HomeMy WebLinkAboutMINUTES - 09212004 - C.15 CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION:Ste`. 21, 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 IV below), given
Pursuant to Government Code Section 913 and
915.4. Please nate all"Warnings".
AMOUNT: UNKNOWN ). _j
CLAIMANT: CHERYLE DiGERONIMO
ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 16, 2004
ADDRESS: 1908 POMAR WAY, BY DELIVERY TO CLERK.ON: AUGUST 16, 2004
WALNUT CREEK, CA 94598
BY MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the.Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWEET ,
Dated: AUGUST 1.6, 2004 Ey: Deputy
II. MOM: County Counsel TO: Clerk of the Board of Sup ervisiors
(,yThis claim complies substantially with Sections 914 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 claire on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim(Section 911.3).
( } Other:
`
.Dated: t. r By;- � Deputy County Counsel
111. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant(Section 911.3).
IV, ARD ORDER: By unanimous vote of the Supervisors present:
(4This Claim is rejected in full.
( } Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
Dated: ` �` JOIN SWEETEN, CLERK.,By ' , Deputy Clerk
WARNING(Gov. code sect on 913)
Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited
in the mail to ,file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING
I declare under penalty of 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: 0a4-e) ROI s SWEETEN,CLERK By. �� Deputy Clerk
N 15DK IIHNHUMEN 1 925 335 1421 P.012
Claim to: BOARD OF SUPERVZORS OF tflN'1`RA COSTA CaUtM
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 rause
of action. Claims relating to any other cause of action must be presented not
later than one year after the accrual of the cause of action. (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. 11' 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
filed against each public entity.
E. ' Fraud. See penalty for fraudulent. claims, Penal. Cade Sec. 72 at the end of this
form.
RE: Claim By ) Reserved for Clerk's filing stamp
Cheryle DiGeronimo _, ,
REE . 4.._
Against the County of Contra. Costa ) AUG 1. c
or } #
District)
(Fill in
The undersigned claimant hereby )rakes claim against the County of Contra. Costa or
the above-gid District in the sum of $ and in support of
this claim represents -as follows. - ---- -
1. When did the doge ter injury occur? (Give enact date and hoar)
Friday, August 6, 2004 around 1.0:00 a.m.
2. Where did the damage or injury oaaw? (Include city and county)
Parking lot at 10 Douglas Drive, Martinez, CA - CCC
3. How did the damage or injury occur? (Give full. details; use extra paper if
required) I was working inside the building in m office. My car was narked in a space
and I was told that my car was h1t b another vehicle. The car was Barked �y Lt. Jerry
�anchezg of the District Attorney s 0 fice. When I inspected the veh cies is vehicle was
tockin his front .left bumper to any bumper on the le t side. He too photos, wrote a
report and the Martinez Police also wro e a' re r004-3 2--Of r. Wa ne tos.
I was instructed to call itis Mgmt and ile a rep at
3m anile vee oleourld`Iiiiw.
4. What particular act or omission on the part of county or district officers,,
ser ant9 or 'employees caused.the.injury or Vie? I did not see the accident happen
and I was told that the-car- rolled•ba`ek and hIt'my 'car
:AUG7o9 *2e,04 " 1051 CCC RISK MANAGMENT 925 335 1421 P.03
wria.c are the tames of county or district officers, servants or employees causing
the doge or injury?
Vehicle parked by Lt. .Terry Sanchez of the District Attorney's Office, 130 Douglas
Drive, #200, Martinez, CA.
What damage or injuries do you claim resulted? (give full 'extent of injuries or
dames claimed. Attach two estimates for auto dame.
My vehicle was damaged. on left side of the bumper, left rear light and panel
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or image.) I have attached two estimates for the damage
8. Names and addresses of witnesses, doctors =d hospitals.
N/A
g. List the expenditures you made on account of this accident or iniu:7.
GsV. Code See. 910;2 prove.des s
"'The claim must be signed by the c1 ai r_.nt
SEZ NC'.l'"TCES TO: (Attorne ) or som person on his.behalf."
Name a_nd Address sof Attorney
G'
Cla 's Signature)
1905 Pomar flay, Walnut Creek, CA- 94598
- Addz'ess '
'telephone No. ?e1ephone No. (925) 935-9053(h) (925) 646-2072(B)
�F iE 4F iF #
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 imprisormment in
the county jail- for a period of not mere than one-year, by a fine of not exceed Ing
one thousand ($1,000), or by 'both such impt;isohment and fine;-,or by imprisonment in
the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by
both such imprisonment and fine.
TOTAL P.div,
Date: 8/1312004 07:59 AM
Estimate ID: 9365
Estimate Version: 0
Preliminary
Profile ID: Mike's Auto Body
r
� s
Mike Rose Auto Body, Inc. � F
2140 North Broadway Walnut Creek,CA 94596-3717 J, ?
(925)210-1739 yy 4
Fax: (925)210-3717 f °
Tax ID: 68-0291453 BAR#: AB170842 EPA#: CAR000068362
Damage Assessed By: Sam Arvizu
Type of Loss: Colitsion
Deductible: UNKNOWN
Owner CHERYLE DEGERONiMO s7
Address: 1908 POMAR WAY WALNUT CREEK,CA 94598
Telephone: Work Phone: (925)646-2072 Home Phone: (925)935-9053
Mitchell Service: 917129 t
Description: 1989 Honda Accord LX Vehicle Production Date: 7189
Body Style: 4D Sed Drive Train: 2.01.4 Cyl 4A
VIN: JHMCA5631KC131415 License: 2RAA032 CA
Mileage: 121,309
OEMIALT: 0 Search Code: None
Color: YR949M/GOLD
",All Crash parts on this estimate are "new" original equipment
manufacturer parts, unless otherwise specified. Parts described as
rechromed, recored, remanufactured or, reconditioned are considered
"rebuilt" parts. Crash parts described as "quality replacement part"
are non-original equipment manufacturer new parts"
Line Entry Labor Line item Part Type/ Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 726280 BOY REMOVE/INSTALL L UPR BACK WINDOW REVEAL MLDG Existing 0.2*#
2 726330 BDY REMOVEIINSTALL L BACK WINDOW REVEAL MLDG Existing 0.2*#
3 728560 BOY REPAIR L QUARTER OUTER PANEL Existing 3.0*#
4 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 2.4
5 729620 BDY REMOVE/INSTALL L QUARTER PROTECT MOULDING Existing 0.3*
6 729660 BDY REMOVE/INSTALL L QUARTER WHEEL OPENING MLDG Existing 0.3*
7 736430 BDY REPAIR REAR BODY PANEL ASSY Existing 1.5*#
8 REFINISH TIME ADJUSTED
9 REF REFINISHIREPAIR REAR BODY PANEL ASSY 1.0*
10 737800 BDY REMOVE/REPLACE L COMBINATION LAMP ASSEMBLY 33550-SE3-A11 204.42 0.5
11 900500 BDY* REMOVEIREPLACE STRIPE TAPE **Qual Repl Part 15.00* 0.3*
12 900500 REF * ADO'L LABOR OP FLEX ADDITIVE **Quaff Repl Part 5.00* 0.0*
13 900500 BOY* ADD'L LABOR OP COVER CAR FOR OVERSPRAY *"Qual Repi Part 5.00* 0.2*
14 AUTO BOY OVERHAUL REAR COVER ASSY 1.5
15 739130 BDY REMOVE/REPLACE REAR BUMPER COVER ORDER FROM DEALER 168.00 INC
16 AUTO REF REFINISH REAR BUMPER COVER C 2.6
17 AUTO REF ADD'L OPR CLEAR COAT 1.5*
18 933003 REF ADD'L OPR TINT COLOR 0.5*
ESTIMATE RECALL NUMBER: 8113/2004 07:59:23 9365
UltraMate Is a Trademark of Mitchell International
Mitchell Data Version: AUG 04_A Copyright(C)1994-2003 Mitchell International Page 1 of 3
02
UltraMate Version: 5.0. 4 All Rights Reserved
Date: 8113/2004 07:59 AM
Estimate ID: 9365
Estimate Version: 0
Preliminary
Profile ID: Mike's Auto Body
19 AUTO ADD'L COST PAINT/MATERIALS 240.00
20 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00"
* -Judgement Item
#-labor Note Applies
C -included in Clear Coat Calc
Remarks
PRELIMINARY ESTIMATE
Add'I
Labor Sublet
1. Labor Subtotals units Rate Amount Amount Totals If. Part Replacement Summary Amount
Body 8.0 70.00 0.00 0.00 560.00 Taxable Parts 397.42
Refinish 8.0 70.00 0.00 0.00 580.00 Sales Tax @ 8.250%m 32.79
Non-Taxable Labor 1,120.00 Total Replacement Parts Amount 430.21
Labor Summary 16.0 1,120.00
111. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 240.00 Customer Responsibility 0.00
Sales Tax @ 8.250% 19.80
Non-Taxable Costs 3.00
Total Additional Costs 262.80
1. Total Labor: 1,120.00
If. Total Replacement Parts: 430.21
Iii. Total Additional Costs: 262.80
Gross Total: 1,813.01
IV. Total Adjustments: 0.00
Net Total: 1,813.01
This is a preliminary estimate.
Additional changes to the estimate may be reguired far the actual repair.
Point(s)of Impact
7 Left Rear Corner(P)
PART PRICES SUBJECT TO CHANGE 11
ESTIMATE RECALL NUMBtER, 8113/2004 07:59.23 9365
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: AUG_04_A Copyright(C)1994-2003 Mitchell International Page 2 of 3
UltraMate Version: 5.0.024 All(tights Reserved
Date: 8/13/2004 07:59 AM
Estimate ID: 9365
Estimate Version: 0
Preliminary
Profile ID: Mike's Auto Body
Cycle Time Information_
Repair Dates:
Is Vehicle Driveable(YIN)?: Y
Assisted With Rental(YIN)?: N
ESTIMATE RECALL NUMBER: $11312004 07:59.23 9365
UltraMate Is a Trademark of Mitchell International
Mitchell Data Version: AUG,_04_A Copyright(C)1994-2003 Mitchell International Page 3 of 3
UltraMate Version: 5.0.024 All Rights Reserved
'- Date: 08J13f2084 08:41 AM
Estirte ID: 807
t Estimate Version: 0
Preliminary
Profile ID: STANDARD
PARKER ROBB COLLISION CENTER.
1760 LOCUST STEET WALNUT CREEK,CA 84586
(925)934.4481
Fax: (929)00-1766
Tax ID: 94-1278730 BAR#: A0103714 EPA#: CAD065391452
Damage Assessed By: ED NIELSEN
Payer: Customer Deductible: UNKNOWN
File Number: P
owner CHERYLE DIGERONIMO
Address: 1908 POMAR WY WALNUT CREEK,CA $"N
Telephone: Work Phone. (925)836-114)63
Mitchell Service. 817125
Description: 11189 Honda Accord LX
Body Style: 40 Sed Drive Train: 2.OL 4 Cyl 4A
VIN: JHMCA6931KC131415 License: 2RAA032 CA
Mllesge: 121,510
OEM#ALT: 0 Search Code: None
Calor: YR94M/BRN
Line Entry Labor Line Rem Part Type/ Dollar Labor
Itam Number Type Operation Description Part Number Amount Units
i 728560 BOY REPAIR L QUARTER OUTER PANEL Existing 2.0"#
2 AUTO REF REFINISH L LIUARTER PANEL OUTSIDE C 2.4
3 728610 BOY REPAIR L QUARTER EXTENSION Existing 0.5'*#
4 AUTO REF REFINISH L QTR PANEL EXT C 0.6
6 7211660 BOY REMOVEINQSTALL L QUARTER WHEEL OPENING MLDG Existing 0.3"
9 =920 BOY REMOVEIREPLACE L COMBINATION LAMP LENS&HOUSING 53861-SE3-A02 104.85 0.6
7 737840 BOY REMOVEIREPLACE L COMBINATION LAMP LENS GASKET 3360340402 22.06
9 AUTO BOY OVERHAUL REAR COVER ASSY 1.6
9 739130 BOY REMOVEIREPLACE REAR BUMPER COVER ORDER FROM DEALER 168.00 INC
10 AUTO REF REFINISH REAR BUMPER COVER C 2.6
11 936012 ADDI.COST HAZARDOUS WASTE DISPOSAL 3.00"
12 936014 AD01-COST FLEX ADDITfVE 5.00
13 AUTO REF ADD'L OPR CLEAR COAT 1.6"
14 953083 REF ADD L OPR 'LINT COLOR 0.6*
16 933015 BOY ADD L OPR TAPED STRIPE 10.00* 0.2"
16 AUTO AOD*L COST PAINT#MATERIALS 2:)3.20"
*-Judgement Iteln
#-Labor Note Applies
C®Included in Clear Coat Calc
ESTIMATE RECALL NUMBER: 0811312004 08:41:21 807
IAiraMate is a Trademark of!Mitchell International
Mitchell Data Version: AUG_04 A CvpyrW(C)1994-2003 Mitchell International Page i of 2
13
UltraMate Version: 5. .024 All Rights Reserved
Date: 0W13rA"08.43 AM
Estimate 1D: 807
Estimate Version: 0
Prehrmnary
Profile€0: STANDAR[)
Add?
Labor Sublet
1. Labor Subtotats Units Rate Amount Amount Totals 11. Part Replacement Summary Amount
Body I,.t a0.00 10140 000 367.04 Taxable Parts 294.70
Refinish 7.6 70.04 4.00 0.00 632.04 Sales Tax 9.290% 24,31
Non-Taxable Labor 899.00 Total Replacement Parts Amount 319.03
Labor Summary 12.7 898.04
01. Additional Costs Amount 110, Adjustments Amount
Taxable Casts 248,20 Customer Responsibility 0.00
Sales Tax @ 8.250% 20.48
Non-Taxable Costs 3.00
Total Additional Casts 273.68
L Total Labor, 899.04
H. Total Replacement Parts: 319.81
111. Total Additional Costs, 271.68
Gross Total„ 1,489.69
rV. Total Adjustments* 0.00E
Net Total: 1,489.68
This is a tarelirrlinatl estimate.
Additjonal chancres to the est"Matemay be regujred for the actual repair.
**SPECIAL PARTS NOTE- ALL CRASH FAR'T'S ON THIS ESTIMATE ARE "NEW"
ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED.
PARTS DESCRIBED AS RECHROMED, RECORED, REMANUFACTURED OR,
RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED
AS "QUALITY REPLACEMENT FART "ARE NON--ORIGINAL EQUIPMENT MANUFACTURER
AFTERMARKET NEW PARTS. "ALL PARTS PRICES ARE SUBJECT TO INVOICE, WHICH
MAY CHANGE FROM ORIG4AL ESTIMATE."
ESTIMATE RECALL.€ JMSER: 0811312004 48:41:21 847
U€iraMate is a Trademark of Mitchell International
Mitchel Data Version: ABLE 44 A Copyright(C)1994-2003 Mitchell International Page 2 of 2
UltraMate Version. 6,0.024 All Rights Reserved
CLAIM
BO&RD OF SUPERVISQRS OF CONTRA COSTA COUNTY
BOARD ACTION: SEPT. 21, 2004
Claim Against the County, or District Governed by )
the Berard of Supervisors,Routing Endorsements, ) NOTICE TO CLAIMANT
and Board Action. All Section references are to ) The copy of this document mailed to you is your
California Government Codes. ) notice of the action taken on your claim by the
Board of Supervisors. (Paragraph IV below), give
Pursuant to Government Code Section 913 and
915.4. Please note all"Warnings".
AMOUNT. $6,114.52 it r
CLAIMANT: JAN FRAGA
ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 18, 2004
ADDRESS: 1770 ADELAIDE ST. , #115 BY DELIVERY TO CLERK.ON: AUGUST 18, 2004
CONCORD, CA. 94520
BY MAIL POSTMARKED: RAND DELIVERED
FROM: Clerk of the.Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN S WE TE Jerk
Dated: AUGUST 18, 2004 By: Deputy
II. FROM, County Counsel. TO. Clerk of the Board of Sup `sors
(4--fhisti claim complies substantially with Sections 910 and 910.2.
{
This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim(Section 911.3).
O Other:
Dated: _. By: ' ; ' `f;`` _. I Deputy County Counse
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. ARD ORDER: By unanimous vote of the Supervisors present:
(This Claim is rejected in full.
( ) Other:
r
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
Dated: Z*&tfJOHN SWEETEN, CLERK,By ,Deputy Clerk
WARNING(Gov. code section 913)
Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6, You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned,have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California,postage fully
prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.
Bated: "Q� 2 OHN SWEETEN, CLERK By Deputy Clerk
Claim to: BARD 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 craps and which accrue on or before December 31, 1987,
must be presented not later than the 100th day after the accrual of the cause of
action. Claims relating to causes of action for-death or for injury to person
or to personal property or growing craps and which accrue on or after January 1,
1988, must be presented not later than six months after the accrual of the cause
of action. Claims relating to any Cather rause of action must be presented not
later than rine 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 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 tie of the District should be filled in.
U. If the claim is against more than one public entity, separate claims must be
filed against each public entity.
E. ' Fraud. See penalty for fraudulent claims, Penal, Cade See. 72 at the end of this
form.
M. Claim By . ) Reserved for Clerk's filing stamp
ECS
Against the Count of Contra Costa. -�
or EE3
Districts � , � up�
0,
The undersigned claimant hereby Bakes clai g ix >t e County of Contra Costa car
the above-maned District in the ;gum of � � d �� and in support of
this claim represents �as follows:
1. When did the: dams- e;ar injury occur? (Give exact date and hour)
C 35
2. Where did the damage or injury occur? (Include city and cTT ty}
3. How dial the damage or injury occur? (Give full d ails; use extra paper if
required) -1,_ it' d IN-1
C - Cor) ftp =
4. What particular act or omission on the part of county or district officers,
servants or .employees caused.the-injury or damage'? bkD6
° U , 10�{"
What are the names of county or district officers, servants or employees causing
whe damage or injury?
- '5 t .:.. . t`
5. What damage or injuries do you claim resulted? (Give full extent of injuries or
damages claimed. Attach two estimates for auto damage.
aa Y-Le
Ak SS
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.) • � .
Names and addresses of witnesses, doctors and hospitals.
.. -
List the expenditures you made on account of this accident or injury;
DATE ITEMS MOUNT
Gov. Code Sec. 910.2 provides:
"The clams must be signed by the claimant
SEND NOTICES T0; (Attorney) or some eron his.behalf"."
Name and Address of Attorney ggn
ClaimantIsk gnature
JdAddress
C�C -� ,
Telephone No. Telephone No. c; 1 34
c�C t cfs 1
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or for
payment to any state 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 imprisorbent in
the county jail for a period of not more than cme yeas, by a fine of not exceeding
one thousand ($1,000), or by bath such i#r'isohment and fine;- or by imprisonment in
the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by .
both such Imprisonment and fine.
2023 Va e Road, Suite 1 7
San Rau o, CA 94806
Phone: 5-10-215-9-092
Fax: 5 a-412-9867
49 -�/acc�onai Ave^uc
u;t n c 'A�t.gu August ��, 2004
pav
TO WHOM IT CONCERN:
Jan Fraga-Teal ININNUMM has worked at Brookside Community Health
Center since October 20, 2003. She was unable to work from July 16 to July 30,
2004. During that time, Ms. Fraga-Teal missed 11 days of work totaling 88
hours. Her pay for those 88 hours would have been$1,364.
If I can be of further assistance in this matter, please do not hesitate to call me at
(510)231-9820.
Sincerely,
Ciery o son
Finance hector/COO
DISABILITY REQUEST
Date JULY 16,2004
To Whom It May Concern: (;00
This is to certify that JAN FRAGA _ _ is under my professional
care and has been placed on disability from W07-116-0 to _07- �=4 for the conditirsn of:
CERVICAL SPRAINISTRAIN;THORACIC HYPERFLEXION/HYPEREXTENSION;LUMBOSACRAL SPRAINIS RAIN;
CERVICAL/LUMBAR RESTRICTION OF MOTIONS DEEP&&SUPERFICIAL MUSCLE SPASMS. _i.
If you have any questions, please feel free to call upon me.
MERCADO-LUCIIA CHIROPRACTIC
2702 CLAYTON ROAD, SUITE 100
CONCORD, CA. 94519
PHONE 925-288-0707/FAX 925-288-0705
__._--------
DR.SIGNATURE
Reorder(800)562-3335 E105 DR. SAM LU'CHA.
CHIROPRACTOR
ICA Chiropractic License 28258
County Administrator Contra r
Risk Management Division
2530 Arnold Drive, Suite 140 Costa
Martinez, California 94553 Risk Management
County Administration (925)335-1450
Fax Number (925)335-1421
c•
CONSENT FOR.THE RELWE
OF MEDICAL INFORMATION
I ; 1 authorise L
(Name of Pati t) (Provider of Health Care)
to disclose to the bearer, who represents the County of Contra Costa — Risk Management
Division and/or designated copy service, all medical information necessary to substantiate a
claim initiated by me.
I "hereby consent and request that the bearer be permitted to examine and obtain copies of all
hospital and medical records of every sort and kind, interview doctors and other attendants
regarding all matters relating to examination, diagnosis, care and treatment of myself.
I understand that this Consent for the Release of Medical Information will remain valid unless
cancelled by me.
I hereby acknowledge that I have received a copy of this Consent for Release of Medical
Information. It is understood that a photostat of this authorization is as valid as the original.
Date: Signed:
Address: -070
rX
(Conservator
or Guardi -
Date of Birth: ( " (0 '
Social Security No.
MEDICAL REPORT
PATIENT'S NAME A06 ESS 'TELEPHONE
Jan Witireimina Frage (SS#557-97-1245) 1770 Adelaide St. Concord,CA.$4520 925-864-7346
AGEQ5#NOLE OCCUPATION -
23 yra. EIMARRIED Dental Assistant
EWILOYER tN.AME,ADDRESSA TELEPHONES)
Brookside C.H.0 2923 Vale Road,#111
DATE OF INJURY DATE OF FIRST TREATMENT DIAGNOSIS
97-1504 97-16-94 848.1)Sacroiliac SprairdStrain;847.2)Lumbar Hyperflexion/Hyperextension;840.0)Shoulder
ISpirak0lindn;719.5)Lumbar Restriction of Motion;728.85)Deep A Superficial Muscle Spasms
PATIENT'S ACCOUNT OF WURY --
Jan Frage presented to our office on 07-1 complaining of lower back,heck and mid-back pain from a MVA on 07-15-04.Jan indicated that her
vehicle was rear-ended by a county sheriff's bus causing moderate damage to her vehicle.According to the patient,forward flexion and sitting for
prolonged tame provoke the pain while pain medication would alleviate it.The pain is constant,sharp and moderate in intensity.
PREEXISTING IWURIES OR ILLNESS
None
`TREATMENT RENDEMO ---- _.
Spinet manipulations to restore osseous cksrelationships.Physiotherapy modalities including electrical muscle stimulation,mechanical traction,massage,
myofaal release and thermal therapies to reduce paintntuscie spasms and increase ranges of motion.Two to three times per week for the following
three weeks.Re-evaluation to follow.N additional active care is required,it will be scheduled following re-evaluation.
X-RAYS
:fan as X-rayed at Kalser Wainut Creek the day of the accident.She was informed by the doctor who examined her that there was no evidence of
accute fracture or gross pathology.
Re=lumbar active range of motion with pain in all planes of motion.Positive Faraminal Compression,Soto-Nall,Lasegues,Braggards,Patrick- w
Fabere,Kamps and shoulder depression orthopedic tests.Tight and tender musculature over entire spine noted upon Wrist palpation.
HOS,PITALt2ATIONREQUIRED IF YES,WHERE
13 YES El NO NIA
SURGERY IF YES, EXPLAIN
NIA NIA
PROGNOSIS
Patient is expected to idly recover if chiropractic care and home care instructions ars followed.
PERMANENT IMPAIRMENT(DESCRIBE IN DETAIL)
Permanent impairment is not expected.
PATIENT 01SCHAR0E0 STILL UNDER GARS t7ATE OI LAST 1fI51 f F'ATiENT DISABLED BILL BILI DATE sr1'Acti
Yes No 07-29-2004 F R O M 07 16-04 07-30-04 $1,255.20 i��mim
o
__ sars�ta�,r
ESTIMATED IrtN&BILL I"AS THIS BILL BEEN PAID? IF SO,BY WHOM
$1,255.00 [3 YES ENO N/A
HAVE YOU REPORTED THIS [3 YES IF YES,TO WHOM -�
INJURY TO ANYONE ELSE? E) No L. WA
DATE SI: 7URE OF ATTENDING PHYSICIAN DEGREE IRS NO. TELEPHONE NO. a_
08-93-2004 i ,L', 71-0948591 925-288-0707
ADDRESS CITY STATE
2702 Clayton Road,Suite 100 Concord CA. 94619
CH=IROPRACTOR
USE REVERSE FOR REMARKS
CA Ch
For your wakv.*n,CaUbmia law requires ftt the fottowing ashes speoillod in hwranoe Code 5octon 7871.2 appear
on it4W form."Any parson Yuba kna mingly presents a fkhw or tori$lent calm for ftpayment of a lass is gritty or s crime -
i
and rrsay los subject to tines and int in slate prison."
Reorder(800)S$2-3335 crat
MERCADQ-LUCHA CHIROPRACTIC
2702 CLAYTON ROAD, SUITE 100
CONCORD CA. 94519
PHONE: (925) 288.0707 FAX: {928} 288-0705
ACCOUNT RECORD
NAME. Jan Fraga DATE: 8/3/2004
ADDRESS, 17703 Adelaide Si. Concord,CA.94520 PHONE: 925-864-7346
INSURANCE COMPANY: Contra Costa County(TNrd Party Cialm) TIN : 71-0948591
DATE CODE SERVICE CHARGE
7/1612904 99354 Prolonged Services $180.203
7/1612004 99204 Comprehensive Examination $175.003
7/16/2004 98941 Manipulation 3-4 Areas $65.00
7/1612004 97032 Electrical Muscle Stimulation $35.00
711612004 97039 Genie Rub $30.00
7/16/20304 97012 Mechanical Traction $25.00
7/16120014 97010 Heat Therapy $20.030
7117/2044 98940 Manipulation 3-4 Areas $65.010
7/17/2004 97032 Electrical Muscle Stimulation $35.003
7/17120204 97039 Genie Rub $30.00
7/17/20344 97012 Mechanical Traction $25.00
7/17/2004 970103 Heat Therapy $20.00
7119120 04 98941 Manipulation 3-4 Areas $65.413
7/1912004 97032 Electrical Muscle Stimulation $35.00
7/1912044 97039 Genie Rub $30.00
7/19/2004 97012 Mechanical Traction $25.00
7119/2004 97010 Heat Therapy $20.00
7/20/2004 Cancelled Appointment $4.00
7/2312044 Cancelled Appointment $0.00
7126/2004 98940 Manipulation 3-4 Areas $65.00
7126/2004 97032 Electrical Muscle Stimulation $35.00
7/26/2004 97039 Genie Rub $30.00
7/26/2004 97012 Mechanical Traction $25.00
7/26/2004 97010 Heat Therapy $20.00
7/27/2004 98940 Manipulation 3-4 Areas $65.00
7127/20024 97432 Electrical Muscle Stimulation $35.00
7127/2004 97039 Genie Rub $30.00
7/27/2004 97012 Mechanical Traction $25.00
7/27/2044 970710 Heat Therapy $20.00
7/29/2004 99048 Missed Appointment Fee $25.00
81212004 Cancelled Appointment $0.00
TOTAL. $1,255.203
JDR. SAM LUCHA
CHIROPRACTOR
CA 0;hlro ra�ctic (,!cense 2$268
DISABILITY REQUES ► -
Date JULY 18,2004 .00
To Whom It May Concern:
This is to certify that JAN FRAGA is under my professional
care and has been placed Can disability from 07.18-04 __._...to Y07-30-04 for the Condition of:
CERVICAL 5PRAINIS`C€tAIN;THORACIC HYPERFLEXION/HYPEREXTENSION;LUMBOSACRAL
CERVICAL/LUMBAR RESTRICTION-OF MOTIQN;C► .V& P RFI 3AC Ml15CLf4.SPA5t 5... ............
if you have any questions, please feet free to calf upon me.
M;ERCADO-LUCHA CHIROPRACTIC
2702 CLAY'T'ON ROAD, SUITE 100
CONCORD, CA, 9451.9
PHONE 925-288-0707/FAX 925-288-0705
DR.SIGNATURE
Reorder(800)562.3335 Eros DR. SAN4 LUCHA
CHIROPRACTOR
CA Chiropractic License 28258
Cate: 7/30/04 01:03 PM
Estimate ID: 7865
Estimate Version: 0
Preliminary
° Profile ID: LAB
LAFAYE.TTE AUTO BODY, INC.
3291 Mt.Diablo Blvd.Lafayette,CA 94549
(925)283-3421
Fax: (925)283-3579
Damage Assessed By: RANDY SANDLIN
Deductible: UNKNOWN
Insured: JAN FRAGA
Address: 1770 ADELAIDE ST#115 CONCORD,CA 94520
Telephone: Work Phone: (925)231-9814 Home Phone: (925)864-7346
Mitchell Service: 913120
Description: 1998 Honda Accord EX ULEV Vehicle Production Date: 3/98
Body Style: 40 Sed Drive Train: 2.31-Inj 4 Cyl 4A
VIN: 1HGCG6671WA146656 License: 4RY3499 CA
Mileage: 114,147
OEMIALT: O Search Code: None
Color: SILVER
Options: ALUM/ALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS
POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER
AUTOMATIC TRANSMISSION,AM-FM STEREO/CDPLAYER(SINGLE)
Line Entry Labor Line Item Part Type! Dollar Labor
Item Number Type Operation Description Part Number Amount Units
1 302192 BDY REPAIR R QUARTER OUTER PANEL Existing
2 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 2.0
3 304116 BDY REMOVE/INSTALL R REAR PILLAR MLDG 0.2
4 302286 BDY REPAIR LUGGAGE LID PANEL Existing 3.0*
5 AUTO REF REFINISH LUGGAGE LID OUTSIDE C 1.7
6 303357 BDY REMOVE/REPLACE LUGGAGE LID ADHESIVE NAMEPLATE 08F20-S84-10032 28.05 0.2
7 302824 BDY REPAIR REAR BODY PANEL Existing 1.5*#
8 AUTO REF REFINISH REAR BODY PANEL C 1.1
9 900500 MCH* ALIGN FOUR WHEEL ALIGNMENT Sublet 65.00* 0.0*
10 900500 FRM* REPAIR SET UP&MEASURE Existing 1.0*
11 900500 BDY* ALIGN ALIGN SHEET METAL Existing 1.0*
12 900500 FIRM" REPAIR PULL&SQUARE Existing 2.0*
13 900500 BDY* ADD'L LABOR OP TINT COLOR Existing 0.5*
14 900500 REF* ADD'L LABOR OP COVER VEHICLE Sublet 5.00* 0.2*
15 900500 BDY* ADD`L LABOR OP RUST&CORROSION PROTECTION(A PER PANEL**Qual Repi Part 10.00* Q.0*
16 900500 BDY* ADD'L LABOR OP FLEX New 5.00* 0.0*
17 302550 BDY REMOVE/INSTALL L REAR COMBINATION LAMP 0.4
18 302551 BDY REMOVE/REPLACE R REAR COMBINATION LAMP LENS&HOUSING 33501-S84-A01 77.71 0.4 #
j 19 AUTO BDY OVERHAUL REAR COVER ASSY 1.2
20 302596 BDY REMOVE/REPLACE REAR BUMPER COVER 04715-594-A91ZZ 280.73 INC
21 AUTO REF REFINISH REAR BUMPER COVER C 2.0
22 302598 BDY REMOVE/REPLACE R REAR BUMPER CLIP 90108-SW3-003 2.00 INC
23 302599 BDY REMOVE/REPLACE L REAR BUMPER CLIP 90108-SW3-003 2,00 INC
24 302604 BDY REMOVE/REPLACE R REAR BUMPER SPACER 71598-SL4-013 2.17 INC
25 302605 BDY REMOVE/REPLACE L REAR BUMPER SPACER 71598-SL4-013 2.17 INC
26 302606 BDY REMOVE/REPLACE R REAR BUMPER SPACER 71598-530-013 1.87 INC
27 302607 BDY REMOVE/REPLACE L REAR BUMPER SPACER 71598-S30-013 1.87 INC
28 302608 BDY REMOVE/REPLACE REAR BUMPER IMPACT ABSORBER 71570-S84-A00 37.52 INC
ESTIMATE RECALL NUMBER: 7/30/0413:03:57 7865
UitraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL 04_A Copyright(C)1994-2003 Mitchell International Page 1 of 3
UltraMate Version: 5.0.024 All Rights Reserved
i
s
Date: 7/30/04 01:03 PM
Estimate ID: 7865
Estimate Version: 0
Preliminary
Profile ID: LAB
29 304077 BDY REMOVE/REPLACE REAR BUMPER NAMEPLATE(ADHESIVE) 08F20-S84-100T 15.00 0.1
30 AUTO REF ADD'L OPR CLEAR COAT to
31 AUTO REF ADD'L OPR COLOR SAND&BUFF 23
32 AUTO ADD'L COST PAINT}MATERIALS 264.00"
33 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00"
-Judgement Item
#-Labor Norte Applies
G - Included in Clear Coat Calc
Add'I
Labor Sublet
I. Labor Subtotals Units Rate Amount Amount Totals_ II. Part Replacement Summary Amount
Body 13.5 70.00 0.00 0.00 945.00 T Taxable Parts 466.09
Refinish 111 70.00 0.00 5.00 782.00 T Sales Tax @ 8.250% 38.45
Frame 3.0 70.00 0.00 0.00 210.00 T
Mechanical 0.0 95.00 0.00 65.00 65.00 T Total Replacement Parts Amount 504.54
Taxable Labor 2,002.00
Labor Summary 27.6 2,002.00
III. Additional Costs Amount IV. Adjustments Amount
Taxable Costs 264.00 Customer Responsibility 0.00
Sales Tax @ 8.250% 21.78
Non-Taxable Costs 3.00
Total Additional Costs 288.78
1. Total Labor: 2,00100
ll. Total Replacement parts: 504.54
Ill. Total Additional Costs: 288.76
Gross Total: 2,795.32
IV. Total Adjustments: 0.00
Net Total: 2,795.32
This is a preliminary estimate.
Additional changes to the estimate may tee required for the actual repair.
This estimate is based on current parts prices and labor rate which
are subject to change at a later date. This estimate does not
include repair costs of any hidden damage found on tear--down.
LAFAYETTE .AUTO BODY, INC. agrees to perform repairs which serve to
restore the damaged vehicle to its pre-loss conditon relative to
safety, function and appearance and further agrees to warranty
workmanship, including refinishing, in writing for a period of not
less than one (1) year from the date of completion of repairs.
i
3
ESTIMATE RECALL NUMBER: 7/3010413:03:57 7865
UitraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL 04_A Copyright(C)1994-2003 Mitchell International Page 2 of 3
UltraMate Version: 5.0.024 All Rights Reserved
Date: 7130104 01:03 PM
Estimate ID: 7865
Estimate Version: 0
Preliminary
Profile ID: LAB
ESTIMATE RECALL NUMBER: 713010413:03:57 7865
UltraMate is a Trademark of Mitchell International
Mitchell Data Version: JUL_04�_A Copyright(C)1994-2003 Mitchell International Page 3 of 3
UltraMete Version: 5.0.024 All Rights Reserved
Ci/27/2004 at 08 : 35 AM Job Number:
17908
MIKE ROSE'S AUTO BODY INC.
License #:BAR# AA07562 Federal ID #: 942621349
WHERE QUALITY COUNTS
2001 FREMONT STREET
CONCORD, CA 94520-2616
(925; 686-1739 Fax: (925) 686-1744
PRELIMINARY ESTIMATE
Written By: BRUCE HUBERT #CAD981159189
Adjuster:
Insured: JAN FRAGA-TEAL Claim #
Owner: JAN FRAGA-TEAL Policy #
Address: 1770 ADELAIDE STREET #115 Deductible:
CONCORD, CA 94520 Date of Loss:
Evening: (925) 864--7346 Type of Loss:
Point of Impact:
Inspect MIKE ROSE'S AUTO BODY INC. Business: (925) 686-1739
Location: 2001 FREMONT STREET
CONCORD, CA 94520-2616
Insurance
Company: 7 Days to Repair
1998 HOND ACCORD EX 4--2 . 3L-FI 4D SED SILVER Int:
VIN: 1HGCG6671WA146556 Lia: 4RYS499 CA Prod Date: Odometer:
Air Conditioning Rear Defogger Tilt Wheel
Cruise Control Intermittent Wipers Keyless Entry
Theft Deterrent/Alarm Body Side Moldings Dual Mirrors
Electric Glass Sunroof Clear Coat Paint Power Steering
Power Brakes Power Windows Power Locks
Power Mirrors Power Trunk/Tailgate Anti-Lock Brakes (4)
Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes
Cloth Seats Aluminum/Alloy Wheels
-------------------------------------------------------------------------------
NO. OP. DESCRIPTION QTY EXT. PRICE, LABOR PAINT
BUMPER
1 REAM. -_--�----`--
N 2 Repl Bumper cover 1 280 .73 1. 1 2 . 8
3 Add for Clear Coat 0 0 . 00 0.0 1. 1
4 Repl Bumper cover clip 41 5 11 . 65 0.0 0. 0
5 Rept Bumper cover clip #2 2 4 .00 0.0 0.0
6 Repl RT Bumper cover grommet side 1 1 .03 0. 0 0 . 0
7 Repl LT Bumper cover grommet side 1 1.03 0. 0 0 .0
8 Repl Bumper cover grommet end 2 3 . 80 0.0 0.0
9 Repl Bumper cover spacer #2 2 3 . 74 0.0 0. 0
10 Repl Bumper cover spacer #1 2 4 . 34 0 .0 0. 0
11 Repl Bumper cover screw 4 1 . 52 0 . 0 0 .0
12 Repl Energy absorber 1 37 . 52 0. 1 0 . 0
13 Repl Reinf beam box 1 3 .37 0.0 0 .0
14 REAR LAMPS
1
G'7/27/2004 at 08 :35 AM Job Number:
17906
PRELIMINARY ESTIMATE
1998 HOND ACCORD EX 4-2 .3L-FI 4D SED SILVER Int:
-------------------------------------------------------------------------------
NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT
---
15 Repl RT Lens & housing 1 77 . 71 0 . 4 0 .0
16 QUARTER PANEL
17* Rpr RT Quarter panel 0 0 . 00 7 . 5 2 .2
18 Add for Clear Coat 0 0 . 00 0.0 0 . 9
19 Add for Lock Pillar 0 0 . 00 0.0 0 . 5
20 R&I RT Pillar molding LX, EX, SE 0 0 . 00 0 . 3 0 .0
21 ROOF
22* Blnd RT Roof rail - UP & OVER 0 0 . 00 0 . 0 1 . 0
23* R&I RT Roof molding 0 0 . 00 0 . 3 0 .0
24 R&I RT Drip molding LX, EX, SE 0 0. 00 0 . 3 0 . 0
25# ROPE WINDSHIELD MLDG. 1 4 . 50 T 0 . 3 0 . 0
26# ROPE BACK GLASS MLDG. 1 4 . 50 T 0. 3 0 .0
27 REAR DOOR
28 R&I RT Striker 0 0. 00 0. 3 0 . 0
29# R&I RR Dome light switch assy 0 0.00 0. 2 0 . 0
30# Mask RR. Door opening 1 0 . 00 0. 3 0 . 0
31 Blnd RT Outer panel 0 0. 00 0.0 1 . 0
32 R&I RT Belt w1strip LX, EX, SE 0 0 .00 0. 3 0 . 0
33 R&I RT Handle, outside LX, EX, SE 0 0 . 00 0. 4 0 .0
USA built silver
34* R&I RT Body side mldg EX, SE 0 0. 00 0 . 3 0 . 0
35 R&I RT R&z trim panel 0 0 . 00 0 .4 0.0
36 PILLARS, ROCKER & FLOOR
37 R&.l RT Opening trim rear gray 0 0. 00 0 .2 0 . 0
38 R&I RT Sill plate rear gray 0 0 . 00 0.2 0.0
39* R&I RT Rocker molding EX, SE 0 0 . 00 0 .3 0 . 0
40 WHEELS
41** Repl RECOND RT/Rear Wheel, alloy 1 179. 00 m 0.3 M 0. 0
type 1
42# Subl MOUNT .AND BALANCE 1 18 . 50 X 0 . 0 0 . 0
43# Subl 4 WHEEL ALIGNMENT 1 85 .00 X 0 .0 0 . 0
44# Repl COVER CAR 1 5 .00 T 0 .2 0 . 0
45## Repl FLEX ADDITIVE 1 10 . 00 T 0 . 0 0. 0
46# Refn TINT COLOR 0 0 . 00 0. 0 0. 5
47# Subl HAZARDOUS WASTE 1 5 . 00 X 0 .0 0 .0
48# COLOR SAND & POLISH 1 0 . 00 0 . 0 0. 0
-------------------------------------------------------------------------------
Subtotals =_> 741 . 94 14 .0 10. 0
Line 2 BUMPER TORN FROM VEHICLE ALL ATTACHING HARDWARE MISSING.
Parts 609. 44
Body Labor 13 . 7 hrs @ $ 70 . 00/hr 959.00
Paint Labor 10 . 0 hrs @ $ 70 .00/hr 700 .00
Mechanical Labor 0. 3 hrs @ $ 85 .00/hr 25 . 50
Paint Supplies 10 . 0 hrs @ $ 30. 00/hr 300 . 00
Sublet/Misc. 132 . 50
2
__:
x'7/27/2004 at 08 :35 AM Job Number:
17908
PRELIMINARY ESTIMATE
1998 HOND ACCORD EX 4-2 .3L-FI 4D SED SILVER Int:
----------------------------------------------------
SUBTOTAL $ 2726. 44
Sales Tax $ 933 . 44 @ 8 .25000 77 . 01
----------------------------------------------------
GRAND TOTAL $ 2803 .45
ADJUSTMENTS :
Deductible 0 . 00
----------------------------------------------------
CUSTOMER PAY $ 0 .00
INSURANCE PAY $ 2803 . 45
THIS IS A PRELIMINARY ESTIMATE AND ADDITIONAL CHARGES MAY BE REQUIRED FOR THE
ACTUAL REPAIR.
FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS
FORM:
ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF
A LOSS IS GUILTY OF A CRIME .AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN
STATE PRISON.
THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO
DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR
ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES :
B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT
LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS :
ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE
PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT
PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL
AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION
NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY
REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS
RECOND=RECONDI'T'ION 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
WI =WITH/_ SYMBOLS : #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE
INFOI:LMATION 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 ARG4422 Database Date 04/2004, CCC Data Date 06/2004, and the parts selected are
OEM-parts manufactured by the vehicles Original Equipment Manufacturer. Asterisk (*) or Double
Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been
modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR
Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described
as ANI, 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 by
National Auto Glass Specifications, Inc. Pound sign (#) items indicate manual entries.
3
G7/27/2004 at 08 : 35 AM job Number:
17908
PRELIMINARY ESTIMATE
1998 HOND ACCORD EX 4-2 .3L-FI 4D SED SILVER Int:
ALTERNATE PARTS SUPPLIERS
41 RECOND RT/Rear Wheel, alloy Part No. ALY63775U10P+ price $179.00
Keystone Auto (800) 263-9727
1069 HENSLEY STREET {510} 234-6960
RICHMOND, CA 94801
Keystone Auto {800} 263-9727
1045 E. TRIANGLE COURT (916) 372-028'7
W. SACRAMENTO, CA 95605
5
STATE OF CALIFORNIA r
TRAFFIC COLLISION REPORT Page � Of �
CHP 555 CARS Page 1 (Rev"8)OP1042
r*aw€n ftT&WN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
SPECJAL:'ONDiTIGNS IN.KfeD PUNY
ON-DLII'Y EMERGENCY VEHICLE 0 UNINCORPORATED RICHMOND SUPERIOR CT
t%Aft-Rx41M KT&RiN COUNTY REPORTING DISTRICT $EAT 1
Ila* 74r
Mi8�0+EptiDR
} CONTRA COSTA 400
COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC 4 OFF{CER LD.
SR 4 W/B 07/15/2004 0835 9320 16503
0 MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: (:';`�NONE
C 7
5 h1ILE(S)WEST OF MPM 4 COCO03.70 THURSL7AY vas NO
AT INTERSE -"WTT't{: _ STATE M^iY REL
sR: .5 MILE(S)WEST OF FRANKLIN CANYON RD. YES NO
PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH.YEAR MAKE t MODEL I COLOR LICENSE NUMBER STATE
EQUIP. `PHONES BUS WHT 1053681 CA
A5031207 �A $ G 2001
DRIVER NAME(FiRST,MIDDLE.LAST)
X AUDREY YVETTE CATUIZA OWNER'S NAME - SAME AS DRIVER
T .Sa STREET ADDRESS CONTRA COSTA COUNTY
' 1000 WARD ST; OWNER'S ADDRESS ( SAME AS DRIVER
PARKED CITY I STATE I ZIP 2467 WATERBIRD WAY MARTINEZ CA 94553
VEHICLE �^—# �-^
?MARTINEZ CA 94553 DISPOSITION OF VEHICLE ON ORDERS OF, I {OFFICER {y{DRIVER OTHER i
{B{C'�'- sex HMR EYES Helf#R' WEIGHT BiRTT1DATE RACE DRIVEN FROM SCENE :_...J 1-=1
j CLIST Mo they Year -
F BRN BRN 5.11 170 02/22/1972 H PRIOR MECH.DEFECTS .X NONE APP. REFER TDs NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
f NINE (925)646-4664 CMP Use ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE UNK ONONE MWOR TOP YY
CO.CO.COI fN PY SELF INSURED 48 MODMAJOR ROLL-OVER
DIR OF TRAVEL.I ON STREET OR HIGHVwWY SPEED LIMIT CA DOT
W SR-4 50 CAL-T TCPIPSC MCRA
PARTY DRIVER'S LICENSE NUMBER STATE CLCsS SAFETY VEH.YEAR MAKEIMODEL/COLOR LICENSE NUMBER STATE
2
D2428438 CA 1 9$ HONDA ACCORD SIL 4RYS499 CA
DRIVER NAME(FIRST,MIDDLE,LAST)
X I JAN WILHEM1NA FRAGA OWNER'S NAME ❑SAME AS DRIVER
PEDES srRs ET AoREss RAYMOND GUERRERO
TRIAN
1770 ADELAIDE ST.APT.115 OWNER'S ADDRESS i 1 SAM As DRIVER
PARKED COY/STATE IZIP 1�J
VEHICLE
CONCORD CA 94520 DISPOSITION OF VEHICLE ON ORDERS OF: nOFFICER DRIVER OTHER
BIcY- sex HAIREYES HEIGHT WEIGHT WRTHDATE RACE DRIVEN FROM SCENE
CLIST Mo Day Year
---1 F BRIQ BRN 5.07 170 02/26/1981 W PRIOR MECNf MCAL DEFECTS X NONE APP. REFER TO NARRATIVE
O'T'rIER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUM$ER:
(925)864-7346 NONE CHP Un ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE CARRIER POLICY NUMBER {}NK
VEHICLE TYPE NONE �MINOR
BRISTOL WEST A52-51913970201 MQDoRROLLOVER
Do OF rRAVEL ON STREET OR HIGHWAY SPEED LIMIT
CA DOT
W SR-4 30 CAL-r TCP/PSC, mow
PARTY DRIVER'S LICENSE NUMBER ]STATE CLASS SAFETY VEH.YEAR MAKE I MODEL I COLOR LICENSE NUMBER STATE
3
DRIVER NAME(FIRSr,MIDDLE,LAST) t -�
OWNER'S Nwe I ;SAME AS DRIVER
PEDES- STREET ADDRESS
TRIAN
OWNER'S ADDRESS SAME AS DRIVER
j PARKED CITY t STATE I ZIP
VEHICLE
DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER DTHER
Noy- SEX HAIR EYES JHEIGHT WEIGHT $tRTTiCSAT'E RACE
CLIST Mio Day Ysa�
PRIOR MECHANCIAL DEFECTS NONE APP. EFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER:
CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURNMCE CARRIER POLICY NUMBER VEMNCI.E TYPE I�ILINK NONE MINOR
iMOD MAJOR ROLL-OVER
DLR OF TRAVEL ON STREET OR HiG~Y SPEED LIMIT
CA DOT
CAL-T rCPfPSC MGIMx
PREPARERS NAME DISPATCH NOTIFIED R9&vffR'S NAME ,DAATTEE REVIEWED
D.ONCENA 16503 YES ANO EWA /owl air/i (� ' "
STATEOfCALIFORNIA
RAF COLLISION CODINGPage 2 of
CHP 555 CARS Pa e2 /1 8 UPI 042
,TATE OF4LLIS WN(MO.DAY YEAR) 7fkIE1��OD) NCIO k OFFICER 1.0. NUMBER
071I5/2 )4 4835 4320 16503 T
OWNER OWNER ADDRESS VIOTIFIEM
PROPERTY [DYES NO
DAMAGE DESCRIPTION OF DNrIAGE
SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VEHICLE 1
OCCUPANTS WC BICYCLE-HELMET
-- L-AIR BAG DEPLOYED - G-NOT EJECTED
A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED 1-FULLY EJECTED
i B-UNKNOWN N-OTHER DRIVER 2-PARTIALLY EJECTED I
Z i-DRIVER C-LAP BELT USED P-NOT REQUIRED V-NO 3-UNKNOWN 1
D-LAP BELT NOT USED W-YES
4. 5 6 2 TO 9-PASSENGERS E-SHOULDER HARNESS USED CHILD RESTRAINT
7-STA.WGN REAR F.SHOULDER HARNESS NOT USED Q-IN VEHICLE USED PASSENGER
8-RR.OCC TRK OR VAN G-LAPISHOULDER HARNESS USED R-IN VEHICLE NOT USED X-NO
9-POSITION UNKNOWN H-LAPISHOULDER HARNESS NOT USED S-IN VEHICLE USE UNKNOWN Y-YES
D-OTHER J-PASSIVE RESTRAINT USED T-IN VEHICLE IMPROPER USE
K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK ri SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 112 3 TYPE OF VEHICLE 1 213 MOVEMENT PRECEDING
LIST NUMBER Of PARTY AT FAULT
t A
VC sEcz na VIOLATM A CONTROLS FUNCTIONING A PASSENGER CAR I STATION WAGO A STOPPED
21558(A) B CONTROLS NOT FUNCTIONING` B PASSENGER CAR-W/,TRAILER,-. X B PROCEEDING STRAIGHT
B OTHER IMPROPER DRIVING'
C CONTROLS OBSCURED
C MOTORCYCLE I SCOOTER C RAN OFF ROAD
X D NO CONTROLS PRESENT t FACTOR* D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN
C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP I PANEL TRUCK WI TRAILER I E MAKING LEFT TURN
D UNKNOWN* A HEAD*ON F TRUCK OR TRUCK TRACTOR I F MAKING U TURN
E FELL ASLEEP' X B SIDE SWIPE G TRUCK ITRUCK TRACTOR Wl TRLR. I IG BACKING
C REAR END H SCHOOL BUS H SLOWING I STOPPING
WEATHER (MARK 1 TO 2 ITEM D BROADSIDE i OTHER BUS I PASSING OTHER VEHICLE
X A CLEAR E _HIT 0$JECT EMERGENCY VEHICLE X U CHANGING LANES
B CLOUDY F OVERTURNED K HIGHWAY CONST.EQUIPMENT K PARKING MANEUVER
C RAINING O VEHICLE I PEDESTRIAN I IL BICYCLE L ENTERING TRAFFIC
G' SNOWING H OTHER*: M OTHER VEHICLE M OTHER UNSAFE TURNING
E FOG I VISIBILITY FT. N PEDESTRIAN IN XING INTO OPPOSING LANE
F OTHER:* MOTOR VEHICLE INVOLVED WITH O MOPED O PARKED
G WIND A NON-COLLISION P MERGING
LIGHTING B PEDESTRIAN CI TRAVELING WRONG WAY
X A DAYLIGHT X C OTHER MOTOR VEHICLE ' 3 OTHER ASSOCIATED FACTORS R OTHER*:
B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS)
C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE 5 A vc s>cna+vsgarED: ClanyEg
D DARK-NO STREET LIGHTS F TRAIN NO
E DARK-STREET LIGHTS NOT Q BICYCLE f ;B.vC °"vw Amo YES
FUNCTIONING' H ANIMAL: <: NO
SOBRIETY-DRUG
ROADWAY SURFACE ; C vc s�Cnar VIOLATED: CITED YES 1 2 3 PHYSICAL
X A DRY I FIXED OBJECT: {MARK i TO 2 ITEMS}
B W D =:'•y"rr ih r X X A HAD NOT SEEN DRINKING
C SNOWY-ICY J OTHER OBJECT, E V1610N OBSCUREMENT: B HBD-UNDER INFLUENCE
D SLIPPERY(MUDDY,OILY,ETC,) F INATTENTION`: C HBO-NOT UNDER INFLUENCE'
ROADWAY CONDITION(S) C STOP&GO TRAFFIC D HBO-IMPAIRMENT UNKNOWN'
MARK I TO ITEM PEDESTRIANS ACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE*
A HOLES DEEP RUT* X I A NO PED>oSTRIANS iNVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL'
B LOOSE MATERIAL ON ROADWAY* CROSSING IN CROSSWALK UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN
C OBSTRUCTION ON ROADWA- AT INTERSECTION I K DEFECTIVE VEH.EQUIP.: CffEO H NOT APPLICABLE
D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT YEB I SLEEPY!FATIGUED
E REDUCED ROADWAY WIDTH AT INTERSECTION r NO SPECIAL INFORMATION
F FLOODED* D CRDSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOUS MATERIAL
G OTHER*: E IN ROAD-INCLUDES SHOULDER IM OTHER*: B CELL PHONE IN USE
X H NO UNUSUAL CONDITIONS F NOT IN ROAD X X1 IN NONE APPARENT C CELL PHONE NOT IN USE
G APPROACHING!LEAVING SCHOOL BUS 10 RUNAWAY VEHICLE X X D CELL PHONE NONEIUNKNOWN
0
SKETCH MISCELLANEOUS
DOr
INDICATE NORTH
SEE SKETCH PG.5
...*...Its CP
t
3 t TATE OF CALIFORNIA
INJURVb/WITNESSES 1 PASSENGERS v 3 ofCHP 555 CARS,Pe e 3 Rev Sl9S C1P#fl42
DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCSC# OFFICER I.U. NUMBER
07/1512004 0835 9320 15543
wRNEss PASSENGER EXTENT OF INJURY('ONE) INJURED WAS('X'ONE) PARTY $EAT
AGE SEX sAFETv EJFcrEO
ONLY ONLY - t#JMBER POS. EQUIP.
FATAL SEVERE OTHER VISIBLE COMPLNNT
DRIVER PASS. PED. BICLYCLIST OTHER 4
INJURY INJURY INJURY OF PAIN
❑# ' 26 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 C 0
NAME/D.O.B.I ADDRESS
TELEPHONE
ROGER CANADY,11 (10/08/1977) 1000 WARD ST. MARTINEZ CA 94553 (925)5454664
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
i
VICTIM OF VIOLENT CRIME NOTIFIED
��# ® 22 M ❑ ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 A 0
NAME 1 U.O.B.I ADDRESS TELEPHONE
t3MA 3AY L7C3NMAYNEE 04/11/1982 SAME ADDRESS AS P-1 NONE
(INJURED ONLY)TRANSPORTED 8Y: TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
❑# Ix; 55I- IM-1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑i 1 0 A a
NAME/D.O.B.I ADDRESS TELEPHONE
RALPH CENDE3A5 08/08/1948 SAME ADDRESS AS P-1, NONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
❑#
139 1 M ❑ ❑ ❑ El ❑ ❑ ❑ ❑I 1 0 A 0
3 NAME I D.O.B.I ADDRESS TELEPHONE
BRUCE MMX 07/29/1954 SAME ADDRESS AS P-1. NONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
❑# _142 1v1 ❑ ❑ ❑ ❑ 1❑ ❑ C7 ❑ ❑ a A a
NAME/D.O.B./ADDRESS TELEPHONE
AN'T ONYLUCAS L07/13/19621 SAME ADDRESS AS P-1. NONE
{INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
;3
VICTIM OF VIOLENT CRIME NOTIFIED
}
❑# ❑ I
23 M . ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 A 0
NAME I D.O.B./ADDRESS TELEPHONE
JOSHUA 13tIRTON 07131/1980 SAME ADDRESS AS P-1. NONE
(INJURED ONLY)TRANSPORTED 8Y: TAKEN TO:
DESCRIBE INJURIES: E
VICTIM OF VIOLENT CRIME NOTIFIED
PREPARER'S NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR
D. ONCENA 16503 0711512004
STATE OF CALIFORNIA
iNJUR D/WITNESSES l PASSENGERS Page 4 of�
CHP 555 CAR PAO 3 Rev§M OPI 042
s DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC# OFFICER LO. NUMBER
07/1512004 4835 9320 16503
WITNESS PASSENGER AGE MEXTENT OF iNJURY('X'ONE) INJURED WAS('X'ONE) PARTY SEAT SAFEW e.I>acreJS
ONLYONLY NLRABER POS. EQUIP.
FATAL SEVERE O'I#iER VIS#B1,E PLAINT' DRIVER PASS.
PED, SIOLYOLIST OTHER
INJURY INJURY INJURY OF PAIN
. 47 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 A 0
NAME I O.O.B.I ADDRESS TELEPHONE
DARRELL MC DONALD (08/09/1956) SAME ADDRESS AS P-1. NONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
7E�] 44 M ❑ ❑ ❑ ❑ ❑ �❑ ❑ El ❑ 1 a A a
I NAME/D.O.B./ADDRESS TELEPHONE
JERRY ROBERTSON 07/08/1960 SAME ADDRESS AS P-1. NONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO;
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
i i Q 43 IM I ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 A 0
NAME I D.O.B.I ADDRESS TELEPHONE
JOHN STOUT 06/17/1961 SAME ADDRESS AS P-1. NONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES:
VICTIM OF VIOLENT CRIME NOTIFIED
❑# � 154 IM El ❑ ❑ ❑ [._El ❑ ❑ ❑ ❑ 1 0 A 0
NAME I D.O.B.I ADDRESS TELEPHONE
THOMAS BONNETTA 07/1911949 SAME ADDRESS AS P-1. NONE
:3 (INJURED ONLY)TRANSPORTED BY: TAKEN TO:
t
5.
DESCRIBE INJURIES:
Ll VICTIM OF VIOLENT CRIME NOTIFIED
LD# ER1 M El ❑ El17 ❑ ❑ ❑ ❑ Loi, . 6 a
NAME I D.O.B.I ADDRESS TELEPHONE
ELI GUERRERO 12/27/2002 SAME ADDRESS AS P-2, (925)864-7346
(INJURED ONLY)TRANSPORTED SY. TAKEN TO:
s
DESCRIBE WDRIES:
VICTIM OF VIOLENT CRIME NOTIFIED
i NAME I D.O.B.I ADDRESS TELEPHONE
(INJURED ONLY;TRANSPORTED BY. TAKEN TOr.
DESCRIBE INJURIES:
a VICTIM OF VIOLENT CRIME NOTIFIED
PREPARE R'S NAME rD.NUMBER MO. DAY YEAR REVtEWER'S NAME M0. DAY YEAR
3 D. ONCENA 16503 07/15/2004
_.j
FACTUAL DIAGRAM
HP 555 P Rev.8-87 OP!042
DATE OF COLLISION(SAD (>AY YEAR) TIME(2446) -�-NCIC t W I OFrtCER L6. - 'NUMBER
ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED{SCALE► }
1
. i
t
XNDiCATE
NORTH
`i
'V� W
Qs fZ� t2�
g
1dtsD $LttIS w4kTS LIJI-l>r
f
nrL ------ 4.2
1
1
i
I
ASPM T` x
�REPAR£D BY i 1.0.NUMBER MO DAY YEAR ;REVIEWER'S NAME MD, DAY YEAR ,
OSP 99 28973
FACTUAL DIAGRAMPogo �j of `7
HP 565 R_4 :8-97 .OPt 042
{ATE 4F COLLISION(MQ DAY YEAR) T99{2s0+0) OFFICER i.6. 'NUMBER
ALL MFASURENIENTS ARE APPROXIMATE AMC NOT TO SCALE UNLESS STATED(SCALE* )
INDICATE
NORTH
'Y1�} Yr kY
C �tb►f( Nk vcTjL�id.
'Yk'LLUw t�hwt' !
I S �
y t 1
?4yrws��f
vjcoccz* , vv T,o C
- PREPARED 8Y !I D.NUMBER NO DAY YEM REVIEWER'$mWE MO DAY YEAR
STATE OF CALIFORNIA
ARRAIMISUEELEMENIAL
bATEOF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
07-15-04 0835 9320 16503
1' FACTS:
2
3. NOTIFICATION:
4
5 ON 07-15-04 I RECEIVED A CALL AT 0837 HOURS FROM GOLDEN GATE COMMUNICATIONS
6 CENTER(G.G.C.C. ) OF A MINOR TRAFFIC COLLISION. I RESPONDED FROM I-80 AT APPIAN
7 WAY AND ARRIVED ON SCENE AT 0912 HOURS. ALL TIMES, SPEEDS, AND MEASUREMENTS
8 ARE APPROXIMATE. MEASUREMENTS WERE OBTAINED BY ODOMETER AND BEST
9 ESTIMATION.
10
I I SCENT!
12
13 THE SCENE OF THIS COLLISION ON R-4 W/B JUST WEST OF FRANKLIN CANYON RD. IS AN
14 ASPHALT ROADWAY IN AN UNINCORPORATED AREA OF WEST CONTRA COSTA COUNTY.
15 THE ROADWAY IS FAIRLY FLAT AND LEVEL. THERE ARE TWO LANES OF WESTBOUND
16 TRAFFIC. THIS SECTION OF ROADWAY IS MAINTAINER BY THE STATE OF CALIFORNIA.
17 SEE FACTUAL DIAGRAM FOR FURTHER INFORMATION.
18
19 PARTIES t VRICLES:
20
21 PARTY#1 (P-1, CATITIZA)WAS LOCATED AT THE SCENE SITTING IN THE DRIVER'S SEAT
22 OF V-1, P-1 WAS IDENTIFIED AS THE DRIVER.OF V-1 BY HER STATEMENT AND HER VALID
23 CALIFORNIA DRIVER'S LICENSE.
24
25 VEHICLE#1 (V-1, SHERIFFS BUS)WAS LOCATED AT THE SCENE PARKED ONTHE RIGHT
26 SHOULDER. P-1 DROVE V-1 THEIR AFTER THE COLLISION. V-1 SUSTAINER MINOR DAMAGE
27 TO ITS LEFT FRONT SIDE. NO PRIOR MECHANICAL DEFECTS WERE ALLEGED OR NOTED.
28
29 PARTY#2 (P-2,FRAGA )WAS LOCATED AT.THE SCENE STANDING NEXT TO V-2. P'-2 WAS
30 IDENTIFIED AS THE DRIVER OF V-2 BY:HER STATEMENT AND HER VALID CALIFORNIA
31 DRIVER'S LICENSE.
32
33 VEHICLE#2(V-2,HONDA)WAS LOCATED AT THE SCENE PARKED ON THE RIGHT
34 SHOULDER JUST AHEAD OF V-1, V-2 SUS'T'AINED MINOR DAMAGE TO ITS RIGHT REAR SIDE
35 AND ITS REAR.BUMPER WAS COMPLETELY TAKEN OFF DUE TO THE IMPACT. NO PIROR
36 MECHANICAL REFECTS OR DAMAGE WAS NOTED.
37
38
39
40
PREPARER'S NAME T.D.NUMBER DA`L'E REVIEWER'S NAME DATE
D. ONCENA 16503 07-16-04
STATE,OF CALIFORNIA
ARRADVEISUPPLEMENIAL
PAGE9
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NLJIvI$EIZ
07-15-04 0835 9320 16503
1' STATEMENTS:
2
3• P-1, CATUIZ,A STATED THAT SHE WAS DRIVING V-1 ON SR-4 W/B JUST WEST OF FRANKLIN
4 CANYON R.D. IN THE#2 LANE AT APPROXIMATELY 55 MPH. P-1 SAID SHE PUT ON HER.
5 SIGNAL AND STARTED TO MERGE INTO THE#1 LANE. P-1 SAID SHEHEARI3 A HONK AND
6 SHE SAW V-2 GOING TOWARDS THE CENTER.MEDIAN. P-1 SAID V-2 HIT HER AS V-2 MADE
7 ITS WAY BACK.INTO THE#1 LANE. P-1 PULLED TO THE RIGHT SHOULDER AFTER THE
8 COLLISION.
9
10 P-2, FRAGA STATED THAT SHE WAS DRIVING V-2 ON SR-4 WB JUST WEST OF FRANKLIN
11 CANYON RD. IN THE#1 LANE AT APPROXINI.ATELY 60 MPH. P-2 SAID AS SHE STARTED
12 PASSING V-1, V-1 SUDDENLY STARTED TO MERGE INTO HER LANE. P-2 SAID SHE WAS HIT
13 BY V-I AND WAS SLIGHTLY PUSHED INTO THE CENTER MEDIAN. P-2 SAID SHE WAS ABLE
14 TO GAIN CONTROL OF V-2 AND PULL TO THE RIGHT SHOULDER
15
16 SUMMARY:
17
18 P-1 WAS DRIVING V-1 ON SR-4 WB IN THE#2 LANE JUST WEST OF FRANKLIN CANYON. RD
19 AT APPROXIMATELY 55 NPH. P-2 WAS DRIVING V-2 TO THE LEFT REAR.OF V-1 IN THE#1
20 LANE AT APPROXIMATELY 60 MPH. DUE TO P-1'S UNSAFE LANE CHANGE, V-1'S LEFT
21 FRONT SIDE COLLIDED INTO THE RIGHT REAR SIDE OF V-2. AFTER THE COLLISION, BOTH
22 PARTIES PULLED TO THE RIGHT SHOULDER AND WAITED FOR CHP ARRIVAL.
23
24 AREA OF IMPACT(A.CI.L ):
25 `
26 A.O.I. #1 (V-1 VS. V-2): WAS LOCATED .5 OF A MILE WEST OF THE WEST EDGE OF THE
27 FRANKLIN CANYON RD. U/C AND S FEET NORTH OF THE SOUTH ROADWAY EDGE OF SR-4
28 WB,
29
30 CAUSE:
31
32 PARTY#1 CAUSED THIS COLLISION BY BEING IN VIOLATION OF SECTION 21655 (A) V.C. --
33 UNSAFE.LANE CHANGE. DUE TO P-I'S UNSAFE LANE CHANGE, V-1'S LEFT FRONT SIDE
34 COLLIDER.INTO THE RIGHT REAR SIDE OF V-2.
35
36 THE SUMMARY, A.O.I., AND CAUSE WERE BASED ON THE STATEMENTS OF P-1 ANDP-2,
37 PHYSICAL EVIDENCE, AND VEHICLE DAMAGE.
38
39
40
PREPARER'S NAUME I.D.NUMBER DA'Z'E REVIEWER'S NAME DATE
D. ONCENA 16503 07-16-04
STATS PF CALIFORNIA
JENTAL -PAGE
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
07-15-04 0835 9320 16503
1 RECOMMENDATIONS:
2
3, NONE,
PREPAREWS NAME I.D.NUMBER DATE REVIEWER'S NAME DATE
D. ONCENA. 16503 07-16-04
CLAIM
tr
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY •
BOARD ACTION: SEPT. 21, 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. P., notice of the action taken on your claim by the
Board of Supervisors. (Paragraph IV below), given
k Pursuant to Government Code Section 913 and
915.4. Please note all"Warnings".
AMOUNT: $1,000,000.00 MARTI L.'Z £ ;
SCOTT AW' JARAMILLO And in Guardian
CLAIMANT: Ad L:item Jake Scott Jaramillo and
Allan ,James Jaramillo
ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 19, 2004
ADDRESS: P.O. BOX 1296 BY DELIVERY TO CLERK ON: AUGUST 19, 2004
OAKLEY, CA 94561
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 19 2004 JOHN SWEETEN, C
Dated: By: Deputy _
H. MOM: County Counsel TO: Clerk of the Beard of Supery cors
vlis claim complies substantially with Sections 910 and 910.2.
4
( ) 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: 5 - By: Deputy County Counsf
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:
(0"
This Claim is rejected in full.
{ ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
Dated: / OHN SWEETEN, CLERK, By , Deputy Clerk
WARNING(Gov, code section 913)
Subject to certain exceptions,you have only six (b) months from the date this notice was personally served or deposite
in the mail to file a court action on this claim. See Government Code Section 945.5. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFII)AVIT 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: ' ' SWEETEN, CLERK.By. Deputy Clerk
t . Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS-TO CLA_iMANI
A. Claims relating to causes of action for death or for injury to person or to personal property or growing
crops and which accrue on or before December 31, 1987, must be presented not later than the I Oe day
after the accrual of the cause of action. Claims relating to causes of action for death or for injury to
person or to personal property or growing crops and which accrue on or atter January 1, 1988, must be
presented not later than six months after the accrual of the cause of action. Claims relating to any other
cause of action must be presented not later than one year after the accrual of the cause of action.
(Gov't Code 911.2.).
B. Claims must be filed with the Clerk of the Board of Supervisors at its office-in Room 106, County
Administration Building, 651 Pine Street,Martinez, CA 94553.
C. If claim is against a district ,governed by the Board of Supervisors,rather than the County, the name of
the District should be filled in.
D. If the claim is against more than one public entity, separate claims must be filed against each public
entity.
E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form.
RE: Claire By Reserved for Clerk's filing stamp
E ..
Against the County of Contra Costa or ) AUG I
9 2004
V District)
(Fill in name)
The undersigned claimanthereby makes claim against the County of Contra Costa or the above-named district
in the sum of .� OV*",'and in support of this claim represents as follows:
I. When did the damage or injury occur?(Give exac.l date and hour)
2. Where did tate damage or injury occur?(Include city and county)
3. How did the damage or injury occur?(Give full details;use extra paper if required)C11' c 4y
5fb I'CJ, 4a.,!� o t,\- my
Sere. C t v t_e5l
W. I'K e 55 ok- 7 5
Fn
� Z ±..fi' 1`4 '�c-r 4 CSC kA,`P-ov Cc- i:����`LL 4ak�+
4. What particular act or omission on the part of county or district officers, servants, or employees caused the
injury or damage? I 4e, , '
7
5, What are the names of county or district officers, servants,or employees causing the damage or injury?
e— Oa v }
6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach
two estimates for auto damage.) .otc, t . e-q + e o+' G"k
7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or
damage.) Ok �_+0 -fl,4p— a a" cv eyeee,.�r..c. " - 4_
A`}& L`.o,+; n%A V{ ;cs Ic-t-ie, �� ►�Y r,I i.+.5 ,4 na, ir-fm� ���f� c r E'�. � , ��'��I'.r� co vP`�-.
Vis,
8. Names and addresses of witnesses, doctors, and hospitals ;
+�~
.�,7� e�- t -!YF.V't i�{e�,,. {i/,
9. List the expenditures you made on account of this accident or injury. A ,- v ,`�_
DATE TAMAMC) #+. �w t
/Ylc"Y J7 5',t� e_5+ 1,e1+,\1,1 `tL ti cd.I ..... -v.c h"'t tt�Svc~- t u40 ? r�tcut�
` . eaL - ;c. t t i± -} i�� r�it eD c
} Gov. Code Sec. 910.2 provides"The claim must be
signed by the claimant or by some person on his behalf."
I END Nth T Att me
Mame and Address of Attorney }
(CI mant's Signature)
b. zw _ 7'
�. .
o a kle�l ) (Address)
Telephone No. '7 I '` - -- '!Telephone No. 7 7
*�sts***ts�**�*���*��*�.*s*s***�**����**�:�:*+�+►,s�*s#ss*����**�*s�:*s����**�r�s��*#e���**
NOTICE
Section 72 of the Penal Cade provides:
Every person who,with intent to defraud,presents for allcm—Ance or the payment to any state board or officer,or to any
county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account,
voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not
exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not
exceeding ten thousand dollars(S10,OW),or by both such imprisonment and fine.
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �
BOARD ACTION: SEPT. 21, 2004
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing F! =#g �, _ NOTICE TO CLAIMANT
and Board Action. All Section refer z � Q' The co of this document mailed to you is our
f� } copy Y y
California Government Codes. <$< _ ? {, � notice of the action taken on your claim by the
r".< Board of Supervisors. (Paragraph IV below), giv
}Y� :. Pursuant to Government Code Section 913 .and
t,AAP, 1,14 - ','". . t.:, 915.4. Please note all"Warnings".
AMOUNT: EXCEEDS $10,000.00 and jurisdiction
rests with. the Superior Court
CLAIMANT: BONNIE BASKIN-GILM0RE
ATTORNEY: MARTIN L. JASPOVICE DATE RECEIVED: AUGUST 19, 2004
ADDRESS: 22274 MAIN STREET, BY DELIVERY TO CLERK ON:AUGUST 19, 20014
HAYWARD, CA 94541
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 19 20}04 . JOHN SWE Jerk
Dated: By: Deputy
II. MOM: County Counsel, TO: Clerk of the Board of Sup soAs
(L),"This claire complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 914.2, and we are so notifying claimant. The
Board cannot act for 15 days(Section 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:
mated:
5011' B 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:
M' 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: A . ' `JOHN SWEETEN,CLERK, By , Deputy Clerk
WARNING(Gov. code se on 913)
Subject to certain exceptions, you have only six (6)months from the date this notice was personally served or 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.
IJated ' " " SWEETEN, CLERK By Deputy Clerk
i
1 1' Martin L.Jaspovice-SBN 55275 AUG 19 RECD
FURTADO,JASPOV€CE &SIMONS
2 ij A Law Corporation { }
3 i
22274 Main Street
Hayward, California 94541 `
4 (510) 582-2080 Telephone
5 i (51.0) 582-8254 Facsimile
Attorneys for Claimant
7 ;�
BEFORE THE BOARD OF SUPERVISORS OF THE COUNTY OF CONTRA COSTA
9
BONNIE BASKIN-GILMORE, NOTICE OF CLAIM
(Government Code §910)
Claimant, e
12
i
?(`• TO THE BOARD OF SUPERVISORS OF THE COUNTY OF CONTRA COSTA AND TO THE CLERK
13 �(
14 AND SECRETARY THEREOF:
i
15 j Claimant Bonnie Baskin-Gilmore presents the following claim:
16 i 1. The name and post office address of claimant is as follows: Bonnie Baskin-Gilmore
17
c/o Furtado, Jaspovice & Simons, A Law Corporation, 22274 Main Street, Hayward, California
18
94541.
19 i
20 2. All notices or other communications regarding this claim should be sent to the
21 address set forth above.
i
22 I 3. The occurrence which gives rise to this claim occurred on or about March 3, 2004 in
{
23 the vicinity of the eastbound lanes of San Pablo Dam Road approximately one mile west of Bear
24
Creek Road in the County of Contra Costa,State of California.
25 i
26 l i
FURTA00 JASROVtCE 6
A LAW CORPO4AT70N ; I
22274 MAIN STREET 4{} q
HAYWARD,CALF.94549 1f '.y'(itICQ{1if�a3�lfll 1
t`5lo7 582-1080 ,tt� 33
(Government Code§910) f
4
f:
( t
i
i
1 4. Claimant was driving her 1992 Ford Taurus eastbound on San Pablo Dam !`toad at
2
approximately 5:00 a.m. For unknown reasons her vehicle drifted to the right where it struck a #
3 •;
metal guard rail. The guard rail speared and entered the driver's compartment of claimant's vehicle l
4 1
striking and injuring her right leg. Claimant's vehicle, with a large section of the metal guard rail
6
inside, continued on past the guard rail down an embankment where it came to rest.
7 The guard rail and its wooden support structure as well as the embankment and roadway
3 a surrounding them constituted a dangerous condition of public property on the date of the subject
9
accident for the following reasons:
10 ;f
i a. improperly installed guard rail.
11
t b. Improperly installed guard rail end treatment.
12
ai
13 C. Excessive shoulder drop off.
is
:4 d. Improper height of guard rail.
i
15 i e. Improper height of guard rail end treatment.
16 f. Improper transverse limits of pavement overlay.
17 :1 l
i` g. Failure to terminate west end of guard rail into an existing embankment
13
thereby leaving an opening.
i 9 !
!i
20 The County of Contra Costa created the dangerous condition of public property described
21
above, and/or had actual or constructive notice of it in sufficient time prior to the subject accident to
22 take remedial measures to repair or correct the condition.
23
5. The injuries sustained by claimant as far as known as of the date of presentation of
24
this claim, consist of fractures to the right leg resulting in an above the knee amputation; fractured
26
pelvis; right arm and wrist fractures; liver laceration; collapsed lungs; and multiple lacerations.
26 I
FL}RTAOO,JASPOV!CE
a SfMONS
A LAW CORPORATION 3'
22274 MAIN STREET � � ,
HAY WAR O,CALF.9454. 1 �
15501 582-1080 Notice Of Claim '
(Government Code§910) i
�� i
i}
1 �� l
E 6. The names of the employees of the County of Contra Costa whose negligence and
2
failure to discharge mandatory duties caused the injuries, damages and losses of claimant are
3
H presently unknown.
4 Hi
7. The amount of this claim exceeds $.10,000.00, and jurisdiction of this claim rests
5 ;#
with the Superior Court.
6 j
7 # 8, This claim is submitted pursuant to Government Code §910, j
6
9. The amount claimed as of the date of presentation of this claim is computed as 11
9 I
follows:
10
is
DAMAGES INCURRED TO DATE
11
1. Expenses for medical and hospital care $200,000.00 (estimated)
12 1ii
13 II 2. Loss of earnings $.50,000.00 (estimated)
14 3. General Damages $7,000,000.00
i
15 4. Future expenses for medical care, prosthetics and loss of earnings are unknown at
16 this point in time.
17 'l
Dated: August 17, 2004
16
19 F RT ,SASPOVICESIj}0
20 `
i
21
Martin L.Jspovice
Attorney for claimant
2223
1
i
24
25
l
26 Q
FURTAOO,JASPOVi.CE 1
&SIMONS
A LAW CORPORATION
22274 MAitV STREET ( +>
HAYWARD,CALIF.94541 J
1510 58
z-I OBD Notice 0#Claim
1 (Government Code§910) (
i, l
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY `
BOARD ACTION: SEPT. 21, 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: $374.00
CLAIMANT: KATHY L. S08A IN , SEL
ATTORNEY: UNKivUWN DATE RECEIVED: AUGUST 20, 2004
ADDRESS: 981 ARGENTA DRIVE BY DELIVERY TO CLERK ON: AUGUST 23, 2004
1'ACHECO, CA 94553
BY MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWE T Clerk
Dated: AUGUST 23, 2004 By: Deputy
II. MOM: County Counsel. TO: Clerk of the Board of Supervisors
s claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so 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:
._.- ; � � Q
Dated: c�' By: � � 4 4--2, ., = < Deputy County Counsf
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: ' "" > � 30HN SWEETEN, CLERK,By , Deputy Clerk
WARNING(Gov. code section 913)
Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or deposite
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage full}
prepaid a certified copy of this Beard Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: • ee4�46HN SWEETEN, CLERK.By Deputy Clerk
Claim to; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. Claims relating to causes of action for death or for injury to person or to pe; _
somal property or growing craps and which accrue on or before December 31, 1987,
must be presented not later than the 100th day after the accrual of the cause of
action. Claims relating to causer of action for -death or for injury to person
or to personal property or growing crops and which accrue on or after January 1,
198$, 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 Beard 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 .*lust be
filed against each public entity.
E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 7E at the end of this
forret.
RE: Claim By Reserved for Clerk's filing stamp
Against the County of Conus.Costa }
AUG 2 0 RECT ,
or -
District)
Fill in name ) `
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sum of $ Qty and in support of
this claire represents -as follows:
1. When dial the damage or injury occur? (Give exact date and hour)
2. Where did the damage or injury occur? (Include cit,�j ane# county) ec...o , C.a�' a+,
C.CsS- c�. t-.,-6A 4---4• SCS tt�e ,'t- h 0 eC
3. How did the damage or injury occur? (Give fuU details; use extra paper if
required)
.._......... .. ---..---------------------- --
4. What particular act or omission on the part of county or district officers��
servants or .employees caused- the. injury or damage?
. +gnat are the names of county or district officers, servants or employees causirZ
the damage or injury?
6. What damage or injuries do-you claim resulted'? (Give full extent of i cuLIZZ
damages claimed. Attach two estimates for auto damage. .CL.Q..-4 0_4` 4'
� (Include the estimated amount of any
7. How was the amount claimed above computed.. (Inv
prospective injury or damage.) 4—Q.R _A,64-, rK A• rj
.
Namesandaddresses of witnesses, doctors and hospitals.
9. List the expenditures you made on accotmt of this accident or injury:
DA'C'E ITEM AMOUNT
Gov. Code Sec. '910:2 provides:
"The claim roust be signed by the clair3ant
SEND NOTICES TO: (Attorney) or some erson on his,behalf."
Name and Address of Attorney
Cla' is Signature
a
Ad ss
Gt c E'c. 401 '�7'i✓'"5
' Telephone No. 7 t?
Telephone No.
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
o nmeentin
claim, bill, account, voucher, or writing, is punishable either by imp.
the county jail for a period of not more than one.year, by a fine of not exceeding
one thousand ($19000), or by both such ildprisonment and fine; or by imprisonment in
the state prison, by a fine of not exceeding ter thousand dollars ($10,300, or by
both such: imprisonment and fine.
10 How did the damage occur?
Our street was being repaved. I noticed small amounts of tar on my carpet.
It kept getting worse. More and more spots started to appear as we came in
and out of our house. The tar is in house and on both sides of the car. We
have tar spots everywhere. We even have it in the driveway. When you
walk on the street with shoes that can collect the pebbles in the soles it
brings it into the house. We have swept, washed off and then they laid.
another layer of street. It is a complete mess. I phoned to let them know
about the street, because it wasn't swept properly.
On the car it is on both sides, near the bottom of the car.
I have an estimate to clean the carpet and to remove the tar from the car.
I would like the carpet and car cleaned to remove the tar spots.
A Plus Auto Detail Sal
3600 Pacheco BlvdDate Sale No.
Martinez, CA 94553
925-229-WASH 8/18/2004 1 04-370
Sold To
f
s 5058
1
1
3
3
i
i
Check No. Payment Method
Check
Services Make/Model LicenseNear Discount Price
.'; Overspray Re... Toyota 99 249.00
f
Complete interior& Exterior Auto Detailing
S 1993
Dark Color Specialists
Buff•Polish•Wax (925)229-9274 Offi
Steam Cleaning (925)337-0003 Ce
motors/Undercarriage 3600 Pacheco Blv
PolymerlScotchguard Martinez,CA.945:
Thank you For your business. Total $249.00
A Pius Auto Detail is LVOT responsible for any personal items not removed from the vehicle prior to services, as well as
any mechanical and or physical malfunctions that arise during or atter service. By accepting our services, you agree to
these terms and cannot take legal action against A Plus Auto Detail.
---$45.00 Fee charged to all checks that bounce!►l---
S C'OrW CQr
:
925-685-6465
5100-8-1 Clayton Goad #338
Concord, California 94521
Client Name Service Date
Address : Technician j.
;•
City Zip Nates
Phone
?AID BY: 0 CASH ❑ CHECK' D CREDIT CARD ❑BILL CUSTOMER BY PRIOR ARRANGEMENT
SIGNATURE
ITEMS TO BE CLEANEDIREPAIRED ESTIMA'T'E AMOUNT
I
Fj. i
l
t
S25 fee on returned checks.
Tips are appreciated. balance Due
4"x
CAUTION: FLOORS MAY BE SLIPPERY WHEN WET. Tony's Carpet Care will not be held responsibiafortsny-;niurtes"ot"damage that may
occur from floors that may be damp or wet.Tony's Carpet Care and its technicians agree to perform the services indicated, in proper workman like manner,
using the highest quality of detergent in the cleaning industry.The customer agrees that Tony's Carpet Care is also not liable for any change in color,texture
or shading that may appear before or after cleaning, nor is Tony's Carpet Care responsible for any shrinkage,fraying or opening of seams.
Upon inspecting the articles to be cleaned,the technician pointed out the following to me:
Exceptions Noted-T
I have been advised that the above visible conditions cannot be corrected by cleaning and I herewith give my permission to clean my upholstery and/or carpet
regardless o.,these conditions.Customer signoture constitutes acknowledgement of the contract and acceptance of the conditions stated above.
Signature:
TO OUR CLIENTS:Tony's Carpet Care and their technicians want our clients to be satisfied with the services performed. You are respectfully requested to
inspect the work done and this cont-act. if satisfied and proper,please acknowledge this with your acceptance and approval below.
I am satisfied with the work completed: Signature:
To enhance the life of your carpets,rugs,draperies/blinds and upholstered items,the technician recommends the following cleaning schedule appropriate to
the individual usage of your household considering number of inhabitants,pets,children,location or special considerations not otherwise mentioned.
Carpets-Traffic areas Monthly Quarterly Semi-Annually Annually
Carpets—Whole house }monthly Quarterly Semi-Annually Annually
Upholstered items Monthly Quarterly Semi-Annually Annually
Drapery/Blinds Monthly Quarterly Semi-Annually Annually
APPLICATION TO FILE LATE CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA C •
BOARD ACTION
Application to File Late Claim } NOTICE TO APPLICANT SEPTEMBER 21, 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
(Ali Section References are to ) the Board of Supervisors (Paragraph III, below),
California Government Code.) ) given pursuant to Government Code Sections 911.8
9.x,,4 P1.ease note the "'WARNING"below.
4
Claimant: RACHEL BLOWN '
Attorney: UNKNOWN
Address: 327 W. 20th STREET,
ANTIOCH, CA 94509
Amount: $5,000.00 By delivery to Clerk on: AUGUST 31, 2004
Date Received: AUGUST 31 2004 By mail,postmarked on:: AUGUST 30 2004
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 31, 2. N SWEETEN, Clerk,By: DEPUTY
II. FROM: County Counsel TO: CIL- of theBoar 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 (ea s,-v; € -
DATED. `' SILVANO B. MARCHESI,County Counsel,By.' ,'f x .: DEPUTY
III. BOARD OftDER 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: • ° OHN SWEETEN,Clerk,By: AA9DEPUTY
WARNING (Gov. Code §911.8)
If you wish to file a court action on this matter,you must first petition the appropriate court for an order
relieving you from the provisions of Government Code Section 945.4(claims presentation requirement). See
Government Code Section 946.6. Such petition must be filed with the court within six(6) months from the date
your application for leave to present a late claim was denied.
You may seek the advice of an attorney of your choice in connection with this matter. If you want to
consult an attorney,you should do so immediately.
IV. FROM: Clerk of the Board TO: (1)County Counsel (2) County Administrator
Attached are copies of the above Application. We notified the applicant of the Board's action on this
Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's
copy of this Claim in accordance with Section 29703.
DATED: JOHN SWEETEN,Clerk,By: DEPUTY
V. R M: (1)County Counsel (2)County Administrator TO Clerk of the Board of Supervisors
Received copies of this Application and Board Order.
DATED: County Counsel,By:
County Administrator,By:
APPLICATION TO FILE LATE CLAIM
r
[[ t<
3
Y
jle
e k
i
AUG-3 1 2004
'LERK BOARD OF SUPEM ORS
s CONTRA COSTA 00,.
The Board of Supervisors Contra John Sweeten
tS and
County Administration Building County Administrator
651 Pine Street,Room 108 (925)335-1900
Martinez,California 94553-1293 Co u my
John Giola,1st District
Gayle B.Ullkema,2nd Districts
Donna Gerber,3rd District .
Mark DeSaulnier,4th District
Federal Glover,5th District
.3,.;_ 3
TO: Rachel Brown
327 W. 20t Street
Antioch, CA 94509
NOTICE TO CLAIMANT
(4f Late-Filed Claim)
(Government Code Section 911.3)
The claim you presented to the Board of Supervisors of Contra Costa County,
California, as governing body of the County of Contra Costa on August 23, 2004, has been
reviewed by County Counsel and is being returned to you herewith because:
X Your claim for an injury to person or personal property was not presented within six
months of the event or occurrence as required by law. (See Government Code sections 901
and 911.0
® Your claim relating to a cause of action other than injury to person, personal
property or growing crops was not presented within one year after the event or occurrence as
required by law. (See Government Code sections 501 and 911.2)
Because the claim was not presented within the time allowed by law, no action was
taken on the claim.
Your only recourse at this time is to apply without defy for leave to present a late
claim. (See Government Code sections 911.4 to 912.2 and 540.5) Under some
circumstances leave to present a late claim will be granted. (See Government Code section
911.6)
Rachel Brawn
Re: Claim
Page Two
You may seek the advice of an attorney of your choice in connection with this matter.
If you desire to consult an attorney, you should do so immediately.
Date: AUGUST 27, 2004 JOHN SWEETEN, Clerk of the Board
of Supervisors and County Administrator
By:
eputy Clerk
Enclosure
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 1 deposited in the United
States Postal Service in Martinez, California, postage fully prepaid, a copy of the above
NOTICE TO CLAIMANT (OF LATE-FILED CLAIM), addressed to the claimant as shown
above.
Date: AUGUST 27, 2004
Depu# Clerk
I:ITORTRISK-MGTi CLAIMS\LATE\Brown.wpd
Claim to: HOARD OF SUPERVISORS OF. CONTRA COSTA COJNI'Y
INSTRUCTIONS TO CLAIYANf'
A. Claims relating to causes of action for death or for injury to person or to per-
sonal property or growing craps and which accrue on or before December 31, 1987,
must be presented not later than the 100th day after the accrual of the cause of
action. Claims relating to causer 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 net 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 mart be filed with the Clerk of the Board of Supervisors at its ,Office in
Room 1036, County Administration Building, 581 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, Vena' Code Sec. 72 at the end of this
form.
RE: Claim By } Reserved for Clerk's filing stamp
}
} R .Y -,
Against the Ccunty of Contra Costa } # AUG 2 0 RECD
or }
District) ; h
Fill in name5
The undersigned clamant hereby makes claim against the County of Contra Costa or
the above--named District in the sum of and in support of
this claim represents -as follows: _
1. When did the damage or injury occur? (Clive exact date and hour)
NOV 4 aQ Ain
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
4. What particular act or omission on the part of county or district officers,
servants or .employees caused.the. injury or damage?
gnat are the names of county or district officers, servants or employees causing
the damage or injury?
.�.c
-.ate ._ '« .. .�t .._
5. What damage or injuries do you claim resulted? (Give full extent of injuries or
damages claimed. Attach two estimates for auto damagej.
s:. i'Jt`��°t .Y
'f•} p'y' .
s he amount c ai aot: ova co tlted? (Include t e estimated amount of any
prospective injury or damage.) _ -:
. Name an addresses o witnesses, doctors and hospitals. `� �' Jt
is Cp�J y:dtd V
q{ / � •-� $ ?i/4A'L..J". +!.3 4. { J J G✓`t..... "'}°i`�.e` '�-C�?"i k .'�. "S..
�. �'.►«���.. f «..«�.�«...rte. ..«+....... .. s�l /A � et" &.c._�3..........r� carc.t
c4;rt 't
s
o,. List the expenditures you made on account of this accident or injury:
DAM Ii` M AMGU�'T
w �
c - Ph s S' c ad t '_r�t J ?e9
Gov. Code Sec. 010;2 provides:
"The claim roust be signed by the. claimant
S"ND NOTICES TO: (Attorney) or by some person on his.behalf."
Name and Address of Attorney
Claimant's grikture
"t`•-
i!p AddrSre�s's
:. �
Telephone No. Telephone No.:51 - qyl !__ o_u`
* �€
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for a?.lowance 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 imprisoriment in
the county jail for a period of not more than one-year, by a fine of not exceed ing
one thousand ($1,000), or by both such imprisonment and fine;- or by imprison n' in
the state prison, by a fine of not exceeding ten thousand dollars ($1G,Q00, or by
both such imprisonment and fine.
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CONTRA C0535TA COUNTY ��'a' FA, kAX
FAMILY AND C:NILI AEN'S SERVICES &CHWO'Xht'S
ACClDENTl1NCIDENT REPORT iZVi� S
i #carne: T` oat f Birth:
` rr14L I'N
,1
center =Daleofn�ncident: 7irne:
\•F..'\ t
Brief description of accidentrncident: -
r
t I' .�^- L. � _ i4. {)Y'�.R.... .,'F` '"`t:�^sL °.a�'a'`�^.S. _`�„•.,G .+,� l<'--tit i...•.� "•� �.��.�.,...i('f'�.
t n Zt . �-.tt fir,,»firms•. t-'� a Kr' .'Jr . "n �f , L7'r: rl, N
Follow-up (first aid, child/person taken to emergency hospital, parent notified, etc.)
Y1 jE
spa � ..rx,v t e1 A`� IN a
.r.
Witness(es): X. -4 _ �°�
I hereby certify that the details of the accidentfincident were explained to me.
61 Q,.- — _.-1
ParenMuardan Signature Person Reporting Accident
^1� r
Address Date
Cita,Mate,Zip Code Teacher Signature / 1
Phone Number Date
Form completed for information only.
[ ) Form completed for insurance purposes• accidentlincident was serious and
needed physician evaluation. (Form must be submitted to central office within 24 hours.)
C`e>IJ3 Ilixlrrhtrttru:: White •bivisirrrt File reflaw-Chihi celarrrl l`le PirrX-1'urrrrtlt;rrrrr`rlirrrt f;r=lrlrrtrrul-Srrfrtr l)ffr`<e r
FACS-208IX/9 )
CONTRA COSTA COUNTY I Amity
FAMILY AND CHILDREN'S SERVICES &CRWDPjrA
ACCIDENTfiNCIDENT REPORT ,rpwicr-s
bate of SittK
centeF:'
gate of accifenthri6dent: "rime:
PR I I i ~�1 Q-T
Brief description of accidenbrincident.;� �
A-f tt
Wu
Follow-up (first aid, child/person taken to emergency hospital, parent notified, etc.)
akz 4t VA k� 1 t
r f` r 1 r
1
YVit ss{es}.
I hereby certify that the details of th6`accidentAinf;ident were explained to me.
Pamt/Guar&an Signatwe RewtinVaident
Acickess Data
CHS
cam.st4�,Zip Code
Ptkww Nth: Date
y
j Form completed for information only.
Form completed for insurance purposes - accidenthncident was serious and
needed physician evaluation. (Form must be submitted to Central office within 24 hours.)
{ovy Pistt7tziuiriri 'li'hifr J311'Cstrflz File }i•!t»+r-C ltifrt trzirrrt F�itr t'izt,t-t'ztr'rYitlf�ttrtt'ititfti ftrrtrtritt'txl-.SFifi°tS"t1,(fi#f C