lcst3;1 ItF-R48Y AJUTI{,3RjZ-.A,Q O1�ECT tJJY V'SJf ANU W&7,9 NV CARR!ER- PAY DIFECTUY .,T1iE?'£101 ER SF+'MN 3:T:S FORT"ANY Y_..'.SER N S t ci2.,.Q" .,: R: ----------------- "G Se. c•.: .. ± ,„uf3Ee"0 PRY T�:E 3.CLRfi#c.E CF KXPE�;.53:5tC,'.'?:,.� �.zR,#1:S Ft.1}f: PATIENT WC ACCT.# GCA ESTER PHYS*DMC SAN PABLO CMP ANTONIETTE STEVENSON 030011-5595 PO BOX 582663 E D-38 _ MODESTO, CA 95358--0046 STATEMENT DATE PAY THIS AMOUNT PAST DUE DATE ADDRESS SERVICE REQUESTED 7/06/04 206.00 07/24/04 IF SERVICES WERE NDERED AT THE HOSPITAL,THIS BILL IS SE:PAR.FE FROM YOUR HOSPITAL BILL. 918;3 ANTONIETTE STEVENSON 2975 DESERET DR ,_s > CA EMER PHYS*DMC, SACT PABLO CHP EL SOBRANTE, C.A. 94803 {4' PCS BOX 582663 MODESTO, CA 95358-0046 []Please 0 if addoess or insuranoo kftmwWp has ctuwged. Make dwngls on f8 me -�#lit lb El!1!lR ilE ll!IE l! !�ill Y lM ffi.ffi>Y Ill 1l ld 111 11 lk± ..#!l;l tlt It 5r F 1N■ll tII![!!!d■MI 1l' !1pF R IIk#1 >�! It-3-iM pK s!!F lb 7E>t ffi ll it il6!#Al 36 2176 x k AIS NAWE COPY OF EN nRE PAGE IF NEEDED l�"M INSURANCE THERE IS A S0.00 SERYIC`E CHAR GE FOR ALL RETURNED CHECKS, BILLING OFFICE#'TOURS. 8 AM-8 PM Phone *- 800 664-7660 TaX ID40- 94 494000 Para ESpB" 01- 1-803.952-8361 Attending Physician * HODG ON, LAUREL M.L. Referring Doctor HO SON, LAUREL M.D. Account Number w Cool 5538 Service Provider CEP DMC SAN PABLO CAMPUS Patient Name ► ANTONIETTE STEVENSON Statement Date ► 7/06/04 DATE POS DIAGNOSIS DESCRIPTION OF SERVICES � AMOUNT _66 2 o4 4 71943 99283 LEVE: 3 EMERGENCY, PHIS CHARGE 180),0); 06/20/04 4 7 .943 99054 SUNDAY/HOLIDAY 26.00 Total for Claim: 206.00 i (# k # F 3 = f t j k F # i i s { t PAYMENT CP 'HIS ACC OUN IS YOUR RESPONSIBILITY. IF YOU HAVE INSURANCE, FLEAS CONTACTTTS"S C F'IC: . THANK YOU 3 i f �hi ( +i". 7Kprf�,q e -"(/ k$ -;' r<ax `pu��'t-�. EMPLOYER F"MARY INJURY DATE ADMISMN DATE DISCMWE mr: BALANCE OUI INSURANCE JC PENNY. SELF PAY/NO INSUR l 2036.00 F S T A T E M E N T Raymond Ximpp D C. 30350 Iiilltop Mall Rd 07-09-2004 San Pablo, CA 94806-p1920 1510-2432425 ACCOUNT NUMBER- 1000-2559 Antoinette Stevenson: PIC LAST CLAIM: 2975 Deseret Drive LAST PAYMENT: El Sobrante CXR 94803 LAST CHARGE: 07=-07-2004 Date Description Code Charge Credit Adjust Balance 06-17-2004 E/M NP Detail W/C 99203 85.00 .00 .030 85.00 06-17-2004 Fula. Spine ? view WC 72020 80.00 .00 .00 i65.00 06-17-2004 Lumbosac ApfLaL 72100 80.00 .100 .00 245.00 06-18-2004 CY-T 1-2 Regions WC 98940 40.00 .00 .00 285.00 06-18-2004 Elec. Stim. W/C 97014 25.00 .00 .00 310.00 06-21--2004 CMT 1--2 Regions WC 98940 40.00 .00 .00 350.00 F 06-21-20034 Elec. Stim. W/C 97014 25.00 .00 .00 375.00 ( 06--2I--2004 Trac. Mech. W/C 97012 25.00 .00 .00 400.00 06-23-2004 CMT 1-2 Regions WC 98940 40.030 .00 .00 440.00 06--23--2004 Elec. Stim. W/C 97014 25.00 .0703 .00 465.00 05_23.-20:04 `Trac. Mech. W/C 97012 25.00 .00 .00 490.00 0624--2004 CMT 1--2 Regions WC 98940 40.00 .00 .00 530.00 06-Y24-2004 Elec. Stun. W/C 97014 25.00 .00 .00 55.5.00 06-24--2004 Trac. Mech. W/C 97012 25.00 .00 .00 580.00 06-25-2004 CMT 1-2 Regions WC 98940 40.00 .00 .00 520.00 176-25--2009 Elec. Stim. W/C 97014 25.00 .00 .00 645.00 06-25-2004 Tra-c. Mech. W/C 9701.2 25.070 .00 .070 670.00 I 06--28--2004 CMT 1-2 Regions WC 9894:0 40.00 .070 .00 710.030 06-28-2004 Elec. Stun. W/C 97014 25.00 .00 .00 735.00 t 06-28-2004 Trac. Mech. W/C 97012 25.00 .00 .00 760.00 035-29-2.0704 CMT 1.--2 Regions WC 98940 40.00 .00 .00 800.070 06-29-2004 Elec. Stim. W/C 97014 25.00 .00 .00 825.00 05-29-2004 Trac. Mech. W/C 97012 2.5.00 .00 .00 850.00 06_30-2004 CMT 1.--2 Regiones WC 98940 40.00 .00 .00 890.00 06--30-2004 Elec. Stun. W/C 97014 25.00 .00 .00 925.00 06-30-2004 Trac. Mech. W/C 9701.2 25.00 .00 .00 940.00 07-01-2004 CHIT .-2 Regions WC 98940 40.00 .00 .00 980.00 07-01-2004 Elec, Stim. W,fC 97014 25.003 .00 .00 1005.00 07--01-2004 Trac. Mech. W/C 97012 25.00 .00 .00 1030.00 07-02-2004 CMT 1-2 Regions WC 98940 40.00 .00 .00 1070.00 037-02-2004 Elec. Stun. W/C 97024 25.00 .00 .00 1095.00 07-02--2004 Trac. Mech. W/C 9701' 25.00 .00 .030 11.20.00 07-05--2004 CMT 1--2 Regions WC 95940 40.00 .00 .00 1:.60.00 Continued. . . S T A T E M E N T FRay,on-8 Knapp D7 C. 1950 Hilltop Mall Rd 07-09-2004 Sari Pablo, CA 948038--19203 53.0-243225 ACCOUNT NEER: 1000-2559 #i I s a Antoinette Stevenson FIC LAST CLAIM. 2975 Deseret Drive LAST PAYMENT: El Sobrante CA 94843 LAST CHARGE: 07--07-2404 i Fete Description Code Charge Credit Adjust Balance i 07-05-2004 Elec. Stim- W/C 97414 25.00 .00 .00 1185.00 { 07--05--2004 'Frac. Mech. W/C 97112 25.00 .003 .00 1..210.00 07-06-2004 CMT 1-2 Regions WC 98940 40.00 .00 .00 1250,00 07--06-2004 Elec. Stint. '/C 97014 25.00 .40 .00 1275.00 07-06-2004 `Frac. Mech. WIC 97012 25.00 .00 .00 1300.00 V-06-2004 E/MY Esu. Expand WC 99213 50.00 .00 .00 1350.00 07-07--2004 Gait Training 1-34 WC 97116 25.001 .00 .40 1375.00 07-07--2004 Elec. Sti.n. W/C 97014 25.00 .00 .00 1400.010 TO7"ALS 1404.00 .00 .00 For proper credit, please enclose this portion with your payment. Antoinette Stevenson BALANCE: $1400.00 2975 Deseret Drive PAY THIS AMOUNT: El Sobrante CA 94803 AMOUNT ENCLOSED: Please fill in blank. DATE DUE: On Receipt Rayrond Knapp D.C. Tax ID:94-33313382 THANK YOU. 3050 Hilltop Mall Rd San Pablo, CA ;94806- L920 ACCOUNT NUMBER: 7.040-2559 ......... ....................... ............... .......... ....................................................................................................................................................... ................ ........................................................................................................................................................................ ................................................................................................................................................................................................ ....................... .................................. ............ ............................................................................................. ....... ............. ...................................................................... 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CLAIM BOARD ULSUPE&VI-SORSOF CO.NT.RAT U BOARD ACTION:gu-'GUST 1-7, 200,/ Wm Against the Coutity, or District Governed by tie Board of Supervisors, Routing Endorsements, NOTICE TO CLAB&ANT and Board Action. All Section references are to The copy of this document aced to you is yet, Califb-rnia Government peso notice oft e'action taken on your claim by the Board of Supervisors, (Paragraph IV below), gi Pursuant to Governtnent Coeec,tiort 913 and, * ' 915.4. Please note all "Warnings". ATTORNEY.- r:7NK,\- o DATE RECEIVED, JULY? 210 2004 ADDRESS: 8;1 (,az( STREET BY DELIVERY TO CLE `> . U Y 2-1 , 2004 s-_= RF-N7 D CA 9451 HND DELWERED Y MAIL POSTM .- FROM: Clerk of the Board of Supervisors TO., County Counsel _ Attached is a copy of the above-noted claim. J mq SWEETENi Dates: uULY 2', 2004 By: ;deputy Board of upet- orss (� is claim complies substantially with Sections 910 and 9:10.2. This Claim FAILS to comply substantially with Sections 9.0 and 910.2, and we are so notifying claimant. The Board coot act for 15 days (Section 9 .0.8). { Claim is not timely filed. Theler'k,should return clam on ground that it was filed tate and send wing of claimant's right to apply for leave to present a tante clay(Section 911 3). Other: By, Deputy County Cou 111, FROM, Clerk of the Board TO, County Counsel (t) County Administrator(2) ( I Claim was. retied as untimely with notice to clamant(Section 911.3). , IV. BOARD ORDER. By unarAmous vote of the Supervisors present: This Claim is rejected full. Others 1 certify tfhat this is a true and eorreet'eopy of the Board's Order entered in its minutes for this date, arear � CLQ ', 8u°,jeot to ee tmn exceptions, you have only six( )months s o; the date this notice was personally served or depo; to the mail to file a eon action on this clafin. See Governnient Cade Section 945.6. You may seek the advice of an attorney of your choice in nnec"tton with this matter. If you want to consult an, attorney, you should do so immediately. *For Additional WninSee Reverse Side of ThisNotice, s, AFFMANIT OFINWLING I declare Wider penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Unite States, over age 18; n that today ep sited in the United States �st�� erviee itmne�, a���or�.�a,p�st��e prepaid a certified.copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above, Da OIDN SWEJETEN1 , CLERK By Deputy l Claim to AM OF I F M-Rk COSTA CMM INS" O T IONS 11M MUMIMT A. C"laims relating to causes of action for death or for irb j,ry to pelrson or C,o per za owirz crops and ich accrue ore or before DeoeffiteA— X997 ��e"�� pr`:o �°"t�3' ire �< '� crops �$ i^; accrue � Y' must to Presented not later than the 00th day after the accrual of the caLlse of action. lay relating causes of action for -depth or for injj�:"y to person or to e or l property or groming crops and i oor-._,e on or after J n rY 1988$ must be presented not 'Umn six months after the accrual of 'ne cause of action. �l 4i r-_JatIng to any oVher cause of action mit be presented not pater, tura one year after the aoo a ° of the cause of action® CCzov+, ("Ode §92.1m2m) m 13: t be filed with the Merk of e of &aper�isorst i office In R Cosu t Anista .tion Builth � Gal Pine Street, M tznez� CA c 53- C� Tf claim is against a district governed ty the Board of Supervisors, rather t 1 tje Count-y, she name of U e District should be f filled In. D. Tf the of aim Is against more than one public entity, separate alai Must be filed against eachl public entity. Q Fraud. See peralty for nraud ent 61ai s Per 1, Code Seco 72 at the end of this E: Claim BY Reserved for Clerk's L1,'61ing stamp WM �;e runty of � a Cosmo x 3 a .. a or .. ., j tr�ot� •��"«�,�� Vis;;}"u��� ' A Q'n .TA a a � The de i, ed c i te trakes claim agairst the C-omty° of Contra Coag or the move-named Di trio in the e° of y.;; J °� in upport of this alai m represents -as follows m W' an d d `L'a '" ,, ion `' c=? (naive at ate and hour *aisam,ross®xeoG. ara:am em�•A.,e — i� 'f ramvmmas�+�a+�¢+�mtam dmam�vnnwz��agy+o�aa�ozvsawvsas.�am+n�rc 2. "vers did the die a." $-n i ° :=? (1,needs aity and oo ty) �. How did the d amage or i nury� oar? ve fel details; use extra paper if �, ,..� � ' ����a,rd,�� �;i� �.�<ti-"f "s'�-`sJ Ate'' � �'`s.✓s ,�vP.g'�" � ," q+ .,E���' f Pardo n act or cuission or. the W. t. o� --o`anty or district off ioers a sere to or rloy i she.i or. "e' r u '✓' -• "ra'f - a" df d` '" /" d J' err r`' s,+"s"�.ridP' Z,;� 41 S>.+�7, +• , _ f 'E` ' ` g✓a✓.'ir °nd ,'�a.,. 'r��✓ a `✓,, ��,q p1 ! 5"� � �` ') Ifs' r �l't. .,:� .G' y� s�` d�✓�' `'A" �. � " �1 �N r�F 6� .�! E�-.7`d':`.j>, .s;;" .y..t" 4✓.� ��s.� f`.✓a .f' WnaL are ��.�_' names of county or districtofficers,i- era3 ��� vd� cif �,++,oy �� he doge o 0.4 � ' � � y✓ � �'♦ ! I€��"✓ d I,a�✓"d {„�-.. �"" .�`, 1 -" , -� � 9,.fr,t'� .f f" �s .� s,- d✓,i '` '"i . � ,PO 1;Qk YAW avE ,. a 5 injuries do you c" resulted?o ((Give full tent f injuries or damages Claimed. Attach twoimate .fir auk damav 711411ow was the amaunt claimed above comnuted? (include the estimated amount of any prospective injury or dmmageJ 6to S. Names P—nd addresses of witnesses, doctors and hospitals. 3 1 , 9. List the expenditures you ode on account of this accident or injx7, DATE UUM 911 fi N Gov. code See. '9102 Provides; Raim, must be signed by the claimant 3,M NOTICES TV ` Mto nsX) or DIT some r'.aWn a h Sys. 00- fa of Attorney ��mn .FrIaTE-F,e977 4l.? .... _ a mf. .:.d Telephone No, Talqhone 'No. 'A 0 T 1 C E Sectio, 72 of the Pence Code provides: "Every person sko, with intent to defraud; presents for allowance or far payment to any area board or officer, or to any county, city or district oard oll officer, autharized to allow or pay the same if .genuinq a y fQse on fraudulent claim, biles, account, vaucher, cor writing, i ;Qni able either by imprisohent in the cotmty jail for a period of not more Won cne-year, by a fine of not exceeding one thousand ($1,000), or by -both suck Woksonment and finey= by impb ison .,s<,t i.. the qq��, &. prison, b fi f o fi wten tb .tea dollars l 3 rs � R,*'�< �'c'"0 r Adm 4,s�:.�� �a�q Sa�- �. .�a. � e���a exceeding bsA3 ��t�; .��.�,�„ ,s .ate a ✓�F�g�r$a:�� '�a by . both stab imprisonnent and fine. ., _y.S�ON OF SPEEDY A:70 GLASS?NC. Quote 20.2 NNORTHAE'ET WA:NUT -PEEK,CA 94596 9689 - 0001063 92514400'112 0712112004 Federai Tax 10#91127015-11 L old To': A CA Tax Exe.i pt NC: Agent ; Agent Ph; Policy Name; Authorization Policy Number- Authorized umber;Aut orized y: Cause of Lass; Cialm PO#. Date of Less: Location: Flest Card Numbe ; Exp; Driver Na et Fl at PO#; Driver License- Network Control#: € nit Number; vehi `e"dear, 200.4 Vft C-H-EVROLET License Prov; Model; TAHOE LT Odometer- 0 Body Styles 4 DOOR UT.UTY Verified By; Work Aequlred; Part Desce tlon OTY List Mscount Net Extended ��"�:� •s nr;�us.^:,�;v� ;riir >sor rt o��, f , m � ?,�� 9'45.v .W o 2£3.5 2" � VMOULDING)(31.50,M.1 J) _A vii Labor ftsr01:5490SYN 11.00 45M 45.00 ! 45.00 45.00 HAH.3v0113G 2.33 20.00 20.^0 t 20.00 2v.0C YS MAT D SPFEE M.A` RiAL/HA1; LlN G DISPOSAL=IE 1.301 5M Mo% 5.30 5.00 YS Sty btota i 353.50 Tax A^:yount 26.45 L.aduL4Eb'Se 'dotal Payable. $373.95 Additional Note; i ONTRACTOR LCENSE#:3781 11 8JREAU OF AUTO MOTNEE REPAIR#:AJ207077 AuT,#^UP.ZAT":ON To PAY her aby au'ho:lza and er^poww t.e aol;vs-named 4insurancs cor;-par y tc way ti's!nvo#can f0 se:t emsn?,sat s#act;on and d scharga o;all?oss under tea above policy. ;upon such payment,all r gifts I may have mr c ain"and dama„c:o. r€b loss and damage cesced above against:^s above~arrAd insurance company sh6 be thereby forever o':schargad. €n,'he event t gat the above named lnsfuranca✓mpa y Woes r`ot rnake,;t;.e:y and/o,fu,i payment of this involce according to'sus terms,i hereby accept responsibllIly for s•.xoh payment and agree to pay al;cnarg"es raflected .s; oceo xaic^t~iitl`®rns as notes bs3owr. TEP..M.S:M�:cT 30 DAYS,SERMCE CHARG E OF f i12e!EER MONTH(16%5ER,ANN:;,M)W1 LL8E CHARGED CME OVERCJE ACCOUNTS. ...... . .. ... ST—MEP 8_,A7=_TAX OR EXEMPSRLESA�: T ORDER 7A4Ei BY ;NSTALLED BY 'EDFRA-: TAX;; 70: 80;-,D TO: A CO. POUCYNO. CO. PHONE NC. CLAW NU P-Q;_-'C Y NNA M E CAUSE& LOSS LOCAT nN AGE-N—NNAME VERT ED BY AGENT PHONE DATE OF LOSS DEDUCT:SLE ------------------------ M I ------------- 4 V ............ ........... ion -- ----------------------------------- AUTHOR2AT!0-.N TO PAY ;sfac,".,on ar�d d' cOrr-Par-Y to oay!.h:!S;nvo'cq i,f,:;selsmqn;,Sal- '0�!cy. UPOn SuCh payment,a;:r,,ghts:r-, �so''a"ga of a����oss undef ns above and dernand for .ay have for 0 iOss and damage dasc,-,.'bsv,. abo�s aga;r!st t,;Ie abo.,Is'n-amed mawrance coT Ycrever daschere c. �n penv . ai!0 be fu;l psymsrt clh;s event t�-at t"!e rl�,,cvq arced insufar.ce com"any does not make tn' �y a' !nvo�cs aa.- 40 Ris":arms:51 h me: nd/or ar6cy accsP�t rss-,Ons!bi�'Y for sueh paymsnt and so to t�e at-ove named g�ass' conn, !a�nvc�c grea to Pa"Y sublect to&r-d a^—^Ordlrlg to a�l'sFr.s CLAIM BOAR OF SUPERVISORS OF CONTRA COSTA COUNTY �+ • �' BOARD ACTION:AUGUST 17, ;,2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT ,and Hoard Action. All Section references are to ) The copy of this document mailed to you is you California Government Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi. " Pursuant to Government Code Section 913 and FPO, 915.4. Please note all"Warnings". I F11 AMOUNT• iI . • $1,440.00 CLAIMANT: IRWIN B. POMEROY MARTINEZ CAL4s, ATTORNEY: UNKNOWN DATE RECEIVED: JULY 21, 2004 ADDRESS: P.O. BOX 1197 BY DELIVERY TO CLERK.ON: JULY 21, 2004 LAKEPORT, CA 95453 BY MAIL POSTMARKED: JULY 19, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN Dated: JULY 21, 2004 By: Deputy II. FkOM: County Counsel, TO: Clerk of the Board of Sup sons (s4�'this claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed.The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { } Other: Dated: By:k°'J - Deputy County Coe 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). V OARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code se on 91 ) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depot in the mail to file a court action on this claim. See Government Code Section 945.6. You may seep the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. ' AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now,and at all times herein mentioned,have been a citizen of the Unite States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: � ' JOHN SWEETEN, CLERK By Deputy C) Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 144's day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presenter) not later than six months after the accrual of the cause of action. Claims relating to any other 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 filed with the Clerk of the Board of Supervisors at its officeinRoom 145, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Against the County of Contra Costa or JUL 1 2 District) � t��' t U , (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum ofS�# 'f and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) Lf 2. VV ere.did the damage or injury occur?(Include city and count 3. How did the damage or injury occur?(Give full details;use extra paper if required) kiii j t j 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury,or damage? S. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) , 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) 8. Dames and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DAM 3BE AM Grew. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." E (Attornev Name and Address of Attorney ) t. (Claimant's Si attire) (Address) LdA Telephone No. }Tel hone No. . .. N0710E SeWon 72 of the Penal Code Provides: Every person who,with intent to defraud,ptesents for allowance or the payment to any state board or officer,or to any county,city,or district hoard or officer,authorized to allow or pay the saltie if genuine,any false or fraudulent clainn,bilk 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 thousazid(S 1,000).or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of exceeding ten thousand dollars($10.000),or by both such.inns isonmernt and fine. STATE OF CALIFORNIA "R41=FIS COLLISION REPORT :���r Page I Of 9 1 CHP 5i5 CARS Page 1 (Rev 1-03)OPE 061 SPECIAL CONDITIONS NUIMER WYARM CITY JUDICIAL DISTRICT LOCAL.REPORT NUMBER r MiilNtlO F@CORY i UNINC. DELTA tvmestKum -4 RafiErM�mE1lN7R COUNTY REPORTING DISTRICT BEAT 6-213 0 J CONTRA COSTA 95 COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC# OFFICER I.D. Z MARSH CREEK ROAD C/R 6/15/2004 1645 9320 015459 Q DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: NONE TUESDAY MILEPOST INFORMATION: X TUESDAY X;YES I NO �AT INTERSECTION WITH: STATE HWY REL M1LE(S)WEST OF WALNUT BLVD. YES X NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VF-H.YEAR MAKE I MODEL/COLOR LICENSE NUMBER STATE j D1694222 CA C M G 2000 CHEV 3500 PIU WHT 1025321 CA DRIVER NAME(fIRST,MIDDLE,LAST) LEOPOLDO JESUS MARTIN OWNER'S NAME ❑SAME AS DRIVER PEDES- STREET ADDRESS CONTRA COSTA COUNTY TRIAN 154.1 APRICOT WAY OWNERS ADDRESS ❑SAME AS DRIVER PARKED CITY tSTATE IZIP 2467 WATERBiRDWAY MARnNEZ CA 94553 VEHICLE BRENTWOOD CA 94513 DISPOSITION OF VEHICLE ON ORDERS OF: I 1 OFFICER [Y]DRIVER ❑OTHER BICY-,. SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE ARCO TOW l J CLIST M BRIT IBRN 6-02 185 2/24/1984 Yasr W PRIOR MECH.DEFECTS X NONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: (925)634-1333 (925)595-5390 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHAM IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER - [:]UW DNONE []MINOR SELF-INSURED 22 MOD X MAJOR -,ROLL-OVER DR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT E MARSH CREEK ROAD 50 CAL-T TCPIPSC MCIMx EL3 PARTY DRIVER'S LfCENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH.YEAR MAKE I MODEL/COLOR- LICENSE NUMBER STATE 2 DRIVER NAME(FIRST,MIDDLE,LAST) LjOWNER'S NAME SAME AS DRIVER PEDES- STREET ADDRESS MAN OWNER'S ADDRESS F�SAME AS DRIVER PARKED CITY/STATE/ZIP VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: 'OFFICER DRIVER []OTHER BICY SEX HAIR EYES HEIGHT WEIGHT BIRTHDATERACE CLIST Mo Day Year PRIOR MECHANICAL DEFECTS NONE APP. , REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POUCYNUMBER GUNK NONE MINOR MOD R ROLL-OVER DR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT CAL-T TCP/PSC MC/MX PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EOUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 3 DRIVER NAME(FIRST,MIDDLE,LAST) OWNERS NAME SAME AS DRIVER PEDES- STREET ADDRESS TRIAN OWNER'S ADDRESS SAME AS DRIVER PARKED CITY 1 STATE f ZIP VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: ' OFFICER DRIVER THER CLIIS7 SEX HAIR EYES HEIGHT WEIGHT SIRTHDATE Y RACE Ma Day i PRIOR MECHANCIAL DEFECTS NONE APP. FIREFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: F-IDESCRIBE VEHICLE DAMAGE SHAME IN DAMAGED AREA Li VEHICLE TYPE iNBUR,A 4M CARRIER POLICY NUMBER ❑LINK NONE ❑MINOR MOD MAJOR ROLL-OVER DR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT C.4 DOT CAL•T TCPIPSC Mcmx PREPARERS NAME DISPATCH NOTIFIED '5 DATA �ED �� D.E.MCCANN 015459 YES ND wn ("/il!, STATE OF CALIFORNIA TRAFFIC COLLISION CODING CHP`555 CARS Paget(Rev.1-03)OPI 061 Page 2 61 g DATE OF COLLISION(MO.DAY YEAR) TIME(2400I NCIC# OFFICER I.D. NUMBER , 6/15/2004 1645 9320 015459 6-213 _T OWNER dNINE=R ADDRESSNOTIFIED PROPER PG&E YYES E]NO DAMAGE OEscRPnoN OF oAMAGE POWER POLE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED WC BICYCLE-HELMET A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER A-CELL PHONE HANDHELD B-UNKNOWN N-OTHER V-NO X-NO B-CELL PHONE HANDSFREE C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES C-ELECTRONIC EQUIPMENT D-LAP BELT NOT USED D-RADIO/CD 1 2 3 1-DRIVER E-SMOKING 2 TO 6-PASSENGERS E-SHOULDER HARNESS USED CHILD RESTRAINT F-EATING 4 5 F-SHOULDER HARNESS NOT USED EJECTED FROM VEHICLE 7-STA.WGN REAR Q-IN VEHICLE USED G-CHILDREN G-LAP/SHOULDER HARNESS USED 0-NOT Y UEC p B-RR.OCC TRK:DR VAN R-IN VEHICLE NOT USED H-ANIMALS H-LAP/SHOULOER HARNESS NOTUSED i-FULLY EJECTED 8-POSITION UNKNOWN S-IN VEHICLE USE UNKNOWN I- PERSONNEL HYGIENE J-PASSIVE RESTRAINT USED 2•PARTIALLY EJECTED 0.OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN J-READING U-NONE IN VEHICLE K-OTHER ITEMS MARRED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE, PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1213 SPECIAL INFORMATION 1 2 3 MOVEMENT PRECEDING UST NUMBER(k)OF PARTY AT FAULT COLLISION 1 VC SECTION VIOLATED: CITED5 JA CONTROLS FUNCTIONING JA HAZARDOUS MATERIAL A STOPPED A 22107 V.C. VNO S CONTROLS NOT FUNCTIONING' IS CELL PHONE HANDHELD IN USE S PROCEEDING STRAIGHT S OTHER IMPROPER DRIVING' G CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE X C RAN OFF ROAD X 10 NO CONTROLS PRESENT/FACTOR* X D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLISION E SCHOOL BUS RELATED I I JE MAKING LEFT TURN D UNKNOWN* A HEAD-ON F 75 FT MOTORTRUCK COMBO I F MAKING U TURN S SIDE SWIPE G 32 FT TRAILER COMBO 10 BACKING C REAR END H IN SLOWING 1 STOPPING WEATHER (MARK 1 TO 2 ITEMS) D BROADSIDE 1 i PASSING OTHER VEHICLE X JA CLEAR X E HIT OBJECT J J CHANGING LANES S CLOUDY F OVERTURNED K K PARKING MANEUVER C RAINING G VEHICLE/PEDESTRIAN L L ENTERING TRAFFIC D SNOWING H OTHER*: M M OTHER UNSAFE TURNING E FOG/VISIBILITY FT. N N XING INTO OPPOSING LANE F OTHER MOTOR VEHICLE INVOLVED WITH 0 O PARKED G WIND A NON-COLLISION IP P MERGING LIGHTING S PEDESTRIAN Q . O TRAVELING WRONG WAY X A DAYLIGHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS R OTHER*: B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROARAY 1 (MARK 1 TO 2 ITEMS) C DARK-STREETLIGHTS E PARKED MOTOR VEHICLE A VC SECTIONwouT>D: CITED RYES D DARK-NO STREET LIGHTS F TRAIN NO E DARK-STREET LIGHT'S NOT G BICYCLE S VCSECTION VOATW: "TED FUNCTIONING' GNEs N ANIMAL: �Nd SOBRIETY-DRUG ROADWAY SURFACE C VC SECTION VIOLATED: CITED YES 1 (MARK PI YSICALO 2 ITEMS) X A DRY X I FIXED OBJECT: Nd S WET POWER POLE D }( A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: B HBO-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) F INATTENTION— C HSO-NOT UNDER INFLUENCE* ROADWAY CONDITION(S) Q STOP&GO TRAFFIC D HBD-MdPA1RMENT UNKNOWN' (MARK I TO 2 ITEMS) PEDESTRIANS ACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE* A HOLES,DEEP RUT' X JA NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' S LOOSE MATERIAL ON ROADWAY* S CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY* AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NpT APPLICABLE D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT YES 1 SLEEPY/FATIGUED E REDUCED ROADWAY WIDTH AT INTERSECTION NO F FLOOpEp* D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER. $ IN ROAD INCLUDES SHOULDER M OTHER*: X H NO UNUSUAL CONDITIONS IF NOT IN ROAD X N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS 10 RUNAWAY VEHICLE SKETCH MISCELLANEOUS DOT 2ND PROPERTY OWNER: INDICATE NORTH STEVE POMEROY CR CRNR - 1600 EUREKA AVE. BRENTWOOD,CA 94513 (925)634-3080 ..�..«19C Cliff' ------- PROPERTY DAMAGED: WALNUT TREE SO - NOTIFIED:S DA PD/ SO STATE OF CALIFORNIA INJURED I WITNESSES f PASSENGERS Page 3 of 9 CHP 555 CARS Page 3 Rev 1-031 OPt 061 DATE OF COLLISION(MO.DAY YEAR) TIME(2400) NCIC# OFFICER I.D. NUMBER 6115/2004 1645 9320 015459 6-213 WITNESS PASSENGER ACE SEX EXTENT OF 1NJURY(`X'ONE) INJURED WAS fX`ONE) PARTY SEAT AIR SAFETY EJECTED ONLY ONLY - NUMBER POS. SAG EQUIP. _ FATAL -:SEVERE OTHER VISIBLE COMPLAINT DRIVER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN ,�-� # ❑ 28 M ❑ E] ❑ a El :� ❑ -,D !J j 1 3 M G 0 NAME 1 D.O.B./ADDRESS TELEPHONE JEREMY DEWS (03/25/1976) 823 SHELL AVE. MARTINEZ CA 94553 (925)313-9103__ (INJURED ONLY)TRANSPORTED BY: TAKEN TO: TO SEEK OWN AID DESCRIBE INJURIES: COMPLAINT OF PAIN TO RIGHT LEG/ANKLE Ll VICTIM OF VIOLENT CRIME NOTIFIED ❑X # 1 ❑ 47 F ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE EILEEN FER13ER 03/18/1957 5819 HEMET AVE. STOCKTON CA 95207 209 952-8086 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: (� (� VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑. ❑. ❑ ❑ ... ❑ ❑ L.J LYl ❑ ❑ NAME 1 D.O.S.1 ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED NAME I D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ QI ❑ ❑ ❑ ❑ ❑ ❑ I ❑ NAME i D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED PREPARERS NAME 1.0.NUMBER MO. DAY YEAR REVIEWER'S NAMEMO. DAY YEAR D.E.MCCANN 015459 6/15/2004 STATE OF CALiFbRNIA F90WAAL DIAGRAM pwo -f DATE OFC StON(MO. DAY YEAR) Slh (2400) WCIC N OFFICER I.D. NUMBER ' Y L--t (SCIS r Z { ALL MEASUREMENTS ARE APPRO)UMATE AND NOT TO SCALE UNLESS STATED{SCALE: } M H CREEKR'*.- � INDICATE NORTH SKETCH V-1 tree 11 i 6 1 V-t WALNw r.BLVD. 3 pourer prole dfh+a•S ` j V-1 r . I double yellow rhe — —— $ VA— Solid white rate£typ.) - j � 1 1 a road edge(typ.) --ig f f PREi'AFIY' ^� � b" � IMER ' O.� DAY YFA� RLME\NEA'&NAME 10. DAY YEAR CSP 96 28973 STATE OF CAUOORN1A FACTUAL DIAGRAM P.g.S CHIP 55 Paae 4 fLay.8-973 OPI 042 � DAM OF COLLIsm(MG. DAY YEAR} Yil (2f00} NC ie# OFFIMP I.D. NUMBER 60 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE M E • INDICATE NORTH P'HY610h EViCEf& VEHICLE POINTS OF REST: l V-i: RtR,f+#r'E of power pole and W N of N tt i road edge of Marsh Creek Rd. } RIF-'78'E of power pole and WN of N 1 road edge of Marsh Creek Rd. PHYSICAL EVIDENCE DESCRIPTION: +h !! A.Poaver foie -API MMI, i B.Tree tree j PHYSICAL EVIDENCE LOCATION- l P A.).5 miles W of W roadway edge prolongation r of Walnut Blvd.and I O'N of N rood edge of Marsh Creek Rd. B.) .5-60'W of W roadway edge proksngafion of Walnut Blvd.and 18'N of N road edge of Marsh Creek Rd. �. __ !A—LALNUT 9LYD. power pole I I 1 �n double yellow lines - tltrird wflrte V �) - it road etige(tyl5) —MI, W � 1 10fL > 10f ..... PREPARED EZ::„ I.D.iJtJM�ER MO. DAY YEAR P"EV ER B NAME MO. DAY YEAR OSP 99 28073 STATE OF CALIFORNIA NARRATIVEI'SUPPLEMENTAL - - - PAGE 6 of g DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 0611512004 1645 9320 015459 6-213 1 FACTS: 2 3 NOTIFICATION: I was dispatched to a call of an injury traffic collision, with an ambulance 4 responding at 1650 hours. 1 responded from Delta Road at Byron Highway and arrived on 5 scene at 1700 hours. All times, speeds and measurements in this investigation are 6 approximate. Measurements were taken by pacing and vehicle odometer, except where 7 otherwise indicated. 8 9 SCENE: At the scene of this collision, Marsh Creek Road is an eastbound/westbound rural 10 roadway consisting of two lades. The roadway is straight and level. The surface is 11 composed primarily of asphalt. See Factual Diagram for details. 12 13 PARTIES: 14 15 PARTY#4 (MARTINI was located at the scene. Party MARTIN was identified by a valid 16 California driver's license. MARTIN was placed as a party by the following items. 17 18 - Driver statements 19 - Driver location 20 - Injuries to passengers 21 22 CHE'V'3500 PIU Driver# 1's vehicle, was located on its wheels as shown on the diagram. 23 Vehicle damage is sustained major front end damage including damage to the right/front 24 fender, right/front wheel, right side door, grille, front bumper,front lights, hood and left front 25 wheel. No prior damage was noted or claimed. 26 27 28 PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. E. MCCANN 015459 06/1512004 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE 7 OF 9 [TATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 06/15/2004 1645 9320 015459 6-213 1 PHYSICAL EVIDENCE: 2 3 See Factual Diagram. 4 5 STATEMENTS: 6 7 Statements are not verbatim and are written in summary form. The statements were 8 related back to the involved parties at the scene for verification. 9 10 PARTY# 1 (MARTIN)- related that he was driving V-1 on E/b Marsh Creek Road, W/of 11 Walnut Blvd. at approx. 55 m.p.h. P-1 related that a vehicle was approaching in the W/b 12 direction and he steered V-1 to the far right side of the E/b lane. P-1 related that he drove 13 V-1 off the south side of the roadway and lost steering control of V-1 on the dirt and gravel 14 shoulder. P-1 related that he steered V-1 back to the left and crossed the W/b lane and 15 collided with the power pole on north side of the road and hen collided into a tree. 16 17 PASSENGER (JEREMY DEWS)was contacted at the scene. Dews related that P-1 was 18 not paying attention and drifted off onto the dirt and gravel shoulder area on the south side 19 of the road and swerved across the W/b lane. Dews related that he just saw the power 20 pole and braced himself for the impact. 21 22 WITNESS#1 (EILEEN FERBER}was contacted at the scene. FERBER related that she 23 was driving her vehicle on E/b Marsh Creep Road, W/of Walnut Blvd. at less than 50 m.p.h. 24 and approx. 5 car lengths behind V-1. Ferber related that V-1 drifted onto the right 25 shoulder several times and then suddenly swerved across the W/b lane and collided into 26 the power pole. 27 28 PREPMD BY I.D.NUMBER DATE REVIEWER'S NAME DATE D. E. MCCANN 015459 06/15/2004 STATE OF CALIFORNIA NARRATIVEISUPPLEMENTAL MAGE 8 OF 9 DATE OF INCIDENT - - TIME NCIC NUMBER OFFICER I.D. NUMBER 06/15/2004 1645 9320 015459 6-213 1 OPINIONS AND CONCLUSIONS: 2 3 The SUMMARY, AOI and CAUSE are based on vehicle damage and statements. 4 5 SUMMARY: 6 7 P-1 was driving V-1 on E/b Marsh Creek Road, W/of Walnut Blvd. at approx. 50 m.p.h. P-1 8 steered V-1 onto the shoulder and then steered left and lost steering control of V-1. V-1 9 crossed the W/b lane and onto the north side dirt and gravel shoulder. V-1 collided into the 10 power pole continued in an easterly direction and collided into a tree. 11 12 AREA OF IMPACT; 13 14 A01 ##1(V-1 vs. Power Pole)was located approx. .5 miles W/of the West roadway edge line 15 of Walnut Blvd. and approx. 10 feet N/of the North roadway edge line of Marsh Creek 16 Road. 17 18 AOI #2(V-1 vs. Tree) was located approx. .5 miles-60 feet W/of the West roadway edge line 19 of Walnut Blvd. and approx. 18 feet N/of the North roadway edge line of Marsh Creek 20 Road. 21 22 23 CAUSE: 24 25 P-1 was the cause of this collision. P-1 was driving V-1 in violation of section 22107 V.C., 26 (Unsafe turning movement). P-1 steered V-1 onto the right shoulder, overcorrected back to 27 the left, lost steering control and collided with the power pole and tree. 28 PREPARED BY J.D.NUMBER DATE REVIEWER'S NAME DATE D. E. MCCAN'N 015459 06/15/2004 N STATE OF CALIFORNIA NARRATIVEISUPPLEM'ENTAL PAGE 9 OF 9 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 06/15/2004 1645 9320 015459 6-213 RECOMMENDATIONS: 2 3 None. 4 PREPARED BY E.D.NUMBER DATE REVIEWER'S NAME DATE D. E. 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CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY G: BOARD ACTION:AUGUST 17, 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 2 1 '20!,4 915.4. Please note all"Warnings". AMOUNT: STILL;TO BE 'COMPUTED C003t% CLAIMANT: LIONSGATE DEVELOPMENT CORPORATION KENNETH BARKER ATTORNEY: UNTKNOWN DATE RECEIVED: JULY 21. 2004 ADDRESS: P.O. BOX 408 BY DELIVERY TO CLERK ON: JULY 21, 2004 ALAMO, CA 94507 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET l Dated: By: Deputy II. MOM: County Counsel TO: Clerk of the Beard of Supervi rs (:,)his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim.(Section 911.3). ( } Other: Dated: = By: �� f" 1 `y. - r P. 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). > 9 IVOARD 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, ByA� , Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or 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 } Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS T O 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 I De day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.1). B. Claims must be filed with the Clerk of the Board of Supervisors at its offict_in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553, C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be fled against each public entity. . E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp RECEIVED} Against the County of Contra Costa or ) JUL 2 1 2004 < L,° r '/ District) "nNTRA COSTA CO. (Fill in name) } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of S and in support of this claim represents as follows: 1,?4&1i9' es 41ZC I. When did the damage or injury occur?(Give exact date and hour) L. 7e1ef 1Z 7-t::\ 171 , 5 !,/ c-3 l V 7705-'...s ea,; E_ 43 C 6 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) 76, M '�5 / , _'T Ls IPA, 4 What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? -5 ,--- ,4 7- ef 14 C--12 G G r ,r`C- 11,41 "l� 1 1 - 5 fes`U f d .1 ,7" "'/-� �J 11X-1 �S/vim 5. What are the names of county or district officers, servants, or employees causing the damage or injury? fel ( t!r d /.,14 12 Y� ��A °'az t /v 5 '' G 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) :5 6c - f ? 7" C.: 1-t l .- 6- L: T-/- / f 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) -'T C- 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE JDAE AMC3UNfi } Gov. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf." SND N UCyES TC); I Attorney Name and Address of Attorney } (Claimant's Signature) c5Y- } (Address) n .. Telephone o. Telephone No. No. N©77CE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state hard 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 clairn,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the stage prison,by a fine of.not exceeding ten thousand dollars(S 10,000),or by both such imprisonment and fine. LIONSGATE DEVELOPMENT CORPORATION l4tailing Address: F 0.BOX 408, Alamo,California 94507 Telephone(925) 831-8500 Fax(925) 831-8502 VIA.CERTIFIED MAIL.RETURN RECEIPT REQUESTED (No.7003 0500 0000 4264 3891) i Mr. Maurice Shiu June 30, 2004 CONTRA COSTA COUNTY, Public Works Department, 255 Glacier Drive, Martinez, CA 94553-4825 RE: MS 03-0015 --County Billing For$14,466.49 Dated 12!10/2003--Lionsgate Public Records Act Request-- County Letter Dated June 8, 2004.(Received by Lionsgate on June 23,2004) Dear Mr. Shui, Reference is made to the subject County billing in the amount of$14,466.49 for alleged County charges for processing Lionsgate's minor subdivision application MS 03- 0015.This billing includes alleged hourly County staff'charges made by the Department of Public Works, Community Development Department, and Office of County Counsel. Lionsgate has previously notified the County that these charges are unproper, and indeed fraudulent, because they are based upon knowingly false County determinations, as follows: r 1)The County falsely claimed Lionsgate had requested an exception to the Creek Set Ordinance Code. Therefore,according to the County,additional staff time was allegedly required to process the alleged exception. No exception to the Ordinance Code was ever made by Lionsgate. Dispositively, Mr. Eric Whan explained in a County meeting that he had erroneously concluded an exception was required based upon his illogical assumption from an undisclosed inference on the Tentative Vesting Flan. Furthermore, at the same meeting held on March 10,2004, Mr. Whan and Mr. Gossett were enable to support the County's creels set back assertions. Ordinance Code Section 94-2.608 expressly mandates that any request for an "...exception..."to the Ordinance Code must be in writing. No `°exception"request was ever made by Lionsgate, either in writing, or verbally. Therefore, the County's claim Lionsgate must now pay for County errors, is absurd. Troublingly,the County billing is not only improper, the County's act of knowingly submitting false billings to Lionsgate for payment violates the law and constitutes fraud. Surely, this should be self evident. 2)The County falsely claimed Lionsgate performed emergency storm drain pipe line repair work at 2501 'Warren Road,Walnut Creek,without a permit.Therefore, according to the County,Legit Counsel time was allegedly required to help the Public Works Department prepare a " Stop'Work Carder" for the alleged'' unauthorized storm drain pipeline repair work. Page leo. 2 --Letter to Maurice Shiu, June 30, 2004 County negligence by not maintaining its storm drain junction box at the corner of Boulevard Way and Warren Road caused it to over flow during wet weather which,in turn, caused severe flooding damages to the subject house and property. Additionally, the flooding broke and clogged the existing ten (10)inch diameter storm drain outlet piping. Lionsgate's subsequent inquiry revealed that not only had the County unlawfully installed about 250 lineal feet of buried ten(10)storm drain piping across the subject property without a drainage easement, or any other agreement, it had also negligently failed to maintain its storm drain piping system. As a result, emergency pipeline repairs were necessary by Lionsgate to prevent further flood damages to the house and property. With respect to the County's continued knowingly false allegations that a permit was required for the storm drain repair work, ( See County Letter dated June 8, 2004 signed by Brian Bulbas)we provide you with a copy of two Fax messages to Manna Wong, and a Lionsgate letter to Mr. Shiu. These confirm a permit was not required for the storm drain pipeline repair work. Nevertheless, some two weeks after the storm drain pipe line repair work had been completed,the County issued an erroneous and irrational " Stop Work Order"for the already completed work on the known false basis that a permit was required. With respect to the County's legal charges of$ 346.61, we memorialize that these legal charges are solely for County errors and grass mismanagement. Furthermore, in an attempt to cover up its grass conduct the County refused to supply Lionsgate with the back up for these legal charges. As you know,Lionsgate was finally forced to obtain a copy of the legal billing back up via a Public Records Act Request. Additionally, the County's further false billing to Lionsgate for these known County errors again violates the law and constitutes fraud. Surely, this should be self evident. Mr. Shiu, there are some very serious ethical and legal problems flowing from the County's false billings. 'Therefore, to equitably resolve this matter without further controversy and further claims against the County, it is respectfully requested that within ten days of your receipt of this letter, the County billing of$14,456.49 be vacated, and the $6,000.00 deposit amount be returned to Lionsgate. We also request a meeting between us be held as soon as possible to resolve any outstanding issues. Kindly advise of the time and date for the requested meeting, in writing, at your very earliest. Sincerer, Kenneth Barker, President, Lionsgate Development Corporation Attachments. Copy. All County Supervisors WtUTT04.B"Y: DATE: SUBJECT: PROJECT N Nt &MMU FME RECO CSF; MM-T NG .-� PHONE CONVERSAT ON ' SPOKE TO: PHONE Nom`.vv=- " OF (DEPT -Y): MF. mimG AT"' :-:NDEEs: 1 r 7 COPIES TO. ff f ,r U 1 , J{jtp r1" '2 w i (if yes) 8Y(person) dtc 1 .agb c�aracr is c..: '" l '► � .gate: DEVELOPMENT # ares w/cover sheet: PCENSE NO. A 427094 Mulling Address: P.O.Box 408 Alamo,CA 94507 Phone: (925)$31-8500 VAX: (925)831-8502 A A u.) � i X 1441. c*^1,F f 4U4P 7"a 6 04 jrp r// 4/C�3 1 G C 4fZ 0/ oV4C 7- Ar-4� r. /I. c�.�' c�► t� � ,rte �� ��''..�"" or 4145-i5 7Y4 7- /I P 101 t 7� ` ,rel0.T S e t C. 4.Aj f 0 " 4' Com,- o Aj Rcfrencr i __S off�, " Additional Comments It is not evident if is it has been determined if the creek is considered a"natural, unimproved creek"or an"improved channel". This should be established, and the creek structure setback line should be taken into consideration,before the project is allowed to move forward. Summary Thank you for your consideration of our concerns about the adequacy of the proposed Mitigation Measures.Please contact us if you have questions or require additional information.We welcome the opportunity to work with.the County to address these complex issues. Kind Regards, AA .. &XOO� Lisa.Ryanlin 'Sha CC: Supervisor Gayle B. Uilkema Mr.Gregory Connaughton,Assistant PublicWorks Director,Flood Control Ms.Catherine Kut=ris,Deputy Director,Community Development Department Mr.John Muzak,Saranap Homeowner's Association Enclosures i Confidential Page 18 2/2/2004 Ms.Candida,Wensley County File#03-0015 2yy v r YR x ......... t g sx3 # t £ F. 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' �`�...� i�=., `�_` � "�*✓�� ,�` � 4 t�X,� `'�# P, � G�x't -�Z��� rc �y �aca# '*A` � �,:,y �.,��� x�.i4^ ��j� :.- ' . .'-t�yY a.-c* ,� .g � 9s 'g: x "'tX 5� % `k � es>,R r�E ?� "#' a•�y� ,��yyw' ��` ✓'a c � .Z.All �~•F�.nw�. 5 "° j'v�c a I >>fk�"�' �" ����� yf ,�,y; r✓ £r ,r sra a't�� rs +r � �� '+�{r ��� ,tk r < x t[yds y t'� +j ;case:. �' , ti� {�`,,?.✓''" � ', )i � P!� t; s�`,x� >. *4 XdrfS'd.a+Y ✓ st a ya N*` ii• ' >+ „��'.€i.. t.y1 '� ^,cFhy ...c sh -0, b*er' ,.�4� S � � .m MA a•r.F' . �'�,�r „..� �Xa'�i* a y,[1 �fr� ,'^i".t��£-�i 8F,� z Xfw .r� '�.* .Y(Z'�-�.g*z <✓ ;v r, ai�v f'F ,� tt r'".0 U-”; "ARMS � �" ;i�►z is f, l � s i JEVELOPMENT # nagesyv/cover sheet; LICENSE No.A 427094 Mailing Address: P.O.Box 408 Alamo,CA 94507 Phone: (925)831-8500 FAR: (925)831-8502 o 1rs . .ecoc TCC Q . r 14c- C1- 7-(4 `C0 Oot e 1 TI 4t 310 . ee nod M 7a , yrs' . iajqcG "" nt` 10iraAi 1 , € l`Cz` u t . Co 1 4 r(/t e*uOt, * G W rC< rbc P R c- Z- C- ' Cre � Conga Public Works Department Maurice ship Public Woorr ks Director ,Costa 255 Glacier Drive R.Mitch Avalon County Martinez,CA 94553-4825 Deputy Director Telephone: (9.25)313-2000 FAX: 925 313-2333 Julia Deputy Director { } p y Web site:www.co.contra-costa.ca.us/depart/pw October 21, 2003 Patricia R.McNamee Deputy Director Lionsgate Development Corp. Attn: Paul Barker P.O. Box 408 Our File: MS 15-03 Alamo, CA 94507 Dear Mr. Barker: This letter is to follow up the "Stop Work Order" issued on your property at 2501 Warren Road in Walnut Creek on September 30, 2003. As the order states: Construction or alteration without a permit violates County Ordinance Code Section 1010-2.006(6). You as the property owner, must apply for and obtain a permit pursuant to County Ordinance Code Chapter 1010-8 and comply with all permit conditions. It is the County's understanding that the work on the private storm drain line is no longer,in progress and the property is currently applying for a minor subdivision, MS 15-03. In order to facilitate the permit and perform the required review of the storm drain line, your minor subdivision conditions of approval will require the developer to address the storm drain line sizing, placement, hydrology, hydraulics, and impacts. I have already notified Larry Gossett of our Engineering Services Division of these issues. Once this review has been completed, and any required modifications implemented, the stop work order will be lifted. Public works has also discussed this matter with our Building Inspection Department and our Community Development Department. Both departments have reviewed the Stop Work Order and determined that there are no actions required by their departments. Any additional work on your property will be subject to the County Ordinance Code. If you have any questions, please contact me at (925) 313-2321. Very truly yours, Mike Carlson Assistant Public Works Director Construction Division mclth G:\GrpData\Const\SUl3S12003\LTR-MC-MS 15-03.doc Cr. Supervisor Uilkema Maurice Sliiu Mitch Avalon Julie Bueren Heather Ballenger Larry Gossett Gary raria--Building Inspection Catherine Kutsuris-CDD LIONSCATE DEVELOPMENT CORPORATION Mailing Address: F 0.BOX 408,Alamo,California 94507 Telephone (925) 831-8500 Fax(925) 831-8502 Mr. Maurice Shiu, October 27, 2003 CONTRA COSTA COUNTY, County Public Narks Director, Public Works Department, 255 Glacier Drive, Martinez, CA 94553-4825. RB: Storm:gain Repair Permit Waiver-MS- 15-03 at 2501 Warren Road, Walnut Creek { -w County Letter Dated.October 212003 (Copy Attached) Dear Mr. Shiu, This letter responds to the above referenced County letter, signed by Mr. Mike Carlson, Assistant Public Works Director, Construction, recording that a permit was required for the storm drain piping repairs. Mr. Carlson's letter, however, failed to record that Mr. Greg.Connaughton, Assistant Public Works Director, Floud Control Engineering, at a meeting with Ms. Hanna Wong, County Engineering Staff, on September 16, 2003 advised that a permit for the storm drain repairs was waived. Therefore,there appears to be a communication breakdown between the various groups within your Department, and this communication failure places the storm drain line repairs in a false light. (See attached copies of our faxes.) Parenthetically, for whatever reason, for many years the County has not maintained the County stormy drain drop inlet structure located at the corner of Boulevard Way and Warren Road, As a result, the drop structure outlet piping was clogged with a large battle and debris. This, in turn, had ruptured the drop structure nutlet pipe, not only causing severe flooding to our house over the past years, but also saturating the slopes above Las Trampas geek on adjacent properties. This could trigger devastating landslides. Therefore, to avoid further flooding problems it was imperative that the storm drain repairs be completed without delay and before the,onset of any wet weather. In view of these facts, we consider Mr. Connaughton's permit waiver to be reasonable, prudent, and in the Public interest. Kindly contact the undersigned if you require further information is required. Sincerely,,,. Kenneth Barker, President, Lionsgate Development Corporation. i Clint Shaw & Lisa Ryan 1430 Boulevard Way,Walnut Creek, CA 94595 Phone: 925.930.9434 January 26,2004 Ms. Candida Wensley =i+ Project Planner ' r--t Community Development Department `p Contra Costa County :r 651 Pine Street,North Wing,4th Floor Martinez, CA 94553-0095 RE: County File#MS 03-0015. Proposed Mitigated Negative Declaration Lionsgate Development Corporation APN 184-150-029 Dear Ms.Wensley: We are in receipt of a"Notice of Public Review and Intent to Adapt a Proposed Negative Declaration"(County File MS 03-0015).We are grafi for the time you have dedicated to this project to date and appreciate the opportunity to provide comments. We understand from our discussions with the Applicant,the Vesting Tentative Map,and documents we have received to date,that the Applicant plans to: 1)complete the drainage project begun.in September 2003,(Exhibit 7 and 7a)by diverting the water originating from the corner of Boulevard Way and Warren Road into an outfall system located on the Looney's property and 2)divide the parcel into three lots. We have lived at 1430 Boulevard Way(directly adjacent to the Applicant's parcel and the Looney's property over which the proposed outfall system will be installed)since 1996.Being long time residents,we are familiar with both properties,the existing drainage system and retaining wall,and the flood behavior of Las Trampas creek. In addition,we have become intimately familiar with the history of the area through public records and conversations with neighbors.In this letter,we have included some, background information to provide context for our comments and recommendations. We believe the Mitigation Measures proposed are not sufficient to reduce the impact of the project to Less than Siccant. We believe additional research and discussion is required before a Mitigated Negahve Declaration should be issued and the project should be allowed to move forward. Confidential Page 1 2/2/2004 Ms.Candida Wensley County File#03-0015 On September 16th,2003, the Applicants installed over 80' of new 18"diameter, corrugated plastic pipe,connected it to the junction box at the intersection of Warren Road and Boulevard Way,and then reduced it to the existing 10"asbestos pipe that terminates on the Ryan/Shaw property. At the same time Applicants re-graded a portion of the embankment adjacent to the driveway. (See Exhibits 7 and 7A).In an effort to prevent further erosion of the hillside adjacent to their home,Ryan/Shaw re-attached a temporary pipe to the 10"pipe to carry the water away from their home and over the top of the bank. Ryan/Shaw then called the County to inquire about the 18"pipe installed by Applicants.Greg Connaughton(Assistant Public Works Director,Flood Control) informed Ryan/Shaw that the upgraded pipe did not require a permit because the pipe was draining only onto the Applicant's property. Ryan/Shaw stated that the new 18"pipe does not drain onto Applicant's property but is connected to an existing 10"pipe that drains directly onto Ryan/Shaw's property. In response to the Ryan/Shaw inquiry of September 161,the Applicant sent a series of letters to the County. In his letter of October 8,2003,the Applicant stated there has been: ...no flow whatsoever through the storm,Frain piping since Lionsgate has owned the property. "At the time of writing it hadn't rained,however,on January 1,2004 there was substantial rain flow(See Exhibit 101 and Exhibit 5). Substantial soil erosion and loss of topsoil continue to be a significant issue. Sheet flow from the slope of the hill,caused by the fill dumped behind the Looney's retaining wall, and sheet flow and concentrated runoff`from the Applicant's parcel and the intersection of Boulevard Way and Warren Road have caused significant erosion of the topsoil, hillside,and bank of the creek. (See exhibit 101). Runoff water currently exceeds the capacity of the existing storm water drainage system (see Exhibit 101). The proposed outfall system may mitigate the drainage problems originating from Warren and Boulevard Way but it will not alleviate sheet flow originating from Boulevard Way and the southeast corner of the parcel. Added sheet flow caused by the structures,patios,and driveways of the proposed development of parcel C will add to the amount of surface runoff. The current vesting Tentative.Map(revision 3,October 23, 2003)shows no proposed collection of runoff from the southwest corner to the southeast comer of the Applicant's parcel(parcel C, approximately 17,800 sq. f1.) Additional grading of the site for the proposed homes,may contribute to erosion problems if the grading is not sloped away from the Ryan/Shaw properly. The Ryan/Shaw easement agreement states that: Confidential Page 12 2/2/2004 Ms. Candida Wensley County File#03-0015 Additional Comments ■ It is not evident if is it has been determined if the creek is considered a"natural, unimproved creek"or an"improved channel". This should be established, and the creek structure setback line should be taken into consideration,before the project is allowed to move forward. Summary Thank you for your consideration of our concerns about the adequacy of the proposed Mitigation Measures. Please contact us if you have questions or require additional information. We welcome the opportunity to work with the County to address these complex issues. Kind Regards, I. .. Lisa Ryan iin Sha CC: Supervisor Gayle E. Uilkerna Mr.Gregory Connaughton,Assistant Public'Works Director,Flood Control Ms.Catherine Kutsuris,Deputy Director,Community Development Department Mr.John Ruzek, Saramp Homeowner's Association Enclosures .. Confidential Page 18 2/2/2004 Ms. Candida Wensley County File#03-0015 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COU.I+ITY BOARTI ACTION:AUOUST 17, 20014 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 you California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi- Pursuant to Government Code Section 913 and 15.4. Please note all"Warnings". AMOUNT: $1.20.00 2 , CLAIMANT: MARY J. REGALIA COUNTY COUNSEL ATTORNEY: UNKNowN DATE:RECEIVED: JULY 26, 2004 ADDRESS: 1514 FRANCIS ST. , BY DELIVERY TO CLERK ON: JULY 261 2004 CROCKEIT, 'CA 94525 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE�'E C erk .Dated: JULY 26, 2004 By: Deputy ;� II. MOM: County Counsel TO: Clerk of the Board of Supeivisors { is claim complies substantially with Sections 910 and 910.2. ( } This Claire 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: E By: ;� �. L ' Deputy County Coy; 111. FROM: Clerk ofthe Berard 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: (tj This Claim is rejected in full. ( ) Other: z I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. ,Dat a ! 02 0 JOHN SWEETEN, CLERK.,By , Deputy Clerk WARNING(Gov. code se6ion 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depo; 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 ante now, and at all times herein mentioned, have been a citizen Of the Unite States,over age IS; and that today I deposited in the United States Postal Service in Martinez, California.,postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated• J"14OHN SWEETEN, CLERK By Deputy C1 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COMM INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for.death or for in, ury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than One year after the accrual of the cause of action. (Govt. Code $911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration. Building, 651 fire Street, Martinez, Ci 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this f orm. RE: Claim By ) 'Reserved for Clerk's filing stamp zLdu' a RECEIVED Against the County of Contra Costa } JUL 2 6 2004 or ':LERK BOARD MqUPERVISORS District) r TrACC',STAOCA. 7111"in tame ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-nod District in the sum of and in support of this claim represents -as follows: 1. When did the damage or injury occur? (Give exact date and hour) I a' aoioq 2. Where did the damage or injury occur? (Include city and county) 1184.l�•`r "T " % � 5!1 46 ci ` f ��t'i t .i Late"; ✓%' 3. How did the, damage or injury occur? (Give full �details- use extra paper if :" tLiZ2"::t /Lf ? j�€4asLG , / tzty9/dfGy �;�b mfr ° .: �'! V'2.)Se%' r'.*' o/. '- 4d�`'Yi 3! ry�J'(trc.fn..e-tg �.✓ 4. y4^...G'V'd/ 'i'f:;�tr't�"' '1 ,..1 f' tzJvri✓ rliw sil 'tubas u �✓�s J_`8v tld1 ti�G teed' s�^'Z��E".�_ 4. W6t particular act or Mission on the part of county or district officers, servants or.empl,oyees caused. the. injury or damage? hr 5• gnat are the names of county or district officers, servants or employees causing the damage or injury? 5.What damage or injuries do you claim resulted?(Give full extent of injuries or damages,.claimed./ Attach two, estimates for auto e. 7. How was the amount claimed above computed' (Include the estimated am,?unt of an prospective injury or damage. V .f' `Z� � f -gig �� � GSL r n"14 a ✓ i �� K.( c`L;/vY �,;, -✓L3 :-G`f} i'1/''t?' „.. iyr`' �f''' �ul 7X..� /�f+t� '��......�L.���:tlf.</��}z`� 'c.(/�' 'i;3.rl.>��__ �4` :,,bl.C"•'��`"£�}.� �z.�§:J .��.... �'\`' _ ,� t'f/���t�..L rr 6. Names and addresses of witnesses, doctors and hospitals EX Z�'W Pz��-�3 ///4/11 Ild:; If 9. List+the iexpenditures you made on account of this accident or injury. DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim mist be signed by the claimant SEND NOTICES TO: (Attorney)_ or some person on his.behalf." Name and Address of Attorney hill/...-- s Sigria - 16W al� Address Telephone No. Telephone No. * * * N O T I C E Section 72 of the Penal Code provides: "Eve_+^y person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by_ imprisoIment 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 impri.soriment and fine,- or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. _..... ADk1HST€TNF_OFA€CE Ra box&,e G SS_.-_ C,0;l ,t RDt „A 9 524 ---- us LA ^ r - --- - %:. ? F ,'v.^i, t'�-�,.JcS -1 R;. AX :_^� ACV t_n,r : _: v SOLO wo now :. -...... j POL�cy NO, ` SU G1 E 00 i'yvj_ic�r;�:l,yrE .... .. . .... — viASw S _— _._..,..—_L __.._._—_.�... OSS MCKMIN DATE F SS r Later LiA sell Total 0170TRAET PER boys k1uhnn'.. x � . . 3 .. :• .. .. is t PREVINT OpEnsups too 41 HOUR, E s s { 77, TS i s s i if t TO-r' hereby MOWS and F#£"W& Jnsumt c-3 £ t":5ny FC p9' tY FS nv3jCe in fu{ S£- £' ent, i and.�' t uF 4 ccs. CzS >der t'✓~ ^...3�f y #'SuM pa. en' d. 1ghm i-Iay�Mc jc_ �"� u't't er Ess i t a�F3g£, uSS #'"£'i r,t)r8 flC&3'SY #F'E a�xvE am d :n.suF3 cq S'(.'Sany S�Fr, be ! BMWs •}to Mw Mat s S owe mt C i L.3FCS r £:.s3r'y dIOS,>'S^i make •met y lq/'•3Y 1 p"Mom, I INNMNM a a nY m N.% w 3.^.,'33°£-?S ;#'S^tEtz to.,such;lay'nrf and 3g£ e.0 i ali MaltWWAd .3.1 c t'5vci.. P, .x, SN:'a:.,.°x ,SrmSL 6�n S'�:;# X12, ,. 51};ES ;i' ai'ns} caccordin ,)ac i c3 3'.ti and canduhns on 000 Kolce. -------- ':' fPvfS x. ._. s a f MS: DAYS3 5_.? r _k'V i°1°P mom-j, o't :AN,'N'L•,< x:4_ K,C$-ARG..E:?ON v^;F;POUE P.CGc-.,# :S. { f to, , 444w opiI4 C,-,5�fw Co--s4"'4 VIA� � s v fv IC . CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:'AUGUST 17, 200 Crim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is you California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi Pursuant to Government Code Section 913 and k{ # 915.4. Please note all"Warnings". AMOUNT: X680.00Il' l . £ € CLAIMANT: JAIME MOLINA COUNTYs< UNSEL MARTINEZ CAUR ATTORNEY: UNKNOWN DATE RECEIVED: JULY 26, 2004 ADDRESS: 512 DOHRMANN LANE, BY DELIVERY TO CLERK ON: JULY 26, 2004 PINOLE, CA 94564 BY MAIL POSTMARKED: _ JULY 23, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET 1 Dated: JULY 26, 2004 By: Deputy II. FROM: County Counsel. TO: Clerk of the Board of Supervisors (•4/'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: s" - ,,; F X11.: f Dated: �-- "% By ' ` � µ ': Deputy County Cou 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: {vj' This Claire is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated• JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sect n 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depo; 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 Unite States, over age 18; and that today I deposited in the United States Postai Service in Martinez, California,postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN SWEETEN, CLERK By Deputy Cl Claim to: BOARD OF SUPERVISORS OF CWM STA COMM INSTRUCTIONS 'rO CLA�';T A. Claims relating to ca+.uses of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 1001-h day after the accrual of the cause of action:. Claims relating to causes of Taction for .death or for injury to person or to peMnal. Property car growing crops and u:ich acs can or after January 1, 1.9881 must be presented rant later the six moths after the accrual of the cause of ,action. Claim relating to any Cather cause of action MLtst be presented not later than one year aft the accrLal of the cause of action. (Govt. Code §1911,2.) B a Claims mit be filed with the Clerk of the BoaM of Supervi3crs at its off Lot: in Room 106, Camty Administration Building, 651 Pine Street, MaLrtinez, CA 94553. C. lf'..claim ..i Agetir t 'a dittrict governed by the i .rd� of Supervizors, ratter tlual the County, the name cf the District should be filled in. Db If the claim is against more than one public entity, separate claims =- st be filed against each public enti.yy. E. Fraud. See pewrlalty for fraudulent clai , Penal., Cade Sec. 72 at the end of this _0M_. RE: Claim By Reserved for Cleric's filing stamp VER t the c6uity or Contra rosra JUL 2 6 2004 or ) .rlERK BOARD OF n SUPERVISORS ",'!TPA COSTA M District) __... 1 The undersigled claimant Eby =kes claim against the County of Contra Costa o.- the ab0V6-rramed District in the ,sem of $ 00 and in support of this claim represents -as follow 1.. When did the dawga,or injury occur? (Give exact date and hoar) E '- -' 2. Where did the dmage or Wury► oocur? (Include city and county) `•"�L� ,�,r'`,%S.+��%... £ i�,w�.b,..r �'--'` � t �� 6 �-%,,.�` t 4 4-�� V�� rw.,e�.1�-,-, t-vf 2,(L%6+ ' � Z.�r "4✓�.*... L 3. HOV did the e zor injury occur:? y'ivve Mall detai si use extra paper if IrCbi •'wr.Wf .`� K. `}4£'7 v�.J 4iTKXS .y '\1y ; ..w. a..? 95 }{,{^�A .L.+ r\..Slf EL.S6-.."r.'h' 4 t4s'�S •` '•.� "��'�':'4�.>- !`s.��✓L�F� '�"�".tR%`� _.�.. :.5,'n z�; 4.. �:'�'�9�}1": " 3 +x�wre ..w.+�w+r.r.xe.sa�rr.wr.r.�rw....r.a.miw,wrre.. 4. What particular act Or mission on the part of oounty or district Officers, s e"var is tar.eMloYeU caused, the.injury cam* e? r g, wmat are the ramex of county ar district of f it-Amp servants or emplsoyees aausin,g the danage cr injury? c v ' k 6. 'What doge or Injuries do you claim r-esulted? (Give full exte::t of iniuries or _Tjdamages claimed. Attach two estimates for auto doge. --Y- T• `fir-C � y .y Z..� a \:5 ��`Z,-.� �i.Jyv �s..�i k14...'.� �f C.riJ.•V h tr � 2 V G..�1 � L`v�����Y � T� �Ar.. 7» How was the amount claimed above muted? (Include the estimated amount Of any prospective injury or e.) »«:w,an.i..�....�•�..3,®..�..,..d.......,...�..«.,..d..w+�..�.w.ol.r.r,«....r�..w.ewK«wne ,�.r.+.r+�e�.sw.:.w..+w.�+e.`+.+ww+w+w.«..r....+..er...ew+9.r..r...,.,kru........o.... .,,. 8. , Names azid addresses of witnesses, doctors and hospitals. ci '0 {`fit r-F `l 4a 6, :c' la'�✓k Ilk AY%kt t F.y• SF List the expenditures you Bade on account of this accident or injury: DAIS AMMT Goi.s Code Sec. 91042 provides: "The claim must be signal by the cla rant SM NOTICES TO: (Attorney) or sow ersc�n on hia. 3.f.� E; and dress of Attorney �• f'r .(44imant,a S 9nature) s (Address) Telephone No. Telephone No. a at s a e NOTICE Se^vion 72 of the Pena. Cote provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay* the same if .geenuine, any false or fraudulent claim, bill, account, voucher, or +ar^iting, is p=i.shable either by impri.soriment in the county Jail- for as period of not mcr+e than cane,year, by a fine of not exceeding one thousand ($1,000)* or by both such imprisor=ent and fine,,, or by imprisozutnnt in the stage prison, by a fisc of not axoeeding ten thousand dollars ($10*0000 or' by both such iMrisonment and fine. CR.00KETTS PREMIER AUTO BODY 900 SAN PABLO AVE PINOLE, CA 94564 (510) 741-9001 CD LOG NO 13522-1 DATE 07/21/04 SHOP: CROCKETTS PREMIER AUTO BODY INSP DATE: 07/21/04 ADDRESS : 900 SAN PABLO AVE, CONTACT: VINCE VEGA CITY STATE: PINOLE, CA PHONE 1 : (510) 741-9001 ZIP: 94564- FAX: (510) 741-9009 OWNER: MOLINA, JAIME HOME PHONE : (510) 233-0576 ADDRESS : 512 DOHRMMAN LN WORK PHONE: (510) 741-9992 CITY STATE: PINOLE, CA ZIP: 94564- LIC# : 5DLP765 STATE: CA VIN: 2HGES26783H567803 BODY COLOR: MILEAGE: CONDITION: ACCTNG CTL# : PROD.DATE: 12/03 PAINT CODE: *=USER-ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS EC=REPLACE ECONOMY UC=RECONDITIONED PRT UM=REMAN/REBUILT PRT EU=REPLACE SALVAGE EP=REPLACE PXN PC=PXN RECONDITIONED PM=PXN REMAN/REBUILT TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR I=REPAIR L=REFINISH BR=BLEND REFINISH TT=TWO-TONE CG=CHIPGUARD SB=SUBLET N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR 2003 HONDA CIVIC EX 4DOOR SEDAN 4CYL GASOLINE 1 . 7 VTEC CODE: H0263E/C OPTNS B/24NCDEFGIJP OPTIONS: TWO-STAGE - EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES FRONT SPOILER ELEC REMOTE CONTROL MIRRORS POWER DOOR LOCKS POWER WINDOWS REMOTE KEYLESS ENTRY SYSTEM MOONROOF ANTI-LOCK BRAKE SYSTEM AIR CONDITIONING CRUISE CONTROL OP GDE MC DESCRIPTION MFG. PART NO. PRICE AJ% B% HOURS R I TAR, REMOVAL REPAIR 10 , 0*1* **REMOVE TAR, POLISH AND WAX** 1 ITEMS FINAL CALCULATIONS & ENTRIES PAGE 1 07/21/04 2003 HONDA CIVIC EX 4DOOR SEDAN CD LOG 40 ,13522-1 PARTS & MATERIAL TOTAL LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL 63 . 00 10 . 0 680 . 00 2-MECH/ELEC 72 . 00 3-FRAME 72 . 00 4-REFINISH 68 . 00 5-PAINT MATERIAL 28 . 00 LABOR TOTAL 680 . 00 SUBLET REPAIRS TOWING STORAGE GROSS TOTAL 680 . 00 NET TOTAL 680 . 00 ADP SHOPLINK U0080 ES CD LOG 13522--1 DATE 07/21/04 10 : 55 :32AM R6 . 35 CD 06/04 PXN: Y/00/00/00/00/00 CUM 00/00/00/00/00 GEOCODE 94525 HOST LOG (C) 1998 -- 2004 ADP CLAIMS SOLUTIONS GROUP, INC. -------------------------------------------------- THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. PAGE 2 07/21/04 Date: 7121/2004 11:22 AM Estimate ID: 487 Estimate Version: 0 Preliminary Profile ID: Mitchell Bill Letson Chevrolet 3233 AUTO PLAZA RICHMOND,CA 94806 (510)222-2070 Fax: (510)223-8569 Tax ID: 94-1699426 BAR M A8007001 EPA#: CAD981997588 Damage Assessed By: Chris Hoglund Deductible: UNKNOWN Insured: JAIME MOLINA Address: 512 DOHRMAN LANE PINOLE,CA 94564 Telephone: Home Phone: (510)827-9056 Mitchell Service: 918120 Description: 2003 Honda Civic EX Body Style: 4D Sed Drive Train: 1.71-Inj 4 Cyl 4A FWD VIN: 2HGES26783H567803 Mileage: 17,100 OEMIALT: O Search Code: None PLEASE NOTE: LINE ITEM REPAIRS DESCRIBED AS SUBLET,REFERS TO THOSE REPAIRS PERFORMED BY OTHER FACILITIES OTHER THAN BILL NELSON CHEVROLET,OLDSMOOBILE. FOR EXAMPLE: GLASS,STEREO, TIRES, AND UPHOLSTERY. IT MAY BE NECESSARY TO OPERATE VEHICLE HEREIN DESCRIBED, TO AND FROM SUBLET VENDOR. Color: BLACK PEARL Options: ALUMIALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION,AM-FM STEREOICDPLAYER(SINGLE) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED,RECORED,REMANUFACTURED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS.CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PARTS" ARE NON ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS. THOSE LISTED AS "LKQ" LIKE KIND AND QUALITY PARTS ARE USED PARTS. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 900500 BDY* CHECKIADJUST REMOVE TAR AND DETAIL Existing 8.0* 2 936007 ADD'L COST SHOP MATERIALS 40.00 ESTIMATE RECALL NUMBER: 712112004 11:22:41 487 UltraMate Is a Trademark of Mitchell international Mitchell Data Version; JUL_04_A Copyright(C)1994-2003 Mitchell international Page 1 of 2 UltraMate Version: 5.0.024 All Rights Reserved Date: 712112004 11:22 AM Estimate ID: 467 Estimate Version: 0 Preliminary Profile ID: Mitchell * -Judgement Item AddI Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary _Amount Body 8.0 63.00 0.00 0.00 504.00 T Total Replacement Parts Amount 0.00 Taxable Labor 504.00 Labor Summary 8.0 504.00 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 40.00 Customer Responsibility 0.00 Sales Tax @ 8.250% 3.30 Total Additional Costs 43.30 1. Total Labor: 504.00 II. Total Replacement Parts: 0.00 Ill. Total Additional Costs: 43.30 Gross Total: 547.30 IV. Total Adjustments: 0.00 Net Total: 547.30 This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair. SPECIAL PARTS NOTE:ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" PARTS {OEM} UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROD, RECORED, OR REMANUFACTURED ARE EITHER "RECONDITIONED" PARTS OR "REBUILT" PARTS. CRASH PARTS DESCRIBED AS QUAL REPL PART" ARE NON OEM AFTERMARKET PARTS. Cycle Time Information Drop Off Date: 712112004 Repair Dates: Promise Date: 712112004 Start Date: 712112004 ESTIMATE RECALL NUMBER. 71211200411:22:41 487 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_04_A Copyright(C)1594-2003 Mitchell International Page 2 of 2 UitraMate Version: 5.0.024 All Rights Reserved I ....�..-- --,-- " ---.--.. ..... ...... 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CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • V4 fl BOARD ACTION:AUGUST 173 ,,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 you California Government Codes. ) notice of the-action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi Pursuant to Government Code Section 913 and 915.4, Please note all"Warnings". AMOUNT: ` X544.00 CLAIMANT: KART ANDREVS Y 0 � EL �5 � ,FEZ: ALiF� ATTORNEY: UNKNOWN DATE RECEIVED: JULY 26, 2004 ADDRESS: 644 DONNA MAE COURT BY DELIVERY TO CLEF.ON: JULY 26, 2004 EL SOBRANTE, CA 94803 BY.MAIL POSTMARKED: JULY 23, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET. ... Dated: JULY 262 2004 By: Deputy II. OM: County Counsel, TO: Clerk of that Board of Supervisors (� This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Cleric 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. F", Deputy County Cou 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. J14DARD 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 HN SWEETEN, CLERK, By ,Deputy Clerk WARNING(Gov. code se ion 913) Zr Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or depo; 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 Unite States,over age 18, and that today I deposited in the United States Postal Service in Martinez, California,postage f 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 Cl Claim to: BOARD OF SUPERVISORS OF CflNi'RA COSTA COMM INSTRUCTIONS TO CLAD T A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1937, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for..death or for injury to person or to phonal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Coda §911.2.) B. Claims must be filed with the Clerk of the Board of supervisors at .its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. if the claim is against more than one public entity, separate claims must be filed against each public entity. E. ' Fraud. See Penalty for fraudulent claims, Penal Code Sec. 72 at the end of this f orm. RE: Claim By ) Reserved for Clerk's filing stamp t , Aft... } . Against the County of Contra.Costa } JUS. 6 2004 car _L_1,K BOARD Districts ^n�:r,�:" ��V�sORS The undersigned claimant hereby makes claim a inst the County of Contra Costa or the above-gid District in thy' seri orf � . and in support of this claim represer4ts as follows: - - l. When did the eor injury occur. (Give exact date and hour) rq B. Where, did thatdamage or injury occur? (Include city and county) "V , 3. Row did the damage o r injury occur? (Give full. details; use extra paper if Corequired) +w, :< �li`v�4 �":.� v..v� UO1,.-' °'nl4F •5b �i�� ..,.�4h_x— v�..4 �'�rw1, -. 4. What particular act or emission on the part of county or district officers, servants or .emplOyees caused the.injury or dapage? � t �"F�..t$ti�'�^',F � '`>. ��......si➢w✓"�'`S," -i .�' '�{+. "" �rv`C`•'.�<. w,. £'. ';; �.v '4•+.a- -...-iia��� '✓... _ `2,a�.1` �`'�'g...?�i�. �''. £ti .:e ':,{ o' '•,✓' 1 ✓ry ✓:.i y;,�v c.a,..P„jr`�4. 4�w,.. si Y e! '�...ko 3 - —s s,.a � .��;;> '':..',r..'..4i ?,�_.' .. ..�3.i ' ✓ *-- d` T k � f . fi ` r" „ ce \. +gnat are the rues of county or district officers, servants or employees causing the damage or injury? !'_^0 0A e,{'a. `+.,,.t.,J"•.'-y. w �.....,.� ,... ,.' S t 4rj"!< Vii\ f•`. {� .i't w. °w,�'^-_1+i 0 �_... X i C, \x.. 03 ;<S, 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed..,,-Attach two estimates for auto damage. f 7. How was the amount claimed above computed? {Include the estimated amount of any y prospective injury or kdama(ge ) y5 4 ^�''a.4i�,? `'•'S 5"3 .: ,.) ,�. ... r,L"h 4,� 3\-.y i Y 3.\-'0 \,v.l ...*.'E. k, s�sf1�.•; Names and addresses of witnesses, doctors and hospitals. ..k� � •~ P d � ..4�2 '\^w k ?.�"�..+1 4.....!- T s ....e 1l ...�`.✓ ,i'A •�fj S ,. •'b �i. 9. List the expenditures you made on account of this accident or injury: DATE ,ITEM AMOUNT Gov. Cade Sec. 9101:2 provides: "'The claim must be signed by the claimant SEND NOTICES TO. (Attorney) or by some pgnson on his"behalf." Name and Address of Attorney Claimant's Signature (Address) h.r i1- Telephone No. Telephone No. +� :# Section 72 of the Penal Code provides: "Every person who, with :intent.._to defraud, pr sents for 61lowsme or �fvr payment to any state board or officer, or to 'any 'qty, city br,�district?board or officer, authorized to allow or pay the same if.genuine, any false or fraudulent claim, bill, account, voucher, or witing, 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)j, or by,--both suoh' imprisonment anis Fine,-or, by; imprisonment in the state prison, by a fine of not exceeding ten .thpusa.nd`dollars ($10,000, on by both such imprisonment and fine. CROCKETTS PREMIER AUTO BODY 900 SAN PABLO AVE PINOLE, CA .94564 (510) 741-9001 CD LOG NO 13523-1 DATE 07/21/04 SHOP: CROCKETTS PREMIER AUTO BODY INSP DATE: 07/21/04 ADDRESS : 900 SAN PABLO AVE, CONTACT: PAUL RAGATZ CITY STATE: PINOLE, CA PHONE 1 : (510) 741-9001 ZIP : 94564- FAX: (510) 741-9009 OWNER: ANDREWS, KA.RI WORK PHONE: (510) 776-1554 ADDRESS : 664 DONNA MAE CT CITY STATE: EL SOBRANTE, CA ZIP : 94803- LIC# : 3XVX698 STATE: CA VIN: 1HGEJ8244WL028619 BODY COLOR: WHITE MILEAGE: CONDITION: ACCTNG CTL# : *=USER-ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS EC=REPLACE ECONOMY UC=RECONDITIONED PRT UM=REMAN/REBUILT PRT EU=REPLACE SALVAGE EP=REPLACE PXN PC=PXN RECONDITIONED PM=PXN REMAN/REBUILT TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR I=REPAIR L=REFINISH BR=BLEND REFINISH TT=TWO-TONE CG=CHIPGUARD SB=SUBLET N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR 1998 HONDA CIVIC EX 2DOOR COUPE 4CYL GASOLINE 1 . 6 VTEC CODE: H0254F/C OPTNS C/24BCDPFEIL OPTIONS: TWO-STAGE - EXTERIOR SURFACES TWO-STAGE - INTERIOR SURFACES ELEC REMOTE CONTROL MIRRORS POWER DOOR LOCKS POWER WINDOWS REMOTE KEYLESS ENTRY SYSTEM MOONROOF POWER STEERING AIR CONDITIONING CRUISE CONTROL OP GDE MC DESCRIPTION MFG. PART NO. PRICE AJ% B% HOURS R -- --- -- ----------- ------------ ----- --- -- ----- - N REMOVE TAR ADDNL LABOR OPERA * 6 . 0*1* N WAX COMPLETE ADDNL LABOR OPERA 2 . 0*1* 2 ITEMS FINAL CALCULATIONS & ENTRIES PARTS & MATERIAL TOTAL LABOR RATE REPLACE HRS REPAIR HRS PAGE 1 07/21/04 98 HONDA CIVIC EX 2DOOR COUPE C LG9 NO 13523-1 1-SHEET METAL 68 . 00 8 . 0 544 . 00 2-MECH/ELEC 72 . 00 3-FRAME 72 . 00 4-REFINISH 68 . 00 5-PAINT MATERIAL 28 . 00 LABOR TOTAL 544 . 00 SUBLET REPAIRS TOWING STORAGE GROSS TOTAL 544 . 00 NET TOTAL 544 . 00 ADP SHOPLINK U0080 ES CD LOG 13523-1 DATE 07/21/04 10 : 57 : 57AM R6 . 35 CD 06/04 PXN: Y/00/00/00/00/00 CUM 00/00/00/00/00 GEOCODE 94525 HOST LOG (C) 1998 - 2004 ADP CLAIMS SOLUTIONS GROUP, INC. -------------------------------------------------- THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE . ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE . PAGE 2 07/21/04 Date, 7/2912004 11:19 AM Estimate ID: 486 Estimate Version: 0 Preliminary Profile ID: Mitchell Bill Nelson Chevrolet 3233 AUTO PLAZA RICHMOND,CA 94806 (510)222-2070 Fax: (510)223-8569 Tax ID: 94-1699426 BAR* ABOO7001 EPA#: CADS81997588 Damage Assessed By: Chris Hoglund Deductible: UNKNOWN insured: KARL ANDREWS Address: 664 DONNA MAE CT EL SOBRANTE,CA 94803 Telephone: Home Phone: (510)222-3087 Mitchell Service: 915130 Description: 1998 Honda Civic EX Body Style: 2D Cps Drive Train: 1.61.Inp 4 Cyl A VIN: 1 HGEJ8244WL028619 Mileage: 103,224 OEMIALT: 0 Search Code: None PLEASE NOTE: LINE ITEM REPAIRS DESCRIBED AS SUBLET,REFERS TO THOSE REPAIRS PERFORMED BY OTHER FACILITIES OTHER THAN BILL NELSON CHEVROLET,OLDSMOBILE. FOR EXAMPLE: GLASS,STEREO, TIRES, AND UPHOLSTERY. IT MAY BE NECESSARY TO OPERATE VEHICLE HEREIN DESCRIBED, TO AND FROM SUBLET VENDOR. Color: WHITE Options: ALUMIALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION,AM-1°M STEREOICDPLAYER(SINGLE) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PA'R'TS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED,RECORED,REMANUFACTURED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS.CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PARTS" .ARE NON ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS. THOSE LISTED AS "LKQ-" LIKE KIND AND QUALITY PARTS ARE USED PARTS. Line Entry Labor Line item Park Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 900500 BDY* CHECKlADJUST REMOVE TAR AND DETAIL Existing 6.5* 2 936007 ADD'L COST SHOP MATERIALS 40.00 ESTIMATE RECALL NUMBER: 7!21/200411:19;43 486 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_04_A Copyright(C)1994-2003 Mitchell International Page 1 of 2 UltraMate Version: 5.0,024 All Rights Reserved Date: 7/211200411:19 AM Estimate ID: 486 Estimate Version: 0 Preliminary Profile ID: Mitchell * -Judgement item Add'l Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals ti. Part Replacement Summary Amount Body 6.5 63.00 0.00 0.00 409.50 T Total Replacement Parts Amount 0.00 Taxable Labor 409.50 Labor Summary 6.5 409.50 Ill. Addltlonal Costs Amount IV. Adjustments Amount Taxable Costs 40.00 Customer Responsibility 0.00 Sales Tax @ 8.260% 3.30 Total Additional Casts 43.30 1. Total Labor: 409.50 if. Total Replacement Parts: 0.00 Ill. Total Additional Costs: 43.30 Gross Total: 452.80 IV. Total Adjustments: 0.00 Net Total: 452.80 This is a Prefiminary estimate. Additional changes to the estimate may be required for the actual repair. SPECIAL PARTS NOTE:ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" PARTS (OEM) UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, OR REMANUFACTURED ARE EITHER "RECONDITIONED" PARTS OR "REBUILT" PARTS. CRASH PARTS DESCRIBED AS QUAL REPL PART" ARE NON OEM AFTEPIVUkKET PARTS. Circle Time Information Drop Off Crate: 7/2112004 Repair Dates: Promise Date. 712112004 Start Date: 712112004 ESTIMATE RECALL NUMBER: 71211200411:19:43 486 UftraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_04�A Copyright(C)1994-2003 Mitchell International Page 2 of 2 UltraMate Version: 5.0.024 All Rights Reserved x ` C5uj Rc, UJ LLJ f uj f uw --F r V c \ CN Jl- fi)): `.°�'✓}3»�d5T4fy � ,,1 �{�"j � ice' T� 5 i � F e ..q Fdi � i.v CLAIM BOARD OF SUPERVISORS OF CONTRA COS'T'A COUNTY BOARD ACTION:AUQ7 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 you California Government Codes. ) notice of the action taken on your claim by the t 5 Board of Supervisors. (Paragraph IV below), gi 5rR ° 3sk4tR'. � Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT. ~J� UNKNOWN CiOUN `f COU,-SEL CLAIMANT: CANDY E. VILLANUEVAN Y-s ATTORNEY: ANDREW B. BOSQUE DATE RECEIVED: JULY 26, 2004 ADDRESS: ANDREW B. BOSQUE & ASSOCIATES BY DELIVERY TO CLERK ON: JULY 26, 2004 2614 SPRINGS ROAD, VALLEJO, CA 94591 . BY MAIL POSTMARKED: JULY 23, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SVY rk Dated: JULY 26, 2004 By: Deputy II. ME: County Counsel. TO Clerk of they Board of Supe iso 78 (;,)`"This clain omplies substantially with Sections 910 and 910.2. i ( ) 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). &4 (j,)-'Claim wo timely filed. truing-off ( Other: V-1 .;.... J„S iji '} !^c...j `y4 .. riv:{:_...--- -y✓�? tt �'/ ..r',.- +..3 y r.�.4...,i n f ,.j, ,Ile, .^' `'.d>:'"; r" f'7� � r �� 1/%. ._ Jl_c; Dated: € "`'° By: ' -� , ,� tr' "" Y Deputy County Cot 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). WIV . OARD ORDER: By unanimous vote of the Supervisors present: (► This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: :JOIN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or depot 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 Unite States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: o&f 42HN SWEETEN, CLERK By Deputy Cl CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:ACT UST 17, _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 you California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". Lxr' f; AMOUNT: UNKNOWN COUNTY� ���, CLAIMANT: CANDY E. VILLANUEVA MARTINEZ AL' ATTORNEY: ANDREW B. BOSQUE DATE RECEIVED: JULY 26, 2004 ADDRESS: ANDREW B. BOSQUE & ASSOCIATES BY DELIVERY TO CLERK ON: JULY 26, 2004 2614 SPICINGS ROAD, VALLEJO, CA 94591 . BY MAIL POSTMARKED: JULY 231 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE rk Dated: JULY 26, 2004 By: Deputy II, FROM: County Counsel. TO: Clerk of the Board of Sup isors (,}'`This claim�. omplies?substantially with Sections 910 and 910.2. ( ) This Clain FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.The Beard cannot act for 15 days(Section 910.0. (4'dlaini timely Filed. t lerl€ a returrrclat warnirtt off. 't;lai {' Other: L�,� '�' # �`,.�.. � •. --.t,-�:.�� � � �,-�-�-_+.�, (_�`�..�r`;,<- .,'.-� ��,,''` ,f r.� ,x- -# �- �....s ? ` ( Yt° v t fs ft 1 ) 4)'`' ' Yi 3 4 f L - I t .tet.' s"" .. 2� k.. f,... G z ALP :6 Dated: �� r` tf<;,�.. By:, ' ,- : :.. Deputy County Cot 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, CLERIC,By , Deputy Clerk WARNING(Gov, code sec on 91 j) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depot 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 Unite States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: KN SWEETEN, CLERIC By Deputy C] _. Law Firm ANDREW B. BO DE & ASSOCIATES Respond to: 93 Devine Street,hear Suite•San Jose•CA 95110-2405 XX 2614 Springs Rd.•Vallejo•CA 945901 Tel.(408)293-3923•Fax(408)2934919 Tel.(707)552-8603•Fax(707)556-3366 July 23, 2004 The',Secretary Certified Mail County Board of Supervisors With Return Receint County of Contra Costa 651 Pine Street, Room 146 Martinez, CA 94553 RE: Our Client: Candy F. Villanueva Our File No.: VJO—0723-04 Dates of Series of Incidents : Continuing since 9/11/2003 to 02/23/2004 Location of Incidents: County Department of Health Services (Contra Costa Regional Medical Center, Units 4 C and D), 2500 Alhambra Avenue, Martinez, CA 94553 SIR/MADAM: The undersigned Attorney of Mrs. Candy F. Villanueva hereby presents this claim to the County of Contra Costa—pursuant to Section 910 of the California Government Code. The full name and post office address of the claimant is: CANDY F. VILLANUEVA, R.N. lRoundhill Court allejo, CA 94591 1. The Post Office address to which the undersigned desires notices concerning this claim to be sent, is the undersigned attorney's street and mailing address specified and checked above. 2. Claimant is an employee as Registered Nurse with Contra Costa Regional Medical Center since October 18, 1989 up to the present and assigned alternatively as team leader for Units 4 C and D of said Medical Center. 3. Claimant was subjected wrongfully to intentional infliction of emotional distress, harassment in the workplace, defamation,portrayal in false light,discrimination and retaliation, through a series of incidents commencing September 11, 2003 and continuing until late February of 2004. 1 Candy F.Villanueva's Claim v. County of Contra Costa Notice of Claim.(Continued) 4. These incidents were proximately caused by an ill-trained charge nurse who was negligently hired and/or supervised by the Medical Center. The full name of the county-employee who caused the claimant's injuries and damages is CHISARA OHANELE—Charge Nurse of the afore-cited Medical Center with the same address referenced above. 5. To the extent the undersigned has been informed to date,the claimant has sustained and continue to sustain damages in terms of Medical bills for her injuries the total amount of which she has not ascertained to date. 6. Mrs. Villanueva had undergone labs,medical check-up, EKG and up to the present,undergoing Job Stress Group,by doctor's slip through her Family Mental Health Therapist,the duration of such treatment is at least once a week. Mrs. Villanueva was treated for her emotional distress in Kaiser Permanente at Vallejo, CA through her personal physician,a certain Dr. Chaco. We are still awaiting med1 reports of her treating physicians as to the specific injuries the claimant sustainel Suffice it to say that as direct consequence of the series of incidents complained of our said client suffered mental anguish& anxieties,great depression and humiliation, shack,nausea and insomnia. 7. To date, claimant claims for damages and for all her pains and sufferings—the total amounts of which are still unknown, and prospectively for her continuing costs of medical care which is presently unknown to claimant and her attorney; Please contact your liability insurance carrier, if any, immediately upon receipt of this letter so that we may discuss the future disposition of this matter. Please furnish us forthwith by mail the following information. Your insurance carrier's name, address, claim number,telephone and fax numbers and name of adjuster. I look forward to hearing from your insurance carrier and hope that this matter can be resolved to the satisfaction of all parties. Sincerely, ANDREW B. BOSQUE& ASSOCIATES ANDRE B Ba t�'�:.• Attorney fo artily viilanueva 2 UjLD M �o ' rs o aQ co cu y is bmf) C� .N.rr.n.w�r.. r Q) E Ln w r'rrrNrr rur4 0 {.3 ru t �.' c 0 . C3 0 .. .. .. 0 IM ow r a. C3 W t- . .. «..� � �. ..` � F-- « U m ui v� �C �r •d C-4 OFFICE OF THE COUNTY COUNSEL SILVANO B.MARCHESM COUNTY COUNSEL COUNTY OF CONTRA COSTA �� � � � � " Administration Building 651 Pine Street, 9=y Floor SHARON L. ANDERSON A Martinez, California 94553-1229 (925) 335-1800 GREGORY C. HARVEY VALERIE J. RANCHE (925) 646-1078 (fax) "rZ3t Asstsrartrs �, STATUTORY WARNING PURSUANT TO GOVERNMENT CODE SECTION 911.3 TO: Andrew B. Bosque 2614 Springs Road Vallejo, CA 94591 RE: Claim of Candy F. Villanueva Please Take Notice as Follows: The claim you presented to the Contra Costa County Board of Supervisors on July 23, 2404 was reviewed by County Counsel. The portion of the claim prior to January 23, 2004 was not presented within six months after the event or occurrence as required by law. Because you allege a continuing violation, the claim is "timely on its face" and will be reviewed and acted upon by the Board of Supervisors within the statutory time period. To preserve the rights of the County, its departments and employees to challenge the validity of your continuing violation claim, you are warned pursuant to statute that if your continuing violation argument is improper, the portion of your claim prior to January 23, 2004 is late, and is being returned because it was not presented within six months after the event or occurrence as required by law. (See Gov. Code, §§ 901, 911.2.) Because portions of the claim may not have been presented within the time allowed by law, we warn you that to preserve your right in the event your claim is determined to be late, your only recourse at this time is to apply without delay to the Contra Costa County Board of Supervisors for leave to present a late claim. (See Gov. Code, §§ 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances, leave to present a late claim will be granted. (See Gov. Code, § 911.6.) Page 1 SILVANO B. MARCIIESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 10 12, 1013a,2015.5; Evid. Cade, §§ 541, 664) 1 am a resident of the State of California,over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel,651 Pine Street,9th Floor,Martinez,CA 94553-1229. Can August , 2004, 1 served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid,in the United States mail at Martinez,California addressed as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice,it would be deposited with the U.S.Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the Stpte of California and the United States of America that the above is true and correct. Executed on August ,2004 at Martinez, California. a hleen O'Connell. cc. Clerk of the Board of Supervisors (original) Risk Management Page 2 CLAIM C. " BOARD OF SUPE VISORS OF CONTRA COSTA COUNTY BOARD ACTICTN.-ASST I7, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references zM Qftf; x ,The copy of this document mailed to you is your California Government Codes. S sn Ex `�°{ � once of the action taken on your claim by the H' pard of Supervisors, (Paragraph IV below), given f I° ursuant to Government Code Section 913 and _ 915.4. Please note all"Warnings". AMOUNT: IN EXCESS OF $I0,000.00 Z ,Ak $E CLAIMANT: MARIA POSAIDA, JOHN BREGLIO AND ROLA POSADA ATTORNEY: REG J. LoRmoN DATE RECEIVED: JULY 27, 2004_ ADDRESS: LAW OFFICE OF REG J. LORMON BY DELIVERY TO CLERK.ON: JULY 27, 2004 2.36 LOS GATOS BLVD. , LOS GATOS, CA 95030 BY MAIL POSTMARKED- NO DATE BY USPO FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Maim. . JOHN SWEE N Dated: JULY 27, 2004 By Deputy 11, MOM: County Counsel, TO. Clerk of the Board of Sine stirs ( 4.�s 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 claire(Section 911.3). ( ) Other: rf 7 Dated: ti By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated. JOHN SWEETEN, CLERK., By Deputy Clerk 11 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 deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter, If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above, Dated: OHN SWEETEN, CLERK.By Deputy Clerk I REG J. LORMON, SBN 46921 2 CHRISTINE M.DEKLOTZ, SBN 159370 3 LAW OFFICE OF REG J. LORMON _ 4 236 Los Gatos Blvd. RECEIVED 5 Los Gatos, CA 95030 6 (408)354-6100 JUL 2 7 2004 7 8 Attorneys for Claimants � _;c SaARD F SUPEP q1 ORS 9 �MTRA COSTACa. 10 CLAIM FOR DAMAGES 11 TO PERSON OR PROPERTY 12 AGAINST 13 CONTRA COSTA COUNTY 14 Reserve for Filing Stamp 15 Claimed By: ) 16 ) Claim No. 17 Marta Posada, John Breglio } 18 and Rosa Posada ) 19 ) 20 ) 21 Against: ) 22 ) 23 Contra Costa County. ), 24 25 To The Contra Costa County Board of Supervisors: 26 27 The above-named Claimants hereby present their claim for damages as follows: 28 1) Their address is 18610 Crane Avenue, Castro Valley, California. 29 2) The address, which all communications and notices on their behalf are to be 30 sent to,is the Law Office of Reg J. Lormon, 236 Los Gatos Blvd., Los Gatos, CA 95030. 31 3) The incident giving rise to this claim was a motor vehicle accident that occurred 32 on March 19, 2004 on Interstate 680 at North Main Street, in Walnut Creek, 33 Contra Costa County, California. At that time and place, due to the negligent entrustment, 34 operation, maintenance and/or other negligent acts and/or failures to act by and/or on 35 behalf of the County of Contra Costa and its agents and representatives, Claimants' 1 Claim for Damages I vehicle, occupied by driver John Breglio and passengers Marta Posada and Rosa Posada, 2 was caused to be struck by a vehicle believed to be owned by John Rusca as further 3 described in California Highway Patrol report number 3-257. This incident occurred 4 around 2 p.m. For further reference, a copy of the CHP report for this accident is 5 attached as Exhibit "A" 6 4) The injuries incurred by the above-referenced Claimants were, amongst others, as 7 follows: 8 a. John Breglio suffered injuries to his neck, abdomen, face, back, chest, 9 shoulder,together with acute distress and shock. 10 b. Rosa Posada suffered injuries to her ribs (broken), chest, abdomen, neck, 11 shoulders, arm, knees,together with blood pressure complications, shock 12 and distress. 13 C. Marta Posada suffered injuries to her back, neck, nose(broken), head 14 (concussion), right foot, shoulders, chest, together with distress and shock. 15 5) The name of the Contra Costa County employee believed to be responsible for 16 this accident and Claimants' damages and injuries giving rise to this claim is Tracy Lynn 17 Hein, 18 6) The amount of damages claimed is in excess of$10,000 and this claim would be 19 filed as an "unlimited civil case" in the Contra Costa Countv Sup"'or rt. 20 Dated: `,-2004 21 RE J' R.140N, Attorney for 22 Clai, is 23 24 25 26 27 28 29 30 2 Claim for Damages r t ' r M - - max♦ ♦ _.w � .ca a ,�y. R _ 130OEM - lnm IT- e e ♦. ! Now ■■ -_ tl y;ysy r f 4 c '_a< _ ■ J y #FYI ■�■�■ ..r�L-'_ :■■■ .Si-.-A.-_ ■. ' ; •Ps `-M� _ t . 'vsL.':r... MEN Ea_ v.a"•_ n- _. # - FZEN . ■ 9 1 w_-....f.. _ ■■■ ■■ ..� INN 1 ::lT • £ �Et K-_. �� ■■■ w1mu-TV77MMr* ,. -. , , ,. OA rjtt-; ■■■ won ■� t�� t.T: ■ .. ■ ■■w ■ M NEW 67 ■ ■■■� a - s r. lr MEQIll low p ii■�i ^ a E ■�� t s DTZ i' ■■■ ri^iE ._:.LiMEN ' d ...., E , MOM 13 - ! ■ .�. >y " . .. : M mrm,lt . QE31113 t• s aim ap*MAMFWK INJURED t WRWE SS10-3 I PASSERS � 3 at Ct+ sw _fjYoftr1F VAa OAY WAM TMSa4= Nuc crs NLMSR 33/T9�1flU4 1440 9= 15503 {)3-?5 T AM SU EX I EN I OF LNJU iYCr CWM (r ORM PIN" sicavetr CULY OlfLY WNW MAL sawm *Tmfmm -4my OWAnA19P P= �iRAY R Qk sawlt! SPAM mm �. md`3YC�C ❑� ❑ 45 F ❑ ❑ ❑ E ❑ inx 101 ❑ 10 3 3 L 0 NAMEI9.fl.e.rnt�R�S '> anE MARTA FSA (W=959) SANE ADD MS A5 P-3 (510)728-1323 ;ow.�ty�ar TAi�1VT+? ABAR JOFW UM MEDICAL CENTER CU&qAU;—1 CW?AIR TO AND NBM � I�i ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ ! ❑ 3 4 G o ,NAM@lOt41.8.! 11E RMAL 115 X335 AI7 A -3 4I '7 2 $ 935 i AUR D6E�dE 1aN COMPLAINT OF PAIR TO CEESTRM AND ARM i ViC;iM OF Y1CX w CAM NOTF= U ❑ ❑ ❑ L. ❑ t ❑ ❑ (�! Nfte/CL0AiAWUWT (> (IFtxltl�31+NLY} 6Y TAXM 1 i t� t � tgG'T�AF V101.17�'L`Ern��tD7v�p L.v ❑ t 1 NAM I AAI.t SoPVnT fWfff TAXWTCC DSWRW KUW-r ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0- ❑ I NAIL/tza6 rAGC> 7ELEPHOW Tmca4 To; i i �-,s e of vxJt:i�tr C N t ❑ ❑ �I ❑ ❑ ❑ ❑ ❑ ❑ s ww+cr�sr.�.�Aoct - r � v�raa�e�v!oL�vr cum xr�rr�m ! Ffi�'Ai 9NAM� 1- Nummm IMO. —DAY- VM ANO% MD. DAY EXHIBIT. 26 LA xawme X19 01 Attu MUMMUPAWN AMAMft=WAIRAMWOrTOWAS WK=*XTASM VX2" ! mwrxse Nre[s�s CPVM • � �� fit, � i►�t _�' .. 6tQ�i�rj�t��if: tnp�xJr IttL+rvJ Lim* f C�tlrrJttt t f414+VWAy LQM i6 aRRT yEMI R6VlYYE_ .M.X i7i�7T Y6d1R i osp 0 zam EXHIBIT..,, ...�► r i k3" tr 11 O r Oils STAIM d-WIFORM �s NAMMMMIMPLEM DATEOF20CMENT Tam"NCICNUMUR MR=La NUMBER 03-19.04 1400 9320 16503 1 IAM 2 3 NQ-lZ CAU(3N'. 4 5 ON 03-19-041 RECD A CALL AT 1410 HOURS FROM CHP DISPATCH OF A nlAMC 6 COLLISION W17H AN AMBULANCE EN ROLE. I RESPONDED FROM T.IE CON-IRA COSTA 7 CHP OFFICE AND ARRIVED ON SCENE AT 1432 HOURS_ ALL TIMES, SPEEDS,AND 8 S IN THIS REPORT ARE APPROXD"TE. 11EASUREMENTS WERE OBTAL i 9 BY VISUAL AND BEST ESTIMATION. 10 1yI/y ■���]��,�yyryry��../�����,� yyy�y����¢`� (/.yam Iii` Sw.M1L"ii.l.il Ri CRH7L N- 13 144 THE SCENE OF T'ETCS COLLISION ON 1-680 N/B AT TEE NORTH mAiN 5T. C/C IS PRpAARiL',� 15 COMPOS OF ASPHALT. THIME ARE FIVE LANES OF NORT OUND TRAFFIC. THE LAS 16 ARE DEI IATED BY BRO10N PAINTED WME LINES. THE#1 LANE IS SEPARATED FRom 17 THE CENTER.MMLAN BY A SOLID YELLOW L M. THE#5 LANE IS SEPARATED FROM THE 18 RICHT SHOUIDERBY A SOLID WEIETE LINE.THE ROADWAY SLIGHTLY ASCENDS AS YOU i9 PRO C NOR.Tf T. THIS SECTION OF FREEWAY IS MA1I+TARIU D BY THE STATE OF 20 CALIFORNIA. SEE FAMAL DIACRAM FOR.FURTIIER INFRO A.TIt7N. 21 22 23 R&Bt XW 32 t : 24 25 PARTY#1 (1-1,EXIN)WAS LOCATED AT THE SCENE ON THE RIGHT SHOULDER STANDING 26 NEXT TO V-1. P-1 WAS IDENTHqEDBYHERVAIJD CALIFORNIA DRIVER'S IACIENSE AND AS 27 THE DRIVER OF V-1 BY IBM STATEMENT. 28. 29 VMICLE#I(V=1,FORD)WAS LOCATED AT THE SCS ON ITS WMEELS ON THE RIGHT 30 SHOULDER.FACING INA.NORniERLY DIRECTION ION. V 1 SUSTAINED MODE ATE DAMAGE TO 31 ITS FRCS':END. NO MECHANICAL DEFEC'T'S OR PRIOR DAMAGE WAS NOTED OR C.LARvIED_ 32 P-I WAS AWE TO MOVE V-I TO THE RICHT SHOULDEK 33 34 PARTY#2(F-2,RUSCA)WAS LOCATED AT THE SCENE ON TUE RIGHT SHOULDER 35 STANDINGS N=TO V=2. P-2 WAS BY HIS VALID CALIFORNIA.DRIVER'S 36 LICENSE AND AS THE DRIVER OF V-2 BY HIS STAMWSNT. P-2 IS ALSO THE RMSTERE.D 37 OWNER OF V-2. 38 39 40 81R$HA'$NAS UL NtZU B$i DATE lvvmwEr:s Nta& DATr' D. ONCE A 16503 0320-04 EXHIBIT STATE of � p ME111't"AL �ac� �t DATA�PII 'I' mm w=wu mm opul.; R LA 03.19-04 1400 9320 16503 k� 1 LAB=VEMC:LES fmn—ga ted lz 2 3 VEHICLE#2(`Y-2,GMC)WAS LOCATED AT THE SCENE ON ITS W EELS ON THE RIGHT 4 SHOULDER FACING IN A NORTHERLY DTRI CTION IN TRONT OF V-1. V-2 SUSTAWED MNOR. 5 DAMAGE TO ITS REAR END AND MODERATE DAMAGE TO ITS FRONT END. NO 6 NECIiAMCAL DEFECTS OR.PRIOR DAMAGE WAS NOTED OR CLAIISIED. P-2 WAS ABLE TO 7 MOVE V-2 TO THE RICH' SHiOLILDEE 8 9 PARTY#3(P-3,BIBLIO)WAS LOCATED AT THE SCENE STANDING NEXT TO V-3. P-3 WAS 10 IDEMAS THE DRIVER OF V-3 BY HIS STA.TEME, U. P-3 IS ALSO TEW REGISTERED 1 I OWNER.OF V-3_ 12 13 VE3HCLE#3(V 3,FORD)WAS LOCATED AT TBE SCENE ON ITS WHEELS F'ACIN'G IN A 14 NOItTIE,L`Y'DIRECTION ON THE RIGHT SHOULDER. V-3 SUSTAINED MODERATE DAMAGE 15 TO ITS FRONT END. NO PRIOR DAMAGE OR MECELANICAL DEFECTS WAS NOTM OIL 16 CIADAED, P-3 WAS.ABLE TO MOVE V-3 TO T13E RIGHT SHOULDER. 17 18 1.9 STATEM3�I1'S_ 20 21 P-1 ((HEW)WAS CONTACTED AT THE SCENE AND RELATED IN ESSENCE THAT SBE WAS- 22 DRIVING ON 1-680 VB Ili TBE#5 LANE AT APPROXIMATELY 64 MPH P-1 SAID THAT 23 TRAFFIC WAS SLOWING AI�t'D V-2 SUDDElq'Y'SLOWED DOWN. P-1 SAID SHE SLAI►rIl1I) ON 24 EER.BRAEES AND BLIT STILL COLLIDED INTO THE REAR OF V-2. 25 26 P-2(RU.,tSCA.)WAS CONTACTED AT TIE SCEs.AND RELATED IN ESSENCE THAT HE WAS 27 DRIVING V-2 ON 1-680"IN THE#5 LANE AT.APPR(7CK:C(4UTELY 45 MPI3 SLOWING DOWN 28 FOR TRAFEC. P-2 SAID THAT AS HE WAS SLOWING DOWN FOR TRAMQ IM WAS REAR 29 QED BY V T. P-2 SAID THAT HE WAS THEN PUSHED FORWARD.AND SIDEWAYS OUT OF 30 CONTROL AND COLIMED INTO V-3. 31 32 P-3(R1 Ll0)WAS CONTACTED AT THE SCENE AND RM ATED IN ESSENCE THAT HE WAS 33 DRIVING V-3 ON 1-690 N IN THE#3 LANE AT APPO CA.TELY 50 MPPL P-3-SAID THAT HE 34 SAW V-1 IRT V-2 AND THAT V-2 VES OUT OF CONTROL AND HIT MS FRONT END. 35 36 37 38 39 40 ?ESA 's NAME La NuMam DA'S REVZWER.'S NAM DATE D. ONCRN'A. 16503 03-20-04 EXHIBIT A.,..... _. ......... __ _ ................................................. ... ......... STATE a CAUFOR" p PAGr- DAnOFINMENT Tna NaCNUUMM OFFIm n. 03-19-04 1404 9320 16503 o� 7 i SU.�1I�ARYe z 3 P-1 WAS DRIVING V=1 NIB I-680JUST UNDER THE NORTH MAIN ST. O/C IN THE 45 LANE AT 4 APPROXIMATELY 60 NM APPROAC.ETLNG V-2. k 2 WAS DRIVING V=2 N/B 1.680 IN THE 45 5 LANE AT APPROXIMATELY 35 YRH SLOWING DOWN FOR TEtAFFIC AHEAD OF V-1. P-3 wAs 6 DRIVING V-3 NIB 1-650 IN TBE#3 LANE AT APPROXMi .TF.LY 55 ASL DUE TO P-1'S UNSAFE 7 SPEED, P-1 WAS UNABLE TO SAFELY STOP V-1 IN MIE AND V"-1'S FRONT END COLLIDED 8 INTO THE DEAR END OF V-2. SUBSE+QUEITTLY, V-2 SPUN OUT OF CONTROL AND V-2'S 9 FRONT END COLLIDED INTO THE FRONT END OF V-3. AFTER THE COLLISION, ALL PARTIES 10 WERE ABLE TO MOVE THS VEHICLES TO THE RIGRT SHOULDER WHERE 111EY WAIIM I1 FOR CBP ARRIVAL- 12 13 14 -QX-nWPACR{A E31. 15 16 A.01.01(V--1 VS,V-2)WAS LOCATED 18 FEET SOUTH OF THE NORTH EDGE OF TBE NORTH 17 MAIN ST. O/C AND 6 FEET WEST OF TETE EAST ROADWAY EDGE OF 1-684 lti/B. IS 19 A.O L X12(V-2 VS. V-3)WAS LOCATED 100 FEET NORTH OF THE NORTH EGDE OF TBE 20 NORTH MAIN ST_ O/C AND 26 FEET WEST OF`11M LAST ROADWAY''EDGE OF 1680 NIB- 21 22 23 US1., 24 25 P-1 (LIEN)CAUSED TEAS COLLISION BY BEING IN VIOLATION OF SECTION 22350 V.C_- 26 UNSAFE SEED FOR TRAFEC CONDITIONS. DUE TO P-1'S UNSAFE SPEF.Ia, P-I WAS UNABLE 27 TO SAMY STOP V-1 IN TSE.AND'V-1'S FRONT END COLLIDED INTO TRE REAR.END OF V-2- 28 SUBSEQUENTLY, V-2 WAS PUSHED FORWARD OUT-OF CONTROL AND V-2'SONTIT END 29 COLLIDED INTO T13E FRONT END OF V-3. 30 31 THE SUNINIARY,A O.L,AND CAUSE WERE BASED ON TBE STAT WENTS OF THE INVOLVED, 32 PARTIES,PHYSICAL EVIDENCE,.AND VEMCLE DAMAGE. 33 34 RiStO1;i17. � 1 35 36 NONE. D'. 0)NCENA 16.503 03-20-04 EXHIBIT 1 PROOF OF SER:YICE 2 I am a citizen of the U.S. and a resident of Santa Clara County. My business 3 address is 236 Los Gatos Blvd.,Los Gatos, California, 95030. I am over the age of 18 4 years and am not a party to the within entitled action. On the date set forth below, 5 following ordinary business practice, I served a true copy of the foregoing document(s): 6 1)Claim for Damages Against Contra Costa County 7 on the interested parties in said action as follows: 8 9 Clerk of Board of Supervisors 10 Contra Costa County 11 c/o County Administration Building 12 651 Pine Street, Room 106 13 Martinez, CA 94553 14 15 ( XX } (BY MAIL) I am readily familiar with my firm's practice for collection 16 and processing of correspondence for mailing with the United States Postal Service, to 17 wit, that correspondence will be deposited with the United States Postal Service this same 18 day in the ordinary course of business. I sealed said envelope and placed it for collection 19 and mailing on the date set forth below, following ordinary business practices. 20 21 22 ( } (BY PERSONAL SERVICE) I caused such envelope(s)to be delivered 23 by hand this date to the offices of the above addressee and via deposit thereto in the US 24 post office at Los Gatos, Ca. with postage prepaid. 25 26 ( ) (BY FACMIME) I caused said document to be transmitted by facsimile 27 machine to the number indicated after the address(es)noted above. 28 29 30 I declare under penalty of perjury that the foregoings true and correct. Executed 31 on July 27, 2004 32 X E M 33 Summer Pr#ijle 34 35 36 37 38 39 40 41 42 Al 3 Claim for Damages LAW OFFICE OF REG J. IARMON Reg J. Lorrnon 236 LOS GATOS BOULEVARD Christine M. DeKiotz regOlormonlaw.com LOS GATOS, CALIFORNIA 95030 christine@lormonlaw.com (408) 354-6100 Fax: (408) 354-8002 July 27, 2004 Clerk of the Board of Supervisors Contra Costa County c/o County Administration Building 651 Pine Street,Room 106 Martinez, CA 94553 Re: Claim for Damages on behalf of John Bregiio,Marta and Rosa Posada To Whom It May Concern: Enclosed is a tort claim presented on behalf of the above referenced claimants, who are my clients. A duplicate copy of this claim form is enclosed which I would appreciate you returning to me in the enclosed'envelope after the appropriate claim number and filed stamp date is attached to it. Should you have any questions, please give me a call. Sincerely Yours, --T ` Reg J. ons✓ RJL:slp Enclosures As Stated cc: Penny Bailey, c%Contra Costa County Administrator via fax& mail (925.335.1421) ........................ iii k. ........... ... ...................................................................... ............................................................................................. ..... .. .......... .. ................................................................. ............................. ... . ........... ................................ ........... .......................................................................................... ... . ..... ...... .............................................. ..." ...."I'l.......... .......................................................... .............................. ......... .......... ............ .......... .......... .......... ........... '15............. ............. ............ ........... ............ ............ ............. ............. ............. SS fi Jn dye ............ U) .................... ................... .................................. .................... P4 rl m 0 C> Ul gm 4-) 44 0 p 0 41 in ..... to ...... -r-i Ln -rj 4 0 0 4-) U U) >4 m 0 Q) 0 rl -H 4-) r. 0 �4 0 V) m kD .......................... MORMOOM r.............. :................... ........... .... .... ........... ........... £f.#:->:::.:::::` .......... ........... ........... is .... .......... .......... ........... ........... ... .......... .......... ... ........... ........... ....... .............. .......... ........... ... ........... ........... ........... ......... ........... ........... ......... ......ilii .... ........... ..... .......... cr W, ti .......... ........... ........... .......... E. V). ........ .......... ........... .......... ........... ........... 10 ........... ........... ........... .......... ........... .......... ........... .......................... CLAIM SUP.F VISORS OF CONTRA COSTA COUNTY + BOARD ACTI0N.AU'-"J8T 17 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 s Y # Pursuant to Government Code Section 913 and €„ n < f.,p 915.4. Please note all"Warnings". AMOUNT: 232.39 0 }<)Nn-'COUNS "L CLAIMANT: c.c.s. comPALIEs A/S/0 AMERICAN STATES A/S/O JOHN RUSCA ATTORNEY: UNKNOWN DATE RECEIVED: JULY 29, 2004 ADDRESS: P.O. BOX 7249 BY DELIVERY TO CLERK ON:JULY 29, 2004 PORTSMOUTH, NB 03$02-7249 BY MAIL POSTMARKED: JULY 26, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE Dated: JULY 29, 2004 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors (I/' l� . t0/4 s claim complies substantially with Sections 910 and 910.2. (This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: _ '?" i By: '� ' 'r .�� 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: (Pf _ 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: -OU04aOHN SWEETEN, CLERK., By ,Deputy Clerk WARNING(Gov. code sec on 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6, You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per ury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: / JOHN SWEETEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL $EA SILVANO B.MARCHESI COUNTY OF CONTRA COSTA dr COUNTY COUNSEL Administration Building " 651 Pine Street, 9", f=loor {r /ti. to SHARON L. ANDERSON Martinez, California 94553-1229f 8 / t °� CHIEF ASSISTANT A GREGORY C. HARVEY 925 335-18001 ( ) VALERIE 1. RANCHE (925) 646-1078 (fax) ASSISTANTS ' NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: The CCS Companies P.O. Box 7249 Portsmouth,NH 03802-7249 RE: CLAIM OF: John Rusca, CCS Client's Insured CCS Client: American States Insurance Company CCS Number: 1559424-3-SAUCAI Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] L The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [X] 6. The claim is not signed by the claimant or by some person on his or her behalf. Page 1 The CCS Companies Re: Claim of John Rusca CCS Number: 1559424-3-SAUCAI Page Two [ ] 7. You are required to submit your claim on the proper form., which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SILVANO B. MARCHESI COUNTY COUNSEL w7 N By Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California,over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez,CA 94553-1229. On August 3, 2004, I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on Auzust 3, 2004, at,Martinez,California. 1` Y h Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 JUL-07-2004 10:30 CCC RISK MANAOMENT 325 3 Claim. to.* BOARD OF _%PERVI `S OF C OffRA COSTA C1C?t=y �� Jut 29 2004 I14S'i'RtTCTIONS TC} CLA tT �k��AR A. Claims relating to causes of action for death or for injury to person or 0S-,4C, �s sonal property or growing craps and which accrue on or before December 31, 1987, must be presented not Later than the: 100th day after the accrual of the cause of actio.. Claims relating to causes of action for-death or for injury to person or to personal property or growing craps and which accrue on or after January 1, 1988, mit 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 om year after the act- of the rause of action. (Govt. Code 5911.2.) B. Claims must be filed with the Clerk Of the Boal of Supervisors at its ,office in Roan 106, County Administration Building, 551 Pine Street, Martinez, ck 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against, each public entity. E.' Fraud. Sea penalty for fraudulent claims, Penal.. Code Sec. 72 at the and of this at orm. RE. Claim By Reserved for Clerk's filing stamp Ale An&�, Agaifist, the County of Contra; Costa or District) (F-M in ramie � The undersigned claimant hereby makes clai t t f C e County oantra. Costa. or the above-rid District in the of and in support of this claim represents-as follows: eo - 1. When did the damage -or injury occur? (Give exact date and hour) 2. Where did the damage or injury o=1 (Include: city and county) 0 AA_FYZk7_7 -a-ex-t atid 3. Hoer did the doge or ink' occur? (Give full tails; e e pa if � required) f �� �. 4. What partimdar act or omi.ssi the part of county or district officers, servants cr.+employees caused.the,injury or.damage? rPc SLIT JUL-07-2004 20:31 CCC FRISK MANAGMENT 925 335 1421 P.03 Wear. are the rames of country or distriet officers, servants or emplOyees causing the damage or injury? 5. What a or in Juries do you claim resulted? (Give full extept ,of injuries or damates cLefzed. Attach two estimates for auto damage. 7V eACY 7. Haw was the amount claimed abovecomputed? (Include the estimated amount Of any prospective injury or Vie.) 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATER IM AMOUNT /, , Gott. Code Sec. 910;2 providest. "The claim must be signed by the claimant SEND NOTICES TO: (Attorne ) some person of his.behalf'." Ra—me and 'Address of Attorney CI t t s SignaER— A dress Telephone No. Telephone No. 999 # 1 99 VFW * * * e99 * NOTICE Section 72 of the Penal Cade provides: "Every mon who, with intent to defraud, presents for allo%r�tce or for payment to any state board or officer, or to any county, city or district board or, of"f'icer, ,authorized to allow or pay the same if.genui.ne, 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 impr#3or t and fines°'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. TOTAL P„03 TPC �t From:Fax number To: 1-917-762-3355 Page:2/11 Date:712/0410:09:29 AM Claim it 215947432015-Auto Status: Open/Subro Loss date: 03-19-2004 Reported: 03-19-2004 Catastrophe: Loss#: 1 Policy It 02CD093458 Eff/Exp dates: 08-12-2003/08-12-2004 Policy name: Rusca,John Agent: Affiliated Insurance Brokers 15-7300 Company: American Economy Insurance Company Adjuster: Credit Collection Services 866 357-8276 Adjuster e-mail: 4CCS ACS claim 9 19A040791818 Claimant: Multiple ASI claim It 9000800957 Writing/Handling Branch: N.California/S. California Type of Loss: Other Police reported to/violation: Loss Description: Clmt r/ended insd who spun into other in and struck oncoming car. Deserve Coverage Group/Class Total Paid Total Original Last Chg Total Subro Total Salvage/Ded Incurred COLL/COLL $7,332.39 $0.00 03-19-2004 03-22-2004 $0.00 $7,332.39 COLL TOTAL $7,332.39 $0.00 $0.00 $7,332.39 MED/AUTO MED $400.00 $1,100.00 03-22-2004 03-22-2004 $0.00 $1,500.00 MED TOTAL $400.00 $1,100.00 $0.00 $1,500.00 TOTAL LOSS $7,732.39 $1,100.00 $0.00 $8,832.39 ACCIDENT f INJURY LOCATION 1-6801/2 From Treat Blvd. Walnut,CA Insured's premises? VEHICLE INFORMATION Vehicle W Auto(including Trailers)- 12000 Driver: Birthdate: Top of Page Copyttght 0 3000 SAFECO Corporation. Last Updated:07102!3004 09:58:08 TRC sup From:Fax number To: 1-617-762-3355 Page: 11111 Date: 7/210410:09:33 AM Claim 1A 215947432015-Auto Status: Open 1 Subro Loss date: 03-19-2004 Reported: 03-19-2004 Catastrophe: Loss#: 1 Policy#: 02CDO93458 EfflExp dates: 08-12-2003108-12-2004 Policy name: Rusca,John Agent: Affiliated Insurance Brokers 15-7300 Company: American Economy Insurance Company Adjuster: Credit Collection Services 866 357-8276 Adjuster e-mail: #CC ACS claim 9. 19A040791818. Claimant: Multiple FINANCIAL DETAIL Display from: Last payment date Back: 3 years FINANCIAL TRANSACTION INFORMATION Processed Transaction Dr1CktVou Cov Cov SAFECO Date Type Number Payee Name Amount Paid Croup Designation Code 06-10-2004 PAYMENT 20069713 John Rusca35,0.00 MED AUTO MED PYMT 06-10-2004 PAYMENT 20069718 Rusca John $750.00 COLL COLLISION PYMT 05-19-2004 PAYMENT 20060567 Classic Auto Body $773.87 COLL COLLISION PYMT 04-23-2004 PAYMENT 20048836 Rusca John $37a.-00- MED AUTO MED PYMT 04-01-2004 PAYMENT 20038310 Jahn Rusca $5.808.52 COLL COLLISION PYMT 03-22-2004 RESERVE --loss Reserve-- $1,500.00 MED AUTO MED RESV 03-22-2004 RESERVE --loss Reserve-- $15,000.00 COLL COLLISION RESV 03-22-2004 RESERVE --loss Reserve-- $1.500.00 MED AUTO MED RESV 03-22-2004 RESERVE --loss Reserve-- $1.500.00 MED AUTO MED RESV Top of Page Copyright C 2000 SAFECO Corporation. Last Updated:07/02/2004 10:06:31 TPC BUT Fax number To: 1.617-752-3355 Page:2/11 Date:7/2/04 10:09:29 AM Claim* 215947432015-Auto Status: Open/Subro Loss date: 03-19-2004 Reported: 03-19-2004 Catastrophe: Loss* 1 Policy It 02CDO93458 Eff/Exp dates: 08-12-2003/08-12-2004 Policy name: Rusca,John Agent: Affiliated insurance Brokers 15-7300 company: American Economy insurance Company Adjuster: Credit Collection Services 866 357-8276 Adjuster e-mail: ACS claim# 19A040791818 Claimant: Multiple ASI claim# 6000800957 Writing/Handling Branch: N.California/S. California Type of Loss: Other Police reported to/violation: Loss Description: Clmt r/ended insd who spun into other In and struck oncoming car. Reserve Coverage Group/Class Total Paid Total Original Last Chg Total Subro Total Salvage/ped incurred COLL/COLL $7,332.39 $0.00 03-19-2004 03-22-2004 $0.00 $7,332.39 COLL TOTAL $7,332.39 $0.00 $0.00 $7,332.39 MED/AUTO MED $400.00 $1,100.00 03-22-2004 03-22-2004 $0.00 $1,500.00 MED TOTAL $400.00 $1,100.00 $0.00 $1,5000.00 TOTAL LOSS $7,732.39 $1,100.00 $0.00 $8,832.39 ACCIDENT/INJURY LOCATION 1-6801/2 From Treat Blvd. Walnut,CA insureds premises? VEHICLE INFORMATION Vehicle 9 Auto(including Trailers)-12000 Driver. Birthdate: TPR of Page Copytght 0 2040 SAFECO Corporation. Last updated:07/42/2404 48:58:08 TPC BUT r c - akl, Wk ;Jays-y5 C f'3 ct` a f 1 99 -732, 0 /5- c c am., O O.W D. .- . s Lk - r) a� sl ZVI • f � *{q F{} A It 81 pit f sfrtAlf At ph Im Mi. ' „ kl VE iLUrl a � rs, i4 . S[t ,.�£ to •t � �,S +, Apr 27 94 I I :2 CIaS43i RUtc CL SS11c. AUTO BODY p. 1 1401 AU,r 3 CENTER DRIVE WALNUT CREEK, CA 94596 PHONE- (925} 938--3131 FAX: (925) 938-071.8 45f cl/ 'ev�� oA4 cl WC> #kt -122 b .^ 'Velltl(�701 - ' Apr 27 04 11 : 28e Classic AUt_O Hada (825) 938-0718 p. 2 CLASSIC SSIC: ,71UTO BODY 1401 AUTO} CENTER DRIVE WALNUT CREEK, CA 94596 PHONE: (92b) 938-3131 FAX: (925) 938-0718 CD LOG BTU 4052-1 DATE, 04/2'1/04 SHOP: CLASSIC: AUTO BODY INS? DATE: 04/27/04 ADDRESS: 1401 AC7` OCENTER DRIVE CONT'AC'T: TIM KAMM CITY STATE: WALNUT C:REFK, CA PHONE 1 : (925) 338--31:31 ZTP: 94-597— FAX: (925) !938-0718 OWNER. KUSC:A, JOHN HOME PHONE: (925) 934-5717 ADDRESS: 70 CHERRY WAY '�rt_ CITY STATE: WC, CA , ` F 1 "C ZIP: 94ti96— LIC #: 5D54140 STATE: CA VIN: 1GTGC24R2YR140956 BODY COLOR: MILEAGE: CONDITTON: ACCT'NG C'.T'L# *=USER—ENTERED VALUE E=R PLACE OEM NG—REPLACE MACS EC-REPLACE ECONOMY UC-RECONDITIONED PIAT M-REMAN/REBUILT PRT Et..�ltEF'I,AGE SALVAC71, L4'=1 F: "LACE L"XN PC-PXN RECONDITIONED PM—PXN REMAN/REBUILT T'E=PARTL REPL PRICE ET-PARTL REPL LABOR IT—PARTIAL RF'PAIR I—REPAIR L—REFINISH BR—BLEND REFTNISH TT=TWO--TONE C:C;=CHIPCsUARD SB—SUBLET N—ADDTTIONAL LABOR RI—R&T ASSEMBLY P--CHECK AA=APPEAR ALLOWANCE RIs--RELATED PRIOR UP-UNRELATED PRIOR 2000 GMC C2500 HEAVY DUTY SL 200OR STANDARD CAP 8C:YL GASOLINE 5.7 CODE: U8024B/E OPTNS R/24Z OPTIONS: TWO—STAGE .. EXTERIOR SURFAC;FS TWO—;TACE .. INTERIOR SURFACES PASSENGER a I DE AIRBAC', OP GDE MC DESCRIPTION MFG.PART NO. PRICE AJPj, P`•+; FOURS R F 0023 FILLFR, FRONT BUMPER 12376285 CSN! PART 59. X30 —1 .0 1 L 0023 1.3 F"IT.LER,FRONT HUMPER REFINTSH 1. 8 4 E 0013 01. C"OOLER,TRANS AUX OIL 159955:3 ; GM PART 179.77 0.5 2 FC.` M20 ANTI-FREEZE-COOLANT ECONOMY PART 1.8.42* *1* I M48 FRAME BUCKLE, R. REPAIR 4.0*3* E INSULATOR (2) NEW PART 7.60* 1* E NUT (r) NEW FART 1.24* 1* 7 ITEMS MC MESSAGF(S) 01 CALL DEALER FOR EXACT PART NUMBER / PRICE 13 INCLUDES 0.6 HOURS FIRST PANET, TWO—STAGE ALLOWANCE FINAL CALCULATIONS & ENTRIES PALL 1 Rpr 27 04 11 : 28a C i ass i o Antra BOW (825) 838-0718 P � 2000 GM(; 02500 HEAVY DUTY SI, 2DOOR ;ST'ANDARD CAB CD LOC NO 4052--1 GROSS VARTS 248.41 OTHER PARTS 18.42 PAINT M.ATFRiAL 52.20 PARTS & MATERIAL TOTAL 319.03 TAX ON PARTS & MATERIAL 8.25UV, 25.:32 LABOR RATE REPLACE HRS REPAIR HEIS 1--SHEET METAT. G8. 00 1.0 58.00 2-MECHIELEC 92.00 0. 5 46.00 3-FRAME 68. 00 4. 0 272.00 4-REFINISH 68 .00 1 .8 122.40 5-P1 TNT MATERTAL 29.00 LABOR TCTAT. 508.40 SUBLET REPAIR: '1OWTNC; STORAGE GROSS TOTAL 853.75 NET TOTAL 853.7.5 ADV SHOPLINK u8275 ES, CD LOG 4052-1 DATE 04/27/04 09: 50:50AM 85.35 CD 03/04 HOST LOG (C) 1998 - 2003 ADP CLIATM S SOLUTIONS GROUP, INC. 0.8 FIRS WERE ADDED TO THIS EST. BASED ON ATOP TWO-STAGE REFTNISH FORMULA. -------------------------------------------------- TEST FAGS r Apr- 27 04 11 . 29a Glassier RLItO Bodtj (525) 938-0718 p. 4 2079 North Main St. Walnut C-rcc k, CA 94596-2712 (925) 932-4800 "WE SERVICE PARTS FOR ALL CHRYSLER&GM CARS* "CHRYSLER PLYMOUTH JEEP DODGE&DODGE TRACKS* *BUICK CADILLAC CHEVROLET OLDS PONTIAC&CMC* *CHRYSLER PARTS DIRECT LINE1325}937-5569* GLNERAL MOTORS PARTS DIREC (800)372-7871 - * • �• 12399 sR CH6 21662208 CHECK C ARLIE DRAEGER 04/21/04 130RS 3 PNW T#1 925-938-31$1 CLASSIC AUTO BODY 4 1401 AUTO CENTER DRIVE �- ' WALNUT CREEK, CA 94596 is ., .� NUMBER/DESCRIPTION SHIP i37-6 � 2 0 362370 NUT 2.737 SP-ORD 0.82 0.62 1.24 ?I l vr-eol t°. • No RETURNS rerELECT�a1L OR SPECIAL ra ITEMS 1�24 •NO R TURN WITIAOUT THIS INVOICE No Itt-tilRN!,A171-H 74 r)Ayrt • 1is'y+,IiAwC>I 1IVC,'a C:HAItC3}'{7N At,1.M,II76tW, TAX 0� •ALL PARTS ACCEPTED FOn RCTU€IN MUST MEET CURRENT MANUI°A+CY'UREA'S PYACKAGr—CUMFI NCS. m]P tI Cf T(}WAII14ANIY C ON)11ICN,,ON i0 Vt I ',I.;IDI. NO AErUNDS FReIGHT 0.00 Sti CID wfitttxit t . I1Y s �' 08,22'45 CUSTOMER COPY NETS21 PAGE 1 OF 1 Apt' 27 04 11 :28a Classic AUto BodB (825) 838-11718 p. 5 M_ _ICIIAEL STEAD PONTIAC - Calc 2679 North Main St. AC Walnut Creek, C.A 94596-2712 (925) 932-4800 *WE SERVICE PARTS FOR ALL CHRYSLER&GM CARS* *CHRYSLER PLYMOUTH JEEP DODGE&DODGE TRUCKS* *BUICK CADILLAC CHEVROLET OLDS PONTIAC&GMC* *CHRYSLER PARTS DIRECT LINE {925}937-5569 *GENERAL MOTORS PARTS DIRECT(800)372-7879 M K • SOLD BY !NVOICE DATE INVOICE 12399 SR CHB 21,6621O$ CHECK CHARLIE DR:-EGFR 04/20/04 3.29996 3 T#1 925-938-3131 I'NW CLASSIC AUTO BODY 9401 AUTO CENTER DRIVS WALNUT CREEK.,CA 94596 � OUANTITY SHIP m 0, PART NUMBER OE,$CRIPTION ISIN LIST NCT AMOUNT i 1 0 92 290 COOLANT 8.800 53 18.42 13.82 13.82 tl j +: w NO RM'RNS ON ELECTRICAL C8 SPECIAL ORDER ITEMS �;+,tsterrat 13.82 •NO RETURNti WITHOUT 1't°tiS INVOICC-, 20%HA#01 Mr,C:H,+RC',f ON ALL fti t WIN!-' TAX 0,00 •ALL PARTS ACGEf TET FOR FtmfgN#1du T mrcr tatlftnew MANU(~AC`t'URIM'S PACKAGE GUt-DELINEgr;. w •M)l Lit'£;# tt}WAf t#"T Y C;ON#dt f IC)Nti i3N I tt VL#t#',I SIDE, . ;o #'t#t:'Ct NO REFUNDSFFtE1C,FiT 0.00 92,46.46 CUSTOMER COPY NET521 PAGE I OF 9 Apra 27 04 11 : 290 Classio Auto Body (9251 838-0718 p. 6 MICHAL.'L STEAD PONTIAC, - C1mc 2679 North Main St. Walnut Creek, CA 94596-2717 1 (925) 932-4800 *WE SERVICE PARTS FOR ALL CHRYSLER&GM CARS* *CHRYSLER PLYMOUTH JEEP DODGE&DODGE TRUCKS* *BUICK CADILLAC CHEVROLET OLDS PONTIAC&CMC* *CHRYSLER PARTS DIRECT LINE, (925)937-5569* GENERAL MOTORS PARK'S DIRECT(800)372-7871 " ----------------- - . BY . DATE INVOIGE 12399 9R CHS 21662208 RUSCA CHECK CHRIS M. 04/27./04 123993 3 PNW T#1 925-938-3131 CLASSICAUTO BODY fit 1401 AUTO CENTER DRIVE ,i WALNUT CREEK,CA 94596 . � ' 6 tP .. --------- PART NWAVER DESCRIPTION t. LIST 49T .. 1 2376285 FILLER '1263 SP-ORD 59.80 311.81 38.81 1 569M6 1,270 5P-03RD 3.78 2.45 2.45 1 5W2547 INSULATOR 1.2701 SP-ORD 3.78 2.45 2,45 1 -89022635 COOLER SP-ORD 179.77 88.88 98.88 it • NO RETURNS ON ELECTRICAL OR SPECIAL.ORDER ITEMS :Iutl:�rinl 142.59 NO RETURNS W11HO JFT THIS INVOICE s NO i;f-IUHM'-Arlt 11:10 DAW'. TA?( 0.00 :: •�U`Y+,HAIL DUNC:C:HMIGE:ON Al 1 !fit:rURN ALL PARTS ACCEPTCD FOR RETURN MUST MEET CURRENT MANUrACTURE.R'S PACKAGE GUMELINES. Y" 11 SU1.111 1 IU W/Vit3AN1Y[;ONC)lTION:C,ON Iti:VI'it`;t NO REFUNDS FREIGHT 4.00 wl n j(,8 rl 142,59 {19'27:47 CUSTOMER COPY NEY519 PAGE 1 OF 1 _From: Fax number To: 1-617-762-3355 Page:5111 Date:71210410:09:31 AM Document 71 of 71 Loss notice report 03-19-2004 Loss not Created By: SHAROS Created Date: 03-19-2004 19:11 Claim Number: 215947432015 Insured: R.USCA, JOHN SAFECO Loss Notice Report Print Date: 20-Mar-2004 ----------------------------------------------------------------------------- Claim#: 215947432015 [Loss History#: 60008009571 Date of Loss: 03-192004 Time of Loss: Date Reported: 03-19-2004 Claim Type: Automobile Claim Status: New REPORTED BY Name: ruska,john Notified By: Phone Relation to claim: Insured ADJUSTER Adjuster Name: MIRROR ASI CLAIMS Phone: Unknown AGENT Agent Number: 15-7300 Agent Name: AFFILIATED INSURANCE BROKERS (Mailing)Address: 2637 PLEASANT HILL RD City: PLEASANT HILL State: CA Zip: 44523-2033 POLICY MOLDER Name: RUSC,4, JOHN (Mailing l)Address: 70 CHERRY WAY City: WALNUT CREEK State: CA Zip: 94596 (Work)Phone:(925)935 -6792{Voice) (Home )Phone: (925 )934- 5717(Voice ) (Day)Phone: (925)765 - 2853 (Cellular) Contact where/when: POLICY INFORMATION Policy#: 02CD093458 Company: American Economy Insurance Company Policy Effective Date: 08-12-2003 Policy Expiration Date: 08-12-2004 LOSS Loss Location Address: I-680 1/2 FROM TREAT BLVD. City: WALNUT, State: CA,Zip: Loss Description: CLMT WENDED INSD WHO SPUN INTO OTHER LN AND STRUCK ONCOMING CAR. IPC BUT ....___a-_. _- From: Fax number To: 1-617-762-3355 Page:6/11 Date:71210410:00:31 AM AUTOMATED POLICY -POLICY INFORMATION AUTOMATICALLY INPUT Vehicle: 2000 *OMC PICKUP Insured's Involved Unit Owned Vehicle Number: 1 V i\T#: 1GTGC24R2YR140956 Coverage Limit Deductible LIABILITY-BODILY INJURY 300,000 LIABILITY-PROPERTY DAMAGE CSL MEDICAL 5,000 UNINSURED MOTORIST BI 300,000 COMPREHENSIVE ACV 100 COLLISION ACV 500 COLLISION WAIVER - NO UNDERINSURED MOTORIST BODILY INJURY 300,000 No Restrictive Endorsements Exist No Policy Warnings Exist No Special Handling Instructions Exist INSURED VEHICLE Vehicle: 2000 *GMC PICKUP Insured's Involved Unit Owned VIN#: 1GTGC24R2YR140956 Damage: rear,frt,rt side,fender DRIVER Name: RUSCA, ELIZABETH Address: Unknown City: Unknown State: Unknown Zip:Unknown (Unknown)Phone: (000)040 -0000(Unknown} OTHER VEHICLE Vehicle: '1900 Unknown UNK Claimant`s Involved Unit VIN#: Unknown Damage: frt end OWNER Name: CLMT-#1 OWNER,CLMT Address:Unknown City: Unknown State: Unknown Zip: Unknown (Unknown)Phone:(000)000 -0000(Unknown) DRIVER Name: UNK-CLMT#1,UNK Address:Unknown City:Unknown State: Unknown Zip: Unknown (Unknown)Phone: (000)0001 -0000(Unknown) OTHER VEHICLE Vehicle: 1900 Unknown UNK Claimant's Involved Unit VIN#: Unknown Damage: Unknown DRIVER Name: UNK -CLMT##2,UNK Address:Unknown City: Unknown State: Unknown Zip: Unknown (Unknown)Phone:(000)000 -0000(Unknown.) CLAIMANT Name: CLASSIC AUTO BODY (Mailing)Address: 1401 AUTO CENTER DRIVE. BUY Apr 01 04 09: 24p p. 1 JOHN A. RUSCA Designer&Builder CONTRACTOR UtCENSE NO.29=5 TO CHERRY WAY - WALNUT CREEK,CA 94597 • (925)9*35-6' 92 FAX(925)934-1973 43 z r i5 fl ofed . P I Apr 01 04 09: 24p p• � ;iTAtr 4F CALWCANIA TRAFFIC COLLISION 1 REPORT CHP SSS CARS Pa"1{Pity )ON 04 Fria 1 at $ rl-VCIAL�,QND+T'OMMAS "TJX+ Off) A.ViCIAL..OWRICT LOCAL XWORT NL&AO€R NAXh'9 Aes.avr i 2 WfiLNLr"T C RE>!CT 4 rR CREEK SUPERIOR I J.tlEi kifJ� y NEACRTL4Ci�SYAICT ✓EFl.7 CONTRA COSTA edgy � -MLMM OCCURRED ON i%40 SAY YEAR YVAE j24M) wMCM "+.1PPICER+D #6130\11 ;03.19 2004 1400 9120 165#ti MIL€POST WFM3AM.4TION; DAY OF WEEK TOW AWAY PF6TOGRAPH3 gY NONE �_ . 1 x 1=mr SOUTH C>8 IlP4r 690 ewer 15-61 1:Rl f7 X3- X YES .• ...•sir iCiT€R$EC3'W1+lMTN' STATE"NV REL t DA' 1 S PELT SIDV i OF*40RTHM t1N ST.CNG 4.YgS ND PARTY STAT CLAiS $ TY >51-1*EAR !JAAiEI+AOUELOC©LCRuCEN>SE!*JM8$N TAT1949 Ft TAURI:3 WITr 1026 36 DRIVER NAAIEIFIR257,MI(CSLE.tAaTT 'f X. TRACY LYNN HE1, cvmf'S NWE !ter smai A5 DRAPER P€Gs4- STREET ADDRESS CONTRA C OSTA CC7L�'NTY 'MAN CA.VJX0 ESTRADA BR'S ADDRESS 'emw As 0+3WER awq.DcmrlrrA7eMzaP 2467 WATCRBIRD WAY MART 1;LZ CA 944 aEn CONCORD CA 94520 01WO3'r+`OMOFV04CLEONORDERS O :OrolLEA ;x-JNNEA — R oft YT sE�c w+R EYES �Ktciwr va'low vwr SL 1 tWfti EC?WCLIS F BJN BLU "1 130 0612411959 W PRIOR nMecri OEP NOrE APA AEP!RTOMwRRAT.1ie "MSR HOME SIFSINESSPM10NE VEHICLE IDE.NTIFICATMONA4wOLM ).ONE, (925)646.4461 CNPWEWR.Y DESONiB€vCI'JCL6°DAAw(+ii SHA99 IN DAW090AR€A IMiSLPRAtX:E GAATt+€A PDi,}OY NWN9DR � SllTM ` MONS WNCR CONTRA oTR:I CCCrST. CC)UNTY SELF INSURED a f i X;MSS -WJOR ROO.L-M*R � Offt O TRAVEL ON"ROY OR Hk*fiNAY SPEED LRR7 CA —Oct ; f-6Rt} 65 CAL-7 —MVP80 M .tASY 4hritEttS LtO$�tdE'tA6iCfiA STATS LASA SAF@YY V",Y.w wxefmODELP,CftOR LICENS'ISZYLMSM STAT$ i#0 23020 CA C G �E�DC? me PICKUP iv1IT 6D54140 CA 3AArQR NAAA$iPIALST,k4DDt4,LADY'! X 1CJIiiti 9ts`dTfi0NY RETSGA OtM1 3 Mum€ x!SAW AS DRAPER 'FOGS- STRMADDR€Ss ,••••+ O4440'S ADORE" M.1 SAPAE 44 DRAPER .......�.�� '"r0 C1iERRY"WAY "X� i 'ARRW wry i srAYK r SIP s Aircts EL'Ay L-p CREEK CA 94597 a+snosncoNnPvsN+cLEONOAD€RsoP .`oPPaA DArveR OTHER y ?KyCY= spat MA IA EY&sMriarr wE�w IRMNOArti w" WN-DOWNTOWsL Ll BRAE OUT 5-14 190 091CW19446 vav W PMOR fGCWACAL DVtCTB iX MMJNC APP �J REPSA 7O NAAAATIVS >T}fFJt Home SHONE SUSMENS PHONE VEHICLe IDI UTI MOATYONNUM4ER: (923)9344717 NONE CAPLISROMa.Y DeacAA4E VMCLE DAAwt3E SHADE IN DA�AC-M AREA -` 1NSttRfNiCE OAFtR{� POCKY Nmeft Y>fMSGLE TMMC LUIK I— t lmmft AMEWCAN ECONO INS. 02-CCD40439-4 22 M�+aD { M R ctOLLovER JEi s D'IA OP TRAVEL ON STREET OR NIDFMfifAY SPECD tPiET" CA DOT i # f V 1680 65' CAL•T TCPmac NCMNC j iRry DAiiYYEAA`S LIOSNSE NkIMB A STATE CLASS BAAwCTY VEIJ YEAR MAAJCeTA ono DOLOR UICENSENUMUR STATE 3 +xtalao0?2 CA c L 1997 F0 E C?R1±RORN 40RN058 CA IN" NAWOWIRST.MOMS,UNSI) . JOHN S.BREGUOowrlEa'4wAAre iy,SAPM AS DRAPER 1 f STA4V A,DDAESS 18610C",4tAvL'. chemMsADDReaa �.�,.tSAW A4DRAPER ' ARCO CATr I SLATE IZP •^•sI HK Li -, C STT O VALLEY CA 94346 OlPCSICYTISH OF VEHICLE ON ORDERS OP' X,ORIVER OT;QEk Gy., 3Sx wvA MtEB >f€t4rMT wwaw+r SINMO TC Y�v RACE SCNDOWNTOW �Ll I312�t till. -10 160 1210411953 W PRIOR MECH&NcuiL DEFECTS NONE AAP -REFER TO NARRATA+E NKR �t;MLc PHOf.� +NESC PHONE VSMC�,f 08"FICATICM MAINISA' f S I Et}72tC.132 i NONE. CRP USE ONLY grtSe;Aq 9 VE"C6H OAkNO€ SMY Oe N(WAAOEC+AA@A INSURAMCE CAR MR POLfCYAI+M PA VHMICLC TYPE �..LMtA 1—Nq'7e kc �•-• ArDM'+ i I:SA,% 00864.05.4?C71m 117 (_+IDD 7m,-,OR `'AOLLOVER DUI OP TRAP€L O+i 37AeEY ORHF41fWAY SPEML"r CA OOT 65 gQPARKA`StWAk OieAATCH NSTCF#ED k f+R'S E SATEA D j a�A Apr 01 04 09s24p p. 3 .4 A TS,OF.^AI.1f:OR NIA TRAFFIC COLLISION CODING page 2 of 8 CHP SM CARS P I"B 0P1.342 :OhYl OF COLLISFORWO DAY YEAR) TLNEi2+�d67 P#1."LEf flMFie�R l.P.. fiUMh@x OJ 0 2L)t)# t lUt3 '32U (630x � WYraEER A66KtES5 t hionRi�v `PROPERTY DAMAGE Q@SCRIPTM tt as 00AM" SEATING POSMON OCCUPANTSSAFETY EQUIPMENT WC ENC:YCLc -t�tbA>; ' EJECTED FROM VEHICLE - _1' L-AIR BAG DEPLOOYEO A-NONE IN VEHICLE M•ALR SAO NOT DEPLOYED ;.»7,LL Y EJECTED S.U NKMOWN N•tlTHRR DRIVER i;*CTED ' d ( 9-DRIVER C•LAP BELT USED P-mor aEGV+REo V-140 fff� ;.•fNKhGP7M i O LAA BELT NOT USED W•YES t d rJ j2 TO 6•PASSENGERS E•SHOULDER HARNESS USED MtW kESfR+ttNT ( i."A WGN.REAR F.fHouLCIER HARNESS NNar U95D Ct-i VICL-U • PASSENGER 8.RR OCC TRK OR VAIN (3,LAPtSWOULC+ER HARNESS USED R-IN VSWCLE NOT UIWO X•NO I t 9-POSITION UNKNOWN H•I APM40ULDER HARNIt"NOT USED S-IN VEMCL.E USE UNKNOWN Y•YES p-07H€R J+PA5StV9 RESTRAWTU$W F'.IN VEHICLE iMPRpPER USE X-PASSIVE R€STRAW NOT USED U-NONE IN V94CLE )TE7iA$S MARKED SMOW FOLLOWED BY AN ASTERISK tl SHOULD BE E XPLAMD tN THE#+tMRATtVE PRIMARY Gt7L1JSIC5N FACTOR' YKAPM CONTROL TROL ODA= 112 '3 TYPE Of V>?HLGLE I ? J MOv8MENT PR lNG OST NUM9@R GKP PARTY AT FAULT GCLLKS�t L ,:.¢:`•cn ncut aw Yffiix A L3 q_AsKNojFt CAR 1A - s 22350 B IS PASSENGER CAR I M&LMR X X Et PROCMING STRAIGHT arl-ISR IMPROPER ORNING' C C:UAd C -MOTORCYCLE 1 scomp RAN OFF ROAD X 0 NOCONTROLSPRESENTIFACTOR' JO PICKUPORRPANEL TRUCK ID MAKING F41G tTTURN C OFKiER THAN i Ty"(*mtjSaN 19 PQ0.PlF`At<RUCKY4fM&L9A JE MAK TURN .moi 0 UNUN&tt W A H. ON F mucKaftmixKTRACTOR PG MAKING U TURN t g F A ,EEp' amomi C T K.I T UCK!%Ag W/TRLR, 9A K(G X C EAR END H SCHICICJL.BUS X H St,OW WC•i STOPPING wEATiLE_R MARK t m2rr KSs JS PASSING VEHICLE A G E Hrr2Mgl EMgRG9NCLY 3 CNAKN KNCi t 8 CLOUDY F CSVERTURNr6 K WGI-WAY CONST EQUIPMEar K PARKING MANEUVER zx RAM1{NCx G VSH&6k I PEDIITRIAN L CLT: L ENTERING NGi T'RAFFlC p c y} H OT M OTHEREH41G OTH teNShFE E FOo A VI LITY H'C �• N RIAN I+t %INC.INTCs ONO ONK !P LY#HIcR:` MOTOR V09CLi=LNVCNVt�D WJYf4 fl p LI PAKOWD G `NAND A7 NON» MON P MFA034 LKtHTIRa $ PEDESTH>" Q TPAV NGL WROINO WAY A DAYLIGHT x c olmcguolmygEgg 1 2 3 OTMER ASSOCIATED RACTORS R OTHiEFY B CkaffiK-DAWN Et TCSR V O . (MARKT TGs 2ITEM Tc DARN«-S772EET La TTS L3 PARK MC3TM VEKCL ,�- :'. A ;fc'crcn•rrsa�a ��"—'yam . I} DARK•NO ICH TRAIN �tq E DARK.STREET Uawm NflT Csiacyom "CTIONw H ANMAl: C tat3 PHYSICAL ROADWAY SOBRIETY+DRUG <."•.*''' L"" WARK t TO 2 A DRY I FIXED 05JSG�T. i $ wer Cf ? »F 5 oixX A D NOT B IMG C: SNOWY• Y J OTIiER CSJWP. E NT E HBO- INP E E7 SUPPtvRY DDY,OILY.em.) -NoT U WF ROADWAY CONOMON(s) t3 STOP 8 GGT Fr, 12 H -IMARMENT - AfARF{K TC) iTEMS3 PED)LSTRIAIf 3 AOTtCxt4$ H NY`s A NG4 MP U E• A OLV I 9 C IMPAIRMENT-PWS 8 L A RCSkDWAY' S C S==ANG N CROSSWALK J UNFAK.UI.IAR WT[M go&o G3 IMPAIRMENT NCTT KNOWN C GIH1 AfT+AtAY' AT IN K DEFEGTNE V€H. CITED H NoT APPt.c AIR C CROSSING INGRRL WALK-NOT yes it SLSEPYt,FATGU9O B READ I }ACSWAY WKtKtiH ATINTERSECTION Kai SPECIAL WFOAMATION F FLOODED. 0CR .ALK L uNiN LVELI VEHpCLE A Af DWA TE G OTH>v'R'•. EE IKa K3 I r U INS R J_jM OTHER-' $ COLL PROW IN USE H NO GNkA9L#fi CONL7IF F INR N N E 14PP O CELL PMONG NOT IN Ustr 0 APPROACHING A LEAVING SCHOOL SUS 0 RUNAWAY VEHICLE X }C X o CELL pMCSNE K1pt+EJUNKNDViK1 ErCH+ 0 MISCELLANEOUS � DOT SKETCH vv f,� ry.y�r ,�•�. 6HStC'ATC NO" L74.'i Cit CRNR 19C C14P W% Pn,!SO 8 CT 07R Apr 01 04 09;25p p• 4 -;TATE OF CALIFORNIA INJURED#WITNESSES f PASSENGERS Pape 3 of � CHP 556 CARS Pace 3 Rev&$8 Pt 04 fA7E OF CCJI510N LMC DAY YEAR) MME(24m) NCiC n OFFICER LO. NUMBER tD i/1912tHi3 1400 j 9320 15503 033-257 wlyliess PASSLNUER .+c s6x EXTENT OF INJURY('A'ONE) INJURED WAS('X'ONE) PARTY SEAT SAFETY edEC7Eo ` ANLv ArriY NUM9ER t FATAL SSYY'RE OTHER VISf61.E I C LAW^ PC>S. ECUIP irtMRY 7tiAJRY IWURY OF PANr 77 tIRIYER FASB. PED. 31ct'YCUu i" OTHER # j 453l _ 3 I. U YRr+dE.C 0.3.f ADDRESS YEI..EI'Ht}NE NI AR2 A POSADA (O 2311959) SAME ADDRESS AS P-3 (S tOP,29-1323 INJURED ONL)T 4ANSPCRTED BYTAKEN TO. HN DESCRIBE ir'JURtas COMPLAINTOF PAIN TO NOSE,HEAD AND NVECK, V'.OTRM CF VIOLENT CRIME NOTTFAEO f..y-..� # y'. }y 13 j NAME I D.0 S 1 ADDRESS tr 11J,4_1 OS.4 ALBA POSA 1111 /192 SANE ADDEESSAS P- (415)587-2936 {1NJUR`cO ONLI)TRANSPORTED BY TAKEN TC: AMR J M33ICAL CE2t1T FR DESCIRISE INJURIES" COMPLAINT OF PAIN TO CHES'1'YMS AM LEFT ARM. ry VICTIM OK VIOLENT CRIME NOTIFR@C ;NAME r D.O E.I ADDRESS TEL 1 j'NJUREC ON0)TRANSPORTED 8Y: TAKEN TO, .,."ESCR]8E fNJUfiiES 3 i VICTIM CP VIOL-:NT CRIME NCTIRE:O T- ^aAPtEtOCS.�;ACORE'SS TELEPHONE f;INJUREO OML e)TRANSPORTED BY: TAKEN TO: FESCRliE iNJURIM II Vfc-mm OF vi ENT CRIME NOTIFIED r"JANE:b.tl F3.IADDRES.S TELEPHONE ...._� t _ `i I!N.iLRfM ONLY)TRANSPORTEO SYS TAKEN TO' I ^'ESCR]9E iNJUR FS_ s j b VCCTIM CE VIOLENT CA IME NOTIFIED .•,AnnE!CCS ;A:DRESS TEL.£K'NCNE f e NJUREC 04LY)TRANSPORTED BY. TAKEN TO: M i C E:7CRI@E INJURIES. I._... VICTIM OF VIOLENT CR:ME NOTIFIED r a#E ARFR`S NAAME ._ - t7 NUMR:FR MO DAY YEAR R£VtELMER'3 PlAi4IF_ MO -AY YEAR' L7. ONCE?NA lCi4t}3 0311')12010)# Apr O1 04 09: 25p 5 iiAd7UAL DIAGRAMp. ? CHP S66 � . 7 QPl 042 �iYw� alr QKTC@PCQti3�#Otd SMQ #Y MAA Wica OPFmto.. MWIER ASH tAFA*UR61NIEl1Tlj AAA APPROX M YN AND MOTTO SCALA VMLM MUM(3CALM� t 0400CATLI AOATX 12, � i�1� � d61�wuc5't Lt�7� &ai�p RtGµfi ,tS�'4M►crSlttiu>D�K yE4LEtVJ V p� wMt*�srw+�5 J-2 v-z �tsrsc��` �L��wRy +'mapmwb BY }ar AT li I.�MI IEER i17. WY YEAR AEVIhv,"z fWA SMO. OMY 1 Flit .„ ,') osi+89 284?] Apr 01 04 09; 25p p' 6 STATE.OF CALIFORNIA r' ATF OF INCIDENT TIME NCIC:vOMBER OFFICER i.D3 NUMBER I 03-19-04 1400 9320 16503 I FACTS: 2 3 NOTIFICA'Y'10N' 4 5 ON, 03-19-04 I RECEIVED A CALL AT 1410 HOURS FROM CMP DISPATCH OF A TRAFFIC 6 COLLISION WITH AIN AMEULANCE EN ROUTE. I RESPONDED FRO'll f THE CONTRA COSTA 7 CHP OFFICE AND ARRIVED ON SCENE AT 1432 HOURS. ALL.TIMES, SPEEDS, AND 8 MEASUREMENTS IN THIS REPORT ARE AI'PR.OXIMA.TE. MEASUREMENTS WERE.OBTAINED 9 BY VISUAL AND BEST ESTIMATION. 10 11 12 5CENE DESCt2IPT., I,QN I3 14 THE SCENE OF THIS COLLISION ON I-680 N/B AT THE NORTH MAIN ST. O/C IS PRIMARILY 15 COMPOSED OF ASPHALT. THERE ARE FIVE LANES OF NORTHBOUND TRAFFIC. THE LANES 16 ARE DELINIATED BY BROKEN PAINTED WHITE LINES. THE #1 LANE IS SEPARATED FROM 17 THE CENTER -MEDIAN BY A SOLID YELLOW LIME. THE 95 LANE IS SEPARATED FROM THE IS RIGHT SHOULDER BY A SOLID WHITE LINE. THE ROADWAY SLIGHTLY ASCENDS AS YOU 19 PROCEED NORTH. THIS SECTION OF FREEWAY IS MAINTAINED BY THE STATE OF 20 CALIFORNIA. SEE FACTUAL DIAGRAM FOR FURTHER ININFROMATION. 21 22 23 PARTIES/VEHICLE& 24 25 PARTY#1 ( P-1, HEIR )WAS LOCATED AT THE SCENE ON THE RIGHT SHOULDER STANDING 26 NEXT TO V-1. P-1 WAS IDENTIFIED BY HER'VALID CALIFORNIA DRIVER'S LICENSE ANIS AS 27 THE DRIVER OF V-I BY HER STATEMENT. 28 29 VEHICLE#1 (V-1, FORD) WAS LOCATED AT THE, SCENE ON ITS W'HE'ELS ON THE RIGHT 30 SHOULDER FACING IN A NORTHERLY DIRECTION V-I SUSTAINED MODERATE DAMAGE TO 31 tTS FRONT END. NO MECHANICAL DEFECTS OR.PRIOR DAMAGE WAS NOTED OR CLAN. MD. 32 P-I WAS ABLE TO MOVE V-I TO THE RIGHT SHOULDER. 33 34 PARTY#2 (P-2,RUSCA )WAS LOCATED AT THE SCENE ON THE RIGHT SHOULDER. 3335 STANDING NEXT TO V-2. P-2 WAS IDENTIFIED BY HIS VALID CALIFORNIA DRIVER'S 36 LIC'EN•SE ARID AS THE DRIVER OF V-2 BY HIS STATEMENT. P-2 I5 ALSO THE REGISTERED 37 OWNER OF V-2. >8 39 40 P€EP;tRER'S N,thif•: LD.NLIN113ER DKI'E REV€EW$It'S`^:r1ME ia,ti'i? D, QNCENA 16503 03-20-04 Apr 01 04 09: 26p P. ? STATE OF CALIFORNIA _ [t E21 "ATI1if f 11PPLEMENTAL FACIE fD<r I'8 OF INCIDENT TIME +tCIC NIJU ER OFFICER I.D. NUVIEFR �- 03-19-04 1400 9320 16503 I PARTIESI'VEHICLES (cont need 1. 2 3 VEHICLE##2 ( V-2,GMC ) WAS LOCATED AT THE SCENE ON ITS WHEELS ON THE RIGHT 4 SHOULDER FACING IN A NORTHERLY DIRECTION IN FRONT OF V-1 V-2 SUSTAINED MINOR 5 DAMAGE TO ITS REAR END AND MODERATE DAMAGE TO ITS FRONT END. NO 6 MECHANICAL DEFECTS OR PRIOR DAMAGE WAS NOTED OR CLAIMED. P-2 WAS ABLE TO 7 MOVE V-2 TO THE RIGHT SHOULDER. 8 9 PARTY #3( P-3, BREGLIO ) WAS LOCATED AT THE SCENE STAN-DING NEXT TO V-3. P-3 WAS 10 IDENTIFIED AS THE DRIVER OF V-3 BY HIS STATEMENT. P-3 IS ALSO THE REGISTERED 1 I OWNER OF V-3. 12 13 VEHICLE#3( V-3,FORD) WAS LOCATED AT THE SCENE ON ITS WHEELS FACING IN A 14 NORTHERLY DIRECTION ON THE RIGHT SHOULDER. V-3 SUSTAINED MODERATE DAMAGE 15 TO ITS FRONT END. NO PRIOR DAMAGE OR MECHANICAL DEFECTS WAS NOTED OR 16 CLAIMED. P-3 WAS ABLE TO MOVE V-3 TO TIME RIGHT SHOULDER. 17 I8 19 STATEMENTS: 20 21 P-1 (HEIN )WAS CONTACTED AT THE SCENE AND RELATED IN ESSENCE THAT SHE WAS 22 DRIVING ON I-680 N(B IN THE#5 LANE AT APPROXIMATELY 60 MPH. P-1 SAID THAT 23 TRAFFIC WAS SLOWING AND V-2 SUDDENLY SLOWED DOWN. P-I SAID SHE SLAMVfE.D ON 24 HER BRAKES AND BUT STILL COLLIDED INTO THE REAR OF V-2. 25 26 P-2 ( RLSCA ) WAS CONTACTED AT THE SCENE AND RELATED IN ESSENCE THAT HE WAS 27 DRIVING; V-2 ON 1-680 NB IN THE 45 LANE AT APPROXIMATELY 45 MPH SLOWING DOWN 28 FOR TRAFFIC. P-2 SAID THAT AS HE WAS SLOWING DOWN FOR TRAFFIC, HE WAS REAR 29 ENDED BY V-1. P-2 SAID THAT HM WAS THEN PUSHED FORWARD AND SIDEWAYS OUT OF 30 CONTROLAND COLLIDED INTO V-3. 31 _ 32 P-3(BREGLIO)WAS CONTACTED AT THE SCENE AND.RELATED IN ESSENCE THAT HE WAS 33 DRIVING V-3 ON 1.680 NB IN THE#3 LANE AT APPROXIMATELY 50 MPH. P-3 SAID THAT HE 34 SAW V-1 HIT V-2 AND THAT V-2 'VEERED OUT OF CONTROL AND HIT HIS FRONT END, 35 36 37 38 39 40 NRI,'V, l lVS I.t).NUNISER REVIEWER'S NA1M1-, D. ONCENA 16503 03-20-04 Apr 01 04 09: 26P P. 8 STATE OF CALIFORNIA I.>XrT`OF INCIMANT TlmF 1`CIC N[.'tr BER ter ICCR ED, 03-19-04 1400 9320 16503 .+I UMMARY: f 3 P-I WAS DRIVING V-I N/B I-680 JUST UNDER THE NORTH MAIN ST. O/C rN THE 45 LANE AT 4 APPROXIMATELY 60 MPH APPROACHING V-2. P-2 WAS DRIVING V-2 N/B I-680 FN THE 45 5 LANE AT APPROX MA.TFLY 35 MPH SLOWING DOWN FOR.TRAFFIC AHEAD OF V-1. P-s WAS 6 DRIVING V-3 " I-680 IN THE 43 LANE AT APPROXI;?wIATELY 55 MPH. DUE TO P-I'S UNSAFE 7 SPEED, P-1 WAS UNABLE TO SAFELY STOP V-1 IN TIME ANIS V-I'S FRONT EIS COLLIDED 3 INTO THE REAR END OF V-2. SUBSEQUENTLY, V-2 SPUN OUT OF CONTROL AND V-2'S 9 FRONT END COLLIDED INTO THE FRONT END OF V-3. AFTER.THE COLLISION, ALL PARTIES 10 WERE ABLE TO MOVE THEIR VEHICLES TO THE RIGHT SHOULDER WHERE THEY WAITED I I FOR CHF ARRIVAL. 12 13 14 AREAS O-F IMPACT-f A.O.L 1 15 16 A.O.I. #1 ( V-1 VS. V-2 )'WAS LOCATED 18 FEET SOUTH OF THE NORTH EDGE OF THE NORTH 17 NAIN ST, O/C AND 6 FEET WEST OF THE EAST ROADWAY EDGE OF I-690 N/B. 18 19 A.0.I. #2 (V-2 VS. V-3 )WAS LOCATED 100 FEET NORTH OF THE NORTH E,GDE OF THE 20 NORTH MAIN ST. O/C AND 26 FEET WEST OF THE EAST ROADWAY EDGE OF I-680 N/B. 21 2.2 ?; AU 24 25 P-1 (HEIN)CAUSED THIS COLLISION BY BEING INI VIOLATION OF SECTION 22350 V.C.- 26 UNSAFE SPEED FOR TRAFFIC CONDITIONS. DUE TO P-PS UNSAFE SPEED, P-1 WAS UNABLE 27 TO SAFELY STOP V-I IN TIME AND V-I'S FRONT END COLLIDED INTO THE REAR END OF V-2. 28 SUBSEQUENTLY, V-2 WAS PUSHED FORWARD OUT OF CONTROL AND V-2'5 FRONT END 29 COLLIDED INTO THE FRONT END OF V-3. 30 31 THE SUl'vIVIARY, A.O.I., AND CAUSE WERE BASED ON THE STATEMENTS OF THE INVOLVED 32 PARTIES, PHYSICAL EVIDENCE, AND VEHICLE DAMAGE, 33 34 R.ECOMMENDATII7tIti:S: 35 36 NONE. 1'10"I'.1RER'S NAME 1,0� NUMBER DATE. REXIELVE R'S N&ME D. ONC:ENA 16503 03-20-04 RECD A F C a APR 2 3 2004 SAFECO PROPERTY & CASUALTY INSURANCE COMPANIES RED, CL DoCtA40 AMM=ECM=Y b=ra=ComeaaY Ph ma: (818)958.4279 Som Rep= Fax: (8"2454572 Post Office Box 347tH Seattlo,WA 98124 wwwMrammu MM)Mg xkhft : Peat Office ba 34700 SeeWe,WA.98124 April 14,2004 John Rusca M ARWATM rresuaMCa$ttaxsRS 70 Cherry Way Walnut Creek,CA 94596 Insured Name: John Rusca - Policy Number: O2CA093458 Loss Bate: March 19,2004 Cly Number: 215947432015 Bees•Mr.John Rusca: We have identified the driver responsible for the accident as Tracy Lynn Dein,Who is an employee of Contra Costa County. We have placed the Risk Management on notice of our intent to recover for your damage and that you sustained injuries.The party we are toll that is handling the claim is a Penny Bailey,(925)335-1455.We have left several messages for Ms.Bailey to determine her liability posture and coverage to handle your claim and that of the driver ofthe vehicle you were pushed into. I have referred your claim to our Recovery department to begin the recovery process.Z believe the rental is outstanding to be paid on areilnbursernent basis,please advise status in this regard. Your injury should be dealt with by Contra Costa County adjuster for consideration of medical expenses,any loss of income and pain and suffering.As we previously discussed,if you did:not qualify for Workers Compensation then our Medical Payment coverage can.assist you With payment of your accident related medical expenses within the limit of coverage which is$5000. Please advise if we will be receiving medical bills for payment consideration? For the remainder of your injury claim you will need to be in direct contact with Ms.Bailey. Sincerely, Denise Eklund Southwest Region American Economy Insurance Company (818)956-4279 Ext:4279 denekl@safeco.com Pax:(866)245-4572 CAM WW1 •A M9kW*d hsd«»wk d8AMW Cam DR. JOHN S. RIDDEL, D.C. B T A T E X $ N T 3147 Putnam Blvd Rte E Pleasant Hill, CA 94523 03-26-2004 (925) 945-7890 r BALANCE: $.00 ACCOUNT Bech RUSCA 1004--954 LAST CLAIM: 70 CHERRY WAY C WALNUT CREEK CA 94596 Date Description Code Charge Credit Adjust Balance i 03-24-2004 Cold Pack for Home Use E0230 10.010 .00 .00 10.00 03-26-2004 PT CK 1697 .00 10 .00 .00 .00 TOTALS 10. 00 10.00 .00 ** MESSAGE *************************** * THANK YOU FOR VISITING RIDDEL * CHIROPRACTIC. HAVE A WODERFUL DAY. yt*iricirlryFirl **ir* IrsY***9r**ir*i *tei �rk** F9rdritiririt RECD APR 2 3 2004 RED. CL DOCIMG For proper credit, please enclose this portion with your payment . Beth RUSCA BALANCE: $.00 76 CHERRY WAY WALNUT CREEK. CA 94596 PAY THIS AMOUNT: AMOUNT ENCLOSED: Please fill in dank. DATE DUE: 04/01/04 DR.. JOHN S. RIDDEL, D.C. THANK YOU. 3147 Putnam Blvd Ste E Pleasant HMI, CA 94523 ACCOUNT NUMBER: 1.000-954 APR 2 3 2004 RED. CL.DCCIMG ,nes 94 r ,aa� i�ma�s"0 AdOo aaGbj4oalKnj 4 ' S ,Tejo, w'SZ/1-0 EZ 54 AT FZ ZI 1+ r'on,'00t�OZS�rSntn� AI OpOiF?908r1@QOZS€b58T00 0I �,FT Ci�lE���F ac ej�sS?a, 6ts, G VI 3111AVII1 sbSb6 tl� 11113AVJVI EOZ 3110; £0Z 31IP5 001 Q 18rif'i 1Ktt0u 994E 4Ai8 01Rtlir1 14 04 5Qt: g 310VWS14J 31f3�n?bl 9 11� Md0ifiN0 3111001 9 tsv 12 91) it the Datts>m at this cage are romsn$ers for cams prsvenbvt aarvtcas bssad art#falser Perrnanenta's current sfactranlc racards. y A it u have artyoinft health problerrts or at high Oak for aaftttt diMM,you May head mora fraquent pmventiva aaMcst W PRMANEWEo slid ft*consult your pitywo if an appointment is neCtrsSary,pf"so scmdut0 f#. APR RECD RED. CL DOCIMG a?SS'Y;: r tU CH Ji7t-N A FUR,CHASER: 00003c3lestifs,000 T , .t"t- ,:..it+ t.,++ r_ + Pi "CF t IF - %Eh, Er T i FE. MEMREF PT WITH, r, R FA TEL Pt.1— rr" , �: -T" L't"TE-,, t Q, ol, c - 1-2 31 /10 -02S15LE CHARGES rIrfT Pl:' - rFEC TI�'E FLEA9E RC-„rIE.W CLINIC VISIT z 31 ,EO/FED t-Ht : HEGGM WCR OTHER FCF : LAB TEST � :;k14 MOV ,,3, EE :30F FATELHA NIC HIC '14CF, XRAY1IMAGING 0 :EVEN r1 . SERVICES :_Ass R i�.v BLOOD FrES2L'Fr -,'t*T',” MRI/CT/FET L-Lt ,-_w E I ANt35 c,t-+'n,`tc INFLUEN-r-i ` AC:CIi.t. it ,+ I HOCC/:.r T't-+: +:1F C,urrt--rtt CHOLESTEROL ,CFNEt,d � :, • ; `t-t`ran t FNEUMO VACCINE -r4.,-, x2 SFELIAL FROCEDUREL t EMERGNCY DEFT V I S I T'r 3 r c AMBULATORY SURCER. r Et It4FERT OFFICE VISIT 'r: 5t DME. OUTPATIENT l Ei_ MEL?I CAL EOU IPME14T FEE HOSF I TAL. YES PRENATAL VISIT $ GENERIC DRUG Return appointment.�---��. nays_._�_ �weeks � ' }� tis f � u= Thlo is only an 00"Moto of today,0 chrar ..►ltotcr moy by cjddltiongi foQn Do�MUM of thecam##YOU MUM lino tstieu'ntsaticrn obout your bonoOfrr,iimi#0tlono end oxrcWcl0"&0011 dombor YoUr olrrc�d#Qday, 8ervico0 Will bD rcn rod to Fm4ranc k� n# ..�•,•. '8 Y Pcrtrnartt ragr�rdlt�as cf c#tEil#y to pay. Patient Receipt Lafayette Chiropractic Group 3466 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 voices 995-283-8140 Fax : 915-283-8234 Tuesday March 30, 2004 Patient: JOHN RUSCA #5141 03/30/2004 $ 35.00 98940 MANIPULATION 1-2 REGIONS 03/30/2004 $ 10.00 97010 HOT/COLD PACKS 03130/2004 $ -40.00 Credit card payment applied to unbilled LAfAlETTE CHIROPRACTIC G 3466 NOW 9IASLO $LVD SUITE 203 Fee(s) : $ 45.00 LAGAYETTE. CA 914549 Sales Tax : $ 0.00 925-283-8148 Total Charges $ 45.00RC'D S a le Total Payments $ -40.00 ID. 661854852668908673169E Remaining Deduct. : $ 0.00 APR 2 3 2004 E3.3E.E4 17 a45 Account Balance : $ 0.00 RED.�b. CL DQClMG inuntwigW Current diagnosis: 847.0 RW CdQc 0004 IRvI: 880016 local; $ 90,80 Castasar CaPY THANK Y001 Next appointment: Thursday April 1, 2004 4:30pm Tuesday April 6, 2004 4:40pm Thursday April 8, 2004 4.40pm Patient Receipt Lafayette Chiropractic Group 3466 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 Voice: 925-383-8140 Fax : 925-283-8224 Thursday April 1, 2004 Patient JOHN RUaCA 45141 ?4101I2004 $ 35.00 9$940 MANIPULATION 1-2 REGIONS 34/01/2004 $ 10 00 97010 HOT/COLD PACKS '4!01.12004 $ -50 00 Credit card payment applied to unbilled Cha LAFAYETTE CHIROPRACTIC 6 3456 MOUNT DIABEO 80D SUITE 283 1AFAYETIE. £A 94544 ree(s) : $ 45.00 525-2x3.814 Sales Tax : $ 0 00 Sal e .otal Charges : $ 45 00ID 0010648520000006731 O Total Payments $ -50.00 REO'D 04,11-104 5:44 00 Remaining Deduct. $ 0 00 APR 9 3 2004 Ush ,ccount Balance : $ -5 00 RED. CL DOCIMG 111111111111;645 -'utrent azagnosis: 847.0 AW Cod/; 849619 10: 68$012 Total: $ 98.60 Custoner Coat THANK YOW next appointment: Tuesday April 6, 2004 4:40pm Thursday April 8, 2004 4:40pm #10A AN#HI "12101 patient Receipt LINN W11 Mot", 'T1 jdav Lafayette Chiropractic Group xX t 3466 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 voices 925-283-8140 It iS 31 Fax : 915-283-8224 w wts 4s0a 0e zs��SOtoe 7I Tueaday April 13, 2004 a T e S 0:8 Eaa-sas LrS:G a3 •31130341 £4t 31RECD ansa 0154I0 IrtIOtiOw 99bf 9 allIVN0£143 3113001 APR 2 3 200¢ V41 i.>r avva v _ 98040 MANIPULATION 1-2 REGIONS RED, CL DOCIMG 04/13/2004 $ 10.00 57010 HOWCOLD PACKS 04/13/2004 $ -45.00 Credit card payment applied to unbilled charges Fee(s) $ 45.00 Sales Tax $ 0.00 Total Charges $ 45 00 Total Paymencs $ -45 00 Remaining Deduct. : $ 0.00 Account Balance $ 0.00 Current diagnosis: 847 0 Next appointment: Thursday April 15, 2004 4:30pm Jjf WAYETTE CHIRUPRACTIC 6 3466 NUURT 01480 BLVD Patient Receipt SUITE 283 LAFAYWE. CA 94549 925-283-8146 Lafayette Chiropractic Group Sale 3466 Mt. Diablo Blvd., Ste C203 IG 48165485?688866731686 Lafayette, CA 94549 64,15,64 16 51.68 voice: 925-283-8140 Fast : 925-283-8224 11SA Thursday April 15, 2004 Aw Code: 110W fru#c 00016 REC'a APR 2 3 2004 Cuata,arr ZaDk THAhn Your RECD. CL DOCIMG 98940 MANIPULATION 1-2 REGIONS 04/15/2004 $ 10.00 97010 HOT/COLD PACKS 04/1.5/2004 $ -45.00 Check payment applied to unbilled charges Fee{s} $ 45.00 Sales `Pax : $ 0.00 Total Charges $ 45.00 Total Payments $ -45.00 Remaining Deduct. : $ 0.00 Account Balance $ 0.00 Current diagnosis: 847 .0 ?text appointment: Patient Receipt Lafayette Chiropractic Groin 3466 )fit, Diablo Blvd., Ste 0203 Lafayette, CA 94549 Voicet 925-283-8140 Fax : 925-283-8224 Tuesday April 6. 2004 atient: JOHN RUSCA #5141 34/06/2004 $ 35.00 98940 MANIPULATION 1-2 REGIONS 74/06/2004 $ 10.00 97010 HOT/COLD PACKS WAYETTE CHIROPRACTIC G 4/06/2004 $ —40.00 Credit card payment applied to unbilled ch 3488 MOUNT OIAaLO .LVO SUITE 203 LAFAYETTE. CA 94549 92$-283-8140 ee{s} $ 45.00 ales Tac $ 0.00 total Charges $ 45.00 REVD IO ae16$98�S209O888si31 ee 'otal Payments : $ -40.00 04�es.04 1i 86.2s 'emaining Deduct. : $ 0 00 APR 2 3 2004 VISA ccount Balance $ 0.00 FLED. CL QUCIMG 11111111111166 'urrent diagnosis: 847.0 Aper Code, 04SW IM: HIM lotal: 4Q.08 Custozer Coav THANK YOif� Aext appointment: ^hursday April 8, 2004 4:40pm Patient Receipt Lafayette Chiropractic Grcup 3465 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 Voice: 925-283-8140 Fax : 925-283-8224 Tbhursday April 8, 2004 latient' JOHN RUSCA #5141 LASAYEITE CHIROPRACTIC G 3461 HOURT OIABLO BLVD '4!0$/2004 $ 35.00 98944 MANIPUIUATION 1-2 REGIONS solif 263 LAFAYETIF� CA 3460 14/08/2004 $ 10.00 97010 HOTICOLD PACKS 925-283-9146 1/0812004 $ -45.00 Credit card payment applied to unbilled c S 8 le } IO gy206a852OB08O06731®}7 13.28 sa,DB•�a eats) $ 45.40 ales Tax $ 4.40 .otal Charges $ 45 00 REC'd til 'otal Payments : $ -45.00 emainxng Deduct. : $ 4.40 APR 2 3 2004 Wr Cabe: �496S4 IAU#+ HIM .ccount Balance $ 0.44 RED. CL DCJCtN1G Custostt Cool arrent diagnosis: 847.0 IH49K YOW ext appointment: _ _ 03/25/2004 AT 08:10 PM 215947432015-001 15838 AMERICAN ECONOMY INS. CO. NORTHERN CALIFORNIA CLAIMS OFFICE PO BOX 34700 SEATTLE, WA 98124 (916)769-0250 FAX: (866)245-4572 ESTIMATE OF RECORD WRITTEN BY: H EDWARD CROWDER # 03/25/2004 05:04 PM ADJUSTER: DENEKL # INSURED: JOHN RUSCA CLAIM #215947432015-001 OWNER: JOHN RUSCA POLICY #02CDO93458 ADDRESS: 70 CHERRY WAY DATE OF LOSS: 03/19/2004 WALNUT CREEK, CA 94596 TYPE OF LOSS: COLLISION OTHER: (925)934-5717 POINT OF IMPACT: 6. REAR DAY: (925)935-6792 INSPECT CLASSIC AUTO BODY DAY: (925)938-3131 LOCATION: CLASSIC AUTO BODY OTHER 1401 AUTO CENTER DR WALNUT CREEK, CA 94597 REPAIR CLASSIC AUTO BODY BUSINESS: (925)- FACILITY: CLASSIC AUTO BODY 12 DAYS TO REPAIR 1401 AUTO CENTER DR LICENSE # WALNUT CREEK, CA 94597 2000 GMC C2500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: VIN: 1GTGC24R2YR140956 LIC: CA PROD DATE: ODOMETER: INTERMITTENT WIPERS DUAL MIRRORS CLEAR COAT PAINT POWER STEERING POWER BRAKES ANTILOCK BRAKES (4) REAR STEP BUMPER STYLED STEEL WHEELS ---------------------------- Q ------------------------ NO. OP. DESCRIPTIONTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 TIRES 2* REPL BG O 245/70R16 BIG FOOT AT WL 1 130.95 0.3 3# SUBL MOUNT & BALANCE 1 12.50 X 44.1 SUBL ALIGN FOUR WHEELS i 79.95 X 5 REAR BUMPER 6 O/H REAR BUMPER 1.2 7** REPL RECOND FACE BAR PRODUCTION 1 278.65 INCL. 1.1 PAINTED 8 ADD FOR CLEAR COAT 0.4 9 REPL RT STEP PAD PAINTED BUMPER 1 18.19 INCL. 10 REPL LT STEP PAD PAINTED BUMPER 1 18.19 INCL. 11 PICK UP BOX 12 REPL SET BACK BOX ASSY 1 1.5 13 BACK GLASS N 14* RPR FIXED GLASS GM, W/DEEP TINT 0.3* UNHEATED 15 CAB 1 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC C2500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: --------------------------- -----Q --------------------------- NO. OP. DESCRIPTION TY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 16 REPL RT NAMEPLATE SL 1 11.19 0.2 N 17* RPR RT SIDE PANEL 1.5* 1.2 18 ADD FOR CLEAR COAT 0.5 19 BLND BACK PANEL 1.5 20* RPR COWL TOP PANEL 1.0* 1.0 21 OVERLAP MAJOR NON-ADJ. PANEL -0.2 22 ADD FOR CLEAR COAT 0.2 23 WINDSHIELD 24* SUEL WINDSHIELD PLUS KIT * 1 320.35* T 254 SUBL WINDSHIELD LABOR 1 40.00 X 26 FRONT BUMPER 27 O/H FRONT BUMPER 1.3 28** REPL RECOND FACE BAR CHROME W/O AIR 1 193.00 INCL. INTAKE W/O IMPACT STRIP W/LSC 29** REPL QUAL REPL PARTS RT FACE BAR 1 23.00 0.3 MOUNT BRACKET 30** REPL QUAL REPL PARTS RT FACE BAR 1 19.00 INCL. BRACE W/0 3500 HD 31 GRILLE 32** REPL QUAL REPT, PARTS GRILLE W/O 1 150.00 INCL. SPORT CHROME 33 REPL EMBLEM 1 44.20 INCL. 34 REPL GRILLE BRACKET 1 3.78 35 FRONT LAMPS 36** REPL QUAL REPL PARTS RT HEADLAMP 1 40.00 SNCL. ASSY W/HALOGEN LAMPS 37 AIM HEADLAMPS 0.5 38 R&I R&I HEADLAMP ASSY ONE SIDE INCL. 39** REPL QUAL REPL PARTS RT PARK LAMP 1 22.00 INCL. 40** REPL QUAL REPL PARTS RT REFLECTOR 1 6.00 INCL. 41 COOLING 42** REPL QUAL REPL PARTS RADIATOR 1 180.00 5.1 1.0 SUPPORT W/O 3500 HD 5.7 LITER 43 EVACUATE & RECHARGE M 1.4 44 ADD FOR DUAL BATTERY M 0.7 45 REPL LOCK SUPPORT 1 24.09 INCL. 46** REPL QUAL REPL PARTS RADIATOR 1 463.00 MINCL. 47 ADD FOR OIL COOLER M 0.2 48 REPL SHROUD W/OIL COOLER LOWER 1 18.47 INCL. 49 REPL SHROUD W/OIL COOLER UPPER 1 41.12 INCL. 50 REPL BLADE W/AC 1 40.70 M 0.5 51 REPL FAN ASSY 1 89.65 M 0.8 52 AIR CONDITIONER & HEATER 53** REPL QUAL REPL PARTS CONDENSER 2ND 1 268.00 MINCL. DESIGN 54 HOOD 55 BLVD HOOD 1.6 56* ALGN HOOD 0.5* 2 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ---------------------------------------- 57 FENDER 58** REPL QUAL REPL PARTS CAPA RT FENDER 1 93.00 2.8 2.6 59 OVERLAP MAJOR NON-ADJ. PANEL -0.2 60 ADD FOR CLEAR COAT 0.5 61 ADD FOR EDGING 0.5 62 DEDUCT FOR OVERLAP -0.4 63** REPL QUAL REPL PARTS CAPA RT 1 65.00 0.6 1.0 WHEELHOUSE W/O 15000 GVWR 64 OVERLAP MAJOR ADJ. PANEL -0.4 65 ELECTRICAL 66 R&I BATTERY M 0.3 67 ENGINE 68 REPL AIR CLEANER UPPER HOUSING 2ND 1 231.77 M 0.2 DESIGN 69# RPR SETUP & MEASURE 2.0 F 70# RPR PULL & SQUARE 2.0 71# RPR RIGHT FRONT RAIL 2.0 F 72 MISCELLANEOUS OPERATIONS 73* REPL COVER CAR/BAG 1 5.00* 0.2 74# PAINT MATCH 1 0.5 75# SUBL HAZARDOUS WASTE REMOVAL 1 3.00 X ------------------------------------- SUBTOTALS => 2933.75 27.5 12.3 LINE 14 MASK GLASS LINE 17 WITH BACK PANEL _.----------------------------------------------------------- ESTIMATE NOTES: 12 REPAIR DAYS ACOR OBTAINED WITH TIM PARTS 2798.30 BODY LABOR 23.5 HRS 9$ 68.00/HR 1598.00 PAINT LABOR 12.3 HRS :@$ 68.00/HR 836.40 FRAME LABOR 4.0 HRS 0?$ 68.00/HR 272.00 PAINT SUPPLIES 12.3 HRS Q$ 27.00/HR 332.10 SUBLET/MISC. 135.45 ---------------------------------------------------- SUBTOTAL $ 5972.25 SALES TAX $ 4075.95 Q 8.25001 336.27 -------------- ------- TOTAL COST OF REPAIRS - -- $ 6308.52 ADJUSTMENTS: DEDUCTIBLE 500.00 3 03/25/2004 AT 08:10 PM 215947432015-001 15836 ESTIMATE OF RECORD 2000 GMC 02500 4X2 HD 5-5.7L-FI 2D P/U WHITE INT: ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 5808.52 *** COPY OF ESTIMATE PROVIDED TO CUSTOMER *** ****NO SUPPLEMENT WILL BE PAID WITHOUT PRIOR APPROVAL*** **** SUPPLEMENTS WILL REQUIRE ALL INVOICES FOR THE ENTIRE REPAIR **** "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR. DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE." ALIO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS N8W, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES. THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN INSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. S. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 4 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR.CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (900) 927-HELP OR (223) 897-8921 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.INSURANCE.CA.GCV 12/39/00 LAST REVISED - JANUARY 03, 2001 COPYRIGHT CALIFORNIA DEPARTMENT OF INSURANCE DISCLAIMER 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=TAMED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST-ESTIMATE EXT. PRICE-UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL 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 W/ =WITH/_ SYMBOLS: #=MANUAL 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. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THE GLASS PART PRICE, KIT AND LABOR HAS BEEN CALCULATED BASED ON MARKET PRICING FOR YOUR AREA. SAFECO'S GLASS ADMINISTRATOR IS SAFELITE AUTO GLASS, PLEASE CALL SAFELITE AT 1-800-800-2727 TO ARRANGE FOR THE WORK TO BE COMPLETED. 5 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC C2500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DRlGH95 DATABASE DATE 2/2004 AND THE PARTS SELECTED ARE DEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS, USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 6 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC 02500 4x2 HD 8-5.7L-FI 2D P/U WHITE INT: ALTERNATE PARTS SUPPLIERS 28 RECOND FACE BAR CHROME W/O PART NO. GM100280IR PRICE 193.00 29 QUAL REPL PARTS RT FACE BAR PART NO. GM1067127P+ PRICE 23.00 30 QUAL REPL PARTS RT FACE BAR PART NO. GM1067116P+ PRICE 19.00 32 QUAL REPL PARTS GRILLE WJO PART NO. GM1200392P+ PRICE 150.00 36 QUAL REPL PARTS RT HEADLAMP PAR.' NO. GM2500112 PRICE 40.00 39 QUAL REPL PARTS RT PARK LAM PART NO. GM2521104 PRICE 22.00 40 QUAL REPL PARTS RT REFLECTO PART NO. GM2557101 PRICE 6.00 42 QUAL REPL PARTS RADIATOR SU PART NO. GM1225145 PRICE 180.00 58 QUAL REPL PARTS CAPA RT FEN PART NO. GM1241133P+ PRICE 93.00 63 QUAL REPL PARTS CAPA RT WHE PART. NO. GM1247104P+ PRICE 65.00 KEYST014E AUTOMOTIVE (800)794-6911 1069 HENSLEY STREET (510)234-6960 RICHMOND, CA 94801 KEYSTONE AUTOMOTIVE (916)372-3300 1045 TRIANGLE COURT, SUITE B (800)669-7528 W. SACRAMENTO, CA 95605 46 QUAL REPL PARTS RADIATOR PART NO. 52481444 PRICE 463.00 53 QUAL REPL PARTS CONDENSER 2 PART NO. 52402209 PRICE 268.00 1-800 RADIATOR HOTLINE (800)472-7016 2990 BAY VISTA CT. BENICIA, CA 94510 1-800 RADIATOR HOTLINE (800)472-7016 3018 ALVARADO #C SAN LEANDRO, CA 94577 1-800 RADIATOR HOTLINE (800)472-7016 5821 FLORIN PERKINS SACRAMENTO, CA 95828 1-800 RADIATOR HOTLINE (800)472-7016 196 BARNARD AVE. SAN JOSE, CA 95125 1-900 RADIATOR HOTLINE (800)472-7016 825 CIVIC CENTER DR. #4 SANTA CLARA, CA 95050 7 RECORD FACE BAR PRODUCTION PART NO. 15025374 PRICE 278.65 OED MAITA CHEV GM (916)481-0855 9650 AUTO CENTER DRIVE ELK GROVE, CA 9S624 7 03/25/2004 AT 08:10 PM 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: TIRE PARTS SUPPLIERS 2 BG 0 245/70816 BIG FOOT AT WL PRICE: $ 130.95 TIRES PLUS PHONE: (530)753-3118 247 F ST FAX: DAVIS, CA 95616 8 03/25/2004 AT 08:10 P.M. 215947432015-001 15838 ESTIMATE OF RECORD 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT Aid AFTERMhRKET PART WAS AVAILABLE: 14 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 11 05/24/2004 AT 08:48 PM 215947432015-001 15838 AMERICAN ECONOMY INS. CO. NORTHERN CALIFORNIA CLAIMS OFFICE PO BOX 34700 SEATTLE, WA 98124 {91.6}769-0250 FAX: (886)245-4572 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: H EDWARD CROWDER # 05/14/2004 08:46 PM ADJUSTER: DENEKL # INSURED: JOHN RUSCA CLAIM #215947432015-001 OWNER: JOHN RUSCA POLICY #02CD093458 ADDRESS: 70 CHERRY WAY DATE OF LOSS: 03/19/2004 WALNUT CREEK, CA 94596 TYPE OF LOSS: COLLISION OTHER: {925}934-5717 POINT OF IMPACT: 6. REAR DAY: (925)935-6792 INSPECT CLASSIC AUTO BODY DAY: {925}938-3131 LOCATION: CLASSIC AUTO BODY OTHER 1401 AUTO CENTER DR WALNUT CREEK, CA 94597 REPAIR CLASSIC AUTO BODY BUSINESS: (925)- FACILITY: CLASSIC AUTO BODY 12 DAYS TO REPAIR 1.401 AUTO CENTER DR LICENSE # WALNUT CREEK, CA 94597 2000 OMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY VIN: 1GTGC24R2YR140956 LIC: 6D54140 CA PROD DATE: 10/1999 ODOMETER: 51040 INTERMITTENT WIPERS DUAL MIRRORS CLEAR COAT PAINT POWER 'STEERING POWER BRAKES ANTI-LOCK BRAKES (4) REAR STEP BUMPER STYLED STEEL WHEELS ---------------------------------------- -. NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 TIRES 2* REPL BG 0 245/70RI6 BIG FOOT AT WL 1 130.95 0.3 3# SU"BL MOUNT & BALANCE 1 1.2.50 X 4# SU'BL ALIGN FOUR WHEELS 1 79.95 X 5 REAR BUMPER 6 O/H REAR BUMPER 1.2 7** REPL RECOND FACE BAR PRODUCTION 1 278.65 INCL. 1.1 PAINTED 8 ADD FOR CLEAR COAT 0.4 9 REPL RT STEP PAD PAINTED BUMPER 1 18.19 INCL. 10 REPL LT STEP PAD PAINTED BUMPER 1 18.19 INCL. 11 PICK UP BOX 12 REPL SET BACK BOX ASSY 1 1.5 13 BACK GLASS N 14* RPR NIXED GLASS GM, W/DEEP TINT 0.3* UNHEATED 25 CAB 1 05/14/2004 AT 08:40 PM 225947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2040 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY ------------------------------------------------------------------------------- NCI. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 16 REPL RT NAMEPLATE SL 1 11.19 0.2 N 17* RPR RT SIDE PANEL 1.5* 1.2 18 ADD FOR CLEAR COAT 0.5 19 BLVD BACK PANEL 1.5 20* RPR COWL TOP PANEL 1.0* 1.0 21 OVERLAP MAJOR NON-ADJ. PANEL -0.2 22 ADD FOR CLEAR COAT 0.2 23 WINDSHIELD 24* SUBL WINDSHIELD PLUS KIT * 1 320.35* T 25## SUBL WINDSHIELD LABOR 1 40.00 X 26 FRONT BUMPER 27 O/H FRONT BUMPER 1.3 28** REPL RECONM FACE BAR CHROME W/O AIR 1 193.00 INCL. INTAKE W/O IMPACT STRIP W/LIC 29** REPL QUAL REPL PARTS RT FACE BAR 1 23.00 0.3 MOUNT BRACKET 30** REPL QUAL REPL PARTS RT FACE BAR 1 19.00 INCL. BRACE W/O 3500 HD 31 S01 REPL CENTER FILLER W/O GRILLE VENT 1 59.80 0.3 0.8 HOLES W/O WT 32 S01 OVERLAP MINOR PANEL -0.2 33 S01 ADD FOR CLEAR COAT 0.1 34 GRILLE 35** REPL QUAL REPL PARTS GRILLE W/O 1 150.00 INCL. SPORT CHROME 36 REPL EMBLEM 1 44.20 INCL. 37 REPL GRILLE BRACKET 1 3.78 38 FRONT LAMPS 39** REPL QUAL REPL PARTS RT HEADLAMP 1 40.00 INCL. ASSY W/HALOGEN LAMPS 40 AIM HEADLAMPS 0.5 41 R&I R&I HEADLAMP ASSY ONE SIDE INCL. 42** REPL QUAL REPL PARTS RT PARK LAMP 1 22.00 INCL. 43** REPL QUAL REPL PARTS RT REFLECTOR 1 6.00 INCL. 44 COOLING 45** REPL QUAL REPL PARTS RADIATOR 1 180.00 5.1 1.0 SUPPORT W/O 3500 HD 5.7 LITER 46 EVACUATE & RECHARGE M 1.4 47 ADD FOR DUAL BATTERY M 0.7 48 REPL LOCK SUPPORT 1 24.09 INCL. 49** REPL QUAL REPL PARTS RADIATOR 1 463.00 MINCL. 50 ADD FOR OIL COOLER M 0.2 51 REPL SHROUD W/OIL COOLER LOWER 1 18.47 INCL. 52 REPL SHROUD W/OIL COOLER UPPER 1 41.12 INCL. 53 REPL BLADE W/AC 1 40.70 M 0.5 54 REPL FAN ASSY 1 89.65 M 0.8 55 S01 REPL COOLER 1 179.77 M 1.4 56 S01 REPL RT RADIATOR UPPER INSULATOR 1 3.78 2 05/14/2004 AT 08.98 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC; 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT.GRAY ---- ---------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --------------------------------- 57 S01 REPL LT RADIATOR UPPER INSULATOR. 1 3.78 58## S01 REPL NUT 1 1.24 59 AIR CONDITIONER & HEATER 60** REPL QUAL REPL PARTS CONDENSER 2ND 1 268.00 MINCL. DESIGN 61 HOOD 62 BLND HOOD 1.6 63* ALGN HOOD 0.5* 64 FENDER 65** REPL QUAL REPL PARTS CAPA RT FENDER 1 93.00 2.8 2.6 66 OVERLAP MAJOR NON-ADJ. PANEL -0.2 67 ADD FOR CLEAR COAT 0.5 68 ADD FOR. EDGING 0.5 69 DEDUCT FOR OVERLAP -0.4 70** REPL QUAL REPL PARTS CAPA RT 1 65.00 0.6 1.0 WHEELHOUSE W/O 15000 GVT,TR 71 OVERLAP MAJOR ADJ. PANEL -0.4 72 ELECTRICAL 73 R&I BATTERY M 0.3 74 ENGINE 75 REPL AIR CLEANER UPPER HOUSING 2ND 1 231.77 M 0.2 DESIGN 76# RPR SETUP & MEASURE 2.0 F 77# RPR PULL & SQUARE 2.0 78# RPR RIGHT FRONT RAIL 2.0 F 79 MISCELLANEOUS OPERATIONS 80* REPL COVER CAS./BAG 1 5.00* 0.2 81# PAINT MATCH 1 0.5 82# SUBL 'HAZARDOUS WASTE REMOVAL 1 3.00 X 83# S01 REPL 'ANTI-FREEZE-COOLANT 1 18.42 84 S01 FRAME 85* S01 RPR FRAME ASSY 1/2 & 3/4 TON 8 4.0* FOOT BED STD CAB 86# S01 SUPPL: $773.87 1 ------------------------------------------------------------------------------- SUBTOTALS ==y .3200.54 33.2 13.0 LINE 14 MASK GLASS LINE 17 WITH BACK PANEL ESTIMA'T'E NOTES: --- 12 REPAIR DAYS ACOR OBTAINED WITH TIM 3 05/14/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY PARTS 3065.09 BODY LABOR 29.2 HRS @$ 68.00/HR 1985.60 PAINT LABOR 13.0 HRS @$ 68.00/HR 884.00 FRAME LABOR 4.0 HRS @$ 68.00/HR 272.00 PAINT SUPPLIES 350.00 SUBLET/MISC. 135.45 SUBTOTAL -$ 6692.14 SALES TAX $ 4730.34 cls 8.2500% 390.25 ---- TOTAL COST OF REPAIRS $-7082.39 ADJUSTMENTS: DEDUCTIBLE 500.00 TOTAL ADJUSTMENTS -- $ - '500.00 NET COST OF REPAIRS $ 6582.39 *** COPY OF ESTIMATE PROVIDED TO CUSTOMER *** ****NO SUPPLEMENT WILL BE PAID WITHOUT PRIOR APPROVAL*** **** SUPPLEMENTS WILL REQUIRE ALL INVOICES FOR THE ENTIRE REPAIR **** "WE ARE PROHIBI`T'ED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ;ABOUT COVERAGE FOR. TOWING AND STORAGE SERVICES. THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN INSURED BEFORE 4 05/14/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. 5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR. OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5220 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AU'T'OMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR.CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOTS AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) .927—HELP OR (213) 897-8921 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.INSIURANCE.CA.GOV 12/29/00 LAST REVISED — JANUARY 03, 2001 COPYRIGHT CALIFORNIA DEPARTMENT OF INSURANCE DISCLAIMER 5 05/14/2004 AT 08:48 PM 215947432015-001 1.5838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L—FI 2D P/U WHITE INT:GRAY 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 ALt,N=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 NOLINE 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 W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION idAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A _.. SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THE CLASS PAR": PRICE, KIT AND LABOR HAS BEEN CALCULATED BASED ON MARKET PRICING FOR YOUR AREA. SAFECO'S GLASS AaMINISTRATOR IS SAFELITE AUTO GLASS. PLEASE CALL SAFELITE AT 1-800-800-2727 TO ARRANGE FOR THE WORK TO BE COMPLETED. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DRIGH95 DATABASE DATE 4/2004 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL, REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 6' 05/14/2004 AT 08:48 PM 215947432015--001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT--- ------------------------------------------------------------------------------- ------- ADDED ITEMS ------- 31 Sol REPL CENTER FILLER W/O GRILLE VENT 1 59.80 0.3 0.8 32 Sol OVERLAP MINOR PANEL -0.2 33 S01 ADD FOR CLEAR COAT 0.1 55 S01 REPL COOLER 1 179.77 M 1.4 56 S01 REPL RT RADIATOR UPPER INSULATOR 1 3.78 57 S01 REPL LT RADIATOR UPPER INSULATOR 1 3.78 58# S01 REPL NUT 1 1.24 83# S01 REPL ANTI-FREEZE-COOLANT 1 18.42 84 S01 FRAME 85* S01 RPR FRAME ASSY 1/2 & 3/4 TON 8 FOO 4.0* 86# S01 SUPPL: $773.87 1 ------------------------------------------------------------------------------- SUBTOTALS ==> 266.79 5.7 0.7 - ----------------------------------- ESTIMATE NOTES: 12 REPAIR DAYS ACOR OBTAINED WITH TIM PARTS 266.74 BODY LABOR 5.7 HRS @$ 68.00/HR 387.60 PAINT LABOR 0.7 HRS @$ 68.00/HR 47.60 PAINT SUPPLIES 0.7 HRS @$ 27.00/HR 18.90 ADDITIONAL SUPPLEMENT MATERIALS/SUPPLIES -1.00 ---------------------------------------------------- SUBTOTAL $ 719.89 SALES TAX $ 654.39 Q 8.2500* 53.99 ADDITIONAL SUPPLEMENT TAXES -0.01 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 773.87 NET COST OF SUPPLEMENT $ 773.87 ESTIMATE 6308.52 H EDWARD CROWDER SUPPLEMENT S1 773.87 H EDWARD CROWDER -------- TOTAL ADJUSTMENTS $ 500.00 WORKFILE TOTAL $7082.39 NET COST OF REPAIRS $ 6582.39 *** COPY OF ESTIMATE PROVIDED TO CUSTOMER *** ****NO SUPPLEMENT WILL BE PAILS WITHOUT PRIOR APPROVAL*** **** SUPPLEMENTS WILL REQUIRE ALL INVOICES FOR THE ENTIRE REPAIR **** ' 'WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC 7 05/24/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC C2500 432 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATER IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PART'S AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES. THE INSURER SHALL PAY REASONA13LE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN INSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. 5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR.CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) 927-HELP OR (213) 897--8921 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 8 05/14/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.INSURANCE.CA.GOV 1.2/29/00 LAST REVISED - JANUARY 03, 2001 COPYRIGHT CALIFORNIA DEPARTMENT OF INSURANCE DISCLAIMER THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRER OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLVD=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-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/0-WITHOUT W/_=WITH/_ SYMBOLS: ##=MANUAL 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 CALCULATED USING A PRESET USER THRESHOLD AMOUNT FOR THE PAINT AND MATERIAL COST. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. THE GLASS PART PRICE, KIT AND LABOR HAS BEEN CALCULATED EASED ON MARKET PRICING FOR YOUR AREA. SAFECO'S GLASS ADMINISTRATOR IS SAFELITE AUTO GLASS. PLEASE CALL SAFELITE AT 1-804-800-2727 TO ARRANGE FOR THE WORK TO BE COMPLETED. ra 05/14/2004 AT 08:48 PM 215947432015-001 25838 SUPPLEMENT OF RECORD I WITH SUMMARY 2000 GMC C2500 4X2 HD 8-5.7L—FI 2D P/U WHITE INT:GRAY ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DRIGH95 DATABASE DATE 4/2004 AND THE PARTS SELECTED ARE OEM—PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (--) ITEMS INDICATE MOTOR NOT—INCLUDED LABOR OPERATIONS. NON—ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL, AUTO GLASS SPECIFICATIONS, INC. POUND SIGN {�) ITEMS INDICATE MANUAL ENTRIES. PATHWAYS — A PRODUCT OF CCC INFORMATION SERVICES INC. 10 05/14/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GR.AY ALTERNATE PARTS SUPPLIERS 29 QUAL REPL PARTS RT FACE BAR PART NO. GM1067127P+ PRICE 23.00 30 QUAL REPT, PARTS RT FACE BAR PART NO. GM1067116P+ PRICE 19.00 35 QUAL REPL PARTS GRILLE W/O PART NO. GM1200392P+ PRICE 150.00 39 QUAL REPL PARTS RT HEADLAMP PART NO. GM2500112 PRICE 40.00 42 QUAL REPL PARTS RT PARK LAM PART NO. GM2521104 PRICE 22.00 43 QUAL REPL PARTS RT REFLECTO PART NO. GM2557101 PRICE 6.00 45 QUAL REPL PARTS RADIATOR SU PART NO. GM1225145 PRICE 180.00 65 QUAL REPL PARTS CAPA RT FEN PART NO. GM1241133P+ PRICE 93.00 70 QUAL REPL PARTS CAPA RT WHE PART NO. GM1247104P+ PRICE 65.00 KEYSTONE AUTOMOTIVE (800)263-9727 1069 HENSLEY STREET (510)234-6960 RICHMOND, CA 94801 KEYSTONE AUTOMOTIVE (800)263-9727 1045 E. TRIANGLE COURT (916)372-0287 W. SACRAMENTO, CA 95605 49 QUAL REPL PARTS RADIATOR PART NO. 52481444 PRICE 463.00 60 QUAL REPL PARTS CONDENSER 2 PART NO. 52402209 PRICE 268.00 1-800 RADIATOR HOTLINE (800)472-7016 2990 BAY VISTA CT. BENICIA, CA 94510 1-800 RADIATOR HOTLINE (800)472-7016 3 018 ALVARADO #C SAN LEANDRO, CA 94577 1-800 RADIATOR HOTLINE (800)472-7016 5821 FLORIN PERKINS SACRAMENTO, CA 95828 1.500 RADIATOR HOTLINE (800)472-7016 196 BARNARD AVE. SAN JOSE, CA 95125 1-800 RADIATOR HOTLINE (800)472-7016 825 CIVIC CENTER DR. #4 SANTA CLARA, CA 95050 II 05/14/2004 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD I WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY TIRE PARTS SUPPLIERS 2 BG O 245/70RI6 BIG FOOT AT WL PRICE: $ 130.35 TIRES PLUS PHONE: (530)753-3118 247 F ST FAX: DAVIS, CA 95616 12 05/14/2044 AT 08:48 PM 215947432015-001 15838 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2000 GMC 02500 4X2 HD 8-5.7L-FI 2D P/U WHITE INT:GRAY ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD. AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 15 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 11 13 - _ _ _ n Iq-gs dL ► , �n is<� 1-44c — se- f + R EC - f MAY 2120(14 a RED.CL DOCIMG Patient Receipt Lafayette Chiropractic Group 3455 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 voices 935-283-81.40 Fax t 925-283-8334 Tuesday April 20, 2004 Patient: JOHN RUSSCA #5141 04/20/2004 $ 35.00 98940 MANIPULATION 1-2 REGIONS 04/20/2004 $ 10.04 97010 HOT/COLD PACKS 04/20/2004 $_,.745_00 Credit card payment applied to unbilled charges Fee(s) $ 45.00 Sales Tax $ 0.00 Total Charges $ 45.00 Total Payments : S -45.00 Remaining Deduct. $ 0.00 Account Balance : $ 0.00 Current diagnosis: 847.0 LAFAYETTE CHIROPRACTIC 6 3466 ROUNT DIABLO WD SUITE 203 LAFAYETTE. CA. 94549 925-283-8149 4 Sale I ID 8010548520000046731000 64/20/04 12:20:26 Next appointment: Tuesday April. 27, 2004 3:50pm {� RPRC' C(�d�. 14161+1 inu�. �0�612 Ictal= - " Cust000r CORY THANK YOU# REC'D MAY 2 12004 RED. CL DOCIMG Patient Receipt Lafayette Chiropractic group 3456 Mt. Diablo Blvd., Ste 0203 Lafayette, CA 94549 Voice: 995-383-6140 Pax a 925-283-8224 , Tuesday May 4, 2004 Patient: JOHN RUSCA #5141 05/0412004 $ 35.00 98940 MANIPULATION 1-2 REGIONS 05/04/2404 $ 10.00 97010 HOT/COLD PACKS 05/04/2004 -$ -90.00., ... -- .Credit card-payment-applied-to-unbilled--charges Fee(s) : $ 45.00 Sales Tax $ 0.00 Total Charges : $ 45.00 ' Total Payments : $ -90.00 Remaining Deduct. : $ 0.00 Account Balance $ 0.00 Current diagnosis: 847.0 �( Next appointment: Tuesday June 1, 2004 4:30pm LAFAYETTE CHIROPRACTIC G 3466 tlSUIT D2ABLQ BLVD SUITE 283 LAFAYETTE, CA. 94549 928.293-8140 S a 5 ID: 0810548629000006731808 0810548629000006731808 05,04+84 17:09.47 �IS4 E .,�aaarra€ra�a4649 �ppr Codc 142694 Invl: 880821 Total: 190.80 Customer Copy THANK YOU+ REC'D MAY 2 12004 RED. CL DOCImG ,t OBER PONANENTEA ( CF< IgAIN lt}'ICYWACY ! Claim Cher+, 0.- 040B.? 01621 .A'' Z RUSCA JOHN A. t 2aUC64 Your Drug Renerilt MR fl: XXX3t2395 r Saved You _ 1. 70 Kaiser Flermanente Retail Price You r-Price t Rx#4 511 3182081 .r � :- ,11.x0""' -"10.00_""� { r e r ' a y- r • , � r ` r 'fir • • j • � l i• rdra�lrx F�rice: �' ,' 3.(3.00, . FIMLS Rx„ Totals" : - Taxabl-6,0iC Total: •' � ., Non-taxable UTc rotal.: - , > }" Sales Tax s. �_ . . •, obalt, 10.00 Time ins ' 605pi Ti"..out; 6=43pns 4 ( t r r t MAY 2 12004 I RED. CL DOCIMG -- -,a --•,.�i,,dSai,,., Mfn......;.$`sw..:..�..�.. i 5".{.rs?'r�'..�.'�.::`c�i`w*.�..'4.�1°-hSe.�.aaL'Lw+wre.���._,S.t —sem+ �`'.�".' 's, [1 At the be tam of this€op ate remkrdera tr some preveri W saMees hated tn►Kb€aer If you heve+�n•go m h prp llm orae th€ph rtak for MWA I+srrnarseras's tun"alectrnnic muds. KAMA uid w"Id eorma your physm a,It in eppoldm"i b 5' mors f"Unt pr t€vs serviou � d �.>Xssdosdute€t +:7672395 RUSCA JOHN A PURCHASER: 000036168/0000 APE='T TIME: 06:30 PM FAC/DEFT: WCC,/URG MEMBER TYF E t MEMBER APPT WITH: H R PATEL M.D. EFFECTV DATES: 09/01/97 — le/31/10 REG BATE 03/22/04 05:28 PM WCPI{E3 EXCEPTION: MA's REG FEE : $30.00 RED. CL DOCIMG AMT PAID : $30.00 POSSIBLE CHARGES AMT ADVANCE DrRECTIVE PLEASE REVIEW CLINIC VISIT $ 30 MED/PEI) PHY: HEGGM WCR OTHER PCP: LAB TEST $ 0 CAN MOV 03/22/04 Oa:3OP PATELHR MIC MIC WCF XRAY/IMAGING $ 0 PREVENTIVE SERVICES LAST DUE Review BLOOD PRESSURE CONTR It/OL/02 MieI/CT/PET $ 0 Current TETANUS 8/25/94 8/c5/04 Current INFLUENZA VACCINE 11 /02/94 10/21 /04 PHYS/OCC/SF' THERAPY $ 30 Current CHOLESTEROL SCREEN 9/18/02 9/18/07 Current PNEUMO VACCINE 9/04/11 SPECIAL PROCEDURES g 0 EMERGNCY DEPT VISIT* i— X20 AMBULATORY SURGERY g 50 INFERT OFFICE VISIT `/. 5U DME, OUTPATIENT % 20 MEDICAL EDUIPMENT FEE HOSPITAL. YES PRENATAL VISIT $ 0 GENERIC DRUG g Lo Return aPPOIntMent days weeks pgAntl3 WWqh, S 35 This Is*my an mstlnra*of today's charges.T�nUilt ba addtttonal fees as o resort of tits sar+rr It you nrou#d i00 I»f'orms�tlorl About your boraft*Ilmlfatione and sxcluslons Ceti Member tksrvl at 01 415 lvdey. .....� .. "Swvicis will bo rsrW*md In IEM*gsncy Deparbnent ragardtess of ability to pay. i Rpr 28 04 01 : 33p Classic Rugs Bodo (8c 5) 930-0719 P. 1 CLASSIC AUTO BODY 1401 AUTO CENTER DRIVE WALNUT CREEK, CA 94596 PHONE: (925)938-3131 FAX: (9?5) 938-(}718 LAA � �� Rpr 38 Q# 01:33p Gl»assio !auto Hods [835} 8363-17718 p.z pv� L/ lV J a.,. 1' ...�J�7;4. .... _�., t .. � ... ...,. > .I,ti;N;�., .. .-.. ,.rf,'.r}_... ..,.ii:s .,.,,•r_ . '1'•1:1 Ad . .it".•.. �'.',.. rY,i1 fp•'�''..r1M„Y.':,i• ,ir:dC.:..,,:eTA J>ili 'rltit+.•I r'et " �:; .. .. ... ..i'7@ a:iwli•' ....-MM:.r... ..: .-.. ..,.,., .. ..iii, A ..Vt I sdo*wW"notiro and omt approval of any memso in tho original oatimalad pdoo. X OT'(. D= TCAMG:(NET:lMM1 PN@%.)PAfiY{MIF GHAlifl-IS CfAtHU FF.O®Y A'FEt110t11C MTC'f5r'1.59b iKA QTY. DOT# WNTN ON LMYFAID t1ALAWL WHICH W AN ANNUAL PMENTAOE OF 514&IF NFC111.13SAW ro ,,.�,...... INNSTrtUFC L=AL ACTION TO rMORCC COLLLCTiOM t1A Twp ANICK NT VVE UNDER TM MOICL OTY, DOT# OU YrI4 AfkFdZ 1 TO PAY At r.NEN'*8U"Y omr5 AND ATTORNEY`C rtm. cOta V>waacLE RECEIVED BY -. .nLYrr.. .._ .:.. .:.:........ :•....PLEASE SIGN x _, . ........ -,OLL FREE CUSTOMER SERVICE 977-Grp-241GO 4077462.2446) NO REFUNDS ON DEPOSITS WSTOMER MUST PRESENT COPY OR INVOICE FOR WARRANTY OR SPECIAL ORDERS MAJOR BRANDS SHOCKS STRUTS ALIGNMENT SUSPENSION � T 8 ' 'o."ASa tiivf5 J:::.[ :,tom', :.1, r•;1a !:''a :;i'IC'.i...,..,... ,'',:iti(il #1 ins r ca W-23-2noto s �- k x i S b R € Zy V 'rig 6 q i Y: t` t ^, �a�a�',+x���. �: »+. '� ?. .a€,..ray_., p�'.,� � � ^ z 3x.,�,,� r� ., x�, �.but d..a3eaEm.<•"� s � � fie•.r�.,'� � .��.�- TPC SUP s rusea oto I`, Y. 3 Tl- r ux_�2 er r � ' p ^ i :. 3. } &,w &;�� �rsr✓ .z,�^c .+. aye �. a"� �.^ ���:�. ,<wk+- �a�� ,�� �� .��Ps.�.:� ���":����; ` �: � 3: TPC BUT Ins; oto lw � DI s a t 3 t .. .. - . .. � nra m. •-eae Mt Indra TPC BUT 94 Un rUSt*-U4- 24)U4 rhoto IN Noma i r= fi+ y w 7PC �uT 4s his c oio 2> r 3. y x • � ..`w b'$ _._ , Vit. 9c,a: - 'x,'e on �»F.:2x�.J4..S n o-^ ��., <LY`i.nb¢� �e�.Jl�s '�q TPC BUT man= #6 ins rusca 2 -2 oto p l: <4 s :i ,,. '� ... �� .. a iu�3'w'�''� 'w c�w,q, .y��t » :,aK 0. Ni •.� �k 9X, � .�i TPC BUT 23-2 oto r 4 dt 4» 1 g � { t ' S• TPC BUT THE CO MPA NtfSO JUL 2 004 GAS July 15, 2004 5301 CLERK OF BOARD PENNY BAILEY CONTRA COSTA COUNTY Certified Mail 651 PINE ST. MARTINEZ, CA 94553 Return Receipt Requested 7003 2260 0007 2517 5700 RE: NOTICE OF SUBROGATION DAMAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . $8232.39 DATE OF LOSS . . . . . . . . . . . . . . . . . . . . . . 03/19/04 CCS NUMBER . . . . . . . . . . . . . . . . . . . . . . . . 1.559424-3--SAUCAI CCS CLIENT . . . . . . . . . . . . . . . . . . . . . . . . AMERICAN STATES INSURANCE COMPANY CCS CLIENT'S INSURED . . . . . . . . . . . . . . JOHN RUSCA YOUR CLAIM NUMBER . . . . . . . . . . . . . . . . . 55607 YOUR INSURED . . . . . . . . . . . . . . . . . . . . . . CONTRA COSTA COUNTY, YOUR CLAIM REPRESENTATIVE . . . . . . . . . PENNY BAILEY CLAIMANT CARRIER TELEPHONE . . . . . . . . 925-335-1455 CLAIMANT CARRIER .FACSIMILE . . . . . . . . 925-335-1424 a PLEASE BE ADVISED THAT CCS REPRESENTS THE ABOVE REFERENCED CARRIER IN CONNECTION WITH THIS SUBROGATION ACTION. THEIR INVESTIGATION INDICATES THAT LIABILITY RESTS WITH YOUR INSURED. PLEASE MAKE YOUR CHECK PAYABLE TO CREDIT COLLECTION SERVICES FOR THE DAMAGES STATED ABOVE -- OR — KINDLY ADVISE THIS OFFICE IMMEDIATELY OF YOUR POSITION WITH REGARD TO THIS CLAIM. ALL NECESSARY SUPPORTING DOCUMENTATION IS ATTACHED. THANK YOU IN ADVANCE FOR YOUR ANTICIPATED COOPERATION. ****VERY IMPORTANT: PLEASE ENCLOSE THIS LETTER TOGETHER WITH PAYMENT**** PAYMENT MUST BE DIRECTED TO THIS OFFICE IN ORDER TO UPDATE OUR CLIENT'S SYSTEM(S) ELECTRONICALLY. PLEASE REMIT PAYMENT TO: CREDIT COLLECTION SERVICES SUBROGATION FINANCE DEPARTMENT P.O. BOX 451 NEEDHAM HEIGHTS, MA 02494 PLEASE DIRECT ALL OTHER CORRESPONDENCE TO THE ADDRESS BELOW. SHOULD YOU REQUIRE FURTHER ASSISTANCE, CONTACT CLAIM REPRESENTATIVE, LANI FLANIGAN AT EXTENSION 4810 P.O. Box 7249, Portsmouth NH 03802-7249 Telephone: (877) 273-0305 Facsimile: (617)762-3361 THE 175 Commerce Way I Portsmouth NH 03801 COMPANIES" M ru r, ru ..r.. to L .W rn rn �m :41. THE $ 7 AUG 0 92004 COMPANIES* 'SOP 4 August 4 , 2004 d6 LTR: 5202 CLERK OF BOARD PENNY BAILEY CONTRA COSTA COUNTY 651 PINE ST. MARTINEZ, CA 94553 RE : NOTICE OF SUBROGATION DAMAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . $8232 . 39 DATE OF LOSS . . . . . . . . . . . . . . . . . . . . . . 03/19/04 CCS NUMBER . . . . . . . . . . . . . . . . . . . . . . . . 1559424-3-SAUCAl CCS CLIENT . . . . . . . . . . . . . . . . . . . . . . . . AMERICAN STATES INSURANCE COMPAN CCS CLIENT' S INSURED . . . . . . . . . . . . . . JOHN RUSCA YOUR CLAIM NUMBER . . . . . . . . . . . . . . . . . 55607 YOUR INSURED . . . . . . . . . . . . . . . . . . . . . . CONTRA COSTA COUNTY, Zz YOUR CLAIM REPRESENTATIVE . . . . . . . . . PENNY BAILEY THIS OFFICE PREVIOUSLY NOTIFIED YOU OF CCS ' REPRESENTATION IN THE THE ABOVE REFERENCED SUBROGATION ACTION. UNLESS YOUR OFFICE IS IN A POSITION TO HONOR THIS CLAIM, PLEASE PROVIDE OUR CLIENT WITH A WAIVER REGARDING THE STATUTE OF LIMITATIONS FOR THIS LOSS . EITHER REMIT FULL PAYMENT TO THIS OFFICE BY 08/14/04 FOR THE DAMAGES STATED ABOVE - OR - THIS CLAIM WILL BE FILED WITH THE INTERCOMPANY ARBITRATION COMMITTEE WITHIN THE NEXT THIRTY (30) DAYS (IF APPLICABLE) . OTHERWISE, LEGAL ACTION WILL BE PURSUED DIRECTLY AGAINST YOUR POLICYHOLDER. THANK YOU IN ADVANCE FOR YOUR ANTICIPATED COOPERATION. ***VERY IMPORTANT: PLEASE ENCLOSE THIS LETTER TOGETHER WITH PAYMENT*** PAYMENT MUST BE DIRECTED TO THIS OFFICE IN ORDER TO UPDATE OUR CLIENT ' S SYSTEM (S) ELECTRONICALLY. PLEASE REMIT PAYMENT TO: CREDIT COLLECTION SERVICES SUBROGATION FINANCE DEPARTMENT P.O. BOX 451 NEEDHAM HEIGHTS, MA 02494 PLEASE DIRECT ALL OTHER CORRESPONDENCE TO THE ADDRESS BELOW. P.O. Box 7249, Portsmouth NH 03802-7249 Telephone: (877) 273-0305 Facsimile: (617) 762-3361 C� �J k O� et h! N N O Cr; G7 -ra d' C1: per., AMENDED ------ CLAIM .BOARD OF SUPE RVI ORS OF CONTRA COSTA COUNTY BOARD ACTION:AUCUST I7, 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 you California Government Codes. x 9e ;:" t r) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), gi Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $7,331.10s `�; ¢� A CLAIMANT: 'ANTOINETTE STEVENSON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 27, 2044 ADDRESS: 2975 DESERET DRIVE BY DELIVERY TO CLERK ON:JULY 27, 2004 EL SOBRANTE, CA 94803 HAND DELIVERED 9 BY MAIL POSTMARKED: MICHAEL FROM COUNTY COUNSEL FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETE ; Clerk Dated: JULY 27, 2004 By: Deputy II. FkOM: County Counsel. TO: Clerk of the Board of Supervisors ( fvThis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: Dated: `{ By: L-L -t° .Deputy County Cot "� III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). . (IV. ARD ORDER: By unanimous vote of the Supervisors present: 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. .Bated: OHN SWEETEN,CLERK.,By ,Deputy Clerk WARNING(Gov. code se on 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or depo, 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 Unite States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage f prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. n SWEETEN, CLERK By Deputy C r, Office of the County Counsel Contra Costa County 551 Pine Street, 9th Floor Phone: (925)335-1800 Martinez, CA 94553 Fax: (925)646-1078 Date: Ju y 2 I 5, 2004 To: Clerk of the Board of Supervisors JUL 2 7 2004 Attn: Emy Sharp, Deputy Clerk � �r ;SRI �A c4,SUPE VIs0 From: Silvano B. Marchesi, County Counsel ~� By: Monika L. Cooper, Deputy County Counsel ' P ': ? Re: Government Tort Claim - ......................................_. The attached document should be treated as an amended government tort claim. Thank you for your assistance. Please call with any questions. Attachment CONFIDENTIAL ATTORNEY CLIENT DOCUMENT Claim to: BOARD OF SOPBRVISORS OF CONTRA Cf3STA CMM INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 32, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any ether cause of action must be presented not later than one year after the accrual of the rause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Bow of Supervisors at its office in Roam 105, County Administration Building, 651 Fine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. L. 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 See. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp .AgaF st the County of Contra Costa } 411-il or lei '?004 District) Fill in name ; The undersigned claimant hereby makes alai in.,qt the County of Contra Costa or the above-named District in the sum of$ and in support of this claire represents as follows: 1. When did the damage or injury occur' (Give exact date and hour) 2. mere did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur' (Give full details; use ex ra paper if required) � �C .� ` l+�r yak W � 4. ghat particular act or omission on the part of county or district officers, servants or .employees caused, the.injury or damage? (over) Wna,t are the names of county or district officers, servants or employees causing the damage or injury's 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. _W,�J VY\ : � - k ) �D 7. How was the amount claimed a e computed' (Include the estimated amount of any prospective injury or damage QA-- Q�\k\Q, w ----------- Names and addresses of witiZasses, do tv s and hospitals. r 00-D T-'6 4j,) 9. List the expenditures you made on account of this accident or injury: BATE ITEM AMOUNT Gov. Code Sec. 910;2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) fir �by sow person on his. behalf." Name and Address of Attorney Claiman s Signature Address Telephone No. Telephone No. I VIWN W NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the sane if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the countar ,jail-for a period of not more than one-year, by a fine of not exceeding one thousand ($1,000), or by 'both such imorisoriment and finei 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. Antoinette Stevenson Re: Claim Page Two [X] 8. Other: You did not state the address where you fell. It is unclear why the County would be liable. SILVANO B. MARCHER COUNTY COUNSEL Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013x,2015.5; Evid.Code, §§ 641, 664) I am a resident of the State of California,over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On July 16,2004, I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on July 16, 2004, at attnez,California. zk��� Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 OFFICE OF THE COUNTY COUNSELSILVANo B.MA€tCHESI O COUNTY COUNSEL COUNTY OF CONTRA COSTA ��.�=,'� `�:�' Administration Building 851 fine Street, 9*f=loor SHARON L.ANDERSON Martinez, California 94553-1229 ;` �._ CHIEF AssisTANT i GREGORY C.HARVEY (925) 335-1$017 e +iddll�l VALERIE J. RANCHE (925) 848-1078 (fax) AsslsrArs NOTICE OF INSUFFICIENCY AND/OR. NON-ACCEPTANCE OF CLAIM TO: Antoinette Stevenson 2975 Deseret Drive El Sobrante, CA 94803 RE: CLAIM OF: ANTOINETTE STEVENSON Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ L The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s)causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation,the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. Page 1 APPLICATION TO FILE LATE LAIM „ 02 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA BOARD ACTION AUGUST 17, 2004 Application to File Late Claim ) NOTICE TO APPLICANT Against the County,Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Beard of Supervisors (Paragraph 111,below), California Government Code.) ) given pursuant to Government Code Sections 911.8 ote the "WARNING"below. Claimant: UCSF MEDICAL CENTER ° Attorney: VIOLA RITA BROWN C0UNTY C0U Nu E #ARTH.N CAUP. Address: STEPHENSON, ACQUISTO & COLMAN 303 NORTH CLOAKS BLVD. , SUITE 700 Amount: BURBANK, CA 91502 By delivery to Clerk on: JULY 19, 2004 1 Date Received: .JULY 19, 2004 By mail,postmarked on:1. JULY 15, 2004 1. FROM: Clerk of the Board of Supervisors TO: County Counsel t Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 20, 200ZSOHN SWEETEN,Clerk,By: DEPUTY 11. FROM: County Counsel TO: Clerk of the,11oard otSupervisors ( ) The Board should grant this Application to File Late Claim (Section 91 L6), (t, The Board should deny this Application to File Late Claim (Section 911.6). DATED: SILVANO B.MARCHESI, County Counsel,By: DEPUTY IIT. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). ( This Application to File Tate Claim is denied(Section 911.6). I certify that this a true and correct copy of the Board's Carder entered in its minutes for this date. DATE: ,I OHN SWEETEN,Clerk,By: DEPUTY WARNING (Gov. Code §911.5) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4(claims presentation requirement).See Government Code Section 946.6.Such petition must be filed with the court within six(6)months from the date your application for leave to present a late claim was denied. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. IV. FROM: Clerk of the Board TO: (1)County Counsel (2)County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,and a memo thereof has been fled and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: ' JOHN SWEETEN,Clerk,By: DEPUTY V. FROW. (1)County Counsel (2)County Administrator TO: Jerk of the froard of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM OFFICE OF THE COUNTY COUNSEL ,�.__.� SILVANO B.MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building SHARON L ANDERSON 651 Pine Street,911,Floor '� � <*� N L.ANDERSON Martinez, California 94553-1229 i SSISTANT as � GREGORY C.HARVEY (925) 335-18004110 IV\ a° VALERIE J. RANCHE (925) 848-1078 (fax) ASSISTANTS August 4, 2004 Writer's Direct Dial: C P Y (925)335-1885 Viola Rita Brown Stephenson, Acquisto & Colman 303 North Glenoaks Blvd., Suite 700 Burbank, CA 91502 Re: Services rendered to Phillip Bayless Dear Ms. Brown: This responds to your July 13, 2004 letter addressed to John Sweeten. The above referenced claim is one for money damages which requires a claim under Government Code Section 905,unless excepted by that statute. Accordingly, the claim must be filed within the time limits of Government Code Section 911.2. We disagree that this claim is covered by any limitations provision other than Code of Civil Procedure Section 342. The indebtedness you seek to recover was incurred no later than June 4, 2003. The claim was filed on June 21, 2004. It is our position that the claim is time barred. Nevertheless, we submitted your July 13' letter to the Board of Supervisors as an Application to File a Late Claim. The Board will act at its meeting on August 17, 2004, and you will thereafter be notified of the Board's Order. Thank you for your attention to this matter. Very truly yours, SILVANO B. MARCHESI COUNT''COUNSEL K Monika L. Cooper Deputy County Counsel sic LAW OFFICES OF 303 North Qlenoaki Blvd. Stephenson, Acquisto & Colman _ suite 700 4 Burbank,CA 91502 July 13,2004 (819)559-4477(P'hone', � ""+"► (818)555-5484(,Facsimile) The Board of Supervisors JL1 92004 Contra Costa County CLE soA n o sv County Administration Building NrRA COSTA Ccs S t S 651 Pine Street,Room 106 Martinez, CA 94553-1293 Attn.: John Sweeten,Deputy Clerk RE: Services Rendered to an Medically Indigent Adult of Contra Costa Patient: BAYLESS, PHILLIP I.D.: M013570051 Provider: UCSF Medical Center DOS: 05114/03-06/04/03 Total Cost: $375,746.80 Our File: 51-717565549 Dear Mr. Sweeten: I reviewed your letters dated June 25,2004. Based on your letter it appears that the County's denial was on the basis that a 6 month cut off for claims relating to a personal injury was applicable. The City's position is erroneous. Under Government Code Section 911.2, claims against public entities are required to be presented to the relevant entity within 6 months if it relates to a cause of action for personal injury or property claim, or one year of the date of accrual for other causes of action. The controlling terms here are "cause of action"and"accrual." The hospital cannot assert a personal injury cause of action, as that is an action that belongs to the prisoner/patient. Rather, the claims against the County are contractual and statutory in basis resulting from the County's obligation to provide for the medical care of its indigent population. In general, counties are obligated to furnish medical needs to indigent persons not entitled to such care under other programs. See Welfare &Institutions §1700. Thus,the controlling provision requires the submission of a claim within 1 year of the accrual of the statutory and/or breach of contract action. Under Government Code § 901,the date upon which the cause of action would be deemed to have accrued is within the meaning of the statute of limitations which would be applicable to such an action if there were no requirement that a claim be presented. Thus, under the applicable Code of Civil Procedure §337, 2. contract claims (other than oral contract)have a four(4)years statute of limitations, and the accrual date commences upon the"breach"of the contract;while statutory obligations are governed by a 3 year statute under CCP § 338. The accrual date for the latter again will commence upon the breach of the statutory obligation. In the instant case, the indigent person Phillip Bayless was provided with medically necessary services from 05/14/03-06/04/03. A bill/claim was timely submitted to the Contra Costa Indigent Program. Until the Contra Costa Indigent Program responded to the claim,there was no"accrual"of a cause of action because there was no breach yet. Our records reflect that in June 28, 2003, Contra Costa denied responsibility for the bill. Thus, it is our position that under § 901,the accrual date for the one year period to submit a claim commenced accruing on June 28,2003. Based on the above we request that the claim for damages presented to Contra Costa Board of Supervisors be reviewed, and payment issued to our client. If you wish to further discuss this matter,please contact me at the above numbers or via email at vbrown ;sacfirmonline.com. Very tru ours, UISTO & COLMAN VIOL O Attorney at Law VRB:ab LAW OFFICES OF SAC- Stephenson, Acquisto & Colman 303 North Gleneaks Blvd. Suite 700 Burbank,CA 91502 (818)559-4477(Telephone) (818)559-5484 (Facsimile) VIA CERTIFIED MAIL-RETURIN RECEIPT REQUESTER-7003 2260 0003 1805 4481 CLAIM FOR DAMAGES June 21, 2004 County of Contra Costa Clerk of the Board 651 Pine Street, I"Floor Martinez, CA 94553 RE: Services Rendered to an Medically Indigent Adult of Contra Costa Dear Sirs/Madam: In accordance with California Government Code section 900 et. sec., this letter shall serve as UCSF Medical Center's claim against the County of Contra Costa for healthcare services provided to Medically Indigent Adult Phillip Bayless. UCSF Medical Center provided authorized medically necessary services and supplies to Mr. Bayless. To date, UCSF Medical Center remains under paid for services rendered Medically Indigent Adult Bayless. A demand has been made upon the MIA Contra Costa correct this underpayment. However, to date the County of Contra Coasta has failed to pay UCSF Medical Center in full on this claim. This letter shall also serve as notice to the County of Contra Coasta of UCSF Medical Center's intention to file legal action against the County of Contra Costa if this claim is not resolved within the time set forth in Government Code section 913. Inaction on this claim will relieve UCSF Medical Center of any further resort to administrative remedies and permit immediate litigation to commence against the County of Contra Costa. The following information is relevant to this claim: CLAIMANT: UCSF Medical Center Box 0810, MCB 300 San Francisco, CA 94143-0810 Northern California Address 5700 Stoneridge Mall Road * Suite 350 * Pleasanton,CA 94588 * Telephone(925)734-6100*Fax(925)463-1805 $ orf £aP t+ 2. CLAIMANT'S REPRESENTATIVE FOR NOTICES AND ACTION: Viola Rita Brown, Esq. STEPEHENSON, ACQUISTO & COLMAN 303 North Glenoaks Boulevard, Suite 700 Burbank, California 91502 DATE, PLACE, AND CIRCUMSTANCES GIVING RISE TO THIS CLAIM: Denial Date : 06/28/03 Date of Service: 05/14/03-06/04/03 Location: UCSF Medical Center -San Francisco, CA Medically Indigent Adult/Patient: Phillip Bayless Social Security 4:553-60-5636 Balance: $207,420.80 On 05/14/03 Contra Costa County Indigent Program beneficiary Phillip Bayless presented UCSF Medical Center emergency room. UCSF Medical Center provided Mr. Bayless with medically necessary services and supplies from 05/14/03 to 06/04/03. Thereafter, a claim was timely and properly submitted to MIA Contra Costa County. On 06/28/03 UCSF Medical Center was informed that the claim needed to be split the emergency room portion of the date of service 05/14/03-05/22/0 would not be paid. An appeal was submitted and the denial was upheld in a 04/16/04 decision. To date, the above claim remains underpaid despite a request that the underpayment be corrected. GENERAL DESCRIPTION OF THE DAMAGES INCURRED TO DATE: The above listed account outstanding balance for medical services and supplies rendered to a Medically Indigent Adult eligible for the Contra Costa Indigent Program total $207,240.80. rat J. Our client desires to resolve this matter amicably and without resort to litigation. However, failure to provide payment as required may result in litigation against the County of Contra Costa as set forth above. Please send all payments to this office, making all drafts payable to STEPHENSON, ACQUISTO & COLMAN on behalf of UCSF Medical Center. Thank you for your prompt attention to this matter. Should you have any questions or comments regarding this correspondence, please do not hesitate to contact us at our Burbank office. Very t ours, ' TP�HH r� UISTO & COLMAN t BR, ' 'Wtorne'y t Law VRB:ab Enclosure: UB-92 UCSF MEDICAL CENTER. z MIA CONTRA CO 3PATIENT CONTROL NO. BOX39000 DEPT 3-9157 M-771 7965 .74!j SAN FRAM', CA 94139-9157 5 FED.Tax NO. 0 STAZ. 1w N-C D. 9 C-1 D. 10 L-A D. >> (PG 1 OF 2 415-671-1113 q4-17816571151403 1060402 1 12 1 12 PATIENT NAME 13 PATIENT ADDRESS 14 BIRTHDATE 15 SEX 18 MS 17 's. a1210 FYR6 2a '2f D HR 2P STAT 23 MEDICAL RECORD N0. gp., 31 F C 38 gENCE SPAN 7 1 (3514 » 0:4 C}4_ b MIA CONTRA CO 39 VAlt1EMmWE, . se STA 595 CENTER AVE 100 a 01 212400 ' MARTINEZ CA 94553-4529 c d' 42 REV.CO. 43 DESCRIPTION 44 HCPCS I RATES 45 SERV.DATE 48 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHANGES 44 1 120 ROOM-BOARD/SEMI 2124 . 00 8 11 1699100 2 2 0 . . . {ACU'? 791 ' .t10 13 1t�2921tt•n1 3 250 PHARMACY 1 7220 1.7 413,3,14 37 s 25`7 :. 1 '` T 5 258 IV SOLUTIONS 1 7 00 75 )0 2753 � , tipoE > 3246 {10 '; 909`10 7 272 STERILE SUPPLY 1 1.991 00 5025 )Q,, 300 ORATORY 130200 13 0 i1 302 LAB/IMMUNOLOGY 1 565642 5275 4 12 q 13 306 LAB/BACT MICRO 1 111510 f to 3.07 ' ' 1 2i. 74 14 '6 Is 324 X X-RAY/CHEST 1 297300 2575 0 312411 10" 4 - 17 370STHESIA 1 6028100 2585 0 1 . to 19 390 LOOD/STOR-PR.00 1 724911. 5725 8 11 412 INHALATION SVC 1 00 368 634 7{7 22 4': i4 '#� i '/E'VAL 1 1. �q4' ` 23 I 50 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST.AMOUNT DUE 58 A MIA CONTRA COSTA 05-0454 c f 375746 0 51L,101 304 58 WUREO'S NAME 59 PAEL 80 CERT.•SSN•HIC.•ID NO. 81 GROUP NAME 82 INSURANCE GROUP NO. A BAYLESS , PHILLIP C 01 553605636 UNEMPLOYED 999999 s c 83 TREATMENT AUTHORI7ATION CODES 85 EMPLOYER NAME 89 EMPLOYER LOCATION A Y 3 UNEMPLOYED c 87 f RIN.DlAG.CDDM loi .CODES 76 AOM.DfAQ.CD. 77 E CODE100 E 41011 199812 12874-----142731 12869 14241 14240 07054 41401. A1011 79 P.C. 80 PRINCIPAL PROCE 8f E 82 ATTENDING PHIS:iD QUE 3612 52303 360 1051403 3606 51403 49794 HOOPES CHARLES W g 11,PRGC 83 OTHER P767; 920, P51403 ,13722 051403 18856 105140d E49794 HOOPES CHARLES W a 84 REMARKS OTHER Pwxs.i A8 0 7 31 90OPES, CHARL b d X 3,Q3 ..o.._ t rc,maV CNP r.PRTIMAmmst nm TNB RPVERM APPLY TO TNM BILI AND ARE MADE A PARI KEr". UCSF .MEDICAL, ""CENTER 2 MIA CONTRA CO 3PATIENT CONTROL NO. BOX39600 DEPT' 3-91.57Q ILL STT FRAN, CA :9413 9-915? 5 FED.TAX N0. EM N 7ON R cav D. s N a D. 9 GI D. 10 L•R D, 1i (PG 2 OF 12 PATIENT NAME 13 PATIENT ADDRESS BAYLESS PT4TTJ,TP r lln-)A M.AnR Cl., BRENMMOn rA QA911 14 BIRTNDAT 15 s a 18 MS . „ 1 :::°1, 18 tYF „2i D H 22 STAT 23 MEDICAL RECORD NO. " go 31 F C=H im 327' OCCt}RR idCE 36 URREHCE'SPAN _• CODE a 0-5;4QT-: �3 b 39 VAL MIA CONT , RA COSTA UE:MOW'CO 0 CODES VAL UE AMOM 595 CENTER AVE 200 a 01 212 00 MARTINET CA 94553-4629 I c d'.. 42 REV.CD. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CiHA%ES 48 NON-COVERED CHARGES 49 1 450 EMERG ROOM 9.4 0 0 , 9 4,3„ 0 2 9 ', CARDIOLOGY 845 845 00 , 4`�,. 04 0(7 1 5 483 CHOCARDIOLOGY 1 305 00 I548. 0 ITHER /FSC 6331100 8 0 7 732EMETR.Y 1 632000 8 761z'9 940 RX SVS 1 23%0 0 10 12 14 Is is 17 �. iN pix is 20 p7. ; 21 22 23 001 MOTAL CHARGES 375? 680 20742a80 50 PAYER (51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST.AMOUNT8 DUE 5 A MIA CONTRA COSTA 05-0454 8 � C 3?5?46 OLIO a i 304 50 INSURED'S NAME 59 P.REL 60 CERT.•SSN-HIC.-ID N0, 51 GROUP NAME 82 INSURANCE GROUP NO. A BAYLESS ,PHILLIP C 01 553605636 UNEMPLOYED 999999 c 03 TREATMENT AUTHORIZATION CODES 64M 65 EMPLOYER NAME 98 EMPLOYER LOCATION A Y 3 UNEMPLOYED C 07 PRIM.DIAG CD ; tk7D 76 ADM.DIAD.CD. 77 E-CODE 41011 99812 2874 42731 2869 4241 4240 07054 41401 ,,:41.011 79 P.C. 8o PRINCIPAL PROCEDURE 141,OWE DATE 1. ' 82 ATTENDING PHYS.'lp '3612 52303 601'. 51.403 3606 1051403 49794 HOOPES CHARLES W oTrIE 53 bTti R PHY$>} 920: 51403 13722 51443 188551403 V49794 HOOPES CHARLES W a 84 REMARKS t?tHR fYS 8 0 7 31 HOOPES CHARL b C OSPAOVM AMMENTATIVE> Dk d 073003 :" nu»s VMMARe AM m MR mi 3 AM AW UAM A aun UPROAR ......... ......... ......... ......... ......... ..................................... . ............................................................................................................................................................................................................................... _.... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... _ _. ......... ......... ........_...._ {Sri ui N UJ Cie". z