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HomeMy WebLinkAboutMINUTES - 08312006 - C.17 • f CLAIM HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: OCTOBER 03y 2006 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 California Government Codes. D �cm� you is your notice of the action taken on your claim by the Board of AUG 3 0 2006 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTyL AMOUNT: $2 400. 00MARTINEZ Section 913 and 915.4. Please note all MART N Z CALIF. ` "Warnings". CLAIMANT: CENTRAL CONTRA COSTA SANITARY DISTRICT BY: KIMBERLY J. GREER AUGUST 31 , 2006 ATTORNEY: UNKNOWN DATE RECEIVED: ADDRESS: 5019 IMHOFF PLACE BY DELIVERY TO CLERK ON: AUGUST 311 2006 MARTINEZ, CA 94553 AUGUST 30, 2006 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, JOHN CULLEN, C etc Dated: AUGUST 31 , 2006 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (>4'/rris 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). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claire (Section 911.3). O Other: Dated: � '— By: r �- � Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). . I V. BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. +� n�,t�y, t` Dated:® G'�40 �lAN CULLEN, CLERK, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only sit(6)months from the da a this uotice was personally served or deposited ur the mail to rile a court action ort this claim.See Goveuliment Code Section 945.6.You may seek the advice of an attorney of your choice ut connection with this matter. If you wall to consult all allorney,you should do so imu►edintely. *For Additional VVar niijg See Reverse Side of 11iis Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjuiy that I ant 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 Stales Postal Service in Martinez, California, postage full} pre i certifi d copy or this Boni d�Order surd Notice to Claimant, addressed to the claim t as sh 1/'n abCe. bated:CL.)'��" ���,6•tC►I1[I CUI_:L,LN, CLERK BSS DeptUy Clerl: F� -rA". 30. 2006 10:55AM CCC RISK MANAGEMENTN0. 924 P• 2/3 BOARD OF STTPFRVLSOR.S OF CONTRA COSTA COUNTY u4sTRuCTIONS To CWZWW m relatu6a to a cause of action for death or for injury to person ar to personal property or growing crops shall be presented not later than six months after the accrug of the cause of action. A claim relating to any other cause of action shall be.presentted not later thaw ate year . after the accrual of the cause of action. (Gov. Code § 911.2.) Claims must be filed with,the Clerk of the Board of Supervisors at its office in Room 1063 County Administration Building,651 Pine Street,Marquez,C.A.94559. 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. ). If the claim is against more than one public entity, separate claims mta be filed against each. public entity. i. Fraud- See penalty for fraudulent claims,Penal Code Sec. 72 at the.end of this fOrM [[i[[llti ct[Ft[iG[F GiR■il[[FC[FGLI[lLi+lLl[/Llt[[[{Fiiii[t RRR[[Rf[FRl[1Rt[C IFLpt tl (/tE: I,C,l-a/i-m By: Reserved for Clerk's filing stamp 1. e���r RECEIVED Against the County of Contra Costa or 3 AUG 3 1 2006 } Pistrct) CLERK 8 TRD OF RA COSTA SUPERVISORS (FM in.the name) The undersigned claimant hereby makxs claim agai ust the County of Contra Cosm or the above-named district in the sum.of S 2-,4o0 0o and in support of his claim represents as follows: L %aa did the damage or injury occur? ((Xve exact date and hour) Jwly Z`I200(0 � = 2. Where did the damage or injury occur? Clnclude city gad county) N1An a,�,nCz C4 ��aw4 n� s�u �a�, Cts- 'Biw*L (2d 3. Haw did r the damage orIury occur? CCrive full details,use extra paper if required} L 1 Y�1 Signed ui I etre b64k Vek,,, ct'CS ka-c( 2 � V' �c�lv1 i 0I BCcured . -PLtaa,e. S-ee i� /v- ef- Qcnd in�erc�o f 4- What'partioular ad i or ortussion oa the part of county or distnc�t officers, se wants, or emplayees . oeide&� caused the injury or damage? llgp n)- T a I ct re p �UlSL1 re T L C sl ylla� s hC?iavu c� 1�rZ��°Lf 5 What are the names of county or district ooffa.cers,serven e nts o emeployees causinggtt e n����� ����`��`i``' damage or injury? n(� AUG. 30. 21006 10:55AM CCC RISK MANAGEMENT N0, 924 P. 3/3 What damage- or injuries do your claim resulted? (Give fL extent of inJudes or damages - `claimed -1Lttach two estimates for auto damage.) - Ylo �ers6noQ l�adil y thjNr, s. Uti(it�clt G�Gvna nw�j l99'7 7. How was the amount claimed above computed? (Include the estimated amount of any Tacw prospective injury or dabgAge;) 11 pa5r5 I x1e"'' - �JPaL vav(t4,e d) 4ik S: Names and addresses olfl witnesses,doctors,an ospi s: vat&,,I- - ?-L1 ,- )1?nh;s �dsenb��-„- 2331 �ac11e�'o ��, -C'onco d CA- 9. List the expenditures you made-on,account of this accident or injury: DATE T7MB AMOUN (00 60 4J a as RaE tar con a BR a gas xaatata a■all alaaRR to RR a OR a F Qa RB Cad NO WE R H¢a at a916 Raft a a R as P R a a B&UK at ) .Gov. Code Sea. 910.2 provides"The claim shall be )siencd by the claimant os by some person oa his ) „ SENM NOTICES TO: (Attomav) 1 Name and address of Attorney } (Address) j ma Telephone No. }Telephone NTo._Lqzs_ d,) 9 - 73 a 0 /1ZGto(/�rc+ vt S w'}aaPlta•KtaPtRt a RRPaaR tanaRaa R[RIa4RHKDtF¢¢B$■R86S¢tl RDa DRa Hat eaRatata Data■at a MEMBER ^�.�� as �- -7366 PUBLIC RECORDS NOTICE: /redo,' q Ae4 t4 Please be advised ma#this claim form,or any claim filed with the County uader the Tort Claims Act,is sibject to Public disolom m under'the CaUoraia Public Rem'rds Act. (Gov. Code, 55 6500 at seq.) 1~urtbmmore, any aitaohmeRt%addeadums,or sapplemeats attached to the claim form, including medical=or&,are also subject m public disclosure, PRa Raiat tan Allw aaaaR RF OR as iat8 at8 cat HD aRa eaaga9t8Q¢BRtlB Re aaaeKa RRaeKRaB■Pa aRt Paa8aa88t NOTICE: Section 72 of the Penal Code provides; Every perwa who,Rrith intent to defraud,presents for allowance or for payment to nay state board or offices, m to any county, city, or district board or officer, anthod=d to allow or pay the same if genuiae, auy false or Eaudulent claim,bsilt, account voucher, or writing, is punishable either by imprisonment in the County jag for a Period of not more titan one year, by a flue of not exceeding one thousand dollars (51,000.00), or by both such imprisoammt and fine, or by unprisonmeut in the stat prison, by a at of not exceeding tan thousand dollars or by both such unprisonment and fine. o ' STATE OF CALIFO.-VIA TRAFFIC COLLISION REPORT ; CHP 555 Page 1 (Rev.7-03) OPI 061 Page 1 o/ 7 SPECIAL CONDITIONS NbrMER IT RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER INJOREO FELONY O ❑ �AJJ7JL uUMeEK WLEO HOa RUN COUNTY REPORTING DISTRICT BEAT DMcDEMEANOR V Yry '/3 ❑ C05-1 A '--2- COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCIC tl OFFICER I.O. o 44C -+ Eco �Z. G �2 - 24 -Ot/�:7 55.E 9320 MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ©NONE Q S MT WTFS W YES ❑ NO C) FEETIMILES OF O ®AT INTERSECTION WITH STATE HWY REL ❑OR: FEETIMILES OF L/�.IAi� I�.1'I `//� ❑YES NO PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR SAG :SAFETY EQUIP. VEH.YEAR MAKEJMODEUCOLOR LICENSE NUMBER STATE L- Kx�. DIIIVER NAME(FIRST,MIDDLE,LAST) �,( ® �Rl F- /tiN)J �Y L C OWNER'S NAME ® SAME AS DRIVER PEDES STREETADDRESS TRIAN ❑ Z/i i 2"J" AvE: SO. OWNER'S ADDRESS GI SAME AS DRIVER PARKED CITY/STATE2IP U VEHICLE (� /� J V ) DISPOSITION OF VEHICLE ON ORDERS OF: ❑ `LEA�vJT T I LIS ,( � ❑ OFFICER H DRIVER ❑OTHER BICY' SEX HAIR EYES IHEIGHT WEIGHT BIRTHDATE RACE �i V C,14 r• / LUST BL-LAI Mo. DRY YBer �[r ❑ ko'� S'7 ',So (; — f- ,57 �,,) PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHEfl 72-7b(,52-- O/A�E PHONE �'T ` BUSINESS PHONE V` VEHICLE IDENTIFICATION NUMBER: ❑ I L —7 6 S 2- 7 2 5 1 1 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER Y'TPOLICY NUMBER 11UNK. [:]NONE ❑MINOR �a p� A-P 064S92- ��4 ®MOD. ❑MAJOR❑ROLL-OVER DIA OF TRAVEL ION STREET OR HIGHWAY % 42 SPEED LIMIT S PAC-14V O I�LI�, v/fl 3S CA Dor CAL-i 7CY/PSL MC/MX --�� PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR SAG. SAFETY EQUIP. VEH.YFAR MAKF/MODEUCOLOR LICENSE NUMBER STATE DRIVER NAME(FIRST,MIDDLE,EAST) NAME'S ul i �_ ,R , + /nK LL S G.S!J OWNERFl SAME AS DRIVER PEDES. STREET ADDRESS GN�.. 1 COS r T OWNER'S ADDRESS 332 L>,r.!o AUE. � ❑ SAME AS DRIVER PARKEDGITY/STATE/ZIP 7R mf-i,o� J�T - lZ_ / .,,,, VEHICLE 7 y/ )YTcam' 11 O�. CIA, / A, 9c—�j (� DISPOSITION OF VEHICLE ON ORDERS OF: • ❑ OFFICER® DRIVER ❑ OTHER BICY SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE CUST A Mo. Day Year O O/f!1V �r I V✓ ElM SU SIG'CJ Zoo _ I _ +F, PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE -f VEHICLE IDENTIFICATION NUMBER: ❑ /v ( — l 6 CgZS 22-9-7 36 2 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA IFISINIaNcIRRIE�F Js�n PDUCY NUMBER SS LLMOD. ❑MAJOR❑ROLL-OVER © DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT �L(,/L.J✓I '_.•��. Gee 35 CAL-T TCPIPSC MC/M% PARTY DRIVERS LICENSE NUMBER STATE CLASS AIR BAG :SAFETY EQUIP. VEH.YEAR MAKE/MODEUCOLOR LICENSE NUMBER STATE 3 NAME _........ . ............... ...// DRIVER (FIRST MIDDLE,LAST) ............... ........................ ............ ❑ OWNER'S NAME ❑ SAME AS DRIVER PSDES- STREET ADDRESS ` TRIAN \ i ElOWNER'S ADDRESS SAME AS DRIVER '.PARKED CITYISTATEMP \ VEHICLE ❑ \ DISPOSITION OF VEHICLE ON ORDERS OF: -E]OFFICER❑DRIVER ❑OTHER CI ST SEX..., HAIR..-., --EYES HEIGHT.. WEIGH, BIRTHDATE RACE Mo. DRY Year ❑ PRIOR MECHANICAL DEFECTS: NONE APPARENT 7REFER TO NARRATIVE OTHER HOME PHONE - BUSINEPS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ ,/ VEHICLE TYPE DESCRIBE VEHICLEDAMA/G/5 SHADE IN DAMAGED AREA - INSURANCE.CARRIER - / POLICY NUMBER DUNK ❑NONE ❑MINOR i ❑MOO. ❑MAJOR❑ROLL-OVER .. DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT CAL-T TCP/PSG MC/MX PREPARERS NAM DISPATCH NOTIFIED REVIEW '$NAME DAT REV WED �+ � ❑YES ENO 0N/A Z . STATE OF CALIFORNIA TRAFFIC COLLISION CODING pr,.. CHP 555 Page 2(Rev.7-03) OPI 061 Page of 7 t(MO. DAY YEAR) TIME(2400) NCIC tl OFFICER I.O. NUMBER 4 -lJ6 lsso 320 l67t3 7- 29-SCWNER'S NAME OWNER'S ADDRESS YES NO DESCRIPTION OF DAMAGE .4 SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M I C BICYCLE.HELMET A-CELLPHONE HANDHELD ^ A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER V-NO X-NO C-ELECTRONIC EQUIPMENT C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES D-RADIO/CD D-LAP BELT NOT USED E-SMOKING 1 2 3 1-DRIVER E-SHOULDER HARNESS USED F-EATING 4 5 6 2 TO 6.PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN 7-STATION WAGON REAR G-LAPISHOULDER HARNESS USED 0-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS S-REAR OCC.TRK.OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED i-FULLY EJECTED i-PERSONAL HYGIENE 9-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING 7 0-OTHER K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE 3-UNKNOWN K-OTHER U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 2 SPECIAL INFORMATION 1 2 MOVEMENT PRECEDING LIST NUMBER # OF PARTY AT FAULT COLLISION A vc SECTION vw-lEO: CITED A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED YES B CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE B PROCEEDING STRAIGHT~ B OTHER IMPROPER DRIVING': C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT I FACTOR' D CELL PHONE NOT IN USE I ID MAKING RIGHT TURN C OTHER THAN DRIVER' _ TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN' _ A HEAD-ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN _ B SIDE SWIPE G 32 FT TRAILER COMBO _ G BACKING C REAR END H H SLOWING/STOPPING ' WEATHER MARK T TO 21TEMS D BROADSIDE I I PASSING OTHER VEHICLE LFOGE HIT OBJECT J J CHANGING LANES F OVERTURNED K K PARKING MANEUVER G VEHICLE/PEDESTRIAN L L ENTERING TRAFFIC H OTHER': M M OTHER UNSAFE TURNING BILITY FT. N N XING INTO OPPOSING LANE MOTOR VEHICLE INVOLVED WITH O O PARKED ANON-COLLISION P MERGING GHTING B PEDESTRIAN Q TRAVELING WRONG WAY A DAYLIGHT C OTHER MOTOR VEHICLE 1 2 OTHER ASSOCIATED FACTOR(S) R OTHER': B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK i TO 21TEMS) C DARK-STREETLIGHTS E PARKED MOTOR VEHICLE "+j ,'hFA VC SECTION VIOWION. CITED ❑ D DARK-NO STREET LIGHTS F TRAIN YEs NO E DARK-STREET LIGHTS NOT G BICYCLE >x,B vc SECTION MOUNON: CITED ❑YES FUNCTIONING' H ANIMAL: ❑No SOBRIETY-DRUG❑YES ROADWAY SURFACE FIXED OBJECT: ONO I _".. - C VcSECTION VIOIATION. CUED 1 2 PHYSICAL A DRY ..v,}.; (MARK 1 TO 2 ITEMS) J B WET _ D, :c=rt c;? t fSYs A HAD NOT BEEN DRINKING C SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: B HBD-UNDER INFLUENCE D SLIPPERY MUDDY,OILY,ETC. - F INATTENTION': C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITION(S) G STOP 8 GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN' (MARK 1 TO 27TEMS) PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE- A HOLES,DEEP RUT' )/,IA NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK - J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN _ C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE _ D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT ❑YES I SLEEPY I FATIGUED- E REDUCED ROADWAY WIDTH AT INTERSECTION ❑NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE _ G OTHER': E IN ROAD-INCLUDES SHOULDERM OTHER': H NO UNUSUAL CONDITIONS _ F NOT IN ROAD N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS O RUNAWAY VEHICLE SKETCH O MISCELLANEOUS INDICATE NORTH _.=Np DOT a [ M'i't1 R ctip Tr, STATE OF CALIFORNIA INJURED 1 V1(ITNESS I PASSENGERS CHP 555 Paqe 3(Rev 1-03) OPI 061 Pages O/7 DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC R OFFICER LD. NUMBER4! 7 15s-0 9320 l6 `-` WITNESS PASSENGER EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) pgRTY SEAT AIR SgFE ONLY ONLY AGE SEX FATAL SEVERE OTHER VISIBLE COMPLAINT NUMBS POS. BAG EQUIP. EJECTED DSS. PEO. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN �# I ❑ ❑ ❑ ❑ ❑ 1190 ❑ ❑ ❑ N ME 10.��J0 B.I ADORE TELEPHONE � hJ T osaJ r T 22-SD 33 .a Qk, C���Lor 1� G�1 -C -902 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑? ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I O.O.B.I ADDRESS TELEPHONE (INJURED ONLY(TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED NAME 20.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: I ,DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ O I ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ 101 NAME/D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN T0: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIMENOTIFIED ❑` ❑ ❑ ❑ ❑ \ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B.I ADDRESS TELEPHONE INJURED ONLY)TRANSPORTED BY: TAKEN TO: ]ESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED �# ❑ ❑ ❑ ❑ ❑ IF-111:1101 ❑ 1111 1 1 1 1 (AME/D.O.0.I ADDRESS } TELEPHONE NJUREO ONLY)TRANSPORTED BY. /J TAKEN TO. ESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED REPAIRER'S NAME - I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR ' STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL Page 4 of 7 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 7/24/2006 1550 9320 16713 7-295 PACHECO N BLVD. I , I I I R/TURN 02 I 11 U TURN LN. SIB I SIB LN. I I i 1 12 ft.a 412 ft..L 12 ft.m 412 ft.ms 12 ft.►i�-20 ft. _ I I I I -) I I I I I TO SR-4 WIB V` /I 12 ft. 14 ft. w I 12 14 ft. 12 ft. 20 ft. 12 ft. FROM BLUM RD. SRS y E/B f�f ASPHALT SHOULDER J ASPHALT SHOULDER 20 ft. 12 ft. a 10 ft. 12 ft. 14 ft. ft. SKETCH (Not To Scale) ' i TUR 81 A2 LN. N B NIB I I I PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE B. Montgomery 16713 7/24/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL Page 5 of 7 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 7/24/2006 1550 9320 16713 7-295 1 FACTS 2 3 NOTIFICATION: 4 On 7/24/2005 at approximately 1552 hours, I was leaving the area office on Blum Rd. 5 At this time, the office had been experiencing several electrical power surges in the 6 prior half an hour. As I left the office and approached the intersection with Blum Rd., 7 I observed three vehicles stopped on the right shoulder of S/B Pacheco Blvd. Upon 8 contact with the drivers, I found there had been a two vehicle, property damage only 9 collision. All times, speeds, and measurements in this investigation are approximate. 10 Measurements were taken by visual estimation. 11 12 STATEMENTS: 13 STATEMENTS ARE NOT VERBATIM AND ARE WRITTEN IN SUMMARY FORM. THE STATEMENTS WERE READ 14 BA CX TO THE INVOLVED PARTIES FOR VERIFICATION. 15 16 Party #1 (Bailey, P1): was contacted at the collision scene and provided the following 17 statement: She was driving in the #2 lane of S/B Pacheco Blvd. at approximately 35 18 MPH, approaching the intersection with Blum Rd. As she approached the intersection, 19 the traffic signal turned red. She began to slow down, to come to a stop at the 20 intersection.. As she slowed down, the light went blank for a second then turned green. 21 She accelerated and continued into the intersection, facing a green traffic signal. As 22 she entered the intersection, she collided with a white car that had driven into her path. 23 24 Party #2 (Husain, P2): was contacted at the collision scene and provided the following 25 statement: He was driving on W/B Blum Rd. and had just come to a stop in the #1 26 lane, at a red traffic signal. After he had been stopped for a few seconds, the light 27 went blank for a second and then turned green. He began to crossing the intersection 28 to enter W/B SR-4, facing a green traffic signal. As he crossed the intersection, a 29 white vehicle struck him from the right side. I'RI:I'ARED BY I.D.NUMBER DATE REW[WER'S NAME DATE B. Montgomery 16713 7/24/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL Page 6 of 7 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 7/24/2006 1550 9320 16713 7-295 1 Witness #1 (Rosenblitt, W1): was contacted at the collision scene and provided the 2 following statement: He was stopped in the left turn lane of S/B Pacheco Blvd, at a red 3 traffic signal, preparing to turn left onto Blum Rd. He had been stopped at the signal 4 for over five to six minutes, waiting for the signals to cycle to him. As he had been 5 watching the signals, he observed them go out completely for a few seconds, then 6 straight to red, then to green for a few seconds, and back again. He observed a white 7 sedan enter the intersection from Blum Rd. He then saw a white SUV, in his rear view 8 mirror, approaching the intersection from S/B Pacheco Blvd. He looked to the traffic 9 signals and saw them turn to green for the SUV. The SUV entered the intersection as 10 the sedan crossed the intersection, towards W/B SR-4. The two vehicles collided in the 11 middle of the intersection then moved to the right shoulder. W1 stated he could not 12 see the traffic signal for the white sedan, but believed neither vehicle had been at the 13 intersection long enough to know the signals were not working properly. 14 15 OPINIONS AND CONCLUSIONS: 16 THE SUMMARY, AREA OF IMPACT AND CAUSE N'ERE BASED ON PHYSICAL EVIDENCE, VEHICLE DAMAGE AND 17 STATEMENTS. 18 19 SUMMARY: 20 P1 (Bailey) was driving in the #2 lane of S/B Pacheco Blvd. at approximately 35 MPH, 21 approaching the intersection with Blum Rd. P2 (Husain) had just come to a stop in the 22 #1 lane of Blum Rd., at a red traffic signal. As PI approached the intersection, she 23 began slowing for the traffic signal, which had turned red. P2 observed his traffic 24 signal turn green and began crossing the intersection, to enter W/B SR-4. PI observed 25 her traffic signal turn green and proceed into the intersection. P1 and P2 collided as 26 they entered the intersection. After this collision, both vehicles moved to the right 27 shoulder. 28 29 PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE B. Montgomery 16713 7/24/2006 J STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL Page 7 of 7 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 7/24/2006 1550 9320 16713 7-295 1 AREAS OF IMPACT: 2 The AOT (V1 vs. V2) was located approximately 18 feet east of the west road edge 3 prolongation of Pacheco Blvd., and approximately 21 feet south of the north road edge 4 prolongation of Blum Rd. 5 6 CAUSE: 7 Due to the electrical power surges that disrupted the proper functioning of the traffic 8 control devices, I found this collision to be other than driver. 9 10 RECOMMENDATIONS: 11 None. PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE B. Montgomery 16713 7/24/2006 4' Central Contra Costa Sanitary District 7)7(j 11111101i Place Malfim,7',CA 94553-4392 t925) -228 9500 www.wntialsan.ni- FAX:(925)676-7211 CHARLES W.BA77S General Manager KEN7ONL.ALM Counselfor the District (510)808-2000 ELAINE R.BOEHME August 3, 2006 Secretary of the Dutrict California Highway Patrol 5001 Blum Road Martinez, CA 94553 REQUEST FOR COLLISION REPORT I am the Safety and Risk Management Administrator at Central Contra Costa Sanitary District. I am requesting a collision report for one of our vehicles involved in an auto accident. I've enclosed payment in the amount of $10.00 for the report. The specifics are: Date: 7-24-06 Time: 1545 Report No.: 7-295 Our Employee: Munawar Husain Location: Pacheco Blvd., and Blum Road, Martinez I may be reached at (925) 229-7320 with any questions or concerns. Thank you, Kimberly J. Geer Safety and Risk Management Administrator Recycled Paper 'e Wl m [ �fAir; ✓1mJt� X14' 1:412000661:111 "' 63 '�► _ � - , Kelley Blue Book - Trade-In Pricing Report - Ford, Taurus' Page 1 of 3 e x Kelley Blue coo k 56 i e 11 THE TRUSTE}RESOURCE. fis •z _ '" x . ow, s x k 1 advertisement �I44 IYI ,•y �' yl I W� ♦ O �5�"K�S� r3 hf l"mk�c i'"YA mF�:wp1��4'®b.G See .Fj`u sv Quick Dealer Price Quote Search Used Car Listings List Your Car for Sas HOME ` USED CARS e � Home> Used Cars> Sedan > Ford >Taurus > 1996 >GL Sedan 4D > Equipment - Print This Page 1996 Ford Taurus GL Sedan 4D Trade-In Value ..- _.. . Finance &Insurance Private Party Value BLUE Suggested Retail Value ConditionValue •¢Get a New Car Loan from Photo Gallery j 5.99%APR R8V12W Excellent $1,625 i Get a Pre-Owned Loan (°�a s� rwra from 6.65%APR x m d " � " m (Selected) QM 1 Shopping Tools ' GOOd 4Q i your Credit Score for Free r i :mm� m �� �iiu� •'a rr:, , A• Free CARFAX Record Check �m � � w Get a Free Insurance Quote M More Photos Fair $1 060 ._ ._. . ._ Auto Loan from 5.99%APR r - - advertisement a x�f iHnt -irsT , 3'10 f� Compare Insurance Rates z Get Pricing on New Vb e 3 Payment Calculator STEPS.NEXT t Sell Your Sedan C? ) � f Z � '. SELL YOUR €15E€1CAR Vehicle Details 0 Change Equipment , on Blue Book ClassifiedsT � �,z I Engine: V6 3.0 Liter ' Reach millions of shoppers on i Transmission: Automatic kbb.com, Cars.com, and other Drivetrain: FWD f 4 p popular sites. Mileage: 54,131 Selected Standard Equipment Find out more, �,` '°� Click �. Air Conditioning Power Windows AM/FM Stereo ° i Power Steering Tilt Wheel Dual Front Air Bags `"�"' k, �............... ............... ..._..._..mom.. .... ,. ..m... ......., m.... ........... .,,.��........�.....�.. w.... . ' 01 fy"4 1 BUY A USED CAR ( � � on Blue Book ClassifiedsTM Blue Book Trade-In Value _ -< Trade-in Value is what consumers can expect to receive from a dealer fora Ford trade-in vehicle assuming an accurate appraisal of condition. This value will r likely be less than the Private Party Value because the reselling dealer incursOf Taurus the cost of safety inspections, reconditioning and other costs of doing business. y 30 Miles or less N':* ZIP Code 94553 Vehicle Condition Ratings Check Vehicle Title History zxv " To View Ads, Click ". .n Excellent (Selected) 2-, s s $1,625 i i "Excellent" condition means that the vehicle looks new, is in excellent g mechanical condition and needs no reconditioning. This vehicle has never FIND THE RIGHT CAR had any paint or body work and is free of rust.The vehicle has a clean ` Compare Used vs. New title history and will pass a smog and safety inspection. The engine New Dealer 5.99:4 [ compartment is clean, with no fluid leaks and is free of any wear or visible { Used Dealer 7.291% http://www.kbb.com/kb/ki.dll/kw.ke.ucp?kbb.CA;;CA013;&94553&;470821&;;uct;sed&ll;FO;W9 8/21/2006 Kelley Blue Book - Suggested Retail Pricing Report - Ford, Taurus Page 1 of 3 Kelley Blue Boca r u 'A THE TRUSTED RESOURCE. a ti .,..,,-... «.,.,,.....—.-.. COt� .. .. _ .r.,...reax. ..,y�' 'r y advertisement [ 5 v.y'51 n� i 1011,000 accessories,6 million applications x •• Quick Dealer Price Quote Search Used Car Listings 0L1stYourCariforS& Home> Used Cars > Sedan > Ford >Taurus > 1996 > GL Sedan 4D > Equipment Print This Page 1996 Ford Taurus GL Sedan 4D Trade-in Value --- -- --- ---- Estimated Payments Private Party Value. BLUE OOKe SUGGEST -(�- JAIL VAl: , EH ,_ �¢.�� i � $75 Amo @ 7s9%APR >Suggested Retail !Value Condition Value Photo Galleryr t J CER CRenee t r.73.0� " Geta Pre-owned Loan Review fiStW a aN�.� from 6.65%APR? x (Selected * Your Credit Score for Free I �50� Shopping TOOIS suggested Retail Value Assumes i � `im "`I ��, � Excellent Condition.., More j v-Get a Free Insurance Quote I Free CARFAX Record Check 01W More Photos — advertisement — Auto Loan from 6.65%APR IIIIIIIIIIII�Il�Illllllllll� Search Local Listings ,N Compare Insurance Rates NEXT STEPS. 0 Get a CARFAX History Report Payment Calculator i Extended Warranty Quote Vehicle Details OChange Equipment Engine: V6 3.0 Liter er.+..A BUY A USED CAR Transmission: Automatic "• on Blue Book Classifieds' Drivetrain: FWD Mileage: 54,131 Ford i Selected Standard Equipment Tauru i Air Conditioning Power Windows AM/FM Stereo .w.,,...._.,�.,... ( — 3 Power Steering Tilt Wheel Dual Front Air Bags 30 Miles or less l j ZIP Code 94553 Blue Book Suggested Retail Value i a To View Ads, Click A� The Kelley Blue Book Suggested Retail Value is representative of dealers' asking prices and is the starting point for negotiation between a consumer and a dealer. This Suggested Retail Value assumes that the vehicle has been fully reconditioned and has a clean title history. This value also takes into i account the dealers'profit, costs for advertising, sales commissions and SRL YOUR USED(AR p g' I other costs of doing business.The final sale price will likely be less on Blue Book Classifieds'" depending on the vehicle's actual condition, popularity, type of warranty offered and local market conditions. Find. Out 1 Reach millions of shoppers on Una kbb.com, Cars,com, and other amNONNI I popular sites. Vehicle Condition Rating Check Vehicle Title History Enter a WIN Below 1 Find out more, T9, Excellent (Selected) i to Get Started? Click _ $3,730 "Excellent" condition means that the vehicle looks new, is in excellent Enter d VIM f mechanical condition and needs no reconditioning. This vehicle has never had any paint or body work and is free of rust.The vehicle has a clean E http://www.kbb.com/kb/ki.dll/kw.kc.ucp?kbb&94553&;954457&;;ucr;sed&11;FO;W9 8/21/2006 Aug-02-06 09:45A P.02 I 07/27/2006 at 09:50 AM Job Number: 16961 NxRhcI.S Amm PAIN'PZNG BAROAL047087 --- EPA4CAD981308127 1075 Boulvard Way EPA$CAD98138812 Walnut Creek, CA 94595 (925) 934-7493 Fax: (925) 934-601'3 PRmLIMIlU1RY BSTXNRTi Written By: Mike Becerra Adjuster: insured: Central Contra Costa Sanation D Claim i Owner: Central Contra Costa Sanation D Policy 0 Address: Walnut Creek, CA 94595 Deductible: Date of Loss; Eusinese: (925) 229-7161 Type of Lona: Point of Impact: I . Right Front lzu"at MIRACLE AUTO PAINTING Business: (925) 934-7493 Location; 1075 Soulvard way EPA4CAD98138812 Walnut Creek, CA 94595 Insurance Oamps": Days to Repair 1996 FORD TAURUS GL 6-3.0L-FI 4D SED White Int: Vin: 1FALP52U7TG143115 Xdc: E024297 CA Prod Date: Odometer: 54131 Condition: Good Air Cond+.tioning Rear Defogger lilt Wheel Inter:nittenc. wipers Tinted Glass 3ody Side Moldings Dual Mirrors Clear Coat Paint Power Steering Power Brakes Power Windows Power Mirrors AM Radio FM Radio Stereo Search/Seek Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats Automatic Transmission Overdrive -------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2 C/Il front bumper 3,2 3** Repl A/M Bumper cover 1 191. 00 Incl . 3.0 4 Add for Clear Coat 1.2 5 Pcpl RT Bumpr.c cover reinforcement 1 2 Incl. ouf.er 6 5epi 2T Bumper ::over reinforcement 19. 15 incl. ir.r.cx• 7* Rhi ^mi-len Incl . 8 -I RONT �i R6 i P- [lccic.l l affrp 1-0 6110;95 0 Rd1 '.'T '2a r k I ampass, Incl . Td L&40:t,0 9007 GD 6rirJ £6D4C£bSdb 'UN 3,UHd 6VL V£6 OTS ?.008 OlDd 3l31d81w w U P.03 Aug-02-06 09:45A 07127/2006 at 09:50 AM Job Number; .16961 YRSLnCMRY ESTnaTE 1996 FORD TAURUS GL 6-3.OL-FI 4D SED Wzite Int: - NO. OP. DESCRIPTION QTY Eke'. PRICE LABORPAINT - 11** Repl AIM RT Side marker lamp .. 8.00 Incl.----___--__ 12 COOLING 13 Repl Radiator support upper support_ 1 200.50 Incl. 1.2 14 Rep! AT Air deflector side inner 1 7.72 0.2 15 Repl AT Air deflector side outer .1 15.33 0.2 16 R41 Radiator m 3.8 17 Repl Evacuate & recharge 1 m 1.4 18 Repl Refrigerantrrecovery } m Q;g Reid AiMA1igaE36§VT1IONER & HEATER 2.1 R&I Condenser assy m 1.3 22 HOOD 23 Repl AT Hinge 1 45.82 0.3 0.2 24* Apr mood 1 .0 2.8 25 FENDER 26** Repl A/M CAPA AT Fender 1 142.00 3.6 2.2 27 Overlap Major Adj . Panel -0.4 28 Add for Edging 0.5- 29 Deduct for Overlap -0.7 30 0 Repl RT Fender mount bracket 1 31 Repl RT Sound absorber 1 :?7 .15 32 Repl AT Fender liner front half 1 !)_3.90 Incl.. 3.OL DOHC & 3.4L 33 ' Repl AT Fenger liner rear half 1 50.00 Incl. 34* Apr AT Apron assy s 3.0 2.0 35 Overlap Major Adj . Panel. -0.4, 36 STEERING GEAR & LINKAGE 37 Repl AT Outer tie rod 1 :;3.37 m 0.5 38 FRONT. SUSPENSION 39 Repl AT Knuckle 1 3(-8.07 m 1.8 40 Align fount wheels m 2.8 41 Repl RT Lower cntrl arm 1 115. 63 m 1.2 42 Deduct For Overlap -0.5 43 Repl AT Lower cntrl arm bushing 1 - .7.65 44 WHEELS 45 Repl RT/Front Wheel cover type 1 1 x1.50 46 Repl RT/Front Center cap type 2 1 36:77 47 FRONT DOOR 48 Repl RT Door shell 1 7')1.2c 5.4 3.5 49 Ov�.rlap Major Adj . Panel -0. 4 50 Rep! AT Body side u..ldg paint to 1 ! 6. 67 0.3 0. 4 rrrtch 51 Repi FT Mirror hca*..ed Incl. 0. 6 52 Refn R. iland!c, cut,ide w1c (1. 6 keyl.e.5s eiitry t:3 Rept Ri t:itzq« ,.ppr.- 1 4:!.27 0. 3 0.3 54 P,,p: RT riir.gc 1,-,we!- t. 1 - 90 0.3 0. 3 55 !r:AR 0,)Cj1 2 Ed I&EM:rO 90OZ Z6 '6nd £6rLr£6SZ6 : *0N 3WHd 6rL r£6 OTS ).Cog alnd 3-10t8lW waa� Aug-02-06 09:45A P.04 07/27/2006 at 09:50 AM Job Number: 16961 rasLnam"s ZSTIM= 1996 FORD TAURUS GL 6-3.0L-FI 4D SED White Int: ------------------------------------------ ------------------------..___� NO. OP. DESCRIPTION QTY EX'i . PRICE LABOR PAINT ------------------------------------------------------ --------------------_ 56 Repl RT Door shell sedan 1 7.51 .25 4.9 3.5 57 Overlap Major Adj. Panel -0. 4 58 Repl RT Body side mldg paint to 1. 31 . 93 0.3 0. 3 match 59 Refn RT Handle, outside 60 Repl RT Hinge upper 1 45.07 0. 3 0.3 61 Rept RT Hinge lower 1 45.07 0.3 0.3 62 QUARTER PANEL 63* Rpr RT Quarter panel 2. 0 2.4 64 Overlap Major Adj . Panel -0.4 65 Clear Coat 2.5 66 REAR LAMPS 67 R&I RT Tail lamp assy 0.4 68 REAR BUMPER 69 R&I R&I bumper cover 1.1 70 WINDSHIELD 71 Repl Windshield NAGS 1 224.25 3.0 72# Repl COOLANT 1 15.00 T 73# CORROSION PROTECTION 1 5.00 0.5 74# COVER CAR FOR OVERSPRAY 1 5.00 0.2 75# MATCH COLOR 1 0.5 760 OPEN FOR HIDDEN DAMAGE 1 77# BENCH SET UP & MEASURE 1 2.0 78# PULL TO ALIGN 1 3.5 79# Repl Goodyear tire Regatta 1 115.0C 0.3 p205/65R15 80}► Repl Balance & Weights 1 3 .00 0.3 ------------------------------------------------------•------------------------- Subtotals =_> 3743.32 49.9 26.1 Parts 3728.32 Body Labor 49. 9 hrs @ $ 72.00/hr 3592.80 Paint Labor 26. 1 hrs @ $ 72.00/hr 1879.20 Paint Supplies 600.00 Sublet/Misc. 15.00 - SUBTOTAL $ 9815.32 Sa.Ies '.Pax 5 434:3.32 @ 8. 25008 358.32 ---------------------------------------------------- GRAND TOTAZ. $10173 .64 ADJUSTMENTS: Deduct_biee O.CO -- ---- CUSTON.ER PAY 5 0.00 1N�t�FiANCE PAY .S1U173.64 Ed WtlBO:r© 90OZ ZO -6ny 26r4r26SZ6 'ON 34OHd 67G r£6 OTS !,aoe ©inti 3�idiw WOa3 Aug-02-06 09:46A P.05 07/27/2006 at 09:50 AM Job Number: 36961 BRiLINXMRY S9T17A►TE 1996 FORD TAURUS GL 6-3.OL-FI 4D SED White Int: All parts prices subject to dealer invoice. After work has started hidden damage or worn parts may be found. Additional parts /Dr labor charges may be required to complete repairs. Old parts will be discarded unless otherwise instructed in writing at time repairs are authorized. All repairs guaranteed one year on workmanship. A] 1. paint repairs guaranteed for one year on (adding and peeling. 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 FINE:3 AND CONFINEMENT IN STATE PRISON. THE FOLLOWING TS A LIST OF ABBREVIATIONS OR SYMBOLS TFj1T MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR RE.13LACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A-APPROXIMA:'F. PRICE LABOR TYPES: B--BODY LABOR D-DIAGNOSTIC E=ELECTRICAL F=FRAME G-GLnSS M=MECHANICAL P®PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED M:15CELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND-BLEND CiI`A=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R-DISCONNECT AND RECONNECT EST=ES'"IMATE EXT, PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL-INCLUDED MISC-MI:;CELLANEOUS 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 REPLACEMEUT PARTS RECOND-RECONDITION REFN-REFINISII REPL=REPLACE R&I=REMCVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT-SECTION SUBL-SUBL13 LT-LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #-MANUAL LINE ENTRY "=OTHER [1E. .MOTORS DATABASE INFORMATION WAS CHANGED] **-DATABASE LINE WITH AFTERMARKET N-NOTES ATTACHED TO LINE. MQVP-MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT `OEM-ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. Estimate Calculated using a preset user threshold amount for the paint and material cost. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEI11CI.F.. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY Th E MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Q Pd L4060:PO 900 P-0 '6nd £6PLP£6S26 *ON 3NOHd 6PL PE6 01S %.QOH 01fyd 3-LVdIW : WOdd Aug-02-06 09:46A P.06 07/27/2006 at 09:50 AM Job Number: 16961 PR6LDMYd1Ar $STIMTS 1996 FORD TAURUS GL 6-3.OL—Fl 9D SED Whita Tnt: Estimate based on WnOR CRASH ESTIXkTING GUIDE. Unless otherwise notc:,i all items are derived from the Guide DE:231496 ratabase Date 07/2CC6, CCC Data Date 07/2006, ani the parts selected are OEM-parts manufactured by the vehicles Original. Equipment Manufacturer. OEM parts are available at Or./Vchjc)e dealerships. OPT OEM (Optional OEM) parts are OF.M parts that may be provided by or through alternate sources other titan the OE/ventcic dealarehips. OPT OEM parts may reflec[ some ,pacific, special, or unigse pricing or discount. Asterisk (�) or nr,tble Asterisk (-*) indicates that, the parts and/or labor information provided by uOTOR may have been modified or may have come from an alternate data source. ^i.lde sign (-1 items indicate MOTOR 14--t-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Neplacemert Parts. Used part-3 are described as LKQ, Qual Recy Part's, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Fart Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the VACS information are NWOR suggested labor operation times. NAGS labor operation time$ are not Sncluded. Pound sign W items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehi::le r+,nufacturer, labor and parts data from the previous year rAy be used. The Pathways escimntor has u complete list of applicable vehicles. Yrurts nuirbers and priceG should be confirmed with t:he local dealership. CCC Pathways - A Product of CCC information SNr•n.i-es fnc. 5 Sd bRi60110 9002 20 'find £6bLt£6526 -ON 3N0-Id 6t,L r£6 OTS JAOH Olf1H 317t1d)W b106.d P.07 Aug-02-06 09:47A 07/27/2006 at 09:50 AM Job Number: ac�ca pwmi miamy ssTnaLTE 1996 FORD TAURUS GL 6-3.01.-FI 4D SED White Int: ALTERNATE PARTS SUPPLIERS 3 A/M Bumper cover Part No. F0100039E�A Price $191.00 26 AIM CAPA RT Fender Part No. F01241189PP Price $142. 00 keystone - P+ B (800)263-.972-1 1069 HENSLEY STREET (510)234-6960 RICHMOND, CA 94801 Keystone - P+ 8 (800)263-9727 1045 E. TRIANGLE COURT (916) 372-0287 W. SACRXXENTO, CA 95605 11 A/M RT Side marker lamp Part No. 18 3459 �l Price $8.00 Action Crash Parts of Oakland (866)247-1391 1951 WILLIAM STREET SAN LEANDROr CA 94577 0 Wki(iT:rE1 90F>z c0 '6^r E6rLa£6SZ6 'Ora 3NOHd 6t4 r26 0TS .gjOH ©ind 37JHalw 610�1j O ACCIDENT tCENTRAL CONTRA COSTA SANITARY DISTRICT Date 719,419006Time _AM ..3.45 pM Vehicle Accident Report Location'. R,9CHEGO B1-VD .4NP _BtuH GENERAL INSTRUCTIONS BINFORMATION RO�4D IAITFRSECT/OAJ. ❑ DISTRICT employees shall complete all applicable sec- YOUR YENICLE: tions of this form. In case of driver injury,passenger! FORA i.auRUS L ¢ supervisgr$Pall complete this form. Vehicle M44 rev Afab eoayslyis q NOTIFY local police immediately.-(Exception: those License# E D2¢297 Vehicle# 1173 accidents occurring on District property which involved Owner LEWRRL CaW'RR 60SM SANITARY A r, District personnel only.) Driver NUN,4WA-R HUSf►!N ❑ NOTIFY Supervisor immediately. Driver's License# N 044 2 857 ❑ SUBMIT this form to the department's Administrative Damage DIREGr Nir1/ryo4cr ON ?4SSeV4E9S1PJ Section for required distribution. 149,rn, 1400S,NI#, EN4raE Con PARr1'7ENr ❑ DO NOT ADMIT ANY RESPONSIBILITY. Passengers NONE ❑ ONLY discuss accident with: • Police officer OTHER VEH[ LE: • Your Supervisor, Driver's name .SE.E �{Il�Ftt✓.trPgrRVL REPoRr 'Risk'ManagerlSafety Office ; FOR 2-rem. LEFT c. VK Address • CCCSO Legal Counsel City&State ❑ DO NOT argue Phone #Passengers NONE ❑ GIVE'other drivet.ybur name,address and show him, Driver license#-. .. your.drivers license if he asks to see it. Vehicle Es U WkW' SUV License 0 0< Jr 497 State CA POLICE: Owner of Vehicle See H1404wRY Paraot Re00lLT FOR IrepsLeer . . .: , r.Dart • . Address Name __,_Badge# , Dept.CAL'F.0 N" '1414wW4YPgrROI City 5001P• City&State Who received Picket? No -&E At: 444_4110_•, Phonv Insurance Co: Policy#. INJURED PERSONS: Damage j 1. fVame NouF' �•�,� ;:.: .._ , Address.. WITNESSES: City' Phone _ Nal'ure`andextent DENN15 ROSENBLITT 2. Name Now F_ Address Address City - Phcne 474- 9102 City Phone 2. Name Nature and Extent Address Ambulance called? ❑ YES... _ NO City Phone 1509A-2/95 F7uctions For Filling Out Accident Diagram • Indicate compass direction on diagram. • Name.streets or,roads and(f any)railroad tracks. • Indicate direction &position of each vehicle involved in the accident. • Use the letter(A)to designate District vehicle &(B), (C),etc.for other vehicle. i VEHICLE SYMBOL i ve i. ra W Q1 �. . (A) . W .I- v (�) {. COMPASS :l �' �}rCrHwAy A $lun Y On/?nrnp RIP What Was the purpose of the Travel? C FLK VAvLr DEStot WORK CNAM4B5 4r 1H8 AvRview PUHo S'ri4-T/O;y To 4 pof.s Cymr'RALrOR CONLERKS ON Ty*e &M FORe,B How 4EgVsrftV 6 nCA1 ADredT (DP 5-4!o Describe What Occurred:Z DRpvE Tow&eos 7Ne 1,vre,esecT/ou VwAwi b.19,47koFr/e 41u!/rA*3 UPA PZ .SropripANP wwrEpArlot 1WL/dMr.TWAIT.lDAL. N471me&R7}re1j4orrcTuRrvbR.EEN, IWoo Toe FIRSTJA, LwC-AND DyAlM4 &e WAIT SEYSAOL CRKS NAD ARR/yED BEH/pD We.*o ARAMlJl e6 i1.4YbV44me- Phesi ems ANDr#fI 140A 401M40FF.OGCASI OVALLY.ANO Fs/cmeesow 4 ori+ex nmec NsiIN Toe LIG✓47 7uRNepCiRElM,I PROCEEDED Lvrt> Imam eitftcr/oN. 6ARJ ON Oscmx4o 9Lvp. ON BOrM S/D8f, OF He MAD CA•tE TO ASWArT,v6.Tira, APTBR SNAD rf.4v#4jap M646 Aw NA&A7N$V/STRNCg /070 Nt /NTERSUrIONr A At4urE 609 APP6A9gp3000ENLY AremMYRIGHT AMO/t/T'.P/STR/Crj How could accident have been avoided? TRAFFIC L/ ,,&r Musr BE tIAPE Te DOE94rB REL14pLy CAR XCO/r/uof •04 47%Q AMpsAFeuY. oN4oI4Jy c4usrRucr/oN ,gcriviries,kor6vF4TH£R 0PowEa Rucrritr n/t nusr morRrfEc7 gw-Lr L14Hr orE2ArtDNS, 56NSoR C8/LS HO/D'PR04RAKH/N(� _huSJ E 7W9,#KLlD 0�t AFEDPERAT/oN5, 194EA*S9 eAwck WITH EDGAR LOPEZ, hp-NAS kECENfLY EMCQO ME J 10"ERQW "F909L9 Pt-6 ON PA6*eCV 3LYD. (� A IM/LAR NATURE . Were seatbelts being worn? `les Signature - Investigated/Reviewed by: — Driver Date SuperinteVDwision _ner Date Supeor Date Department ana er Date 15098-2/95 l , _ D�SGR/BE 1�1�gT- OCGdRRED �V�IeL�R �nlrrNuED PRivE2 OF 07;/ 8�/� ce�E Amo JOE .fT•�T�fZ_— r �2 : �ENNIS�OS�I� /TT _R/VE,e DL ANontmy R1clP__W/�s) Fi R.ED TO BE L.J W/T CE53 SiATF!? eft __Tl,FE—L/ „cLT�_�tIFRE Al or NLri N/N(�_�Qp�QLY A,vILI+IE�?E GO/�uG Dti1 t1tiDD� Ey % �a 'ul % ƒ vir, k \ 2 0 \ / § 6 ! - o ® fft � . % 43) 46 ® +$ + X00 © k egg « % I CIO k \- 0 \\ PA 0, © : U) v + CL.AIAI BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY titC BOARD ACTION: OCTOBER 0.3 , 2006 Claim Against tine County, or District Governed by' ) the Board of Supervisors, Routing I-ndorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) . The copy of this document mailed to ,California Government Codes. ) you is your notice of the action taken on your claim by the Board of `7 (� Supervisors. (Paragraph 1V below), SEP 0 6 2006 given Pursuant to Government Code ANIOUN'f: $150. 00 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT' SABU AKAMAL ATTORNEY: UNKNOWN DATE RECEIVED: SEPT. 05 , 2006 ADDRESS: 2109 BEDROCK WAY, BY DELIVERY TO CLERK ON:SEPT. 05, 2006 ANTIOCH, CA 90509 BY MAIL POSTMARKED: SEPT. 02 , 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. SEPTEMBER 05 , 2006 HN CUYLEN, lei Dated: y: Deputy It. FROM: County Counsel T0: Clerk of(lie Board of Supervisors (,This clainr complies substantially .with Sections 910 and 910.2. ( ) This Claim PAILS 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). O 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: DatedBy: CA.4 Deputy County Counsel 111, FRONT Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV BOARD ORDER: By unanimous vote of the Supervisors present: (V� This Claim is rejected in full O Other: I certify that this is a true and correct copy of the Board' Order entered in its nriuutes for this date. DatedCULLEN, 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 delimited in the mail to file n court action on this claim.See Govennuenl Code Section 945.6.You nray welt the advice of all altonrey of your• choice in coutecfioa with tills matter. If you warm to cousult art attorney,you should do so imuhediately. *Fo•Additional Warning See Reverse Side of1his Notice., AFFIDAVIT OF MAILING I declare under penally of perjuiy that 1 ant now, and at all limes herein mentioned, have been n citizen of the United StltteS, ovel' age IS; and that today I deposited in the United .51i les foslal Serriec in Martinez, Californimt, Hostage fully Irrepaid It certified copy of this Homed l lido mitt Notice to Claimant, addressed to (lie ch(i r if a shown above. I1►11N CUI-1.E1d, CLERK } ,Deputy Clerl; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A claim relating to a cause of action for death or for injury to person or to personal property of growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) 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. If clam is against a district governed by the Board of Supervisors, rather than the County, the :narne of the District should be filled in. >. If the claim is against more than one public enti)w, separate claims must be filed against each. public entity. :. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. fanaa■lUSE aa■laaSan aK am a as as K a s C USE a aaa[f[a[aa Rana a aaant■a as a[a aKaaa[a[[[a[[[al ZE: Claim By: Reserved for Clerk's filing stamp Gtr XP q4 ) tt3edrocL�4� tv / c+�9 SQ 9 RECEIVE® Against th County of Contra Costa r ) � ) SEP 0 5 2006 V* CeetODlstrlct) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA CO. The undersigned claimant hereby des claim against the County of Contra Costa or the above-named district in the sum of$ 0 G-d and in support of this claim represents as follows: 1. When did the damage or injuryy occur? 4Give exact date and hour) ` 6�2 Cf r'"l P16 12r� v c �,c 2. Where did the damage or injury occur? (Include city and county) P is/l n-11VII``" ��� i �flfsr� a V) 3. How did the damage or injury occur? ( ve full details;use extra pape if reri-c4c'.ec ired} R� cti?aS � fti9 �- rte, / aoi e oZ Cvu 4. What particular act or omission on the part of county or district officers, servants, or employees C caused the injury or damage? -� ,Z / ,� F"7 5 What are the names of county or district officers, servants, or employees causing the damage or injury? N Q®i V PC( � r rY�Gvact < �h0,1 1dalC a y caY �o0/c i. What damage or injuries do your claim resulted? Give full extent of injuries or damages - claime(L -Attach-two estimates for auto damage.) Zd Q C� 1. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or darnage.) S. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE t1/0 ME ■ va a a a a a5 ea a is a a Is a a Is Is is a a a in a a m a a[a t a so a[a11 a u a1111511a a a■11au ua a as as Eau u a a a[a a as s e c t a, .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornev. 1 Name and address of A omey ) /,� �/� (Claimant's Signature) (Address) T Telephone No. } Telephone No. Ix 7 7 ■.■Ica■■IK1111IK111R11■11111111115111121 a a alae a WINES■11a11111lW WE11RNa5511■ERIK[991%099119 KKR■■11I a11IK1111SW111 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, s"§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■ aa111111saEaa11a11a11Wt11■saga as wa[[11catu11IKaE1111s[1111IIKsa[a11a[ta11a11ra11aEtau e[■a1111 a1111R■1111IIt NOTICE: Section i2 of the Penal Code provides: Every person who, Mth intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. SHA.r4.HY SCS-OhFC17D ell JUN s zoos VEHICLE ACCIDENT REPORT tiATE !-{` l Y TIME 5 rC�O 40A ACCIDENT LOCRTION Vehicle Equipment No. Lic. Plate No.�G �Year/Make/Type County Driver: '. vF .8 Dther Driver: 1Q`� ' Name �,�'`Q,� Name b G1 't Horne Address ZZ f1 _ Home Address 'e Home Phone # a Home PhoneOtt W Work Phone -^ Work Phone # Driver's Lice n�' Driver's License Lt � Car. Year abs- _ Makee A e. m del if Personal or Rental Vehicle) Registered Owner L Name &-Address of Agent Address P one. ),, -i cerrsh P"" e � Insurance Company Polite Report Taken; Yes No Address Policy # Police Dept. Agents flame List ured Par fes. f e% .List-Nitaesses: R • ,O:r♦ � r , f 1. •.W1.e • Y I". P 1��,. x Phone # Phone # a •° ,. Address t Address y aZTreFy 17, 77 R tf ,3;-City " .- Sate �.' Z� COde : ,•.Ji y ate r � ;bode Z r;rJ.r^+�2..��� ` r �� ! �+ .• a Lf• i.'�. �.i .�� ' Lry.' iM'^�•t. "'' i •r � • 4 s r Phone # Address Address street treet City State Zip Ga a City zip Go e 3. Nave - - 3. Name Phone f ' _ Phone # , - Address Address Stre)t Street City../ f State 71,p Code City State, seat Belt Worn By county Driver. Yes No Damage to County Vehicle '^ oa£/Z 'do Oti16 *Whicle y PREPARE SKETCH OF ACCIDENT SCENE: Indicate direction, street names, traffic signs, landmarks, etc. (I = County Vehicle 2 = Other Vehicle) 1. Number vehicles, show travel direction by arrows. Com] E-- (.030 Nd.� 2. Show path before accident with solid 1 i ne. ---s CC> I 69kr - LaR 3' hoi 'pgtt- 4ecz,dtnt. with broken line. 4. Show:� strfiassr ,�{=-0 5. ShoR.'r'41rb2dei&ao%1' -0%4 DESCRIBE HOW ACCIDENT OCCURRED: Include approximate speeds of involved vehicles, whether any parties appeared to be under the influence of substances, etc. (Add another page if necessary,) 6' � �N ��o �6• d� � C� a AJU de�� GtX ' 11 SUPERVISOWS INVESTIGATION t` Mcv4 k"e k a5 kc-It- be i ccw 1�- icy, 0--14ic-L �y�ve�, CYac� .ir. c(er� Cfe��w�f / r SUPERVISOR'S RECOMMENDATION TL�rnn of v�t0y wicc?1�y, {� �o�e , -{-D � l vi q� 0-6vv 4'4-tt,5 S u� c c+. Pb C._e_'h ev\. ACTION CO ETED - Yes No nn 4` U D SUP IS SIGN URE c/c -d lC6 'ON iN3NgVVNVA Ki �0� �NdLiv c 'As i ' 1 C4,' V y t� U W %nn/ y� v �' f a i 'QD . �Q �t C=� oat 2 v s AMENDED----CLAIM (/ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY 1 BOARD ACTION: OCTOBER- 03 , 2006 Clairn Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section i` Tile copy of this document mailed to California Government Codes. } you,is your notice of the action taken - AUG 2 $ 2006 on your,claim by the Board of Supervisors: (Paragraph IV below), j COUNTY COUNSEL. given Pursuant to Government Code MARTINEZ CALIF. Section 913 and 915A. Please note all AMOUNT. $_364,000_ A CLAIM FOR INDEMNITY "Warnings". j CLAIMANT: BLACKHAWK HOMEOWNERS' ASSOCIATION' ATTORNEY: SHARON B. FUTERMANt DATE RECEIVED. . AUGUST 28 , 2006 PROUT * 'LEVANGIE AUGUST 289 2006 ADDRESS: 2150 RIVER' PLAZA ORIVE;BY DELIVERY TO CLERK ON: SUITE-'4:20 , , SACRAMENTO, 'CA 95833 AUGUST 23, 2006 i BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. i JOHN CULLEN. Cl k Dated: AUGUST 128 , ,-2006 By Deputy, 2-- 11. FROM: County Counsel TO: Clerk of the Board of S6lJdNls0rs 1 ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we ate so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claiin is not timely Filed. The Clerk sliould 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: G �-y Dated: By: / Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O 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. O Other. i 1 certify that this is a true and correct copy of the Board's Order entered in its minutes fon this date. Dated:CeVXW N CULLEN, CLERK, By C Deputy Clerk . WARNING (Gov. co e section 913) Subject to certain exceptions,you Gibe only six(6)niontlis from(lie dnte leis notice was personally served or deposited hl the mail to rile n court action on this elm-mi See Govennuent Code Section 945.6:You nlay seek the advice of air nlloiney of your choice hr connection with this hatter:It you warp to consult [iii attorney,yon should do so urnnediately. *ro,•Additional Warning see Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjui. that I ant now, and at all times herein mentioned, hove Wert it citizen of the United States, over age 1$; and flint today I deposited in the United Slates Vuslarl Service in 111n1 tinez, Cnitrornin, Hostage fully prepniit it certified copy of this 13osird (-It der ,uid [Notice W Claimsint, 71d(Iressc(t to lire clatiuxaui s shown above. Dated dry ����� �IQIIN CUI_;L.1.3H, CLERK � ( Delmly Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAMANT A.. ; A claim relating to a cause of action for death or.for injury to person or to personal property or growing.crops-,shall.be,presented not later than six`months after the accrual bf the'cause•of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. .(Gov. 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. •�������o��o■��ru�u�����■■■■������u•e�ou a u������o��a���u ........... RE: RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) , AU Bl k►rlawk Cid KPA Na2erd ry1'�4.6istnct) �tER G z 2006 (Fill in the name) ) coNTRA°FsuaERvrS OSTq Co QRS The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of P 304 t ODD and in support of this claim represents as follows: 15 is a Cl2.l rv� 1•4-1 1. When did the damage or injury occur? (Give exact O►'2 Dr fou t dat 9a ., `ek ��v✓kD�,w\ aer 1�i Z�2- wi roar M tdrn A FI �rsG2A�►r5 rch�ZDO(y 2. Where did the damage or injury occur? (Include city and county) [2 o tier �doy- Rau. , Day)v►l lsz, 2 CP V1 t r9 Cosmo CRL1+4 3. How did the damage or injury occur? (Give full details; use extra paper if required) (YMU65UA-e l2n�sl+ate , �'cl�tiv.te to �u '3t�2��nS�t rode�►ts QY tev� 1✓a I LLAjU fio r nO n►�C wee y TT w 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? �c1 i�U•r e to Mo)f1 ito�' s��pe- cs�v�,vt^•clY� \r t3la•�l�k Subd kris,o t t AQL )X3 Aman it��- ureA cl��rtn1la� 5 What are the names of county or district officers, servants, or employees causing the damage or injury? , C�l2.c,kln2,wl� C�-•NUJ 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ¢ 0V)2J to nt-�i'Fs Cla.t m over �31.Qa1 uov �a wc-s lz � 1 rgr e vt-y�W t►�n Cet l2r $k'1cllYl�wt:. tto rv�R(N�NU2,rs f'cssvZ. cy2�C was 1 v�ccwt n�1-y l=nx� ►31zc.Cc.lnarwl<G��'f� 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) C�►�pat�d �y pta�rtt� , b CAAQ449_Atd► s/" �tmzks dor rq 2;c r 8. Names and addresses of witnesses, doctors, and hospitals: flair k-"s G v iC_ " Unn sl i l ur 1 Lo Deg r R%ackz kd L-Q Q ZWnv�tla_., Ci4 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT o.,00)0 to ar -CV1'1.6 IS 'd C�a lrn 40 V A a N NNem Na mam.somm a as N.NNN■rN Nae Neu a■u■NnNasasn saoaE Ns saNaaN mean Nuevo 0 s me 0 man Ne NNei ) Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) -i- Y o-t+• ) Claimant's Signature) lee Uang�e —� 1 ) Btt�,awt� t-{onnecswM12rs� > cxA2t(cn� 2.1 so Rcver.t'laz�. Oriv�. ) g l 25 �IacJcl�a„�k �pta2a G rclR.a �• 2?D S�ie4420 "' 1 i ) OlYllle ,4� 4(Address) Telephone No. 4 3-91`1 )Telephone No. ■mumbom a■ommonnomum 0 mosommom■NNanu NseaOanaasa a nNnENnnosa NN a s■■so NNi■■■BE a a■e Nn Nonl PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any,claim filed with the County under the Tort Claims Act, is subject to public disclosure"under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. as■■■■■sa■OEM■■asRam■■as as aes nose Nam NONE mean■■man Nomen Mao'Noi"OiiaoeiNOME a ani a nae ram am 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 imprisonment in'the County jail for a period of not more than one year, by a fine of not exceeding one"thousand,dollars.($1,000.00), or. by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. ` A, j R.MACPROUT • LE VANGIE 7251 LAS VEGAS OFFICE MICHAELLJ.1.LE LEVANGIE WEST LAKE MEAD BLVD. SHARON B.FUTERMAN«t SUITE 300 ATTORNEYS AT LAW LAS VEGAS,NV 89128 2150 RIVER PLAZA DRIVE (702)562-4044 BRYAN L.MALONE SUITE 420 FAX(702)554-3272 JEFFERY C.LONCO SACRAMENTO,CALIFORNIA 95833 LAURIE L.MARQUIS MARY IMELTON 9]6)443-4849 FAX 916)923-2151 . JOHN W.(JACK)BEEBE Sharon mnan an LYNETTE P.HOANG Sharoafuterman@prounaw.com Members of the Bar in California, Nevada(1),Missouri(2)and Oregon(3) August 23, 2006 RECE91VED AUG 2 8 2006 CLERK BOARD OF CONTRA COS APCoVISORS Clerk of the Board of Supervisors Roam 106 County Administration Building 651 Pine Street Martinez, CA 94553 Re: Bachelor v. Patterson, et al. Jurisdiction : Contra Costa Superior Court Case No. C05-02627 P•L File No. : 16110 Dear Clerk: Enclosed please find completed claims form, as requested. Please note this is a claim for indemnity only, against The Blackhawk GHAD, submitted by our client, Blackhawk Homeowners Association. All questions and notices should be directed to the undersigned. Very truly yours, PROUT • LEVANGIE SHARON B. FUTERMAN SBF:tmc Enclosures i C\client\BachelorkLetters\clerk.Ldoc � � � � �� \ co Ul Ln co 0 C* LO VA M 0 r— C3 CIL C5 C:3 "—P n rn E.3 ca Co cm C=) rL ui C"i < 00 LU -4 0 a C.3 CD a: ui 7\ �{ w UD 6 v / . 0 \ \ / e & u \ n , \ ®Ln $ n . $ \ k . / ) ® 0 n '0 . . C3 LL & — / « 0T- M \ . r 5) C) \ \ - m ® � f / . \ 3 § kcm fL . ) . u »{ - L 2 9 5 CD d ƒ . ~ }} G U § « \\