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HomeMy WebLinkAboutMINUTES - 08142007 - C.20 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Cj ' BOARD ACTION: AUGUST 14, 2007 Claim Against the County,or District Governed by ) the Board of Supervisors,Routin dcrsRTents, ]nil-� w,l;tr Ir NOTICE TO CLAIMANT and Board Action. All Section refer�en�es.are to g�) �� cr I) The copy of this document mailed to California Government Cod.s,• �J you is your notice of the action taken JUL 1 1 2007 on your claim Uy the Board of COUNTY COUNSEL Supervisors. (Paragraph IV below), MARTINEZ CALIF given Pursuant to Government Code AMOUNT: OVER $25,000. SUPERIOR COURT Section 913 and 915.4.Please note all UNLIMITED "Warnings". CLAIMANT: SAVANNAH WILLSON ATTORNEY: VICTOR LIPOVETSKY, Esq. DATE RECEIVED: JULY 11, 2007 VELAN LAID FIRM JULY 11, 2007 ADDRESS: 3701 GEARY BLVD., S. 101 BY DELIVERY TO CLERK ON: SAN FRANCISCO, CA 94118 BY MAIL POSTMARKED: JULY 10, 2007 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 11 2007 JOHN CULLEN, r Dated: By: Deputy II. FROM: County Counsel TO: Clerk of tile. Pery e.Board of S isors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.'The Board cannot act for 15 days(Section 910.8). ( ) Claim is not timely filed. The Clerk should retum claim on ground that it was filed late and send warning of claimant's right to apply for leave to resent a late claim(Section 911.3). o �t ds Dated: /'ICD—d 7 By: —Deputy County Counsel III. 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. ARD ORDER: By unanimous vote of the Supervisors present: (vThis Claim is rejected in full. O Other: I certify that this is a true and con-ect copy of the Board's Order entered in its minutes for this date. Dated: CULLEN,CLERK, By Deputy Clerk WARNIN Gov.code section 913) Subject to certain exceptions,you have only six(6)months h-onr 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. ll'you want to consult an attorney,you should do so Immediately. *For Additional Wanting See Reverse Side ofTltis Notice. AFFIDAVIT OF MAILING [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 clahnnui ns shown above. Dated: �oG�l' JOHN CULLEN,CLERK By eputy Clerk i! u i I i i This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction,or Federal Civil Rights claims. The abovelistis not exhaustive and legal consultation is essential to understand all the separate11limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim.Consult the specific statutes;and cases applicable to your particular claim. I . The County of Contra Costa does not waive any of its,rights under California Tort Claims Act =�. r nor;does,it waive rights under the statutes of limifatioris applicable to actions not subject to the California Tort Claims Act I i I r - I i I I I i I I , I I i I i I I I I I i i i I . DE,'22/,1026 15'70 CpIFT� C-CUMTY C-E`. DiF J.'rE :3141527,993437 ;,110.15� P21 BOARD OF ERV e9 OFCOTvTRA COSTA CO rV, 1QNjj - _QCLAIMA.NT A. A claim rela-1-111.9 cause ofaumm for&--aih or for injU3v to PeTcon oT to rarsola! property or grovirig, crops shali be pw6!.-nttd not later Tilan six Manths after 1-he accrual of Ot cauzof accri. A chum relating to any other cause of actiar.. shall be presant--,4 not latev.. 1a one ye,'j, after the accrual afflie cause crziction (Gov. Code § 911.2) B. 4 Clwint mast be Aled witb the Clerk of the Board of' Supervisors ai its in Room 106, County Adminisn-adon Building: 651 Pine Suvet,Martinez,CA 94 X53. ff claim is ag&2'Ls-. a district governed by the Board of Supalvism:)rs, rathe,'Lh2m the Cov-nry, the name of the Dstfic'l should be iFilled in, D. If the claim is against More than one public entity, separate claims Ea-,.A be fi'lad apallin ca h public enti-,V. S. irgli;L See penalty for jraudalent clsims,Penal Clone Sec, "-ar th�t end of this form. ...............6...■goad toosof 8 01a a.0........... ...... RE: Claini BY: Reserved. fz:Clerk's filing stamp Savannah Willson __j RECEIVED Agairun the County of Co'ntra CoSUArx and �J JUL 1 1 2007 Boaz*ld of Supervisors, PubliCLERK BOARD OF SUPERVISORS cbistri cz; CONTRA COSTA CO. CFO in the nam'. The urders#ad claimant i-xreby makes ciai.,r- agairkst the County of Contra Costa or the above-narned district.in Q sum, ofS /2 5, 0 0 0ar4 in support of this claim represents as follows: ove.t (Tu-F(Tn7or Court - unlimited) 1. VZ-wn d-id the da-rug-.or Injury occur? (Olive exaci dao and hour", Friday, January 12, 2007 at 9: 58 p.m. 2. Where did the darnvge or irju:ry occv.r? (Include ci-y and courty.) James Donlon Blvd. near Nightingale Dr. in Antioch, CA 3. How did tDe dama.gt or inixy occur? (Give AM demils;use extra papet.if required) solo vehicle auto accident See Attachment 1 4. What Particular a,.,;t 0!,urni.qEior on the part of county or MvTicl offlicers, serarts, or amployees, eaueod the injury or don-age', See Attachment 1 What are the names of county or distiki officers, 3ervarals. OT employees causing the. damale or injury? under investigation see Attachment 1 E15.'�2�2ME 1_:LID CC,•:TRF CCE?= C=UNT1' ZLERK OF THE 4 3_1415379934_+ NO.157 P02 6. What damage or injuries do your claim resulted? (Give fill, extent ml injuries or damzRes cla;mn &- Attach two estimates for auto damage.: See Attachment 1 - under investigation 7. Taw was the amo•.mt claimed a>•,ove roroputed? (1D..011de the estimated amount of any prospective injury or damage.) under investigation 8. Names and addresses oFmitnesses,doctors,and hospitals: under investigation 91 List_the expenditures you mad-on account of this accident or injury: nATE AMOUNT under investigation sa/9fee eresoevoago ssaas■sgoo■996//■■■s//\euroYee/eAge 1900/■■966■0.9■/R9/■or9■a690069, l Go Code Seo. 910.2 provides"The claim shall be c by the claimant or by some person on his SEND NC I ES i • "Aherne Name and address of Attorney 1 Victor Lipovetsky, Esq. Velan Law Firm 1 ant's Signa#tire) 3701 Geary Blvd. S. 101 ) VELRNLAW FIRM) 3701 Geary Blvd. S 101 San Francisco, cA 94118 (Address) 415-379-9343fax San Francisco, CA 94118 Telephone No41 5-379-9300 )Telephone No. 415-379-9300 ■o99ss/9ressr9esell e00■/s.o..as96990■■ss■sNo*soloop 9s■s■e9a■+.e/s99■.■..9■o■......e9■. PUBLIC RECORDS NOTICE: Please be advised tlhat trtis c;aim form,or any claim tiled with the County under tie Tor:Claims Act, is subject to public dieelosure and r th.e Californie Public Records Ac:. (Gov. Code. g15 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form, including medical records,are also subject to public disclosure. aseeeae/realone■o■/■■rs■■r/■■/oerr9■■s/e//r■9magma re■■9rosrarNot ss/s/s■6■s9s ■.eo9rue I NOTICE: Section 72 of tht Penal Coda provides' E%,my person who,with intent to defraud,presents for allowance or for payment to any state board or orir�e.r,c- to any counts, ;ivy, or distri:.t board or officer, autbor'tzed m allow ❑r pay !l,e same if genuine, any fr.ls,: fraudulent oluim,bili, acocunt voucher,of writing, is punishable either by imprisonment in the County jai period of not more than one year, by a fine of no`exr.eading one thousand dollars($1,000.00), or by bot r imprisonment and fine, or.by irnpr;.sonment in the state prison, by a fine of not exceeding ten dhousand d.ol:a;. ($10,000), or by both such imprisonment and fine. 1 THE VELAN LAW FIRM 3 A Professional Corporation Victor Lipovetsky (SBN. 170962) 5 3 701 Geary Boulevard, Suite 101 7 San Francisco, California 94118 9 Telephone: (415) 397-9300 Facsimile: (415) 397-9343 11 13 Attorneys for Claimant SAVANNAH WILLSON 15 GOVERNMENT TORT CLAIM 17 19 SAVANNAH WILLSON, 21 Claimant, 23 Vs. CLAIM FOR DAMAGES 25 CITY OF ANTIOCH, PUBLIC (PERSONAL INJURY) WORKS DEPARTMENT, Government Code section 9101 27 COMMUNITY DEVELOPMEN 29 DEPARTMENT; COUNTY O CONTRA COSTA, PUBLIC WORKS ATTACHMENT 1 31 DEPARTMENT, - COMMUNIT 33 DEVELOPMENT DEPARTMENT, 35 BOARD OF SUPERVISORS, 37 Respondents. To: CITY OF ANTIOCH, PUBLIC WORKS DEPARTMENT, 35 COMMUNITY DEVELOPMENT DEPARTMENT, COUNTY OF CONTRA 91 COSTA, PUBLIC WORKS DEPARTMENT, COMMUNITY q, DEVELOPMENT DEPARTMENT, and BOARD OF SUPERVISORS 95 You are hereby notified that SAVANNAH WILSON, ("Claimant"), claims 97. damages from CITY OF ANTIOCH, PUBLIC WORKS DEPARTMENT, 49 COMMUNITY DEVELOPMENT DEPARTMENT, COUNTY OF CONTRA 51 53 COSTA, PUBLIC WORKS DEPARTMENT, COMMUNITY 55 DEVELOPMENT DEPARTMENT and BOARD OF SUPERVISORS 1 inclusive, individually,jointly, severally, or vicariously for personal injury as follows: 7 Claimant's name is SAVANNAH WILLSON and her address is c/o 3701 9 1l Geary Blvd., Suite 101, San Francisco, California 94118. 13 Claimant requests that notices regarding this claim be sent to her attorney o _s 17 record: Velan Law Firm, 3701 Geary Blvd., Suite 101, San Francisco, California 19 94118; telephone: (415) 379-9300. 21 23 This claim for damages arises from a motor vehicle accident which 25 occurred at approximately 9:58 p.m. on Friday, January 12, 2007, on eastbound 27 29 James Donlon Boulevard near the intersection of Nightingale Drive in Antioch, 31 California. 33 35 Basis of Claim and Description of Injury 37 In reference to "Damage or Injury Occurred", Claimant provides the 39 following detailed facts and circumstances of the incident. In addition, Claimant 41 43 provides a description of personal injury and damage or loss. 45 47 At that time and location, Claimant SAVANNAH WILLSON was a front 4 9 seat passenger in a 1994 Acura Integra vehicle being driven by TYLE 51 O'DRISCOLL that lost control due to reasons outlined below and subsequently hi 53 55 a median divider tree resulting in extremely serious and life threatening injuries. 2- 1 Defective Design and Other Dangerous Conditions of Roadway 3 1) Dangerous curve. — The area of James Donlon Blvd. neat 5 7 Nightingame Drive , in Antioch where the accident occurred was designed 5 improperly where vehicles would lose control due to a curve in the road. Ther 11 3 were no signs warning of a curve, and an absence of a sign of a curve was 15 improperly designed. There was a steep reverse curve, a curve to the left and cure 17 to the right, with no distance in between. There were no warning signs of 1 9. 21 approaching this dangerous condition, which was important and especially true in 23 view of other dangerous conditions of the roadway listed below. 25 27 The above conditions were in violation of the Federal and State Manual on 21 Uniform Traffic Control Devices, referred to herein as "MUTCD". 31. 33 2) No caution/safety devices. - There were no pavement guidance lane 35 markers (reflectors), cones, or other safety control devices on the roadway, an 37 this was extremely dangerous driving in this area especially when it was dark a 3° i 1 night. The presence of reflectors would have made the separation between the 4-3 two lanes more visible. The presence of reflectors and other temporary traffic 45 47 controls would also have made it easier to see the raised portion of the roadway. 41 There were no signs of any kind that would point which direction vehicles should 51 proceed and where the lanes were. There were also no signs warning drivers to b 53 ss careful of the conditions ahead. 3- 1 The absence of above-described temporary traffic controls and existing 3 temporary traffic controls were in violation of the Federal and State Manual o 5 7 Uniform Traffic Control Devices, referred to herein as "MUTCD." 9 3) Differential height of lanes - In addition, the raised/uneven portion of the 11. 13 roadway caused a dangerous condition. There was a differential in height between 15 Lane 1 and Lane 2, Lane 1 being higher than Lane 2 due to a transition asphalt lip, hereby creating a raised portion of the roadway. Due to these conditions the drive 19 21 lost control in Lane 2, the second lane from the left. 23 The uneven surface or raised portion of the roadway was the result of long-term 25 construction going on in this area. The absence of a sign warning drivers that the 2 29 road was uneven and, therefore, giving them a chance to reduce speed made this 31 condition significantly more dangerous. Such sign "Uneven Pavement" was 33 35 apparently lying on the ground with grass growing over it and was not visible t 37 traffic. 39 These conditions were in violation of the Federal and State Manual on t3 Uniform Traffic Control Devices, regarding temporary and permanent traffic 45 47 controls, referred to herein as "MUTCD". 99 3) Ongoing construction— All temporary and permanent traffic control 51 during construction were performed.in violation of the State and Federal Manua 53 55 on Uniform Traffic Control Devices, referred to herein as "MUTCD", and other '- laws and manuals. 3 Claimant believes that construction had been going on for an unreasonably long 5 7 period of time for up to 2 years. This is especially true with regard to keeping 9 "uneven pavement" as described above. 11 13 It was extremely unreasonable to keep construction going on for such a long 1J period of time. There was no reason to keep going on with construction of the road 17 19 in that area for so long. 21 5) No posted speed signs were in effect. The 25 mph signs that applied 23 25 before construction were covered during construction. The 35 mph signs were 27 installed but not valid as no actual construction was going on pursuant to Vehicl 29 31 Code Section 22262. Therefore, there was no speed limit posted, and, thus, th 33 55 mile-per-hour speed limit on the road would apply. 35 6) Dangerous wet, slippery, icy road conditions. The dangerous road 37 39 conditions were caused by freezing weather conditions and that sprinklers were o 41 that night before and/or during the accident. The icy, extremely slippery surface o 43 45 the road made the driver of the Acura lose control, and the vehicle continued t 47 slide out. The sprinklers- were apparently on even though the weather was 49 expected to be freezing temperatures, and the sprinklers were apparently on during 51 53 and before this tragic event. These conditions caused the driver to lose control an 55 hit the elevated portion of the roadway causing the subsequent injuries and 5- 1 fatalities. 3 5 The weather was forecasted and, therefore, Respondents should have made 7 sure the sprinklers were not functioning or operating during such cold weather. 9 ,1 Respondents should've known that such continuous operation of the sprinklers 13 would result in water freezing and therefore, creating extremely dangerous and 15 .7 hazardous conditions for the traffic. 19 7) Tree was dangerous obstacle. Claimant believes that it a violation of la 21 and regulations to have a tree of this size and diameter located on the media 23 25 divider. Caltrans regulations apparently provide that a tree should be no more than 27 4 inches in diameter and similar standards should apply here. 29 31 The tree that was struck by the vehicle in which Claimant was riding made i 33 even more dangerous due to its location in the median divider, the size of the tree, 35 and especially due to the absence of speed limit signs as discussed above. 37 39 8) Other Accidents: Claimant believes there were numerous previous an 41 subsequent accidents resulting in serious injuries and fatalities on James Donlon 43 45 Blvd. 47 Therefore, Respondents were on notice that this was a dangerous condition as 49 described above and had the highest duty to take appropriate measures to insure the 51 53 road was safe. 55 This reverse curve, raised section of the roadway, differential in height o lanes, ongoing construction, no posted speed limit, dangerous road conditions, 6- ' obstacle of the tree in the center divider, all causing numerous other accidents, 3 were responsible for the Acura losing control and causing all the subsequent J consequences thereof. The Acura driven by TYLER O'DRISCOLL had struck the 9 raised section of the roadway and lost control causing very serious injuries t 13 Claimant and 2 fatalities to other rear seat passengers. Dangerous Condition of Public Property 17 19 Claimant incorporates all statements described herein as though fully se 21 forth herein. 23 25 Respondent(s)' had created the dangerous condition of public property by 27 their own actions as described above. Respondent(s) allowed the dangerous 29 3 conditions to exist on public property. Respondent(s) has failed to properly hire, 33 train, and supervise their employees and their actions. Respondent(s) b 35 37 disregarding their responsibilities had created a hazardous condition of the 39 roadway. 4i 43 Respondent(s) and employees were aware of the above-described careless 45 and reckless conduct, and should have been aware. Despite numerous and multiple 47 accidents and injuries, Respondent(s) failed to properly hire, train, and supervise E9 51 city employees in the safe condition of the roadway so as to guard the public from 53 safety hazards and injuries. 55 7- 1 Negligence 5 Claimant incorporates all statements described herein as though fully se forth herein. 11 Claimant claims that Respondent(s) were negligent in that Respondent(s) 13 owed a legal duty to use due care, but failed to do so thereby breaching their duty, 15 17 and proximately causing Claimant's injury. The negligence consisted o 9 misfeasance or nonfeasance. There was active negligence, i.e., Respondent(s)' 21 employee negligently failed to correct the dangerous conditions of the roadway. 23 25 Respondent(s)' employee knew, or should have known of the danger and failed t 27, warn Claimant. In addition, said Respondent(s)' employee failed to correct the 2'9 31 dangerous condition of the roadway. 33 Failure to Warn of Dangerous Condition 35 37 Claimant incorporates all statements described herein as though fully se 3� forth herein. 41 9s Claimant claims that Respondent(s) had either actual or constructive notice 45 4; of a dangerous condition and failed to warn and protect Claimant against the harm 49 suffered. Respondent(s)' employee driver failed to warn the public of the 51 53 dangerous condition of the roadway. 55 Respondent(s) failed to warn the public of the dangerous condition in that 6- that they do not engage in proper hiring, do not properly investigate employees' s background upon hiring, do not properly train and supervise the employees. 7 Respondent(s)' disregard to warn the public constitutes a hazard to the public. 9 ,1 Negligent Hiring 13 Claimant incorporates all statements described in reference herein as though 15 1-7 fully set forth herein. 19 Respondent(s) was negligent in not properly hiring and investigating the 21 23 employees' backgrounds. Respondent(s) did not properly train their employee 25 and did not inquire that their employees do not engage in such callous/reckles 27 29 conduct. 31 The name or names of the public employees causing the injury, damage, o 33 35 loss is unknown to Claimant. However, as to said employees, Claimant claims tha 37 the negligence of said employee is imputed to respondent herein based on the JG doctrine of respondeat superior. 9i 93 The name or names of the independent contractors causing the injury, 9.7 damage, or loss is unknown to Claimant. However, as to said independent 49 contractors, Claimant claims that the negligence of said independent contractors i 51 ss also imputed to respondent herein based on the doctrine of respondeat superior, 55 agency-principal or vicarious liability principals. 9- 1 Damages 3 5 Damages to be sought by Claimant include damages for medical expenses, ' rehabilitation, lost earnings and earning capacity, and other economic losses 9 11 according to proof; and non-economic damages for pain and suffering according t 13 proof. 15 17 Jurisdiction over this claim will rest in the Superior Court of the State o 19 California, Unlimited Jurisdiction. 21 23 Dated: July 10, 2007 AN LAW FIRM, APC 25 27 29 Victor Lipovetsky, Esq. 31 Attorney for Claimant, 33 SAVANNAH WILLSON 35 37 39 41 43 45 47 49 51 53 55 19 PROOF OF SERVICE BY MAIL C.C.P. 1013a I, WILLY C. BONVIE, certify and declare as follows: I am over the age of 18 years, employed in the City and County of San Francisco, State of California, and am not a party to this action. That on JULY A� 2007, a true and correct copy of the following documents: CLAIM PRESENTED TO THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY - on behalf of Saivannah Willson CLAIM FOR DAMAGES (PERSONAL INJURY) [Government Code section 910] (Certified Mail No. 7006 0810 0004 3049 4327) were served by mail by placing the documents in the United States Postal Service with First Class postage prepaid thereon addressed as follows: Clerk, Board of Supervisors County of Contra Costa County Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 I certify and declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this f0 lh day of JULY,2007, at San Francisco, California. WILLY C. NVIE VELAN LA W FIRM RECEIVED A PROFESSIONAL CORPORATION JUL 1 1 2007 3701 Geary Boulevard, Suite 101 San Francisco, CA 94118 1CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Phone: (415) 379-9300 Frei: (41 S) 379-9343 16 July/,'2007. VIA CERTIFIED MAIL NO. 7006 0810 0004 3049 4327 Clerk, Board of Supervisors County of Contra Costa County Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 Re: Our Client: Savannah Willson Date of Injury: January 12,2007 Agency: Department of Public Works (Fifth District) Dear Clerk: Enclosed is our Government Claims pertaining to the above-entitled incident. Please return to us a copy of this document in the enclosed self-addressed postage paid envelope indicating that they were filed or received by your office. Thank you. Very truly yours, (Ms.) Wi y C. Bonvie Legal Assistant Enclosures - Claim - Original and copy Self-addressed, stamped envelope uj o 1:4 <r v ^ Ll7oo l tI""'7rM,� oo���Z LL to Iff•:f;i- :r ti a -- zz— Lo _ ? ~ v p� Zl1 zz ZVCD CL Q m Q ru zz Cu EM 15 Em co C3 qs C3 -'3 r- s' a 7177, cc Cl CO a) LLI Cil ZD C f o �.N I� -1 Ui CU y MCI) f.". .'id5r• ....j"r;EatC., C"«IIs; - M ati. _ '.'�4,f':JI-• t i �` a 1- A'$L—�4•.7%1 C4C:'�Trrc:.e..Y`,y:,---+-5_Yn. .4 ___ Y � N � 0 °-' 3 m J0 �- �N O 9 Q wo .�, 4 �:.� ...' `, y car✓" c% ; � lei O \ CLAI.M' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i BOARD ACTION: AUGUST 14, 2007 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: I you is your notice of the action taken on your claim:by the Board of j UL ]: 2 ;2007 -•Super•vis61s.-(Paragraph IV below), given Pursuant to Government Code AMOUNT: $6,015,000. :COUNTYCOUNSEL Section 913 and 915.4. Please note all i nilARl"I1vEZ CALIF. ,.Warnings KELLI KILLIAN, MICHAEL ESPINDOLA CLAIMANT: individually:and on .behalT for JACOB ESPINDOLA ' ATTORNEY: ALFRED H. BUCHTA: DATE RECEIVED: JULY 12, 2007 THE. BUCHTA LAW OFFICE JULY 12, 2007 ADDRESS: 18 CROW CANYON COURT',:' i BY DELIVERY TO CLERK ON: SUITE 325.. i SAN RAMON, CA 94583 BY MAIL POSTMARKED:. JULY 11, 2007 ' FROM: Clerk of the Board of Supervisors TO County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, . er 1 JULY 12 . 2007 Dated: By Deputy I.I. FROM: County'Counsel TO:'Clerk"of the Board of Supervisors cvrnis claim complies substantially with Sections 910 and 91.0.2. ( ) :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 retum 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: i —7 CPR94 Dated: / ' /�eU� 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). i IV. ARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full: ( ) Other [ certify that this is a true and correct copy of the Board's.Orderentered in its minutes for this date. Dated: ULLEN,CLERK, By Deputy Clerk i WARN IN Gov..code section 913) i Subject to certain exceptions,you have only six(6) months fivm the date.this notice was personally served or deposited in the mail to Ole a court actioi.l.on this clahn.See Government Code Section 945.6.You may seek the advice of an attom.ey.of your choice in connectiai Witli this matter. If you want to consult an . attoniey,you should do so.inin ediately, *For Addidoilal Warnhzg See Reverse Side of This Notice. AFFIDAVIT OF MAILING [ declare under penalty.of per jury thin I aui 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 N'lartinezi California, postage fully prepaid a certified copy of this Board Order.and Notice to Claimant, addressed to the claimant as shown above. } Dated: %.' -2N CULLEN, CLERK By D uty Clerk i This warning does not apply to claims which. are not subject to the California Tort Claims Act suchas.actions in inverse condemnation, actions for specific relief stich as. mandamus or injunStion,:or'Federal Civil Rights claims. The above.lis.t isnot exhaustive and legal consultation'is essential to understand all .the separate limitations periods .that may apply. The limitations period within which suit.must. be filed may be.shorter or longer depending on the:nature of the claim:.Consuit the specific statutes and cases applicable to your particular claim.. The County of Contra Costa does not valve any of its rights under California Tort Claims Act nor:does it waive rights under the statutes of limitationsapplicable to actions snot subject t0 the California Tort.Claims Act i .. _ .. is '::r: �'��::y+'• .. .+' .n...e., .. ���, ..... .. .,- BOARD OF$4FMV=t'.S OF CONTPA COSTA COL*Wry A. A claim relatiu2 z.it ceuse of action for death or for Injury to penon or to pawmil property or gwwing crops shell be preaeutod riot lator tbeu six months after the ar4nW of tha cause cf ac-jou. A claim rtlering to any other cave:of acdty.shall be presantec not laux that one year after tha aretual of'the cause of action. (Gov.Code j 911.21. B. Claims crust be filed with the Clerk of the Board of Supervisors at its ofhw in Room 106, Courcy AdtttW9fttiou Bttiidicg.631 Ph!Street,lblatdj=,Q4.94,553. C. If claim is agairs:a district govamtd by the BoW of Supa w.st r% ralhrs than the CoMty, *e name of the district should be fMed irL D. If the elalm is against more than one public entity, separaio claims must be filCd against tach publio entity. E. See penalty for is avdulerrt claims,Penal Code Sac. 72 at the and of this form. 0pYa 1.64011*116*11MNM.6*-r00IL.409000.00V"Goods vow 01.6►Y■0.6"..4 6010Yr Y•W*..*no iE. Claim By: fit= III- k t i AIQ Paervad for Clerk'a f ling etarmp tM�c[�IiZG SQ /UJJbL/-1 ;rND10at14 RECEIV AgktiW Cot Co-unty e C ntra cotxa ) J U L 1 2 2007 6511 P4 cvt- -'A 411/ Coe n MU n3 t c=�? i�+/t�e�zJiEtrict� CLERK Pf .,){;;=SUPERMSORS (Fill in the 11=z) CU, CTA CO. C�<i l'a1 The undersipad claimant!usteby m,akcs claim against the County of Contra Costa or the above-nantaf dist;iat in the sum of S�b. c r o&nd 1n support ref this claim rapresents as fullowE: 1. When did the damage or:ziury occur? (Give exact dam and hour) SAN / ��L�C3`j cr �:S� �►►� Z. W'wr did the damage or i4jury occur' (hrIMe city and county) 3. How did the d2t no or itiluri occur? (Give 1'iull dmaib;use extra paper if requ4e4l 5E- !`iTi�>Ec' � r L.Ai"A �f%Q- �� i��011'l�`t` JN,f t1;2 1, Cf 4. WW particular eZ or uraiseion oz the palt of county ar district officers, servwtk, or Mplovew's oaused the iNwy or damage? {� a' 711 fie.1111%i� L/4 ►►� E 5 ghat are the names of county or disaict ofuccrs,servants,or employers the damage or injury? 6. What die or injuries do your slants resuhed? (Clive full extant of is0udes or damages r claimed. Attach two cstinaates for am damage.) DA--T4 a� (? -5'6 Al --U—A<dQ t-A 7. How was the amount clairard above aemptned? (Include the, emmatad amount of any proVeetive injury to damage.) I� j S. Names and addresses of wit wsse3,doctors,acct hospitals: A) `n y 1�'C ) MV �I<< 9. List the expmditttres you made on account of this accident or i Vary: ALvlOM r aasaas*onaasas few aasarrra Sasso garSsoasraoila arrrrrtri Yirrsrraaaaars as irrYM. } Gov.Code Sec.910.2 provides"The claire shall be signed Ey • or by.*", SEND NC?TlCES 7Q: fAttom;y) 4T ) Namaddress of } fLt� /–/ - B t� i E f TC� T �'tll /_' L (Claimant's Sigtsettae) 613 00LI-P-T (.gddreas) ' gz T - 890 Telephone No. }Tclephoue No. •steams aeamotot same sorttY■aausas moans*#gloss a stair a.. PUBLIC RECOILS NOTICE. Piease be s,Ovised that this chum form,or say claim filed wicb tlha Courcy undar the Tart Claims Act.is suk*1 rc pubhe dimlocure uudar thc-Carie rublic Records An. (Gov. Code, 56 6$00 et seq) Furtharanore. sap' attaduments,stidandwms,or suppiamethts attached to cite cisit'th form,lnclvdiag medical rtnords,are also subjaot.� public disclosure. *Sasso own moves olives sea&arriaaarro**aeasae�aaacarr NOTICE: Seal*"72 of the Fend Codo provkks: Every person who,with intent to defraud,pr6wrts for 01orwance or for payment to any stat'hoard or officer,or W any county, city, or dimict board or oftim, atxborised to allow or pay tba same if gtauinb. any frlw � freuduleat otaim, bill, acoaunt v¢urber,or writing, is punW%I)lo aithar by ixapt 9unment in She County jai: iw period of not mare than one yesr> by a fine of»ai mwocdiag-ane thousand doUws(31,040.00), or by bol=l e imprUotlttiaat and fine, or by impti.coacwt in dit stats prison,by a fine of not oxceeding tan thousand 1101.64 (510,000),or by both such iraprisomeat and fine. t 1 ALFRED H. BUCHTA, SBN 060698 THE BUCHTA LAW OFFICES 2 CENTERPOINT BUILDING 3 18 CROW CANYON COURT, SUITE 325 SAN RAMON, CA 94583 4 (925) 743-8900; FAX(925) 855-9996 5 Attorney for Claimants, MICHAEL ESPINDOLA 6 and KELLI KILLIAN, as Successors in Interest 7 8 IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA 9 IN AND FOR THE COUNTY OF CONTRA COSTA U 10 ) co� 11 MICHAEL ESPINDOLA and KELLI CASE NO.: C07-01160 x us, 12 KILLIAN, as JACOB ESPINDOLA'S 'To Successors in Interest CLAIM FOR PERSONAL INJURIES g o ° 13 (GOVT C §910) =a Z o Plaintiffs, w=0M 14. N U 01 am0Qv 15 vs. W 3:W ~ 16 TYLER O'DRISCOLL, ROBIN co O'DRISCOLL, and DOES 1-60 17 18 Defendants. 19 20 To Contra Costa County, Contra Costa County Public Works'District,Contra Costa County 21 Board of Supervisors, Contra Costa County Community Service District. 22 You are hereby notified that MICHAEL ESPINDOLA AND KELLI KILLIAN, 23 individually and as JACOB ESPINDOLA'S Successors in Interest,whose address is c/o Alfred H. Buchta, 18 Crow Canyon Court, Suite 325, San Ramon, CA 94583, claims damages from 24 the City of Antioch. 25 This claim is based on personal injuries and death sustained by JACOB ESPINDOLA 26 on January 12, 2007, in the vicinity of James Donlon Boulevard near the intersection with 27 Nightingale Drive in Antioch, California. See Traffic Collision Report number 07000432-1 28 attached hereto and incorporated herein. That area of James Donlon Boulevard in the City of Antioch was an unreasonably dangerous condition due to the following facts: I CLAIM FOR PERSONAL INJURIES(GOVT C§910) a 1 1. There was insufficient road markings, including but not limited to reflectors 2 delineating the lanes of travel eastbound on James Donlon Boulevard at or near the 3 scene of the collision. 4 2. There was differential of at least 2 inches in the height of the two eastbound lanes 5 on James Donlon Boulevard. The left hand lane was at least 2 inches higher than 6 the right hand lane. The centrifugal force of a vehicle transversing the curve to the right just before the scene of the collision would cause a vehicle to drift to the left 7 encountering the 2 inch lip between the left and right lanes. There was insufficient 8 signage to warn motorists of this lip. 9 3. There were insufficient warning signs at or near the scene of the collision such as to LO 10 warn motorists traveling eastbound on James Donlon Boulevard that there was road N LU 11 construction in that area. There was an absence of cones to warn of the road LU LLLOS 0 12 construction. o m o cai� 13 4. At or near the area where the Acura went out-of-control,there was ice on this road 0¢0�� 14 as a result of a negligently installed and maintained sprinkler system. IIIa Z 5. There were no speed limit signs in effect at the time of this collision. a°w°�� 15 X 0 6. The tree involved in the collision was of an unsafe diameter and was located too 0 16 Go close to the roadway. 17 7. There was an absence of pavement guide lane markers at or near the scene of this 18 collision. 19 8. The reverse curve in the road created an unreasonably dangerous condition as a 20 motorist approaches the scene of this collision in an eastbound direction. 21 9. Prior accidents with injuries and fatalities were not provided to the City of Antioch 22 regarding these dangerous conditions. 23 10. Road construction in this area continued far too long. 24 Said dangerous conditions were a cause of JACOB ESPINDOLA'S death. 25 26 The name(s)of the public employee(s)causing claimant's injuries under the described 27 circumstances: These names are unknown at this time. 28 The injuries sustained by claimant, as far as known, as of the date of presentation of this claim, consist of Jacob: fatal personal injuries, destruction of clothing and other personal 2 CLAIM FOR PERSONAL INJURIES(GOv"r C§91o) 11. 1 effects. Michael Espindola and Kelli Killian: loss of love, companionship, comfort, care, 2 assistance,protection,affection, support and services. 3 The amount claimed, as of the date of presentation of this claim, is computed as 4 follows: 5 Damages Incurred to Date 6 Expenses for medical and hospital care......................................................$ 5,000.00 7 Loss of earnings............................................................................................$ 10,000.00 8 General damages..........................................................................................$3,000,000.00 g Total damages incurred to date..................................................................$3,015,000.00 10 N �Uj 11 M 12 � Estimated Prospective Damages as Far as Known ��01 Qrn g000?1Cn 3 Future expenses for medical and hospital care.........................................$ TBD QZ w=o 14 Future loss of earnings.................................................................................$ TBD woz Q w < 15 Prospective general damages......................................................................$3,000,000.00 =o ~0 U 16 Total estimated prospective damages.........................................................$39000,000.00+ co 17 Total amount claimed as of date of presentation of this claim................$6,015,000.00+ 18 All notices or other communications with regard to this claim should be sent to 19 Alfred H. Buchta at 18 Crow Canyon Court, Suite 325, San Ramon, CA 94583, (925) 743- 20 8900. 21 Dated: July 11, 2007 THE BUCHTA LAW OFFICES 22 23 24 ALFRLVD H. BUCHTA, 25 Attorney for Claimants 26 27 28 3 CLAIM FOR PERSONAL INJURIES(GOVT C§910) S'TAIEOFCALIFORNIA TRAFFIC.COLLISION REPORT CHP 555 Page 1 (Rev.7-03)OPi 061 ` Page 1 of 17 SPECIAL CONDITIONS mum Eo "a&Nv CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER FATAL 2 ❑ ANTIOCH PITTSBURG SUPERIOR COURT 07000432-1 NUMBER IOUED NRA RLW COUNTY REPORTING DISTRICT BEAT M30DAEANOR 2 ❑ CONTRA COSTA COUNTY :411 4 COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCI-a OFFICER I.D. Z Q JAMES DONLON BOULEVARD 1 / 12 /2007 21:58 0070100 2296 MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ❑ NONE U S MTWT FS AYES ❑ NO 2475 O ❑ AT INTERSECTION WITH STATE HWY REL J ❑X OR 273 FEET/MILES E OF NIGHTINGALE DRIVE ❑ YES ❑X NO PAR DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG I SAFETY EOLAP. VEH.YEAR M&KENODELICOLOR LICENSE NUMBER STATE D9396471 CA C L G 1994 ACUR/INTEGRA/GRN- 5LSM038 CA -------------------------------------------------- DRIVER NAME(FIRST MIDDLE LAST) aTYLER M ODRISCOLL _ OWNER'S NAME ❑ SAME AS DRIVER PEDES STREET ADmEss TRIAN ROBIN ODRISCOLL ❑ 523 W 6TH STREET#C OWNERS ADDRESS a SAME AS DRIVER PARKED cITY/sTATEaIP V EHICLEEl ANTIOCH,CA 94509 DISPOSITION OF VEHICLE ON ORDERS OF: ❑X OFFICER ❑ DRIVER ❑ OTHER BIICY APD LOT a SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE Ma. Day Year PRIOR MECHANICAL DEFECTS: X NONE APPARENT REFER TO NARRATIVE M 8LN BLU 505 130 5 1 18 / 1989 W OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER ❑ 9257067464 9253540970 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER 01 I ❑ UNK ❑NONE ❑ MINOR AAA CAF02333907 ❑ MOD.❑X MAJOR❑ ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT D EB I JAMES DONLON BLVD 35 CAL-T TCP/PSC MC/Mx (:— PARI DRIVER'S LICENSE NUMBER�STATE CLASSAIR BAG I SAFETY EIM QUIP. VEH.YEAR KEIMODELICOLOR LICENSE NUMBER STATE I _____ ______________________ ____________ _____ OF LAME(FIRST MIDDLE LAST) OWNER'S NAME ❑ SAME AS DRIVER PEDES' STREET ADDRESS TRIAN ❑ OWNERS ADDRESS ❑ SAME AS DRIVER PARKED CITYISTATEIZIP VEHICL 11 DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE COST ElMa. Day rear PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ VEHICLE TYPE J�E�j BE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ' NK ❑NONE ❑ MINOR ' OD.❑MAJOR❑ ROLL-OVER >DillOF TRAVEL I ON STREET OR HIGHWAY SPEED LIMIT CA DOT CAL-T TCPIPSC MC1Mx 'PARTy DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG I SAFETY EQUIP. VEH.YEAR MAKE/MODELICOLOR [LICENSE NUMBER STATE _____ _________ ____________ _____ _____________ DRIVER NAME(FIRST MIDDLE LAST) ❑ OWNER'S NAME ❑ SAME AS DRIVER PEDES- ED N STREET ADDRESS TRL❑ OWNER'S ADDRESS ❑ SAME AS DRIVER PARK D CITY/STATE/ZIP ElDISPOSITION OF VEHICLE ON ORDERS OF'. ❑OFFICER ❑ DRIVER ❑ OTHER BICY-CLIST SEX HAIR EVES HEIGHT WEIGHT BIRTHDATE RACE Mo. Day Y. PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA ;URANCE CARRIER POLICY NUMBER ' u LINK NONE ❑ MINOR I I r 0 MOD.❑MAJOR L] ROLL-OVER DIR OF TRAVEL I ON STREET OR HIGHWAY I SPEED LIMIT CA i CAL.T _—_TCPIPSC MC mx I REPARER'S NAME DISPATCH NOTIFIED REVIEWER'S NAME DATE REMEWEO ANARINI,JOE X YES = No NIA BROOKS,TAMMANY n�!nannm STATE OF CALIFORNIA TRAFFIC COLLISION CODING \S CHP 555 Page'2 (Rev.7-03)OPI 061 `- Page 2 of R DATE OF COLLISION(MO. DAY YEAR?) TIME(2400) NCIC a OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07000432-1 OWNERS NAME OWNERS ADDRESS NOTIFIED NROPERTY CITY OF ANTIOCH 212 H STREET ANTIOCH,CA 94509 ❑X YES No DAMAGE DESCRIPTION OF DAMAGE Damage to shrubs and possibly sprinkler heads. SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M I C BICYCLE-HELMET A-CELLPHONE HANDHELD A A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER 8-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 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN 4 5 6 7-STATION WAGON REAR G-LAPISHOULDER HARNESS USED Q-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS 8-REA OCC.TRK OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-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 I-)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 SPECIAL INFORMATION MOVEMENT PRECEDING LAST NUMBER(0)OF PARTY AT FAULT COLLISION A VC SECTION VIOLATED: CITED YES X A CONTRAS FUNCTIONIN A HA7JIRDOUS MATER A STOPPED 1 22350-1-VC X NO 13 CONTROLS NOT FUNCTIONING- B CELL PHONE HANDHELD IN USE X B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING' C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF ROAD D NO CONTROLS PRESENT/FACTOR- X D CELL PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN D UNKNOWN' AHEAD-ON F 75 FT MOTORTRUCK COMBO F MAKING U TURN 13 SIDE SWIPE G 32 FT TRAILER COMBO G BACKING C REAR END H SLOWING/STOPPING WEATHER RK 1 TO 2ITEMS D BROADSIDE { I PASSING OTHER VEHICLE X A CLEAR X E HIT OBJECT J J CHANGING LANES B CLOUDY F OVERTURNED K K PARKING MANEUVER C RAINING G VEHICLE/PEOESTRUW L L ENTERING TRAFFIC D SNOWING H OTHER': _ M M OTHER UNSAFE TURNING E FOG/VISIBILITY FT. _�N —— _ N XING INTO OPPOSING LANE �')THER': MOTOR VEHICLE INVOLVED WITH O O PARKED NO �I�N-COLLISION _ P MERGING LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY A DAYLIGHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTOR(S) R OTHER' B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS) X C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE :y-' i Y A VC SECTION VIOLATION: CITED O YES D DARK-NO STREET LIGHTS F TRAIND No E DARK-STREET LIGHTS NOT G BICYCLE -=1: B VC SECTION VIOLATON: CI7 ED FUNCTIONING' YES H ANIMAL: NO SOBRIETY-DRUG ROADWAY SURFACE _ F, ' C VC SECTION VIOLATION: CnED ,ES PHYSICAL X A DRY X I FD(ED OBJECT: 8 NO (MARK f TO 2ITEMS) B WET TREE D KI; 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 CONDITIONS) G STOP 8 GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN (MARK 1 TO 2ITEMS) PEDESTRIAN'S ACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE- HOLES.DEEP RUT X A NO PEDESTRUWS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK- J UNFAMILL4R WrrH ROAD X G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED I H NOT APPLICABLE X D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT YES I I SLEEPY/FATIGUED- ' E REDUCED ROADWAY WIDTH AT INTERSECTION X NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER': E IN ROAD-INCLUDES SHOULDER L M OTHER': _ H NO UNUSUAL CONDITIONS F NOT IN ROAD X N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE SKETCH MISCELLANEOUS SKETCH NORTH Q See Sketch on page 18. I STATE OF CALIFORNIA INJURED] WITNESSES / PASSENGERS �5 CHP 555 Page 3 (Rev.1-99)OPI 042 Page a or DATE OF COLLISION TIME(2 00) NCIC 1 OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07000432-1 EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) .=SS PASSENGER AGE SIX PARTY SEAT AIR :SAFETY SEC ONLY ONLY NUMBS POS. BAG ,EQUIP. TEt FATALSEVERE OTHER VISIBLE COMPLAINT DRNER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF IN EJ' 1 ❑ 17 M ❑ a ❑ ❑ a ❑ ❑ ❑ ❑ L ; o NAME I D.O.B.I ADDRESS TELEPHONE TYLER M ODRISCOLL / 0511 8/1 989/523 W 6TH STREET#C ANTIOCH,CA 94509 9257067464 nwUREDONLYITRANSPORTEDBY: AMERICAN MEDICAL RESPONSE TAKENTO: JOHN MUIR MEDICAL CENTER DESCRIBE INJURIES Shearing Brain injury,which causes bruising to the brain,Short term memory loss,30%chance of having brain seizures, Loss of mobility to left arm,and bruised right lung. VICTIM OF VIOLENT CRIME NOTIFIED ❑' ❑ 18 I F ❑ L^J ❑ ❑ ❑ ❑X ❑ ❑ ❑ I 1 1 3 1 M : B 0 NAME/D.O.B./ADDRESS TELEPHONE SAVANAH ROSE WILLSON / 0312211 988 1 523 W 6TH STREET#C ANTIOCH,CA 94509 9257067464 ONJl1REDONVATRANSPORTEDBY: CALSTAR TATO' JOHN MUIR MEDICAL CENTER DESCRIBE INJURIES Fracture to base of skull,broken left arm,shearing brain injury,which causes bruising to the brain,and slightly paralized on the right side of her body. ❑VICTIM OF VIOLENT CRIME NOTIFIED EJ ❑ 1 15 M N_1 ❑ _1_ ❑ ` ❑ 10 ❑ ❑ ❑ 1 7 P B 1 NAME/D.O.B./ADDRESS TELEPHONE AARON ROBERTSON / 08/03/1991 /1791 DIAMOND SPRINGS LN. BRENTWOOD,CA 94513 9253058438 (INJURED ONLY)TRANSPORTED BY: AMERICAN MEDICAL RESPONSE TAKENTO: JOHN MUIR MEDICAL CENTER DESCRIBE INJURIES Broken legs and visible cuts to face and body fatal injuries —1 VICTIM OF VIOLENT CRIME NOTIFIED ❑' E] 17 M 0 ❑ _1 E] I E] ( ❑ a ❑ ❑ ❑ , 7 P B NAME/D.O.B./ADDRESS TELEPHONE JACOB MICHAEL ESPINDOLA / 04121119891201 MARBLE DR ANTIOCH,CA 94509 9257785398 ONJURED ONLYI TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES Visible cuts to face and neck. Unresponsive at accident scene.Fatal injuries ElVICTIM OF VIOLENT CRIME NOTIFIED o', ❑ I 33 LM ❑ I ❑ I ❑ i ❑ I Ej ❑ I ❑ 1 ❑ ❑ 1 NAME I D.O.B.I ADDRESS TELEPHONE ERIC ABENOJA / 01/22/1973/1555 OAK ST ALAMEDA,CA 94501 5108128457 (INJURED ONLY)TRANSPORTED BY TARN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED []X '2 1 ❑ 581-M i ❑ _❑ ❑ I ❑ I ❑ 1 ❑ I ❑ I ❑ ❑ NAME I D.O.O.I ADDRESS TELEPHONE JEFF U ABRAMS / 0911 3/1 948 1 5360 RO_C_KR_O_SE_W_A_Y ANTIOCH,CA 94509 _ 9257669646 INJURED ONLYI TRANSPORTED BY: TAKEN TO: )ESC �'IURIES I I VICTIM OF VIOLENT CRIME NOTIFIED 'REPARER'S NAME I I.D.NUMBER 'MO. DAY YEAR I REVIEWER'S NAME I MO. DAY �- ZANARINI,JOE 2296 I 1 12 / 2007 BROOKS,TAMMANY 3 I 6 1 2007 STATE OF CALIFORNIA INJURED./ WITNESSES / PASSENGERS ,5 CHP 555 Page 3 (Rev.1-99)OPI 042 Page 4 of DATE OF COLLISION TIME(24011 NCIC 0 OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07300432-1 EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) ' .. NESS PASSENGER AGE SEX PARTY SEAT AIR (SAFETY ONLY ONLY NUMBE POS. BAG I EQUIP. EJEC FATAL SEVERE OTHER VISIBLE COMPLAINT �TH� PED. BICYCLIST OTHERTEE INJURY INJURY INJURY OFPAIN �N-3 ❑ 19 F ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/D.O.B.I ADDRESS TELEPHONE KRISTINA MICHELLE RODRIGUEZ / 1 111 311 987 1 816 W.6TH STREET ANTIOCH,CA 94509 9258120825 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I D.O.B./ADDRESS - TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES . ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑• ❑ I ❑ I ❑ ❑ I ❑ I ❑ I ❑ I ❑ I ❑ i ❑ f NAME I D.O.O./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESIRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑e ❑_� I ❑ I El ❑ I El ❑ ❑ ❑ El 101 NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 .0 1 ❑ NAME I D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TARN TO: DESCRIBE INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED El I ❑ 1i1 ❑ 10 1 1 1 11 1010101 ❑ 101 I i l NAME ID.O.B./ADDRESS TELEPHONE (INJURED ONLY1 TRANSPORTED BY: TAKEN TO: DE.' .INJURIES ❑VICTIM OF VIOLENT CRIME NOTIFIED PREPARERS NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR ZANARINI,JOE 2296 1 / 12 / 2007 1 BROOKS,TAMMANY 3 r 6 1 2007 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL 15 CHP 556 (Rev.7-90)OPI 042 page 5 or DATE OF INCIDENTIOCCURRENCE TIME(240M NCIC NUMBER OFFICER I.D. NUMBER 01/1212007 21:58 0070100 2296 07000432-1 'r ONE TYPE SUPPLEMENTAL r)-APPUCABLEI 0 Narrative 0 Collision report ❑ m update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICTIREAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :411/4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑x NO FACTUAL DIAGRAM LEGEND: A) Light poles 2980-2983. B) Espindola body at rest. C) Robertson body at rest. D) V-1 at rest. E) Uneven pavement sign and barricade. F) 25 MPH sign and barricade. G) Double fine zone sign and barricade. H) Raised asphalt edge. 1) Espindola body at rest. 2) Robertson body at rest. 3) Stereo amplifier. ! 4) Car floor mat. 5) Car jack. 6) Vehicle debris. 7) Paint ball gun hopper. 8) Vehicle rear spoiler. 9) Blue jean pants. 10)Paint ball gun. 11)Passenger inside door panel. 12)Back pack. 13)Right rear tail light. 4)CD case with CD's. 15)Scarf. 16)Vehicle debris. 17)Rear window. STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL IS CHP 556 (Rev.7-90)OPI 042 Pa e s of DATE OF INCIDENT/OCCURRENCE TIME(24001 NCIC NUMBER OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07000432-1 ONE TYPE SUPPLEMENTAL rX APPLICABLE) 19 Narrative n Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CRY/COUNTY/JUDICUL DISTRICT !:411 TING DISTRICTA3EAT �VTAMNNUMBE-R ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT /4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑x NO 18)V-1 left front tire friction mark. 19)V-1 right front tire friction mark. 20)V-1 left rear tire friction mark. 21)V-1 right rear tire friction mark. 22)V-1 at rest. STATION LINE: A station line was established 273' east of the east prolongation curb line of Nightingale Drive. VEHICLE POINT OF REST: V-1 Right front tire is 74' east of the station line, and 34' north of the south curb of James Donlon Blvd.. Right rear tire was 81' east of the station line, and 37' north of the south curb of James Donlon Blvd.. Left front tire was 76' east of the station line, and 29' north of the south curb of James Donlon Blvd.. Left rear tire was 83' east of the station line, and 32' north of the south curb of James Donlon Blvd.. PHYSICAL EVIDENCE DESCRIPTION: 1) Espindo(a's body at rest. 2) Robertson's body at rest. 3) Stereo amplifier. 4) Floor mat. STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL �S CHP 556 (Rev.7-90)OPI 042 page 7 of DATE OF INCIDENT/OCCURRENCE TIME(2400) NCIC NUMBEROFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07000432-1 -X'ONE TWE SUPPLEMENTAL rX'APPL)CABLE) QNarrative Q Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other. CRY/COUNTY)JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :411 /4 LOCATION!SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X NO 5) Car jack. 6) Vehicle debris. 7) Paint ball gun hopper. 8) Vehicle rear spoiler. 9) Blue jean pants. 10)Paint ball gun. 11)Passenger side door panel. 12)Back pack. 13)Right rear tail light. 14)CD case with CD's. 15)Scarf. 16)Vehicle debris. 17)Rear window. 18)305' of left front tire friction mark from V-1. 19)158' of right front tire friction mark from V-1. 20)162' of left rear tire friction mark fromV-1. 21)183' of right rear tire friction mark from V-1. I PHYSICAL EVIDENCE LOCATION: 1) Head-68' east of the station line, and 23' north of the south curb of James Donlon Blvd.. Feet- 63' east of the station line, and 25' north of the south curb of James Donlon Blvd.. 2) Head-93' east of the station line, and 44' north of the south curb of James Donlon Blvd.. Feet-99' east of the station line, and 45' north of the south curb of James Donlon Blvd.. 3) 5' west of the station line, and 2' north of the south curb of James Donlon Blvd.. 4) 42' east of the station line, and 39' north of the south curb of James Donlon Blvd.. 5) 56' east of the station line, and 3' north of the south curb of James Donlon Blvd.. STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL j CHP 556 (Rev.7-90)OPI 042 Pa e a of DATE OF INCIDENVOCCURRENCE TIME(2400) NCIC NUMBEROFFICER I.D. NUMBER 01112!2007 21:56 0070100 2296 07000432-1 'r ONE TYPE SUPPLEMENTAL r7P APPLICABLE) QNarrative 0 Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY I COUNTY I JUDICIAL DISTRICT REPORTING DISTRICTMEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :411/4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES N1 NO 6) 60' east of the station line, and 28' north of the south curb of James Donlon Blvd.. 7) 61' east of the station line, and 24' north of the south curb of James Donlon Blvd.. 8) 63' east of the station line, and 2' north of the south curb of James Donlon Blvd.. 9) 66' east of the station line, and 7' north of the south curb of James Donlon Blvd.. 10)69' east of the station line, and33' north of the south curb of James Donlon Blvd.. 11)69' east of the station line, and 40' north of the south curb of James Donlon Blvd.. 12)86' east of the station line, and 37' north of the south curb of James Donlon Blvd.. 13)91' east of the station line, and 30' north of the south curb of James Donlon Blvd.. 14)98' east of the station line, and 47' north of the south curb of James Donlon Blvd.. 15)140' east of the station line, and 53' north of the south curb of James Donlon Blvd.. 16)116' east of the station line, and 56' north of the south curb of James Donlon Blvd.. 17)174' east of the station line, and 71' north of the south curb of James Donlon Blvd.. 18)Left front tire Begin- 285'6" west of the station line, and 15'6" north of the south curb of James Donlon Blvd.. Left front tire End- 18' east of the station line, and into the center median curb. 19)Right front tire Begin- 125'7" west of the station line, and 9'6" north of the south curb of James Donlon Blvd.. Right front tire End- 31' east of the station line and into the center median curb. 20)Left rear tire Begin- 125'7" west of the station line, and 9'6" north of the south curb of James Donlon Blvd.. Left rear tire End-48' east of the station line, and into the center median curb. 21)Right rear tire Begin- 125'7" west of the station line, and 9'6" north of the south curb of James Donlon Blvd.. Right rear tire End- 55' east of the station line, and into the center median curb. STATE OF CALIFORNIA NARRATIVEISUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Flam 9 DATE OF INCIDENTUOCCURRENCE TIME(240M NCIC NUMBER OFFICER I.D. NUMBER ^x112/2007 21:58 0070100 2296 07000432-1 .E 7r ONE TYPE SUPPLEMENTAL r7r APPUCABLEU QNarrative M collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CrTATION NUMBER ANTIOCH 1 CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :411 /4 LOCATION U SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES NO FACTS: NOTIFICATION: I was dispatched to a call of a major injury traffic collision at 2200 hours. I responded from my residence and arrived on scene at approx. 2245 hours. All times, speeds and measurements in this investigation are approximate. Measurements were taken by rollmeter, Sokkia Total Station, and LTI Laser Gun in the survey mode, except where otherwise indicated. Ofc. Tom Beyhan #157 from the Pittsburg Police Dept. assisted in drawing the factual diagram with his Departments Sokkia Total Station. See factual drawing on pages 22-29. SCENE: At the scene of this collision, James Donlon Boulevard is a eastbound/westbound city street consisting of four lanes, two in each direction. The roadway is currently under construction. The posted 35 MPH speed limit signs have been covered with plastic sacks. 25 MPH black, white and orange construction zone signs have been posted throughout the construction zone. This construction zone meets the requirements of CVC 22362. The roadway is divided by a 16' wide raised center median. The center median is landscaped with shrubs and trees. The roadway is curved and level. The surface is composed primarily of asphalt. The number two lanes in both directions of James Donlon Boulevard have been repaved with a base coat of asphalt. A second coat of asphalt is still needed. The number one lanes of both directions of James Donlon Boulevard still has the previously existing asphalt. The number one and number two lanes are divided by plastic reflective markers that are glued down to the road. The number one and number two lanes are also separated by an approx. 1-1 1/2" transition asphalt lip as shown in the factual diagram. PARTIES: PARTY # 1 (ODRISCOLL) was located at approx. 2200 hrs. by Ofc. Stanton sitting in the drivers I STATE OF CALIFORNIA NARRATIVEISUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Page 10 of IX`J DATE OF INCIDEWPOCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER C""212007 21:58 0070100 2296 07000432-1 'r ONE TYPE SUPPLEMENTAL rX*APPUCAM-0 51 Narrative 0 Collision report ❑ 11A update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY I COUNTY r JUDICIAL DISTRICT REPORTING OISTRICTIBEAT [CITATIONNUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :411/4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑j NO seat behind the steering wheel, on the center median of e/b James Donlon Blvd.. Odriscoll was pinned in the car and had to be removed by the Fire Dept.. See Ofc. Stanton's supplemental report for further details. Party Odriscoll was identified by a valid California driver's license. Odriscoll was placed as a party by the following items: - Driver location - Driver injuries ACUR INTEGRA Driver# 1's vehicle, was located on its wheels as shown on the diagram. Vehicle damage is major damage to the entire vehicle. OTHER FACTUAL INFORMATION: Odriscoll's drivers license was issued on 10-3-06. The drivers license is provisional for one year. Odriscoll's drivers license is attached below and shows no departmental actions, no convictions, no failure to appears, and no accidents. SPEED CALCULATION: A speed calculation was formulated by using the "ARC", (Accident Reconstruction Calculator). Using a 100' cord, the middle ordinate was 29". A drag factor of .70 was used in the formula for James Donlon Blvd.. I determined V-1's speed to be a minimum of 73.78 MPH.. Refer to page 30 for speed calculation. _ .11CLE INSPECTION: i i On 1/16/07 at approx. 1400 hrs., I scheduled a vehicle inspection of Odriscoll's green 1994 Acura Integra STATE OF CALIFORNIA NA.RRAT(IVE/SUPPLEMENTAL i5 CHP 556 (Rev.7-90)OPI 042 page 11 or tZ DATE OF MCIDENT/OCCURRENCETME!24001 NCIC NUMBER OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 , 2296 07000432-1 'X'ONE TYPE SUPPLEMENTAL r'X'APPUCABI.EI 0 Narrative nX Collision report ❑ EIA update i._1 Fatal ❑ Hit and run update EJ Supplemental [] Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT ATMBER ANTIOCH 1 CONTRA COSTA COUNTY 1 PITTSBURG SUPERIOR COURT :41114 LOCATION I SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X No through Willy Fraser, City of Antioch Vehicle Maintenance Manager. He had Alan Alvarez complete the inspection while I monitored and video taped it. See Alvarez' report for further information. I STATEMENTS: PARTY# 1 (ODRISCOLL) On 2/5/07, 1 was told by Tyler Odriscoll's mom, Robin Odriscoll, that Tyler had been released from the Hospital, and that I would be able to talk to him tomorrow, 2/6/07. On 2/6/07, at approx. 1200 hrs., I contacted Tyler.Odriscoll at his residence. I spoke to him for approx. 45 minutes and Tyler Odriscoll could r. emember anything about the collision. I explained everything to him about the collision and how it happened and he still could not remember a single thing about the collision. Tyler Odriscoll's mother Robin stated the Doctors at the Hospital said due to his brain injury, Tyler may never remember what happened during and before the collision. Robin Odriscoll also stated that Tyler is going to have to go through extensive physical therapy to try and regain normal brain functioning again. PASSENGER (SAVANAH WILSON) was contacted at approx. 2200 hrs. by Ofc. Stanton. Wilson was pinned in the front passengers seat of the car on the center median of e/b James Donlon Blvd., and had to be removed by the Fire Dept.. Wilson was unconscious and unable to provide a statement. See Ofc. Stanton's supplemental report for further details. PASSENGER (AARON ROBERTSON) was contacted at approx. 2200 hrs. by Ofc. Stanton. Robertson was found lying on the ground to the rear of the car and was unconscious. Robertson later died from his inil Ivies at John Muir Medical Center. See Ofc. Stanton's supplemental report for further details. PASSENGER (JACOB ESPIN DOLA) was contacted at approx. 2200 hrs. by Ofc. Stanton. Espindola was found lying in the number one lane of e/b James Donlon Blvd. with a fatal injury. See Ofc. Stanton's STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL r5 CHP 556 (Rev.7-90)OPI 042 Page 12 DATE OF 1NCIDENTIOCCURRENCE TIME 84= NCIC NUMBER OFFICER I.D. NUMBER n1/12/2007 21:58 0070100 2296 07000432- 1 E W ONE TYPE SUPPLEMENTAL(7f'APPLICABLE) i 0 Nanabve rx-1 Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Omer. ❑ Hazardous materials ❑ School bus ❑ Other. CIT//COUNTY/JUDICIAL DISTRICT REPORTING DISTRICTISEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY!PITTSBURG SUPERIOR COURT , :411/4 LOCATION I SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X NO supplemental report for further details. WITNESS ABRAMS: On 01-20-07 at 1340 hours I re-contacted Abrams. I spoke to him in person at his residence. He told me he is not 100% certain about the color of the car. He is not really good at differentiating similar colors. He believes that the car was older and grey. The color was dull. Even with a detailed interview Abrams could not provided any further information about the car other than it was possibly a dull colored grey car. He first arrived behind these cars at the red light on e/b James Donlon Blvd. at Blythe Drive. He was in the number 1 lane behind the grey car. The green car (V-1) was in the number 2 lane. They sat there at red light for a minute to a minute and a half. He did not see any conversation or communication between the cars. When the light turned green, both cars took off at a high rate of speed. Abrams could not estimate the speed, but said it was "fast." As the cars approached the first bend in the road near Nightingale Drive, he saw the brake lights come on from the grey car in the number one lane. He lost sight of the green car (V-1) as it rounded the same corner still in the number two lane. Once he came around the corner near Nightingale Dr., he saw that the green car had collided with a tree-He then saw the car that was in front of him in the number one lane slow and move to the number two lane and go around the collision seen. He saw that there was a body in the number one lane. He is certain that the other car went around this body and did not strike the body in anyway. At that point, all of his attention was directed to helping the people at the scene and he did not see where the other car went. Initially he thought that V-1 may have struck the raised section of roadway and lost control. However after looking at the scene more closely and reflecting on what he saw, he no longer thinks the raised portion of roadway was a factor in this collision. Abrams believes that the speed of the green car is what caused this c,-.,lsion. Abrams had no further information. WITNESS RODRIGUEZ: STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL is CHP 556 (Rev .7-90)OPI 042 Page 1 S of DATE OF INCIDENT/OCCURRENCE TIME(240M NCIC NUMBER OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 , 2296 07000432-1 E -X'ONE TYPE SUPPLEMENTAL roc-APPLJCABLEI 0 Narrative [K Collision report ❑ BA update ❑ i-atal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY lCOUNTY lJUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER ANTIOCH I CONTRA COSTA COUNTY I PITTSBURG SUPERIOR COURT :411/4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD I NIGHTINGALE DRIVE ❑ YEs [X] NO While doing an inventory search of V-1, I located a cell phone that belonged to Tyler Odriscoll. I searched the recent calls on this phone and saw that the number 925-812-0825 was called on the date of the collision, 1/12/07, at 2140 hours, for 39 seconds, again at 2':11 hours for 61 seconds, and again at 2149 hours for 9 seconds, and at 2151 hours for 45 seconds. 1 c0led this number and spoke to a female that said her name was Kristina Rodriguez, Dob 11-13-87. She provided me with an address of 816 West 6th Street in Antioch. I went there and spoke to her at 1600 hours on 01-21-07. She identified herself with a California Identification card. Rodriguez told me that she has known Odriscoll for several months. She has bought marijuana from him :ast 4 times in the past. On 01-12-07 she spoke to him ,:.everal times. The first two calls at 2140 hours and 2141 hours, she called him and they talked about the purchase of marijuana. At 2149 hours he called her and said that he was outside of her house. After getting this call she and two friends that she would not name went to the car. She saw that Odriscoll was parked in front of her house. He was facing e/b in the w/b lane. She said that (Pass) Willson was sitting in the front passenger seat. (Pass) Robertson was sitting in the left rear back seat. (Pass) Espindola was sitting in the right side rear back seat. She talked to Odriscoll at the drivers window. The window was all the way down. She paid him ten dollars for a "dime sack of weed", (Marijuana). As she talked to Odriscoll, she did not smell the odor of marijuana or alcohol. Odriscoll did not appear to be under the influence of marijuana or alcohol. Someone in the car then fired a paintball gun at Rodriguez and her friends as they were walking away from the car and entering the side yard of her house. She turned to see the car pull away and make a U-turn at the intersection of"I" Street. She saw the car go back by w/b on W. 6th Street towards "L" Street. There were no other cars in the area. At that time (2151 hours) she got another call from Odriscoll. He asked her if anyone got hit by the paint balls and was laughing. She informed him that no o. did and they hung up after a short conversation. This was the last she saw and heard from Odriscoll. Her two friends that were with her do not drive or own a car. They remained with her at her house into the night and smoked the marijuana. STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Page 14 of DATE OF INCIDENT/OCCURRENCE TIME(240M NCIC NUMBER OFFICER I.D. NUMBER 01/12!2007 21:58 0070100 2296 07000432-1 7C ONE TYPE SUPPLEMENTAL r7PAPPLICABLE) RNarrative O Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICTISEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY 1 PITTSBURG SUPERIOR COURT :411/4 LOCATION I SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X NO Rodriguez had no further information. OPINIONS AND CONCLUSIONS: SUMMARY: P-1 Odriscoll was stopped for the red signal light e/b James Donlon Blvd., in the number two lane at the intersection of Blythe Drive. Next to Odriscoll was and unknown make and model possibly grey or silver compact car in the number one lane. As the signal light for e/b James Donlon Blvd. turned to green, both Odriscoll and the unknown possibly grey or silver car took off at a high rate of speed and appeared to be racing each other. As Odriscoll's car rounded the slight right hand turn near the intersection of Nightingale Drive, he lost control of his car due to the high speed, and skidded towards the center median. All four tires of Odriscoll's car hit the south center median curb, then jumped up onto the center median sliding through shrubs, before broad siding into a tree in the center median. This collision caused two fatal injuries to Odriscoll's back seat passengers as they were both ejected from the car during the impact with the tree. The unknown possibly grey or silver car was last seen driving e/b James Donlon Blvd. and did not stop for the collision. AREA OF IMPACT: A01#1: 18' east of the station line, and at the south side center median curb. A0I#2: 31' east of the station line, and at the south side center median curb. A0I#3: 48' east of the station line, and at the south side center median curb. A0I#4: 55' east of the station line, and at the south side center median curb. STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL i S CHP 556 (Rev.7-90)OPI 042 Pa s 15.f t DATE OF INCIDENTIOCCURRENCE TIME(24001 NCIC NUMBER OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 2296 07000432-1 W ONE TYPE SUPPLEMENTAL rX APPUCABLE) i Narrative I—XI Collision report ❑ BA update ❑ Fatal ❑ Hit and run update Hazardous materials ❑ School bus Other. E] Supplemental ❑ other. ❑ CITY I COUNTY I JUDICIAL DISTRICT REPORTING DISTRICTMEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :41114 LOCATION r SUBJECT STATE HIGMNAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X No A0I#5: 76' east of the station line, and 40' north of the south curb of James Donlon Blvd.. CAUSE: P-1 Odriscoll caused this collision by being in violation of CVC 22350, speed, which states, No person shall drive a vehicle upon a highway at a speed greater than is reasonable or prudent having due regard for weather,visibility,the traffic on, and the surface and width of, the highway,and in no event at a speed which endangers the safety of persons or property." RECOMMENDATIONS: Refer to the Contra Costa DAIS office for review. STATE OF CALIFORNIA TRAFFIC COLLISION REPORT CHP 555 Page 1 (Rev.7-03)OPI 061 Pepe I of 3 SPECIAL CONDITIONS NUMBER 11R a RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER BaIURED '"a FATAL 2 ❑ ANTIOCH PITTSBURG SUPERIOR COURT 07000432-2 NUMBER KaLEO NRa RUN COUNTY REPORTING DISTRICT BEAT NSDEMEANOR 2 ❑ CONTRA COSTA COUNTY :411 4 Z COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCIC• OFFICER I.D. z JAMES DONLON BOULEVARD 1 / 12 /2007 21:58 0070100 2990 MILEPOST INFORMATION OAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ❑NONE U SMTWTFS N YES ❑NO 2475 O ❑ AT INTERSECTION WITH STATE HWY REL J ❑X OR 273 FEETIMILPS E OF NIGHTINGALE DRIVE ❑ YES ❑X NO PARTY DRIVER'S LICENSE NUMBERS TATE CLASS I AIR BAG :SAFETY EQUIP. VEH.YEAR MAKEIMODELICOLOR LICENSE NUMBER STATE 1 ' ' ______________________ ____— DRIVER NAME(FIRST MIDDLE LAST) ❑ OWNERS NAME ❑ SAME AS DRIVER TEDESS- STREETADORESS ❑ OWNER'S ADDRESS ❑ SAME AS DRIVER VPAXEDI ENT CTfY/STATE/ZIP ❑ DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY• SEX HAIR EYES HEIGHT WEIGHTBIRTHDATE RACE 1 T Mo. Day Year PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑ UNK ❑NONE ❑ MINOR ❑ MOD.❑MAJOR❑ ROLL-OVER OIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT > CAL-T TCP/PSC MC/MX PAR DRIVER'S LICENSE NUMBER STATE GLASS AIR BAG I SAFETY EQUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE I I c NAME(FIRST MIDDLE UST) OWNER'S NAME ❑ SAME AS DRIVER PEDES STREETADDRESS TRIAN ❑ OWNERS ADDRESS (—� SAME AS DRIVER VPARCRYISTATElLIPEHICLE u 1:1DISPOSITION OF VEHICLE ON ORDERS OF: ElOFFICER ❑ DRIVER ❑ OTHER GUST SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE ❑ MD. Day Year PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATIVE VEHICLE IDENTIFICATION NUMBER: OTHER HOME PHONE BUSINESS PHONE 11VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ❑ UNK ❑NONE E] MINOR I ❑ MOD.❑MAJOR❑ ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT > CAL-T TCP/PSC mcw- PARTY DRIVERS LICENSE NUMBER I STATEC LASS AIR BAG :SAFETY SAFETY EQUIP. VERYEAR MAKE/MODELICOLOR LICENSE NUMBER — STATE_ _____ _ _ DRIVER NAME(FIRST MIDDLE LAST) ❑ OWNER'S NAME ❑ SAME AS DRIVER TEDES- STREETAODRESS AN ❑ OWNERS ADDRESS ❑ SAME AS DRIVER PARKE VEHICD CITY/STATE2IP ❑ DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY• SEX HAIR E\'ES HEIGHT WEIGHT 81RTHDATE RACE CUST ❑ Mo. Day Year PRIOR MECHANICAL DEFECTS: El NONE APPARENT ❑REFER TO NARRATIVE O� HOME PHONE I BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: . VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA AZURANCE CARRIER POLICY NUMBER I 0 LINK ❑NONE F] MINOR — ❑ MOO.❑MAJOR❑ ROLL-OVER OIR OF TRAVEL1 ON STREET OR HIGHWAY SPEED LIMIT CA DOT >CAL-i TCPIPSC _mew_] — — PREPARER'S NAME i DISPATCH NOTIFIED REVIEWER'S NAME 7DATEWED KOLtO,KEVIN X}YES ❑NO ❑NIA DEE,WILL 07 STATE OF CALIFORNIA TRAFFIC.COLLISION CODING CHP 555 Page 2 (Rev.7-03)OPI 061 Page 2 of 3 DATE OF COLLISION(MO. DAY YEAR) I TIME(1400) NCIC i OFFICER I.D. NUMBER 01/1212007 J 21:58 0070100 2990 07000432-2 OWNERS NAMEOWNERS ADDRESS NOTIFIED PROPERTY 1 []YES QX NO DAMAGE DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M I C BICYCLE-HELMET A-CELLPHONE HANDHELD A A--NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER V-140 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-SMOKNG 1 2 3 1-DRIVER E-SHOULDER HARNESS USED F-EATING 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN 4 S B 7-STATION WAGON REAR G-LAP/SHOULDER HARNESS USED 0-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS 8-REA OCC.TRK OR VAN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED 1-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 SPECIAL INFORMATION MOVEMENT PRECEDING LAST NUMBER(#)OF PARTY AT FAULT COLLISION A vc sEcTlON VIOLATED: CITED YES X A CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED 1 22350-I-VC X NO 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/FACTOR' D CELL PHONE NOT IN USE D 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 SLOWING/STOPPING WEATHER ARK 1 TO 2?EMS D BROADSIDE I 1 PASSING OTHER VEHICLE X A CLEAR X E HIT OBJECT J I J CHANGING LANES B CLOUDY F OVERTURNED _ K K PARKING MANEUVER C RAINING _ G VEHICLE/PEDESTRIA_N__ _ L _ L ENTERING TRAFFIC D SNOWING __ H OTHER': _ M M OTHER UNSAFE TURNING E FOG!VISIBILITY_FT. _ N N XING INTO OPPOSING LANE THER' MOTOR VEHICLE INVOLVED WITH Q 0 PARKED AND ANON-COLLIMy___. _ _ P MERGING LIGHTING B PEDESTRIAN Q TRAVELING WRONG WAY A DAYLIGHT . C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTOR(S) R OTHER' B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 21TEMS) X C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE _; +F. A VC SECTIONVIOLATION: CITED YES D DARK-NO STREET LIGHTS F TRAIN F, '� - NO E DARK-STREET LIGHTS NOT G BICYCLE Gk B VC SECTION VIOLATION: CITED FUNCTIONING* -- -- '4; ' YES H ANIMAL: NO SOBRIETY-DRUG ROADWAY SURFACE ; , ; 4 C VC SECTION VIOLATION: CITED YES PHYSICAL X A DRY X I FIXED OBJECT: -').r. ': B NO (MARK 1 TO 2 ITEMS) B WET TREE 9 REMMn _ A HAD NOT BEEN DRINKING C SNOWY-ICY j OTHER OBJECT: E VISION OBSCUREMENT: B HBO-UNDER INFLUENCE D SLIPPERY(MUDDY.OILY.ETC.) _ F INATTENTION': C HBO-NOT UNDER INFLUENCE ROADWAY CONDITION(S) G STOP&GO TRAFFIC _ D HBD-IMPAIRMENT UNKNOWN (MARK 1 TO 2/TEMS) PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP E UNDER DRUG INFLUENCE' A HO LES DEEP RUT' X A N 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 X D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOTIy�,�I YEs I SLEEPY/FATIGUED' E REDUCED ROADWAY WIDTH AT INTERSECTION LX No F FLOODED' D CROSSING-NOT IN CROSSWALK _ L UNINVOLVED VEHICLE _ G OTHER': E IN ROAD-INCLUDES SHOULDER M OTHER': H NO UNUSUAL CONDITIONS _ F NOT IN ROAD _ N NONE APPARENT I G APPROACHING I LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE ;SKETCH MISCELLANEOUS STATE OF CALIFORNIA NARRATIVEISUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Psge 3 o/3 DATE OF INCIDENTIOCCURRENCE TIME 240M NCIC NUMBER OFFICER I.D. NUMBER 01/12f2007 21:58 0070100 2990 07000432-2 IE 'JC ONE TYPE SUPPLEMENTAL MAPFUCABLE) QNarrative LJ Collision report ❑ BA update ❑ Fatal ❑ Hit and run update . ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other. CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICTA3EAT CITATION NUMBIBR ANTIOCH/CONTRA COSTA COUNTY I PITTSBURG SUPERIOR COURT :411/4 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑x NO On 1-12-07, I responded to the scene of this traffic collision. When I arrived I spoke to (wit)Jeff Abrams. Abrams was visibly shaken and told me the following in summary; He was traveling East on James Donlon Blvd and was following a grey unknown type of vehicle. The light.turned red at the intersection of James Donlon and Contra loma so he stopped. The grey car was in front of him and there was a green vehicle next to the Grey vehicle. The light turned green and both the vehicles accererlated away from the intersection at a high rate of speed. It was obvious to him that the two cars were racing. He saw them as they traveled neck in neck until they got to a slight bend in the road. The green card was in the number 2 lane and the gray car was in the number one lane (the fast lane). He saw that the cars started to slow,but the green car was not able to keep control and he hit the ridge that was in the I and lost control. He saw the green vehicle hit the tree and the first boy was ejected out of the car, onto the street. i ,at victim's body was now in the number one lane and in the path of the grey vehicle. The grey vehicle had to swerve to miss the body. The grey vehicle slowed,then it sped away. He did not see the driver or the passengers of the grey vehicle and he does not know what type it was. He did not see a license plate either. Abrams described the vehicle as an older dull grey small vehicle. It's unknown if it had 2 or 4 doors. He knows that the vehicle did not have tinted windows, but he is unable to provide any further details at this time. At the time of this report, I have no further information. Kollo #2990. I PREPARER'S NAME AND I.D.NUMBER � DATE I REVIEWER'S NAME DATE ' KOLLO.KEVIN j 01/14/2007 DFE,WILL 01/14/2007 STATE OF CALIFORNIA TRAFFIC,COLLISION REPORT CHP 555 Page 1 (Rev.7-03)OPI 061 Page 1 of S SPECIAL CONDITIONSE NUImER NRl RUN INJURD FELONY CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER FATAL 2 l [] I ANTIOCH PITTSBURG SUPERIOR COURT 07000432-3 NUIBER IOU ko y?.RUN R COUNTY REPORTING DISTRICT BEAT 2 ❑ CONTRA COSTA COUNTY :411 4 COLLISION OCCURRED ON MO. DAY YEAR TIME(2400) NCIC 0 OFFICER ID. Z O JAMES DONLON BOULEVARD 1 / 12 /2007 21:58 0070100 3579 F: MILEPOST INFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: ❑ NONE U S M T W T F S ❑X YES ❑NO 2475 O ❑ AT INTERSECTION WITH STATE HM REL -j ❑X OR 273 FEET/MILES - E OF NIGHTINGALE DRIVE ❑YES ❑X NO PARTY DRIVERS LICENSE NUMBER STATE CLASS AIR BAG I SAFETY EQUIP. VEH.YEAR' MAKEIMODELICOLOR LICENSE NUMBER I STATE r I . I _ NAME ----- ---------------------- DRIVER (FIRST MIDDLE LAST) ------ --— ❑ OWNERS NAME ❑ SAME AS DRIVER PEDES STREET ADDRESS TRWJ ❑ OWNERS ADDRESS ❑ SAME AS DRIVER PARKED CITYISTATE/ZIP VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY- SEX HAIR EYES FIEIGFif WEIGHT BIRTHDATE !ql cusr Mo. Dry Year IOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE EJi1CLE IDENTIFICATION NUMBER: ❑ VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER I ❑ UNK ❑NONE E] MINOR — _— ❑ MOD. —][ MAJOR❑ ROLL-0VER DIR OF TRAVEL ON STREET OR HIGHWAYSPEED LIMIT CA DOT CAL-T TCPIPSC MC1MX -- PAR DRIVER'S LICENSE NUMBER STATE CLASS f AIR BAG I SAFETY EQUIP. VEH.YEAR MAKEJMODELICOLOR LICENSE NUMBER STATE I — -----�— ' -------------------------------------------------- NAME(FIRST MIDDLE LAST) OWNER'S NAME ❑ SAME AS DRIVER PEDES- STREET ADDRESS TRIAN ❑ OWNERS ADDRESS ❑ SAME AS DRIVER PARKED CITY/STATE2IP VEHIC El DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE LIST ❑ Mo. Day year PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: ❑ VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER ' ❑ UNK ❑NONE ❑ MINOR ❑ MOD.❑MAJOR❑ ROLL-0VER DIR OF TRAVEL I ON STREET OR HIGHWAY SPEED LIMIT CA DOT J CAL-T TCPIPSC MC1mx PARI DRIVER'S LICENSE NUMBERSTATE CUSS AIRBAG I SAFETY EOUIP, VEH.YEAR MAKFIMOOELICOLOR LICENSE NUMBER I STATE 7I I _ I ____________ DRIVER NAME(FIRST MIDDLE LAST) E] —__— OWNER'S NAME ❑ SAME AS DRIVER PEDES- STREET ADDRESS TRIAN ❑ OWNER'S ADDRESS ❑ SAME AS DRIVER PARKED CITY/STATFJZIP --- --------------— VEHICL ❑ DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑ OTHER BICY- SEX HAIR EYES HEIGHT WEIGHT I BIRTHDATE RAC£ CLIST ❑ i I i Mo. Day Year � PRIOR MECHANICAL DEFECTS: ❑NONE APPARENT ❑REFER TO NARRATiVc OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: DVEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGE:)AREA --- ------- ❑ VI El LINK ❑NONE MINORSURANCE CARRIER POLICY NUMBER _— ' ❑ MOD.E]MAJOR❑ ROLL-OVER DIR OF TRAVEL l ON STREET OR HIGHWAY �SPEED LIMIT CA CAL-T TCPIPSC MC/MX PREPARER'S NAME DISPATCH NOTIFIED REVIEWERS NAME DATE REVIEWED STANTON,JEFF i j X YES rl'NO NIA ,DEE,WILL nl I+ennm STATE OF CALIFORNIA TRAFFIC COLLISION CODING CHP 555 Page 2 (Rev.7-03)OPI 061 Page 2015 DATE OF COLLISION(MO, DAY YEAR) TIME(2400) NCIC a OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 3579 07000432-3 OWNER'S NAME OWNER'S ADDRESS NOTIFIED PROPERTY M YES MX NO DAMAGE DESCRIFTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M(C BICYCLE-HELMET A-CELLPHONE HANDHELD A 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/CO D-LAP BELT NOT USED E-SMOKING 1 2 3 1-DRIVER E-SHOULDER HARNESS USED F-EATING 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT EJECTED FROM VEHICLE G-CHILDREN 4 6 6 7-STATION WAGON REAR G-LAP/SHOULDER HARNESS USED Q-IN VEHICLE USED 0-NOT EJECTED H-ANIMALS 8-REA OCC.TRK OR VAN H-LAPISHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 1-FULLY EJECTED I-PERSONAL HYGIENE 7 9-POSITION UNKNOWN J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN 2-PARTIALLY EJECTED J-READING 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 SPECIAL INFORMATK)N MOVEMENT PRECEDING LAST NUMBER(II)OF PARTY AT FAULT COLLISION VC SECTION VIOLATED: CITED 1 A YES X A CONTROLS FUNCTIONINGAHA ZARD9SJiSMATERIAL A STOPPED 22350-1-VC X�No 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/FACTOR- D CELL PHONE NOT IN USE D 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 SLOWING/STOPPING WEATHER ARK f TO 2TTEMS _D BROADSIDE I i PASSING OTHER VEHICLE X A CLEAR _X E HIT OBJECT I J CHANGING LANES B CLOUDY ___ F_OV_E_RTURNE_D K _ K PARKING MANEUVER C RAINING G VEHICLE/PEDESTRIAN _ L _ L ENTERING TRAFFIC D SNOWING_ _ H OTHER-i M _ _ M OTHER UNSAFE TURNING E FOG/VISIBI_LITY_FT. NN XING INTO OPPOSING LANE ITHER`. MOTOR VEHICLE INVOLVED WITH _ _O _ O PARKED AND A NQ ----C_Qk .WN_ _ P MERGING LIGHTING _ B PEDESTRIAN Q TRAVELING WRONG WAY A DAYLIGHTC OTHER MOTOR VEHICLE 1 OTHER ASSOCIATED FACTORIS) R OTHER B DUSK-DAWN D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS) _ X C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE e.; vc secnoN vlourloN: CITED Fyy,u;} A I YES' 0 DARK-NO STREET LIGHTS^_ _ F TRAIN_ Ef?;:' *..: NO E DARK-STREET LIGHTS NOT G BICYCLE_ ?'' YES VC SECTION VIOLATION: CITED FUNCTIONING' — .Yg - B H ANIMAL: .' SOBRIETY-DRUG ROADWAY SURFACE _ 4r'' C VC SECTION VIOLATION: CITED YES 1 PHYSICAL X A DRY x 1 FIXED OBJECT: '" '? No (MARK I TO 2 ITEMS) -:f.3 B WET TREE DA 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&GO TRAFFIC _ D HBD-IMPAIRMENT UNKNOWN (MARK I TO 2ITEMS) PEDESTRIAN'S ACTIONS H ENTERING/LEAVING RAMP_ E UNDER DRUG INFLUENCE' ES DEEP RUT' X A NO PF DESTRUWS INVOLVED 1 PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' 8 LOOSE MATERIAL ON ROADWAY- g CROSSING IN CROSSWALK- J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY- Al INTERSECTION K_DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE X D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT yEs I SLEEPY I FATIGUED' E REDUCED ROADWAY WIDTH AT INTERSECTION X NO F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE G OTHER` __ E IN ROAD-INCLUDES SHOULDER M OTHER': H NO UNUSUAL CONDITIONS_ F NOT IN ROAD N NONE APPARENT G APPROACHING/LEAVING SCHOOL BUS O RUNAWAY VEHICLE SKETCH MISCELLANEOUS i STATE OF CALIFORNIA INJURED I WITNESSES I PASSENGERS CHP 555 Page.3 (Rev.1-99)OPI 042 Page 3 of S DATE OF COLLISION TIME f!#00) NCIG i OFFICER I.D. NUMBER 01/12/2007 21:58 0070100 3579 07)00432-3 EXTENT OF INJURY("X"ONE) INJURED WAS("X"ONE) ..�fNESS PASSENGER AGESEX -- PARTY SEAT AIR SAFETY ONLY ONLY NUMBE POS. BAG:EQUIP.EQUIP_ EJECT£ FATAL SEVER£ OTHER VISIBLE COMPLAINT IWURY Y INJURY DRIVER PASS. PED. BICYCLIST OTHER IWUR — OF PAIN � ❑X ' ❑ 33 1 M ❑ —_ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/O.O.B./ADDRESS TELEPHONE ERIC ABENOJA / 01/22/1973/1555 OAK ST ALAMEDA,CA 94501 5108128457 ONJUR£D ONLY)TRANSPORTED BY: TARN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ai ❑ ❑__l o �_ ❑ I ❑ I ❑ I ❑ f ❑ ❑ ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED NAME I D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY TAKEN TO: DF-'-IBE INJURIES EIVICTIM Of VIOLENT CRIME NOTIFIED ❑i 1 ❑ i ❑ _ j_ �--L--��--�- ❑ ❑ ❑ 01 o L❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES OVICTIM OF VIOLENT CRIME NOTIFIED ❑' ❑ ❑ _L-❑ j ❑ 1 ❑ 1010101 ❑ j ❑ NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED I El ❑ -- --��--�-��-!-- --�-❑ ❑ I ❑ I ❑ ❑ ❑ NAME/O.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: Of :INJURIES EVICTIM OF VIOLENT CRIME NOTIFIED PREPARERS NAME I.D.NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR STANTON,JEFF ' 3579 1 13 / 2007 DEE,WILL 1 / 14 1 2007 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Page 4 of 5 DATE OF INCIDENTIOCCURRENCE TIME QI001 NCIC NUMBER OFFICER I.D. NUMBER 01/1212007 21:58 0070100 3579 07000432-3 IE 'r ONE TYPE SUPPLEMENTAL rX APPUC AEI LJ Narrative X Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other. ❑ Hazardous materials ❑ School bus ❑ Other. CITY I COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :41114 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES No SUPPLEMENT REPORT NOTIFICATION This call came into APD at 2159 hrs, and was dispatched at 2200 hrs. Responding from Lone Tree Way and Deer Valley Rd, I arrived on scene at 2203 hrs. OBSERVATIONS Upon arrival, I observed a Green Acura(CA Plate 5LSM038) on the center median to James Donlon Blvd. The vehicle was facing west with the front left of the vehicle in the number I east bound lane to James Donlon Blvd. The vehicle had major damage to the passenger side and two of the passengers had been ejected from the vehicle. The vehicle had collided with a tree in the center median. i --served a male who was laying on his back approx 5 feet behind the vehicle, who was later identified as Aaron Robertson. Robertson had what appeared to be a broken leg and additional cuts to his face and body. Another passenger, who was later identified as Jacob Espindola, was found laying on his back approx 6 feet in front of the vehicle in the middle of the number 1 lane to EB James Donlon. Espindola was none responsive and not breathing. I attempted to locate a pulse on his wrist and was unable to find one. Espindola had a visible laceration to the front of his neck. I located two additional subjects inside of the vehicle. The front passenger was later identified as Savanah Willson and the driver was identified as Tyler Odriscollo. Odriscollo was stuck inside of the vehicle. I was unable to open the driver side door. The front passenger seat had been pushed towards the driver seat from the collision. The steering wheel and the dash board was preventing both Odriscollo and Willson from being removed from the vehicle. Odriscollo was conscious and yelling. Willson was unresponsive,but breathing, and would not respond to questions. Contra Costa Fire engine 83 was first to arrive on scene. Engine 81 and 82 arrived later to the incident to assist. AMR bus numbers 298 and 299 both arrived on scene to assist. After Contra Costa Fire arrived, Captain Dominic Ciotola pronounced Espindola deceased, based on county protocol, at the scene at 2230 hrs, due to he was unable to obtain any vital signs. Robertson was transported by AMR to John Muir Hospital for his visible injuries. Willson was air lifted by Calstar to John Muir Hospital for her unknown internal injuries..Odri scollo was transported by AMR to John Muir Hospital for his visible injuries and also complaint of pain. . STATEMENT While on scene I spoke with WIT-Eric Abenoja. Abe.noja originally was not on scene during the incident. Abenol'2 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL CHP 556 (Rev.7-90)OPI 042 Page 5 of 5 DATE OF INCIDENTIOCCURRENCE TIME QtU(n NCIC NUMBER OFFlCER I.O. NUMBER 01/12/2007 21:58 0070100 3579 07000432-3 W ONE TYPE SUPPLEMENTAL r X APPLICABLE) 51 Narrative X Collision report ❑ BA update ❑ Fatal ❑ Hit and run update ❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other. CIT'I COUNTY/JUDICIAL DISTRICT REPORTING DISTRICTA3EAT CITATION NUMBER ANTIOCH/CONTRA COSTA COUNTY/PITTSBURG SUPERIOR COURT :41114 LOCATION/SUBJECT STATE HIGHWAY RELATED JAMES DONLON BOULEVARD/NIGHTINGALE DRIVE ❑ YES ❑X NO returned to the scene after some time. Abenoja was unaware the vehicle crashed and was on his way home when he observed the crash scene. Abenoja stated he was driving WB James Donlon, in his vehicle, when he observed a smaller size vehicle traveling EB James Donlon at a high rate of speed. He estimated the speed at over 60 mph. The vehicle was rounding a curve in the road just prior to Nightingale Dr. The vehicle began to veer to the left due to the speed and the curve in the road. As Abenoja continued to travel WB passing Nightingale Dr, he observed the smaller vehicle began to lose traction to the rear tires in the number 2 lane. Abenoja lost sight of the vehicle as he continued WB around the curve. Abenoja assumed the vehicle hit the curb and recovered. Abenoja did not see the vehicle racing any other vehicles. There were no other vehicles near the car as they were traveling EB. Abenoja did not see the actual collision. Traffic officers were later called to the scene. Refer to Ofc Zanarini's original report for additional information on this incident. . K—er to Ofc Kollo's supplement report for additional witness statements. further action taken. I i PREPARER'S NAME AND I.D.NUMBER DATE TD EWER'S NAME DATE STANTON,JEFF 101/13/2007 E.WILL 01/14/2007 STATE OF CALIFORNIA FACTUAL DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE ZZ OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER -12-2007 2158 0701 2296 07-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) Sk [TCH- Nightingale Drive A61 1 A 011, IL AOI "3 AOY�� A OIC'S James Donlon Blvd PREPARED BY I.D.NUMBER DATE REDATE VIEWER'S NAME Be han 157 01-29-2007 x STATE OF CALIFORNIA FACTUAL DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE z3 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. INUMB=ER -1-12-2007 12158 0701 2296 07-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) G F A E r Nightingale Drive A 4r Popp vim.. A B ° James Donlon Blvd ° A PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE Be han 1-57 01-29-2007 x STATE OF CALIFORNIA FACTUAL DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE y OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER '-12-2007 2158 0701 2296 07-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) 18 Nightingale Drive t-� 19 •: 3 ._ 6 4 5 9 8 7 10 James Donlon Blvd 12 14 16 15 17 PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE Beyhan 157 . 01-29-2007 x STATE OF CALIFORNIA SKETCH DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE 25 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER '-12-2007 2158 0701 1 2296 107-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) , rJ i I I I I j I it I I I jl I I I it I I • `I I I i • i II I � I � I I . I 1 t PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE Beyhan __ 157_-. 01-29-2007 x STATE OF CALIFORNIA SKETCH DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE 614 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER -12-2007 12158 1 0701 1 2296 07-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE Be han 157 01-29-2007 x STATE OF CALIFORNIA SKETCH DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE a2 7 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER -12-2007 2158 0701 1 2296 107-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) � 1 I +II i� l I + + � I + ' f ' I ' I I! I f I PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE Be han 157 01-29-2007 ' x r. STATE OF CALIFORNIA SKETCH DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE A8 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 12-2007 2158 1 0701 1 2296 107-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE_ ) ' CG Car lF�I I+iI � Crush Car True Car � I ++ I+ i � � I; J) PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE Beyhan 157 1 01-29-2007 1 x STATE OF CALIFORNIA SKETCH DIAGRAM CHP 555 Page 4(Rev.8-97)OPI 042 PAGE 29 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER ^4-12-2007 2158 0701 1 2296 107-432 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE= ) i 1 , I I + iI '7n I I i i II i 0 7 n I , g8 .. 310.8 " 3' 1 .90' 1 � I I r 7" II PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE Be han 157 LL1-29-2007 x I tEPORT NARRATIVE/SUPPLEMENTAL PAGE So .TE OF INCIDENT/OCCURRENCE TIME NCIC NUMBER OFFICER ID NUMBER _r"42/07 1 2158 0701 2296 07-432 n NTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER Antioch/Contra Costa/Delta 41014 None (CATION/SUBJECT STATE HIGHWAY RELATED James Donlon BlvdJNi htin ale Drive. No Critical Speed and Radius - Results Solve for Critical Speed and Radius: VC3 m = SRS R= —+— SM .5tw Variables Name Variable Value Unit Drag Factor f 0.70 Nemo Variable Value Unit -d C 100.00 ft Name Variable Value Unit Middle Ordinate M 29.00 in Name Variable Value Unit Track Width tw 0.00 ft Calculation Result Name Variable Value Unit Velocity V 73.78 mph Variable Value Unit V 108.21 fps Name Variable Value Unit Radius R 518.45 ft 'ARER'S NAME I.D.NUMBER MONTH/DAY/YEAR REVIEWER'S NAME MONTH/DAY/YEAR ..anarini 2296 01/23/07 VEHICLE INSPECTION REPORT Inspected By: Alan Alvarez Inspection Date: 01-23-07 Time: 0830hrs. LOCATION: Antioch Police Department MAKE: Acura MODEL: Integra YEAR: 11-93 LICENSE: 6LSM038 MILEAGE: 125,660 V.I.N. # JH4D62386RS004589 Case# 07-432 On January 23, 20071 Inspected the vehicle listed above at the request of Officer Joe Zanarini. Please refer to the following: Brakes Fluid in the master cylinder is just below the max. line. Pedal pressure feels to be normal and holds pressure when pedal is applied and held. Front rotor min. thickness- .750" Rear rotor min. thickness- .310° Front left brake: Brake pads—75% OF rotor measured— .805' Front right brake: Brake pads—75% R/F rotor measured- .806° Rear left brake: Brake pads—70% UR rotor measured- .297° Rear right brake: Brake pads—70% R/R rotor measured- .303° 1 ares Nexen N3000 205/40ZR17 **Max tire psi—50 psi The general condition of the wheels and tires are O.K. The OF had a cut in the tire and damage on rim of the wheel. After removing the tire from the wheel to inspect inside the tire; it appears the cut on the tire and damage on the rim was caused by the impact with the curb. R/F also lost air after impact with the curb and R/R tire tires has debris between the bead of tire and rim, from the collision. Front left tire tread depth— .246" OF tire Pressure— 0 psi Front right tire tread depth— .247° R/F tire Pressure— 0 psi Rear left tire tread depth— .284" UR tire pressure—29 psi Rear right tire tread depth— .275" R/R tire pressure- 25 psi Ref: **spec. on tire. /Napa Brakes spec. book p/n FO 3381 Additional Comments Throttle functions normally when applied and released. Clutch fluid in reservoir is below min. line, clutch pedal when activated feels to function normally. Qualifications of Inspecting Mechanic Alvarez attended and graduated from the Sequoia Automotive and Truck Technology Institute in j-..e 1987. He has been an Equipment Mechanic for the City of Antioch for approximately 17 years. During this time he has attended many specialty, as well as multiple car and truck, repair classes. DECLARATION OF MAILING CASE NAME: Michael Esnindola and Kelli Killian, Individually and as Jacob Esnindola's Successors in Interest v. Tyler O'Driscoll, Robin O'Driscoll,et. al. Contra Costa County Superior Court Action No.: C07-01160 I7ie undersigned declares the following: I am a citizen of the United States employed in Contra Costa County, California, over the age of eighteen years and I am not a party to the within action or proceeding. My business address is Centerpoint Building, 18 Crow Canyon Court, Suite 325, San Ramon, CA 94583. 1 served a copy of the attached: CLAIM. FOR PERSONAL INJURIES(GOVT C §910) on the following addressee(s): Clerk of the Board of Supervisors Room 106 County Administration Building 651 Pine Street Martinez,CA 94553 by the following method(s): X BY CERTIFIED/REGISTERED MAIL #7006 0810 0002 77613080: I placed a true copy of the above document(s) in a sealed envelope with postage thereon ft ly prepaid for first- class mail, for collection and mailing at San Ramon, California, following ordinary business practices. I am readily familiar with the practice of The Buchta Law Offices for processing of correspondence, said practice being in the ordinary course of business, correspondence is deposited in the United States Postal Service the same day as it is placed for processing. BY FED EX DELIVERY: I delivered to Federal Express a true copy of the above document(s)in a sealed envelope to be delivered overnight. BY PERSONAL SERVICE: I placed a true copy of the above document(s) in a sealed envelope and caused it to be delivered to the above addressee(s). BY FACSIMILE TRANSMISSION: I caused the above document(s) to be transmitted by facsimile to the number indicated above by the above addressee(s). The above service was made on the date this declaration was executed. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and this declaration was executed on July 11, 2007,at San Ramon, California. MICHELE STATER IL co toty� �} - F., ru `®® C-1 o - la Q ;� CO ._. o cri to cc cn 0 N -Cco -0Q � U ,� Od f Y O cd . <-- tf U0c) U ] m o cccc o .-, OLn � t Ll... CJ L ' N wq (L zwz z Qcr: LU ab,AghkO fn CD G -7 cU z C4 uj ,s j J"•�1�\ J �1 pO�N�p Vo m N o CD Z7. G 4O o O � V to.rL v d a r- da � v � v d V �' CLAIM i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i BOARD ACTION. AUGUST 14, 2007 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: ) you is.youn notice of the action taken on your claim.by the Board of I CLAIM AGAINST DEPUTY CLAWS Supervisors. (Para aph IV below), B. given Pursuant to Government Code i ecton 913 and 915.4. Please note all j AMOUNT: UNKNOWN -JUL 1 6, .2007 S � i "Warnings". CLAIMANT: RICK. SMITHCOUNTY COUNSEL MARTINEZjCALIF. T-98778/ D-B-1T ATTORNEY: UNKNOWN DATE ,RECEIVED: JULY 05, 2007 ' ADDRESS: MARTINEZ DETENTION FACILI BY DELIVERY TO CLERK ON: JULY 05, 2007 901 COURT.°STREET, MARTINEZ CA 94553 . BY MAIL POSTMARKED: JULY 03, 2007 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached'is a copy of the above-noted claim. JULY:_16, 2007 JOHN CULLEN, le Dated- By: ;Deputy H. FROM.: CoseTO: Clerk of the Board of S pervisors ( his claim complies substantially with Sections 910;and 910.2. ( ) .,This Claim FAILS to comply substantially with ,Sections 910 and 910.2; and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): I , ( ) 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 9.1. 1.3). ( ) Other: i i I . I ! - / 7-07 j Dated: By: Deputy County Counsel i Ill... FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) i ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I IV. OARD ORDER: By unanimous vote of the Supervisors present: ' ( This Claim.is rejected in full. ( ) Othet ! i i Iceitify tinct this is a true and cort•ect copy of the Board's Order entered in its minutes for i this date. Dated: CULLEN, CLERK, By Deputy Clerk. WARNIN (Gov. code section 913) ` t Subject to certain exceptions,you have only six(t7 Inontlrs from the state this notice was personally served or deposited in the nuall to file a court acdon on this claiin.See Government Code Section.945.6.You may seek the advioe.ol'an. attortley of your choice in connection with this matter. if'you want to consult an i. attonrey,you should do so immediately, *For Additional Wanting See Reverse Side ofTliis Notice. AFFIDAVIT OF MAILING _ I declare under. penalty of`perjury that i. ani 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 I States Postal Service in N[artlnez, Califoi iiia, postage fully prepaid a certified copy of this I Board Order and Notice to Claimant, addressed to the clahnan.t as shown above. i i I Dated: /,r •:?.OJDHN CULLEN, CLERK By Deputy Clerk i I I I .S"W,,l _ This warning does not apply to.claims which -are not•sublect to the California Tort Claims Act such.as actions in inverse condemnation, actions for specific relief such as.mandamus or injunction; or:Federal Civil Rights claims. The abovedist is not exhaustive.and legal consultation is essential to understand all the separate Ilinitatipns periods that may apply. The limitations period..within which suit must be filed'may be shorter or longer depending on the nature of the claim: Consult the•specitic statute's and cases applicable to your particular` claim. The County of;Contra Costa does not waive any, Of its,rights under. California Tort Claims Act �. 4 ,,•� or d.0i, t waive rights. under the statutes of limitations ajiplicable to actions Inot subject to'. : the California Tort Claims Act ''••'§ i4:*,:...r,"'.r;fr'-�,�,.i' tom.i. 'i�� ;`� . .,j`.t:*a�,'+t.;r;ti,F, VA r �� STO ( If JUL 0 5 2007 _ CLERK BOARD OE SUPERVISORS CONTRA.COSTA CO. si&u'I lI",* JIJL 0 5 2007 ?-Ro���, ��CO�UNTY�COUN�SEL MARTINEZ CALIF. IV ±Q r /��y�•=.�: � � Lc1.: um // i - 1046 1d1 U-W 1jr l a 1 2- Case Number: 3 4 5 6 7 8 CERTIFICATE OF FUNDS 9 IN 10 PRISONER'S ACCOUNT 11 12 I certify that attached hereto is a true and correct copy of the prisoner's trust account 13 to ent ro in transa tions of G Y\ ,. t`� for the last six months [prisoner name] 14 where(s)he is confined. [name of institution] 15 _ I further certify that the average de osits each month to this prisoner's account for the 16 most recent 6-month period were$ and the average balance in the prisoner's 17 account each month for the most recent 6-month period was $ 18 19 Dated: [Authorized officer of the institution] 20 21 22 23 24 25 26 27 28 - 5 - r ^I • ✓ ,�� t JIL 610 Ifi, NMI MAW& III! Admw l� ��' Lei►_ J 11 " km orI M `.r J- �1 i; 'i. AAISNB N- - NOT Iv Iurs �. �. UACs_.Iw_ftD)7_C Gf�'[�hN�C I. TO u tz ti _man�c7— �1s� p—ezv�T�— �9_ -a�-� � �A�.✓S �2v1� rrallGll���D a A ITS �c a��4ct�— To 7- (VIP cz� � l24B+ 714 C_r - -- - 7 RUQ f3dV.D LesPl12� � �Wi -�l� 3'UH 2C�0 ;,4 f23-JM��AhLL�� RA+��— LAO Poll 000- 1 nom:Ter OAC-q At T y so 00, Jim -- Q- -fib' ' ---------- z MP A LS 1-4-n cAA W on iAv ?.w--A- TOr( U� EKY A&Iff �� -7LW T—=eta 73W I c==-44) j7k-rLASS -n� W, A-- wF '}e7 645 3�_w_�__ ar a -7-- - ro.. =.�Tv �c Q5 0-" Ld 0 -T7! h, -rL&"V 6L-P�i 't —C-L-Aa,��zN T. D Ces L JA k, DUN G ��^/ ilk � Zt7��f1r ��_ Offil �I1NJG- AMD - -&A- - L-kZo- .—T1,4-:T-S2-b(L�_. am .—Y'd 1 Proof of Service - Mail PROOF OF SERVICE Re: Case Number Case Tide I hereby declare that I am a citizen of the United States, am.over 18 years of age, and am/am not a party in the above-entitled action. I am employed in/reside in the County of (_0P4 T N ,49- and my business/residence address is 101 COy d1—T ST o/Y I(14 2, - IT_. S_5;3 -- On S®" , I ser-,,ed the attached document described assa//-CAVA' A 69s_T�-Y ISI ryU R z��� on the parties in the above-named case. I did this by enclosing tttie copies of the document in sealed envelopes with postage fullyprepaid thereon. I then placed the envelopes in a U.S. Postal Service mailbox in California. addressed as follows: I, h it�t�� declare under penalty of perjury that the foregoing is true and correct. Executed on �� �� � C= o' at (_pAt7-I (D�(,� C d A California. )_ Signacurc �r UNITED STATES DISTRICT COURT`^; FOR THE NORTHERN DISTRICT OF CALIFORN;JA ��• '•i 6- 0 Dear Sir or Madam: 07 1 .4 Your complaint has been filed as civil case number IWUA Your complaint is deficient because: G?R) 1. You did not pay the appropriate filing fee of$350.00. If you are unable to pay the entire filing fee at this time, you must sign and complete this court's Prisoner's In Forma Pauperis Applicati h in its entirety. 2. The In Forma Pauperis Application you submitted is insufficient because: You did not use the correct form. You must submit this court's current Prisoner's In Forma Pauperis Application. Your In Forma Pauperis Application was not completed in its entirety. You did not sign your In Forma Pauperis Application. _ You did not submit a Certificate of Funds in Prisoner's Account completed and signed an authorized officer at the prison. You did not at a copy of your prisoner trust account statement showing transactions for the last six months. Other Enclosed you will find this court's current Prisoner's In Forma Pauperis Application;which includes a Certificate of Funds in Prisoner's Account form, and a return envelope for your convenience. Warning: If you do not respond within THIRTY DAYS from the filing date stamped above, your action will be dismissed and the file closed. If you submit the application,you will automatically be liable for the full filing fee,regardless of your present ability to pay the full amount of the fee. Sincerely, RICHARD W. WIEKING, Clerk, By Deputy Clerk rev.4/9/06 5Ae/J_/� d F ON UNITED STATES DISTRICT COURT;."<<��;� /,� FOR THE NORTHERN DISTRICT OF CALIFb1tl\IIAw <' c Dear Sir or Madam: 4, � � �y i ��• Your complaint has been filed as civil case n Yo r laint p umber Your com nt is deficient because: (FIR) 1. You did not pay the appropriate filing fee of$350.00. If you are unable to pay the entire filing fee at this time, you must sign and complete this court's Prisoner's In Forma Pauperis Application in its entirety. 2. The In Forma Pauperis Application you submitted is insufficient because: You did not use the correct form. You must submit this court's current Prisoner's In Forma Pauperis Application. Your In Forma Pauperis Application was not completed in its entirety. You did not sign your In Forma Pauperis Application. You did not submit a Certificate of Funds.in Prisoner's Account completed and signed by an authorized officer at the prison. You did not attach a copy of your prisoner trust account statement showing transactions for the last six,months. Other Enclosed you will find this court's current Prisoner's In Forma Pauperis Application, which includes a Certificate of Funds in Prisoner's Account form, and a return envelope for your convenience. Warning:. If you do not respond within THIRTY DAYS from the filing date stamped above, your action will be dismissed and the file closed. If you submit the application,you will automatically be liable for the full filing fee, regardless of your present ability to pay the full amount of the fee. Sincerely, RICHARD W. WIEKING, Clerk, By Deputy Clerk rev.4/9/06 S rl l ref' LAND-ECF-Docket Report https://ecf.cand.circ9.dcn/cgi-bin/DktRpt.pl?100349973781673-L 9... Prose U.S. District Court California Northern District (San Francisco) CIVIL DOCKET FOR CASE #: 3:07-cv-01464-WHA Internal Use Only Smith v. Tillman et al Date Filed: 03/14/2007 Assigned to: Hon. William H. Alsup Jury Demand: None Cause: 42:1983 Prisoner Civil Rights Nature of Suit: 555 Prisoner: Prison Condition Jurisdiction: Federal Question Plaintiff Rick Smith represented by Rick Smith T-98778/D-B-11 Contra Costa County Detention Facility 901 Court St. Martinez, CA 94553 PRO SE V. Defendant Deputy Tillman Defendant Deputy Guzman Defendant Deputy Clausen Defendant Deputy Noble Defendant Deputy Hall Defendant Deputy Muse Defendant Sullivan Defendant 1 of 2 5/16/2007 10:54 AM CAND-ECF-Docket Report https://ecf.cand.circ9.dcn/cgi-bin/DktRpt.pl?100349973781673-L 9... Perry Defendant Nurse Lois Defendant Deputy Brennan Defendant Deputy Morales Defendant Deputy Black Defendant Deputy Rector Defendant Silva Date Filed # Docket Text 03/14/2007 41 CIVIL RIGHTS COMPLAINT (ifpp) against Perry, Nurse Lois, Brennan, Morales, Black, Rector, Silva, Guzman, Clausen,Noble, Hall, Muse, Sullivan. Filed byRick Smith. (sis, COURT STAFF) (Filed on 3/14/2007) (Entered: 03/14/2007) 03/14/2007 32 CLERK'S NOTICE re completion of In Forma Pauperis affidavit or payment of filing fee due within 30 days. (sis, COURT STAFF) (Filed on 3/14/2007) (Entered: 03/14/2007) 03/14/2007 ***Set/Clear Flags (sis, COURT STAFF) (Filed on 3/14/2007) (Entered: 03/14/2007) 04/03/2007 (33 MOTION for Leave to Proceed in forma pauperis filed by Rick Smith. (sis, COURT STAFF) (Filed on 4/3/2007) (Entered: 04/04/2007) 04/26/2007 34 Copy of Letter to the Bar Association requesting forms from Rick Smith. Sent Pro se handbook.(sis, COURT STAFF) (Filed on 4/26/2007) (Entered: 04/27/2007) 04/27/2007 J5 Prisoner Trust Fund Account Statement by Rick Smith. (sis, COURT STAFF) (Filed on 4/27/2007) (Entered: 04/30/2007) 2 of 2 5/16/2007 10:54 AM N LU n p y y cr" $ Nd LU•� N fr..� � r � �,.:c.. cN r 4C) r" a._ .. �>Q� 00 �a � N G co 0 r lL F,— 0 4 41 cl 40 ZA r w CLA[Ivi 0 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action: All Section iefeiences are to ) the copy of this document.mai led to California Government Codes: ) you is your notice of the action taken your claim.by the Board of CLAIM AGAINST SHIELDS, A. -# -619 �4 Supervisors: (Paragraph IV below), JUL: 1> 8 2007 given Pursuant to:Government Code AMOUNT: $25,000 0o Section'913 and 915.4. Please note all COUNTY COUNFL "Warnings". I1AARTINEZ CALF CLAIMANT: RICK P. .SMITH. T=98778 2006019202 ATTORNEY:. UNKNOWN DATE RECEIVED: JULY 18, 2007 MARTINEZ, DETENTION_ .'FACIL y' JULY 18, 2007 ADDRESS: BY DELIVERY TO CLERK ON: 901, COURT STREET, MARTINEZ, CA 94553 JULY 17, 2007 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supprvisol•s TO County Counsel Attached is.a`copy of the above-noted claim. JOHN CULLEN, { Dated: JULY 18 :_:2007. By; Deputy I.I. FROM.: County-Counsel TOi Cler of the Board of Su er visors . ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8), ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: . i Dated: ��'23" By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as.untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the. Supervisors present: (� This Claim is rejected in full. ( ) Other: l certify that this is.a true and correct copy of the Board's.Order entered in its minutes fol, this date. Dated: / CUL.LEN, CLERK, By . Deputy Clerk. WARNIN (Gov. code section 913) Subject to certain excel tiars,you have only six(6) nontlis front the date this notice was personally served or deposited fn tile. niall to tiie A court Aedes on this,claim.See Government Code Section 945.6.You may seek the advice of an attosiley of.your choice hi connectiai`with this matter. tf you want to consult on attontey,you should do so.hnrnedlately. TO Additional Wanting See ReVerse Side of This Notice. AFFIDAVIT OF MAI:LING.: I declare under penalty of .�ier jury that I alli now, sand at all tinies herein mentioned, have been a citizen of fire United States, oyertge 18; rad that today,l deposited nil the United States Postal Service in lllartinez, Callfornla, postage fully prepaid a certilled copy of this Board:Order and Notice to Claimant, addressed to the clalinan.t as shown above. Dated: -9-00,-IOHN CULLEN, CLERK By Deputy Clerk i n S i `ft>u•' f , This warning does not apply to claims which are not subject to the California Tort Claims Act.-such as actions in inverse condemnation, actions for specific relief such. as mandamus or, injunction, or Federal Civil Rights"claims. The above list is not exhaustive and legal consultation is`essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be flied may be shorter.or.longer depending on the nature of the claim: Consult the specific . stat ites'and ceases applicable to your particular Claim* The County of Contra Costa does not waive any.. of its,'xights under.California Tort Claims Act � nor`''does^it waive rights tinder the statutes of limitations applicable to actions not subject to the California Tort Claims Act I - I I \ I i S~ Irv" •• � • j i i • iti .. I I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By: —,7 00,b®l q w;�- Reserved for Clerk's filing stamp YLT CIS �. �� ' T pQ ? ' � ao ) (001UT 5J4 1\1667 / L �E� Against the County of Contra Costa or ) ' - I --�"l'.L1. S 1 N-® District) L FJIJO (Fill in the name) The undersigned claimant 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? (Give exact date and hour) 6- ,2Po�- 15S PM 2. Where did the damage or injury occur? (Include city and county)MAA �-1 -7, � CU T q- CM7/�- ce)Jm ry 3. How did the damage or injury occur? (Give full details; use extra paper if required) OP 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? PC Y 5 What are the names of county or district officers, servants, or employees causing the damage or injury? PC QLY �-iq C--NC LMLD ��GN 6 iA,- 1 16 t f�Nl 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) P&N-MM6-W ScA�-L. aN P`0K.4-1464�)D , G�NCLD5GO COLO 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) I �q � .S TO 8. Names and addresses of witnesses, doctors, and hospitals: WT VA, (— MW7c.h4, CL-4-: 2S'cO &44"?,LA- W. M LTN711 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT WERE..r..............................................■■..t................E00museumso ) 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) 1 Name and address of Attorney (Claimant's Signature) (Address) > gV's 3 ) Telephone No. ) Telephone No. ..................0 0 am news 0 a MONO MEN MORENO 0 MEN..........t......oRoseau NOME NOSE M E N...■+ 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. . 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. - AL7—t ui4n�-- —PU TT .—:#I PGLL-�Y , A *tlq�q k4n C/40LAMD L T'. I, - -:)-to h -r(4-C— 4% DA TuI4 ca 2-097- 10. 1 fs-�.— Turr:-�VAN AND WTLL ;5�7L QzZ ' 9 `fib 19 'El A Ci-- , 141 AL S .' �Q L - 4 • "T � - �K - o --rL. Q-,u 4 77 It AP T- wkA:-S , �� � �. r-\ �[ I ' tvk v �U �A V ibA-(..,,k C-P .7 C-- s A/ttl IMC-/ G LA IV Q k- c- Sv kT7 kJC �-1 I/V� 10 c US .. Lkc 7-L Ol &-V 1 `t T C %- SgOVS COOTZ Ls;i A&D -TAZT ST S 4:F-T-- V-rn 12111{ --�l] IST 1+ C4am+ ! l-' s fm r--Al - qj l - qj-2A: bA T4 &T ro 74 C- v "N � - ® 14 A7 Th� 1 VJ TT N f .-5-S sm -L 1+ -6G : W bGkI 1,1 a L,(!t.5 CONTRA COSTA DETENTION FACILITIES Incident Report Incident Information: Entry Dt/Tm: 06-08-2007 1555 Entered By: JENGL , ENGLAND Updated By: 71794.,PERRY Supplement: On June 8, 2007, 1 was assigned to D Module with my partner Deputy Perry. At around 1200 hours, I had just returned from lunch. Deputy Perry advised me that when I was out to lunch, I-Smith (BK 2006019202)was sliding magazines from underneath his door to underneath I-Minors door, Aggravating I-Minor. Deputy Perry told me that he had warned I-Smith twice by the time I arrived back to the module. At that time Deputy Perry and I went to I-Smith's room (cell# 14) to remove him from his cell and place him in a visiting room for disobeying Deputy Perry's order and to prevent him from causing further disruption to the module. Once we got to I-Smith's room I saw I-Smith lying on his bed with a towel covering his face. At that time Deputy Perry told I-Smith to stand up so that he could be placed into handcuffs. I-Smith ignored Deputy Perry's order to stand up and prepare for transport. Deputy Perry then physically removed the towel off of I-Smith and again told him to stand up so that he could be handcuffed. I-Smith then stood up saying "This is fucking bullshit, you motherfuckers are going to the US. District court." Deputy Perry then told I-Smith to place his hands behind his back and to face forward. I-Smith placed both hands behind his back and continued to state that he was going to sue us and take us to the District Court. Deputy Perry then placed a handcuff on I-Smith's right arm. As Deputy Perry started to grab I-Smith's left arm, I-Smith began looking back towards Deputy Perry and began cursing at Deputy Perry. Deputy Perry told I-Smith to continue to look forward so that he could be handcuffed and transported to a visiting room. I-Smith continued to look back towards Deputy Perry and did not listen to his commands. Deputy Perry repeated his command for I-Smith to face forward and stop turning his head toward him. -Smith continued to ignore Deputy Perry's commands. I immediately grabbed I-Smith's left arm and helped Deputy Perry place handcuffs on I-Smith. Once I-Smith was handcuffed, we informed I-Smith that he was going to a visit room and that he needed to cooperate. I-Smith continued to yell profanities and again stated that he was going to sue us. Due to I-Smith's erratic behavior, Deputy Perry placed I-Smith's left arm in a rear wristlock and began escorting I-Smith into a visit room. As Deputy Perry exited the cell, I-Smith began stating "Fuck You" and pushed Deputy Perry with his shoulder causing Deputy Perry to lose control and to hit the wall. I immediately tried to place I-Smith's right arm into a rear wristlock. I-Smith had both fist clinched, making it impossible for me to complete a rear wristlock. Deputy Perry then forced I-Smith to the wall and told I-Smith to cooperate. I-Smith again stated, "Fuck you guys,.you won't get away with this." I pried I-Smith's right fist and finally got I-Smith's right arm into a rear wristlock. Deputy Perry then regained control of I-Smith's left arm and placed it into a rear wristlock. I advised I-Smith that he.was going to the visit room and that he needed to remain calm. I-Smith stated, "Fuck you, you won't get away with this." At this time Deputy Perry and myself began escorting I-Smith to a visit room. About half way to the visit room, I-Smith stopped and began pushing backwards, nearly causing us to fall. Deputy Perry and myself lost control of our rear wristlocks. Deputy Perry preformed a leg sweep and I regained control of I-Smith's right arm while he was falling to the ground. I-Smith fell to the ground and again stated, "You guys wanted this huh, Fuck you guys." I then saw that I-Smith's forehead was bleeding. Deputy Perry immediately had Deputy Zaiser call a nurse. I advised I-Smith that he was going to have to see the nurse and that he needed to remain calm in order for the nurse to see him. I-Smith just continued to state that he was going to sue us. While I-Smith was on the ground he repeatedly tried to smear blood from his wound onto my boot. Deputy Perry informed me that I-Smith was trying to smear blood on my boot and I moved it away from I-Smith's head. At this point Deputy Perry noticed that the handcuffs appeared to have become too tight in the struggle with I-Smith. Deputy Perry ordered 1-Smith to remain calm while he loosened the handcuffs, double locked them and checked for proper fit. Nurses Marytese and Fatmata arrived on the module and examined I-Smith. Both Nurses stated that I-Smith needed to be transported to CCCRMC for stitches to the forehead. I-Smith had about an inch laceration on his forehead. Deputy Perry sustained a 2-inch abrasion with bruising on his right arm. Sgt. Evans arrived on the module and took photographs of I-Smith's injury, Deputy Perry's injury and the pool of blood on the ground from the initial fall. Facility: 1 Page 5 of 6 Printed: 06-12-2007 2008 5271 MAIN Printed By:61961, SHIELDS CONTRA COSTA DETENTION FACILITIES Incident Report Incident Information: Entry Dt/Tm: 06-08-2007 1549 Entered By: 71794 , PERRY Updated By: 71794 ,PERRY SYNOPSIS: Inmate became combative during transport to a visit room. Inmate taken to ground. Sgt. Evans notified. NARRATIVE: On June 8, 2007 1 was assigned to D module with my partner Deputy England (71612). D module is the administrative segregation unit in the Martinez Detention Facility. Inmates are housed on D module when they are classified as either too violent, or too disruptive for general population. At approximately 1145 hrs I-Smith, Rick (booking#2006019202) pressed the call button in his cell and asked me if he could slide a magazine under his door and into the cell of I-Minor, James (booking#2007002695). 1 told I-Smith that he could not pass a magazine to I-Minor because I-Minor had already torn up a magazine earlier in the day and thrown the torn pages under his cell door and made a large mess on the module floor. Approximately 5 minutes later, I-Smith pressed his cell call button again and told me that he had passed a magazine under the door of I-Minor. I told I-Smith not to pass any more magazines to I-Minor. I-Smith said, "I know what fucking games you are playing. If you aren't going to turn down the t.v., I don't care what the fuck you say." At this point, I-Minor was already becoming disruptive by shouting obscenities from his cell and I was concerned that I-Smith's and I-Minor's disruptive behavior was going to cause other inmates on the module to become disruptive. It is common for other inmates on D module to become disruptive as a result of an inmate that is being verbally abusive towards the deputies. Deputy Zaiser(70044) remained in the control booth while Deputy England and I immediately went to I-Smith's room to remove him from his cell and place him into a visit room as a result of his insubordination and to prevent him from further disrupting the module. As we entered I-Smith's cell, I-Smith was laying on his bunk with a towel covering his head. I ordered I-Smith to stand up and "cuff up". I-Smith was not responsive to my order. I removed the towel from I-Smith's head and repeated my order to cuff up. I-Smith stood up, turned around and presented his hands for me to place the handcuffs on them. As I secured the handcuffs on I-Smith's right hand, he started turning his head toward me and said, "This is bull shit. I'm taking you to the U.S. district court." I ordered I-Smith to turn around and face forward. I-Smith ignored my command to face forward. I repeated my command to face forward and I-Smith once again refused to comply with my order. At that point, I reached up with my left hand and turned I-Smith's head away from me while Deputy England gained control of I-Smith's left arm. I secured the handcuff on I-Smith's left hand and began escorting him from his cell. I was unable to double lock the handcuffs at this time because I-Smith was struggling and trying to free himself from my control hold. As I was exiting the cell with I-Smith, he forced himself backward, causing me to hit the wall of his cell and lose control of my grip on his left hand. I immediately.forced I-Smith against the wall outside his cell and regained control of my grip on his left hand. Deputy England then placed I-Smith's right hand into a wrist lock. Deputy England then told I-Smith that he was going to be moved to a visit room and that he needed to calm down. I-Smith said, "Fuck you guys. You won't get away with this." Deputy England and I then began escorting I-Smith to the visit room. During transport, I-Smith continued to struggle and tried to break free of the control holds that Deputy England and I had on both of his wrists. As we were walking past the inmate phones, I-Smith pushed against me and tried to push me over the bench next to the phones. I began to fall over the bench and lost control of my grip on I-Smith's left hand. In order to regain control of I-Smith, I performed a leg sweep takedown to I-Smith's left leg and forced him to the ground. Deputy England then regained control of I-Smith's right hand. I-Smith then said, "Fuck you guys. This is just what you wanted. Isn't it?" I then noticed that I-Smith had blood running from his forehead. I called Deputy Zaiser and had him request medical staff to respond to the module. While I-Smith was on the ground, I noticed that the handcuffs appeared to be too tight on his wrists. I ordered I-Smith to remain still while I loosened the handcuffs. I then double locked them and checked them for proper fit. Facility: 1 Page 2 of 6 Printed: 06-12-2007 2008 5271 MAIN Printed By:61961, SHIELDS CONTRA COSTA DETENTION FACILITIES Incident Report I then noticed that I-Smith was trying to smear blood from his wound onto Deputy England's boot. I told Deputy England to move his boot away from I-Smith's head to avoid contamination. Deputy England and I then assisted I-Smith to his feet and placed him into a chair so that the medical staff could examine his injury. Nurse Maritess, Nurse Fatmata. and Nurse Mary responded to the module to evaluate I-Smith's injuries. The medical staff determined that l-Smith needed to be transported to CCCRMC for stitches to the laceration above his right eye. I-Smith had a laceration over his right eye that appeared to be approximately 1 inch in length. I suffered an abrasion approximately 2 inches in length with bruising on my right arm during the initial struggle in I-Smith's.cell. I treated my injury with an alcohol swab to prevent contamination. Deputy Tycer transported I-Smith to CCCRMC to receive stitches on the laceration above his right eye. Refer to D.R. #07-15143 for further information and crime scene photos of the incident. I-Smith has a history of threatening MDF staff and disruptive conduct in this facility. Refer to the following incident reports: #3002082, #3003516, #4007106, #6005150, #6005454, #6005760, #6005911, #6007533, #7000577, #7001670, #7002578 Sgt Evans was notified and approved of all activity. Cc: Classification NFI Facility: 1 Page 3 of 6 Printed: 06-12-2007 2008 5271 MAIN Printed By:61961, SHIELDS CONTRA COSTA DETENTION FACILITIES Incident Report Facility: 1 Page 4 of 6 Printed: 06-12-2007 2008 5271 MAIN Printed By:61961, SHIELDS CONTRA COSTA DETENTION FACILITIES Incident Report Deputy Tycer transported I-Smith to CCCRMC for medical treatment. Facility: 1 Page 6 of 6 Printed: 06-12-2007 2008 5271 MAIN Printed By:61961, SHIELDS r - 1) ems/ _ S1fT RICK 646-47707 CONTRA COSTA HEALTH SERVICES r_, F CONSENT TO SERVICES AND CONDITIONS ^r /05 / 196 a DU rR a K Z_�i F r rt OF SERVICES-AND OF ADMISSION E 6 /oe /o7 C s E /! MEDICAL/SURGICAL TREATMENT CONSENT: The undersigned consents to the procedures that may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, which may include but are not limited to laboratory procedures, x-ray examinations, medical or surgical treat- ment or procedures, anesthesia, or hospital services rendered the patient under the general and special in- structions of the patient's physician or of any other member of the hospital or health center's medical staff, including physician residents and independent contract physicians. The undersigned further agrees to the pro- In visions expressed on the reverse side of this form. TEACHING PROGRAM: The undersigned understands that Contra Costa Health Services, Contra Costa Regional Medical Center and Contra Costa Health Centers are teaching institutions and that residents, interns, and health care students, under the supervision of professional staff, may be involved in providing medical and/ or health care. CONSENT TO RELEASE MEDI-CAL ELIGIBILITY: The undersigned authorizes the Contra Costa County Employment and Human Services Department to release information concerning the status of the patient's Medi-Cal application, and to send information regarding the patient's Medi-Cal eligibility to the Contra Costa Health Services Department. The undersigned also authorizes the above Agency to send Contra Costa Health Services.a Letter of Authorization, to allow the Medi-Cal program to be billed for any medical services re- ceived at a county facility that may be covered by the Medi-Cal program. FINANCIAL AGREEMENT: The undersigned promises to reimburse the County of Contra Costa for any services not covered by Medicare, Medi-Cal, insurance, or any other health care compensation carrier, at the rates established by the Contra Costa County Board of Supervisors during the time this consent is in effect. This consent is valid and in effect for any hospital, outpatient, emergency or other medical care and/or ser- vices rendered to the patient at any time within 365 days from..the date indicated below. The undersigned fur- ther agrees to use any damages or indemnity paid to or on behalf of the patient as a result of the injury or illness which necessitated this care to reimburse the county up to the amount billed, but not to exceed the rates set by the Board of Supervisors. —continued on reverse The undersigned certifies that he/she has read the foregoing, received a copy thereof, and received a copy of the "Patients' kights", and is the patient, the patient's legal representative, or is duly au- thorized by the patient as the patient's general agent to execute the above and accept its terms. DATE SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE WITNESS TO SIGNATURE IF REPRESENTATIVE, STATE RELATIONSHIP If patient unable to sign,STATE REASON: Date By ADVANCE DIRECTIVE (ED, inpatient) ACKNOWLEDGMENT OF HIPAA NPP Do you have an Advance Directive? M Yes Cl No If yes,will you provide us a copy? C Yes O No Place sticker here If"no",was an Advance Directive if signature not already obtained. pamphlet given to you? Ej Yes C No Sionaturet + _ Date_. -7 MR463-1 (11-06) Side 1 Original: Chart Copy 1: Patient Accounting Copy 2: Patient i CONSENT TO SERVICES AN® CONDITIONS OF SERVICES AND OF ADMISSION, CONT. FINANCIAL AGREEMENT,continued:The undersigned waives the statute of limitations on this matter for a period of 10 years.This agreement and waiver is binding on the undersigned,his or her heirs,assigns,administrators, and executors. y The undersigned authorizes the Social Security Administration to release to Contra Costa Health Services Department information concerning the status of the patient's Social Security benefits,including the type of benefit,amount receiving, and the effective date.The undersigned also authorizes the above agency to release information about the patient's Medicare benefit,including the effective date. ASSIGNMENT OF BENEFITS: The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to Contra Costa County of any insurance benefits otherwise payable to or on behalf.of the patient for this hospitalization and/or these outpatient services, including emergency services if rendered, in an amount not to exceed the County's regular charges. A photocopy of this authorization shall be considered as effective and valid as the original. y The undersigned authorizes and directs the attorney,claims adjustor,insurance company and any person(s),company or corporation who may effect a settlement or payment of any claim for damages or indemnity that the patient may have arising from the injury or illness which necessitated this hospital care and/or outpatient services,to deduct the amount of the charges of these services from any sum due the patient and to pay that amount directly to Contra Costa County and, the undersigned hereby assigns that I mount to Contra Costa County. I hereby authorize Contra Costa Health Services or its representative,including a third party vendor,to prepare;com- plete,and file any paperwork,or documents,including medical and financial records necessary to process claims under a pharmaceutical assistance or drug ireimbursement program.I assign all benefits due and received on my behalf to Contra Costa Health Services. RELEASE OF INFORMATION FOR REIMBURSEMENT: The undersigned agrees that; to the extent necessary to determine liability for payment and to obtain reimbursement, Contra Costa County may disclose".- portions of the patient's record, including his/her medical and psychiatric records; to any person or cor'pora' - tion which is or may be liable for all or any portion of the charges, including but not limited to insurance com- panies, health care service plans, orkers's compensation carriers, Social Security Administration, and peer review organizations. NURSING CARE: The undersigned understands that Contra.Costa Regional Medical Center'and Contra Costa Health Centers provide only general duty nursing care unless the physician orders more intensive nuns-( ing care to be provided. PERSONAL VALUABLES: The undersigned understands and agrees that this hospital maintains a.safe:foi the safekeeping of money and valuables and that the hospital is not liable for any loss or damage to money, jewelry, documents, or any other personal property, which is not deposited in the safe. The liability.;of.the hospital for loss of any personal property which is deposited with the hospital for safekeeping is limited by statute to five hundred dollars ($500.00) unless a written receipt for a greater amount has been obtained from the hospital by the patient. CONSENT TO PHOTOGRAPH: The undersigned consents to the taking of pictures (digital, video, still photography) of the patient's medical or surgical condition or treatment for the purpose of diagnosis or treat- meet, or for medical education conducted by the hospital. or health centers. LEAVING HOSPITAL AGAINST ADVICE: In the event the patient elects to leave the hospital against the advice of a physician, I, the patient, or the patient's representative, hereby release the County of Contra Costa, its officers, agents, servants, employees, and physicians, from any and all responsibility for any ill effects which may result from leaving. DRUGS & ALCOHOL: Patients admitted to Contra Costa Regional Medical Center shall not use or pos- sess any alcohol or drug or drug appliance/apparatus not prescribed by or on behalf of the attending physician and dispensed by the hospital staff during the patient's current stay. MR463-1 (11-06) Side 2 I ` ' Contra Costa County Detention Facilities - DISCIPLINARY HEARING REPORT DETENTION FACILITY —� ���7A—� INMATE: 13����' I.��. LAst First H EARI NG DATE & TI M E: —17- C 7 INCIDENT DATE & TIME You have been 8CCUSpd Of violating the fUl]O�iDQ FU]�( or regulation(s) : As a result of this charge, you may be subject to one or more of the following penalties: Loss of good/work time, privileges or progmms, job or housing transfer, extra work detail . segregatinn, reprimand, criminal prosecution INMAJE RIGHTS TN QTSCTPITNE : l) To receive 24 hour prior notice of a disciplinary hearing. This may be waived in order to receive an immediate hearing. If not waimd, the hearing will be held within 72 hours of the completed report (excluding weekends and holidays). 2) To receive a copy of the incident report within 24 hours of the completed report 3) To be present during the hearing process. unless security of the Facility is jeopardized. 4) To present witnesses at the hearing. unless security of the Facility is jeopardized. 5) To represent yourself or have a staff member represent you 6) To appeal after the disciplinary hearing to the Facility Administrator for review. Such appeal request will be written on^the Inmate Request Form and filed within 5 days of the Hearing : o l do not want a Disciplinary Hearing and do not contest the charge. El I waive the 24 hour prior notice rule and request an immediate disciplinary hearing. o I do not waive the 24 hour rule o Other Inmate Signature: Date Time : INMATE: 0.. Present 0 Not Present Inmate Comments: Hearing Officer/Committee Investigation: Findings: ~< Inmote committed the ort as charged o Inmate did not commit u prohibited act o Inmate committed the following probibited act(s): Sanctions/Punishment imposed: Hearing Officer: 69 Name Employee Number Committee Member: Name Employee Number Copy to Inmate by: 1,11MApproved by Operations Director:________ ouxnuutmn: BAS(Original) Copies to: Facility Administrator,Inmate Booking,Operations Director,Inmate,Classification,Module where inmate is housed oET013:FRM nev.8w197 Proof of Service - Mail PROOF OF SERVICE Re: Case Number Case Title 5qq /M n+ P _'� w rc'4-0 -- I hereby declare that I am a citizen of the United States, am over 18 years of age, and am/am nota parry in the above-entitled action. I am employed in/reside in the County of ( rtLA-- CO, S7ilr- and my business/residence address is Cl' 01 Liv 9-1 ST-, n A! VA IZI - o n CIA-- On IA=On /A 41 0_V TU L-4 � t5rp Ise^red the attached document described as a on the parries in the above-named case. I did this by enclosing true copies of the document in sealed envelopes with postage fully prepaid thereon. I then placed the envelopes in a U.S. Postal Service mailbox in California. addressed as follows: I. !�� �.- SAA-171 I+ declare under penalty of perjury that the foregoing is true and correct. Executed on �6W 0V! at An �(�.sT� �� �"s( California. u � 1- Si�nanlre - .� } CONTRA COSTA COUNTY .DETENTION FACILITY ( ) INMATE REQUEST FOR INFORMATION (')�) MEDI•CAL REQUEST fN From: ,1v°q" (DOB) . 't' ae. .. � d { . Date: ' W Housing Assignment: Check One: ( ,)Request ( ) Grievance ( ) Appeal ( ) Other Request: ' • FM. •wtY:.:..y F Y , cY.:1 ^� J+�-S - GhigTa ,7 : I...r.f :." k�: r r� r 1_ tt gg �. . r, I.. is Date Recd / / Rec'd Bv: C Routed To: ANSWER: ( )APPROVED ( ) DENIED-(state reason) I _ By: _ Date: U, jPink:Kept by Inmate Yellow:Reply to Inmate ! White:To Booking k: DET 024:FRM 1/2/91 . Y W. CONTRA COSTA COUNTY DETENTION FACILITY ( ) INMATE REQUEST 1FOR INFORMATION ( ) MEDICAL REQUEST From: _. �a s� � B k g# (��� r �.�� �• �. ki s (DOB) Date: r. / ' / Housing Assignment: Check One: (Request ( ) Grievance ( ) Appeal ( ) Other Request: 0 fir' s r'' _ f'1 �.r' ' ,v.� .;y"'� .rr..�.�.�t., �r .:yam )b... ' 3 i.• //�; p/,+/+tel} . $11 r.�.r..,t/ y 11 Vb.n'i ..a.rt�' !•�t., !- I .._ 1 d �� w,.� G....I .tJi ' 1 Date Recd: �-�/ `-` / -� Rec'd Bv: �� t Routed To: ANSWER: ( ) APPROVED ( ) DENIED-(state reason) By: Date: Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1/2/91 July 02, 2007 Rick P. Smith T-98778 Martinez Detention Facility 901 Court Street, D-14 Martinez, CA 94553 Dear Mr. Smith, I am sorry for not responding to your request right away because I was on a week vacation and two days sick leave. I just came back today. Enclosed are ten (10) copies of Claim Forms you are requesting. With regards to the copies of the filed claims, I will be sending you the copies a day after each Board Actions of your claims. Five of your claims, the Board Action will be on July 10, 2007, so on July 11, 2007, I will be going to the Post Office to mail the result of your claims. Please have patience and I don't forget you. Please write your Identification no. after your name on each of your claims. Thanks. Sincerely Yours, Emy L. Sharp #� oLo N-'3- m �ws a) LU coo cr- t u_ . Lu �Sczilw w lu rri CL q J aCC so cr Ui 10 NO O� to 0%0 O V N 6� m oor C � `rC13.i.iNn �'o C0 0 �✓ 0 `D r � w L �CDP CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors,.Routing Endo;seme.nts ) NOTICE TO CLAIMANT and Board Action. All Section refe�eiices are to` ' ) "The copy of.this document mailed to California Government Codes:: ou rs your notice of the action taken � � Q:P on your claim.by the Board of CLAIM AGAINST FOREMAN #68550 a d : Supervisors. (Paragraph IV below), GRIGGS #68551 :. JUL 1.8 2007 . ' given..Pursuant to Goveirment Code AMOUNT: $10,.000:00 COUNTY COUNSEL Section`913 and 915.4. Please note all PRARTINEZ CALIF. "Warnings". CLAIMANT: RICK P. ..SMITH, T-.98778 2006019202 ATTORNEY:. UNKNOWN..... DATE RECEIVED: JULY 18, 2007 MARTINEZI DETENTION FACIL Ty JULY 18, 2007 ADDRESS: HY.DELIVERY TO CLERK ON: 901 COURT STREET, . MARTINEZ,. CA 94553 JULY 17, 2007 BY MAIL POSTMARKED:. FROM; Clerk of the Board of Supervisors TO County Counsel Attached isa copy of the above-noted claim. JOHN CULLEN, r r JULY:18- ;I2007.'.. Dated: , - = By:' Deputy ft.. FROM.: County Counsel ' TO: Clerk of theBoard of Su ervisors 4/� ,pa i�r (�1`liis clan omp nes substantially with.Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2; and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8); ( ) Claim is not timely filed. The Clerk should return claim on ground that it was .filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). (,.Other: 7hJSG�Qrw1 /S �7i»CIV only _r,s /ncfd/ 1775 DCG(J`r/'irJ Oh OraTO Oa l ZDo? 1.l►'7 p-7 arc_ 1,a4c 6Z^C( rr u•re<cv. I t C 4A dA Let- L Aq J ni. S.ee a on-, t�ovn ���5•c.ls � ti. Dated: ?_ �3- 0-7 By: 4�j&jC Q,,U Deputy County Counsel iII. FROM: Clerk of the Board TO: County Counsel (1) County.Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I.V. OARD ORDER: By unanimous vote of the Supervisors present: (v) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Boar'd's.Order entered in its minutes for this date. Dated: CULLEN, CLERK, By Deputy Clerk. WARNI (Gov. code section.913) Subject to certain excel)tlons,you have only six(6).niontlis from the date this notice was personally served or deposited in the mail to Nle avourt action on this claim:See Government Code Sectim 945.6.You may seek the advice of an httortey of your choice In coninectioi widi this matter, if you want to consult all attonrey,you should do so iitnrriediiately. *F01'.Addidoiiai Waiiririg See Reverse Side ofTlris Notlm AFFIDAVIT OF MAILf.NG I declare under penalty of perjury that I ani now, find at all times herein mentioned, have been a citizen of the United States, over age 18 and that today l deposited In the United States Postal Service In Martinez, Califof'nia, postage fully prepaid a certified copy of this Bonrd.Order and [Notice to Claimant, addressed to tine claimant as shown above. Dated: 7 !U`.ZzL3Omw CULLEN, CLERK By Deputy Clerk i i This Warning does not apply to claims which are notsubject to the California Tort Claims 4 Act such as.actions in inverse condemnation, j actions for specific relief such as, mandamus or j injungtion, or Federal Civil Rights claims. The above,llst Is not exhaustive and legal 4 consultation is essential to understand all the separate limitations.periods that may apply. The limitations period within.which suit must I be tiled may be:shorter,or longer depending on the,nature,ofthe.claim. Consult the specific I statutes and cases applicable to your particular The County.of Contra Costa does hot waive any �f it�s_-riglits .undeir.California Tort Claims Act .•-f�no'rdoes it waive rights under the statutes of limitations appilc able to actions not subject to the California Tort Claims Act I i I i i I 4• 4 F y ' `� i " ' ?.'.>,_ ';t'. .yon..,_i�;2..:•2..°.-f 4 j I i I , OFFICE OF THE COUNTY COUNSEL SILVANO B. MARCHESI COUNTY COUNSEL COUNTY OF CONTRA COSTA 1 --=- — •,;' Administration Building —651 Pine Street, 91h Floor SHARON L. ANDERSON b�•�/f _ �'�,QO CHIEF ASSISTANT Martinez, California 94553-1229 l GREGORY C. HARVEY 925 335-1800 n: .;;3 nt`" ( ) O. = �' �` VALERIE J. RANCHE (925) 646-1078 (fax) �' e3� �- ASSISTANTS �oST'`� COUK� NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Rick P. Smith 901 Court Street, D-14 Martinez, CA 94553 RE: CLAIM OF RICK P. SMITH Please Take Notice as Follows: In regards to the claim you submitted on July 17, 2007, portions of the claim are timely and portions are untimely. The portions of the claim prior to January 17, 2007 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2,because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 17, 2007 were not presented within the time allowed by law, no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. The only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. See Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. 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. SILVANO B. MARCHER COUNTY COUNSEL /, By: Monika L. Cooper Deputy County Counsel Page 1 CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5. Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On —E-9 -.0 , I served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid,in the United States mail at Martinez, California addressed to Rick P. Smith, 901 Court Street, D-14, Martinez, CA 94553, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws o th State of California and the United States of America that the above is true and correct. Executed on , at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAINLANT 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 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.) 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. a MEN Known al RE: Claim By: Reserved for Clerk's filing stamp Ou IW S-1-0-�Oc.�"I C' � \ \M � RECEIVE® Against the County of Contra Costa or ) J U L 1 8 LU U 1 c A&M � District)) CLERK BOARD OF SUPERVISORi (Fill in the pame) ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of 9(M and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) � p �0 � � ����rU� � �:��•�� �� Oct �� Q � ��� ��—� �,��'� 2. Where did the damage or injury occur? (Include city and county) M er—® 1000V4--D IST' 3. How did the damage or injury occur? (Give full details; use extra paper if required) C. 'S C 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ,�` � 5 What are the names of county or district officers, servants, or employees causing the damage or injury? C� c� , VG CJ+ AND S...�-.�:V r 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) U '� e�� T CH-'�T" 9-3-tq4qVI V1 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Q0 VG� Pw� 8. Names and addresses of witnesses, doctors, and hospitals: _ 9. List the expenditures you made on account of this accident or injury: N DATE TIMEAMOUNT ■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrraraaeevaa'rree ) 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 ) Q f � (Claimant's Signature) j o ro u S r (Address) Telephone No. ) Telephone No. rrr...rrrrr.rr.rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrra■a.r.rrrrr.r.rr.rrrrr.r .rrr.rr.i 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. ■■rrrrrr�rr�r�rrrrr�rrrrrr�rrrrrman rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrnrrr11r1111r11i 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. 1 i - - -- --- C o a AP-- - - - - -fid. _ _ TSs- -e- 6 N-to. t�✓�-�El '--, �� - - - -0 G o yo 7 � S —1 - f _ -- �.,T Com-- ---�� a ..- .- - - _-(Ism -. m- P Gf 7 K S ' l - -- I - - r - - 1 WO� j AI, Kid ROOM W-m-TAM.-MOR WIWO .�y® � - - ` - ~ -- fir.•.: - -- -- Id 20M . KI I Ma MW :r I �� jl .. f r CONTRA COSTA DETENTION FACILITIES Incident Report Incident Information: Entry Dt/Tm: 05-21-2007 0941 -Entered By: 68551 , GRIGGS Updated By: 68551 ,GRIGGS Narrative: On the above date I was assigned to D module with my partner Deputy Foreman. At approximately 0910 I-Smith, Rickey (2006019202)was on freetime on the A side of D module. Deputy Foreman told I-Smith that his freetime was over and to lock down, via the module intercom system. [-Smith did not reply due the fact that he was in the shower. I then walked to the A side of D module and told I-Smith that his freetime was over and that he needed to lock down. I-Smith acknowledged me with a unclear statement. I had to tell I-Smith approximately three more time that he needed to lock down. After 10 minutes I-Smith exited the shower and went back to his room, while in his room I-Smith said "you guys need to chill out."Then he laughed as he closed his door. I told I-Smith that this was the second time that Deputy Foreman and I had to tell him to lock down while he was in the shower. Due to that fact that I-Smith was late locking down, failed to obey module rules, and disobeyed deputies it pushed freetime back approximately 15 minutes. Time is very valuable on D module because there is (10) Ad-Seg O/A on the A side of D module. Sgt. Hobbs was notified of the incident. Facility: 1 Page 2 of 2 Printed: 05-21-2007 1910 5271 MAIN Printed By:48393,OEST CONTRA COSTA DETENTION FACILITIES Incident-Report Incident Information: Entry Dt/Tm: 09-06-2006 1708 Entered By: 68550 , FOREMAN Updated By: 68550 ,FOREMAN Synopsis: Inmate failed to follow-directions and was escorted-to cell-3 in intake: Narrative: On the above date I was working as an escort working in intake. At approximately 1655 hrs. I went to room 9 to bring an inmate out to fingerprint. I-Smith was standing in the doorway and I instructed him to have a seat because he was obstructing my view into room 9. Smith looked at me and said that he would move. Smith continued to stand near the door. I repeated my instruction.and Smith said, " I'm movin'. " Smith slowly walked over to a chair and sat down. Approximately 5 minutes later I returned to fingerprint another inmate. I-Smith was still standing in the doorway. I asked Smith why he wasn't sitting down and he said, "I have been sitting down." I told Smith to tum around and put his hands behind his back. Smith quickly turned towards me and raised his hands in my direction. I perceived this as a threat and grabbed Smith by his arm and pulled him out of room 9. 1 put Smith in an armbar control hold and directed him towards the ground. Deputy Griggs responded and grabbed Smiths' left arm and placed it in a arm bar control hold. We escorted Smith to cell 3 in intake. Approximately 20 minutes after placing Smith in cell 3, the intake worker informed me that cells 2,3,4, and 5 were flooding from the drains. When l responded to the area,water was spreading towards the intake area from the above listed cells. When I looked into cell 4 1 noticed that Smith had removed his red coveralls and was doing pushups in the cell in his boxers. The red coveralls were not visible from the cell window. I asked Smith where his red suit was, and he responded ,"I don't know what you're talking about." I determined that Smith had flushed his coveralls down the toilet and was responsible for the flooding. I notified Sgt. Katz of the situation and he instructed us to extract Smith from cell 4 and place him in a safety chair (due to safety cell 1 and 2 being occupied). The flooding of the cells created a facility security issue, placing inmates and staff in danger. Following a briefing, Deputies Brown, Griggs, Welch, Silva, and I formed infront of cell 4. Deputy Brown was holding a shield for our safety and I was armed with the pepperball delivery system. The rest of the deputies were formed behind us, prepared to make entry. Deputy Brown ordered Smith to lay on the ground and place his hands behind his back. Smith complied with the order. We entered the room and secured Smith without incident and placed him in a safety chair in cell 8. During the incident Smith was using profanity and making perverse comments directed towards female deputies. Nurse Cynthia checked the restraint chair and cleared Smith to remain in the facility. The observation log was started at approximately 1745 hrs. The incident was filmed by Sgt. Borbley. Smith was moved into safety cell 1 once it was available. CC: Classifications Facility: 1 Page 2 of 3 Printed: 03-14-2007 1214 5271 MAIN Printed By:51229,BARDEN CONTRA COSTA DETENTION FACILITIES Incident Report Incident Information: Entry DtITm: 05-21-2007 0941 Entered By: 68551 , GRIGGS Updated By: 68551 ,GRIGGS Narrative: On the above date I was assigned to D module with my partner Deputy Foreman. At approximately 0910 I-Smith, Rickey (2.006019202)was on freetime on the A side of D module. Deputy Foreman told I-Smith that his freetime was over and to lock down, via the module intercom system. I-Smith did not reply due the fact that he was in the shower. I then walked to the A side of D module and told I-Smith that his freetime was over and that he needed to lock down. [-Smith acknowledged me with a unclear statement. I.had to tell I-Smith approximately three more time that he needed to lock down. After 10 minutes I-Smith exited the shower and went back to his room, while in his room I-Smith said"you guys need to chill out."Then he laughed as he closed his door. I told I-Smith that this was the second time that Deputy Foreman and I had to tell him to lock down while he was in the shower. Due to that fact that I-Smith was late locking down, .failed to obey module rules, and disobeyed deputies it pushed freetime back approximately 15 minutes. Time is very valuable on D module because there is (10) Ad-Seg O/A on the A side of D module. Sgt. Hobbs was notified of the incident. Facility: 1 Page 2 of 2 Printed: 05-21-2007 1910 5271 MAIN Printed By:48393, OEST 3 00 �.y, i W 0 V N pe W P�.•O ��� j � ) - r' f,E 9v9 '7 0.. 00 �; �. dam V • J7 __ ... -') ,.f i \ ! CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i BOARD ACTION: AUGUST 14, 2007 ' I Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endoi:sementsl ) NOTICE TO CLAIMANT and Board Action. All Section references are to I ) The copy of this document mailed to California Government.Codes.. D � `pf) ;. • L�� �, you is your notice of the action taken on your claim:by the Board of ! JUL'.1 '3 2007 Supervisors. (Paragraph IV below), ! given Pursuant to Government Code AMOUNT: UNKNOWN COUNTY CUPJSEL Section 913 and 915.4. Please note all MARTINEZCALIF. "Warnings". CLAIMANT: ROBERT .J:::JONES . ;:..,... • I. ATTORNEY: WILLIAM P. LUCKE DATE_ RECEIVED. JULY 13, 2007 LAW.OFFICE OF WILLIAM .P. LUCKE' 'ADDRESS: 526 MAGNOLIA AVENUE .: I. BY DELIVERY TO CLERK ON: JULY 13, 2007 j PIEDMONT,-CAf. 94611 . .2063 MAIN STREET, SUITE 229.Y MAIL POSTMARKED:. . JULY 11, 2007 ! OAKLEY, CA 94561 I FROM: Clerk-of the Board of Supervisors TO: County Counsel I Attached is a copy of the above-noted claim. t JULY 13, 200.7 `JOHN CULLEN, Cl Dated: By Deputy IL FROM: County Counsel "TO: Clerk of the Board.of Supe isors ( " This claim complies substantially with Sections 910 and 9i0.2. ( ) This Claim FAILS to-comply substantially with Sections 910 and 910.2; and we are so notifying claimant. The Board cannot act for 1.5 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and ' send waining of claimant's right to apply for leave.to present a late claim (Section 911.3). ( ) Other: ! i I I Dated: By: Deputy County Counsel � - I 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). . I (IV. B ARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full: ( ) Other: I i I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. i Date CULLEN, CLERK, By Deputy Clerk, i WARNI (Gov. code sectioir.913) Subject to certain exceptions,you linve.only six(6) months 1'rotn the date this notice was personally served or deposited in the niall to file a court acdon.on this claiin.See Government Code Sectiou 945.6.You may � seek the advice of an attorney of-your choice in connection wide this matter. If you vivant to consult an attorney,you should do so immediately. *For Additimal Warring See Reverse Side of This Notice. ! AFFIDAVIT OF MAIQ..NG ' I declare under penalty of perjury that [.Aur 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 IYlartinez, Callibrilia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, Addressed to the claimant as shown above. I Dated. V—' oj�HN CULLEN, CLERK By : �' vt­ Deputy Clerk I 1 i I t r b r w i , i 1 This warning does not apply.to claimswhich i are not subject to the California Tort Claims . Act such,as.actions in inverse condemnation, actions for specific relief such as mandamus or injun tion,.or'Federal Civil Rights claims. The i above list is not exhaustive and legal ? consultation is essential to understand all the separate limitations periods that.may apply. ! The limitations:period within which suit must be til ' may be-shorter or longer depending on t the'nature of the claim: Consuit the specific statutes and cases applicable to your particular Claim. The County of Contra Costa does not'waive any ? of its.rights under California Tort Claims Act j .-` nor does it waive'rights tinder the statutes of limitations applicable,to actions not subject to ? the California Tort Claims Act, I I4 I i I . •^.4+ .+._ _ t .�„_.,. ,moi'... =+:T•+; a.t..,a;; 4; ” _ • is I i oll Lj � / `[I��, Cp JD WO GIERK1B PB sip, - �r� OC U OL u jo Ekp,I VU, CIL, -n ) 6 N EJ TY 77D 92 /,-1 i < f'Y)'E-o t CA tj q SN 7c, 1'� C-0/i c�T-!�- �cc 04 F— A- o Ar 7c jj11 7145- :57 C�E C 771 �"l�� � � � S ��� � ��� S �� ��� Sri t. EA At\JP (2 L X1 7W �E:'Y As sAl � NJ - r -7 L UPU Ty f C/v 76��U(- Cu FoE OAJr pct:� vis, "-x S 7/ C 0, --rci PL/ NJ SO ) co- H )"-s L \LN 3 "1, 'TYh- S\jP-c--sL\Vi � die .� '.� J 1� l `r✓o 1LD LO � � 6C (�,�� ���� �� ;fir �f�)%�'������� � is ��Tc. v, ou A 4- - s 2- )A Of cv Lb-)- 07 "ro, t 5 rl"i�E ,67 9 -U 1, 'OV$G, 15'2 i - t t ' qo 1-- � I ,,moo �t I I �. i CD"\ tYNO 6� .. i.�to C2 s OM �4'- �, I-Ij C3 • ? © '. r" coo a 0 N Ln 1A so �O = rip J 1iNn _. N 00 co T LA ru h Ln - a1N� co co © v — Jm — C3 0. 'm C3 - oru Z CO Ln . � C3 O: h, N. CO o C=:) C=) wC-) cv a c"D (1)Cl) L.LO o(L) LLJ CC m0 U \ c W l` .J i CLA.INI i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors' Routing Endorsements, . ). NOTICE TO CLAIMANT and Board Action. All.Secf,.. i'efe ences are to i ) The'co of this document mailed to PY California Government Codes: ) you is your notice.of the action taken i on your claim.by the Board of Supervisors: (Paragraph IV below), given Pursuant to Government Code AMOUNT: UNKNOWN AUL 1 6 2007 Section,913 and 915.4. Please note all I "Warnings". COUNT;COUNSEL . CLAIMANT:. .LISA KEHR;; MAC{TitVcZCALIF.' ATTORNEY: UNKNOWN DATE:RECEIVED:. JULY 16, 2007 ADDRESS: 1973 ALVINA DRIVE: BY DELIVERY TO CLERK ON: JULY 16, 2007 PLEASANT. HILL, CA:94523 :I RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT I FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a Copy of the above-noted claim. . JOHN CULLEN, Cle'k JULY ..16;. "2007. . Dated:. By: Deputy f I. FROM.: '0ounty�CounseI . ... 'I O: Clerk of the Board of Supervisors ( "This claim complies substantially with Sections 910 and 910.2. ( ) This Claim. FAILS. to:comply substantially with Sections 910 and 910.2; and we' are so notifying claimant. The Board cannot act for l.'5 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 91.1.3). ( ). Other: nn I Dated: 7­0 By: I t '" � Deputy County Counsel j Ill... FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) I ( ) Claim was returned as.untimely with notice to claimant (Section 911.3). i I IV. OARD ORDER: By unanimous vote of the Supervisors present: (+ This Claim is rejected in full. ( ) Other: ' i I certify that this is a true and correct copy of the Board's Order entered in its minutes for j this date: _ Dated: - ,6z#W CULLEN, CLERK, ByDeputy Clerk. I WARNIN (Gov. code section 913) Subject to certain exceptia�s,you Dave only six(6) inonths from the date this notice was personally served j or deposited in the mail to file a court actioii on this claim.See Government Code Sectiai 945.6.You may seek.the advice Of an atttimey.of your choice in connection with this matter. {f you want t0 consult an i attorney,you sitouid do so immediately. VQr Addido ial Warring See Reverse Side of This Notice. AFFIDAVIT OF MAILING' [ declare under penalty of 1) J 111 that [ am now, and at all times herein mentioned, hhve been a citizen of tlie.Unitech States; over itge 18; aricl that today 1 deposited in the United States Postal Service in Martinez; Ciififornia, posta ge fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. j I Dated: ,v-.,,,,Q�jHN.CULLEN, CLERK By. Deputy Clerk s :This warning does not apply io.claims which 1{ are not subject to the California Tort Claims i Act.such as actions in inverse condemnation,. actionsfor specific relief such: as mandamus or Injunction, or Federal,Civil Rights Claims. The above list is not exhaustive and legal: consultation is essential to understand all the : separate limitations.periods that may apply, The limitations period within which suit must be flied may be.shorter or longer depending on the-.nature,ofthe claim. Constilt the specific statutes and cases applicable to your.particular claim. The County,of ContraCosta does not waive any*.' of its rights under California Tort Claims Act -,nor sloes it waive rights under the statutes of. limitations applicable to actions not subject to the California Tort Claims-Act , , ^• BOARD OF SUPSOBS OF CONTRA COSTA CO*'Y 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 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.) 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 again` each. public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ttttREM Elm RRMttettattttE■ tttattt e RE: Claim By: Reserved for Clerk's stamp Against the County of Contra Costa or ) ct 6 District) (Fill in the name) The undersigned claimant hereby slakes claim against the County of Contra Costa or the above-named district in the sum of$ an4 i-9 support of this claim represents as follows: UUR5WY1 1. When did the damage or injury occur? (Give exact date and hour) Maxcli 2, .20 1 ( 6 0 0 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 required) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? �e l c r� 5 t causing the What are the names of coon or VO officers servants or employees ees us damage or injury? F Y tj 6. ; What damage or injuries do your claim resulted? (Give full extent of injuries or damages -claimed. -Attach-two estimates for auto damage.)—-Se,-- Akqt._-Ckn%rn Wo . 03-9t—OD {to I—0 . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or dainage.) Cc ,coq_ C, —h YY�e l l k XloU_Y) , V S. Names and addresses of witnesses,doctors, and hospitals: l . 4C -P —� 1n n P� • LG Nl-`D• Kz-u%-+r (,�)a h u�—�c•c�-t� br. St,-5.rl &I00awi n , OG C_Kk rD r�-J6(_, 4 l (PA 415- C01--,C . St,i 4e, ('5(!) m 9. List the expenditures you made-on account of this accident or injury: CCt­,C_0-rd. CA qqs 116 DATE TINE AMOUNT -3-45 -0-7 3=-2,0P.M. to - (60pay. 3-co -d7 . -7%3g p.r•ti . 5 C p�, ac J V O-VsQ r- . ass season Ins Bona 11ME ENS son 11rwoman sesaM■■MM1111sno■s[smassBan■sa.1111etsas.aamanME%aaasaeat .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) 1 Name and address of Attorney ) (Claimant'sSignature) (Address) CA- gLt5Z3 - Telephone No. )Telephone No. -114 Z> ■,aseast agas sts..1111111111..a11It11 ..ansummits%Mose[aaRuss anon■oIssue tsatssssaman aWas Eggs now st 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 at seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■ 11 11 a s■.s as a a s s a M MIKE a Russ a f a f am a s s a s s s e s■■■M 11..11 a f 11 11 f 11[a 11 e s a 11 s 11 M.11 e t 11 s an 11[11 s name No not 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. :;County Administrator Contra Risk Management Costa County Administration Building L 651 Pine Street,6th Floor County Martinez,California 94553 Liability Claims (415)646-4155 Safety (415)646-2203 Vocational Rehabilitation (415)646-2239 Workers'Compensation (415)646-2926 CONSENT FOR THE RELEASE OF MEDICAL INFORMATION C�ocl����n ro.prztc�►� ch.► i, L1so- ��e�t authori e _SU-50n 6h LUjYj ,r�)C (Name of Patient) (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: Y Signed: ,�, 9 ► 1 - Address : ,C g�5Z3 ( Conservator or Guardian) Date of Birth: Social Securitv No. 5(oZfg-l-41 V-1 i i 2 y7� • .-County Administrator Contra 'Risk Management Costa County Administration Building Costa 651 Pine Street,6th Floor �Ou1'1+� Martinez, California 94553 County l Y Liability Claims (415)646-4155 Safety (415)646-2203 p E...C. Vocational Rehabilitation (415)646-2239 Workers'Compensation (415)646-2926 CONSENT FOR THE RELEASE OF MEDICAL INFORMATION X � , I , U�� ���(�-�' authorize K1a_�e Pe�-rnr�,ner1�� (Name of 'Patient) . (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: L4-I1-0- 1 Signed: X V�-�� • lJ J" r Address : �a 1 O—)O— C I'C' Be 11 , CA 9 L 513 ( Conservator or Guardian) Date of Birth: Social Security No. �. CLAIM , I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY . ILO � BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by .) . i the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Section references„are to ja . V, .r `��u )`a Thelcopy of.this document mailed to California Government Codes: �J9 you is your notice of the action taken JUL 16: 2007 on your claim.by the Board of. Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Goverment Code MARTINEZ CALIF. `. - Section 9l 3 and 915.4. Please note all I AMOUNT: $7, 942.98 ' "Watnirigs". CALIFORNIA`STATE..AUTOMOBILE. ASSOCIATION. _CLAIMANT: FOR: LISA KEHR : ! BY: JAMIE BOWMAN i ATTORNEY: UNKNOWN ,:; : DATE RECEIVED: JULY. 16, 2007 P.O. BOX.-920 ...:.. :.::'•.. ADDRESS: BY DELIVERY TO CLERK ON: JULY 16, 2007 , SUISUN.,CI.TY,,.CA 94585 RECEIVED FROM RISK BY MAIL POSTMARKED:. MANAGEMENT FROM: Clerk of the Board.of Su 'visors TO: County Counsel j . 11 Attached i5 a'copy of the above-noted claim. JULY 16;.. 2007 :. JOHN CULLEN, Cier Dated: i: .. By: Deputy } II. FROM: County Counsel TO: Clerk of the Board of pervisors . i (�iis 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 waining of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: ! i I . . I Dated: _71� � 0�'. " By: Deputy County Counsel 111, FROM.: Clerk of the Board T0; County Counsel (1) County Administrator(2) � ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I I I.V. BOARD ORDER: By unanimous vote of the Supervisors present: (yj This Claim is rejected in full. ( ). Other: . - I I certify that this is a true and con.ect copy of the Board's Order entered in its minutes for this date. Dated: CULLEN, CLERK, By Deputy Clerk. j WARNi. (Gov. code section 913) Subject to certain exceptions,you have only six(6) inontlis from the date this notice was personally served or deposited In the nail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attoiiiey of your choice in connection with this matter. ff•you want to consult an attorney,you should do so Immediately,:*FQr Addldotjal W9njh g See Reverse Side of This Notice. AFFIDAVIT OF MAILING: ! [ declare under pen'alfy'of.lierjury tlilnt I ani 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 N'W- luez, Califurnia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. _ I Dated: J'o���HN CULLEN, CLERK By Deputy Clerk I I ......... .... ... .._.._..... Zti This warning does not apply to.claims Which . :.are notsubject to the California Tort Claims ...Act-such as actions in inverse condemnation, actions for specific relief'.such as mandamus or injunction, or Federal Civil Rights claims. The abovelistisnot exhaustive and legal consultation is.essential to understand all the separate limitations periods that may apply- The limitations period.within which suit must be tiled may be.shorter or.longer depending on the:nature of.the claim. Consult the`specific statutes and cases applicable to your particular. claim.`:: . The Countyof:Contra:Costa does`not.Waive any. of its.rights under California Tort Claims Act nor.d.oes it waive rights under the statutes of limitations'..appI!cable:to actions not subject to. the California Tort Claims Act ' • .� 1, •� � , I i URGENT- Facsimile Transmittal Please hand de ive to addressee. TO: penny Bailey RECEIVED Company/Location: Contra Costa County Risk Management JUL 1 6 LUUI Fax No.: 925-335-1421 Phone No. 925-335-1455 CLERKCONTRAC SSTACO.BOARD OF ISO:�S Sub)ect: Requested Claim Form FROM: California State Automobile Association Fax No. 707-863-9052 Phone No. 888-900-6520 x 6218 Department/D.O,: Subrogation Person Sending: Jamie Bowman Your File No. 62472 ---- -.--- _---- Our File No. 03-8L0461-0 � Remarks: 9 Management Approval: All /a y7Z . Date/Time: 7-10-07/ (� No. Pages including Cover Page: 3 i i 157C f F20(Rev.Apr 2003) I -d LOOI -069-BIL ddSO WWLI� :9 LOGO OI I :�� I t JUL. 9. 2001 3: 11PM CCC RISK MANAGEMENT N0. 538 P. 2 13C ARD OF StTPFRVISORS OF CONIU COSTA COUNTY INSTRU ORIS TO CLAID?AIY— 1�srv+w.. t�. �I—-� •...r a.��w� G4-T�r�. Zs�To fiJ.t.�r ` A6 clsim r to a came of action for death or for Wuy to pehson or to pasoual propar[y of proving crap shall be presented not lir than sx mond after the m mal of the ciahse of action. A relating to any other came of action shell be.pres�:d not lsbr thea oma year . aha the ne of the cause ofsation_ (Croy. CO&j 11.2.) Cleans must a filed with. the Cleric of the Board of SW=vbors at its office, in Room 106, County on Building,651 Pine Sfte` ,1�er,CA 94553. if claim is a t a district governed by the Board of Sapervisors, rather ton the Cotmty, the �e of the 'ct should be filled in. 1. if the alalm egaiast niore than one publio enft wpm-ate claims mast be fled against each. public entity. ? Frau See p fair fraudulent 619m,Penal Code Seo. 72 at the end of this foam. Raf{ii■Ra a am IREft a RF naw fl Gar RRaaa as aallkhfaRaf/IYR aRRiRkMam am kifaR[k a llllf Ria a e■III ZE: Claim By: &served for Clerk'8 $stamp )' R / ECEI 'EE® Against the County Contra Costa or ) JUL 1 6 LUU1 CLERK BOARD OF SUPERVISORS . (FRIintbA ripme) CONTRACOSTACO. The rmda r ped cI t hwdby olaim against$ie,Cmm±y of Comma Costa or the above-named dishier lathe s=cd$, 7'`/Z• 9 and is support of this seam repres eels es follovm 1. 'M=did tbt damage or a uiy ooaur? (Gin enact date and hour) .f /�:OU 2. Where did damage or injury occur? (include city and coaatyy) 3. How did f1k ge or iAmuc occur? (Diva fa dabilr. use Wra paper if regd=) ' t���..✓ •Glii v�f I-�e .ti.1.�.i�.C.c- 1 v c.�..� .S/��t�� �/�/L_�.C.�.i. 4. VAut'P=tim lar act or omission on the part of bounty or#tr1ot efficets, servsuts, or eraplo 5 aV� Z caused the' 'ury or dannage7 �•.�.,r yv�`�✓.,L�,�" /"/' Aa •.�r. /fes. /' �r"�'L �dr7a�.��rV� o-ii��� ��'�.'�_.- 5 What are 6z names of cotmtp cw dist do t ofoer% servants,or era�loyaes=using the Z 'd LzOi -06S-6iL UUSO wuL*, :9 LOOZ OT inc JUL. 9. 2007 3; 11 PM CCC RISK MANAGEMENT N0. 536 P. 3 i.. What da=j& or iujurles do your obdm resulted? (Gin full mttmt of IWUdes or dgma7e9 chimed.' • two estimates for au3a damage:) �,;jv.� �(�c...,�,,� c ';� V—� 'Z4� . 7. Haw was amotmt clamed above comp (Iaclvde tb+e es�imacted amount of any Pa°sPeclive 'ury o�z clama�:) ��-�' f� .�eS��-��-.t-< . rx.-,�..../ �,,✓��-yrc..�.,5 S. Nem .md j ddresses of vihawses,doatoss,and hospitals: 9. ListtheDp nditures you x�aadTcryryo��uppaccomf ofthis accident a``r''ia``jmy: . AI 13 ■sons■Es■I■a all wake a saw she us■a a Masa as Lasa is a was taaaa PIKE[[$*K■las Ramm f M■MR Kwa as a as KPIl -Gov.Code Sea.910.2 provides'I"=claim sball be. signed by tba claimant pr by some person on his bebatf." slitm N 0: ttom v) N=c and address f Attorney ) C3aimsnt's Signature) . (Addroes) . } Telephone No. )Telephone I\To. 16; _7 a t IKa it most a at■ MEN■■■a aPaw a{men Kaala■fill as a as to amid It saas\Oaa■aa aaaamswRism eat Est a Ra a■ PUBLIC RECORDS NOTIUK: Please bo advised this claim &M or my claim fled.with lbe Cotmty tmder the Tart ClaimAs%!s snbj eat to public disQlom a ider'&; C•affor*+ 6 Public Reowdv A.at. (Gov. Code, 96 65 DD ea seq.) Fwtherraore, wY amchuuents,omem ums,or mpplem=enwW to tho claim fcrm, iucludhg medical rworda,We abo snbje to public&szlomm 1 aova■n amwl,tIa I■sRwm§%a1sawa a I a INN ass lona EE E a s■s was aunt Ian tan to a a lea pea as a a PI Ran as RE ail - I�IOTICE: . Secdoxe 71 of die P o rW Cods pravidas: Every pmen who, with iatmt to deftud,p¢z wu for allovmoe w Ior p*wwt to any state board or offices,or to any coumy, , or dis66t board or officer. aWhoriud to allaw or pay the sanua if gmume. any&4e, or fraudulent oiaim,t M,ace u t vo-a&er, or wrttinr.i punishable either by imprisonment in the County jell for a peaiod of not mort than on$year, by a fine,of not mceedlugg one thousEnd dollars($11000.01J), or by bo*such immpzi +�3nd a, or by impriwument in$te state prison, by a$ne of not monft ten thousand doll= ($10,0001 or by bc th snoh itaprisoamrint and fixe. E 'd LOOT -OSS-6IL UUSO wuLb =9 Looa of Znr California State Automobile Association Inter-Insurance Bureau P.O.Box 920 Suisun City.CA 94585-0920 April 18,2007 Contra Costa County Risk Management 2530 Arnold Drive Suite 140 Martinez,CA 94553 Penny Bailey RE: Your Insured: Jay Alan Winter Your Claim No.: 62472 APR Our Insured: Jeffrey Or Lisa M Kehr ���� Our Claim No.: 03-81-0461-0 ! b� Date of Loss: 03/02/2007 - Dear Contra Costa County Risk Management: This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts,request payment directly to California State Automobile Association Inter-Insurance Bureau (CSAA-TIB): In order to assist with and expedite the evaluation and processing of this subrogation demand, we enclose the relevant documentation in support of our claim. This information may contain personal or privileged information about our insured,and is being provided to you pursuant to California Insurance Code Section 791.13 and may not be used for any unauthorized purpose. Based upon this information,we ask that you issue payment of$7,942.98 Repair Bill $7,343.34 Deductible $0.00 Loss of Use $274.00 Rental—out of pocket $325.64 ------- ------------------ TOTAL $7,942.98 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will not constitute a full and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination,unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as"payment in full"or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction,as CSAA has not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CSAA's specific agreement to accept an amount less than that demanded in this letter. If you have any questions,please feel free to contact the CSAA Subrogation Department. Sincerely, JXfnie?oCWH,Xn Subrogation Specialist 888-900-6520 extension 6218 Fax 707-863-9052 Enclosure 0 0 N O c7 , • M O 0 U CHECK NO: 711 L487405-7—R m DATE: 03-30-2007 C w > NAME AND ADDRESS INFORMATION: LU U w PARKER ROBB CHEVROLET PO BOX 5500 WALNUT CREEK CA 94596 INSURED: KEHR,JEFFREY;OR LISA M PAYMENT INFORMATION/DESCRIPTION: REPAIRS/FINAL PAYMENT DATE OF LOSS: 03-02-07 CLAIM NO.: 03—BLO461-0 CLAIMANT: KEHR,JEFFREY;OR LISA M PAYEE: PARKER ROBB CHEVROLET AMOUNT: $7 ,343.34 IN PAYMENT OF: REPAIRS/KEHR ADJUSTER: SCOTT SLOAN ADJUSTER NO: 32450 KIND OF LOSS: COL 16510702 DETACH AND RETAIN FOR YOUR RECORDS No. 711 L487405-7- DATE OF LOSS CLAIM INSURED'S NAME DATE 03-02-07 03-81-0461-0 KEHR,JEFFREY;OR LISA M 103-30-200 POLICY TYPE KIND OF LOSS SUFFIX CLAIMANT'S NAME PAY AUTO COL 01F I KEHR,JEFFREY•OR LISA M $7 ,343 .34 D.O. ADJUSTER NO. IN PAYMENT OF BANK OF AMERICA DR2 32450 REPAIRS/KEHR Rank of, Amorlc■ Customor connacllon Bank of Amorlca, N.A. TIN: 94-1278730-00 Atlanta, Dokalb County, coorola PAY *SEVEN THOUSAND THREE HUNDRED FORTY THREE 34/100* PARKER ROBB CHEVROLET This check must be properly endorsed on the reverse side by all F TO THE ORDER OF Date: 3/22/2007 02:38 PM Estimate ID: 2307 E slim ate V ersi on: 2 Supplement 1 (P) 3/22/200702:36:52 FINAL Profile ID: CSAA PARKER ROBB COLLISION CENTER 1750 LOCUST STEET WALNUT CREEK,CA 94596 (925)476-4255 Fax: (925)943-1765 Tax ID: 94-1278730 BAR#: AG103714 EPA M CAD055391452 Damage Assessed By: Kristin Freeman Supplemented By: Kristin Freeman Type of Loss: Collision Date of Loss: 3/2/2007 Final to Owner 3119/2D07 C1 Payer. Insurance Deductible: WAIVED C1 File Number. F VPolicy No: 8L04610 Claim Number: A03SL0461001 N N M Insured: JEFFREY/LISA MKEHR Address: 1973 alvina dr pleasant hill,CA 94623 Telephone: Work Phone: (925)4517829 Home Phone: (925)6917434 fA U Mitchell Service: 913498 m p Description: 2002 ChevroletTahoe LS Vehicle Production Date: 7/02 W Body Style: 4D Ut 116"WS Drive Train: 5.3L Inj 8 Cyl 4WD VIN: 1GNEK13Z12J334669 License: 5LPML597 CA W Mileage: 43,717 W OEIWALT: A Search Code: C318473 W Color: red Options: 4WD OR AWD,ALUM/ALLOY WHEELS,AIR CONDITIONING,POWER WINDOWS,POWER DOOR LOCKS POWER PASSENGER SEAT,CRUISE CONTROL,DUAL A/C,AUTOMATIC TRANSMISSION CAPTAIN CHAIRS (2),LUGGAGE RACK,POWER DRIVER SEAT AM-FM STE REO/CDPLAYER(SINGLE),CENTER CONSOLE,PASSENGER-FRONT AIR BAG POWER REMOTE MIRROR,4-DOOR,MULTI-PURPOSE VEHICLE,DRIVER-FRONT AIR BAG Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 302449 FRM REMOVEIREPLACE R FRAME EXTENSION -F 88938444 GM PART 480A6 3.0 # 2 900500 BDY` REPAIR LT FRAME RAIL Existing 2A` 3 900500 BDY' REPAIR PULL AND ALIGN BODY Existing 0.00 2A' 4 900500 BDY' REMOVE/INSTALL: MISC WIRING ON FRAME RAILS FOR REPAIR Existing 05' 5 900500 MCH` ALIGN FOUR WHEEL ALIGN Sublet 91.25' OA* 6 spare tire hit rear axle 7 900500 BDY' REMOVE/REPLACE MASK FOR OVERSPRAY "Qual Repl Part 0.00' 02` 8 900500 BDY' REMOVE/REPLACE RESTORE CORROSION PROTECTION "Qual Repl Part 10.00' 02' 9 2 panels 10 900500 BDY` REMOVE/REPLACE UNDERCOATING "Qual Repl Part 5.00' OA' 11 900500 FRM' REPAIR FRAME RACK SET UP Existing 15• 12 900500 FRM' ADD'L LABOR OP PULL TIME Existing 2A' 13 900500 BDY' ADD'L LABOR OP INSPECT RT REAR SWAY BAR Existing OA' 14 301805 BDY REMOVE/INSTALL LOCK Existing 0,3`# 15 301806 BDY REMOVE/REPLACE LOCK CYLINDER CASE ORDER FROM DEALER 19.40 INC # 16 301809 BDY REMOVE/REPLACE GUIDE 15029707 GM PART 11.48 17 301810 BDY REMOVE/REPLACE SPARE WHEEL HOIST 15026912 GM PART 118.74 OA 18 301018 REF BLEND R REAR DOOR OUTSIDE C 1.0 This estimate has been recalculated with a modified profile. ESTIMATE RECALL NUMBER: 3/7/2007 11:57:16 2307 UltraMate is aTrademark of Mitchell International Mitchell Data Version: MAR 07_A Copyright(C)1994-2003 Mitchell International Page 1 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 3/22/2007 02:38 PM Estimate ID: 2307 Estimate Version: 2 Supplement 1 (P) 3/22/200702:36:52 FINAL Profile ID: CSAA 19 900500 BDS' ADD'L LABOR OP R AND I RT QTR GLASS Sublet 10625' OA' 20 302686 BDY REMOVEANSTALL R REAR OTR BELT MOULDING 02 21 301998 BDY REMOVE/INSTALL R REAR DOOR ADHESIVE MOULDING Existing 02' 22 301044 BDY REMOVE/INSTALL R REAR DOOR TRIM PANEL INC 23 301595 BDY REMOVEANSTALL R REAR DOOR HANDLE 0.7 # 24 301170 BDY REMOVE/INSTALL RACK ASSY 15 25 301206 BDY REMOVE/REPLACE R QUARTER OUTER PANEL 15770070 GM PART 48761 14.0 # 26 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 29 27 AUTO REF REFINISH R QUARTER PANEL EDGE C 05 28 301227 BDY REMOVE/REPLACE R QUARTER LAMP MOUNT PANEL 15762986 GM PART 48.20 2.0 29 3012Z9 BDY REMOVE/REPLACE R QUARTER LAMP OPENING REINF 15717504 GM PART 4.70 1 A 30 301235 BDY REMOVE/REPLACE R QUARTER ADHESIVE NAMEPLATE 15036135 GM PART 8.87 0.1 31 301245 BDY REMOVE/INSTALL R UPR QUARTER APPLIQUE Existing OA' 32 301284 BDY REMOVE/REPLACE LIFTGATE SHELL 15201297 GM PART 98420 35 33 AUTO REF REFINISH LIFTGATE OUTSIDE C 2.7 34 AUTO REF REFINISH LIFTGATE JAMBS&INSIDE C 12 35 302053 BDY REMOVE/REPLACE LIFTGATE PULL HANDLE 15750911 GM PART 64.21 INC # S11 36 301305 BDY REMOVE/REPLACE LIFTGATE ADHESIVE NAMEPLATE 15126056 GM PART 30.50' 0.1 37 301307 BDY REMOVE/REPLACE LIFTGATE ADHESIVE NAMEPLATE 15707463 GM PART 28.28 0.1 S1 38 302055 GLS REMOVE/INSTALL LIFTGATE GLASS Existing 1A' 39 301516 BDY REPAIR LWR REAR BODY PANEL Existing 6A' 40 AUTO REF REFINISH LWR REAR BODY PANEL C 1.1 41 301519 BDY REMOVEANSTALL R REAR BODY ANCHOR PLATE Existing 02' 42 301535 BDY REMOVEANSTALL REAR BODY SCUFF PLATE Existing 02' 43 301539 BDY REMOVE/INSTALL REAR BODY CARPET Existing 05• 44 301540 BDY REMOVEANSTALL R REAR BODY HOOK Existing 02' 45 302690 BDY REMOVE/REPLACE R REAR COMBINATION LAMP ASSEMBLY —Qual Repl Part 89.00INC 46 301570 BDY REMOVE/INSTALL STOP LAMP 0.3 47 AUTO BDY OVERHAUL REAR BUMPER ASSY OA S1 48 301577 BDY REMOVE/REPLACE REAR BUMPER FACE BAR 19121288 GM PART 425.76 05' 49 RECON BMPRS,POOR QLTY, 50 301578 BDY REMOVE/REPLACE R REAR BUMPER STEP PAD 15756336 GM PART 65.99 INC 51 301579 BDY REMOVE/REPLACE L REAR BUMPER STEP PAD 15756335 GM PART 65.99 INC S1 52 301582 BDY REMOVE/REPLACE REAR CTR BUMPER STEP PAD 12335696 GM PART 48.72 INC 53 302431 BDY REMOVE/REPLACE R REAR BUMPER BRACE 15726730 GM PART 38.73 INC 54 302432 BDY REMOVE/REPLACE L REAR BUMPER BRACE 15726729 GM PART 38.73 INC 55 301585 BDY REMOVE/REPLACE R REAR BUMPER BRACKET 15008432 GM PART 60.37 INC 56 301586 BDY REMOVE/REPLACE L REAR BUMPER BRACKET 15008433 GM PART 60.37 INC 57 301587 BDY REMOVE/REPLACE REAR BUMPER HITCH BAR 15154375 GM PART 185A3 INC 58 AUTO REF ADD'L OPR CLEAR COAT 2.7 59 AUTO ADD'L COST PAINT 290A0' 60 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00' -Judgement Item -Labor Note Applies C -Included in Clear Coat Calc This estimate has been re-calculated with a modified profile. ESTIMATE RECALL NUMBER: 3/7/2007 11:57:16 2307 UltraMate is aTrademark of Mitchell International Mitchell Data Version: PAAR_07_A Copyright(C)1994-2003 Mitchell International Page 2 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 3/22/2007 02:38 PM Estimate ID: 2307 E slim ate V ersi on: 2 Supplement 1 (P) 3/22/2007 02:36:52 FINAL Profile ID: CSAA Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amoun Body 37.7 58.00 0.00 0.00 2,186.60 Taxable Parts 3,38D. Bdy-S 0.0 58.00 0.00 106.25 10625 Parts Adjustments 163.1 Refinish 12.1 58.00 0.00 0.00 701.80 Sales Tax 8.250% 265: Glass 1.4 58.00 0.00 0.00 8120 Frame 6.5 58.00 0.00 0.00 377.00 Total Replacement Parts Amount 3,481.; Mechanical 0.0 58.00 0.00 91.25 9125 Non Taxable Labor 3,544.10 LaborSummary 57.7 3,544.10 III. Additional Costs Amount iV: Adjustments Amoun Taxable Costs 290.40 Insurance Deductible WA IV Sales Tax 8.250% 23.96 Customer Responsibility 0! Non Taxable Costs 3.00 Total Additional Costs 317.36 I. Total Labor. 3,544. II. Total Replacem ent Parts: 3,481; III. Total Additional Costs: 317: Gross Total: 7,343: IV. Total Adjustments: 0! Net Total: 7,343: Less Original Net Total: 6,843: Net Supplement Amount 499: S7: Kristin Freeman 499: THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Insurance Co: CSAA Insurance Inspection Date: 3/6/2007 Body Shop: PARKER ROBB COLLISION CENTER Address: 1750 LOCUST ST Walnut Greek,CA 94596 Work Phone: (925)476-0255 Fax Phone: (925)9434765 **SPECIAL PARTS NOTE: 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 This estimate has been recalculated with a modified profile. ESTIMATE RECALL NUMBER: 3/7/2007 11:57:16 23D7 UltraMate is aTrademark of Mitchell International Mitchell Data Version: MAR-07- 7-A Copyright(C)1994-2003 Mitchell International Page 3 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 3/22/2007 02:38 PM Estimate ID: 2307 Estimate Version: 2 Supplement 1 (P) 3/721200702:36:52 FINAL Profile ID: CSAA AFTERMARKET NEW PARTS. "ALL PARTS PRICES ARE SUBJECT TO INVOICE, WHICH MAY CHANGE FROM ORIGNAL. ESTIMATE. ** Cycle Time Information Drop Off Date: 3/312007 Repair Dates: Promise Date: 3/23/2007 Start Date: 3/6!2007 Pick Up Date: 3/20/2007 Completion Date: 3/19/2007 Is Vehicle Driveable(Y/N)?: N Assisted With Rental(Y/N)?: Y This estimate has been recalculated with a modified profile. ESTIMATE RECALL NUMBER: 3/7/2007 11:57:16 2307 UltraMate is aTrademark of Mitchell International Mitchell Data Version: MAR_07_A Copyright(C)1994-2003 Mitchell International Page 4 of 4 UltraMate Version: 5.0215 All Rights Reserved o- . f. i F. 8... S' 70 u � �_gFryg1r;'3�,. �t•�' i � .es ,p��"fe.}) ufi. s g� j TR Yrcv..•h-d4o:: f r 4 h., iY "vp 4 1 # y :t g k ell R4 � fix. ��+�, ��' • ���•�A# R tM" M1�X � x Mi M IS Sul w , I eA - t € ) % yy MIAMI Maw mi rg '� �' "" � �� ��•' " x°fie � , t{ ...' �,,. * r � . `.. a Woof NOW— OWN- "41 r } Y , r, w 1. fily d > � 5 'H '�� � ~ ✓� '�., TV FFFFFFkkkkkk a� r � A� iANN ll Wf '� RIB- ------------ fi UP x 71 t �cL Y AL � �� �. � r �• '� i ray ��_ � � a.,nz— ����� .X ►3S� � AO r p �3 i" ;R'!Y t 3 � ',# � fir,y�s �„ _ ✓^_Y 9� t '�� ^� ^ � M i itsYly .-1 3: tea 1116 +.'"XT.+ ,� �:.,. �, i ...,,,...+�+.�.�- '� f sfti�s�,••>... ,�p � c:�:dt�.v- ywrrr i .a. �, K'1 � 1 �`y'v r .�'• '�'f9 EF6 s� � •�.. - E3 � �at r his. "a i J ' A o . aa.. V 6 w Ilio, txar5l .... ✓ �•„» '3�'... £. �a ?"wwe k ppm# � y'� `� �k z� YDS m* o�.m s -�.,. i i �. .. t a.. _ws y Y la N� 1 ,t � ,�� .^fit' :��.°.• . Lis'.; ���•i, •. <.,�;�� v f amt ..,}•. � � r t .fix .� ,>t•.�,ay 0 0 N M N ' M O rn CHECK NO.: 711 L475395-4—R U m DATE: 03-23-2007 D .. W > NAME AND ADDRESS INFORMATION: iLwu THE HERTZ CORPORATION PO BOX 26141 OKLAHOMA CITY OK 73126 INSURED: KEHR,JEFFREY;OR LISA M PAYMENT INFORMATION/DESCRIPTION: VENDOR PAYMENT FOR DATE OF LOSS: 03-02-07 INVOICEtt: A42551924 CLAIM NO: 03-81-0461-0 BATCH#: 1070800 CLAIMANT: INSURED PAYEE: THE HERTZ CORPORATION AMOUNT: $274. 00 IN PAYMENT OF: A42551924 , 1070800 ADJUSTER: ACH REP ADJUSTER NO.: ACH01 KIND OF LOSS: XLU 16610702 DETACH AND RETAIN FOR YOUR RECORDS No. 711 L475395-4- DATE OF LOSS CLAIM INSURED'S NAME DATE 03-02-07 03—SLO461-0 KEHR,JEFFREY;OR LISA M 103-23-200 POLICY TYPE KIND OF LOSS SUFFIX CLAIMANT'S NAME PAY AUTO XLU 02F I INSURED $274. 00 D.O. ADJUSTER NO. IN PAYMENT OF BANK OF AMERICA LRW ACH01 A42551924 , 1070800 Bank or Amorlca Customer Connoctlon Bank of America, N.A. TIN: 13-1938568-00 Atlanta, Dokelb Coumy, Georgia PAY *TWO HUNDRED SEVENTY FOUR 00/100* THE HERTZ CORPORATION This check must be properly endorsed on the reverse side by all p TO THE ORDER OF THE HERTZ CORPORATION Rental Agreement #: A4255-1924 Invoice Date: 03/21/07 Batch: 1070800 Insured: KEHR,JEFFREY;OR LISA M Renter: JEFFREY KEHR HERTZ LOCAL EDITION PO BOX 26141 OKLAHOMA CITY, OK 73126-0000 TIN: 13-1938568 CSAA INSURANCE ATTN: MAIL CENTER P.O. BOX 920 SUISUN CITY, CA 94585-0920 Claim #: 03-8L0461-0 Suffix: 02 KOL: XLU Loss Date: 03/02/07 Rental Car: SIR MURA AWD F Rental Veh License #: 5XZE056 Hertz Local Edition Store: 0737501 WALNUT CREEK CA Rented On: 03/03/07 Returned On: 03/20/07 Total Rental Days: 0018 FRP: 274 .00 Extra Days: 000 @.00 .00 Subtotal: 27.4 .00 Upgrade: .00 Damage Waiver(CDW/LDW) : .00 PAI: .00 Fuel and Service: 30.91 Customer Paid: -325.64 Time and Mileage: - .00 Amount Due: 274 .00 Billing Inquiries: PHONE: 1-888-777-3700 FAX: 405-775-6413 E-MAIL: CUSTOMERBILLING@HERTZ.COM Arnold W^SL Mb 140 Mwfinm CA 945ai Contra Costa County Phone;(925)33x1450Risk Management Foc(925)335-1421 Q To: -&- Q Froann .4/4 %�lf /7bJlfl Pboee� _ f Fam _ - 90 s D TuC1 - O Pbone: 6 of Pages to Follow: C-2 Re: Q 3..._ Q r0 —0 CCa ❑ Per your Request ❑ For Reh!iew O Please Comment Olease Reply❑For your Info /eG s e /?1.turn elavrn fpm ' - 9a� 33L -Comments: /eke and /51.r io I)V as S000 a S'po-SS 1&c ANY PROBLEMS WLTH THE TRANSMISSION OF THIS FAX,OLEASE CALL Ar 9d J— 3 3s iYs"s: Please Note: The information contained in dds fadsimile message may be conKdential and/or legaAy pr"aged information intended only for the use of the hoWiduai or entity nerved above, if the reader of this message is not the intended ►edpierP4 you are hereby notrFred that the copying, drsseminatidn or destnbutbn of confidential information is sbidtly pmhibjted CLAIM I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 I Claim Against the County, or District Governed by the Board of Supervisors; Routing Endorsements ) NOTICE TO CLAIMANT and Board Action. All Section refei en l e are to ,,. . 7�'' ' N, p ) The copy of.this.document mailed to California Government Codes: )i=f you is your notice of the action taken I JUL 1 8 200 C_,�on your claim by the Board of i Supervisors: (Paragraph IV below), COUNTY'COU�.'.�==t given Pursuant to Government Code EIARTINEZ CA,L i_F: Section 013 and 915.4. Please note all AMOUNT: MORE THAN $10,000.00 UNLIMITED JURISDICTION "Warnings". CLAIMANT: LOUIS DEL..BARBA. . • j ATTORNEY: SCOTT PEEBLES,. Es JULY 18, 2007 i q• � i DATE RECEIVED: TERRY O'.REILLY," Esq. - ADDRESS: O'REILLY & DANKO`, BY DELIVERY.TO CLERK ON: JULY 18, 2007 1900 .0'.FARRELL ST. , STE. 360 SAN MATEO', CA 94403 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Boar=d of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C r' Dated: JULY 18;. :2007. By: :Deputy iI. FROM.: County'Counsel ''TO: Clerk of the Board of Su -vi I ( iris claim compliessubstantially 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 ( ection 91. 1.3). (•Other: /S r7jkn D nC O Ci/�'!714 jaefdCOV h 0-/ Or7�Y Cos ' i Dated: By: �� C_" "�" 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. BOARD ORDER: By unanimous vote of the Supervisors present: (t� . This Claim is rejected in full. O Other: ! j i I certify that this is.a true and correct copy ofthe Board's.Order entered in its minutes for j this date. i Dated: CUL.LEN, CLERK, By eputy Clerk. f WARNIN (Gov. code section.913) I Subject to ceitain exceptions,you have only six(6) inontlrs from the date this notice was personally served I or deposited in the mala 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 connectiw Willi this matter. 1f you want to consult an I' attorney,you should do so Immediately; *For Additional Wartring See Reverse Side of This Notice. , AFFIDAVIT OF MAILING I i I declare under penalty.of per jiury that I ani 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 Ntartlnez, Caliio1•n6, postage fully Prepaid a certiiied copy of this Board Order and Notice to Claimmit, addressed to the claimant as shown above. Dated: •*�� JOHN CULLEN, CLERK By Deputy Clerk _..- ..... .....__............ ...... .. ... I This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims: The above'lis.t is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed tnay be shorter or longer'depending on the-nature,of the claim.-Consult the specific statutes and cases.applicable to your particular The County of Contra Costa does not walve`any' . ' of its.rights under.California Tort Claims Act nordoes it waive rights under the statutes of limitatloris applicable to actions 4not subject to the California Tort Claims Act t • • BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ..........................................................................................:................................ RE: Claim By: Reserved for Clerk's filing stamp Louis Del Barba RECEIVED Against the County of Contra Costa ) JUL 1 8 LUU/ CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. (Fill in the name) ) The undersigned claimant hereby makes claim against County of Contra Costa or the above-named district in the sum of$(more than $10,000; unlimited jurisdiction) and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) On or around April 16, 2007, at around 8:30 a.m. 2. Where did the damage or injury occur? (Include city and county) City of Oakley, in Contra Costa County, California, at or near the intersection of Rose Avenue and Main St. 3. How did the'damage or injury occur? (Give full details; use extra paper if required) Louis Del Barba drove his vehicle and turned onto Main St. when American Medical Response ("AMR"), under contract, as .an agent, or otherwise on behalf of the County of Contra Costa, Contra Costa County Sheriffs Dept., and/or East Contra Costa County Fire Protection Dist. ("Government Defendants") negligently, recklessly, and with willful and wanton disregard operated, controlled, and/or possessed a vehicle so as to cause it to collide with Mr. Del Barba's vehicle, causing him severe injury and paralysis. AMR operated, controlled, and/or possessed its vehicle in response to negligent instruction by Government Defendants whereby the AMR vehicle and at least one other vehicle were instructed to respond to the same call for assistance. Government Defendants were negligent in their policy,procedure, instruction, management,and/or supervision for providing emergency medical response. 4. What particular act or omission on the part of the county or district officers, servants, or employees caused the injury or damage? Government Defendants,by and through AMR, negligently, recklessly, and with willful and wanton disregard operated, controlled, and/or possessed a vehicle so as to cause it to collide with Mr. Del Barba's vehicle, causing him severe injury and paralysis. AMR operated, controlled, and/or possessed its vehicle in response.to negligent instruction 1-„y Government Defendants whereby the AMR vehicle and at least one other vehicle were instructed to respond to the same call for assistance. Government Defendants were negligent in their policy, procedure, instruction, management, and/or supervision for providing emergency medical response. 5. What are the names of'county or district officers, servants, or employees causing the damage or injury? The names of public employees causing the injury, damage,or loss are not known at present. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) The injury, damage, or loss incurred, to the extent known at the time filing this claim, include injuries to Mr. Del Barba that consist of a broken pelvis, broken ribs, and broken neck. He is quadriplegic as a result of the accident. Damages include past and future medical costs, lost wages, pain, suffering, punitive damages, and any other damages permitted by law. Estimates for auto damage are not yet available. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Pursuant to Government Code §910(f), if the amount claimed exceeds $10,000, no dollar amount shall be included in the claim. However, the claim shall indicate whether the claim would be a limited civil case. Plaintiff's claim herein exceeds $10,000. The claim would not be a limited civil case. It falls under unlimited jurisdiction. 8. Names and addresses of witnesses, doctors, and hospitals: Louis Del Barba. Witnesses and doctors at John Muir Hospital. The names of all witnesses, doctors, or hospitals are not known at present. 9. List the expenditures you made on account of this accident or injury. The expenditures made on account of this accident or injury are unknown at this time. Additionally, pursuant to Government Code §910(f), if the amount claimed exceeds $10,000, no dollar amount shall be included in the claim. However, the claim shall indicate whether the claim would be a limited civil case. Plaintiff's claim herein exceeds $10,000. The claim would not be a limited civil case. It falls under unlimited jurisdiction. ................................................................................................................................... ;l Gov. Code Sec. 910.2 provides "The claim shall be signed ;I by the claimant or by some person on his behalf" SEND NOTICES TO : (Attorney) ;1 Name and address of Attorney ;1 1.-oU i S Del a"6,3 Terry O'Reilly, Esq. ;1 (Claimant's Signature) Scott Peebles, Esq. ) 1O'Reilly & Danko -0 1900 O'Farrell St., Suite 360 j (Address) San Mateo, CA 94403 ) S a.w M &Aa G q 4403 Telephone No. (650) 358-5901 ) Telephone No. (D 50 351 5101 ..................................................................................................................................... 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 es seq.)Furthermore,any attachments,addendums,or supplements attached to the claim form, including medical records,are also subject to public disclosure. .................................................................................................................................. NOTICE: Section 72 of the Pena!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 vaoucher,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(S 10,000),or by both such imprisonment and fine. i I CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY j • BOARD ACTION: AUGUST 14, 2007 i Claim Against the County,or District Governed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT j and Board Action. All Secfion'refei•ences are to ) The copy of this document mailed to California Government Codes. -� you is your notice of the action taken T G 1 1, on your claim.by the Board of Supervisors..(Paragr•aph IV below), JUL 1 .8 '2007 given Pursuant to Government Code j AMOUNT: $1,000,000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all k4RaTINEc CALIF "Warnings". ARNA MORSE and CLAIMANT: FRED MORSE , i ATTORNEY: JUSTIN" A. ROBERTS i DATE RECEIVED: JULY 18, 2007 LAW OFFICE. OF. JUSTIN`A ROBERTS ADDRESS: 1990 NORTH CALIFORNIA BLvD13,Y DELIVERY TO CLERK ON: JULY 18, 2007 SUITE 830: .WALNUT CREEK, CA 94596 BY MAIL POSTMARKED:. JULY 16, 2007 j FROM: Clerk of the Board of Supervisors TO: County Counsel ' Attached is a copy of the above-noted claim. JOHN CULLEN, r Dated: JULY, 18; 2007: By: -Deputy iI. FRol.: County"Counsel : TO: Clerk of the Board of Si1pervisors ( <This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to.comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). i ( ) Claim is not timely. filed. The Clerk should return claim on ground that it was filed late and send warping of claimant's right to apply for leave to present a late claim (Section 91. 1.3). (other: C lG i M is -/6 me/rr a 0 Iv '7r,,- 1,,,l. 6cc C-) or u4 —a z6o7. A // C14ImS C o r r o r 40. l / Lo 7 rl c�rtief� l ?i�- C14 r.s-I, I Dated: 3�-07. By: �� Deputy County Counsel Ill. FROM: Clerk of the Board . TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I IV. BOARD ORDER: By unanimous vote of ihe.Supervisors present: (P< This Claim is rejected in full. I ( ) Other [ certify that this is a true and c;oi7ect copy-of the Board's Order entered in its minutes for this date. Dated. •s �4affN CULLEN, CLERK, ByA0!6��eputy Clerk. WARN1. G (Gov-.'code section 913) Subject to certain exceptions,you have only six(6) months Front the date this notice was personally served or deposited in the runs to file a court ned-aii on this claim..See Government Code Section 945.6.You may seek the srdvice of an attoiirey of your choice in connection widr this matter. [f you want to consult an attorney,you should do so 1inniedlately. *Foy Additional War•tting See Reverse Side of This Notice. AFFIDAV[T OF MAILING - I declai-• under• penalty of Iierjury that I ani 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 i States Postal Service.in Nlartinez, Califgi•nia, postage fully prepaid a certiiled copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By eputy Clerk I i i i i I . Ope This warning does not apply to.claims wch are not subject to the California Tort Claims . Act such as actions in inverse condemnation; . actions for specific relief such as:mandamus or injun tion, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations eriod.within which suit must be tiled may be shorter or longer depending on i the nature of the claim: Consult the specific statutes and cases applicable to your.particular . The County of Contra Costa does'not waive any.' of its.rights under. California Tort Claims Act it waive rights under the statutes of `'limitations.applcable to actions not subject to the California Tort Claims.Act I i i 1 1 OFFICE 6F THE COUNTY COUNSEL g� _L SILVANO B. MARCHESI COUNTY OF CONTRA COSTA .j►'.=: _�'��.� COUNTY COUNSEL Administration Building ,; '; `=�•` 651 Pine Street, 9" Floor *;' �A =�•p SHARON L. ANDERSON Martinez, California 94553-1229 CHIEF ASSISTANT GREGORY C. HARVEY (925) 335-1800 01l�;yjjP!1� ! i� ;� VALERIE J. RANCHE (925) 646-1078 (fax) '�' `' o ASSISTANTS NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Justin A. Roberts Law Offices of Justin A. Roberts 1990 North California Boulevard, Suite 830 Walnut Creek, CA 94596 RE: CLAIM OF ARNA MORSE AND FRED MORSE Please Take Notice as Follows: vi regards to the claim you submitted on July 16, 2007, on behalf of Ama Morse and Fred Morse, portions of the claim are timely and portions are untimely. The portions of the claim prior to January 16, 2007 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to January 16, 2007 were not presented within the time allowed by law, no action was taken on those portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. The only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. (See Gov. Code, §§ 911..4 to 912.2, inclusive, and 946.6.) Under some circumstances, leave to present a late claim will be granted. (See Gov. Code, § 911.6.) SILV ANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel Page 1 _I CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California,over the age of eighteen years, and not a party to the within action. My bus' ess address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On D 7 , I served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Justin A. Roberts, Law Office of Justin A. Roberts, 1990 North California Boulevard, Suite 830, Walnut Creek, CA 94596, as set forth.above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on X.. 'd at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 LAW OFFICE OF JUSTIN A. ROBERTS 1990 NORTH CALIFORNIA BOULEVARD, SUITE 830 WALNUT CREEK CA 94596 TELEPHONE(925)283-4880 MAILIN13 ADDRESS: POST OFFICE BOX 876 FACSIMILE(925)283-4888 http://justinaroberts.com L4FAYETTE CA 94549-0876 ustln@jus tinaroberts.com SEC July 16, 2007 c/(/( j 8 �uu/ CREAK� CON R�OF!3 RA COSTH t p V/SOBS CERTIFIED MAIL NO. 7003 0500 0000 4165 2450 RETURN RECEIPT REQUESTED Clerk of the Board of Supervisors Contra Costa County 651 Pine St Rm 106 Martinez CA 94553 Re: Arna.Morse, Fred Morse Dear Sir/Madam: Arna Morse and Fred Morse hereby make claim against the County of Contra Costa, Contra Costa Regional Center (aka Merrithew Memorial Hospital), for the sum of One Million Dollars ($1,000,000.00) and make the following statements in support of their claim: a. Claimants' address is 653 Main Street, Martinez, California 94553. b. Notices concerning the claim should be sent to the Law Office of Justin A. Roberts, c/o Justin A. Roberts, Esq., I'O Box 876, Lafayette, California 94549; telephone: (925) 283-4880. c. The date and place of the occurrence giving rise to this claim are that on or about January 19, 2007, claimant Arna Morse underwent at Contra Costa Regional Center, Martinez CA, a surgical procedure for bimalleolar fractures of her right ankle. At said time and place, agents and/or employees of the County of Contra Costa and/or Contra Costa Regional Center failed to properly operate, examine, diagnose, treat or otherwise tend to the condition of claimant. As a result of said failures, claimant developed mal-union of said fractures, requiring further surgery and other treatment. Claimant Fred Morse sustained loss of consortium. LAW OFFICE OF JUSTIN A. ROBERTS Page 2 of 2 d. A general description of the injury or damage includes mal-union of fractures requiring further surgery and other treatment. e. The true names and complete name or names of all public employees causing the injury, damage or loss are not known at present but it is believed that physician Nanda Sinha, M.D. participated in the aforesaid surgical procedure. f. The amount of this claim is One Million Dollars ($1,000,000.00). The basis of the above amount includes medical expenses to date, future medial expenses, loss of wages and earning capacity, and all special and general damages as allowed by law. I /Z�� ustin A. Roberts On Behalf of Claimants Arna Morse, Fred Morse J AR:clr Lr 0 uj d UCS U-O v 00 ccQ \ 1 = QZ IME—_5 co 0 crf CD GAJ, o •�_ .i N N CO G a � <- Y i O� Ln t` t 01 w Q� Aio W�x oQam gZo7Q , ria � .O_qd'•- X16.. ) uj lJ (LLL 0 Q r r-i 0¢ s 00 s ¢zco 0 =;0 J r U P o r �- U) f Ln .v tD G Lr) Ul ~. = p — 4 �mo � © oN � © � �.. Q 7 ca LO Ln Q �i tt r tit F m �ED o oQo �m LL U 3 a S2od tl1 m 3 CLA.i.M J BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors,;Routing..Endoi5eme.nts; ) NOTICE TO CLAIMANT and Board Action: All Section.references are to ) The copy of.this documenc.mailed to California Government Codes: ) you is your notice of the action taken : on your claim.bythe Board of CLAIM AGAINST MICHAEL KELLY. Supervisors. (Paragraph IV below), 900 FERRY ST. , MARTINE CA, given Pursuant to:Government Code '+Section 9'13 and 915.4. Please note all AMOUNT: $11,000.00 E "Warnings" -:JUL 1 8 2007 CLAIMANT: RICK.P. 'SMITH_ T-.98778 . 2006019202 CO!JNTY'Cbuw,-Qr= ATTORNEY: UNKNOWN DATE RECEIVED: JULY 18, 2007 MARTINEZ DETENTION:,FACIL�y JULY 18, 2007 ADDRESS: I3Y DELIVERY TO.CLERK ON: 901. COURT STREET, MARTINEZ, CA 94`553 BY MAIL POSTMARKED: JULY 17, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is:a copy of the above-noted claim. JOHN CULLEN,. Dated: JULY.18;.;2007 =By Deputy ft. FROM.: County.-Counsel TO: Clerk of the Board of Sup i visors ( leis claim complies substantially with Sections 91.0 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 91.0 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.waining of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: c-;2 3' Off. gy; `6-r Deputy County Counsel III.: FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as.untimely with notice to claimant (Section 911.3). . I.V. ARD ORDER: By unanimous vote of the Supervisors present: ('This Claim is rejected in full. ( ) Other: [ certify that this is.a true and correct copy of the Board's Order entered in its minutes for this date. Z, .Z•�v ' Dated: JOHN CULLEN;CLERK, By Deputy Clerk, WARNING (Gov. code section.913) Subject to certaln exceptions,you have only six(6) inontlis fivm flip date this notice was personally served or deposited in the mail to Ole a court Action on this elaiin.See Government Code Section 945.6.You may seek the advice of an attotirey ot':your choice in connectimi widr .this matter. tf you want to consult 4n attorney,you should do so immediately, *For Addlaial Warring See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under nenAlty`of perjury that [ ani now, and at all times herein mentioned, have been a citizen of the United States, over ap. 1.8; and that today l 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 elaiman.t as shown above. i Dated .Xr JOHN CULLEN, CLERK By Deputy Clerk This warning does not apply to claims which are notsubject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as.mandamus or injunrition, or Federal Civil Rights claims. The above,list it not exhaustive and legal consultation Is essential to understand all the separate ilmitations periods that may apply. The limitations period within.which suit must be filed may be,shorter or longer depending on the nature of the claim, Consult the.specific statutes and cases applicable to your particular claim. The County of:Contra Costa does not waive any. t; of'.,lts:righis under.California Tort Claims Act nor-does. it waive.,rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act I I .. I I I I i I I I I - I I i I I I j 9 ' d BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) 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. ■�� ������������������...r..... Mnow nNownal RE: Claim By: Reserved for Clerk's filing stamp quo I Go ki S((- M hkTN 7_� ,�, � RECEI V9: Against the County of Contra Costa or ) GLJL V District] JUL 8 Cwt (Fill in the name) CLERK BOARD or� r0 BC W ST ail 1(LTIq 21 ► a The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 11 C)d 0 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur'? (Include city and county) �Zct w mf) \, M4U(:FKC-�z- 3. How did the damage or injury occur? (Give full 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? �&LD POV5tC- U-QOZT \,QY3��-FCoOP � , RO-Pb� Gc-roc 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 6. 'What damage or injuries do your claim resulted?- (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) PC 7. How was the amount claimed above cornputed? (Include the estimated amount of any prospective injury or damage.) Q o� vk� SAT® yiN__Y A-M O DA-AXA6 8. Names and addresses of witnesses, doctors, and hospitals: COW-T `-MA MSCYC P l S / 'PL% 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ..r....................r.r.............................■000002x000220000DOME 00names 001 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) 1 Name and address of Attorney ) u (Claimant's Sfgnature) �A I rQY) e Gam, � ' S; e�� v v (Address) ) �o q [K-S ) n Telephone No. ) Telephone No. tl ■■0■■■■2■■N22■■■■222■■22292■■2■r0000.000 ON 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. 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. 4 A It 17 LPr C" All _T 7�771 > _ ' _ ............ Kc 4C .. _ - �G ----1 r .C�- --E-��� VIA5----/ SGS. rG 1� L A- A.S- �.�_� ��T���t-c�y----- -�-----rte� -�---- .���� ........ .......... _-RUA OL A- -Y, ----CS, �4_07 T�_Z_y_ vv- ------ L c ve- C,< u In Y AN ( _ r y 4.....` •,gid !_ t ..w- _`. ---may,- +-------'-�- - , -t C E '°` J `....e- �si.:'l�.s. f "t• i �.�'r r k ` •. III �. ' �1° _>. ,�"` __ 1 ' 1 '!". .esaa+'a.r - �x1 +-x-r.:M::. ��`�� , .a.•s+N+p 1i' t f --•mr +rk 'd. ..lr .I {+ !"``, , A ,...-`, r .�, ::'+ :.-•:� �p�._,�.,,. ....... .�``' "J:;�� +g"'-..tz"" ,�'^ ems, p..+..' .,,�,�•1 ( k - il; l ( i �,_...•- �' � ;jars' E�.._.,, f� ��,......r'�f y ( 1+ \ .J' p t y t +p i � 1n� �'L!J Y,_'•'� •'.e�Ti � .E•• i \. 1� + r\ryn_ +� .-. f.. � :• t p� +�. t i � r • )2 n to :h n t � ilk --. J ate` � ,{' t^ , + t '�� .�. •1 4' - a� a lil V' Oh .I rr9-l.... Via. A } + �� +•`�,,+ fi'1 +,,: iV i . t� c;� tt - II r �4 71 a1\1771, --- -/I� '•w6+V�\-:,r: , R_l� k•b.�=Vr F...� !(..-V�y L F.�r i, . e S k> i I �I . C7 ill j III 1 .4 oil (.P o ------------- 7—r 0 A[ -- - -------- ------ ------ ----------- T-t-j- Ike is t. ................ ... ......... VA_\ A�f g30 X07 0 MARLIN S. GRIFFITH, PH.D. Clinical and Forensic Psychology California License PSY 5355 1305 Franklin Street, Suite 509. Oakland, CA 94612 Phone: (510) 287-5324 December 13, 2006 Honorable Theresa Canepa Superior Court of California Contra Costa County, Dept. 35 725 Court Street, Room 127 Martinez, CA 94553 Re: Defendant: Ricky-.Paul Smith Docket #: 02-290860-6 O(.o k Subject: Determination of Mental Competency under Section 1368 of the California Penal Code Dear Judge Canepa: I examined Ricky Smith on December 9, 2006 pursuant to Section 1-368 of the Penal Code. The examination took place at the Martinez Detention Facility and consisted of a face-to-face clinical interview with mental status examination. Prior to meeting with Mr. Smith, I reviewed the following documents provided to me: 1. District Attorney's Complaint (04/07/06) 2. Probation Report of DPO Bonnie Pannell (09/13/06) 3. Contra Costa County Fire Investigation Reports (11/05/05, 02/06/06, 04/06/06) 4. Contra Costa County Sheriffs Department Investigation Report (11/05/02) My opinion regarding Mr. Smith's mental competence is based on my clinical interview and review of the above referenced records. It is my understanding that Mr. Smith is charged with arson (451(c) PC), with a prior arson conviction (451.1(a)(1) PC), and criminal threats (422 PC) in an incident that occurred on November 5, 2005. He was told that I was appointed by the court to conduct a competency evaluation and that the Judge and District Attorney, in addition to his attorney, would see my report. He acknowledged that he understood the purpose of the evaluation and consented to the interview. Hon. Theresa J. Canepa Re: Ricky Paul Smith Page 2 Social-Psychological History: Mr. Smith was guarded and provided a sketchy social history that gave little detail about his past. He stated that he was born.on July 5, 1964 in Oakland and grew up in San Pablo, California. He dropped out of school in the 10th grade and went to work for his stepfather in his auto parts shop. He gave no history about his family except that they all had restraining orders against him. He refused to elaborate on the causes of these actions. His probation report noted that he had a dysfunctional family upbringing and grew up in group homes from age 8 to 15. Mr. Smith stated that he has received SSI for the past seven years due to depression. He was treated at the Richmond Health Center and received Elavil, "The only medication I would take." He stated that he last took Elavil in 2004 and doesn't need it anymore. He denied psychiatric hospitalizations or treatment by a mental health professional. Mr. Smith stated that he drank alcohol heavy in his 20's and smoked marijuana but denied other drug use. His probation report however noted a parole revocation in 2004 due to a positive drug test. Reportedly, his drugs of choice are methamphetamine, cocaine, and marijuana. Behavioral Observations and Mental Status Examination: Ricky Smith is a 42 year-old, medium statue Caucasian male who presented without apparent physical deficits. He was dressed appropriately in a T-shirt and yellow county jail pants and revealed good personal hygiene and grooming. His eye contact was intense and somewhat challenging, and his psychomotor activity was normal. Mr. Smith was guarded and evasive during the interview. His speech was normal rate, clear, and brief. He provided little elaboration in his answers. He expressed feelings of persecution due to his legal situation but psychotic delusions were not indicated. Neither was there indication of hallucinations or other psychotic processes. His mood was mildly hostile, distrusting, and angry. He accused the examiner, who coughed in the interview, of knowing that he had TB and thus was acting inappropriately. Mr. Smith was fully oriented and his attention and concentration were within normal limits although he was poorly motivated to do the tasks administered to assess these areas. His abstract ability as determined by interpretation of proverbs, was generally concrete and his judgment as determined by responses to common sense situations, fair but suggestive of impulsive tendencies. Diagnostic Impressions: Mr. Smith presents with guardedness and poor motivation but no overt mental illness. He has a positive history for depression but is not currently taking medications and does not appear depressed. He also has a history of substance abuse but denies this, and is currently in sustained full remission due to his controlled environment. Although he is angry about his legal situation, he is maintaining control. Hon.Theresa J.Canepa Re: Ricky Paul Smith Page 3 Mental Competency-Examination Mr. Smith has-present ability to understand the nature and purpose of the proceedings taken against him and to cooperate in a rational manner with counsel in presenting a defense. He is aware that he is incarcerated on charges of arson and criminal threats. He revealed adequate knowledge of the legal system and the possible dispositions and penalties he would receive if found guilty. He is also aware that if found incompetent, he would likely go to a psychiatric hospital until he was determined competent. When questioned about his ability to cooperate and collaborate with counsel, Mr. Smith expressed doubts that his lawyer was helping him. His feelings toward present counsel were not based on perceptions distorted by mental illness but rather his by his disagreement with strategies for his defense. He believes that his lawyer is stalling the process and not following up on his alibi. Mr. Smith has present ability to follow court testimony for contradictions or errors and to so inform counsel. He also has ability to testify relevantly, if necessary, and to respond appropriately if cross-examined. He is angry and hostile toward the legal system but does not lack the ability to act in his self- interest. It is my opinion that Mr. Smith.is presently a mgr tally coi3ipetent in`dividual's: The additional questions addressed in my evaluation are as follows: (a) Whether treatment with antipsychotic medication is medically appropriate and likely to restore defendant to mental competence. No. I did not find a mental disorder that would be appropriately treated with psychotropic medication. (b) Whether a psychiatrist should evaluate defendant to determine if antipsychotic medication is appropriate. No. Mr. Smith does not present with mental disorder. (c) Whether the defendant has the capacity to make decisions regarding such medication. Not applicable. However, if indicated, he has present ability to make decisions about his medication. (d) Whether defendant is a danger to self or others. No. Mr. Smith revealed no . indication of suicidal or homicidal tendencies. Thank you for your referral of Mr. Smith for examination. If I can be of further assistance, please give me a call. Respectfully submitted, 1oL-tL_ s , ate arlin S. Gn jh'D 04/03/2007 15: 56 5107704 . TiAR PAGE 01/05 MARLIN S. GRIFFITH, PHD, CEA.P Licensed Pspcho%gisr PSV 5355 .�mpo�tJp'�sC�:ssistArrce,Prvgcams_ 1305 Fcanidin Street Suite 509.Oakland,CA 9"12 Phonc: (510)287-5324 FAX Date: O # Pages: •r' _►� Fax 9: �S Phone. Fra: �� rcr� Fax: (510)7704452 Re: Comments: Oro 1n;1"I CC % �A--- —A, �Eekif A '335-8'0 The medical information in this FAX message is confidential and privileged. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate medical infamstion. If you are not the intended recipient,you arc hcteby notified that any use,dissemination,or copying of this communication is strictly prohibited. If you have meeived this facsimile in crmr, picasc immediately notify the Sender by telephone_ 04/03/2007 TUE 14:37 [TX/RX NO 76941 [7J 001 04/03/2007 15: 56 51077044 TMR PAGE 02/05 MARLIN S. GRIFFITH, PH.D. Clinical and.Forensic Psychology California L icense PS 5355 1305 Franklin Street,Suite 509•-Oakland, CA 94612 Phone: (510) 287-5324 April 3, 2007 Honorable Theresa J. Canepa Superior Court of California Contra Costa County, Dept. 35 .725 Court Street, Room 127 Martinez, CA 94553 Re: Ricky Paul Smith Docket No.: 070058-3 Subject: Determination of Mental Competency under Section 1368 of the California Penal. Code Dear Judge Canepa: I examined Ricky Paul Smith on March 30, 2007 pursuant to Section 1368 of the Penal. Code. The examination took place at Martinez Detention Facility and consisted of a clinical interview with.mental status examination. Prior to meeting with Mr. Smith, I reviewed my previous PC 1368 evaluation of him dated December 13, 2006 and the following documents provided to me: 1. District Attorney's Complaint (03/15/07) 2. Probation Report of Bonnie Pannell (09/13/06) 3. Contra Costa County Fire Investigation Reports (1.1/05/05, 02/06/06, 04/06/06) 4. Contra Costa County SberifPs Department investigation Report (11/05/02) Additionally, I received collateral information from his former Public Defender., Michael Kelly, regarding his current legal situation. My opinion regarding Mr. Smith's mental competence is based on my clinical interview and my review of the above referenced information and records. Mr. Smith was informed that I would be conducting a court ordered competency evaluation and that there were confidentiality limitations to the information I may obtain. He acknowledged that he understood the purpose of the evaluation and consented to the interview. Mr. Smith is charged with Criminal Threats (422 PC) with enhancecn.ents in an incident that occurred on or about November 4, 2005. The Court declared a mistrial on March 15, 2007 and the examiner was rc-appointed pursuant to Sec. 1368 PC. It is my 04/03/2007 TUE 14 :37 [TX/RX 140 7894] f2 002 04/03/2007 15: 56 51077044 TMR PAGE 03/05 Honorable Theresa J.Canepa Re: Ricky Paul Smith Page 2 understanding that a second charge of criminal threat against the previous presiding judge is pending. Social-Psychological History: The following social-psychological history was taken from my report of December 1.3, 2006 with corrections obtained iu the current interview. Mr. Smith was born.on July 5, 1964 in Oakland and grew up in San Pablo, California. He dropped out of school in the 10th grade and went to work delivering auto parts. He stated that bis family has restraining orders against him but that he does not know the specifics of their complaints because he was in jail at the time. He believes that his brother has closed him out of any inheritance of his mother's estate following her death.. His probation report noted that he had a dysfunctional family upbringing with placements in group homes from age 8 to 15. Mr. Smith received SSI for about seven years due to depression but believes that be no longer qualifies. He was last treated at the Richmond Health Center where he was prescribed Elavil (an antidepressant). He stated that he has not had any psychiatric medication or treatment since 2004 and is no longer depressed. Mr. Smith drank alcohol heavy and smoked marijuana in his 20's. In later years he stated that he used methamphetamine occasionally. Behavioral Observations and Mental Status Examination: Ricky Smith is a 42 year.-old, medium statue Caucasian male who presented without apparent physical deficits. He was dressed appropriately in the county jail uniform and presented,with good personal hygiene and grooming. His eye contact was direct and his psychomotor activity normal. Mr. Smith was cooperative and acknowledgedhaving previously met with the examiner. His speech.was normal rate, clear and relevant. The content of his thoughts revealed paranoid trends of distrust of the legal system and his previous counsel whom he believed was working against his defense. He believes that this competency evaluation was his lawyer's attempt to keep him in jail. However, he could not give a reasonable explanation for his lawyer's motivation for such an action. He expressed feelings of persecution involving mistreatment by the deputies at MDF and stated that he has filed a "Complaint by Prisoner Report" with the U.S. District Court. Mr. Smith denied knowing why the Judge recused herself in.his case but expected that it was due to her refusal of his request for a Marsden motion to change his lawyer. He believes that he was successful in getting ri.d.of his lawyer and the Judge. There was no evidence of hallucinations or bizarre delusions in his thoughts processes. 04/03/2007 TUE 14 : 37 [TX/RX NO 7694] [a 003 • 04/03/2007 15:56 51077044 TMR PAGE 04/05 41 Honorable Theresa J. Canepa Re: Ricky Paul Smith Page 3 Mr. Smith was fully oriented and his attention d concentration were within normal limits. His memory functions were intact but his judgment was questionable. In contrast to the previous evaluation, his mood was less guarded and friendlier. He revealed a range of appropriate affect. There were no overt hostility or evidence of anxiety or depression, and he seemed pleased with the recent changes in hi court case. Diagnostic Impressions: Mr. Smith presented with Lrdedness and paranoia but without overt mental illness. He exhibits features of Paranoid Personality Disorder that include pervasive distrust and suspiciousness of the motives of others, hyper-alertness for potential threats; reluctance to confide in others, and tendencies to respond with legal actions to perceived threats. He also exhibits antisocial personality features that include hostility and irritability, rationalizing questionable b haviors, manipulativeness, and lack of conformity to lawful.behavior. He has a positive bi.story for depression but does not exhibit depressive symptoms at this time. He also hL a positive history for substance abuse but is currently in sustained full remission in a controlled environment. Mental Competency Mr. Smith has present ability to understand the tore and purpose of the proceedings taken against h.irn and to cooperate in.a Fational manner with counsel in presenting a defense. He is aware that he is charged with making criminal threats in an incident that occurred on November 4, 2005 and that a charge of arson has been dropped. He is also aware that a mistrial has been declared in s case and associates-it with the Judge's handling of his request to substitute lawyers. He made vague reference to a new charge of threatening a public official but would not Iaborate on it. Mr. Smith has the ability to cooperate and collaborate with counsel although he holds firmly to his belief that previous counsel was n t representing him adequately. He stated that he has not met his new lawyer but had no roblern with,the lawyer assigned to his case in 2003. His ability to cooperate and coll.ab rate is colored by his personality attributes that include paranoid and antisocial person dity features. However, he does not exhibit psychotic thinking. It is my opinion that Mr. Smith is given to manipulativeness in his attempts to obtain a favorable disposition and is presently am.entally competent individual. My opinions regarding the specific questions directed of this evaluation are as follows: 1. Is antipsychotic medication medically appropriate and likely to restore the defendant to mental competence? No. Mr. with is mentally competent and does not have a psychiatric condition that requires psychotropic medication. 2. Does the defendant have the capacity to mak decisions regarding antipsychotic medication? Yes. Mr. Smith has the capacity to make decisions about any medication that is prescribed for him. 04/03/2007 TUE 14 : 37 [TX/RX NO 7894] 12 004 04/03/2007 15: 56 5107704cf TMR PAGE 05/05 Honorable Theresa J. Canepa Re: Ricky Paul Smith Page 4 3. Should a psychiatrist examine the defendant to determine if antipsychotic medication is appropriate? No. A medication evaluation is not presently indicated. Should symptoms of depression surface, such an evaluation would be in order. 4. Is the defendant a danger to himself or others? Mr. Smith does not display symptoms or behaviors that suggest he is presently a danger to himself or others. Thank you for your referral of Mr. Smith for examination., If I can be of further assistance, please do not hesitate to call.me. Respectfully submitted, Marlin S. GAt Ph 04/03/2007 TUE 14 : 37 [TX/RX NO 7694] 16005 N 0 S Lu G n oma'. f,„=, a W Q n.+ Lt,t.) d.7 W o N � m �•-w � J a 0 z i Q W -7 m y coo c0 Cz . 004 Y✓ ���•'t tom, � ��. _ c",� t ....... e-.. C U, C ,,�, C- cn. UN -� nv ..Y 0 CD X00 � 6f Fail �O Or 0 rn� 00 0 r4 v C O X! i I CLA.i.M O BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by .) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Section t•efei•ences are`to. Y; ) " The copy of this document.mailed to California Government Codes.. , )o ou is YoL.ir notice of the action taken on your claim;by the Board of CLAIM AGAINST CURRAM, D. #659 JtJL l 8 ZQ07 �Su}�ervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $11,000:00 COUNTY COUNSEL Section 913 and 915.4. Please note all j P.MRTINEZ CALiF. 'Warnings". ; . I CLAIMANT: RICK P. .SMITH . T-.98778 2006019202 ATTORNEY: UNKNOWN .DATE RECEIVED: JULY 18, 2007 MARTINEZ DETENTION FACILW JULY 18 2007 901 COUP'' BY DELIVERY TO CLERK ON: T STREET, MARTINEZ, -CA 94553 i BY MAIL POSTMARKED: JULY 17, 2007 i FROM: Clerk of the Board of Supervisors TO: County Counsel IAttached is a copy of the'above-noted claim. JOHN CULLEN, Dated: JULY.18; 2007 . By: Deputy I.I. FROM. County Counsel TO: Clerk of the Board of Su ervisor•s (✓This claim complies substantially with Sections 910 and 910.2. I ( ) This Claim FAILS. to comply substantially with Sections 910 and 910.2; and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): ( ) .Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warming of claimant's right to apply for leave to present a late claim (Section 91. 1.3). i I O Other:: , I I i Dated: 3� 0_7 By: /'✓I Deputy County Counsel i I 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). I IV. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected.in full. ( ) Other: . i [ certify that this is a true and correct copy of the Board's Oider entered in its minutes for this date. . I Dated ! ate-3CHN CULLEN; CLERK, By eputy Clerk. WARNI (Gov. code section 913) i Subject to certain exceptions,you have only six(6) inontlis 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 attoMey of your.choiae.in connection wide this matter. I(i'you want to consult an attoi'lrey,you should do so liiurtediately. *For•Additionni Warning See Reverse Side ofTlrls Notice. AFFIDAVIT OF MAILING :I declare:under.penalty of pei jpry that 1. ani now, and at all times herein mentioned, lihve been a citizen ,ol' the Urnited States, over age 18; and that today I deposited fit the United States Postal Service in Martinez, California, postage fully prepaid a.certilied copy of this j Board Order and Notice to Claimant, addressed to the clainian.t as shown above. i Dated: JOHN CULLEN, CLERK Bi�/ 'C eputy Clerk i i This wanting does not apply to claims which are not subject to.the California Tort Claims Act such as actions in inverse condemnation, . actions for specific .relief such as-mandamus or . initinrtion,or Fedora! Civil Rights claims. The above list is not exhaustive and legal consultation'is essential to understand all the separate limitations periods that may apply. The limitations period,within which suit must be filed may be,shorter or longer depending on the nature.of.the claim. Consult the specific statutes and Gases applicable to your particular claim. . The County of".Contra Costa:does not walve any of its,rights under California Tort Claims Act nor'does it waive.rights'under the statutes of din ita6 S applicable to actions not subject to the California Tort Claims Act vl F I BOARD OF SUPERVISORS OF CONTRA COSTA COUINTTY r INSTRUCTIONS TO CLAIMANT 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 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.) B. Claims must be filed with the Clerk of the Board of Supervisors at .its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By: 7.0 0 6 0 19W C' Reserved for Clerk's filing stamp ter 101 CSV U ST. �A-TM-G_ > R�����E® Against the County of Contra Costa or ) . " � ) 'JUL 1 8 Luuj ()Sq `j� f Distnct) CLERK BOARD tLNM E (Fill in the name) ) Co < �oRVISORS:. The undersigned claimant 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? (Give exact date and hour) PA 2. Where did the damage or injury occur? (Include city and county) MA�� tttc-7, Coiu7 WSTAr-- 3. How did the damage or injury occur? (Give full details; use extra paper if required) 00� WAGN-T5 WA C.0 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? SGA_ 0%qX%...uAAT_s AT VI A 61710" 5 What are the names of county or district officers, servants, or employees causing the damage or injury? Cot kk WA D :M �Sq_11_ 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) .9 e=G. L&( 7-�� WMIJ 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) !�� A-003 jW � ' ®� P r 9 mTTT a-e. cwf o 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Mono owasommusessomanON ommoommonsomasmanommoomasamwomen Sol ) Gov. Code Sec. 910.2 provides"The claim shall bp- ) e) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) (Claimant's Signature) AN UJ Imo' S-" Q c dq (Address) 17,10 Telephone No. ) Telephone No. d •■��������������������o����s����soma BODEENRon 0MommummomWasson 0anone mean mean aaDaemon of 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. 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. i II I . .......... CONTRA COSTA COUNTY - DETENTION FACILITY ( ) INMATE REQUE_{ST FOR INFORMATION ( ) MEDICAL REQUEST E. To: From: I - `� -J Bkg# :. (DOB) ° f Date: . / �-i .. Housing Assignment: s C Check One: ( ) Request Grievance ( ) Appeal ( ) Otther Request: :J� '� �- `- C-eft/I t; q.I{_�I AA C-G!-" .. J 7 , ..7� 1.A fA1 r�r �.� u;_�!""` `!'� }j f ,'� i�,�1�r• � ��y, ` ..ter f "�o:r Ald .T ' IC /` 6` (h5 s-r,. )/ -:� r��.�.� , ,�r� �"'"�_,-� � �f ��� ,��� .��� _.L. fir'/tel •'� Date Rec'd: Of- Rec'd Bv: GC�ur�c l7 Routed To: ANSWER: ( )APPROVED ( ) DENIED-(state reason) ' .: By: Date: / J I Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking: '.'.•^.; DET 024:FRM 1/2/91 L-ALZ!�UTrc-- ars Nor pq WMakic OUC- fiLD) CCS-S Tc-c t o C F )-S c or- 6 0 7 ic-m 4 = S CS MID CALT?:oM7jA- �3TAT—C----S .d - 1.1 (,) n- -L Ll 0 F- ..'TH C— Mt-- -1-!Y C) yAc -S () F 4CCCI-S-S -7D 7 1C- L &A/ L-T- b VV Ly A MD Or ro)-U LC / pr-` 164h D A 0P U/V�� t:�� 7N Co A(TK-A- NSO� Coulqr�� 2 2 W a h C7 3: 00 o a .n 0 V N t w .+hw , J d �. G �7Q. co t sQ lvNn o Q L .� ..1 f'► % 4 y LLtci i Lu O¢2 �_•� Y. �� �+ S �� V. m a e { > W , CLAM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY !' BOARD ACTION: AUGUST 14, 2007 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: �l t� ou is you r notice of the action taken {• " � ":' r y 'on your claim by the Board of CLAIM AGAINST DEPUTY PARK JU j- 2007 ,.>. Superviscirs. (Paragraph IV below), given Pursuant to Government Code COUVT`(cC)wSEL Section'913 and 900. Please dote all AMOUNT: $11,000-00-- MARTiNEZ CALIF ``Wat nitigs". CLAIMANT: RICK.P. .SMITH 1-98778 2006019202 ATTORNEY:. UNKNOWN DATE RECEIVED: JULY 18, 2007 MARTINEZ. DETENTION. FACIL�y JULY 18, 2007 ADDRESS: ; t3Y DELIVERY TO CLERK ON: 901 COURT STREET, ; MARTINEZ, CA 94553 : JULY 17, 2007 BY MAIL POSTMARKED:. FROM: Clerk of the Board of Supervisors TO: County Counsel At ached is a copy of the above-noted claim. ,CORN CULLEN; Cl Dated: JULY>18;. 2007 i By`. )6puty 1. li. FROM.: County-counsel .` T0: Clerk'ofthe Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): ( ) Claim is not timely filed. The Clerk should mtum claim on ground that it was .filed late and send waiving of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated: ��3� 8� By: FYI Deputy County Counsel 111. FROM: Clerk of.the Board TO; County Counsel (l) 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: IV. Claim is rejected in full. ( } Other: I certify that this is a true and co��'ect copy of the Board's Order-entered in its minutes for this date. Dated: &*?A-0)5HN CULLEN,CLERK;`By eputy Clerk. WARNI (Gov. code section 913) Subject t6 certain exceptions,you have only six(6)months filoi.n the date this notice was personally served or deposited iii the mill to file a court action ou this Gain.See Government Code Section 945.6.You may seek the advice of an attorney.of your cholve In connection wltii this natter. tf you want to consult an attoivey,you should do so lininedlately. *Por Additiaial Wailling See Reverse Side of Tlils Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I. Ani now, and at all tulles herein mentioned, have been a citizen of the United States, overCage 81' lir d that today 1 deposited In the United States Postal Service hi Py.Iarthiez, Calllbrpta, postage fully preliald a certified catty of this Board Order wid Notice to Clahnaiit. Addressed to the claininiq as slioNvn above. Dated: .04w--7-JOHN CULLET~!, CLERK BY _� _.._ duty C This warning does not apply to claims which are not.subJect to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as, mandamus or injunction, or Federal Civil Rights claims. The above,list is not exhaustive and legal consultation is essential to understand all the separate limltations.periods that may: apply. . The limitations period within which suit must be flied may shorter or longer,depending.on the nature of the clalm- Consult the specific statutes and eases applicable to your particular claim. The County of Contra Costa does not waive any. of Its,rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions,not subject to the California Tort Claims Act I r•t' 4 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) 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. NO a M MONNENDEN No O r s a v e m o 1\w a s so Y U R O/\M M\R E 0"O N N O r E N D O W E a E E m C O\D O W ONE 0 W 0 0 0 5 E a a 0 M 1 RE: Claim By: 2d 6 019 loa, Reserved for Clerk's filing stamp T� 7--q 9�4? ) q01 cou /. M x-TAI P,- Rec�IV� Against the County of Contra Costa or ) JUL 1 �J&QU V �G District) [uU/ (Fill in the name) ) -Rvi.SORs The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ CM-0 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 10 &AN 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) �p 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? U Nt � 44$4 A:Q 5 What are the names of county or district officers, servants, or employees causing the damage or injury? . 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) C N, k 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ku— LNS 8. Names and addresses of witnesses, doctors, and hospitals: mcu PSN%-S 0 1)UA�— 9. List the expenditures you made on account of this accident or injury: DATE TEME AMOUNT . ■...Monson...■.■r........r..Ross.■....■s..............■......r.Seamansan0..eaMSomme0at 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) 1 Name and address of Attorney ) SAA1 "V (Claimant's Signature) n��U (Address) Telephone No. )Telephone No. OMENS......■r..........................■ .................................�.�.......� 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. 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. ................ .......... _ InN D��v ,7 M. r n �t—z c MawNb MA:il- L F r �s. u A4)(�-- s Gd/q c1 U -TTI. U�Ap c LIN c C. CL--pw SON (n ��Q ker��) w 6.Ll-K, Ar, T- 2�I-, LL 6 C_C— ]�(D L vt�T,I a iv o IN o Xf a Tp _ Aim,.. ... 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Ck r • t CLAIM BOARD Of SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Govemed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Secfion referei nces are to The copy of this document mailed to California Goveriment Codes �- you is your notice of the action taken r on your claim.by the Board of JUL 1 .9 2007 Supervisors. (Paragraph IV below), given Pursuant to Goverment Code COUNTY COUINSEL Section 913.and 915.4. Please note all AMOUNT: UNKNOWN,:. MARTINEZ CALIF. "Warnings". ; CLAIMANT: JAVIER AND,GRACE ALVAREZ ATTORNEY: UNKNOWNDATE RECEIVED: JULY 19, 2007 i' ADDRESS: 201 FOURTH STREET, ! BY DELIVERY TO CLERK ON: JULY L9, 2007 j. RODEO, CA 94572 j BY MAIL POSTMARKED: JULY 18, 2007 FROM: Clerk of the Board of Supervisors ; - TO: County Counsel Attached is a copy of the above-noted claim. j. ! JOHN CULLEN, C rk JULY 19 2007 Dated: By: Deputy I If.. FROM.: County Counsel TO: Clerk of the Board of Sti ei•visors ( Tliis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): ( ) Claim is not timely filed.The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: t Dated: 7— a3"o7. ! By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ! ( ) Claim was returned as untimely with notice to claimant (Section 911.3). . IV. JROARD ORDER: By unanimous vote of the Supervisors present: i ( This Claim is r•ejected.in full. ( ) Other: i i ceitify.that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: q CULLEN, CLERK, By eputy Gler k. j WARNI (Gov. code section.913) Subject to certain exceptiars,you linve only six(6) months from the date this notice was personally served j or deposited In the mail to file a court action on this claim.See Government Code Section 945.6.You may j seek the advice of all attollleY of your choice in connection widl this matter. It'you want to consult an attorney,you should do so Immediately. *ForAdditional Warning See Reverse Side ofTlris Notim j AFFIDAVIT OF MAILING lare'ui*r enalt .`of "�er'ur that I atn flow, And at all times hereln mentioned, have I [ dec. P Y I . J • Y been a citizen of tine United States; over• age 18; and that today I deposited Irl the United States Postal Service in Martinez, Calif'oi-nia, postage fully prepaid a certified copy of this Board Order and Notice to-Clainrant, addressecl to the clainian.t as shown above. I Dated: �a��,l�'HN CULLEN, CLERK By �eputy Clerk ........._..-...... i r . -This warning does not apply toclaims-which• are not subject to the California Tort Claims Act such as'actions in inverse condemnation, actions for specific relief such as mandamus or injunction;or Federal Civi! Rights claims. The above list is not exhaustive and, legal consultation is essential,to understand all.the separate limitations periods*that,may apply. The limitations period within which suit must be tiled may be,shorter or longer depending on . the nature of the claim: Consult the specific statutes and cases applicable to•your particular claim. . The County of Contra Costa does not waive any of its,rights under California Tort Claims Act andr does it waive rights under the statutes of limitations; app !cable to actlons'hot subject to the California Tort Claims Act I I , f f • i .tet 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 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.) 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. ■t aaaaaaaaaaaaaaataaa■ ■aaataaaaaaanaaaateaslaaRun aaaaanaRosso IaaIto aaaaamIagas aa RE: Claim By: Reserved for Clerk's filing stamp _ 7ay►er- t Grace atyc,-rez ) Against the County of Contra Costa or ) RECEIVED eb ti rc- 0 os-+CX- District) JUL 1 9 tuu r (Fill in the name) ) CLERK BO..; ; i.: �iiS C0 The undersigned claimant 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. ollows:1. When did the damage or injury occur? (Give exact date and hour) ��l.y "a, 2.00'] at 11.0o P.v►-. 2. Where did the damage or injury occur? (Include city and count') QarKcr lie. `Rodeo �p, g4Si�-Core Cosa ocz►� . A\.4liz QccS F S't-'Qe.uJa�. � 3. How did the damage or in1 ury occur? (Give full details;use extra paper if required) O eto,!►�q1� b� -to qo ha wie -f ro w% �rlc. Sfc fpcel o,-. s:d z o �p o� +^ouNoi r av kd 4-a? -F►.CXi '-F �e1� r,ke �� Jkw�Prc(. l•Q wv,• �r� Sd�, )4K.d Srct.�eof ��c S«t�o d.r"Ger• 5--de - 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage?-they p r-o�a b l e1 dam+ s e r c.,e -N�e Bc��s e o h Ore S7d4 was t���er -I�ctr � oi-��r .5icte . �� Wa d r14 oc• iG.;r ��reP'�. J ctihcl Sri <-�. --"t}}�t r W�er� S C al�rt'c{ o� -� � -F � �4 ,2007 I.c ,n<xt elaw n T eKf YJ Y `( 5 Wha arMef names of county or district officers,servants, or employees causing the damage or injury? Cords easo, em k,4-y - ;a 6. , What damage or injuries do your claim resulted? (Give full extent of injuries or damages -claimed. -AttacbAwo estimates for auto damage.) Pmt o4 0-t— . 7. Q-- . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) U)e..4 4v boA� sko� +-0 es-4�►Y.o-k-1o,^, 8. Names and addresses of witnesses,doctors, and hospitals: ToaUier p\varez ZoW PO%x, --SrL 9. List the expenditures you made-on account of this accident or injury: DATE TIME AMOUNT ■ .s.assssssas■■"anon.■sseaa.assassasssassasa■as.■as■■s■■as vaa.aaassuaas no l at a s alaas a ai .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 ) (Claimant's Signature) (Address) Telephone No. )Telephone No. 5/ 0 yS -- S o ■■aa■■asssssaassssssss,ssasa■■,s,saasssssRasa Runs Nunn sassassssassasaswas 9site sssss,s51 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim fled 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. . ........a■assas■a.assass . out sess■annals,s,■assss■sa■a■asasssssasasssssssssassssassa� 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. telephone: ---- -- 550 san pablo avenue r . (510) 799-4135 rodeo, california 94572 OWNER e 72C PHONE( y5 (e—%Il DATE 7 ACC. DATE ADDRESS AGENT INSURANCE CO. PHONE MILEAGE I.D. NUMBER LICENSE NO. ^ YEAR : p�MA� : ODEL eDY TY�E e ESTIMATE U�Y FRONT LABOR HRS PARTS LEFT ABOR HRS. PARTS RIGHT 1/ LABOR HRS. PARIS MISCELLANEOUS (/ LABOR HRS. PARIS Bumper Fender Frt. - Fender FA. Bumper Gd. Fender Shield Fender Shield Brkt. Fender Midg. Fender Mldg. Frame Heodlomp Headlamp Cross Member. Headiamp Door Heodlomp Door Frt.System Sealed Beam Sealed Beam Wheel Park.Light Park.Light Hub Cap Disc. Cowl-Dash Cowl-Dash Hub IL Drum Windshield TINAR Windshield Midg. Knuckle Door,Front Door,Front Knuckle Sup. Door Hinge Door Hinge Lr.Cont.Arm Door Glass TINT R Door Glass CLEAR INT Up.Cont.ArmVent Glass AR TINTT Vent Glass r NAR Gravel Shield Door Mldg. Door Midg. Steering Gear Door Handle Door Handle Steering Wheel Center Post Center Post Horn Ring Door Rear Door Rear Rad.Grille Door Glass CLEAR Door Glass CLEAR TINT Door Midg. Door Midg. Rocker Panel Rocker Panel Rocker Midg. Rocker Midg. FLOOR&W/HSG. FLOOR 8 W/HSG. Quar.Panel Quar.Panel REPAIR RE Fender PANEL Fender PAIR ' PANEL Quar.Ext. Quar.Ext. Quar.Midg. Quar.Mldg. Tail Light Tail Light T d Hood Top Hood Hinge Hood Midg. REAR MISCELLANEOUS Ornament•Emb. Bumper Front Seat-Add. Lock Plate,Up. Bumper Gd. Top Lock Plate,Lr. Bumper Brkt. Aerial Horn Gravel Shield Tire/32 TREAD wW EFT B Rad.Sup. Frame Point . C 61 Rod.Core Gas Tank Undercoat Anti-Freeze Tail Pipe Rod.Hoses lower Panel Labor Hours @ 70r $ SS- (3_1 Fan Blade-Belt Floor r CSS-5 Water Pump,Pulley Trunk Lid Parts Less Disc. $ U� Motor Mts. Trunk Mldg. Sublet 8 Net Items $ Trans.Link Wheel Hub A Drum Axle Towing $ Sales Tax $ Total $ 2, A-Align N-Now OH•Overhoul S-Stralghten or Repair- EX-Exchange RC-Rechrome U-For Used Parts Signed: CCTIAAATI; CYPIDCC 4n IIAVC rQe1AA nATC Date: 7/16/2007 12:07 PM Estimate ID: 1718 Estimate Version: 0 Preliminary Profile ID: CUSTOMIZED FRAME AND SUSPENSION EXPERTS FOR 30 YEARS B.A.F. Autobody 2218 Market St.<bafautobody.cora>,SAN PABLO,CA 94806 (510)233-1448 Fax: (610)233-7631 BAR # AK043701 FED # 94-1649823 Damage Assessed By: JR Stowell Deductible: UNKNOWN Insured: villager Mitchell Service: 916495 Description: 2000 Mercury Villager Estate Vehicle Production Date: 1/00 Body Style: VanPass Drive Train: 3.31-Inj 6 Cyl 2WD VIN: 4M2XV14TGYDJ05368 License: 4MXB290' CA Mileage: 12,345 OEM/ALT: A Search Code: C319261 Options: ALUM/ALLOY WHEELS,LEATHER SEATS,POWER DRIVER SEAT Line Entry . Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 600594 BDY REPAIR L ROCKER OUTER PANEL -S Existing 6.0' 2 AUTO REF REFINISH L ROCKER PANEL C 1.6 3 AUTO REF ADD'L OPR CLEAR COAT 0.6' 4 933003 REF ADD'L OPR TINT COLOR 0.6• 5 933018 REF ADD'L OPR MASK FOR OVERSPRAY INC' 0.2' 6 AUTO ADD'L COST PAINT 81.00 7 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00' '-Judgment Item C-Included in Clear Coat Calc Add'I Labor Sublet . I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 6.0 70.00 0.00 0.00 420.00 Refinish 2.9 70.00 0.00 0.00 203.00 Total Replacement Parts Amount 0.00 Non-Taxable Labor 623.00 Labor Summary 8.9 623.00 ESTIMATE RECALL NUMBER: 7/16/200712:07:52 1718 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAY_07_A Copyright(C)1994-2005 Mitchell International Page 1 of 2 UltraMate Version: 6.0.023 All Rights Reserved Date: 7/16/2007 12:07 PM Estimate ID: 1718 Estimate Version: O Preliminary Profile ID: CUSTOMIZED 111. Additional Costs Amount N. Adjustments Amount Taxable Costs 81.00 Customer Responsibility 0.00 Sales Tax (ai? 8.260% 6.68 Non-Taxable Costs 3.00 Total Additional Costs 90.68 I. Total Labor: 623.00 II. Total Replacement Parts: 0.00 III. Total Additional Costs: 90.68 Gross Total: 713.68 N. Total Adjustments: 0.00 Net Total: 713.68 This is a preliminary estimate. Additional chances to the estimate may be required for the actual repair. ******************Parts Price's Subject To Change**************** All Workmanship is Guaranteed For As Long As You Own Your Vehecle. All Parts Guaranteed As Per Manufacturers Warranty. Any Additioal Repairs or Supplements Relation To This Loss Should be Brought To B.A.F. For Futher Repairs Or All Guarantees Are Void. I Authorize Any Additioal Parts And Labor Needed To Complete Repairs. Estimate Authorized By Date I AUTHORIZE ANY ADDITIONAL PART OR LABOR NEEDED TO COMPLETE. DUE TO MANY UNFORSEEN CIRCUMSTANCES IN THE REPAIRING OF AUTOMOBILES, WE REGRET THAT WE CAN ONLY ESTIMATE, NOT PROMISE A COMPLETION DATE AND TIME. ESTIMATE RECALL NUMBER: 7/16/200712:07:52 1718 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAY_07_A Copyright(C)1994-2005 Mitchell International Page 2 of 2 UltraMate Version: 6.0.023 All Rights Reserved 07/16/2007 at 11:36 AM Job Number: 94763 CCS AUTO BODY License #:BAR AC250539 1868 Rumrill Blvd San Pablo, CA 94806 (510)215-9528 Fax: (510) 215-9597 PRELIMINARY ESTIMATE Written By: Faiyaz Khan Adjuster: Insured: Alvarez Javier Claim # Owner: Alvarez Javier Policy # Address: 201 forth st Deductible: Rodeo, CA 94572 Date of Loss: Cellular: (510)245-9804 Type of Loss: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2000 MERC VILLAGER ESTATE 6-3.3L-FI 4D VAN Int: VIN: 4M2XV14T6YDJ05358 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Theft Deterrent/Alarm Dual Air Condition Rear Wiper Steering Wheel Controls Body Side Moldings Dual Mirrors Privacy Glass Roof Console Luggage/Roof Rack Clear Coat Paint Two Tone Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Passenger Seat Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek Driver Air Bag Passenger Air Bag Leather Seats Bucket Seats 7 Passenger Option Automatic Transmission Overdrive Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 PILLARS, ROCKER & FLOOR 2* Rpr LT Outer rocker pnl s 4 .3 2.0 3 Add for Clear Coat 0.8 4 Add for Two Tone 0.8 5# Subl HAZARDOUS WASTE REMOVAL 1 5.00 X 6# Repl COVER VEHICLE FOR OVERSPRAY 1 5.00 T 0.3 7# DE NIB AND POLISH AS NEEDED 1 0.5 ------------------------------------------------------------------------------- Subtotals =_> 10.00 5.1 3. 6 Parts 0.00 Body Labor 5.1 hrs @ $ 70.00/hr 357.00 Paint Labor 3. 6 hrs @ $ 70.00/hr 252.00 Paint Supplies 3.6 hrs @ $ 30.00/hr 108.00 Sublet/Misc. 10.00 ---------------------------------------------------- SUBTOTAL $ 727.00 Sales Tax $ 113.00 @ 8.2500% 9.32 1 07/16/2007 at 11:36 AM Job Number: 94763 PRELIMINARY ESTIMATE 2000 MERC VILLAGER ESTATE 6-3.3L-FI 4D VAN Int: ---------------------------------------------------- GRAND TOTAL $ 736.32 ADJUSTMENTS: Deductible 0.00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 736.32 I authorize CCS Auto Body to perform the needed repairs to my vehicle. Repairs include parts, labor, and diagnosis. The above estimate is based on our inspection and does not cover additional parts or labor which may be required after the work has started. Worn or damage parts, not evident on first inspection, may be discovered and you will be contacted for authorization for additional work. Parts prices are subject to change without notice. ACKNOWLEDGEMENT: I have read and understand the above estimate and authorize repair service to be performed, including sublet work and acknowledge receipt of this estimate. An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount of repairs completed. Authorized By: Signed: Date• Work Accepted By: Signed• Date• POWER OF ATTORNEY: I do hereby appoint the aforementioned business as my attorney in fact to accept on my behalf any and all checks, drafts, or bills of exchange for deposit to the aforementioned business' account for credit on my account for repairs on my vehicle which had been released and accepted. Signed• Date: 2 07/16/2007 at 11:36 AM Job Number: 94763 PRELIMINARY ESTIMATE 2000 MERC VILLAGER ESTATE 6-3.3L-FI 4D VAN Int: 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 0/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR2MV99, CCC Data Date <MM/DD/CCY2>, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual 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 Recond. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 3 v 1Ja 4p p ; ' V CD U V ti\t r 17 10) �� s N moo. �,• � ' o d ' //r�te tJ1 4p 0o . i tilt cl i . I CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION. AUGUST 14, 2007 Claim Against the County, or District Governed by . the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT . and Board Action. All Sectioi►nrefei ences are to ) i The copy of this document mailed to i California Government Codes: ) you is your notice of the action taken I on your claim.by the Board of Supervisors. (Paragraph IV below), dUL S given Pursuant to Government Code AMOUNT:. $705.16 2007 Section 913 and 915.4. Please note all COUNTY COUNSI_L "Warnings". AtAIRTINEZ CALIF. I CLAIMANT: TIM SUTLIFF i ATTORNEY: UNKNOWN DATE RECEIVED: .JULY L9, 2007 '. ADDRESS: 120 SEQUOIA AVENUE BY DELIVERY TO CLERK ON: JULY 19, 2007 WALNUT CREEK, CA 94595 !.BY MAIL POSTMARKED: jny- 18, 2007 FROM: Clerk of the Board of Supervisors j. TO: County Counsel j Attached'is a copy of the above-noted claim. JOHN CULLEN l JULY 19; .2007. �: Dated: By: Deputy i.I. FROM.: County Counsel T0: Clerk of the Board o.f S pervisoi's (01 This claim complies substantially with Sections 910 and 910.2. i ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for I.5 days (Section 910.8). j i ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and j send waining of claimant's right to apply for leave to present a late claim (Section 911.3). O Other': • � I Dated: 7-12 3`U7 By: tel , Deputy County Counsel III.. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I IV. _.POARD ORDER: By unanimous vote of the Supervisors present: � I (Pr This Claim is rejected in full. , ( ) Other: f i " I [ certify that this is.a true and correct copy of the Board's..Order• entered in its minutes for i this date: j Date / l -- CULLEN, CLERK, By Deputy Clerk WARN1 (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 snail to file A court action on this claim.See Government CodeSection 945.6.You may seek the'advioe of an attorney of your• choice in connection with this matter. It'you want to consult an attorney,you should do so immediately. *Fol-Additional Wanting See Reverse Side of This Notice. AFFIDAVIT OF MAILING [ declare under penafty of perjury that [ aur now, and at all times herein mentioned, hlrve been' a citizen of the United States, over age 18; and that today I deposited in the United ' States Postal Service in Marti.nez, Catlfornia, postage fully prepaid a certilied copy of this Board Order and Notice to Claimant, Addressed to the claimant as shown above. i Dated: i``r'�' HN CULLEN, CLERK By. Deputy Clerk I I jrr�fi+� This warning does not apply to claims;wliicl� are not.subject to the California Tort Claims .. Act such.as:actions 111.1nverse condemnation, ..actions for specific relief"such as,mandamus or- injuneltion; or Federal Civil Rights claims. The above.list is not exhaustive and legal consultation is essential to understand all the separate limitations perlods that may apply. . The limitations period within which suit must be filed may be shorter or longer depending on. the nature of the claim: Consult the specific statutes and cases applicable toyour particular claim: - The County,of.Contra Costa does`,not Walve any of its.rights under. California Tort Claims Act `oesA waive rights under the statutes of 1=limitationk• appiicable to actions not subjeef to _ the California Tort Claims Act l 07 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 properly or 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 claim is against a district governed by the Board of Supervisors, rather than the County, the -name of the District should be filled in. s. If-the claim is against more than one public enq)L,, separate claims must be filed against each. public entity. s. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. Bass Can Cf an f fff f f f C a C■ on f iftC us mass Clf L'fffffff fang C C CCG!6Cff[ff;as an f Cfalf Cff!! ZE: Claim By: Reserved for Clerk's filing stamp �i� ��� ® � R Against the County of Contra Costa or ) 1 �L �s District) C�ER1CgO�RRpUGUSSPUU' (Fill in the name) Y The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 7 o,5-. t ( and in support of this claim represents as follovn: L. When did the damage or injury occur? (Give exact date and hour) ) , 6 '&,,- 2-D0 .1 cap- 10:Ys .4.". . 2. Where did the damage or injury occur? (Include city and county) V a..� , AJ a.p� CJS—e-k G6-� C.9A� Z. How did the damage or injury occur? (Give M details;use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or emp ogees caused the injury or damage? �a.�-Ce_ ,;, -� -� �- 0't 5 What are the names of county or district officers, servants, or employees causing the damage or injury? What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed Attach-two estimates for auto damage.) 1. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) w,u,�;, `& vl" L $LlCiC1 -4 s,4 ,ems - 's0 _ C— Z-O�2 Co G Z 3 9 -7 !o lj3 Cj -4 � 8. Names and addresses of-witnesses, doctors, and hospitals: Cifi�-<%►, C -� 3,' 5 7 r dam-.- C -�"-� . C'- 9. List the expenditures you rnade on account of this accident or injury: DATE TaJE AMOUNT a l a a C 2 a ti l l l t t l a l t l a l l l a a a l Q ERROR a l l l l■■tea l a n a s a WERE l a l l l a■99 a l l a a l l a a t t a t a Kit l l l l a a t a at ) .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) 1 NTame and address of Attorney ) (Claimant's Signature) (Address) Telephone No. ) Telephone No. t a a a t MERNERSILER a ZERO a l l I l■ ■ NINE l 1911132 RESERVE l tall s a a t l l a l t l a s a a a a l l l l a a l!Ban a l l l a am 91 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. aaaaa■llaaaalalaalaaatllrallaasaallaa5aaaaalalallllaataaaallllaltlaallaallalllalt NOTICE: Section 73 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 ($10,000),or by both such imprisonment and fine. ek fIJ 1ji :.F P5�ALPS`'� � ,,,,. USP � � �� .� :1 ,✓ ' �� •� s.�. .� �' '�:._ t � ,� f P 7, \ ` �� �' � \ 4y ��� � �6 � ��O �''- 1 � �,� a. � r � �� �': �. � �. �. � r� . . Vic' . �`�` �' ,.._ � ce ��, �;.., `� � �,a � (� ` r � �ti.� ti ,:.� .. �. iii �� °� ;,_ .. `.y , ���.' i. f - L O` _ � � � . C � ,� ' W a:,r� ,� � �, ��$.0 y `� N E�� ,�r f` .. .�� CLAiM ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 1 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Section'refei-ences 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 Supervisors. (Paragraph IV below), given Pursuant to Government Code � 913 and 915.4. Please note all AMOUNT: $5;000;000.00. !Section.. � ��r j JUL 2 0 2007 1 Warnings": CLAIMANT: LIONEL .BRACKINS i COUNTY;COUNSEL #F09091 MARTINEZ CALIF. : i ATTORNEY: LNKNpWNDATE RECEIVED: JULY 20, 2007 ADDRESS: SAN QUENTIN •STATE PRISON. BY DELIVERY TO CLERK ON: JULY 20, 2007 SAN QUENIN, CA. 94964 RECEIVED FROM COUNT BY MAIL POSTMARKED:: COUNSEL FROM: Clerk of the Board of Supervisors TO: County Counsel I" Attached is a copy of the above-noted claim. JULY 20 2007 : JOHN CULLEN, Cl r Dated: By: Deputy 1.1. FROM.: County,Gourisel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. I ( his 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 j send warning of claimant's right to apply for leave to present a late claim (Section 91. 1.3). j ( ) Other: i - i Dated: 7,�3— 0 By: Deputy County Counsel ill.. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 91 1.3). I IVOARD ORDER: By unanimous vote of the Supervisors present: I (✓ . This Claim is rejected in full. ( ) Other: I certify that this is a true and con-ect copy of the Board's.Order entered in its minutes for this date. j. Dated: $",BHN CULLEN, CLERK, By Deputy Clerk. ' WARNIN (Gov. code section.913) Subject to,certain exceptions,you have only six(6) i:nontlis fivtn 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'all attomey of your cltoioe in connection with this matter. If'you want to consult an attorney,you should do so Immediately. *For Addid(mial Waiiiii%See Reverse Side ofTltis Notice. AFFIDAVIT OF MAILING [declare under �enalty'of pet jury that i. ani now, and at all times herein mentioned, have been a citizen of tlte'United States; over age 18; and that today I deposited in the United States Postal Service In N.1arth ez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. i i Dated: 2 �.`' JOHN CULLEN, CLERK By Deputy Clerk I i This warning does not apply, to claims.which are not subject to the California Tort Claims Act such as actions in inverse condemnation, . actions for.specific relief such as mandamus or inion tion; or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may,apply. The limitations period within which.suit must be tiled may be shorter or:longer depending on the,nature.of-the claim. Consult the specific . statutes and cases applicable to your particular Claim— The-County of Contra Costa does not waive any. of its:.rights under.California Tort Claims Act `no.r..Vbes it waive rights under the statutes of limitations applicable to actions not s�ib�e.ct to the California Tort Claims Act *;,��:%•...,.''�-f' <<��\ . :L •.\.,, `�:•1 .�n;`.:ter•" �. 1 I ' ._. ..A':.�"'%': , .:-.:jam r,.:;h:;��. •'>F; w1 _i 1 1 i . I "OFFICE OF THE COUNTY COUNSEL 5E_.L SILVANO B. MARCHESI COUNTY OF CONTRA COSTA _0, COUNTY COUNSEL Administration Building 651 Pine Street, 911 Floor SHARON L. ANDERSON °; l `� Martinez, California 94553-1229 � _' ,e CHIEF ASSISTANT (925) 335-1800 GREGORY C. HARVEY (925) 646-1078 (fax) VALERIE J. RANCHE .� _�i- -• �Q ASSISTANTS C�Osr'� COUIy'�,G4' NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Lionel Brackins #F09091 San Quentin State Prison San Quentin, CA 94964 RE: CLAIM OF LIONEL BRACKINS Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [X] 1. The claim fails to state the name and post office address of the claimant. [X] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [X] 6. The claim is not signed by the claimant or by some person on his or her behalf. Lionel Brackins Re Claim of Lionel Brackins Page Two [X] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: k� ZLIC5�z� Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My bus s ddress is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On es ' -v , I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the d cument in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Lionel Brackins, #F09091, San Quentin State Prison, San Quentin, CA 94964, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on at Martinez, California. Kat een O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 RECEIVE® JUL 12 0 zuui CLERK pCIR. OF SUP;'RVISOii$ rR,a co^ ,co. July 13, 2007 Sil vara B. Marchesi County Counsel JUL 1 8 2007 County of Contra Costa 651 Pine street 9th Floor COUNTY COUNSEL Martinez , Ca 94533 MARTINEZ. CALIF. Re People vs Lionel Brackins Contra Costa County Warrant Number 04-153967-5-001 Dear Counselor: This letter will serve as my demand for payment and notification of my intent to bring legal action I demand the payment of five million dollars for injuries medically , emotionally and constitutionally suffered from my being sunjected to excessive use of force by the Contra Costa County Sheriff ' s Department- Oakley Police Department . Incident Number -07-12363 . This matter is presently pending before the courts and a warrant has been issued for my production. I have sent for processing with the Contra Costa Distict Attorney , a demand For Trial . I anticipate having full hearings in this matter which will seek to establish the constitutional . violations by the Officers. That information ( i .e. ) transcripts from any preliminary and other hearings ) , will be used in my federal civil rights claim against the Offending Officers and Municipal employees. Attached is any additional criminal justice information you may need to .note my„-request and notification. Sincerely, Lionel Brackins LB/dlg Y-j� •1 t Y 4 /''�li ,c tp Lp 90 I S' Ul CA .1!'t Al '.0v n � S 41 N CP S• 9 UJ o , �s~ (n .:d CLAi.M BOARD.OF SUVERVISORS OF CONTRA COSTA COUNTY I BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by ) tine Board of Supervisors, Routing .Endorspmentsi NOTICE TO CLAIMANT and Board Action. All Section iefeiences are.to The copy of this document mailed to California Government Codes: ) you is your notice of the action taken NOTE: THE SAME CLAIM WASFILED ON ' .9 your claim.by the Board of JULY-18, 2007 Supervisors. (Paragraph IV below), I. g1 iven Pursuant to Government Code AMOUNT: EXCEEDS $10,000.00: 'JUL 2 0. 2dction'�b and 915.4. Please note all 2007 Warnings CLAIMANT: LOUIS DEL' BARBA. COUNT. yCOUNSEL. MARTINEZ CALIF. ATTORNEY: SCOTT PEEBLES,. ESQ. DATE RECEIVED: JULY 20; .2007 O'REILLY. &-..DANKO. JULY 20, 2007 ADDRESS: Y DELIVERY TO CLERK ON: 1900 O.',FARRELL ST. , ST.E. 36 SAN MATEO; CA 94403 RECEIVED FROM COUNT` BY MAIL POSTMARKED: . GO�r1.1S , FROM: Clerk of the Board of Supervisors i T0: County Counsel Attached is'a copy of the above-noted claim. JULY '20,; 2007: JOHN CULLEN, Cler i Dated: �. By: De}iuty i.I. FROM.: County Counsel ' TO: Clerk of the Board of S per•visors ( Tlnis 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 91. 1.3). (Other: A MR 15 fb� oLolied [ion Dated: -7—�3-O7 By: �� Deputy County Counsel III.` FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice.to claimant (Section 911.3). i i I.V. BOARD ORDER: By unanimous vote of the Supervisors present: (I� This Claim is rejected in full. ( ) Othei': I ceitify that this is a true and con-ect copy of. the Board's.Order entered in its minutes for this date. I I Date �/ ' 40HN CULLEN, CLERK, By Deputy Clerk. ' WARNI . (Gov. code section.913) Subject to certain exceptions,you have only six(6) inontlns fivm the date this notice was personally served or deposited in the mail to Nle a court action on this claim.See Government Code Section 945.6.You may seek the advice ..an.attorney of your choice in connection widr this matter. ll'you want to consult an attorney,you should do so lmiiiediately: *.For Additional Warning See Reverse Side ofTbls Notice. AFFIDAVIT OF MAILING [ declare under penalty of,perjury that ( ani nonw, and at all times herein mentioned, have been a citizen'.611' the. United States, over age 18; and that today I deposited iii the United I States Posted Service in Nlartinez, Caliloi•nia; postage fully prepaid a certiiled copy of this Board Order and Notice to Claimant, Addressed to-the claiinan.t as shown above. Dated:gj�4 JOHN CULLEN, CLERK By Deputy Clerk i 6 This warning does not apply to.claims which are not subject to the California Tort Claims " Act such as.actions in inverse condemnation, ""actions for specific relief such as mandamus or injunetion,.or. Federal Civil Rights claims. The abovel.list is not.exhattstive and legal consultation is essential to understand all the separate limitations p6rlods that may apply. The limitations period within which suit must. be tiled may be shorter or longer depending on the nature of the clalm Cons tilt the specific stattites and cases applicable to yotir particular claim. The County of Contra Costa does not waive any of its rights under: California Tort Claims Act ihor'do-ks it waive rights under the statutes of . limifations,apnlicable,to actions not subject to:: the California Tort Claims Act i i I JUL 1 8 2007 MIS COUNTY COUNSEL MARTINEZ. CALIF. CLAIM AGAINST CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT To: Contra Costa County Sheriffs Department- 651 Pine Street, 7th Floor o Martinez, CA 94553 : rn `= Z�. A. Claimant Name and Address: "c T co T rn>Z VJJ Louis Del Barba ��� Mr >M c/o Julie Del Barba-Favalora 350 N. Civic Drive, Walnut Creek, CA 94596, ; NJ T -c B. All Correspondence Should Be Mailed To: O'Reilly & Danko REC I ED 1900 O'Farrell St., Ste. 360 San Mateo, CA 94403 JUL 2 0 cuu, (650) 358-5901 ' CLERK BOARD OF SUPERVISORS C. Date of Incident; Location of Incident; Facts: CONTRA COSTA Co. The date, place, and circumstances.of the occurrence giving rise to this claim are that on or about April 16, 2007, at around 8:30 a.m., Louis Del Barba was driving his vehicle in or near the City of Oakley, in Contra Costa County, California, at or near the intersection of Rose Avenue and Main Street. He turned onto Main St. when American Medical Response ("AMR"), under contract, as an agent, or otherwise on behalf of the County of Contra Costa, Contra Costa County Sheriffs Department, and/or East Contra Costa County Fire Protection District ("Government .Defendants") negligently, recklessly, and with willful and wanton disregard operated, controlled, and/or possessed a vehicle so as to cause it to collide with Mr. Del Barba's vehicle, causing him severe injury and paralysis. AMR operated, controlled, ' I I i and/or possessed its vehicle in response to negligent instruction by Government Defendants whereby the AMR vehicle and at least one other vehicle were instructed to respond to the same call for assistance. Government Defendants were negligent in their policy, procedure, instruction, management, and/or supervision for providing emergency medical response. D. Injuries or Damage The indebtedness, obligation, injury, damage, or loss incurred, to the extent known at the time filing this claim, include injuries to Mr. Del Barba that consist of a broken pelvis, broken ribs, and broken neck. He is quadriplegic as a result of the accident. Damages include past and future medical costs, lost wages, pain, suffering, punitive damages, and any other damages permitted by law. E. Name of Employee(s) Causing Iniury or Damage The names of all public employees causing the injury, damage, or loss are not known at present. F. Amounts Claimed The amount of this claim exceeds ten thousand dollars. This claim qualifies as an unlimited case and will not proceed as a limited civil case. Dated: July 17, 2007 O'REILLY & DANKO S By: SCOTT PEEBLES, ESQ. Attorney for Claimant , j CLAiIVI t j BOARD O.F SUPERVISORS OF CONTRA COSTA COUNTY i. ` ! BOARD ACTION: AUGUST 14, 2007. i Claim Against the County,;or District Governed by ) . the Board of Supervisors, Routing Endorse.me.nts, ). NOTICE TO CLAIMANT II and Board Action.All Section references are to ) ':The copy of this document mailed to ! California Government Codes: : i` ) you is your notice of the action taken a on your claim.by the Board of Supervisors. (Paragraph IV below),' JUL 2 2007 given Pursuant to Government Code AMOUNT: $1 500.00 ; Section 913 and 915.4. Please note all COUNTY COUNSEL „Warnings": MARTINEZ;CALIF. CLAIMANT: PATRICIA:BRYSON. . I ATTORNEY: UNKNOWN DATE RECEIVED: JULY 24, 2007 j ADDRESS: . 166 SOth 37th STREET ' BY DELIVERY TO CLERK ON: JULY 24 2007 RICHMOND., CA.94804 i + BY MAIL POSTMARKED:. ,7ULX 23, 2007 FROM: Clerk of the Board of Supervisors i TO: County Counsel Attached is a•copy of the above-noted claim. JOHN CULLEN; Gle I JULY24. 2007 Dated: By: Deputy I li. FROM'. County�CounseC: `I O: Clerk of the Board of Sup rvisors his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2; and we are so �. notifying claimant. The Board cannot act for 15 days (Section 910.8). " i ( ) Claim is not timely.filed. The Clerk should r•etur n claim on ground that it was filed late and send warping of claimant's right to apply for leave to present a late claim (Section 91. 1.3). ! i I ( ) Other: . Dated: 7'� �'.D 7 By: �/��� Deputy County Counsel III. FROM: Clerk of the Board . TO: County Counsel (1) County Adtninistt•ator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: I i This Claim;is rejected in full. I ( ) Other: I certify that this is a true and correct copy of the Board's.Order entered in its minutes for this date. j Dated: / CULLEN, CLERK, By Deputy Clerk WARNi. I (Gov. code section 913) ; Subject to certain exceptions,you have only six(6)months filum the date this notice was personally served or deposited in the mail to file a,couit action on thls claim.See Government Code Section 945.6.You may seek the advice of an attorney. oi'your choice in co'nnection widr this matter. kf you want to consult an attorney,you should do so lmtned3ately: *For Additional Wanting See Reverse Side of This Notice. AFFIDAVIT OF MAILING I decla res under penaltyof'jierjury that i. ani riow, and at all times herein mentioned, have I been a citizen of the United States; over age 18; and that today i deposited in the United States Postal Service in Nlartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. . i Dated: N" 27410AJOHN CULLEN, CLERK By eputy Clerk .. ; This warning does not apply to claims which are notsubject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief'such as mandamus or injunction; or Federal Civil Rights claims. The above�list is not exhaustive and legal consultation is essential to understand.all the -separate limitations periods that may .apply. The limitations period within .which suit must be filed may be.shorter or longer depending on the. nature. of the claim: Consult the specific statutes and cases applicable to your particular claim: The Countyof Contra Costa does not waive any of its.rights. under:California Tort Claims Act :.:Per) bes it waive rights under the statutes of limitations applicable to actions root subject to the California Tort Claims Act BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO.CLAiMA.NT 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 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.) 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. on an o a a a a a o t a s s a a man WEINER MR a a a name ata!11 e a 3 a t a RMER a a Rang a a 1I 11 R 11 M O R a all MWERE I a coal RE: Claim By: Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or ) JUL 2 4 2007 C � �1C.Id 9h15tI1Ct) CLERK CON TR OC STACO.ISORS (Fill in the name) Y The undersigned claimant hereby makes claire against the County of Contra Costa or the above-named district in the sum of$ /5W,01-� and in support of thus claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) , - av 6�� jv�. p� o�t � at6-TAJSuRq (amu64 W, 2. Where did the damage or injury occur? (Include city and county) cx-SA� 14R O1 oN +hF rpt FdoaR. AII 3. How did the damage or injury occur? (Give full details;use extra paper if dorequired �v.)�S wA\K,i�q wer l � � IP l . 1' SlipPf tel/ OV4 4h6 �(oDR..WK e otl •AkE �'1oOP-.-T: N o4ti Cid =14PA 11 e.N tN R add lE o F w 4. What"particular act or omission'on the part of county or district officers, servants, or era loVees caused the injury or damage? Cd r*�+i7a Cao S-r 'i4 44-ea/441 CG✓�C- n1 c�i� e-7' C- 1 -For P4ddle o� 1VA4t3P. ons 96- IFIM 5 What are the names of county or district officers, servants, or employees causing the damage or injury? I445E(t66p 1�9 '00+i •6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages - -claimed. -Attach two estimates for auto damage.) 15 A 965( W Off- 'A f�, Z'/?q VE � SP a,i ry c-d Knrc-G avt(Jso mass=nt Mt )Q9 t f Lip. .pya I4 4 ,4chG-d Phq s i U&N PA f*r sc. . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Jr'd Li K6 +o eo}kp&Ns A 4Q �b r M tf Pce,sWha � Pas a�d s� Ferv9 •� i 8. Names and addresses of witnesses,doctors, and hospitals: W 0 urn Knokm1 "et-4A 1614s& Eikn► ' Wk1,b\J ��N sc-E M& �l(. T 0 As' wa-bte 4-0 qe+ 0-1d Addmsses, 9. List the expenditures you made-on account of this accident or injury: DATE T12VIE AMOUNT /I., 1%Cie? :VYC- A-ff*d1Ed <prod(- CR- pLtr- he s& V o r M.Gd�Cj 4 E e a■t a[■a■■Kansas■a■[■Masan a Is■t■a■■a■1■■t t a a■t a■t■a■t[■t■aft{[[[[[[■[f[[■■[ata■HERBER■ ) .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 ) Aa } (Claimant' Signature) ai r y ) 3� 4- 9A - ������- ) (Address) Telephone No. )Telephone No. D— a3to-0-957 ■,aaaaaa[aaaaaaananon anon■aata■rant/■artnraraaaaaaataannanartnnaataataHER aman aanaaaus, 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. ■ a■aaattatgagman man an■■nf ■ aiatHas afafaratnaaaaatanaaaaatnaaln■aanntan/a annanaBass INN Hill NOTICE: Section 71 of the Penal Code provides: Every person vvho, 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. Ai _ ... CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER B R Y S O N P A T R.I C I A CONTRA COSTA HEALTH CENTERS F 3 /23 /1956 510 236 - 2957 ❑MTZ E]BHC ❑CHC E]AHC TO ❑PHCRHC E]BPCWC PUELL , MICHAEL ND RICH ADVICE RECORD DATE: TIME: L %J12 RHC RECORD# / - NAME 1 PRIMARY PROVIDER r ✓ DOB PHONE COMPLAINT/PROBLEM AND DISPOSITION: i r r0-1 Lo W1,, -. DISPOSITION: ❑ Advised per protocol and sent home I., ❑ Referred to Provider • ❑ MMH and HC ❑ Private MD ❑ Other(specify): SIGNATURE/TITLE -------- ------ ——————————————=— — ——————— AAD,VICE`MEDICAL DOCUMENTATION: AT74, _.`,c„ ;:x - 4` 71 r' r //r f J ./i i}..n/ f� r' t Jr^,-. .� f '!i L�• f*�'�✓/' � L ,�'t i 4, SIGNATURE/TITLE Distribution: WHITE-CHART' _ YELLOW-FILE MR 537-9(4/98) PINK-PATIENT(UPON DISCHARGE) ADVICE RECORD ' 1, / I. 77 1 G.Q.N°T..'RA:C S.T..A ' CONTRA-COSTA'REOIONAL•'MEDICALCENTER .r:.:'.:.';' RY:5.OtJ,''. .:',,,.. ; TRtIC RA , CONTRA COSTA-HEALTH-CENT RS ' Z. ' (( 5 61'0 ❑MTZ.. ':,.:Q BHC;`:` CHC AHC: " , I, ❑PNC RHC ❑BPCVVC, :.': - : C 4'1 li E L: ' .T ADVICE A LC RECORD DATE: . . . ...." .. ! _ 12 RH-c - RECORD:H. . AME'..`: PRIMARY:PROVI ER .DOB PHONE' ' COMPLAINT/PROBLEM:AND DISPOSITION:.'_.:.: ;:...: ;I., . .:, ;.:r'::;I;:'•..': ::; _;;./ :...; ' �" (Ii r:, PP .... . ..... . , i : e • - _ : DISPOSITIONS P iAdvised er. rotocol and sent P , ome _ Referred to Pro .... ...::. ;r+. ❑ vider� and - �.Mlvlli H C. Llqt ❑' Private MDs ` — ``: ��' •.L ,3• �� Other�(specify) : J. " SIGNATURElrITLE' Fr ADV L'.D000IIIIENTA , TION: 7 " : is , .. �..'...r� : 5. f-�- a .r.. �'��� :.; �.��•r., ':r:�{, :'� _ .`�' .�� :I -::� � �� , ' i - :'r Q .. - ' :�^" �:-��;;�, � -,' ..�• - f r• C-:7�,.: 1•; L 1. �•i•r �r/!—{:- '<;�-r'.'.�:'_';��i.:�_"7:!'. �:��-'~ �--!•r��t..✓ r� r' s. .1 , f� 77 'r RETITLE' r ' Dist�ibiiliori:'.WHITE—CFIA .i YELLOW""FILE ' PINK-PA''TIENT UPON DISCHARGE) 537 9(4/98) en\ifrF R�r_nRn L i CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS �(ar ON PATRICIA PATIENT INSTRUCTIONS t 510 236 -2957 VISIT UPDATE i 6111- 2R - 1 TO Today's date: 5 j Pur MEDICINES: MICHAEL NO It ICK MEDICINES: (THISiIS NOT A LEGAL PRESCRIPTIrni) 0 b050 nlli; U LI) ❑ REMINDER: PLEASE BE SURE TO BRING ALL MEDICINES OR A LIST OF ALL MEDICINES TO EACH APPOINTMENT INSTRUCTIONS: a PROVID Signature ❑Martinez Hth Centers ❑North Richmond Center for ❑Concord Health Ccnter ❑ y Point Family Health 2500 Alhambra Avenue Health,1501 3rd Strcct 3052 Willow Pass Road enter,215 Pacifica Ave. Martinez,CA 94553 North Richmond,CA 94801 Concord,CA 94519 Bay Point,CA 94565 1-877-905-4545 1-877-905-4545 1-877-905-4545 1-877-905-4545 and Health Center 0 Pittsburg Health Center :---'Brentwood Health Center 0 Antioch Health Center ,i' c..ee. ,a„ T --;,4—A^oid 171 cs.,r;( r"Ir Rti Ciii+w A 'i m5 T,nne Tr"Wav 5 , ' h AhWa h MU Patricia Bryson 2222 MEDICATION: IBUPROFEN [Adult] Ibuprofen(brand name: Motrin)is an anti-inflammatory drug. It is also available over-the-counter in a lower strength as Advil, Nuprin, Motrin IB and other brand name€. It is very useful for pain,fever and inflammation. DIRECTIONS FOR USE: You may take this medicine with food or milk to reduce stomach upset. WHAT TO WATCH FOR: POSSIBLE SIDE EFFECTS: Nausea,upper abdominal pain, dimness—>(Contact your doctor if these symptoms persist or become severe). Bleeding from the stomach,which may appear as blood in vomit or stool(red or black color); rapid weight gain, leg swelling or easy bruising —>(Contact your doctor or return to this facility promptly). ALLERGIC REACTION: Rash, itching, swelling,trouble breathing or swallowing--> (Contact your doctor or return to this facility promptly). IMPORTANT MEDICAL CONDITIONS: Before starting this medicine, be sure your doctor knows if you have any of the following conditions: — Stomach ulcer(active or in the past), history of vomiting blood or bloody stool — Chronic alcoholism or it you consume more than three alcoholic drinks every day — Allergic reaction to aspirin or other anti-inflammatory medicines -- Asthma, nasal polyps or angioedema;pregnancy or breast feeding -- Liver or kidney disease; bleeding disorder DRUG INTERACTION: Before starting this medicine,be sure your doctor knows if you are taking any of the following drugs: — Coumadin(warfarin), Lasix(furosemide)Lithium, blood pressure medicine, Dyazide(triamterene), diabetes pills, prednisone,aspirin or other anti-inflammatory drugs, Lanoxin (digoxin), methotrexate,cyclosporine WARNINGS: -- Do not take with prednisone, other anti-inflammatory drugs or ALCOHOL since this increases the risk of getting a bleeding ulcer. — This drug may cause dizziness. DO NOT DRIVE, ride a bicycle or operate dangerous equipment while taking this medicine until you know how it will affect you. jNOTE. This information topic may not include all directions, precautions, medical conditions, drugRood interactions and warnings for this drug. Check with your doctor, nurse or pharmacist for any questions that you may have j !t}7 13:21 Exit-Writer" Instructions Copyright©1990-2007 Parker Hill Associates, Inc. PATIENT COPY-Page 1 of 3 i DOCTORS MEDICAL CENTER-SAN PABLO 2000 Vale Road, San Pablo CA 94806 (510)970-5140 Discharge Instructions Ian Ahwah MD Patricia Bryson 2222 MEDICATION: IBUPROFEN [Adult] Ibuprofen (brand name: Motrin) is an anti- inflammatory drug. It is also available over-the-counter in a lower strength as Advil, Nuprin, Motrin IB and other brand names. It is very useful for pain,fever and inflammation. DIRECTIONS FOR USE: You may take this medicine with food or milk to reduce stomach upset. i WHAT TO WATCH FOR: POSSIBLE SIDE EFFECTS: Nausea, upper abdominal pain, dizziness --> (Contact your doctor if these symptoms persist or become severe). Bleeding from the stomach, which may appear as blood in vomit or stool (red or black color); rapid weight gain, leg swelling or easy bruising --> (Contact your doctor or return to this facility promptly). ALLERGIC REACTION: Rash, itching, swelling, trouble breathing or swallowing-->(Contact your doctor or return to this facility promptly). ********** IMPORTANT ********** MEDICAL CONDITIONS: Before starting this medicine, be sure your doctor knows if you have any of the following conditions: -- Stomach ulcer(active or in the past), history of vomiting blood or bloody stool -- Chronic alcoholism or if you consume more than three alcoholic drinks every day -- Allergic reaction to aspirin or other anti-inflammatory medicines -- Asthma, nasal polyps or angioedema; pregnancy or breast feeding -- Liver or kidney disease; bleeding disorder DRUG INTERACTION: Before starting this medicine, be sure your doctor knows if you are taking any of the following drugs: -- Coumadin (warfarin), Lasix (furosemide) Lithium, blood pressure medicine, Dyazide(triamterene), diabetes pills, prednisone, aspirin or other anti-inflammatory drugs, Lanoxin (digoxin), methotrexate, cyclosporine WARNINGS: -- Do not take with prednisone, other anti-inflammatory drugs or ALCOHOL since this increases the risk of getting a bleeding ulcer. -- This drug may cause dizziness. DO NOT DRIVE, ride a bicycle or operate dangerous equipment while taking this medicine until you know how it will affect you. [NOTE: This information topic may not include all directions, precautions, medical conditions, drug/food interactions and warnings for this drug. Check with your doctor, nurse,or pharmacist for any questions that you may have.] 6/5/07 13:21 Exit-Writer TM Instructions Copyright©1990-2007 Parker Hill Associates, Inc. PATIENT COPY-Page 1 of 3 DOCTORS MEDICAL CENTER-SAN PABLO 2000 Vale Road, San Pablo CA 94806 (510)970-5140 Discharge Instructions (con't) Ian Ahwah MD Patricia Bryson 2222 SPRAIN: KNEE You have a knee sprain,which is a tearing of the ligaments that hold the joint together. There are no broken bones. Sprains take from 3-6 weeks to heal. HOME CARE: 1)Stay off the injured leg as much as possible. 2)Apply an ice pack over the injured area for 20 minutes every 2 hours for the first day. Continue this 3-4 times a day for the next two days. 3)You may take Tylenol (acetaminophen)or ibuprofen (Advil, Motrin)for pain, unless another pain medicine was prescribed. 4) If you have a plaster or fiberglass SPLINT OR CAST: -- Keep it dry. When bathing, protect the splint/cast with a large plastic bag, rubber-banded at the top end. If a fiberglass cast or splint gets wet, you can dry it with a hair-dryer. 5) If you have a VELCRO KNEE BRACE: -- You may open the splint to apply ice. -- You may remove the splint to bathe and sleep, unless told otherwise. 6) If CRUTCHES or a walker have been recommended, do not bear full weight on the injured leg until you can do so without pain. Check with your doctor before returning to sports or full work duties. FOLLOW: UP with your doctor or this facility as advised. Return sooner if you are not starting to improve within the next five days. If a cast or splint was applied, it should be checked in 24 HOURS to be sure it has not become too tight from swelling. Look for the warning signs listed below. [NOTE: If X-rays were taken, they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care.] RETURN PROMPTLY or contact your doctor if any of the following occur: -- The plaster cast or splint becomes wet or soft -- The fiberglass cast or splint remains wet for more than 24 hours -- Pain or swelling increases -- Toes become cold, blue, numb or tingly 6/5/07 13:21 Exit-Writer TM Instructions Copyright©1990-2007 Parker Hill Associates, Inc. PATIENT COPY- Page 3 of 3 rn M Z r O = 4The?Pharmacy America Trusts •Since 1901' I'm JORDAN. Thank you for allowing me o W � a to serve you today. i� (r j: ,;; Z) w 1- 601 10 5201 03770 035 0 i o ir Cn RFN# 0377-0355-2013-0706-0520 a io u- F RX 077830 1 .00 Z c g o co 0 CF RX 07.7829 i 19.99 Ha ` TOTAL 19.99 Aw M 0) = CASH 20.00 }" W¢ Cr 9 a _ , C7 CHANSE .01 Cr O a , III 1111111111 IN 1111111111111111111111!1111III111111111111111111111111111111 grmo Z a o _ 11565 San Pablo Ave El Cerrito, CA amyl o Z0 � < STORE(510)234-9300 } o F=ELIGIBLE FLEX SPEND ACCT ITEM (FSA) THANK YOU FOR FASTER SERVICE, CALL IN YOUR m PRESCRIPTION ORDER OR PLACE IT ON WWW.WALGREENS.COM 24 HOURS IN ADVANCE JUNE 5, 2007 5:26 PM to YOUR OPINION COUNTS! o W a o � aLo _ so a 4 ENTER FOR A CHANCE TO WIN $10,000 CASH o kc) ii a o M 5N � p O s PLEASE CALL TOLL FREE Go o o 1-888-424-1018 �� o W OR LOGON TO n13 5= s o v WWW.WALGREENSSATISFACTION.COM rn a i d WITHIN 72 HOURS TO COMPLETE A a SHORT SURVEY ABOUT YOUR RECENT m I N VISIT TO THIS WALGREENS. Q s � Z= z SURVEY# 0377-0355-2013-0706-0520-16 v o �; m LO a ZSEE STORE FOR CONTEST RULEStes� � �' JUNE 5, 2007 5:26 PM D z f • C-401'DCGOOO'n C2-C. ` IC LA I ol- zrN Ln10 p .. .. . —85-161 ` Nis O ... '� �e�/ _ _ • U. - c,j Q�l tcc d CG s J yV'. VVV T � 1 . C i d m r o 0 I r C�°3q yCJ t� �P p w � i a O t O � � t .. O t11. I CLAiM BOARD OF SUPERVISORS'OF CONTRA COSTA COUNTY f BOARD ACTION:.1 AUGUST 14, 2007 Claim Against the County, or District Governed by I the Board of Supervisors, Routing Endoi:seme.nts ) NOTICEITO CLAIMANT and Boand Action, All Section references are to ) The copy oflthis document mailed to California Government Codes.` ! ) you is your-notice of the action taken �) on your claim by the Board of JUL ` Supervisors 1 (Paragraph IV below), 2007 �- given Punsuj nt to Government Code ! Section 913 and 915.4. Please note all ! AMOUNT: $286.60 COUNTY COUNSEL �°Warnings" IVIARTIiVEZ:CALIF. f CLAIMANT: LAURITA HERBERT I i JULY 24, 2007 ATTORNEY: UNKNOWN DATE RECEIVED: ADDRESS: 1810 PHEASANT DRIVE i BY DELIVERY TO CLERK ON: JULY 24, 2007 HERCULES;, CA, 94547 ; RECEIVED FROM RISK BY MAIL POSTMARKED: MAMA,fir i FROM: Clerk of the Board of Supervisors .'J. -TO: County Counsel Attached is a.copy of the above-noted claim. JULY 24;, 2007 JOHN CULLEN, rk Dated: By: Deputy ! I.I. FROM: County:Counsel TO: Clerk of the Board of Supervisors ! ! I (This claim complies substantially with Sections 910 and 910.2. I ( ) This Claim FAILS. to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8): j ( ) Claim is not timely filed. The Clerk should return claim on groundjthat it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 91. 1.3). ( ) Other: I I I j Dated: '7' 2k("07 By: !til L6�-i� Deputy County Counsel I 111.: FROM: Clerk of the Board TO: County Counsel (1) County Administt•ator (2) ( ) Claim was returned as untimely with notice to claimant (Section;91 1.3). ! 1V. ARD ORDER: By unanimous vote of the Supervisors present: IV. Claim is rejected in full. ! ( ) Other: I i ! i I � [ certify that this.is.a true and coi7•ect copy of the Board's Orden entered in its minutes for this date: � Dated / 4001 CULLEN, CLERK, By Deputy Clerk. WARNI (Gov. code section.913) Subject to certain exceptions,you have only six(6) inontlhs from the date this notice was personally served or deposited in the mail to file a.court acdon on this claim.See Government Code Section 945.6.You may seek the advice of ani attorney.of your choice in connection with this matter. If you want to consult an atton iey,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT Of. .MAILING I declare under penalty of ilei jury that f. 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 N.1artlilez, California., postage fully prepaid a certified copy of this j Board Order and Notice to Claimant, addressed to the claimant asishown above. i I Dated. ��/�`' .��� JOHN CULLEN, CLERK By eputy Clerk. ! j i _..._!...._... I I ' BOARD OF SUPERVISORS OF CONTRA COS'T'A COUIM INSTRUCTIONS TO CLAMUNT j 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 of I the cause of action. A claim relating to any other cause of action shall b--sresented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez,CA 94553. If claim is against a district governed by the Board of-Super-visors, rather than the County, the :name of the District should be filled in. I ). If the claim is against more than one public enti)L,, separate claims must be filed against each. public entity. - - i Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. ■! !!! sun!■!!■!!C!■C C!Qt[ttttN Y[a C C It C!C C QCt!ttt IR I t![!!!!t C t t!1 I tE: Claim By: Reserved for Clerk's filing stamp I jRECEIVED NTRRECEIVED COSTA CE VECOUNTY Against the County of Contra Costa or ) JU.L 2 4 2001 �QA7 JUL 2 o District) CLERK BOARD OF SUPERVISORS (Fill in the name) ). CONTRA COSTA CO. RiS� MANAGEMENT I i The undersigned claimant hereby makes claim against the Count'. of Contra Costa or the above-named district in the sum of$�a(o.ldp and in support of this claim represents as folloRrs: I I 1. When did the damage or injury occur? (Give exact date and hour)on i I I 2. Where did the damage or in' occur? clude g ur3 (In city and county) Pt�R�FW.ck S+Ant 41Q RWEW"rrm �h� C1 or i i 3. How did the damage or injury occur? (Give full details;use extra paper if required) i I 4. What particular act or omission on the part of county or district officers, se amts, or employees caused the injury or damage? ?N t fa Q& C.pp\�W14ans,� % �,,p�'d ��� WA et/c C.o�►�ss4� 5 What are the names of county or district officers,sen�ants, or employees causing the damage or injury? j i j I i What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 1. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) S. Names.and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TWE AMOUNT ■ aa aaaas[assasaaaall aassign atBills aalaaa■saaa■aasaads aaaaaaits■sslaaaaaaaaaaaaaaaflsaa8a ) .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 ) (Claimant's Signature) } (Address) ) Telephone No. )Telephone No. 510 "199-_MX9 I a,aaaaaa[aftfllftsaw mug aits ia *SEE aaaaaaaa■asalaassigns■alaaaataaaatafaalalssag saaafaaal 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, ss 6500 et seq. ) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records , are also subject to public disclosure. a a s a a a a a a a t a a■a a f a a s s t a s a ■ MEN a a a a a a a t a a a a a t a a a was MWEERVERR Sam 111119115 a IN a a a it a a am it an Nora a NOTICE: a Section 173 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 count�,, 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. I I i SERVICE ORDER 2502—A 1.0487 DEALER CUSTOPAER'S NAME AND ADDRESS DATE&TIME '!DED AUTOTECH. INC . HERBEF:T/L ; 7/i)I TA I 0 (,)7 WARRANTY APPLIES i? . TO THE FOLLOWING DBA HONEST--1 AUTO O CARE 1810 PHEASANT DR 08:41 ITEMS AS CHECKED 65 ) FAR.F..ER AVE. RODEO .CA 94572 HERCULES CA WRITTEN BY (CI(y :) 245 _.?475 TUNE-UP/EMISSIONy4L ? - SHOF B.A.t . NUMBER AC2.48418 I (51(--) .) 799-2119 EST COMPLETION ❑ 12 MO./12,000 MI. E.F.A. NUMBER CALL C)C)144517 I /r i� BRAKE OVERHAUL !VEHICLE LICENSE NO. ODOMETER VEHICLE DESCRIPTION VEHICLE IDENTIFICATION c, i?5.(-)0 ❑ 24 MO./241000 MI. �FLB889 y8. 784 9'?TOY CAMR.Y. . ❑ DELIVER BRAKE SERVICE PAYMENT METHOD ❑VISA/MC CREDIT CARD NO. CREDIT AUTHORIZATION I WILL CALL ❑ 12 M0.112,000 MI: ❑OTHERI 1❑ PHONE WHEEL ALIGNMENT p p % • WHEN READY ❑ 12 M0./12,000 MI. _HECk.. FOR .CAUSE OF NOISE jAND VIBRATION WHEN A/C TURNED PREPARED BY AIR CONDITIONING CIN. CUSTOMER DROVE OVER DUMP I SHOP ❑ 4 MO./4,000 MI. CERTIFIED BY OTHER PARTS/SERVICE SAUL ❑ 4 MO./4,000 MI. (.)a 1 DIAGNOSTIC: LABOR I .i;(j D FOUND RADIATOR COOLING FAN SHROUD BROf:'.EN AND A/C CONDENSOR FAN BLADES BROF'Et�l FARTS WERE JARRED FOR HITING BUMF' HARD. : 009 1 16711-2(-)(--5(:) FAN SHROUD 5_i.77 48.C i() i)( 9 1 1 6361-2003C))3i) FAN BLADE ASS _ '75.96 48.(--)(-) I I I . CUSTOMER REQUESTED ED RETIIRPJED PARTS [.]YES: J NO 4;W.,,:n51���,q�',' •,f- ' 0 D 0 .;,.�••,r,,;��., _ 1,lhe registered owner,authorize you to perform the above LABOR 144.()(i repairs and turnish necessary materials.I understand any — cost quoted heretofore is an estimaie only. your PARTS .131 .73 + employeos may operate vehicle for inspection. testing, . delivery at my risk.you will riot be responsible for loss or - SALES TAX I0.R7 damnoe to vehicle or articles left in it. I agree to pay reasonable storage on vehicle left more than 48 hours after GASOLINE notification that repairs are completed. An express Mechanic's Lien is acknowledged on above vehicle to >ir 4xec.R:..•'� ; e .d; _ ' secure the amount of repairs thereto•including those from ' • .1 '`''`"'':''`. ' F. 0 0 ' ,� f r any prior work.or repair contract on this vehicle. Ir. the aTIRES RF LF RR LR -SPARE `t event an attorney is retained to foreclose this lien or to bring suit for collection of any sums due, I agree to pay T PEA costs of. collection and any reasonable attorney fees. Fjeceipt of a copy of this order is herebv ac!cnowledged' PSI SUBLET CUSTOMER'.S SIGNATURE BRAKES-F BRAKES-R I DEPOSIT ( ,l)() ) BATTERY I *;. �••. ' ALL PARTS ARE NEW UNLESS SPECIFIED.OTHERWISE i COOLANT I 4 =, Mt, y 2196.60 PARTS L.ABiiR i IOT.aL INCL GATE TIN',E c TAY ❑ IN PERSON I ACKNOWLEDGE N01ICE'.AND ORAL APPROVAL OF AN INCREgISE IN THE ORIGINAL ESTIMATE PRICE. REVISED 1 1 .'�3 .14 4.(.)(_l 286.r>(i i 17/(?C 1 q.3() [X! BY PHONE ESTIMATE BY � � .AUTHORIZED BY CUSTOMER, PHONE N& � SAUL_ LAR I TA 79921 19 o. NOTE:Time and mileage warranties are based on whichever occurs first.Warranty is for ali installed p r acid labor against defects-and failure, our shop only.-Void if owner/operator abuse is evident.Void where owner supplied or used parts are utilized. IS, 2CC7 .1 Pee area u&ew tfw damage u w done ta m*taut J auku avemw d San J afi&Quemw Prow a Bump in the wad-.1 Pee otxeet uww paced and eeY"except t"W6 6ump.aha no.oign uraw put out ta watt$out kn the in tfee wad. J hanA 2jou, Rau4ita 33(vdw t I SI C Yheaoant DW e .3Ezccu,Peo,ea 94547 Noone: 510 799-2119 Ww&: 51C 643-SC96 CONTRA COSTA COUNTY RECEIVED JUL 2 0 2007 RISK MANAGEMENT CLAIM 130ARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 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 i ) The copy of this document mailed to California Government Codes. ) you is your•Inotice of the action taken on your claim by the Board of Super-vis61-s. (Paragraph IV below), �: given Purs JUL uant to Government Code �% g AMOUNT: $3,000.00 Section 913 and 915.4. Please note all COUNTY cr•- "Warnings'I'. MARTINET . ... . . CLAIMANT: JOSE ROBLES j ATTORNEY: [MOWN DATE RECEIVED: JULY 26, 2007 ADDRESS: 4041 JOAN AVENUE ' BY DELIVERY TO CLERK ON: JULY 26, 2007 CONCORD, CA 94521 j HAND DELIVERED BY BY MAIL POSTMARKED: ONE HOUR DELIVERY SERVICE FROM: Clerk of the Board of Supervisors TO: County Counsel Attached isa.copy of the above-noted claim. JOHN CULLEN, G erk Dated: JULY 26; 2007 By: Deputy iI. FROM.: County'Counsel TO: Clerk of the Board of Su er•visors (-l-'This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for-15 days (Section 910.8). .j ( ) 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•: I I ' i i -7- — Dated: Z& By: Deputy County Counsel I ill... FROM.: Clerk of the Board TO: County Counsel (1) County Adininisti-ator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911-3). IV. OARD ORDER: By unanimous vote of the Supervisors pr-esent:� (► This Claim is rejected in full. ( ) Other: I ' I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. i i Date / ��.x)HN CULLEN, CLERK, By Deputy Clerk WARNL (Gov. code section 913) Subject to certain exceptions,you have only six(6) i.nouths from the date oris 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 adviee of aii attoiiiey of your choice in connection widn this matter. If you want to consult an attorney,you should do so inninediately. *ForAdditional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I ani 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 IVtartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimnn.t ns] shown above. Dated:�r �a.o JOHN CULLEN, CLERK By Deputy Clerk I j j I I BOARD OAPERVISORS OF CONTRA COS4k_-OUNTY INSTRUCTIONS TO CLAIMANT 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 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.) I B. Claims must be filed with the Clerk bf 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. I 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 sof this form. ! ■■������������������������������������������������������������������em"M now 0r0k RE: Claim By: Reserved for Clerk Is filing stamp Jose Robles ) RECEIVED Against the County of Contra Costa or ) J U L 2 .61 2001 District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONrRACOSr4co. i I I The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$3,000.00 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) j February 2, 2007, at 7:02am. 2. Where did the damage or injury occur? (Include city and county) j I John Muir Medical Center, Concord Campus, 2540 East. Street, Concord, CA 3. How did the damage or injury occur? (Give full details; use extra papier if required) See attached insert. I 4. What particular act or omission on the part of county or district officers, servants; or employees caused the injury or damage? j See attached insert. I 5 What are the names of county or district officers. servants, or employLs causing the damage or injury'? Identity of the advice nurse is unknown at this time. I I i 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ' Death of Angelica Robles. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Wrongful death of 4-year old child. Damages are based upon loss of .love, comfort, society and future support. 8. Names and addresses of witnesses, doctors, and hospitals: John Muir Medical Center, Concord Campus,. 2540 East Street, Concord, CA. Autopsy performed by Arnold Josselon, M.D. , Forensic Pathologist. 9. List the expenditures you made on account of this accident or injury: DATE TIME, AMOUNT 2/5 — 2[9-10-7 $3,352.59 Ouimet Brothers Chapel 2/9/07 $3,81315.63 —( Olivet Memorial Park Cemetery Gov. Code Sec. 910.2 provides "The I laim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) 8r l (Claimant's Signature) 041 Joan Ave. (Address) )Concord, CA 94521 Telephone No. ) Telephone No. (925) 497-3552 ■..................0a00EM...........r......MEN0nor...■................... ..0mmomm...i PUBLIC RECORDS NOTICE: I 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. NOTICE: Section 72 of the Penal Code provides.- Every rovider: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 isame 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 thanone 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. INSERT 3. Angelica Robles, 4 years old, died on February 2, 2007, after, suffering from diarrhea and vomiting during the preceding two days. Jose Robles is the child's father and heir. INSERT 4. Claimants are members of Contra Costa County Health Plan. They contacted the advice nurse at Contra Costa Regional Medical Center on several occasions during the two days prior to the death of Angelica. Nichol Rocha described Angelica's worsening symptoms in detail alild wanted to bring Angelica to the emergency room. However, on each occasion, the advice nurse told Nichol Rocha not to bring Angelica to the emergency room or to call 911. Nichol Rocha relied on that advice until Angelica became completely unresponsive and stopped breathing. The response of the advice nurse who spoke to Nichol Rocha was below the standard of care and was relied upon by Nichol Rocha resulting in the decedent not receiving proper medical care, and thereby, causing her death. I.CLAIM ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against.the County, or District Governed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TD CLAIMANT and Board Action. All Secfibn"references are to ) The`copy of this document mailed to California Government Codes. you is your nonce of the action taken on your claim1by the Board of . � Supervisors. (Paragraph IV below), given Pursuant to Government Code j JUL 2 b 2007 - Section 913 and 915.4. Please note all i AMOUNT: UNKNOWN I "Warnings" I COUNTY COUNSEL g MARTINEZ CALIF, CLAIMANT: LINDA ANN, DRYER-: I j ATTORNEY: UNKNOWN.' DATE RECEIVED: I JULY 26, .2007 ADDRESS: . 832 BROWN STREET. BY DELIVERY TO CLERK ON: JULY 26, 2007 MARTINEZ, CA:.94.553 BY MAIL POSTMARKED: JULY 25, 2007 .4 I FROM: Clerk of the Board of Supervisors j TO: County Counsel ii Attached is a.copy of the above-noted claim. JOHN CULLEN, Cle'. i Dated: JULY .26; ..2007. .': _ By: Deputy 11. PROM.: County Counsel TO: Clerk of the Board of supervis rs ("",61iis 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 9.1. 1.3). 'I ( ) i Other: I' i Dated: .a 07 By: Deputy County Counsel i 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). I.V. BOARD.ORDER: By unanimous vote of the Supervisors present: I (, This Claim is rejected in full.. ( ) Other- j I [ certify that this is a true and coirect copy of the Board's Order entered in its minutes for j this date: I I Date CULLEN, CLERK, By Deputy Clerk WARNi. (Gov. code section.913) Subject to certain except" is,you Have otiiy six(� i�tontlrs fivm file date thislnotice was personally served or deposited in the mail to the a court action on this claim.See Government Code Section 945.6.You may seek the advice of an uttomey ofyour.choice Ili Connection With this matter. tl'you want to consult an attorney,you should do so immediately. *For Additimal Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING [ declare under penalty of pet jury that 1.. aur now, and at all times herein mentioned, hstve beena 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 clainran.t as shown above. i i Dated JOHN CULLEN, CLERK ByDeputy Clerk I I i _- -. ..... ........ ......_ -_. . .. _ _-.._... ................_.. . .._.. ......-.. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIlYIANT 7 1 A., A claim relating to a cause of action far death or for injury to person or to personal property or 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.) 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 945 53. 1 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. 1 D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. i E. Fraud. See penalty for fraudulent claims,Penal Code Sec.72.at the end of this form. . I ■a a KNERENERMERIER MR Kum S a a a■a a■a Rungs t a a r/l a a t a a a a Q MMMURNINKIREMI a a n a a l a I a a I t a l RE; Claim By: Reserved for Clerk's filing stamp L/N p6 AA N ) RECEIVEDi Against the County of Contra Costa or ) JUL 2 6 20071 1 CLERK BOARD OF SUPERVISORS District) CONTRA COSTA CO.i (Fill in the name) ) I I I The undersigned claimant hereby makes claim against the County of Contra Costa I r the above-named district in the sum of$STD / P�2/ and in support of this claim represents as follows: ESTIMATE f-7TAC//457b� R�NTi`hC- CFFi� 1. When did the damage or injury occur? (Give exact date and hour) 2o0 '7 a7-.'3o 2. Where did the damage or iriJ 'occur? (Include city and count y) i y tv/4)/ S7-op //V 4 Ro wn/ •5T * P Nc 6 MART nIEz, coal/mo C�OSTn eCo)TX 3. How did the damage or injury occur? (Give full details;use extra paper if rlequired) 4. What'particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 14,19 1A,u leE T STo P .#7- :5-r p S/GN 1-- AMI 7- lgls 7-VR-V. 5 What are the names of county or district officers,servants, or employees causing the damage or injury? T19U 1... M w-i• 6A-A . S7WT&D HCWoRl�s /4T s 7'ie e-r fr-r-roreiv�}�s oFFre >N MAP-riv&. 1 6. `What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach-two estimates for auto damage.) j No /NiU�R_/�S C�i4in��D, DRMP9UE'S To My L'flR ,95 �/c Td✓a to tTN /4'I'Tr4cHp-ts 5S r/M ►'t'T&. /�o p y �t�j° S j9 D U9,� t,��U DR . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) EST/MtTE� P2ovIDED 0 CiAlTy 19,0R2oV6-b Homo "Cop/dy 9 4T . //R ex7-t _ C� qte. foto V/DEZ If S w�G L . 8. Names and addresses of witnesses,doctors, and hospitals: Al y DALtGNT.R 6v/4-S A4 p/g65EN6-EFR- ' ,4,(V Z)A/fir- So/Z&N,4, /.73 L/#c7 e a r/q 9. List the expenditures you made on account of this accident or injury: DATE TIlylE AMOUNT ! Ru7'o /&P '2S 0 2VTI4� � To cue �r5/Y/�+6MT �T`riJ; SHft�eo�/oFFvRA 335-/yy� . .■■.MIR Sol Ina ass■.■■■a..■.. .■Ian aaaSZEasat■ass amaa■Eno Soso ta■..■.a a t a.a ■a s am a I a a aa■■1 I .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." J SEND NOTICES TO: (Attbmeyl 1 j Name and address of Attorney ) (Claimant's Signature) (Address C>� q g", s3 Telephone No. )Telephone No. ............a..■......■... ......■.a........■a..aa.....■............ ................. 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 etiseq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. .........a.........a...■a ■Ago a..a...aa..a..mug a...aa..■Its....aa.a.aa.... a.aaaaaa..at NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents far 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. 11i G/NDf� !�f I f}SCf1 ME To ff SToI�° Cv_&Si/3ouN�D_�1 �,ec�wN ST 7-X1-_V_�4&b TTD-t4 /NT�?s�GToff. 6.4-N ST-/,, ND- s ft/n1 Y 7-7-fE /&8 CT W I.9's O/ll Y�D g k V 2 51 D_ i 142_T_ e.7"e-_�i4N�� �t_f TO;C eiA P_f �2 �l_9-�`>_G�.5_Ti+�l_TS G_v��� Gi V cN -:; I j C gR 131 = Co14(ti i -- P,-N�s -- o —' STciP I � I t I ory Date: 6/20/2007 02:26 PM Estimate ID: 5016 Estimate Version: 0 Preliminary Profile ID: CUSTOMIZED PRECISION PAINTA COLLISION 1932 ARNOLD INDUSTRIAL PLACE,CONCORD,CA 94520 (925)609-8595 Fax: (925)609.8407 BAR M AJ112956 EPA#: CAD981388739 Damage Assessed By: Frank Mercado Payer: Customer Deductible: 0.00 Claim Number. 5012 Owner: LINDA ANN DRYER Address: 832 BROWN STREET,MARTINEZ,CA 94553 Telephone: Home Phone: (925)229-1454 Mitchell Service: 916723 Description: 2006 Hyundai Elantra GLS Vehicle Production Date: 11/05 Body Style: 4D Sed Drive Train: 2.01-Inj 4 Cy!5M FWD VIN: KMHDN46D86U236963 License: 5VYK248 CA Mileage: 7,852 OEMIALT: O Search Code: B316636 Color: BURGANDY Options: AIR CONDITIONING,POWER WINDOWS,POWER DOOR LOCKS Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 600958 REF BLEND L REAR DOOR OUTSIDE C 0.8 2 601902 BDY REMOVE/INSTALL L REAR DOOR MOULDING 0.3 3 600972 BDY REMOVEnNSTALL L REAR OTR BELT MOULDING 0.3 4 600988 BDY REMOVE/INSTALL L REAR DOOR TRIM PANEL I INC 5 601024 BDY REMOVE[INSTALL L REAR OTR DOOR HANDLE 1.3 # 6 601180 BDY REMOVE/REPLACE ADD TO R8d BACK GLASS 0.3 7 601937 BDY REMOVEIREPLACE L QUARTER OUTER PANEL - ---- 2DA10 471.09 14.0 # 8 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 2.0 9 AUTO REF REFINISH L QUARTER PANEL EDGE C 0.5 10 AUTO REF REFINISH L ADD FOR PILLAR C 0.5 11 601186 BDY REMOVEIREPLACE L QUARTER VENT GRILLE 97510-38010 21.38 INC # 12 603055 BDY REMOVEIREPLACE L QUARTER SPLASH SHIELD 86821-21)500 10.97 INC 13 602419 BDY REPAIR REAR BODY PANEL Existing 3.0'# 14 AUTO REF REFINISH REAR BODY PANEL C 1.1 15 601363 BDY REMOVE/REPLACE L REAR BODY SIDE PANEL 65531-213010 49.30 2.0 16 602436 BDY REMOVEIREPLACE L REAR COMBINATION LAMP LENS&HOUSING 92411-21)550 136.08 INC 17 AUTO BDY OVERHAUL REAR BUMPER ASSY I 0.6 # 18 602423 BDY REMOVE/REPLACE REAR BUMPER COVER ORDER FROM DEALER 291.02 INC # 19 AUTO REF REFINISH REAR BUMPER COVER I C 2.4 20 601411 BDY REMOVEIREPLACE R REAR UPR BUMPER MOUNTING BRACKET 86681-20000 1.77 INC 21 601412 BDY REMOVEIREPLACE L REAR UPR BUMPER MOUNTING BRACKET 86681-213000 1.77 INC 22 602027 BDY REMOVE/REPLACE REAR BUMPER IMPACT BAR 86631-26000 237.03 INC 23 933006 FRM ADD'L OPR FRAMEIRACK SET UP 1.5• 24 AUTO REF ADD'L OPR CLEAR COAT 2.1 25 933003 REF ADD'L OPR TINT COLOR 0.5' 26 933018 REF ADD'L OPR MASK FOR OVERSPRAY 5.00' 0.2' ESTIMATE RECALL NUMBER: 6/20/200714:26:50 5016 UltraMate is a Trademark of Mitchell International Mitchell Data Version: APR_07_A Copyright(C)1994-2005 Mitchell International Page 1 of 2 UltraMate Version: 6.0.022 All Rights Reserved 14 Copy y � Date: 6/2012007 02:26 PM Estimate ID: 5016 Estimate Version: 0 Preliminary Profiie ID: CUSTOMIZED 27 AUTO ADD'L COST PAINT/MATERIALS 237.60' 28 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00' *-Judgment Item #-Labor Note Applies C -Included in Clear Coat Calc Add'i Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals IL Part Replacement Summary Amount Body 21.8 50.00 0.00 0.00 17090.00 Taxable Parts 1,220A1 Refinish 10.1 50.00 5.00 0.00 510.00 Sales Tax @ 8.250% 100.68 Frame 1.5 50.00 0.00 0.00 75.00 Total Replacement Parts Amount 1,321.09 Non-Taxable Labor 1,675.00 Labor Summary 33.4 1,675.00 I 111. Additional Costs Amount IV. Adjustments I Amount Taxable Costs 240.60 Insurance Deductible 0.00 Sales Tax @ 8.250% 19.85 Customer Responsibility 0.00 Total Additional Costs 260.45 I. Total Labor. 1,675.00 11. Total Replacement Parts: 1,321.09 III. Total Additionallcosts: 260.45 Gross Total: 3,256.54 IV. Total Adjustments: 0.00 Net Total: 3,256.54 This is a preliminary estimate. Additional chancres to the estimate may be required for the actual repair. Insurance Co: CONTRA COSTA COUNTY RISK MANAGEMET ESTIMATE RECALL NUMBER: 6120/200714:26:50 5016 UltraMate is a Trademark of Mitchell International Mitchell Data Version: APR_07_A Copyright(C)1994-2005 Mitchell International Page 2 of 2 UltraMate Version: 6.0.022 All Rights Reserved E n fe rp" r ie CUSTOMER COPY PAGE I o 23CCASPR s i-soo rent-a-car 2 ,%JER6FVEHICLE: 'J ZANCH ADDRESS: Sri N1 RENTAL SOURCE# I.D.4 TYPE RENTER 7 _fir file ti:i:; _ FIT CHARGES IF DIFFERENT 4 ------------ ORIGINAL VEHICLE COLOR LICENSE NO. MODEL ECAR# % MILE- IN BILL COMPANY TO AGE —=----..... ATTN: PHONE EXT [wT EMPLOYEE# W REFERENCE NUMBER: CONDMONAGR x. nn RENTER I ADDITIONAL AUTHORIZED DRIVER(S) EXCEPT AS REQUIRED BY LAW,NONE PERMITTED WITHOUT OWNERS 0 WRITTEN APPROVAL I REQUEST OWNEITS PERMISSION TO ALLOW QQ _.° j�' LL WHO IS UNDER MY CONTROL AND DIRECTION TO DRIVE VEHICLE FOR ME AND ON MY BEHALF.I AM RESPONSIBLE FOR THEIR ACTS WHILE THEY ARE DRIVING,AND FOR FULFILLING TERMS AND CONDITIONS OF THIS RENTAL AGREEMENT(AGREEMENT).USE OF VEHICLE BY AN UNAUTHORIZED DRIVER WILL AFFECT M LIABILITY AND RIGHTS UNDER THIS AGREEMENT. O R X=DENT -'SCRATCH PERMISSION GRANTED TO OPERATE VEHICLE ONLY IN THE STATE OF RENTAL AND I )UT E 118 114 3/8 1/2 518 314 718 F THE FOLLOWING STATE(S): No rl n'js .4 E lffl IM 318 la 518 3/4 M F OPERATION IN ANY OTHER STATE OR COUM RY WILL AFFECT YOUR LIABILITY AND RIGHTS UNDER THIS AGREEMENT RENTER DECLINES OPTIONAL DAMAGE RENTER ACCEPTS OPTIONAL DAMAGE NMAGE WAIVER NOTICE WAfVEFt(DW)AND ASSUMES DAMAGE WAIVER(DW)AT FEE SHOWN IN COL- RENTER,X. E_NTER ACKNOWLEDGES RESPONSIBILITY.SEE PAGE Z PARAGRAPH UMN TO RIGHT.SEE DW NOTICE TO —------- 6. LEFTAND PAGE 3.PARAGRAPH 1&OW Is NOT[Ns� E_CEIPT OF ORAL DIS- Is -OSURE THAT DAMAGE RENTER;X I .... 7 - AIVER MAYBE DUPLICA- RENTER DECLINES ovnomAL PERSONAL RENTER ACCEPTS OPTIONAL PERSONAL ACCIDENT INSURANCE(PAI� ACCIDENT INSURANCE(PAI)AT FEE RENTER:x __---- VE OF COVERAGE MAIN- SHOWN IN COLUMN TO RIGHT.SEE PACE UNED UNDER HIS OR 3.PARAGRAPH Ill . , _ER OWN POLICY OF :ti 2 OTOR VEHICLE INSUR- RENTER DECLINES OPTIONAL SUPPLEMENTAL RENTER Aum OPTIONAL SUPPLE- LlABIJJTY PROTECTION(SUP).SEE PAGE Z MENTAL LIABUM PROTECTION(SLP) RENTER.X 4CE. THE PURCHASE OF PARAGRAPH 7. A AT FEE SHOWN IN COLUMN TO RIGHT_ p SEE PAGE 3.PARAGRAPH 17. I\MAGE WAIVER IS RENTER _ ............ PTIONAL AND MAY BE ACKNOWLEDGMENT OF THE ENTIRE AGREEMENT, WHICH CONSISTS OF PAGES I THROUGH 4. M-CLINED. I HAVE READ AND AGREE TO THE TERMS AND CONDrrIONS ON PAGES I THROUGH 4 OF THIS AGREEMENT AND BY MY SIGNATURE BELOW I Am THE"RENTER'UNDER THIS AGREEMENT.BY SIGNING BELOW,I AM AU'rHORIZING OWNER TO PROCESS CHARGES ON MY CREDIT CARD(S)AND/OR DEBIT CARD(S)FOR ADVANCE DEPOSITS.INCREMENTAL AUTHORIZATIONSIDEPOSITS,AND CHARGES INCURRED,AS WELL AS PAYMENTS REFUSED BY A THIRD PARTY TO WHOM BILLING WAS DIRECTED.I CERTIFY THAT THE DRIVERS ENTER: LICENSES)PRESENTED IS CURRENTLY VAUD AND 93 NOT SUSPENDED,EXPIRED,REVOKED,CANCELLED En OR SURRENDERED. REPLACEMENT VEHICLE DATE A 0 OWNER EMPL. E T T REP X' It COLOR LICENSE NO. I WILL RETURN CAR BY: DEPOSIT(S): DATE TIME AMOUNT PAID BY MODEL ECAR# MILE- IN AGE OUT ADDITIONAL INFORMATIONI EMPLOYIEE# CONDITIONAGREED TO x TOTAL CHARGES RENTER 0 DEPOSITS 0 REFUNDS 0 ff BY 0 u 0 BY CLOSED 7!E PAID CASH I CHECK I CHAR( )UT E 1/8 114 318 112 5/8 314 7/8 F Nk) 1:_�3 ­n.zo ­sn' 1EIMOF I DATE I AMOUNT IRECEIVED 4 E 118 114 318 12 518 314 710 F CASH REFUND i I I I CL 3 _ I Cy I cr o C5 d wU rte- ct� ul c t La p LU OM 00 !' Ct X w I I , i 11 E �N f l� 1 I I 1 VN O i cf) O t- R s U)w ,Y CLAIM i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 14, 2007 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endoi:sements ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes.. D t? )jam01'11 you is your, notice of the.action taken �aon your claim.by the Board of UL 2 6 2007 Supervisors. (Paragraph IV below), given-Pursuant to Government Code AMOUNT: $3,000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings', CLAIMANT: NICHOL ROCHA ATTORNEY: LINnOWN DATE RECEIVED ' 26, 2007 • I ADDRESS: 4041 JOAN AVENUE BY DELIVERY TO CLERK ON: JULY 26, 2007 CONCORD, CA 94521 HAND DELIVERED BY BY MAIL POSTMARKED: ONE HOUR DZLTVERY SERVICE FROM: Clerk of the Board of Supervisors TO: County Counsel', Attached is a copy of the above-noted claim. JOHN CULLEN, eti Dated: JULY 26; 2007 By: Deputy i1. FROM.: County'Counsel T0: Clerk of the Board of Supervisor's ( This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should retum 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). i ( ) Other: Dated: -7 - a &- 0 -7 By: /V (.� ewe Deputy County Counsel III.. FROM: Clerk of tine Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.;3). (1V. B ARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: / 4�0,4014N CULLEN, CLERK, By Deputy Clerk WARNi. G (Gov. code section 913) Subject to certain exceptions,you have only six(6) months fi-om the date this notice was personally served or deposited in the mail to file a court acdon on this claim..See Government Code Section 945.6.You may seek the advice of an attortrey of your choice in connection wide this matter. If'yoti want to consult an attorney,you should do so itnmedlately. *For Additional Warming See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i ani now, and at all tithes herein mentioned, have been a citizen of the United States, over age 1.8; and that today I deposited in the United States Postal Service in N..tartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: -JOHN CULLEN, CLERK By v Deputy Clerk r This warning does not apply to claims which are not subject to the California Tort Claims Act such as.actions In inverse condemnation, actions for.specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustiveand legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be tiled may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra'Costa does not waive any of its rights under California Tort Claims Act nor,cloes.it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act .'" `• tib.,i ,� .:� �::=�'+:; moi:� .T.l.,};.;.• : .,;y�y•j ' i BOARD OF*PERVISORS OF CONTRA COS7*O1NTY INSTRUCTIONS TO CLAIMANT 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 laccrual 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.) i 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. i i 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. WON MENOREENRMENEONE0noRon No MOWN 0.0MENI RE: Claim By: Reserved for Clerk's fling stamp Nichol Rocha ) RECEIVED Against the County of Contra Costa or ) JUL 2 6 2007 1. District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA CO! i The undersigned claimant-hereby makes claim against the County of Contra Costa or the above-named district in the sum of$3,000.00 and in support of this claim represents as follows: i 1. When did the damage or injury occur? (Give.exact date and hour) February 2, 2007, at 7:02am. i i 2, Where did the damage or injury occur? (Include city and county) John Muir Medical Center, Concord Campus, 2540 East Street,! Concord, CA 3. How did the damaize or injury occur? (Give full details; use extra paper if required) See attached insert. . 4. What particular act or omission on the part of county or district officers, servants; or employees caused the injury or damage? Seeattached insert. 5 What are the names of countyor district officers. servants, or employees causing the damage or injury? Identity of the advice nurse is unknown at this time. i 6. What damage or injuries .do your claim resulted? (Give full extent of injuries or damages claimed.. Attach two estimates for auto damage.) I Death of Angelica Robles. i I 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Wrongful death of 4—year old child. Damages are based upon loss of love, comfort, society and future support. 8. Names and addresses of witnesses, doctors, and hospitals: John Muir Medical Center, Concord Campus, 254.0 East Street, Concord, CA. Autopsy performed by Arnold Josselon, M.D. , Forensic Path logist. 9. List the expenditures you made on account of this accident or injury: DATE TIME, AMOUNT 2/5 — 2/9/07 $32352.59 Ouimet Brothers Chapel 2/9/07 $3,835.63 —,' Olivet Memorial Park ■......s...■r...............................................■■...i.....MEE=am.....no,Cemetery I 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 ) (Claimant's Signature) 4041 Joan Ave. (Address) Concord, CA 94521 Telephone No. ) Telephone No. (925) 497-3552 j I ....................NONE a E.........................................:...... ■ME a w o\...■1 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 iseq.) Furthermore, any attachments, addendums, or supplements attached to the clai n form, including medical records, are also subject to public disclosure. 0 a 0 a a 0 0 a a a a so 0 0 0 a a a a a 0 0 a a a a 0 0 0 0 a a 0 a a 5 0 a 0 0 a 0 a 0 a a a 0 a 0 0 a a a a a a 0 0 0 0 NOT 0 0 0 0 0 a 0 a 0 0 a 0 0 0 a a NOTICE: Section 72 of the Penal Code provides: Ever), person who, with intent to defraud, presents for allowance or forpayment 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; allyfalse 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. ly i I I i • I INSERT 3. Angelica Robles, 4 years old, died on February 2, 2007, after suffering from diarrhea and vomiting during the preceding two days. Nichol Rocha is the child's mother and heir. I i I y INSERT 4. Claimants are members of Contra Costa County Health Plan. They contacted the advice nurse at Contra Costa Regional Medical Center on several occasions during the two days prior to the death of Angelica. Nichol Rocha, decedent's mother, described Angelica's worsening symptoms in detail and wanted to bring Angelica to the emergency room. However, on each occasion, the advice nurse told Nichol Rocha not to bring Angelica to the emergency room or to call 911. Nichol Rocha relied on that advice until Angelica became completely unresponsive and stopped breathing. The response of the advice nurse who spoke to Nichol Rocha was below the standard of care and was relied upon by Nichol Rocha which resulted in the decedent not receiving proper medical care. I . I I I I i I I I I I i I I I I I AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA.COUNTY BOARD ACTION: AUGUST 14, 2007 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. rejra, rT you is your notice of the action taken l on your claim by the Board of JUL ] g �` Supervisors. (Paragraph IV below), 2007 given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: $12,075.49 MARTINEZ CALIF. "Warnings". CALIFORNIA STATE AUTOMOBILE ASSO. CLAi.MANT: FOR VIRGINIA McKELVIE BY: KIMBERLY CHAPPELL ATTORNEY: UNKNOWN DATERECEIVED: JULY 12, 2007 ADDRESS: ' P.O. BOX 920 BY DELIVERY TO CLERK ON: JULY 12, 2007 SUISUN CITY, CA 94585-0920 BY MAIL POSTMARKED: I JULY 11, 2007 FROM: Clerk of the Board of Supervisors TO: .County Counsel Attached is a copy of thelabove-noted claim. JOHN CULLEN, C o,I Dated- JULY 12, 2007 By: Deputy ll. FROM: County Counsel TO: Clerk of the Board of Su ervisors (V�4liis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FALLS to comply substantially with Sections 91.0 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 thatlit was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 7"O'� By: Deputy Y t Count Counsel P , _ l .111. FROM.: Clerk ofthe Board TO: County Counsel (l) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 91113.). i.V. J OA.RD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I i certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 4?zWR v CULLEN, CLERK, By .Deputy Clerk WAI.tNI NC (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was petsonally sewed or deposited in the mail to file a covet 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 sliotdtl do so iittittediately. *.Foi•Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING t declare under penalty of per•ur that I am now, and at all times herein mentioned, have i � i � y been a citizen of the United States, over age 18; and that today i. deposited in the United States Postal Service iii Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Mt&0,�DHN CUI_..LEN, C.L.ER.K By Deputy Clerk I This warning.does not apply, to claims which, ; 'are. not subject to the:California '$'ort:Claiuns - Act such as.actions in inverse coidemnatitin, actions for specific reliefsuch as mandamus or. injunction; or Federal Civil Rights claims. The above list is not exhaustive and,legal :constiltation is essential to understand all the eparate limitations periods that: plnja .a , plY` ;. Y The limitations ' p►er�od witl�izi which suit must be tiled 'may be shorter or:longer dependig on the nature of the claim. Consult the,specific ;statutes and cases applealile,to your particular`: claim. Tle.County of Contra Costa does..not,:waveany of its rights antler California:Tort Claims Act: n`or'does it waive ri lits under the statutes of -; ;nu a ons applicable to actions:not'sohject to' the California Tort Claims Act Catifornia State Automobile Association R E C E i VL® /nter-Insurance Bureau JUL 1 2 2007 P.1 0.Box 920 Suisun Citv.CA 94535-0920 CLERK BOARD OF SUPERVISORS July 11, 2007 CONTRA COSTA CO. Salvage Sold! � Clerk of the Board of Supervisors Room 106 County Administration Building 651 Pine Street Martinez,CA 94553 RE: Your Insured: driver of Town of Danvile emergency vehicle Scott D. Dickerson Your Claim No.: Our Insured: Virginia Mckelvie Our Claim No.: 01-1 W4184-9 Date of Loss: 05/11/2007 Dear Contra Costa County: This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts, request payment directly to California State Automobile Association Inter-Insurance Bureau (CSAR-IIB): In order to assist with and expedite the evaluation and processing of this subrogation demand,we enclose the relevant documentation in support of our claim. This information may contain personal or privileged information about our insured,and is being provided to you pursuant to California Insurance Code Section 7911.13 and may not be used for any unauthorized purpose. Based upon this information,we ask that you issue payment of$12,075.49 Settlement $16,152.49 Less Salvage $4,811.00 Deductible Waived Loss of Use $377.00 Tow/Storage $357.00 -------------------------- TOTAL ------------------------- TOTAL $12,075.49 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will not constitute a full and final settlement�and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination, unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as"payment in full"or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction,as CSAA has not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CS 's specific agreement to accept an amount less than that demanded in this letter. If you have any questions,please feel free to contact the CSAA Subrogation Department. Sincerely, F268K(Apr 2002) i I I Subrogation Specialist 888-900-6520 extension 6205 Fax 707-863-9052 Enclosure I COPART INC - TIN: 94-2867490 Invoice Date: 06/28/2607 4665 BUSINESS CENTER DR Seller Code: ACRC FAIRFIELD CA 94534-0000 CSAA INSURANCE ATTN: MAIL CENTER P.O. BOX 920 SUISUN CITY SA 94585-0920 Claim#: 0 1-1 W4184-9 Suffix: 01 Loss Date: 05/111/2007 Lot#: 08635157 Vehicle Year: 2003 Yard#: 003 -HAYWARD(CSAA) Make: VOCK Salvage Certificate#: 6533332 Model: PASSAT GI- Color: SILVR i Recovery Date: 00/00/0000 License: 4ZTV 114 Call In Date: 06/01/2007 State: CA P/U Cleared Date: 06/01/2007 VIN#: WVWMD63B33P112518 Pick Up Date: 06/04/2007 Mileage: 0030578 Title Transfer Date: 06/18/2007 Salvage Sale Date: 06/28/2007 ACV: 14818.00 Insured: MCKELVIE, VIRGINIA Registered Owner: MCKELVIE.VIRGINIA I Buyer Name: ART MOBIL,STAR CO.I I'D Pickup From: COOKS COLLISION Address: SHOPRON 2-ND SIDE-ST.5B.A Address: 2700 HOOPER DR. City: YEREVAN City: SAN RAMON State: AM Zip: State: CA Zip:94583- Phone: 0000000000 Phone: 9257434041. Item#: 00001 Salvage Sale Amount: 03577 %of ACV 5300.00 Advance Charges: - 330.00 Tow Fee: 150.00 Storage Fee: 180.00 MISC Fee: 0.00 Gate/Yard Fee: 0.00 Labor Fee: 0.00 Estimate Fee: 0.00 Credit/Refund: 0.00 Tax Fee: 0.00 Copart Charges: - 159.00 Vehicle Evaluation Fee: 0.00 Title Fee: 0.00 PIP Fee: 159.00 Special Transfer Fee: 0.00 Pooling Fee: 0.00 Tow In Fee: 0.00 Tow Out Fee: 0.00 Heave Tow: 0.00 Copart Other Seller Additional Fees: - 0.00 CSAA Advance Pay: 0.00 Adjustment Amount: +/- 0.00 Amount Due Copart: 0.00 Amount Due CSAA: 14811.00 1, tit O ct �c d V C C os its 1 ♦ j N1 7cr- .._ NN 10 co n 5 ss��,dAsJd6 = . n r:. _.s t t L 0 A N cck Q e rn o C O O 0 m � THIRD -- ANI EN DED CLAIM. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: AUGUST 14, 2007 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. ) you is your notice of the action taken ea •— on your claim by the Board of `� � r:•:� Supervisors. (Paragraph 1V below), JUL 2 3 2007 i_:' given Pursuant to Government Code Section 91.3 and 915.4. Please note all AMOUNT: $15, million COUNTY COW:-!; EL "Warnings". MARTINEZ CALIF. CLAIMANT: DANIEL W. AWTHIST AT'I'ORN.EY: UNKNOWN :DATE RECEIVED: JULY 23, 2007 ADDRESS: 2405 SUNNY LANE #7 BY DELIVERY TO CLERK ON: JULY 23, 2007 ANTIOCH, CA 94509 BY MAIL POSTMARKED: HAND RELIVED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JUNE 239 2007 JOHN CULLEN, aer Dated. By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( this claim complies substantially with Sections 9.10 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 cla.iri�ar�t's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: Deputy County Counsel I.I.I. 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. BPA.RD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: e4r ORHN CU:LLEN, CLERK, By Deputy Clerk WARN]WT (Gov. code section 913) Sut�ject 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 uumediately. 'For Additional Warning See.Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that 1 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 Stakes Postal Service in IN'Lartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant is shown above. Dated: __� 60", 1N IN CUI_,L.EN, CLERK By _ eputy Clerk y jI �r�f r - �i This warning does not apple to claims which are-riot subject to the.Califo� oia Tort,Claims'. Actsuch as:'actions in inverse condemnation;' actions'for'specific relief such as mandamus or injunctions or Federal Civil Rights claims; The above list is not exhaustive and legat Conscdtation is essential to understand all" the " ;`separate limitations t*riods that,may apply; T' . - he itati'ons period within:which suit must g be filed may he shorter ar longer epen �n o" '; the nature of the clam Consult the specific statutes and cases applicable.to.your particular claim. The County of Contra Costa does not:wave any. : . of its rights under Califo -inia:Trim Claims:Act` nor does it waive rights under the statutes of i"'.`limi"tations.applicable to actions; not subject to the California Tort Claims Act r-3c n-yz� CO 07 V� -- �-0-7-t h aye BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) 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. I,E: Claim By: Reserved for Clerk's filing stain 1/09 Against the County of Contra Costa or ) LIN �aggo ��U &r Ra) &/yci Fill in a name �Z District) �RCoti gOC csup� sTgc°��sOgS ( ) ) STq CO VASO-is The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$154r, d in support of this claim represents as follows: 1. When did the.. jF..ipa;I:- or occur? (Give exact date an hour) 2. Where did tlfe damag or inj occur? (Incl a city d co ) 3. How did'the'dams a or m occur? Give full details; use extra paper if re"uired Wim. .g Jury ( P P q U��'I Il C3L , �- .1.Gi'1��ff���v` �l _-' p�, }'� cX/y�}— �at particular act or o4liss'onon the,�part o county/or distract o cers,`�ervants, yees = '2 alrnvs� C�� 'used the in' Jam'or damage? g r� �•?C.. 7nC.. li'v ',d A�.aCC,���� ��"I l Gl�j� \4A1L4r1q 'J T'gWa 'are Se names of coup or district offices servants, ore to county ts, employees causing the damage or injury? /�72&nt_v Ik hx)4 —" v`Yi, U� 1fix►ULA tl 7 , ale W e 5c_ 6. What damage or injuries do your claim resulted? (Give full extent of In uriesL or damages claimed. Attach two estimates for auto damage.)� Q y4Q�- Id-f -'1 v �-r9-1 '► t r �e �.7Y� 5�'C� How was the amo c d aboveC/computedl; l eest mated amount oi�any prospective injury or damage.) l k a/o /e, /�Si,� •//rI'Jil 5kDa aw?�l 8. Names and addresses o witnesses, doctors, and hospitals ��9. List the expendity;•^ e�n c„Gunt of s acciden��jjmjury: DATL._• z �: 'p ` /� ;'f . h=AMOUNT de Sec. 91 .provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES T0: (Attorney) ) Name and address of Attorney ) f �� ) (Claimant's Signature) Af P-t6fVk .,t 0./1 9 A.0) # vo (Address) Telephone No. �'-) 0 2 ) Telephone No. C �. �.. � f � ■■1 �alse .■. ..■■.............................0 PUBLIC RECORD NOTICE: 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 c#rn form, including medical records, are also subject to public disclosure. ..................is ..�.:. .M:..:S.a�...�. .: .No"%is ....... TICE: 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. Clerk of the Board of Supei-visors Contra John Cullen Comm: Administration BuildingCQSta Clerk of the Board 6 i 1 Pine Street.Room 106 l• and Martinez. California 94553-4068 County County Administrator (925) 335-1900 John Gloin,District 1 Gavle 11. Uilkcmn,District Il . % III N.Picpho,District III Ynciud: Districl I\' Federal 1).GluAcf., District C TO: Daniel W. Amythist 2405 Sunny Lane, #7 Antioch, CA 94509 RE: CLAIM OF DANIEL W. AMYTHIST NOTICE TO CLAIMANT OF 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 July 9, 2007, has been reviewed by County Counsel and is being returned to you herewith because: X Your claim relating to a cause of action for death or for injury to person or to personal property or growing crops was not presented within six months after the event or occurrence as required by law. (See Government Code sections 901 and 911.2.) _ Your claim relating to a cause of action for anything other than injury to person or to personal property or growing crops was not presented within one year after the event or occurrence as required by law. (See Government Code sections 901 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 delay to the Board of Supervisors of Contra Costa County for leave to present a late claim. (See Government Code sections Daniel W. Amythist Re: Claims of Daniel W. Amythist Page Two 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances leave to present a late claim will be granted. (See Government Code section 911.6.) 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: JULY 20, 2007 JOHN CULLEN, Clerk of the Board of Supervisors and County Administrator By: D6putf Clerk Enclosure CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§641, 664) I am a resident of the State of California and over the age of eighteen years, and not a party to the within action. My business address'is Clerk of the Board of Supervisors, 651 Pine Street, Room 106, Martinez, CA 94553. On JULY 20, 2007 , I served a true copy of this Notice to Claimant of Late-Filed Claim by placing the document in a sealed envelope with postage thereon fully prepaid,-in the United States mail at Martinez, California addressed to Daniel W. Amythist, 2405 Sunny Lane, #7,Antioch;CA 94509, as set forth above. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on JULY 20, 2007 -at Martinez, California. Deputy lerk 1:\'I'OR IWSK-MGT\CLAI MS\LATE\Amythist.wpd ' RE DEIVED � I JVL 0. 9 cuui �` -- coNr°"suPERVIs pg ��CO TA IR I id f �I � .i l. j. is .ii• ji i IT�i 11� l I i.l a. SECOND ---AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: JULY 24, 2007 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 Conies. ) you is your notice of the action taken l,t - on your claim by the Board of 1 s I Supervisors. (Paragraph IV below), JU1_ .p J given Pursuant to Government Code ANIOUNT: $15 MILLIONSection 913 and 915.4. Please note all Ci)UNT`c'C-C) 1NSE1_ "Warnings". t}7lfT1Pi :�`�r^tL.11 CLAIMANT: DANIEL W. AMYTHIST ATTORNEY: UNKNOWN DATE RECEIVED: JULY 09, 2007 ADDRESS: 2405 SUNNY LANE #7 BY DELIVERY TO CLERK ON: JULY 09, 2007 ANTIOCH, CA 94509 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JULY 09, 2007 JOHN CULLEN, Cle Dated: By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) '['his claimcomplies 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). OvrClaim 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: �— r 7 By: ��1C.Q&��� Deputy County Counsel HL FROM.: Clerk of the Board TO: County Counsel (1) County Administrator(2) (y/ 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: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) - - •-- .■._r_._.y a..,.J..�..•1■:e r■niV`P WAC nP.1:Cf111AI1V SC11'f'd r ' j i I + I I i I i ! i 1 I it separate 1imitatinnS periods Mat. ay Apply, j The limitations period within wlticp soft most 1 be Merl maY be shorter or.longcr clepeding on ,+ laCfithenatureoftheent cc statutes and eases applicable to.YoUr particular � The County County ot;Contra Costa cloeS not waiYer►y j of its rights itndetr l for. N Tort I P rets t I nAr:c nes if IYe.rightslondpr the st tttt s df �> limitations aplieble to actiaps .not,sttbaect t® i .. the CA in Tort Claims het APPLICATION TO FILE LATE CLAIM ` BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT AUGUST 14, 2007 Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) 1 giytien purs�uaUae o Government Code Sections 911.8 Danda9+1+5.4 note the WARNING below. w Claimant: MARY CONN J U L 13 2007 Attorney: UNKNOWN COUNTY COUNSEL MARTINEZ CALIF Address: 3081 GOLDEN RAIN ROAD #1 WALNUT CREEK, CA 94595-1974 Amount: $4,689.00 By delivery to Clerk on: , ,.IDLY 13, 2007 Date Received: JULY 13, 2007 By mail,postmarked on: July 12, 2007 I. FROM: Clerk of the Board of Supervisors TO: . County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 13, 2007 JOHN CULLEN, Clerk,By: DEPUTY II. FROM: County Counsel TO: Crerk of thejBoar8 of Supervisors > ( ) The Board should grant this Application to File Late Claim (Section 911.6) s (� The Board should deny this Application to File Late Claim (Section 911.6): DATED: I tL 0� SILVANO B.MARCHESI, County Counsel,By: DEPUTY III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) " ( ) This Application Is granted (Section 911.6). This Application to File Late Claim is denied (Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE: HN CUL.LEN, Clerk, By: DEPUTY WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your anycation 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: �V' Zu-0 7- JOHN CULLEN', Clerk,By: DEPUTY V. FROM: (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 1 •jod swivID pol uiuiojjjvD a.qj of loofgns IOU suoilop 01. ajquoijddu. suoilul!wil jo saln4lals aql .zapun sludi.i OATVM-JPsaop,:iou,413V suzllaio 1101 Ptuzojtivo .zapun sig'�i� sji Jo SUL' antlann jou'saop LIsoD 10uu00 jo Xjunoo aqs •uuiljo .ignoiplod.inoS of ajquoijddL, sosuo puu solmuls ogpods oqj linsuoo •uirejo oqj jo a.imuu oql uo 2utpuodop . IOSUOI zo .iopogs oq X7auz .pajg oq isnuz Ims goigm.utTll!m popod suoTlviiuzij oU •Ajddu Suuz jugj spoilad suoijuliuuj op*iudos oqj II P uuls o un u uiluosso si uoijujinsuoo P o� t . 182a uL antjsn� a IOU si Isi ano L, a suut� o i I P � .i g tLI. I sIg2PjinY� j 110pa3 10 `uopounfui jo snuu,,pu,3uz s� eons jaita z ogtoods uoj suoiloe `uoiiuuwapuoo asaanui ut suoilou su gons Iod su ulD pol u uuopluo aql of joafgns IOU alu goigm suiplo of �jddu IOU saop iftiufom sigZ S 1 Y ar�R�- IDs s RECEIVE JUL�1 3 2007 CLERK BOARD OF wi1PE1111 $ D2&115i R 1tq RVA H 74 42 1� � : RECEIVED JIM 1 3 2001 LERK BOARD OF SUPERVISORS An .10 ,, CLAiM BOA11D OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 08, 2007.: 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 ►nailed to California Government Codes. ) you is your notice of the action taken oi1 your claim by the Board of P('718 Supervisors. (Paragraph IV below), given Pursuant to Government Code F.,:y. f Section 913 and 915.4. Please note all AMOUNT: $4,689.00 APR ii 4 Cu,11 .:, "Warnings". ti 03.NTIr CLAIMANT: MARY COHEN sti?FA�T1"°.!r- s'r•'',I IE=, ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 03, 2007 ADDRESS: 3081 GOLDEN RAIN ROAD #1 BY DELIVERY TO CLERK ON: APRIL 03, 2007 WALNUT' CREEK, CA 94595-1974 RECEIVED FROM RISE BY MAIL POSTMARKED: MANAC FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C k Dated: APRIL 03, 2007 . By: Deputyif l� H. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( j 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). (vrClaim is not timely filed. .The Clerk should retum 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: �- ( � '"U By: PJ � 4- Deputy County Counsel V1.11. ROM: Clerk of the Board TO: County Counsel'(]) 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: O This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months finny the date this notice was personally served or deposited in the snail 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 attontey,you should do so immediately. *For Additional Waming See Reverse Side ofTltis 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, Calif-ornia, postage fully prepaid-a certified copy of this Board Order and Notice to Claimant, addressed to the clainnan.t as shown above. Dated:r!/�y7 I& . 'E'd-0 JOHN CULLEN, CLERK Lay -y�—Dehuly Clerk i I , f I I I This warning does not apiply to claims which I are not subject to the Californin TorUClaims Act'such as actions in inverse condemnation, r actions f'or specific relief' such as mandamus or injunction, or Federal Civil Rights claims. The . above list is. not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be flied may be shorter or longer depending.on the nature of the claim. Consult the specific statutes and cases applicable to your partictilar claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statures'ot, limitations applicable to actions not subject to the California Tort Claims Act BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 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.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Count),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. ■a a aUSX MEN aaaaaamaaaa■ aagnus aaaRam asamuzzaalRRago anRaanaREaIRS a�.RaaaaZan noaIna I RE: Claim By: Reserved for Clerk's filing stamp M- The Against the County of Contra Costa or ) 5 District) o (,O I�f D ) (Fill is the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ $1 I.M. o p and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) A?PAOV-itil) - o1I1610(. �DoNis Re CFILd.T�►2 1iouR� 2. Where did the damage or injury occur? (Include city and county) 30`x, COloPA RA;ct Rv t,wR��-r GRee , cfllt�oP,r(iA q 95 X4'1 3. How did the damage or injury occur? (Give full details;use extra paper if required) 014iu- c: ".%4CA �ooG 0" 0059,PADVI a'TI-To A L0641DpLA) CV114%0G AN0), the U-fFJZA'i -'to" l."A&ZAuS►"a9j-J44&ta1NC A oN2r?ooit, gRioge,Ae4►1f RP vW1VAec*T• i1 DWI LAOT- Oge-p- 4. What'particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? T�kove- R es;os- M oo� RW,5 La,T�4z SLLAYe; u.A tice� A Gwge j _ 5t--0-"I-CM 5 What are the names of county or district officers,servants, or employees causing the damage or injury? , Q,f.A M,�' Re sty W;-rH Se e;,R,TM• PRo o� M LIST t3� i�7 i rt, 6. ` What damage or injuries do your claim resulted? (Give full extent of injuries or damages - -claimed. Attach-two estimates for auto damage,) S i tic e,-i�,e, fi u.�P-e R ( o K,��Y WZP-Q- "LLsHep, PA I-V To HAYe,-V�e- DAwl G-ev-TY-CAp c--tt,°ev)Pg,N,Ol v. zNo�,�eea q PROS- E-Vi-0.91p4e—PhRriMPZKOLF��• 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) #•5,51 b.00 $A7, 00 StX i oR DfSt DU PM S. Names and addresses of witnesses,doctors, and hospitals: A1Q.�4_IdAr10 3017 Tel GAOpH Aye-. #3oo ge.RK�,c�G.�Rrri A 9705 9. List the expenditures you made on account of this accident or injury: DATE TIIviE AMOUNT 5 ob ►JIP. aoo.00 �'li3 N FlA4I ;.00 4 A6S,00(t31�,o0'#9.ao)3TY�.J�G 8 s R ■ r a s a r3��"2i�a�i!r s a a A am ME a a W E ass a a rh/n�)r r r i t Zan an MINE MR as SEX r e an a a a I as as am a a a a no MR BE a a a I�SQV �N1w/N7�• ) -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) 1 Name and address of Attorney ) (Claimant's Signature) ) 3�f�1 �Ot.0�i�1 RAiN R�•�l'l (Address) WAlrtu.T C RPK,C u1 ohrgA 9 b�95— I97� Telephone No. )Telephone No. (q2 ) 935- 6-4b, ■,■aaaaaaaaa■aaaanor Monona aaa■araaaa■ataaaaaaamass ass aEvans aaaaaaaaaaaman aman Eggs Ong&I 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. ■ ■aaaaraaaataaaaaaaaRasa■ ■ MEN aaaaataaaaaaaaaaaraaaarrasaataaaaaaaaaaaaaaaaaaaaa.nasal NOTICE: Section 172 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 County of Contra Costa County Administrators Office Risk Management Division 2530 Arnold Drive, Suite 140 Martinez, California 94553 Phone: 5-1443 Fax 5-8500 Cell: 858-0377 April 2, 2007 TO: Clerk of the Board FROM: Ron Harvey ffkq Risk Manager SUBJECT: Claim of Mary Cohen Please process the claim of Mary Cohen, which is attached. If you have any questions feel free to call me at the above number. J ALEX IVANOFF, D. D. S . 3017 TELEGRAPH AVE #300 BERKELEY, CA 94705 (510) 849-1500 Cohen, Mary Date . . : 03/12/07 3081 Golden Rain Rd #1 Walnut Creek, CA 94595 (925) 935-5492 Tooth Surface Code Description Amount ----------------------------------------------------------------------- 30 F 02391 Resin/Comp 1 Surf Post 156. 00 6 D 02330 Resin-1 Surface Anterior 156. 00 ----------------------------------------------------------------------- Charges this Visit 312 . 00 Plus Prior Account Balance 0 . 00 Less Today' s Payment 0 . 00 Total Balance Due 312 . 00 a�s°o �10� R QF�7 C 4vz cJ CD ce CIA— r� tG c cr C5 o u d � W � cG r, u•o W 1-+ o V +2 -Z W Co CC J 3 "Z o It:7 1 y rn o o C � 7 rn 57- Lo �rna„ t�m pi o Ul 0 10 �s 1 7P r� w APPLICATION TO FILE LATE CLAIM O BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION AUGUST-.14, 2007 Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING"below. 7R,71-;7_1 Claimant: .HOOSBMOND B. HESSAR Vi Attorney: UNKNOWN JUL 2 f 2007 COUNTY COUNSEL 5214 PEBBLE GLEN DRIVE Address: CONCORD, CA 94521 h4ARTINEZ CALIF. Amount: UNKNOWN By delivery to Clerk on: , �_ Y 24, 2007 I Date Received: JULY 24, 2007 By mail, postmarked on: HAND DELIVERED I. FROM: Clerk of the Board of Supervisors TO: . County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: JULY 24, 2007 JOHN CU LLEN, Clerk,By: DEPUTY II. FROM: County Counsel TO: Cler of thejBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6) ( � The Board should deny this Application to File Late Claim (Section 911.6). DATED: -7- .2 Y 67 SILVANO B. MARCHESI, County Counsel,By: DEPUTY III. BOARD ORDER By unanimous vote of Supery?sors present (Check one only) ( ) This Application is granted (Section 911.6). (v1----Tliis 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: / W_N CU.L�L.EN, Clerk, By: DEPUTY WARNING (Gov. Code §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within 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. _ ��" - J01-INCU.L.LEN,Clerk,By: DEPUTY � V. FRO •I: (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 i , i I I i i i i f •13d sLuiujD POJL utuuopluD oql o} loafgns jou suoijou o4 ojquoijddu SuopujuLuq jo sain1uls agj .�apun slgsll OAiuM,- i..SQO .l0~u, ' sLUiu O ulwo J!ILD is Iijl=S� til,\' ' �. P � �v' I .I. 3I � P u .' ti. sj! Jo ATT OAMM IOU scop ulsoD u iluoD jo f4unoD oq jL •Luiujo iujnoipLd.inoA of ajguoijddu sasuo.puu sainjuls ogpods oqj ljnsuoD -wit,jo agj jo ;Dimtu oqj uo Ouipuadap ioguoj jo ioliogs oq Xuw pajg aq jsnw jjns goillm.uiglinn popod suoijullwil oqj, •Xjddu Xuw jugj spopod suoijuliuii alujudos oqj jju puuis opun of jutluossa si uoiluljnsuoo 1u2aj puu ;)Aljsnugxa IOU Sl IS11 anoqu ags, •suitujo a jintD jusapoa io `uopounfui to snLuupuuw su Bons jaija.i ogpods ioj suoiJou `uoijuuuzapuoo as.ianui ui suoijou su gons Iod sunujD poZ uiuuopjuo oqj of loafgns IOU,on, -pull suntlo of �jddt, IOU scop Sumaum sigl i i CO ARp OFS NTRq COS.COV/SpRS - --, ��►� -�-�� � �-�S 53-;-G-lam-_ i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ' INSTRUCTIONS TO CLAIMANT 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 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 § 9l 1.2.) 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. .u................................................................ ............l RE: Claim By: Reserved for Clerk's filing stamp Rec IV I) Against the County of Contra Costa or ) JUL 2 4 LOU/ CLERK 80ARD OF SUP lstrlct) CONTRA COSTA CpViSORS ( ill in the name ) The undersigned claimant 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? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers; servants, or employees caused the injury or damage? C-o NRA 5 What are the names of county or district officers, servants, or employees causing the damage or injury? er/1A �. '6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages - ' claimed. Attach two estimates for auto damage.) o�� � ►w�- r4 �� P - �eli.,; ��/eY 7. ljow was the amount claim�d a ove computed? �Incrude t estimated amount of any prospective injury or damage.) tNIQ �, 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Kk.c) uatv .4 0 NONE mono No Susan MEN mmmum MOONS Nassau am as am mmmummummummm mummummun Mmmummmalm an 60 am mmmmmml ) Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some per on on his f �� ) behalf." �� SEND NOTICES T0. (Attorney) 1 r ��- Name and address of Attorney ) j laimant'.s Signature)- (Address) ) Telephone No. ) Telephone No. �C 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. ■.......o............................................■■......a 0 WOMEN mono 0 MEN M mom....) 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 thestateprison, by a fine of not exceeding ten thousand dollars " ($10,000), or by both such imprisonment and fine.