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HomeMy WebLinkAboutMINUTES - 09142004 - C28 CLAIM man BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTIONBEPTDIBER 14, 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 915.4. Please note all"Warnings". AMOUNT: UNKNOWN UG 0 3 200 CLAIMANT: TERRY D. BULLE'R COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: TERRY D.`'BULLER DATE RECEIVED: AUGUST 02, 2004 ADDRESS: 1418 LAKESIDE DRIVE BY DELIVERY TO CLERK.ON:AUGUST 03, 2004 OAKLAND, ;CA 94612 RECEIVED THROUGH BY MAIL POSTMARKED: INTER OFFICE MAIL FROM RISK MAMA FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 03 2004.. JOHN SWEET Dated: r By: Deputy IT FROM: County Counsel, TO: Clerk of the Board of Supervis rs { } This claim complies mplies 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:�-' eq e L , Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { } Claim was returned as untimely with notice to claimant(Section 911.3). VOARD 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: T 4 JOHN SWEETEN,CLERK, By ,Deputy Clerk WARNING(Gov. code sect i 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:SE 1, 1 JOHN SWEETEN,CLERK By Depur- OFFICE Of THE COUNTY COUNSEL s_AL SILVANO B.MARCHESI 'COUNTY OF CONTRA COSTA , - t) , COUNTY COUNSEL Administration Building *,♦• SHARON L. ANDERSON 651 Pine Street, 911, Floor CH#EF A55#STANT Martinez, California 94553-1229 } } ! � `� GREGORY C. HARVEY (925) 335-1800 b. .,,>.Mintt VALERIE J. RANCHE (925) 646-1078 (fax) t F} k3 ' A55#STANr5 y ♦t. t♦;Yq NOTICE OF UFFICIENCY AND/OR NON-ACCEPTANCE-OF CLAIM TO: Terry D. Buller 1418 Lakeside Drive Oakland, CA 94612 RE: CLAIM OF: TERRY D. BULLER 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: j ] I. The claim fails to state the name and post office address of the claimant. j ] 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. j ] 4. The claim fails to state the name(s)of the public employee(s) causing the injury, damage, or loss, if known. [X] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage oy 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. [XJ 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 6 Terry D. Buller Re: Claim Page Two ] & Other: SILVANO B. MARCHESI COUNTY COUNSEL By:— Z y Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ.Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 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. On August 4,2004, 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 August 4, 2004, a�t�Martinez, California. ./1/41-6? �/ Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 �X LAW OFFICES "PERRY D BULLER PROFESSIONAL CORPORATION THE CAMRON- STANFORD HOUSE HAROLD L.STROM 1418 LAKESIDE DRIVE CHRISTINA PONTIFLET 1915.2004 NOELLE MEEKS OAKLAND,CALIFORNIA 94612 PARALEGALS (510)832-4295 FAX(510)832-4364 July 28, 2004 Contra Costa County Risk Management Department 2530 Arnold Drive, Suite 144 Martinez,CA 94553 Re: Terry D. Buller Date of Accident: 5/34/04,between 12:00-1:00 p.m. Location of Accident: Danville Blvd. approx. 200 yards south of Livorm To Whom It May Concern: I am writing because of a bicycle accident that occurred on May 30, 2004 in which I was involved and seriously injured. While proceeding northbound on Danville Blvd., approximately 200 yards south of the intersection with Livorna Road, my bicycle struck a pothole,turning the front wheel sharply to the right, and throwing me to the left onto the pavement. I have enclosed photos of the location which were taken approximately two weeks following the incident. As you can see from the photos, the pothole was filled in sometime after this incident and before the photos were taken. I sustained several fractured ribs,punctured lung and spent six days at Summit Hospital in Oakland. I would appreciate if you would turn this matter over to the claims department and have them contact me at their earliest convenience. I have been instructed to send this claim to you as the City of Alamo is unincorporated, therefore,has no city office. Sincerely, Terry.D. Buller TDB/cp ffJ j .s:: ttf t t r .:f ` , Al t: ............. t t s .. f.. '� f t t. M1 f . ...i:i:;:f .. :. <, it f F f' ft . f ; { t s fr .. ;. ., .,.. .. .. . ... ii if r S �fff ;d l f fff -J. l ff r i� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �, + BOARD ACTION:SEPTEMER 14, 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 Beard of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and a note all"Warnings". AMOUNT: $326,080.00 - Not less thanAi �27094 CLAIMANT: COREY AMORE PINKINS COUNTY C;OUNESEL MARTINEZ CALIF ATTORNEY: NICHOLAS W. HORNBERGER, ESQ. DATE RECEIVED: AUGUST 02, 2004 ADDRESS: HORNBERGER & BREWER LLP BY DELIVERY TO CLERK.ON:AUGUST 03, 2004 ST 444 SOUTH FLOWER, EET, STE. 301.0 LOS ANGELES, CA 90,071 BY MAIL POSTMARKED: JULY 30, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 03 2004 JOHN SWE Jerk Rated: By:; Deputy IT FROM: CountyCounsel, TO: Clerk of the Board of Supervisors vy { 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 Counsel III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) { ) Claim was returned as untimely with notice to claimant(Section 911.3). IV { BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: "` 14. JOHN 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 Warming See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:' �. ,�,... JOHN SWEETEN, CLERK By Deputy Clerk 1 Claim to: BOARD 8F SUPERVISORS OF CONTRA COSTA COUNTY JN&J=n0NS TQ-CL 24ANI A. Claims relating to causes of action for death or for injury to person or to personal prOperty or growing crops and which awe on or before December 31, 1987, must be presented not dater 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 moss after the accrual oft the cause of action. Claims relating to easy other cause of actio must be presented not later than one year after the accrual of the case of action. (Gov't Code 911.2.). B. Claims must be filed with the Clerk of the Board of Supervisors at its,6f itr its Room 1€16,County Administration Building, 651 Pine Street„.Martinez, CA 94553, C_ If claim is against a district governed by the Board of Supervisors, rasher 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. aud. See penalty for fraudulent claims,Penal Cade Sec. 72 at the end ofthis form. tsstttttr�tt+�s3kisttts►sc+t*,stress***sits+s4stt��trtt*s+rte►Rtss�s*kesttr*t1sMtttse�r�ss��cst*t+�,tt:# RE: Claim By Reserved for Clerk's filing stamp COREY ANDRE PINKINS � 2822 14th Street, #3 RECEIVEDFBOARD San Pablo, CA 94806 '} Against the County of Contra Costa or � Z004 � Not applicable District) (Fill in name) UPERVISORS The undersigneclaimant h� by makes claim against the County of Contra Costa or the above-named district in the sum ofd X26 ,Wein support of this cairn represents as follows: 1. When did the damage or injury occur?(Give enact date and#sown February 11, 2004 at approximately 11.00 a.m. 2. 'What did the damage or injury occur'. dude city sand ccssmty) on property owned, maintained and controlled by Contra Costa County and its employees, agents and contractors, contiguous to a Union Pacific Railroad right-of-way at or near theunction of Union Pacific and Burlington Northern & Santa Fe Railroad Co. tracks in the City � of Richmond, County of Contra Costa, State of California. 3. How dad the damage or injury ratter?(Grivo full details;use extra paper if required) See Attachment,, 3.attached hereto and made a part hereof by this reference. 4. 'What particular act or omission on the part Ofcounty or district officers, servants,or employee&caused the injury or damage! See attachment 3-attached hereto and made a part .hereof by this reference. S. What at the names of county or district officers,aarvants, or employees causing the damage or injury? Investigation into the facts and circumstances of this accident is continuing. Employees, agents, contractors and representatives of Contra Costa County. 6. What damage or injuries do you ciairn resulted?(Give full extent of injuries or damages claimed, Attach two estimates for auto damage.) .Claimant sustained massive internal injuries and was placed in intensive care for 3 days .and hospitalized in total for 18 days during which time he underwent surgical repair of the tibia with nailing. ?. How was the amount claimed above computed?anclude the estimated amount of any prospective injury or damage.) The amount stated in the first complete paragraph before Item I was obtained by totalling known medical expenses as of this time, this amount is a minimum amount and includes no amount for pain and suffering, loss of earnings and earnings' capacity. g. Names ani!addresses of witnesses, doctors, and hospitals. John Muir/Mt. Diablo Health System, Post Office Box 39000, Department 33370, San Francisco, CA 94139 9, List the expenditures:you made on account of this accident or injury. DAs.. I A, QMT 2/11/04--3/1/04 n/a $316,515 2/11/04 n/a 1,250 2/11/04 n/a 8,314 r+��rt*+�r:*s#�+r*#r►s**err*awe,w*#rts*y#�*+�t�rr�3*�tr�#ss**1�rr�t�r�w�*.Rus*#s+��r#sir*�+�*sfys*t**t**#r,r�r* ) Gov.Code Sec. 910.2 provides"`The claim must be signed by the claimant or by some parson on his behalf." o Name and Address of Attorney � NICHOLAS W. HORNBERGER, ESQ. A LA } HORNBERGER & BREWER, LLP } 444 south Flower Street, (Clttirnartt's Signature) Ste. 3010 � NICHOLAS W. HORNBERGER, ESQ. FOR Los Angeles, CA 90071 Corey Andre Pinkins Wdress) 444 S. Flower Street, Suite 3010 } Los Angeles, CA 90071 Telephone Nm {213) 488-1655 )Teleph011eN0.,_„213) 488-1655 WIMCE Section 92 of the'Pet*J Code provides: Every person obo,with k t m is ddmud,prt�s au for atfoaance or the prjmat to any darte'beard or officer,or to any w=IY.citY,or distinct board oroffloer,au*wrixed to slloW nr pay tt am it pftli e,ny Me or ft udulastt claim,bA Wit, voKbet,or vnitia&is puWdabtt either by imprisa mirtttbt the txttsrtty;jail hr a'period of slot more than we year.by a Bents of luau VM4&X8 We fho3t A4(z i.OWX of by barb such impeisw unit sari f",os,or by ftttpristmmestt is the state prism,by a fou of oot .......+:«..*••"'kM*e2"t1t Antlarc(110.0W L or by bout such ivo rfilmmettt and fes. ..............................................................-..................-........I...........I............................................. Attachment to Paragraph 3 Board of Supervisors of Contra Costa County Claim Claimant, Corey Andre Pinkies, was a pedestrian trespasser who, while walking along unfenced, unguarded and negligently maintained property owned, maintained and controlled by the County of Contra Costa and its employees, agents and contractors, was struck by Amtrak on- track equipment and sustained numerous injuries and required hospitalization from which Claimant incurred damages to his detriment. By leaving open and unobstructed access through open fencing to property under the ownership, control and maintenance of Contra Costa County, Contra Costa County knew or should have known, that said property would become an attractive nuisance to individuals seeking a 'short cut' through an unfenced, highly dangerous area rather than walking substantially further on nearby streets to reach residential properties surrounding the accident site, had appropriate fencing been in place. [Claim of PinkinsJ ATTORNEYS CX AT LAW ' � S 444 SouTH Ft.owx STREET,SUITE 3010 5 AU'! � WEBSITE:wwvv.hgblaw.com Los AxG Es,CALtFoRNIA 90071-2901 (213)488-1655 FwcstMtt$(213)458-1255 ORANGE COUNTY OMCE 19200 Vox KARmANAvmquR,St3 m Ft om 1xv K CAt.womatA92612 (949)622-5466 LETTER OF TRANSMITTAL July 30, 2004 To: Clerk, Board of Supervisors Contra Costa County Room 106, County Administration Building 651 Fine Street Martinez, CA 94553 From: Carole McSweeney, Law Clerk Subject:. Claim of Corey Andre Pinkins Document(s): original and three copies Comments: For necessary action. Please return a conformed copy of the Claim after filing. A stamped, self-addressed envelope is enclosed. 4 ti O c+'d Cz Oz H L 'C fir.,., td] Cil 0 e� . rrrwwrwrrrn` .A 0 (� 0 y iwrrrrwrw+ m cd o Ir �wlrwrr�r�ir�.� rA rm J'`i 0 � o ^y �[t��� y h �Y, k v, < JV 0 uj LL W L4 o � CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: SEF'. 14, 20€ 4 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 tW� , Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $350.00 A'U G 4 2,0;.i4O a CLAIMANT: MOHINDER SINGH COUNTY INE UNSEL ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 04, 2004 ADDRESS: 800 EDWARD WERTH DRIVE BY DELIVERY TO CLERK ON:AUGUST 04, 2004 RODEO, CA 94572 BY MAILPOSTMARKED: HAND DELIVERED FROM: Clerk of the Board.of Supervisors TO: County Counsel Attached is a copy of the above-noted claim.. JOHN SW T Jerk AUGUST04 2004 Dated: By: Deputy II. MOM: County Counsel. TO: Clerk of the Board of Su ervis6is (-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 warming of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: Dated: L - ' By, �. Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IV./BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: t EP 1 JOHN 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 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 ofpe&ry 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 Carder and Notice to Claimant, addressed to the claimant as shown above. Dated: SP 15 20H, JOHN SWEETEN, CLERK':By Deputy Clerk Clain to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not Later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing craps and utich accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. ' Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim BY } Reserved for Clerk's filing stamp ;'t ? RETIED } Against the County of Contra Costa } AUG 4 2004 or } District) 4E`?K 8(3Ai ?r1r SuPSRVISORS .)STA CO. 7= in name } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of 350and in support of this claim represents -as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? Give full details; use extra paper if required) Ccctz dwrem Wott C&-'a-0 Irf �-� ' a 4. What particular act or omission on the part of county or district officers, servants or .employees caused. the.injury or damage? wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 9ac/< do (as 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 3. Names and addresses of witnesses, doctors and hospitals. r rnue s=�g� Gr ua�� -a goo Cojkpleo r. R-ftt , � Ot t �� s-72 9. List the expenditures you made on account of this accident or injury: DATE AMOUNT 415S 3S-0 Gov. Code Sec. 910;2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney)--- or b, -some g2Eson on his.behalf." Name and, Address of Attorney C1" is Signature Address -9(3 1)Lo Cry ( - Telephone No. Telephone No. :Std NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisont in the county jail for a period of not more than one-year, by a fine of not exceeding one thousand ($1,000)t or by both such imprisonment and fine; or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($101000, or by both such imprisonment and fine. ALL GLA5S CO , 12517 SAN PABLO AVE . k not RICHMOND, CA 94805 ( 510)232-7444 j -TYPE FAX# ( 510033-4947 � - QCs ICS# 20-0818141 ':1,�_1 - - -- SINGH 800 EDWARD WER`t`H DR RODEO , CA 94572 L — HJsl0—;?99--`. 999 Wk II £ VAN ' -:-�`_"" _... -•-__ __ __ .._.moi _._...__ _..... s .__.__.._.. Og, E '• ....;....,...::ez_. f'i#`'�(-- 3F��ir F-Y #sd....�,. �.� £3E..f.. Us"", :'� 1 MEASUREMENT 0.00 000 0-7-66M) i 7 _-7 1 } TOTAL LABOR (NON—TAXABLE ) 0 .00i -00 �r f s. } iC#fit.##fw rtl U{TECtNl,= A I M,3 erto rad{.c Of t##�> !#'vo ce, is guaranteed to be as wettled, and isf C c >a,etyz glazed materiFl unless � �t sol marked. It is acrid vMh he undorshndirsg that this mat ria# MP n,_# tet Vann iin a ~azard,us, €e ca.ta '' as domed by me conS:u+rer pmduct saloy fti. -nerchandise returned fifer Credit, f-ef Y c£ exchange e m st be in resaeablc unditi.en, fc f ret;;rn, acc-ampamed bye this receipt, a..: may b ,aai.bjiect w iCSMing `ea Nf, returns ii. be authorized fc.r TOTAL. .00 specia-1 orders or cut flat glass. 'Terms W payment are 010 days €om irwoke data. A service charge s { of l .8 %.per mi)n:,h; 21 Znnurr;;wilt be sawed W pmt He aUco t:s. � :w;Ak r ' 0.00 RECE EU Sy. g ass f sac ;,as teen x �j r #r.. 2 sv istira s ,p..:� .;?�:•a,� f-.., 'F..,cu,, a.:i2c're,a_o , �.,_,.o .,ony ar .:r�k y �E A df_ 5+ 905 Gr. "Awl'a,a:cn•Iza acs n sS3at s. _ -- _. _�__1 ...........................................................................................................................................................................''I'll, ........................................................................................... CLAIM 8!2ARD OF SUPERVISORS OF QQNTRA COSTA COUNTY e. 0 BOARD ACTION;.SU_TDQERA4,i2 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section reference410-- �,-,R'17 The copy of this document mailed to you is your California Government Codes. Pi notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given ,UGf k Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings cou,Nrf COUNIISE�Z,-, AMOUNT: IN EXCESS OF $10 00J, CLAIMANT: KEVIN HOLLINS DOROTHY HOLLINS fSpouse of Kevin Hollins) ATTORNEY: ROBERT S. ARNS DATE RECEIVED: AUGUST 05, 2004 ADDRESS- THE ARNS LAW FIRM BY DELIVERY TO CLERK ON:AUGUST 05, 2004 515 FOLSOM STREET, 3rd FLOOR HAND DELIVERED BY SAN FRANCISCO, CA 94105 BY MAIL POSTMARKED: AGOSTINHQ TRGL.EZI FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE erk Dated: AUGUST 05, 2004 By: D2EIty— II. MOM: Co7tyCounsel, TO: Clerk of the Board of Supervisors {,,,}�"'This claim upe Misorsclaim 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 Counsel III. FROM: Clerk ofthe Board TO: County Counsel(1) County Administrator(2) Claim was returned as untimely with notice to claimant(Section 911.3). IV OARD ORDER: By unanimous vote of the Supervisors present: ( B 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: ;%P 14 201 JOHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code section;§1 3) 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: JOHN SWEETEN,CLERK By Deputy Clerk .............. ................................. "El +CLAIM AGAINST PUBLIC ENTITY ��2 TO:3 ISORS4CLERK TO THE SAN RAMON UNIFIED SCHOOL DISTRr 699 Old Orchard Drive 5 Danville,CA 94526 6 Phone: (925) 552-5504 7 CLERK TO THE CITY OF SAN RAMON 8 2222 Camino Ramon, San Ramon, CA 94583 Phone: (925) 973-2530 9 Fax.: (925) 856-0547 10 CLERK OF THE BOARD OF SUPERVISORS i 1 651 Pine Street, Room 106 Martinez, CA 94553 12 (925) 335-1900 13 24 PLEASE TAKE NOTICE that the undersigned hereby serves and makes a 15 demand upon you for the cause and amounts set forth in the following claim: 16 Claimants Names and Addresses: 17 KEVIN HOLLINS,AGE 42 �$ DOROTHY HOLLINS (SPOUSE 19 OF KEVIN HOLLINS) 1600 Aster Drive,Apt. 34 20 Antioch, CA 94509 21 (925) 745-7172 22 Claimant's Mailing Address To 'Which Notices Are To Be Sent: 23 The Ams Law Firm 24 Robert S. Arns, State Bar No. 65071 25 Jonathan E. Davis, State Bar No. 191346 515 Folsom Street, 3rd Floor 26 San Francisco, CA 94105 27 phone: (415) 495-7800 Facsimile: (415) 495-7888 28 gov.entity claim.doc 1 PRAYER FOR RELIEF 2 3 First Cause of Action Negligence 4 l. Claimants requests payment of all special damages. 5 6 2. Claimants requests all general damages according to proof. 7 8 3. Claimant Dorothy Hollins requests all damages as a result of her loss of consortium. 9 10 . REQUEST FOR INFORMATION 11 If any public entities named above is aware of any other public entity, division, 12 13 department or sub-department that has any responsibility, oversight, control or 14 involvement with the subject incident that is not named on this claim form, claimants 15. requestimmediate notification so that the claim form may be sent to that entity. 16 17 18 DATED: July 27, 2404 THE ARNS LAW FI 19 20 By: 21 A. ARNS 22 At rn ys for Claimant 23 24 25 26 27 28 -4- gov.entity claim.doc Amount of Claim: z Claimant has a claim based upon the negligence of Defendants. Claimants is 3 4 informed and believes that such losses are in excess of$10,000. Therefore, pursuant to 5 Gov. Code section 910(f) no amount shall be stated. 6 All damages for all claimants are in excess of the jurisdictional minimum of the 7 8 Superior Court for unlimited jurisdiction. 9 Date and Occurrence Giving Rise To The Claim Asserted: 10 TIME OF INCIDENT: 11:10 a.m., February 25, 2004 11 12 PLACE OF INCIDENT: SR-24, Rumford Freeway, West Portal Caldecott 3 Tunnel 14 LEGAL LIABILITY: is CLAIM NUMBER ONE: NEGLIGENCE OF A PUBLIC ENTITY 16 17 1. That at said time and place, as aforesaid, the above-mentioned Public Entities, and 18 each of them, owed a duty of reasonable care toward Plaintiff and others based upon 19 above-mentioned Public Entities ownership, possession, operation and maintenance of til the subject 1992 Ford E350 Yellow School Bus, License Plate Number 366456 21 22 2. At all times relevant to this claim, Dorothy Hollins has been the legal spouse of 23 Kevin Hollins, 24 Zs 3. Additionally, said duty is based on the requirements of Civil Code §1714 requiring 26 27 all persons to act in a reasonable manner toward others. 28 _2_ gov.entity clairn.doc t 1 4. The above-mentioned Public Entities, and each of them breached said duty by 2 negligently, carelessly and recklessly inspecting, maintaining and operating 1992 Ford 3 4 E350 Yellow School Bus, License Plate Number 366456. s 5. As a direct and legal result of Defendant's aforementioned conduct, while Plaintiff 6 7 was driving in the Nest Portal of the Caldecott Tunnel on the Rumford Freeway, traffic 8 slowed and the 1992 Ford E350 Yellow School .Bus, License Plate Number 366456, operated by Kelly Lynn Martin, a employee of Defendant, failed to stop and crashed into to 11 the rear of Claimant's car causing Claimant Kevin Hollins personal injuries and 12 emotional distress requiring hospitalization. 13 DAMAGES: 14 is As a direct result of this incident, Claimant Kevin Hollins suffered personal 16 injuries and emotional distress. Claimant is informed and believes that such losses are 17 18 greatly in excess of $10,000. Therefore, pursuant to Gov. Code section 910(f) no i g amount shall be stated. 20 As a direct and legal result of this incident, Claimant Dorothy Hollins has 21 suffered a loss of consortium. Claimant is informed and believes that such losses are 22 23 greatly in excess of $10,000. Therefore, pursuant to Gov. Code section 910(f) no 24 amount shall be stated. 25 26 27 28 _3_ gov.entity ciaim.doc CLAIM BOARD OF SUPERVIS RS OF CONTRA COSTA COUNTY BOARD ACTI0N;SEP13 8ER 14, 2M 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 3 ;y <� Pursuant to Government Code Section 913 and l 915.4. Please note ail"Warnings". AUGr AMOUNT: UNKNOWNf € r: CLAIMANT: REGINA TAMAYO ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 05, 2004 ADDRESS: 149 N. CATAMARAN CIRCLE BY DELIVERY TO CLERK ON: AUGUST 05, 2004 PITTSBURG, CA 94565 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO County Counsel Attached is a copy of the above-noted claim. JOHN SWE C erk Bated: AUGUST 05, 2004 1 By: Deputy 11. ]MOM: County Counsel TO: Clerk of the Board of Su 'sors (This claim complies substantially with Sections 914 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: 4 k Dated: " Cf $y: Deputy County Counsel Ili. 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: (N4 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: SEP 14 2004 JOHN SWEETEN, CLERIC., By , Deputy Clerk WARNING(Gov. code secti 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 1'8; and that today I deposited:in the United States Postai Service in Martinez,California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. JOHN SWEETEN, CLERIC.By Deputy Clerk ... _ . .._ ..... .... ....................... _. ... .._... Claire to: BOARD OF SUPERVISORS O7F CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property; or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for_death or for injury to person or to personal property or growing amps and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its .office in Room 106, County Administration Building, 651 Fine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the 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 ) AUG) 5 2OQ4 , RD OF SUPERVISORS District) h ; RrAc Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum sof $ and in support of this claim represents-as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2 26 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) . n 'D vvG�S 4. What particular act or omission on the part of county or district officers, servants or .employees caused.the. injury or damage? 'w �. wnat are the names of county or district officers, servants or employees causing the damage or injury? .�113 OYTY)l C� .Q i`1Cs.i'3 til r ��,�K. Ali L P i ~� Q34;;S 5 What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. rNames and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident : nt or injury DATE ITEM Gov. Code Sec. 910;2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or erson on his.behalf Name and Address of Attorney :4 Lz -- ClaiZan Address Telephone No. 3�- Telephone No, 1 * * * * NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for,'a13.owance 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 waiting, 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,L00?, or by both such imprisonment and fine;-or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,004, or by both such imprisonment and fine. Date: 111412004 11:35 AM Estimate ID: 808 Estimate Version: 0 Preliminary Profile ID: CUSTOMIZED EAST BAY AUTO BODY REPAIR 620 GARCIA AVE#S PITTSBURG,CA 94565 (9261473-1876 __ _ Fax: (925)473-0786 EAST BAY Damage Assessed By. MIKE SAYECtI AliTo BODY REPAIR y . Custom Paint & Frame Deductible: UNKNOWN insured: TAMAYO!HECTOR Address: 149 CATAMARAN CIR PITTSBURG,CA 94566 I II Telephone: dome Phone-- (326)432-4909 MIKE SAYEDI 620 Garcia Ave., Unit B Ph: 925-473-1876 MitchellService: 914626 Pittsburgh, CA 94565 Fax: 925-473-0796 Description: 2001 Ford ExplorerSportTrac Body Style: 413 Ut Drive Train* 4,01.Inj 6 Cyl 4WD VIPs: 1 FMZU77E01 UA81996 Options: ALUMIALLOY WHEELS,AIF!CONDITIONING,POWER WINDOWS,POWER DOOR LOCKS CRUISE CONTROL,AUTOMATIC TRANSMISSION,AM-FM STEREOICDPLAYER(SINGLE) Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 400200 FRM REPAIR FRAME ASSEMBLY -F Existing 4.6* 2 401055 REF REFINISH L BED OUTER PANEL C 2.2 3 401142 BOY REMOVE/INSTALL R REAR COMBINATION LAMP 0.2 4 931106 BOY REMOVE/INSTALL SEDLINER Existing 0.8* 5 401143 BOY REMOVEIINSTALL L REAR COMBINATION LAMP 0.2 6 AUTO BOY OVERHAUL REAR BUMPER ASSY 1.4 7 402366 BOY REMOVE/REPLACE R STEP PACs 0.2 8 402367 BOY REMOVEIREPLACE L STEP PAD 0.2 9 401162 BOY REMOVEIREPLACE REAR BUMPER COVER 31-2Z 17K83S AAB 415.87 INC 10 401163 BOY REMOVEIREPLACE R REAR BUMPER STEP PAD 1 L5Z 178807 AAS 18.57 INC 11 401164 BOY REMOVEIREPLACE L REAR BUMPER STEP PAD 1L5Z 17SO07 SA 18.57 INC 12 401185 BOY REMOVE/REPLACE REAR BUMPER REINFORCEMENT 1L5Z 17906 AA 455.52 INC 13 401823 BOY REMOVEIREPLACE R REAR BUMPER STUD PLATE 1 LSZ 17CS79 AA 38.58 INC 14 401824 BOY REMOVEIREPLACE L REAR BUMPER STUD PLATE 1 L5Z 17C979 AA 38.58 INC 15 401166 BDY REMOVEIREPLACE REAR BUMPER HITCH PLATE 1LSZ 17D826 AA 74.47 INC 16 401167 BOY REMOVEIREPLACE R REAR BUMPER BRACKET 1LSZ 17E986 AA 24.53 INC 17 401168 BOY REMOVEIREPLACE L REAR BUMPER BRACKET 1 L5Z 17ES87 AA 24.53 INC 18 401169 BOY REMOVEIREPLACE R REAR BUMPER MOUNTING ARM 1 L5Z 17787 AS 34.87 INC 19 401170 BOY REMOVEIREPLACE L REAR BUMPER MOUNTING ARM 1L5Z 17788 AA 34.87 INC 20 401827 BOY REMOVEIREPLACE REAR BUMPER TOW BALL COVER 1 L5Z 1713754 AAA 3.27 INC 21 936007 ADD'L COST" SHOP MATERIALS 8.00* 22 AUTO REF ADD'L OPR CLEAR COAT 0.9 23 933003 REF ADD'L OPR TINT COLOR 0.5* 24 933006 FRM ADO L OPR FRAMEIRACK SET UP 2.0* 25 933018 REF ADD'L OPR MASK FOR OVERSPRAY 5.00* 0.3* 26 AUTO ADD'L COST PAI€VTIMATERIALS 88.40* 27 AUTO ADD`L COST HAZARDOUS WASTE DISPOSAL 5.00* ES'CIMATE RECALL NUMBER: 814/200410:41:10 808 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: 8t 41200411:35 AM Estimate ID: 808 Estimate Version: 0 Preliminary Profile ID: CUSTOMIZED * -Judgement Item C-Included in Clear Coat Calc Add'I Labor Sublet I. La tior Subtotals Units Rate Amount Amount Totals It. part Replacement Summary Amount Body 3.0 68.00 0.00^ 0.00 204.00 Taxable Parts 1,183.33 Refinish 3.9 68,00 5.00 0.00 270.20 Sales Tax tL'b' 8.250% 97.62 Frame 6.5 62.00 0.00 0.00 403.00 Total Replacement parts Amount 1,280.85 Non-Taxable Labor 877.20 Labor Summary 13.4 877.20 fit. Additional Costs Amount IV. Adjustments Amount Taxable Costs -94.40 Customer Responsibility 0.00 Sales Tax 8.250% 7,79 Non-Taxable Costs 5.00 Total Additional Costs 107.19 I. Total Labor: 877.20 It. Total Replacement Psrts: 1,280.85 Iii. Total Additional Costs: 107.19 Gross Total: 2,265.24 lV. Total Adjustments: 0.00 Net Total: 2,265.24 This is a preliminary estimate. Additional changes to the estimate may be required-for the actual repair. Z HEREBY AUTHORIZE THE REPAIR WORK TO BE DONE ALONG WITH. THE :NECESSARY PARTS AND MATERIALS. AUTHORZEZED SINGATURE__.._—___w_—_—_—______—..__..___—__—____-----DATE_______--- : ESTIMATE RECALL NUMBER: 814/2004 10:41:10 808 UltraMate is a Trademark of Mitchell International Mitchell Data Version: JUL_04_A Copyright(C)1994-2003 Mitchell international page 2 of 2 UttraMate Version. 5.0.024 All Rights Reserved 08/04/2004 at 09: 42 AM Job Number: 19377 JESS HERNANDBZ BODY SHOP & TOWING License #:AD188279 Federal. ID #: 680413927 AS GOOD AS ANY BET'T'ER THAN MANY 107 BLISS AVE. E-MAIL JHTOWINGCAOL.COM PITTSBURG, CA 94565 (925) 432-3000 Fax: {925} 432-7588 PRELIMINARY ESTIMATE Written By: MARIO HERNANDEZ Adjuster: Insured: REGINA TAMAYO Claim # Owner: REGINA TAMAYO Policy # Address: 149 CATAMARAN CIR. Deductible: PITTSBURG, CA 94565 Date of Loss: Business: (925) 434-4909 Type of Loss: Point of Impact: 6. Rear Inspect Location: Insurance Company: Days to Repair 2001 FORD EXPLORER 4X4 SPORT TRAC 6-4 . OL-FI 4D P/U BLACK Int: VIN: 1FMZU77E0IUA81996 Lie: 6K25219 CA Prod Date: Odometer: Air Conditioning Intermittent Wipers Body Side Moldings Dual Mirrors Privacy Glass Luggage/Roof Rack Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag Cloth Seats Captain Chairs (2) Automatic Transmission Styled Steel. Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H rear bumper 1 . 6 3 Repl Bumper cover 1 415. 87 Incl. 4 Repl Bumper 1 456.52 Incl . 5 Repl Hitch plate 1 74 . 47 Incl. 6 Repl RT Step pad medium titanium 1 18 . 57 Incl. 7 Rept LT Step pad medium titanium 1 18. 57 Incl. 8 Repl Bumper stud plate 1 38 . 58 Incl. 9 Repl RT Bumper bracket 1 24 . 53 Incl . 10 Repl LT Bumper bracket 1 24 . 53 Incl. 11 Repl RT Bumper arm 1 34 . 87 Incl . 12 Repl LT Bumper arm 1 34 . 87 Incl. 13 FRAME 14 Repl Tow hook brkt 1 164 . 29 15# FRAME/UNIBODY SETUP & GAUGE 1 1 . 5 F 1 08/04/2004 at 09: 42 AM Job Number: 19377 PRELIMINARY ESTIMATE 2001 FORD EXPLORER 4X4 SPORT TRAC 6-4 . OL-FI 4D P/U BLACK Int: -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ----------------------------------------..__------------------------------------ 16# Rpr REPAIR LT. HORN 1 .0 F 17# Repl REPAIR RT. HORN 1 1 .0 F ------------------------------------------------------------------------------- Subtotals =_> 1305 . 67 5 . 1 0. 0 Parts 1305 . 67 Body Labor 1 . 6 hrs @ $ 68 . 00/hr 108 . 80 Frame Labor 3. 5 hrs @ $ 75 . 00/hr 262 . 50 ---------------------_-_---------__-------------------- SUBTOTAL $ 1676. 97 Sales Tax $ 1305. 67 @ 8 .2500% 107 .72 ---------------------------------------------------- GRAND TOTAL $ 1784 . 69 ADJUSTMENTS: Deductible 0. 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 1784 . 69 WE GUARANTEE ALL REPAIRS AND PAINT FOR 1 FULL YEAR. THIS IS A PRELIMINARY ESTIMATE AND ADDITIONAL CHARGES MAY BE REQUIRED FOR THE ACTUAL REPAIR. 2 CLAIM B OF SUPERVISORS OF CQNTRA COSTA COUNTY BOARD ACTIOl gi ER 14i 2 4 Claire Against the County, or District Governed by ) the Beard of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Boars)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 Cade Section 913 and 915.4. Please note all"Warnings". AMOUNT: $806.42 CLAIMANT: AKIKO TAI JI COUNTY COUNSEL ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 06, 2004 ADDRESS: 658 LARCHMONT DRIVE BY DELIVERY TO CLERK,ON:AUGUST 06, 2004 DALY CITY, CA 9401.5 BY MAIC.POSTMARKED: 'AUGUST 05, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 06, 2004 JOHN 5WEETE C e Dated: By: Deputy II. FROM: County Counsel, TO: Clerk of the Board of Supervis rs (0.-Tis 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 noticing 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 � 2 By: C Deputy County Cour. III. FROM: Clerk of the 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: { 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: 'UP 14 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code secti n 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposii 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 ful prepaid a certifies)copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:&P 15 2004 JOHN SWEETEN, CLERK.By Deputy Cie _... ........ .. ... .... _.. .... ..... ......... _... _.. _.. ....... .... Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO GLA11W'T A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing, 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. Cade §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 105, County Administration Building, 651 Fine Street, Martinez, CA 91553. 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 } AUG 0 6 2004 Distrct) lf ''; tfi S� vrst� 7111 in r ) �sr co AS The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of ' t _ and in support of this claim represents as follows: 1. When did the damage or injury odour? (Give exact date and hour) Q r� 'd Wil}Lei j GLt�1 2. Where did the damage or injury occur? (Include city and county) • �1l? �Dv�t l tit} �D.�62xdt� Q_ r G�J't�tirA W� .� .�...__.... 3. How did the damage or injury occur? (Give full details; use extra paper if t required) � 1 ' vx41 AY- f $ -r 'AL ef (A,�n C H� t -t �, 4 I sIvrpd tiAv-. Taw is i:.� PA D k ��,.�s +VO4 k of W, 6 hk'1cAi 4 (Ar 1 'Q�r1s41� Ir 5 � 1{lYt t , }-�u► t ni Ll+t 1'ttY Cdb'f VA 4. What particular act or omission on the part of county or district officers, servants or employees caused.the injury or 'damage? 7, wtat are the names of county or district officers, servants or employees causing the damage or injury? k v_ Rol a- RU;4',{,►v� a.�._.�....�..r. .rr �... ,yL_r.......�.w_rr..+.w.�.r.� ........_._... �_wa......�.r.+r.....�r.w 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Ca, pwt , my kVV-, C4- t n11�a" k t 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 3. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorney)___ or by some erson on his.behalf." Name and Address of Attorney (Claimant Is Si Lure Address CA Telephone No. b � � P "_ Telephone No. * * � 4* * �t NOTICE Section 72 of the Penal Code provides: "Every F r person who with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, ,authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than ane.year, by a fine of not exceeding one thousand ($1y000), or by both such' imprisonment and fine,,,--or by imprisonment In the state prison, by a fine of not exceeding ten thousand dollars ($109000, or by both such imprisonment and fine. 07120/2004 at 02:14 PM Job Number: 29767 STEWART'S BODY SHOP, INC License #:BAR#AJ112826 Federal ID #:680032104 SERVING THE BAY AREA SINCE 1944 12540 SAN PABLO AVE RICHMOND, CA 94805-1406 (510) 235 .3515 Fax: (510) 235-9022 PRELIMINARY ESTIMATE Written By: VAMA EMFINGER Adjuster: Insured: AKIKO TAKEJI Claim # Owner: AKIKO TAKEJI Policy # Address: Deductible: Date of Loss: Business: (650) 997-3828 Type of Loss: Day: (510)717--6682 Point of Impact: 12. Front Inspect STEWART'S BODY SHOP, INC Business: (510) 235-3515 Location: 12540 SAN PABLO AVE RICHMOND, CA 94805-1406 Insurance Company: Days to Repair 1994 MITS GALANT S 4-2.4L-FI 4D SEL) VIN: 4A3AJ46G7RE015315 Lie: Prod Date: Odometer: Rear Defogger Tilt Wheel Intermittent Wipers Tinted Glass Body Side Moldings Dual Mirrors Clear Coat Paint Power Steering Power Brakes Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2 O/H bumper assy 2.2 3 Repl Bumper cover 1 248.38 Incl. 2.5 4 Add for Clear Coat 1.0 5 Repl License molding 1 5.87 6# **POSSIBLE HIDDEN 1 Incl. DAMAGE! M ! ! t t t<<«<<<< 7# Color Tint 1 0.5 D 8# Flex Additive 1 12.50 9# Subl Hazardous Waste Disposal 1 1.00 X ------------------------------------------------------------------------------- Subtotals =_> 267 .75 2.7 3.5 1 07/20/2004 at 02: 14 PM Job Number: 29767 PRELIMINARY ESTIMATE 1994 MITS GALANT S 4-2 .4L-FI 4D SED Parts 266.75 Body Labor 2.2 hrs @ $ 65.00/hr 143.00 Paint Labor 3.5 hrs @ $ 65.00/hr 227.50 Diagnostic Labor 0.5 hrs @ $ 65.00/hr 32.50 Paint Supplies 3.5 hrs @ $ 30.00/hr 105.00 Sublet/Miss. 1.00 ----------------------------------------------------- SUBTOTAL $ 775.75 Sales Tax $ 371.75 @ 8.2500% 30. 67 ---------------------------------------------------- GRAND TOTAL $ 806.42 The above is an estimate based on our inspection and does not cover any additional parts or labor which may be required after the work has been started. Occasionally, worn or damaged parts are discovered, which are not evident on the first inspection. Because of this, the above prices are not guaranteed and are for immediate acceptance only. I authorized Stewart's Body Shop to repair above said vehicle as itemized per this estimate. X Date: THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIEb 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. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARP6240 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. 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. 2 Date: 7/22/04 02:25 PM Estimate ID: 23316 Estimate Version: 0 Preliminary Profile ID: Mitchell THE DEALERSHIP COLLISION REPAIR FACILITY SEBBB O TE AUTO Pt= BODY SHOP INC* 435 SERRAMONTE BLVD.www.SERRAMONTEBODYSHOP.COM COLMA,CA 94014 (650)992-1400 Fax: (650)301-1750 Damage Assessed By: FONSECA PABLO Deductible: UNKNOWN Owner AKIKO TAKEJI Address: 658 LARCHMOUNT DR DALY CITY,CA 94015 Telephone: Home Phone: (950)997-3828 Mitchell Service: 916388 Description: 1994 Mitsubishi Galant S Body Style: 4D Sed Drive Train: 2.41-Inj 4 Cyt 4A VIN: 4A3AJ46G7RE015315 License: 3UAH076 CA Color: GRAY Options: AUTOMATIC TRANSMISSION Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 600720 BOY OVERHAUL FRT COVER ASSY 2.0 # 2 600800 BOY REMOVE/REPLACE FRT BUMPER COVER Remanufactured 194.00* INC # 3 AUTO REF REFINISH FRT BUMPER COVER C 2.2 4 600960 BOY REMOVE/REPLACE FRT BUMPER LICENSE FRAME MBS88866 5.87 INC 5 900500 REF* REMOVEIREPLACE FLEX ADDITIVE **Qual Rept Part 10.00* 0.0* 6 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00* 7 AUTO REF AOD'L OPR CLEAR COAT 0.9* 8 933003 REF ADD'L OPR TINT COLOR 0.5* 9 AUTO REF ADO'L OPR COLOR SAND&BUFF 0.7 10 AUTO ADD'L COST PAINTIMATERIALS 126.00* *-Judgement Item #-Labor Note Applies C -included in Clear Coat Calc SE � �' ' .. #' z .Is>ll ;. 333 t a t 17 3.... �t:. ...... pnm ruh?630#. 9I 3 :i r .......... ESTIMA'T'E RECALL NUMBER: 7122/0414:25:38 23316 UltraMate Is a Trademark of Mitchel International Mitchell Data Version: JW-04;_A Copyright(C)19M-2002 Mitchell International UltraMate Version: 5.0.023 All Rights Reserved Page 1 of 2 ......... ......... ......... ......... _........ ._... ....... ........_......._.._.. ...........__.........._... _........ ......... ........._...._... __. . _.......... Date: 7122/04 02:25 PM Estimate ID: 23316 Estimate Version: 0 Preliminary Profile ID: Mitchell Add'I Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body 2.0 $0.00 0.00 0.00 160.00 T Taxable Parts 209.67 Refinish 4.3 80.00 0.00 0.00 344.100 T Sales Tax @ 8.250% 17.31 Taxable Labor 504.00 Total Replacement Parts Amount 227.18 Labor Summary 6.3 504.00 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 126.00 Customer Responsibility 0.00 Sales Tax @0 8.250% 10.40 Non-Taxable Costs 3.00 Total Additional Costs 139.40 1. Total Labor: 504.00 N. Total Replacement Parts: WAS Ill. Total Additional Costs: 139.40 Cross Total: 870.58 IV. Total Adjustments: 0.00 Net Total: 870.58 This is a Preliminary estimate. Additional changes to the estimate may be required for the actual rep air. ESTIMATE RECALL NUMBER: 7/2210414:25:38 23316 UltraMate is a Trademark of Mitchell International Mitchell Data Version. JUN 04_A Copyright(C)1994-2002 Mitchell International Page 2 of 2 UltraMate Version: 5.0.023 Ali Rights Reserved __ W CLAIM 6. 0 B ARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOAR}ACTION.• SEPT. 14, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors, Routine. Endorsements, } NOTICE TO CLAIMANT F The copy of this document mailed to you is your and Board Action. All Sectio €�� TIg ;t California Government Code notice of the action taken on your claim by the AUG 10 2004 Board of Supervisors. (Paragraph IV below), gives Pursuant to Government Code Section 913 and COUNTY r`o. , 915.4. Please note all"Warnings". tOARTIN Z CALi RE51 }a 3 : . COUNW OF CONTRA COSTA: CONTRA AMOUNT: In excess of the jurisdiction COSTA COUNTY SHERIFF'S DEPT. : CONTRA COSTA of Superior Court COUNTY SHERIFF WARREN E. RUPF, IN HIS INDIVI- DUAL AND OFFICIAL CAPACITIES: CONTRA COSTA COU 'I'y SHERIFF'S DEPUTIES Does 1-100, AND Does 1-20, Inclusive. AUGUST 10, 2004 ATTORNEY: MARK E. MIaRIN DATE RECEIVED: ADDRESS: LAW OFFICE OF MARK E. MERIN BY DELIVERY TO CLERK'.ON:AUGUST 10, 2004 2001 P. S'T'REET, SUITE 1.00 SACRAMENTO, CA 9581.4 BY MAIL POSTMARKED: AUGUST 09, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET rk Dated: AUGUST 10, 2004 By: Deputy ILFROM: County Counsel. TO: Clerk of the Board of Superviiors, ( This claim complies substantially with Sections 910 and 914.2. t ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 914.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: Dated- LZL 02 By: Deputy County Counst 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: (4 This Claim is rejected in full. ( ) Other: a I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 14 Dated: + JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code sects n 913) Subject to certain exceptions, you have only six (6)months from the date this 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: "� JOHN SWEETEN, CLERK.By Deputy Clerk ..._.. . . ......__. ......... ......... ......... ......... ......... .......... ........ ........ .... ....... ....... ....... ........ ....._...._........._._.................. ......... 1 LAW OFFICES OF MARK E. MERIN Mark E. Merin, SBN. 043849 2 Jeffrey I. Schwarzschild, SBN. 192086 2001 P Street, Suite 100 3 Sacramento, California 95814 Telephone: (916)443-6911 4 Facsimile: (916) 447-8336 Email- markCamarkrnerin.com 5 GASPER, MEADOWS & SCHWARTZ � AUG 1 02004 6 Andrew C. Schwartz, SBN 64578K ��,�p Et 2121 North California Blvd., Suite 1020 7 Walnut Creek, CA 94596 ars f,Q5; Telephone: (925)947-1147 8 Facsimile: (925)947-1131 Email: schwartzcroslaw.com 9 Attorneys for Claimant, and all those 10 similarly situated 11 -----000- 12 ROSALETY BARNETT, on behalf of herself CLASS CLAIM AGAINST COUNTY OF 13 and all those similarly situated; CONTRA COSTA; CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT; 14 CONTRA COSTA COUNTY SHERIFF Claimants, WARREN E. RUPF, IN HIS INDIVIDUAL 15 AND OFFICIAL, CAPACITIES; CONTRA V. COSTA COUNTY SHERIFF'S DEPUTIES 16 DOES 1 THROUGH 100; AND DOES I COUNTY OF CONTRA COSTA; CONTRA THROUGH 20, INCLUSIVE,PURSUANT 17 COSTA COUNTY SHERIFF'S TO GOVERNMENT CODE § 910 DEPARTMENT; CONTRA COSTA COUNTY 18 SHERIFF WARREN E. RUFF, IN HIS INDIVIDUAL AND OFFICIAL CAPACITIES; 19 CONTRA COSTA COUNTY SHERIFF'S DEPUTIES DOES I THROUGH 100; AND 20 DOES'1 THROUGH 20, INCLUSIVE, 211 Respondents, 221 Pursuant to the provisions of California Government Code Section 910, claimant,ROSALETY 23 BARNETT, on behalf of herself and all those similarly situated, hereby presents the following claim: 24 \\\ 25 \\\ i t 26 \\\ Pace!00 CLASS CLAIM 1 (1) CLAIMANTS: 2 Rosalety Barnett, on behalf of herself and all those similarly situated DOB: November 8, 1973 3 c/o Mark E. Merin,Esq. Law Office of Mark E. Merin 4 2001 P Street, Suite 100 Sacramento, California 95814 5 Telephone: 916/443-6911 Facsimile: 916/447-8336 6 (2) DATE OF INCIDENT: 7 On or about March 1, 2004 8 (3) LOCATION WHERE INCIDENT OCCURRED: 9 Martinez Detention Facility(M.D.F.) 10 1000 Ward Street Martinez, CA 94553 11 (4) FACTS: 12 On or about March 1, 2004, claimant Rosalety Barnett was asleep in her vehicle which was legally 13 parked on Lafayette Circle, in the city of Lafayette, when she was falsely arrested and subjected to excessive force by Lafayette City Police Officers,by Contra Costa County Sheriff's Officers and others. 14 She was then transported to Contra Costa County Jail (Detention Facility) where she was further 15 subjected to unnecessary and excessive force, required to urinate in the presence of males to produce a sample for testing,deprived of privacy,and forced to disrobe completely for a strip search including visual 16 inspection of her body cavities. 17 The strip search was humiliating and in violation of Penal Code § 4030, Civil Code § 52.1, the California Constitution and the Fourth and Fourteenth Amendments to the United States Constitution. 18 (5) CLASS CLAIM 19 Ms. Barnett is informed and believes, and on that basis alleges that the strip search to which she was 20 subjected was performed pursuant to policy and procedure to which all persons arrested on minor crimes are similarly subjected. 21 This is a class claim made on behalf of all persons similarly situated who were subjected to a strip 22 search, prior to arraignment, at the Contra Costa County jails after having been arrested on charges not involving violence,drugs and weapons and for whom there was no stated reasonable suspicion to believe 23 a strip search would be productive of contraband or weapons. 24 (5) PERSONS/ENTITIES RESPONSIBLE: 25 Contra Costa County, Contra Costa County Sheriff Warren E. Rupf, Contra Costa County Sheriff's 26 Department, Contra Costa Sheriffs Does 1-100, and others whose identity is not now known. E€!I Pale 2 of 3 F CLASS CLAIM ......... ......... ......... ......... ......... .._-.... _ -- ._... ........ ........ .......... ........ ............. _........ ......... ......... ......... v 1 ' (6) DAMAGES: 2 Ms. Barnett, and all persons similarly situated on behalf of whom this group claim is submitted, experienced a deprivation of her state statutory and constitutional and federal constitutional rights. She 3 was humiliated,denied ofprivacy,and subjected to psychological and emotional distress. The strip search to which she was subjected was clearly in violation of well established state and federal law and therefore 4 all deputies and other officers and employees of Contra Costa County, as well as the Sheriff of Contra Costa County are liable of punitive and exemplary damages. E 5 The amount of damages for which Ms. Barnett and the class she represents seeks recovery is well in 6 excess of the jurisdiction of superior court. 7 (7) JURISDICTION OF COURT: 8 This case, if not settled at the claim level, would be appropriately filed in superior court, or in the United States District Court having jurisdiction over Contra Costa County. 9 DATED: August 9, 2004 Respectfully submitted, 10 LAW OFFICE OF MARK E. MERIN and 11 CASP , MEADOWS & SCHWARTZ 12 13 BY Mark E. Merin 14 Attorneys for Claimants 15 16 17 18 19 20 21 22 23 24 25 26 Pana 3 of 3 _ CZAR CLAIM LAW OFFICE OF MARK E. MERIN ATTORNEY AT LAW MARK E.MERIN OF COUNSEL JEFFREY I.SCHWARZSCHILD CATHLEEN A.WILLIAMS August 9, 2004 Clerk of the Board of Supervisors By Certified First Class U.S. Mail County of Contra Costa Return Receipt Requested 651 Pine Street, 1S` Floor, Rm. 106 Martinez, CA 94553 RE: Class Claim of Rosalety Barnett Dear County Clerk: Enclosed please find the original and two copies of a Claim against the County of Contra Costa, Contra Costa County Sheriff's Department, Contra Costa County Sheriff Warren E. Rupf, Contra Costa County Sheriff's Deputies Does 1 through 100, and Does 1 through 20, inclusive, brought on behalf of above-referenced claimant. A self-addressed, stamped envelope is enclosed for your convenience in returning an endorsed copy of the Claim. Please send notice of acceptance or rejection of this Claim to the undersigned. Very truly yours, rW OFFICE OF MARK E. MERIN a k E. Merin MEM:klk Enclosures cc: Rosalety Barnett S:\WpWork\Strip Search Cases\Barnett\Counzy_00 i.Wpd 2001 P STREET, SUITE 10001SACRAMENTO, CALIFORNIA 9581401916/443-6913 DFAX 916/447-8336 e o P t:, U LU ta, C WC 00 cogr Hwr WJ tr cc ru � w 0 CA civ a� t 4 ru Ln C] �.." 6 C3 kt k�- � ct 0 . . CLAIMS« BOARD OF SU ERVI ORS OF CONTRA COSTA COUNTY (� BOARD ACTION:SEPT- 14, 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), gives Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings", 00 000.00 plus; AMOUNT: + AUGA1 CLAIMANT: BARBARA CLARK COUNTY COUNSEL MARTINEZ CALIF ATTORNEY: UNKNowNN DATE RECEIVED: AUGUST L0, 2004 ADDRESS: 1307 BLACKOAK COURT BY DELIVERY TO CLERK ON-AUGUST 1.0, 2004 PINOLE, CA 94564 BY MAIL POSTMARKED: HADD DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of above-noted claim. JOHN SWE erk AUGUST 10, 2004 Dated: By: Deputy II. MOM:_ County Counsel, TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notiking 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 Counse III. FROM: Clerk of the Beard 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: Sff-1 4 M, JOHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code sects n 913) Subject to certain exceptions, you have only six(6)months from the date this 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: '' JOHN SWEETEN,CLERK By Deputy Clerk RECEIVED Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA CUJNTY AUG 1 Q 2004 INMUCTIONS TO CLAIMANT ARK BOA G� ;UPERVISORS; A. Claims relating to causes of action for death or for injury to perio'n`rbF,16`,�@r sonal property or growing crops and which accrue on or before December 31, 1957, must be presented not later than the 200th day after the accrual of the cause of action. Claims relating to causes of action for,death or for injury to person or to personal property or growing craps and which accrue on or after January 1, 2988, must be Presented not Tater than six,months after the accrual of the cause of action. Claims relating to any o er cause 8 adt—i6 mush be preseri�ad not ._... 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, 652 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. _w D. _If the claim is a inst more tYaan on ublic entfty, separate claims must be r filed atainst eac entit E. ' Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this forte. RE. Claim By ) 'Reserved for Clerk's filing stamp } 4 3 Against the ty of Contra.Costa } or _ District) The undersigned claimant hereby makes claim against the 'aunty of Contra Costa or the above-named District in the sum of and in support of this claim represents ,as follows: e - _ '. 1. When slid the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) —L2 L-1 3. How did the damage or injury cur? (Give full details; use extra paper if required) 52 9 J e, � �'0 �� �� tTe lJ I -�-A,10, S0 Y 1A A ` - 4. What particular act or omission on the part of county or district officers0 it,, servants or employees caused. the.injury or damage. It e t te - — I/ lye );i V;e /Y7 JAI 44 V ' � a 3 t I{ l - I� ,- ` - 1 { ; f� .f kiAae, 912& T2 I '1 ✓� .r o r 47 MA 1 1A lll� 00 ,.. r I F r a t ll r tr !l .ell YaL ov,} f 1 f( j i, i f� .i I• i f -- YES I DO MATTER! To Whom It May Concern, 5-7-04 I contacted an attorney regarding the events that took place at my home on March i$ and 19, 2004. On March 18 , several law enforcement agencies responded to a domestic disturbance at my next door neighbor ' s house. My neighbor has threatened to commit suicide several times before and was threatening to harm himself once again. A Hercules Police Officer snatched me to the ground and injured me during the "evacuation" of my neighborhood. After evacuating me from my home, members of the law enforcement agencies entered my home illegally without my permission and vandalized it. The police have responded to my next door neighbor ' s house before regarding domestic disturbances involving fire arms, yet this man is still permitted to own registered weapons. How is this possible? The number of law enforcement agencies that were involved, and their procedures for the abatement of any escalation of the situation with the neighbor, would lead one to believe that he was extremely .dangerous. Why has my next door neighbor been allowed to remain a resident within my neighborhood, living next door to me, if he was an extreme danger Why was this acceptable? I spoke with the attorney about the disruptions of my life, the inflicted pain that I must endure, my unresolved anger caused by the illegal invasion and vandalization of my personal property. I talked about the psychological impact of all of these things and how they have effected me. The feelings of revulsion caused by the law enforcement invasion and occupation of my bedroom still remains. I am still experiencing feelings of repulsion in my own bed, knowing that strangers were all if. I am still disgusted by the thoughts of my three bathrooms having been used as though they were public toilets by strangers. I am still shocked and angered by the audacity of the actions of the law enforcemnent officers who went through my personal papers, and left them strewn about the table and floor. One month later I am still the one in pain, going to the doctor, physical therapy and mental health therapy. I am the one who has been forced to use monies from my limited income to restore my home to it ' s level of cleanliness, and to repair and replace my belongings, while everyone 'else has gone on with their lives uneffected. I have been victimized by the conduct of the law enforcement officers, and it is an atrocity. Who do I turn to, when the people who are sworn to protect me are the ones who have hurt me physically and maliciously vandalized my home and disrupted my life, and have walked away from this maleficence as though it doesn' t matter . The Pinole Police Commander, who was supposed to call me back on March 31, has still not contacted me to discuss the events of March 18 and 19. The Hercules Police Officer who snatched me to the ground and injured me, came to my home and tried to lie to me about the unwarranted excessive use of force he used against me. His actions cannot be justified by the mitigated circustances. The attorney assured me that the police will attempt to justify the officer snatching me to the ground, so as to make his actions appear necessary, because of the supposed situational danger. I stated that the officer had no right or reason to strong arm me, it was unnecessary. I was already following the verbal instructions that I was given, fully cooperating with the evacuation. The attorney said it would be a hard case to win, but he thinks that any charges relating to the police vandalizing my home may be a possible positive outcome for me if persued. The lawyer further states that I probably would he paid for the damages to my home, his fees, maybe something for pain and suffering, however, none of if would be very much. Well I want to know, where is my justice, my protection, my retribution? The attorney said that I wont get any, unless I can find someone to fight for me. Well it is obvious it wont be him who is really fighting for my rights. I want to know when did this lack of "citizens rights" get out of control? When did criminal behavior of the police become so common place, as to be justified and acceptable by the police? Out of control police are not acceptable. Well I do matter so I am asking for your help because I don't want my victimization to be swept aside as if I don' t matter. Recognizing that those who make decisions about public policy are insulated from those who are effected by them, I have decided to make the effects of March 18 and 19 of 20144 known. So I will send a copy of this letter to the Mayor of Pinole, Pinole City Council and the A.C.L.U. , etc. Thank you in advance for your consideration and help. Respectfully yours} ` Barbara Clark ccs See Attached . .................................................................................................................................................................................................................................................... ....... .......... ._._..._.. ..._..... ......... ........ _.__......_.........................__.. ._._..... . ......... .......... ......... ......... M NO• E OF CLAIM AGAINST THE CITY OF p )LE G t� (Government Cade ss 910,910.2 et seq.) Received u. JUL 2 6 2004 t zn ) A Office of the City Clerk ity Claim:# "Please read the attached instructions before completing 1. Claimants Name: (Please Print) Claimant's Address: 10ft Z2 11V/Ze-- - City —'— State �I "Zip Day Phone: ( ) Evening Phone: flf " 2. When did the lama e or in.u_ry occur? �`a Month: -Adt&h Day:/? Year: 201 Time: or _ 1 At which location did the damage or injury occur? 1. � Was a police report taken? [X)YES [ ) NO. 4_ What ha tined and why is the City res onsible? A77' / ' 1.1 00d/L,,)' 7 �V Name and_position of responsible City Employee(s), if known: ? L`'✓ ! j'� �7 l b. 5. What dama-ge or injury occurred? 6. Claim amount(ori#v if less than$10,0001: If the amount exceeds$10,000, please check the court of appropriate jurisdiction: [ j Municipal Court(claims up to$25,000) Superior Court(claims over$25,000) 7. How did you arrive at the amount claimed? Please attach documentation. 'e 8. 1 declare under penalty of perjury under the laws of the State of California that the foil owin informa"on is true and correct,and that this declaration was executed on "" /' 2 at ` CA. 7gnature ofClar ant or Represent,tivess Slgnattrre 9. Ufcial Notices and Correspondence ff represented by an insurance company or an attorney.,please provide the information requested below. NAME AND CAPACITY:(Please Print) ADDRESS: City Mate Zip Daytime Telephone: { } Evening Telephone: ( ) i jy„ d: Com,,...� U J -� O...C-• ,LS 'S) t. CJ ,,., Er tn go R 23 b.... � W bpCZ 0 Q C � cc CV 073 '20'�. pr;'N w CL Gl,-.r '"' O ice. Lam, CL G7 'C7 tG x. 13 O 13 Ln W co 0W cz ' 04,E ca cu cu{� bA'� > _Wo '` `ate' Ica cG •� „ cabO y C,1........ bk ul i7 C7 C s, ci f JF E O v ua DA 80 ` cs` ' vows o v 15 mNc� ct G w Wiz' J ... ..... ..... _ } 1 C3 c �jUJj �y mom uj f; c a 4.Cxn ��O m W en 4; CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i • BOARD ACTION: SEPT. , 20 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 £ s�.� 915.4. Please note all"'Warnings". AMOUNT: $50,000.00AUG .15 2004 �` CLAIMANT: JOHN A. RUSCA COUNTY CC`.�a.e! SEL MARTI IE CALiF, .ATTORNEY: MITCHELL A. STEVENS DATE RECEIVED: AUGUST 13, 2004 ADDRESS: LAW OFFICES OF MITCHELL A. STEVENS BY DELIVERY TO CLERK.ON: AUGUST 13, 2004 1320 WILLOW PASS ROAD, SUITE 500 CONCORD, CA 94520 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 13 2004 JOHN SWE rk Dated: By: Deputy IL T OM: County Counsel. TO:Clerk of the Board of Sup isors {* This claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { ) Other: Dated: 4: _ 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: This Claim is rejected in full. { ) Other: a 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 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. *Farr Additional Warning Sec Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United States,over age 18; and that today deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: a.. 1 JOHN SWEETEN, CLERK By Deputy Clerk Claim to: BOARD OF SUPERUSORS OF aQN '#it# OOSrA COUNTY IH=crioms Tio a AlKW A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and 'which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing crops and uhich 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 muse of action. (Govt. Cade 5911.2.) B. Claims must be filed with the Clerk of the Board of supervisors at its of'f'ice 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 farm. RE: Claim By Reserved for Clerk's filing stamp JOHN A. RUSCA F Z '!5 Aga nst a County OF Coma Costa } � 4r } AUG 13 RECII District) r. . I MT; } CLERK LrPERVISORS CONTRA The undersigned el.a want hereby mattes claim against the County of Contra. Costa or the above-termed District in the sum of * 50'0700.00 and in support of this claim represents-as follows.- 1. ollows:1. When did the damage or injury occur? (Give exact date and hour) March 19, 2004 at aip'proxiniately 2400 hours. 2. Where did the damage or injury occur? (Lxl ude city and county) 4n I-680, Walnut Creek, Contra Costa County. 3. How did the dame or injury occur? (Give full details; use extra paper if required) Contra Costa County vehicle rear ended claimant's vehicle. 4. What particular act or omission on the part of county or district officer, servants or.employees caused.the,injury or damage? Negligence on-part of the Contra Costa County veUcle driver. wnat are the names of county or district officers, servants or employees causing the damage or injury? Tracy Lynn Hein diver of the Contra Costa County vehicle. 6. 'khat damage or injuries do you claim resulted? (Give full extent of injuries or damages eUdned. Attach two estimates for auto damage. Soft tissue injuries consisting of sore ribs; shoulder; neck and back injury. Personal ipjM claim $50,000.00 _.. 7. How was the amount claimed- above computed? (Include the estimated amount of any prospective injury or damage.) My attorney cmputed the amount of damage. "B. Names and addresses of witnesses,. doctors and hospitals. See attached Police Report. 9. List the expenditures you made on account of this accident or injuryt DATE I AMOUNT Rental car 1.,378.47 Deductible 500.00 Medical cLoss (30 hrs. @ $65 per) 11,950.00 co-pays� � �/,��j1y�.tl� �t �6�t �t +��} � +e'� � �ta � � Goo. Code Sec. / iLrr provides: "The claim must, be signed by the claimant SEND NOTICES TO: (Attorney) or by sopeperson on is.behalf." Name and ddress of Attorney . MITCH UZ A. STE't SISBN: 46005 LAT+ OETICES OF M1TCHE1Z A. STEVENS trlaimatftls Signature) 1.320 IIILIIJW PASS rDM, SUITE 500 A4ITC1 A. STEVENS, AW�]E'�' FOR CLAIMANT CONCORD, CA 94520 JOHN A. RUSCA Address Telephone No. (925) 602--1777 Telephone No. a a a NOTICE Section 72 of the Fetal. Cede provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district beard or officer, 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 qty Jailfor a period of not more than one.year, by a fine sof 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 tent thousand .dollars ($10,000, or by. hrsh.h glir%h and fine. .......................... 3 1 A I E.O TRAFFICCOLLISIONREPORT CHP 5M CARS Page I(Rev M)OPI 042 page1 of WWAA.CONDITIONS Nwoep +NrAft" CrTy w-tow V&Ow AJOICIAL DISTRICT LOCAL REPORT NUMBER 2 WALNUT CREEK WALNUT CREEK SUPERIOR "t 4 tsom401 COtmrY REPORTM Ops"cr WAT % "op 3 — 0 0 CONTRACOSTA 682 COWSION OCCURRED ON' mo DAY YEAR TIME t24M) N=t OFFICER 10 Z 1.-690 N B 103 19 2004 1400 9320 j 16503 0 WLEPOST WFORWATK*t i My OF WEEK TOW AWAY PH<ITOGRAPHS,SY NONE 18 FEET SOUTH OF MPM, 630 COCO 15.61 FRIDAY YES No STATE KWY REL x OR' IS FEET SOUTH OF NORTH MAIN ST.OIC ye. NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS 1wry VEH YEAR MAKE I MODEL I COLOR LICENSE MA48ER STATE C5906-351 acup 1999 FORD TAURUS WHT C G 11026536 CA TRACY LYNN HEIN Ovw9Rls NAME 7-7 SAME As DRIVER STREETADCAM TMAN CONTRA COSTA COUNTY" 1892 CAMINO ESTRADA OWNER'S ADOMS 1-7 SAME AS DRIVER 4ARK90 CITY I STATE I ZIP XMICLE 2467 WATERBIRD WAY MARTINEZ CA 94553 CONCORD CA 94520 DISPOSITION OF VEHICLE ON ORDERS OF OFFICER �DRIVER' f I x OTHER wCy- SIX EYES INEIGHT WEfQHT MTMDITE RACE CLIST jHAIR "= Y F SUNDOWN TOW Mo Dwy Yew BLU Z7 NONE A REFER TO HAAaATIVE F BLN 5.05 ISO 06124/1959 W PRIORMECH.DEPEM 71 7 3THeR NMI!PHONE SUSIINESS PHONE VEHICLE IDENTIFICATION 1AAAM. NONE (925)646-4461 CNP USE ONLY DE$CMW VEHICLE DAM04E SHADEWOM04EDAREA *4SLfitANCISCARRIER POLICY NUMBER VEHICLETYPE r--1 r-7 I IUNK NONE 7�MINOR 71, CONTRA COSTA COUNTY SELF INSURED 01 x MOD MiA" 1 fROLL-OVER DIR 01 TRAVEL 1*4 STREET OR HKIHWAY SPEEOLUT CA DOT 1-680 N 65 C4-T yc"ac MC*AX YLRTY DRIVER'S LICENSE NUMBER STAM CLASS SAFETY VEH.YEAR MAKEIMODELICOLOR LICENSE NUMBER STATE M0725020 CA c G 2000 OMC PICKUP MIT 6654140 CA )RIVER UVMFIRST,momc LOOT) JOHN.-UNTHONY RUSCA OWNER'S NAME 14W AS ORNIM lKM15- &MET AODRESS I:x 70 CHERRY WAY OWNER'SADORESS SAME AS DRIVER 7i7l ARXED CITY iSTATE IZIP CHICLE WALNf-7 CREEK CA 94597 -"J.- BIRTHDATE DISPOSITION Of V041CLE ON ORDERS OF: OFFICER XDRIVER OTHER UCY- sex HAIR EYES Mu Day ,LIST y,, RACE SLNDOWN TOW 77 M IBRN 181-11 5-10 190 09/0411946 W PR4OR MECKANICAL OffECTS, APP. W REFER TO W~TIVIE 4— nWR HOME PH OHE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: (925)934-5717 NONE CHIP USE ONLY OMPUSE VEHICLE DAMAGE SKMX IN DAMAGED AREA f--j WGURANCE CARRIER POLICYNIUM11111IR VEHICLE TYPE UNK '—INOW m"o ANIERICAN ECONO INS. 02-CD-09345&4 22 11 lt0L't`OVER 010 Or TRAVEL 1 ON STREET OR l"MAY SPEED LIWr CA DOT N 1-690 65- M-T SO MC/MX i In tftyv DRIVER'S LICENSE KEN STATE CLASS my ve"uft MARE IMODELICOLOR LICENSE NUMM STATE 3 N0020072 CA c L 1997 FORD EXPLORER GRN 4GRN058 CA Irwit Howfrmst MIDDLE.LAST) JOHN S.BREGLIO OWNER'S NAME ## SAME AS OftfVgFt D&S' STREET ADDRESS AN 18610 CRANE AVE. OWUNER'S ADDRESS SAME AS DRIVER Uma CITY i STATE XIP HICLE CASTRO VALLEY CA 94546 "-7oFficert —OTHER oispowrm OF!V841CLE ON ORDERS OF, CST SEX HAIR EYES VVEKW allkIMAT9 �J—E SLNDOWN TOW -M o" V 141IN HZL 160 12,'04J1953 W PRIOR WCHNNCAL DEFECTS NONE APP REFER To RARRATIVE fx- 'HER HOME PHONE BUSINESS,PHONE VZIOCLe IDENTIFICATION NUMBER: (510)728-132.1 NON E CMP U09 ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA 24URANCE CARRIER POLICY NLIM"R VEHICLE TYPEIUNK ;M*4R F-] NONE vff=51 I I - -' OI-t.-OVER 00964-05-47C71039 07 x1moo MOJOR 1 i-- F 7 iR Il*Of TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT N 1-680 65 CAL-T TCP/PSC MCRAX 'tEPAfte&%NAME DISPATCH NOTIFIED DATE RrEWED r A A I TRAFFIC COLLISION CODING Chip 655 CARS Pam?(819f3}OPI 042 Page 2 of {MT¢Of COLUSiON}A 0 DAV YEAR}-----1 Tgo*24003 HC}Ci OFFICER Co. hUMER 03 19.2(X)4 1400 9330 t6503 } OAR OWNER A00ft" NOTIFI£O i !PROPERTY YES (NO DAMAGE DESCRIPTION OF ouw,cE SEATING POSITION OCCUPANTSSAFETY EQUIPMENT MIC BICYCLE HELMET EJECTED FROM VEHICLE • 1 L-AIR SAG DEPLOYED `ICT E.XCTSO I� A-NONE IN V941CLE M-AIR BAG NOT DEPLOYED J =ULLY EJECTED 1 :. 8-UNKNOWN N-OTHER DRIVER 3ARTIALLY EJECTED W J I-DRIVER C-LAP BELT USED P-NOT RSOUIRED V-NO 3•':NKNOWN D-LAP BELT NOT USED W-YES S 7 2 TO B-PASSENGERS E-SHOULDER HARNESS USED CHILD RESTRAINT t j ' 7•STA WON REAR F-SHOULDER HARNESS NOT USED O R V H L USED PASSENGER 8•RR OCC TRK:OR VAN 0-LAPjSHIOULDER,HARNESS USED R-IN VEHICLE NOT USED X-NO } S-POSITION UNKNOWN H-LAP13HOULDER HARNESS NOT USED S,IN VEHICLE USE UNKNOWN Y-YES 0-OTHER J-PASSIVE RESTRAINT USED T-IN VEHICLE IMPROPER USE K-PASSIVE RESTRAWT NOT USED U-1 ONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ABTERiSKt*j SHOULD BE EXPL MNED IN THE 71 MRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 213 TYPE OF VEHICLE � � � MOVEMENT PR ED" LIST NUMPJER OF PARTY AT FAULT COLLISION vC 3EC"uN x+ct,+.TffD CtIETi S A PASSENGER CAR IST TION WNQN A. STOPPED A 22350 B tRt S NOT RR/NCTIONlNG* B PASSENGER CAR W I TRAILER X K 8 PRDC MW_q STRAIOHT B OTHER IMPROPER DRIVMk3• C C M2TCIRCYCL I 2CC3C?TER C RAN OFF ROAD X D NO CONTROLS PRESENT I FACTOR' D PICKUP OR PANEL TRUCK O MAKING RIGHT TURN C OTHER THAN PRW—ER` TYRE Of CC4LL18m E P I ftWL L TRUCK WI TRAILER E MAKING LEFT TURN D UNKNOWN` A meADoN F TRUCK OR TRUCK TR oR F MAKWG U TURN E ML ESP` B p-ms"PE C TR CK t TRUCKTRACTOR WI TRLR. CS SACKING ! X C`'REAR END H scmOoLsus X H SLOWING I STOPPING WEATHER ARK t TO 2 6 A I OTHER BUS I PASSING OTHER VEHICLE A gLe6tg E HIT OBJECT J R VEHICLE J CHANGING L S CLOUDY F OVERTURNED K HNGHWAYCodST.EaUIPMENT K PARKING MANEUVER C RAM!tg vskiCLEIKOESTRIAN IL BiCYC.LE L RENTERiINGTRAFFIC D No H OTHER-7 M 22M VEHICLE M O UNSAFETUEIMNG • E FOG I VISIBILITY Fi. N PE STRIAN N XING INTO OPPOSNQ LAN F OTHMOTOR EHCEBGH VIP SMITH 0 MOPED 10 PARKS 0 WIND JA N N-GOLLWN IF MERGING LIGHTING 18 PC-OESTRIA G TRAVELING WRONG WAY A DAYLIGHTX #. C?TSIER RAOTCMt 3 OTHER ASSOCIATED FACTORS R OTHIER^ B DAWN D MOTOR VEtIIC OTHE ROADWAY MARK I TO 2ITEMS) C DARK-STREET LIGHTS PARKED MOTOR VE A •:�iT Or rif f aT€C Ct7ED YES D DA -NO STREET LICH F TRAIN +4o !9 DARK•STREET LIGHTS NOT GS BICYCLE B •:SECTION+<ureD "TED �YB FUNCTK#� H ANIMAL. ROADWAY SURFACE C rC SECTx,�+•-A,ITED :,reo YES Z 3 PHYCSt36RI Y$} AR A DRY 1 FIXED Ci@JECT, �No {MARK I TO 2(TEMS) B )69L f7lD ,. A HAD NOT BEEN ga!Nm O SNOWY•ICY J OTHER OBJECT: E VISION C3BSCUFIEMENT; iT HBD-U INFLUENCE O SUPPERi'( ODY.OLY,ETC.) F INATTE ` C HW T UNDER M ` ROADWAY CONDITU",S) G STOP TRAFFIC D IAWAIRMEN7 UNKNOWN' ARK I TO PEOESTRG4N'SAGTII3NS H E ILEA AMP E UN I U ` A HOLm.DEEPRUI" XIA NO pEoEsTmANs wvoLvED I PRMVIOWS F IMPAIt2ME4T-PHY AL- B L2M MATMAL ON ROADWAY` 8 C"S51NG IN CROSffiSNAtK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C% qfWTRUCTIONONRQADWAY AT K OEFEcTive VER,MP: crmo H NOT h ICABLE D ONSTRUCTM-REPAIR ZONE C CROSSING IN CROSSWALK-NOT YES I SLEEPY I FATIGUED E ROADWAY WICSTH AT 1 RSIRMN ',,0 SPECIAL INFCSRMATION F f i : D` O CROSSING•NOT IN ALK L UNINY, VED VE g LE A H MATERIAL C OTHER. E w AD-#�RCR.LAIE M OTHER` B CELL PHONE IN USE H NO UNUSUAL OtpMNS F IN ROAD X )C N NE APPARENT C I LL PHONE NOT IN USE C's APPROACHING I LEAVSNG SCEWUL BUS 0 RUNAWAY VEHICLE X X X D LL PHONE MONE113NKNOVJN :ETCH MISCELLANEOUS 0 tNOICATE NtlOORTH i IEE SKETCH PG.-I .,._..,...._.CR CRi A ' 19C CHP CI.-k P!),!SO -CT OTHER STATE OF CALIFORNIA INJIJREb3/WITNESSES /PASSENGE"'N CHP 555 CARS P C Rey 199 OP1042 Page 3 of g 1 {SATE OF COLLISION(MO DAY YEAR) TIME(2400) NCIC 9 OFMER I.D. NUMBER 0.3/19/2W4 1400 9320 16503 03-257 WITNESS PASSeWfR EXTENT OF INJURY'X'ON SLY ONLY AGE sex { P INJUREDWAS{'X'ONEj PARTY SEAT sAEL=r^r EJEGTEO €ATAL SEVERE OTFtR VISf3LE COMPLAINT tANSER POS. EO1AP INJURY INJURY INJURY OF PAIN DRIVER {SASS. PED. WCLYCLIST OTHER 45 F ❑ ❑ ❑ i EXI ❑ ❑ 3 3 L 0 NAME 1 C O B 1 ADDRESS TELEPHONE MARTA POSADA (0€123/1959) SAME ADDRESS AS P-3 (510)728-3323 (sNJURED ONLY)TRANSPORTED BY TAKEN TO. AMR JOHN MM MEDICAL CENTER OESCR,BE INJURIES COMPLAINT OF PAW TO NOSE,HEAD AND NECK. i V ICTIM OF VIOLENT CRIME NOTIFIED - y 77 F ❑ ❑ ❑ a ❑ ❑ G NAME!D.O.B.I ADDRESS TELEPHONE L_ROSA ALBA POSADA_(11/1511926) SAME ADDRESS AS P-3 {x}15)587-2936 (INJURED ONLY)TRANSPORTED BY: — — TAKEN TO: I AMR JOHN MM MEDICAL CENTER DESCRIBE INJURIES COMPLAINT OF PAW TO CHEST,RIBS AND LEFT ARM. � 77 VICTIM OF VIOLENT CRIME NOTIFIED �# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ i ❑ 1 NAME 10 O.B.I ADDRESS TELEPHONE 3 i '?NJLIREO ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: 1 VICTIM OF VIOLENT CRIME NOTIFIED NAME l 0 0.B I ADDRESS TELEPHONE ,INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED NAME/0.0,B.J ADDRESS TELEPHONE i ;INJURED ONLY)TRANSPORTED BY TAKEN TO DESCRIBE INJURIES V#CTIMOF VIOLENT CRIME NOTIFIED .._._.� � t—J I� L� ❑ i_J '� i-1 Imo. �__. NAME 10 O B /ADDRESS TELEPHONE I (INJURED ONLY)TRANSPORTED BY: TAKEN TO'. DESCRI8E NJJURIES i �- VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME #.D.NUMBER MO DAY YEAR REVIEWER'S NAME MO DAY YEAR D. ONCENA 16503 03/1912004 GNPCAM 042 QRSV.W-6 Oe! OILY Yom... MW�- TIW�12-4) 63 19 01 6 " - 2-S 7 AU MOUROIENU AM APPROXWTV AM Wt WAAA%#IUM STAM V$Cftg wo"Ye mom fgoiLgoj PAI-MO 21C, MO. OKY YEAR OSP 99 28979 .. ... ... ...... .... . CHP: 5 P #tay.8-$T {7Pt 042 ►+�• , �t a cr ca uta tom. OAY r+ ima-13) ►tee a e�i rr C3I� of l -/&- iiSu" 3 5 Au MEASURMWWM Asp AOMMM 'M AM IM to SCAU UWM$TAM(s G U• � sw"n warns ttx+t+li Ctu�gEpt �' �� 12 12' 12 1,2' so�sS> A 14 RT AVOAc.'rS}hu;.D61L Sftwgsc¢rHatB,t PAIwWO tEPAR86 eir F.n.MUABER MO- dAr r R REMEYAWS nu,E Mol OOZY YEAR OSP 99 28973 SLATE OF CALIFORNIANARRAIMEISUETLEMENI&. EA 9, / ,o DATE OF INCIDENT TIME NCIC NUMBER OFFICER LD. NUMBER 03-19-04 1400 4320 16503 ) = r ~? I FACTS; 2 3 NOTIFICATION: 4 5 ON 03-19-041 RECEIVED A CALL AT 1410 HOURS FROM CHP DISPATCH OF A TRAFFIC 6 COLLISION WITH AN AMBULANCE EN ROUTE. I RESPONDED FROM THE CONTRA COSTA 7 CHP OFFICE AND ARRIVED ON SCENE AT 1432 HOURS. ALL TIMES, SPEEDS, AND 8 MEASUREMENTS IN THIS REPORT ARE APPROXIMATE. MEASUREMENTS WERE OBTAINED 9 BY VISUAL AND BEST ESTIMATION. 10 11 12 SCENE DESCRIP'T'ION: 13 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 LINE. THE 95 LANE IS SEPARATED FROM THE 18 RIGHT SHOULDER BY A SOLID WHITE LINE. THE ROADWAY SLIGHTLY ASCENDS AS YOU 19 PROCEED NORTH. `PHIS SECTION OF FREEWAY IS MAINTAINED BY THE STATE OF 20 CALIFORNIA. SEE FACTUAL DIAGRAM FOR FURTHER INFROMATION. 21 22 23 PARTIES/VEHICLES: 24 25 PARTY#1 ( P-1, T EIN ) WAS LOCATED AT THE SCENE ON THE RIGHT SHOULDER STANDING 26 NEXT TO V-1. P-I WAS IDENTIFIED BY HER VALID CALIFORNIA DRIVER'S LICENSE AND AS 27 THE DRIVER OF V-I BY HER STATEMENT. 28 29 VEHICLE #1 ( V-1, FORD )WAS LOCATED AT THE SCENE ON ITS WHEELS ON THE RIGHT 30 SHOULDER FACING IN A NORTHERLY DIRECTION. V-I SUSTAINED MODERATE DAMAGE TO 31 ITS FRONT END. NO MECHANICAL DEFECTS OR PRIOR DAMAGE WAS NOTED OR CLAIMED. 32 P-i WAS ABLE TO MOVE V-I TO THE RIGHT SHOULDER., 33 34 PARTY #2 ( P-2, RLSCA ) WAS LOCATED AT THE SCENE ON THE RIGHT SHOULDER 35 STANDING NEXT TO V-2. P-2 WAS IDENTIFIED BY HIS VALID CALIFORNIA DRIVER'S 36 LICENSE AND AS THE DRIVER OF V-2 BY HIS STATEMENT. P-2 IS ALSO THE REGISTERED 37 OWNER OF V-2. 38 a9 40 PRE.11ARER`S NAME I.D.NUMBER DATE REVIEWER'S NAME D. ONCENA 16503 03-20-04 STATt OF CALIFORNIA r DATE OF INCIDENT TIME NCIC�B£R OFFICER F:I3. NUMBER . 03-19-04 1400 9320 16503 1 PARTIES/ VEHICLES (continued-): 3 VEHICLE #2 ( V-Z, 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 STANDING 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 t 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. INTO PRIOR DAMAGE OR MECHANICAL DEFEC'T'S WAS NOTED OR 16 CLAIMED. P-3 WAS ABLE TO MOVE V-3 TO THE RIGHT SHOULDER. 17 18 19 STATEMEN'T'S: 20 21 P-1 ( HELN ) WAS CONTACTED AT THE SCENE AND RELATED IN ESSENCE THAT SHE WAS 22 DRIVING ON I-680 NJB IN THE #5 LANE AT APPROXIMATELY 60 MPH. P-1 SAID THAT 23 TRAFFIC WAS SLOWING AND V-2 SUDDENLY SLOWED DOWN. P-1 SAID SHE SLAMMED ON 24 HER BRAKES AND BUT STILL COLLIDED INTO THE REAR OF V-2. 25 26 P-2 ( RUSCA ) WAS CONTACTED AT THE SCENE AND RELATED IN ESSENCE THAT HE WAS 27 DRIVING V-2 ON I-680 NIB IN THE #5 LANE AT APPROXIMATELY 45 MPH SLOWING DOWN 28 FOR TRAFFIC_ P-2 SAID THAT AS HE WAS SLOWING DOWN FOR TRAFFIC, HE WAS READ 29 ENDED BY V-1. P-2 SAID THAT HE WAS THEN PUSHED FORWARD AND SIDEWAYS OUT OF 30 CONTROL AND COLLIDED INTO V-3. 31 s 32 P-3 ( BREGLIO ) WAS CONTACTED AT THE SCENE AND RELA'T'ED IN ESSENCE THAT HE WAS 33 DRIVING V-3 ON I-680 NIB 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 PREPARER'S NAME I.D.NUMBER DATE REVIEWER'S N,V'vI : DATE D. ONCENA 16503 03-20-04 STArt OF CALIFORNIA DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 03-19-04 1400 9320 16503 7 I SUMMARY. 2 3 P-I WAS DRIVING V-I N/B I-680 .JUST UNDER THE NORTH MAIN ST, O/C IN THE 45 LANE AT 4 APPROXIMATELY 60 MPH APPROACHING V-2, P-2 WAS DRIVING V-2 NIB I-680 IN THE #5 5 LANE AT APPROXIMATELY 35 MPH SLOWING DOWN FOR TRAFFIC AHEAD OF V-1. P-3 WAS 6 DRIVING V-3 N/B I-680 IN THE#3 LANE AT APPROXIMATELY 55 MPH. DUE TO P-I'S UNSAFE 7 SPEED, P-I WAS UNABLE TO SAFELY STOP V-1 IN TIME AND V-I'S FRONT END COLLIDED 8 INTO THE REAR END OF V-2. SUBSEQUENTLY, V-2 SPUN OUT OF CONTROL AND V-21S 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 CHP ARRIVAL, 12 13 14 AREAS OF IMPAC 15 16 A.0.1. #1 ( V-I 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-680 NIB. 18 19 A.U.I. #2 ( V-2 VS. V-3 ) WAS LOCATED 100 FEET NORTH OF THE NORTH EGDE OF THE 20 NORTH MAIN ST. OIC AND 26 FEET WEST OF THE EAST ROADWAY EDGE OF I-680 NIB. 21 22 23 CAUSE. 24 25 P-I ( HEIN ) CAUSED THIS COLLISION BY BEING IN VIOLATION OF SECTION 22350 V.C.- 26 UNSAFE SPEED FOR TRAFFIC CONDITIONS. DUE TO P-I'S UNSAFE SPEED, P-I WAS UNABLE 27 TO SAFELY STOP V-1 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'S FRONT END 29 COLLIDED INTO THE FRONT ENL)OF V-3. 30 31 THE SUMMARY, A.U.I., AND CAUSE WERE BASED ON THE STATEMENTS OF THE INVOLVED 32 PARTIES, PHYSICAL EVIDENCE, AND VEHICLE DAMAGE. 33 34 RECOMMENDATIUNS., 35 36 NONE. PREPARL ICS NAME I.D.NUMBER DA"fE REVIEWER'S NA IF. DATE D. ONCENA 16503 03-20-04 AMMED CLAIM> BOAM OF SUPERVIS RS OF CONTBA COSTA COUNTY • ROAM ACTION;SEP "EMEER 14, 200E 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. s A notice ofthe-action taken on your claim by the jiFk} x > t ` Beard of Supervisors. (Paragraph IV below), given L ` Pursuant to Government Code Section 913 and UG 0 5 °?x 915.4. Please note all"Warnings". AMOUNT: N/A kIAIRTNE-2 C,�1,#.!F. CLAIMANT: JENNIFER PUMPHREY, by & through her Guardian ad L,item, GUNVOR MARTA SUNDSTROM ATTORNEY: MICHAEL I'. DORSHKIND DATE RECEIVED: t�ST 05,, 2004 THE CAMRON - STANFORD HOUSE AUGUST 05, 2004 ADDRESS: 1418 LAKESIDE DRIVE BY DELIVERY TO CLERK ON: OAKLAND, CA 9461.2 BY MAIL POSTMARKED* AUGUST 04, 2004 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEETEN Dated: AUGUST 05 2004 By: Deputy II. FROM: County Counsel. TO: Clerk of the Board of Supervisork Gy' 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). (q—Other: V,/f y7 ff Dated; - �'~' By-L- r Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV 0ARD 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: _9P_1 4 M. JOHN SWEETEN, CLERK., By ,Deputy Clerk WARNING(Gov. code se ion 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or 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 ofperjury that I am now, and at all times herein mentioned,have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ' 1 JOHN SWEETEN, CLERK By De uty Clerk _ .... ..... ..... __ ..... _..... a Claim to: BOARD OF SUPERVISOPS OF CONTRA COSTA COUNTY 2MMCT1£IN TC CLAS 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 OOP day Baer 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 7amiary 1, 3988,must be presmed not later than six months ager the accrual of the cause of action. Claims relating to any other cause of action niust 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 affwe:in Room 106, County Administration Building, 651 Pine Street,Martine4 CA 94353. C. If claim is against a district governed by the Board of Supervisors,father 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. Fhud. See penalty for fraudulent claims,Penal Code Sec.73 at the end of this form. ###### * ���11##i####�lt�F4###+f#M#M#rt#t#*4#t#+k*f4ki*tV�#'##s#ssi#*#***rt#****#+####*i+t#+tt***s♦ RE: aim' By Reserved for Clerk's filing stamp JENNIFER PUMPHREY:t: ; by & through her Guardian ad Litem, UN A 'RECEIVED ---� SUNDSTROM ��v Against the County or Contra Costa or } AUG 0 5 2004 District) �! � � � ruPPRvrsogg Gill in name) C . The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum oft N/A and in support of this claim represents as follows- 1. When did the damage orinjury oacut?(Give exact date and hour) Claimant is a gravely disabled person as a result of a mental disorder and is a conservatee of Contra Costa County and was at all times at issue. Claimant was transferred to Contra Costa Health Center in Martinez on July 29, 2003 and remained an 2. Where did the damage or injury oacttr7 (Include city W txntnty) (continued on Attachment "A") Claimant's injury occurred at the Contra Costa Regional Medical Center and Contra Costa Health Centers in Martinez , CA. 3. How did the damage or injury occur?(Give full details;use extra palter if"ired) During Claimant's admission, agents, servants and employees of the County of Contra Costa failed to timely diagnose and treat Claimant' s left femoral neck fracture. Such failures and other actions by the County and its agents, servants and employees, resulted in the deterioration of Claimant's condition. The County and its agents•, servants and employees transferred Claimant to another facility without full, complete and meaningful discharge documents regarding her stated condition. 4. What partiwlar act or omission on the part of ommq or district offecers, servants, or employees caused the injury0fdamage? Agents, servants and employees of the County of Contra Costa failed to diagnose and treat Claimant' s injury during her admission from July 29, 2003 to August 21 , 2003. During Claimant' s admission, (continued on Attachment "A") S. What are the names of county or district officers, servants,or employees causing the damage or injury? All names are contained in Claimant' s medical records. 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach M estimates for surto damage.) As a result of the failure _of all health care providers to timely diagnose and treat said fracture, the femoral shaft became subluxed & displaced superiorly & most of the left femoral neck has been eroded. Claimant remained in a (continued on Attachment . "A") 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) This is an unlimited jurisdiction claim. However, Claimant's claim is controlled by Civil Code Sec. 3333 . 2 . 8. Names acid addresses of witnesses,doctors,and hospitals. Please see Claimant' s medical records. 9. List the expenditures you made on account of this accident or injury. DA'; Discovery is pending. rr!lr�sr!#r#*##f*+Muir*#!M#rtsls�►tff*#'�r#rrrrlr!!t##*#�t�tiM#F##t#ti#+IF+�wiiitlW#ir##k�rr*�iik*ri! Gov.Cade gee.910.2 provides"The claim must be signed by the claimant or by some person on his behalf." Name and Address of Attorney • 1 Michael I . Dorshkind (SBN .70682) Attorney at Law U) Attorney (dal6lantos Signature) for Claimant 1418 Lakeside Drive Oakland, CA 94612 (Address) Telephone No. (510) 832-5300 M )Tetaphtmt NO. •*r+�l�►rllrl+M�1s#*rr+►�isrts!!«*s#�rss#t�+M�sstwstt�#is*i#*Iia#�+Mrd*y!s**t�w�+Mtr**ss*+M*+sss�►rrs NGn cs T Seedoo 72 oftho Penal Cade p wAdes_ Every person who,with invent!o dettar d,p mau for allaanrx or the palnsu m to any awe board of ammr,or to nay WJAY,city,or disttid hoard or offim,sutbotized to allow or pay the am if genuine,aoY latae or ftxWWem chunk bili,aeaastot, "Uttar,or wft%is pur4ftWs aitbe r by irnmt in ft mirdy jail for a period of no*nacre then ciao year,by a Am Or= oxmodi q one ted tg JAM or by batt►aucb k2pd= near and fto,or by W primcs:c mi in the mase pima,by a fino odna exmcdtna to OwnsaW dollus(310.M arby both mch impimmus and fore. ATTACHMENT "All TO AMENDED CLAIM OF JENNIFER PUMPHREY, et al. AGAINST THE COUNTY OF CONTRA COSTA 1. (cont. ) inpatient at said facilities through August 21, 2003 . At the time of transfer, Claimant had a then recent history of falls and did complain of pain to her left leg and hip. On March 17, 2004, Claimant underwent x-rays that revealed an old and untreated left femoral neck fracture. At all times between July 29, 2003 and August 21, 2003 , agents, servants and employees of the County of Contra Costa failed to timely diagnose and treat Claimant's fracture that was discovered on March 17, 2004. 4 . (cont. ) agents, servants and employees of the County did cause Claimant to participate in physical therapy activity which was deleterious to Claimant's injury and did cause Claimant pain and suffering. b. (cont. ) chronic non--union status and now requires hemiarthroplasty repair. MICHAEL I. DORSHBIND ATTORNEY AT LAW TELEPHONE THE CANNON-STANFORD HOUSE FACSIMILE (810)832-5300 1418 LAKESIDE DRIVE ;` 510)838-4364 OAKLAND,CALIFORNIA 04612 sj n 2004 TRANSMITTAL_ REQUEST "ryA DATE: August 4, 2004 TO: Clerk of the Board of supervisors County Administration Building, Room 106 651 Pine. street Martinez, CA 94553 SUBJECT•+ JENNIFER PUMPHREY, et al. v. COUNTY OF CON'T'RA COSTA ENCLOSURES: Original & copy(s) of AMENDED CLAIM AGAINST THE COUNTY OF CONTRA COSTA Stamped & Self-Addressed Envelope. REQUEST: File the original (s) ; Endorse file copy(s) and return in the reply envelope provided. Your cooperation and assistance are greatly appreciated. Very truly yours, 14"444AC .7; `; MICHAEL I. DORSHKIND MID:ml Encs. F IN sll� En t� 4-1 � ri M ca r 4J � �t G 4 , f 0 4J 4-J M IL W4ft7 f ,' -H 41 U g; APPLICATION TO FILE LATE trLAT BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA /. BOARD ACTION - Application to File Late Claim } NOTICE TO APPLICANT SEPT. 14 2004 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to } the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the"WARNING"below. Claimant: MARIA CHRISTIE .. ` Attorney: MICHAEL. B. NISHIYAMA €UG1 o,ti,4 + Address: 711 VAN NESS AVENUE #31.0 COUNTY COUNSEL SAN FRANCISCO, CA 94102 &1-ART��4EZ CALIF, Amount: By delivery to Clerk on: AUGUST 11, 2004 Date Received: AUGUST >11, 2004 By mail,postmarked on: HAND DELIVERED 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: AUGUST 11, 2{7J)6HN SWEETEN, Clerk,By: DEPUTY II. FROM: County Counsel TO: C erk of the Board of Supervisors { ) The Board should grant this Application to File Late Claim (Section 911.6), ( The Board should deny this Application to File Late Claim (Section 911.6). DATED: -/� _ SILVANO B.MARCIIESI,County Counsel,By2 DEPUTY III. BOARD ORDER. By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted(Section 911.6). ( This Application to File Late Claim is denied(Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE: " JOHN SWEETEN,Clerk,By: DEPUTY WARNING (Gov. Code§911.8) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4(claims presentation requirement).See Government Code Section 946.6. Such petition must be filed with the court within sic(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 filed and endorsed on the Board's copy of this Claim in accordance with Section 297113. DATED. JOHN SWEETEN,Clerk,By: DEPUTY V. FROM: (1)County Counsel (2)County Administrator TO: Flkrk of the 11bard of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: APPLICATION TO FILE LATE CLAIM Claim to: 'BOAR OF SUP of CQt+m a)STA- CaRM X INSMGT ONS To C.ADIiW A. Claims relating td causes of action for death or for i n js.:. to pet-sonorto per- SCOR'f. property or growing crops and which accrue on or before December 31, 1987,' must be presmted mt later' than the 100th day after the acerml, of the cause of action. C181= r-Iat :ng to cat rs s of actio for Aeath or for injury to person or to personal property or groin crops and which accrue on or-after January 1, I9883, must be presented not later tan six moxths after the accrual of the cause of action. Claims relating to any other fni,_e of action must be presented not later. than m year after the a.ccrual 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 Boom 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 claire 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. BE: Claire By Reserved for Clerk's filing stamp MARIA CHRISTIE } Againstthe C=ty of Contra.Costa 41 AUS 1 1. 2004 Distr: � �t.ppK S F`311 tri OA RD 0nS PEPVISORS The undersigned claimant hereby.mikes claim against the County of Contra Costa or the above-rid District in the SUM of $qnilited Ciel and in s ppert of this OL'Jm represents -as follows: Jurisdiction in the Superior Court -- 1. When did the ._or injury o=ur? (Give exact date and hour) August 13, 2003 at 10:00 a.m. • –—a --till r rr+ rw - wrr.r.r..rrrr.�arrrw. ww.+�+..� 2. Where did the doge or injury dour? (Include City and county) 2530 Arnold Drive, Martinez; CA 94553 3. Hoyt did the damage or injury oecur? (Give full details; use extra paper if recriired)I was attending a t'raining course. While participating in a role playing exercise under the supervision of a trainer, I injured my neck as a result of physical contact with another student. 4.1 What .particular act or opiwion on the part of county or district officers, servants Gr.employees caused.the.injury jury ar.dam? The trainer negligentiy•supervised.the rale play_ng.exercise•. wnat are tate res of cOunrty or district officers, servants or employees causing the damage or injury? Unknown at this time'. 5. that damage or injuries do you claim resulted? (Give full extent of injtg-ies or damages Claimed. Attach two estimates for auto damage. I suffered an injury to my neck.. I have incurred lost wages. 7. HOW was the amount claimed• above computed? (Include the estimated amount of any prospective injury or damage.) I am seeking compensation for lost wages and general damages. The amounts have not yet been ascertained. S. Names and addresses of witnesses, doctors and hospitals. Ms. Gina Espinosa witnessed the incident. I have attached a copy of her statement to this Claim. I have attached a list of my health care providers to this Claim. 9. List the expenditures you made an account of this accident or injury.- ITEM njury.ITEM .AMC NT • eee -ee � � � �• .� � eee � t ee •� �.eeee � ,� a •�tt� e � � � � �tt� � � � �� �€ Gov. Cade See. '910;2 provides. "The claim mast be signed by the clah nt SAID NOTICES TO: (Attorne ) or n on his.behalf." Name and Addre S of A.ttnrney Michael B. Nishiyama, Esq: •07758$ 8 is 1gT3atur 711 Van Ness Avenue, X6310 San Francisco, CA 94102 3545 Tabora Drive Address Antioch—Q4' 2A502 Telephone No. r65Q). 4Ag_�o�o Telephone No-(9Z5) _7�-$c�$ aeee ee * eae eae N0TTCE ' Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state beard or of'fic r, or to any county, city or district board or offiow, authorized to allot or pay the same if.genuine, any false or fraudulent claim, bi.l3., account, voucher, or writing, is punishable either by imprismriment in the county Jan,for a period of not more than cne•year, by a fine of not ending one thousand ($1,000), Or by •both such- ion 3imxammt and f ine i nor by i mprisorent in the state Prism, by a fine of not exceeding ten thousand ,do lays ($10,000, crx by . tenth }s+h imnri-qnnssv+nf and fine- - Pt7• -mai-r ++.•..r ..�.� 1 `i Me o Ta: Donna Teutschel,L UM Frorm Gina Espinosa CC: Maria Christie Date: 10/0212003 Re: P.A.R.T. Training On August 11, 12 13, 2003, f attended the P.A.R.T. training with Maria Christie, a coworker. Maria Christie and l were on the same team during most of the hands on training exercises. During one of the exercises,we were working with another female student who was acting as a client that needed to be restrained. In this Exercise, another student and I broucint the Client face down onto the exercise mat and were physically holding the client face down by her arms. Maria Christie was called in to assist in holding the client down by wrapping her arms around the client's ankles. Maria Christie wrapped her arms safely around the client's ankles and positioned herself as instructed to do so earlier by the P.A.R.T. trainer. The student that was acting as the client suddenly lifted Maria off of t!e floor with her legs and Maria fell forward onto the client. Again Maria returned to the restraining position and appeared to use more strength and body weight in trying to hold the client's legs down, but the client once again lifted Maria off of the floor pushing her forward once again. Maria was unable to hold the client's lens down and a 20';llb male student took Maria's place to assist in retraining the client. The male student was also unable to hold down the client's lege: and was lifted off of the fluor in the same mariner. 0 Page 1 MARIA CHRISTIE CHRISTIv. CQLTNjY Qf CONTRA STA: ATTACHWNT TO CLAIM Ms. Gina Espinosa is a co-worker. Our business address is Department of Social Services, 360 - 22'd Street, Suite 740, Oakland, CA 94612-3019. 1 have received medical treatment and care from the following health care providers: Dr. Jacob Rosenberg 2485 High School Avenue,4201 Concord, CA 94520 Dr. Gloria Vreeland 401 Gregory Lane,#146 Pleasant Hill, CA 94523 Dr. Kulveen Sachdeva 5401 Norris Canyon Road, #110 San Ramon,CA 94583 Open-Sided MRI 710 S. Broadway, #203 Walnut Creels, CA 94596 Michael B. Nishiyyama, Esq. SBN 077588 � � 7LA Van Ness A MACS MICHAEL BONISHIYAMA A(I(; 00 San Francisco CA 54142 ?` '�eA � 3 Telephone: (6�0) 888-7090 �ftsoq Facsimile: ( 08)629-0098 c s, 4 Attorneys for Claimant MARIA CHRISTIE 6 7 CLAIM OF MARIA CHRISTIE, APPLICATION FOR LEAVE TO PRESENT LATE CLAIM ON s V. BEHALF OF MARIA CHRISTIE (GOVERNMENT CODE SECTION COUNTY OF CONTRA COSTA. 11.4) 10 11 12 TO: THE COUNTY OF CONTRA COSTA County Administration Building 13 551 Pine Street 14 Martinez, CA 94553 15 1. Application is hereby made, under Government Code section 911.4, for 16 leave to present a late claim founded on a cause of action for personal injuries, which 17 18 accrued on August 13, 2003, for which a claim was not presented within the six (6) 19 month period prescribed by Government Code section 911.2. For additional 20 circumstances relating to the cause of action, reference is made to the proposed claim 21 attached to this application. 22 2. The failure to present this claim with the six (6) month period prescribed 23 24 by Government Code section 911.2 was through mistake, inadvertence, surprise and 25 excusable neglect on the part of the claimant, MARIA CHRISTIE, and the COUNTY 26 OF CONTRA COSTA was not prejudiced by this failure, all as more particularly shown 27 by the attached declaration of MARIA CHRISTIE. 28 APPLICATION FOR LEAVE To PRESENT LATE CLAIM 1 3. The failure to present this claim within the six (6) month period prescribed 2 by Government Code section 911.2 was through mistake, inadvertence, surprise, and excusable neglect in that the claimant, MARIA CHRISTIE, did not know the nature of 4 5 the contractual relationship by and between the COUNTY OF CONTRA COSTA and 6 Professional Growth Facilitators concerning the training course conducted from August 7 11, 2003 to August 13, 2003 at the Contra Costa Training Institute, 2530 Arnold Drive, s Martinez, CA 94553. Specifically, the claimant did not know, and still does not know, 9 whether the relationship was that of lessor--lessee, or whether the COUNTY OF 10 11 CONTRA COSTA and Professional Growth Facilitators were ee-sppons�partners or 12 joint venturers. 13 4. On August 13, 2003, the claimant, MARIA CHRISTIE, was acting within 14 the course and scope of her employment as an employee of the State of California 15 16 Department of Social Services. She was attending a training course, conducted by 17 Professional Growth Facilitators, at the Contra Costa Training Institute, 2530 Arnold 18 Drive, Martinez, CA 94553. While participating in a role playing exercise, she was 19 injured as a result of physical contact with another student. 20 5. The names of the public employees causing the claimant's injuries under 21 22 the above-described circumstances are not known to the claimant. 23 6. The injuries suffered by the claimant, MARIA CHRISTIE, as a result of 24 this incident, as far as known as of the date of this claim, consist of neck injuries and 25 related problems. 26 7. The claimant has filed a workers' compensation claim against her 27 28 employer, the State of California Department of Social Services. The State 2 APPLICATION FOR DAVE TO PRESENT LATE CLAIM � Compensation Insurance Fund, P.O. Box 1609, Rohnert Park, CA 94927-1609, is 2 handling the workers' compensation claim. 3 8. This matter constitutes an unlimited civil case. 4 5 9. All notices or other communications with regard to this claim should be 6 sent to Michael B. Nishiyama, Esq., LAW OFFICES OF MICHAEL B. NISHIYAMA, 711 7 Van Ness Avenue, Suite 310, San Francisco, California 94102. 8 Dated: August 11, 2004 LAW OFFICES OF MICHAEL B. NISHIYAMA9 IO zI Attorneys for Claimant MARIA CHRISTIE 12 13 14 is 16 17 18 19 20 21 32 23 24 25 26 27 28 1 Michael B. Nishiama Esq. SBN 077588 LAW OFFICES 8F M'iCHAEL B. NISHI'YAMA 2 711 Van Ness Avenue, Suite 310 San Francisco, CA 94102 3 Telephone: 650)868-7090 Facsimile: ( 8)829-0098 4 Attorneys for Claimant 5 MARIA CHRISTIE 6 7 CLAIM OF MARIA CHRISTIE, DECLARATION OF MARIA CHRISTIE IN SUPPORT OF APPLICATION FOR 8 V. LEAVE TO FILE LATE CLAIM (Government Code section 911.4) 9 COUNTY OF CONTRA COSTA. 10 -� 11 I, MARIA CHRISTIE, declare: 12 1. I am the claimant in the above-entitled action. 13 2. I have read the proposed Claim against the County of Contra Costa, and 14 15 the contents therein are true and correct. 16 3. At all material times, I have been an employee of the State of California 17 Department of Social Services. 18 4. From August 11, 2003 to August 13, 2003, I was attended a training 19 course, conducted by Professional Growth Facilitators, at the Contra Costa Training 20 21 Institute, 2530 Arnold Drive, Martinez, CA 94553. 22 5. On August 13, 2003, while participating in a role playing exercise under 23 the supervision of a trainer, I suffered an injury to my neck as the result of physical 24 contact with another student. 25 26 6. During the six (6) month period following the subject incident, I did not 27 retain legal counsel to represent my interests in a personal injury claim. 28 7. From the outset, I have assumed that the COUNTY OF CONTRA COSTA 1 DECLARATION OF MARIA CHRISTIE IN SUPPORT OF APPLICATION FOR LEAVE TO FILE LATE CLAIM ..................................................................................................................................................................................................................... . ..... .................... .............. ........................................................................................... simply rented the training location to Professional Growth Facilitators. If my 2 assumption is correct, I do not wish to pursue a government tort claim because I do not 3 believe that any condition of the premises caused or contributed to the incident. 4 5 8. On the other hand, if my assumption is incorrect, and the COUNTY OF 6 CONTRA COSTA was either a partner or joint venturer with Professional Growth 7 Facilitators, and the supervising trainer was actually an employee of the COUNTY OF 8 CONTRA COSTA, I do wish to pursue a government tort claim. 9 10 9. 1 have requested my attorney to obtain documentation concerning the 11 contractual relationship between the COUNTY OF CONTRA COSTA and Professional 12 Growth Facilitators. 13 10. 1 am available to be interviewed by representatives of the COUNTY OF 14 CONTRA COSTA at any time upon reasonable notice, and I am amenable to signing an 15 16 authorization to enable the COUNTY OF CONTRA COSTA to obtain copies of my 17 relevant employment and medical records. 18 In view of the foregoing, I respectfully request the COUNTY OF CONTRA 19 COSTA to grant this application so that my claim can be decided on its merits. 20 21 1 declare under penalty of perjury, under the laws of the State of California, that 22 the foregoing is true and correct. 23 Executed on the 11th day of August 2004 at Oakland, California. 24 25 MARIA CHRISTIE 26 27 28 2 DECLARATION OF MARIA CHRISTIE IN SUPPORT OF APPLICATION FOR LEAVE TO FILE LATE CLAIM A MED -- CLAIM BOARD OF&PERVISQRS OF CONTRA COSTA COUNTY BOARD ACTION SE ''I'. 14, 2004 Claim Against the County, or District Governed by ) the Board of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT and Beard Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph I'V'below), give: pursuant to Government Code Section 913 and '1 915.4. Please note all "Warnings". AMOUNT: $2{3{3,000.40 AlJG 3, rr.,� ;%� ,sv COUNTY CONJNI;.SEL, CLAIMANT: TERRY D. BULLER VA T€N E Z CA,Lz{ ATTORNEY: TERRY D. BULLER DATE RECEIVED: AUGUST 30, 2004 ADDRESS: 1418 L' ESIDE DRIVE, BY DELIVERY TO CLERK ON: AUGUST 30, 22004 OAKLAND,, CA 94612 BY MAIL POSTMARKED: COUgEL FROM: Cleric of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET , Dated: AUGUST 34, 2044 By: Deputy IL FROM: County Counsel, TO: Clerk of the Board of Supervisors (L. 'This claim complies soba tantially with Sections 910 and 910.2. ( } This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: By. 1`' , ' `f' Deputy County Counse III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). (IV. ARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( } Other: I certify that this is a true and correct'copy of the Board's Order entered in its minutes for this date. Dated: 14 4 JOHN SWEETEN,CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you %ave 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: ud JOHN SWEETEN, CLERK By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA. COUNTY i 1NS1RUCTI0NS TO CLAIlAANT 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 la*e*f ion the 1{>0a'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 offiofin Room 106, County Administration Building, 651 pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Terry D. Buller Against the County of Contra Costa or ) District} �. <vov (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of 2 00,0 00 and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) May 30, 2004 @ approximately 12:00 p.m. 2. Where did the damage or injury occur?(Include city and county) Danville Blvd. , approximately 200 yards south of the intersection with Livorna Road,. Alamo, CA, Contra Costa County . See photographs previously 3. How did the damage or injury occur?(Give full details;use extra paper if required) provided. Claimant' s bicycle struck a pothole causing claimant to loose control of the bicycle and fall striking the pavement. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? Failure to inspect, maintain and repair the roadway surface which allowed the pothole and adjacent cracks develop and remain on the surface. 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.) Physical injuries including several fracutred ribs and punctured lung requiring hospitalizaton for six days. 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) General damages, medical expenses and time missed from work. 8. Names and addresses of witnesses, doctors, and hospitals. Summitt Hospital, Emergency Room and Medicalstaffing for six days and thoracic surgeon Coyness Ennix. 9. List the expenditures you made on account of this accident or injury. ATE TD64E 5/30/04-6/3/04 $42,400 Summitt Hospital Additional- medical. bills will be provided for additional medical services Gov. Code Sec. 910.2 provides"The claim must be signed by the claimant or by some person on his behalf.,, END NOT T : (AgQme Name and Address of Attorney ) } (Claimant's Signature) 1418 Lakeside Drive, Oakalnd, CA 94612 (Address) Telephone No. )Telephone No. {510? 832-4295 ****************s*s*s*****s*t**s********s*sss**s*«*#*******#**************:** NOME Section 72 of the Penal Code provides: Every person who,with intent to defim4 presents far allowannae or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,airy false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000or by bath such urrprisouuruent and fine,or by inpisonment in the state prison,by a fine of not exceeding ten thousand dollars($10.000),or by both such imprisonment and fine. i k f Y C L spy C) ui IF � C31 tt� UCS ` tt� C0 c CL ,C cu n; co Q z � ° O adQ ry ° � ° 4 F'i © F a 0 o d a a 0 U Q H C ~ d 0