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MINUTES - 08192008 - C.15
CLAIM HOARD O.F SOPERVI:SORS OE CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) /4rNOTICE TO CLAIMANT and Board Action. All Section references are to ) • The copy of this.document mailed to California Government Codes. ) :you is your notice.of the action taken on your claim by the Board of Dj Supervisors. (Paragraph IV below), JUL 4 2008 -given Pursuant to Government Code AMOUNT: $5,394-18 Section 913 and 915.4.'Please note all COUNTY OOUNSEL "Warnings". CLAIMANT: ROMEO QUEZON MARTINEZ CALIF. . ATTORNEY: UNKNOWN ..DATE RECEIVED: JULY. 14, 2008 ADDRESS: 1826 OPHIR COURT BY DELIVERY TO CLERK ON: JULY 14, 2008 MARTINEZ, CA 94553 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 14, 2008 JOHN CULLEN le k Dated: By: Deputy 11. f'ROM.: County Counsel TO: 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. 'rhe Board cannot act for 15 days (Section 910.8). O C_ laim 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 presenC a late claim (Section 91. 1.3). ( ) . Other: . • Dated: �� �� By: J Deputy County Counsel 111. FROM:: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. OARD ORDER: By unanimous vote of the Supervisors present: (1 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: zo [N CULLEN, CLERK, By Deputy Clerk WARNI.N (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 niail to file a court action on this claim.See Government Code Section 945.6.You may seek the advim of an attorney of%your choice in connection wide this matter. If'you want to consult an attorney,you should do so immediately. *ForWarning Additional Wanin>g See Reverse Side of'This Notice. AFFIDAVITOF MAILING I declare under penalty of per jury that'l aria now, and at all tinnes herein Mentioned, leave been a citizen of the United .'States, over age 18; and that today I deposited in the United States Postal Service in l�Tartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. D a I e :Z-&V'r J01-IN CULLEN, CLERK By ..Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO'CL_kEVLA TI' A. A claim relating to a cause of action foi:death or for injury to person or to personal property or gro«rin; 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 "an t on -ter after the accrual of the cause of action. �'� Y bailey (Gov. Code § 911.2.) JUL 0 7 2008 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 naive 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. ■aaaaaaasaaaaaaataaaa■■aaaaa■■aaaaaaaaaeeeaaaaRon aaExam aasaeaaBEEN aaa■eaasaaaal RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) REC LVED. C'l�,�G' (r�L/� %e� District) JUL 44 2008 (Fill in the name) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. The undersigned claimant hereby intakes claim against the Counq of Contra Costa or the above-named district in the sum of$yr 3 9Y,IS and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Ally �y, �a�S X3 '.30. �• . 2. 'There did the damage or injury occur? (Include city and county) Ale,W dr,ve a'nd 0e nen-d Ave . , Ce-ne,-n�;( 6A. - How />t .How did the damage or injury occur? (Give full details; use extra paper if required) /f cr wa,3 0. rOOC( -n Oo-n C.z,il�' ���L, r'CalS«,mr Sr e944.1 6?4e Ve' 'M&"1 G ° 6tvenrovri,,1c// r�j m,Slow, a47en at t df a, su���°e� my ccs wa-s s'�rur�C bJ 2 Tr���le 7*(, Ai e M& ren, r F�'u , X.,pe/iee- Cle m :21O elIC-1- z`r�ffG. 4. W-ha7particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ��e .,�� � � j � , ���l.� �� c ��ep ell, 7",� rte 17�y 5 What are the names of county or district officers; sen ants, or employees causing the damage or injury? 6. Vv'•11a' damage or iniuries do your c.lailu resulted? (Lire mall extent of injuries or damages clai a:-d.. t«vo csti.lnates for auto damma.g-t.) - clar .Da-vnc�e - pleeue_ see, onto_ ewe - I�✓�rcy — //Lek" �/' ��bC�i� 7. Ho-w vas the aniount claimed above computed? (Include the estimated amount of any prospective in,w-v or damage.) cA2 ,AmRCs � Baa , to 13i/( Alec(, -51 J q`i g /)w'n 'R O(` ♦ �� aa�Eupe Medi e S. Dames and addresses of witnesses. doctors. and" ospitals: Fh//�,,�r /�cr, al Stet ?.,leoe cN tila.�fcnez -- /�k. Dewe-C til- Sori�tN itt- b, Y� Sc.r ()errmo,Hw& Wledrwt- (eee�k - d R. Gab,,I vC t tgait a. iTe-,V-77a. eesfit +r��, tr 9. List the cxpenditures you made on. aCCount of this accldellt or injury: DA-TE- TDfE A-MOUNT 7:44S a-rn . �` a o.d 0 - �ccl��car 3 0.dQ - rii ecec u`�� 6 -a7- 08 a,oaa . 0 — �lii�U�Factc %2�•ne� 0 ■■ 0295 aa ■a a2a ■ saaa ■ ■■sa ■ ea ■■ ■ea■■■t as among owns among ■ t■ a aaa■at■taaa■■■ ■ ■ ■ . ■ aaaas■a■, Gov. Code Sec. 910.2 provides "The claim shall be signed by d1e claimant or by some person on his behalf.' SEND NOTICES TO: (A.ttornev) 1 Mann,- and address of Attorney ) 4401 ` 1 YCtaiifs Signature) ( `�� fur (Address) j Mart,t fl e.z , 6 A . R 4553 Telephone Nio. _ ) Telephone No. 9a.5` - d - a73,s . .2945.2 a a I aIaaaa.. aa5aaaaaaaaaaaaaaa0aaaaaaaaa.aaa2as a a a2aaaaaaaaaaaaaa0aaaaaaa2aaai PLTBLIC RECORDS NOTICE- Please be advised that this c.lainl fora-!, 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; §,5 6500 et seq.) Furthermore, any attac11l11ents, acidelldunls. or supplements attached to the claim form, including medical records, are also subject to public disclosure. ` ■ von- age ■a a a a alsoa ■ ■ ■a a■ a a a t a a a a a a a a t a a■■a e a a ■■■■a a a a a a a a a■a a a a a t a i a a■a ■ Ron ■a a a a a a a l NOTICE: SeCi1071 %? of,:he Fe7za:' Code prol-ides: Ev,.7,Y person who, %ylth Intent,to defraud, presents for allowance- or for payment to any state board or officer, or tO all\ COU11,\' cllv'. Or dl.s--l'ct board or oi'L1Ce.", authorlZvGd to all Or pay die same 11 genuine. tI7�' IaljP, -or fraudulent claim, bill, a:_coullt voucher, or writing, is punishable either by imprisonment in the Count\ jail Ior a period of no; more than o11e vear, by a fele of not exceeding one thousand dollars (51,000.00), or by both such imprisonment and fine, or bv.imprisonment in the state prison, by a fine of not exceedine ten thousand dollars (S 10.000), or by bo-.11 such imprisonment and fire. Visit Verification Dorm • Page 1 of 1 6 n 'r MINOR INJURY CLINIC 1515 Newell Avenue Walnut Creek, CA 94596-5120 Main: 925-295-4000 Kaiser Permanente Visit Verification Form Patient Name: Romeo R Quezon Date Of Visit/Advice: 5/12/08 Medical Record Number: 110006769816 Date of Illness: Diagnosis: Mva Cause Of Injury [E819.9A] Muscle Strain Neck [847.OZA] ................................. . . . .... ............ .. ................._... .. ..._........_... .. Romeo R Quezon was seen in this office Romeo R Quezon can participate in a modified work program starting 5/12/2008 and continuing through 5/19/2008 If modified work is not available, Romeo R Quezon is unable to work for this time period. Ernployer/Supervisor - if you have questions, please call our Office at the phone number-above. Patient has the following restrictions/limitations: Occasionally = up to 25% of shift. Intermittently = up to 50% of shift. Frequently = up to 75% of shift. Patient can lift/carry' up to 10 pounds. Force for push/pull should never exceed force for lift/carry. Electronically signed by DANIEL M. SONNIER MD on 5/12/08 http://kaiserpermanente.org f-j'(>; !.:_._•.'':.' . .^c c,z —''; ..4. � #"" r r s3 nQ 1i!'S a{E^#TOES C?@CGr(8. A#1h3'hotwin OY this pago are remindEr�for OrC18 p:B10n�f4f0 SPrV1003 ha eft to{uiaE Pf.f� Yt If yJu haV {3Yti^esti{np health$t3Cs i84Yt$orate,tt high isle for. •cerl.3iY�d1�e3 es,you may reit$ire u ;t4'pYevenli?i eraiaes .' end sls4�uld sons�itt yo3f physician:If an a0ppintment is_,oebssaryj please scneduO R. Ex C t 0te - - f • s j!•• 1i'i f +. a.t•,}3:' .ti'.Y�-g'i'.Y4,.ti`;'�,.{:?' r:1. f"s - ?`y'��ri";' 4a'�4.t:_ •-�,.°}y s{'•'t-j.�-'-- 1;;t r 1, 5.: ..... .. - <.. o. -3 jtt . �'} s• , j i, s.'_:�.:a;•} 1.r..... .•u,i :.}.. rx—_f {•'` .. - . } }.� ;= 'Si; �+`t `it'' .. t.,-x.'.- .j'•1;,::^;;f.-; .. : - -.'L::�.: i=`.;' "t •r.t,r_- - .. . t - 'i .•} s:d' `a�. r:� t ... _,'t+ i.'z - ;c:s3 ..- _ m 3 9'3 -1lz.Ztx . .� "}1.-'-..sit `::^",=}` . x , 1.., ;.- :,l f.t, .r -•",tf' i .T" l-i _ 'r - '�;:�..1"• z i.}, _�.: •t�: '?'-i^ '_'.�.{•j,..; ,.t,_;. - _ - i. taiC:P-'!C:""•'7.-LC-it '� 1':{.;t„. �`f-:•..t'e C:.;.:i.. f i : .. G•: F.. -'yyy'!l:'Y” y.°i•;?y:='C°A fC.,�'. '1,M�,� 4„�{-%.. . _.. ,r�Y: r#;j i= �..j -i•fF'L - >5 �[[ - 3..:ii.-t" 1'S• , .y L. Qa..:: str .{••- :i;3 r'• - _a.x.^�Ali',."` I t E •t"�1:.. ,_:✓�. '�. 3. ,C:�'' .•:et"�' ��`� { .. 4 r , i ^.{�SqOntdays tL�•C7[p+9;Lg)i`�k�Nw.::'•, months.. ..Rle•UM,Op '. [. $No 9ti only 06 couMaf44 00 66�2ff 8 .-reau. IifEfi3t«�y1:3C1� ¢s�E��yDY92�$fC�?q��L36}p� (! k RQ.jfwttd S +YA$tii:$i a iris sa iib ial�a�re ..c1'oc�s:����ti#�;.19�IF�4:�l��e�q�rYW.��GIQ�{i10po-'odil i J bl .b.or 3-'GSir�tr"s t]Ii$�����J�;•����. - :•;'<31f(Rc•V.2.{y}i)... "�'.'�: a:OiRi�UTiOif:F3if.EC0?V.F=UVY,-CdAfi • Af. :i:, .,c.€; frli,-T,..11Si1 �fi�". >� ..'{tt, .i..c d�: :,s:s,.. .�:st: � ^i• cfi:�• "n-::i, i.4 :di: a. :l! i' _ ,fia. .r •�_ '':iSCi fti;. 5}�t'�i:."•;::S:i:.' ,1 S'a�`°is(7".�z(C`;C�'x , r. r•+z" -.tri'�.....,."t.......��:•.. ...9_...:...:..{.�.. ..-......:..: .. :.4ri . . .... .s.. . fill'= ;?eitv,{ 1 ' .tet-.,.f:.li :,•4.: .».....i..: .............`..�.._...._ ..i.'':}i ..�_,.........._......,.._ .... •� ...._..,.....__..e...•i�:'...c. _.. _...,.a.. ... .... ..,., .. f... :_._:..;..:.: k;..>,;. ,ate:•. :-,:.'c''':F�i .. {f;,, : ...,. - .. =•i;;=r` , .. .. E, .. <k MAi.NI P HAtlMwt�.r lQ5 ;7r;nh MwH J2. isl !'I.. WALNUT CREEK - CA 94596 925) 29- -srt:! Box-a; A LOS Ack 4:705M.01179 CAJ"r_ i1v. PiiMEG u 120y05 . 401911 tt- l62 4 1...90 110P P r .. Ihi51 . A! I P f'dSC.f':U`i of i Jcu;ca ni,e I-l no Unopened" Over-The-Counter 128!115 may :i8 . ..onsS I .. 2t' 1a: iitei.li t:a't.4::it.S 'r C`8 'en I 1c?King if ilyV.`. slily' questions awuVa&wsem:%Q mmi Qrs. J HANV, YOU . 3k CHOOSING KA.I SER, PEPMANE.N T-F IC = ,07?cJ7 WCRN09 A 0,5/102008 at 10 : 46 AM Job Number: 7821 FEDERAL AUTO BODY Federal ID # : 954666673 FEDERAL AUTO BODY 1.410 CONCORD AVE. # B CONCORD, CA. 94520 (925) 798-1264 Fax: (925) 798-5051 PRELIMINARY ESTIMATE Written By: MARK KAMRANFAR Adjuster: Insured: ROMEO QUEZON Claim # Owner: ROMEO QUEZON• Policy # Address: 1826 OPHIR CT Deductible: MARITINEZ, CA 94553 Date of Loss: Evening: (925) 229-2735 Type of Loss: Point of Impact: 6. Rear Inspect Location: Insurance Company: Days to Repair 1998 NISS SENTRA GXE 4-1 . 6L-FI 4D SED BLACK Int:GRYA VIN: 1N4AB41D4WC713732 Lic: CA Prod Date: Odometer: 104000 Condition: Good Air . Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Body Side Moldings Dual Mirrors Console/Storage Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek Driver -Air Bag Passenger Air Bag Cloth Seats Bucket Seats Recline/Lounge Seats 5 Speed Transmission Overdrive Full Wheel Covers ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAP. BUMPER 2 O/H bumper assy 1 . 5 3 Repl Bumper cover 1 183 . 47 Incl . 2 . 5 4 Add for Clear Coat 1 . 0 5 Repl Energy absorber 1 50 .78 Incl . 6 Repl LT Closing plate 1. 4 . 50 Incl . 7 Repl RT Closing plate 1 4 . 50 Incl . 8# Subl HAZARDOUS WASTE DISPOSAL 1 5. 00 X 9# Repl CAR COVER/ .MASK FOR OVERSPRAY 1 5 .00 T 0 .2 10# Rpr TINT COLOR 0 . 5 11# Repl FLEX ADDITIVE 1 5 .00 T ------------------------ - --- - ------------------- ------------------------ Subtotals =_> 258 .25 2 .2 3 . 5 1 (35/10%2008 at 10 :46 AM Job Number: 7821 PRELIMINARY ESTIMATE 1998 NISS SENTRA GXE 4-1 . 6L-FI 4D SED BLACK Int:GRYA Parts 243 .25 Body Labor 2 .2 'hrs @ $ 74 .00/hr 162 .80 Paint Labor 3 . 5 hrs @ $ 74 .00/hr 259.00 Paint Supplies 3. 5 hrs @ $ 32 .00/hr 112 ,00 Sublet/Misc. 15 . 00 ----------- ---------------------------------------- SUBTOTAL $ 792 . 05 Sales Tax $ 365 .25 @ 8 .2500% 30. 13 ---------------------------------------------------- GRAND TOTAL $ 822 . 18 ADJUSTMENTS : Deductible 0. 00 ---------------------------------------------------- CUSTOMER PAY $ 0.00 INSURANCE PAY $ 822 . 18 I authorize FEDERAL 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. This Estimate 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 ' G5/10%2008 at 10 :46 AM Job Number: 782.1 PRELIMINARY ESTIMATE 1998 NISS SENTRA GXE 4-1 . 6L-FI 4D SED BLACK Int:GRYA FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES : B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=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=MANU.FACTURER'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 AEF3735, CCC Data Date 03/01/2008, 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 pasts 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 ,4!b � J rleu� cI __—_ Penny � Penny Bailey JUL 0. 9 2008 UL 0. 9 2008 I I CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: . AUGUST 19, 2008 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. hr you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV.below), given Pursuant to Government Code AMOUNT: $150 000.00 JUL 15 2008 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings".. CLAIMANT: SANDRA DEWORKEN MARTINEZ CALIF. ATTORNEY: FARLEY S. TOLPEN DATE RECEIVED: JULY 15, 2008 ADDRESS: 339 LOWELL AVENUE BY DELIVERY TO CLERK ON: JULY 15, 2008 MILL. VALLEY, CA 94941 BY MAIL POSTMARKED: JULY 12, 2008 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 15, 2008 JOHN CULLEN, er- Dated: By: Deputy- ' 11, eputy' fI. FROM: County Counsel TO: Clerk of the Board of Su erviso•s (t�/This claim complies substantially with Sections 9l0 and 910.2. ( ) This Claim FAILS to cornply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim'on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other. . Dated: / `I�'Q� By: rn Deputy County Counsel i1I. FROM: Clerk of the Board TO: County Counsel (1) County Adrninistrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I V.,B'OARD ORDER: By unanimous vote of the Supervisors present: ( This Clairn 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. Date /1 D HN CULLEN, CLERK, By Deputy Clerk WARN1. G (Gov. code section 913) Subject to ceitain exceptions,you have only six(6) months fivnt the date this notice was liersonalt served or deposited in the null 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 niatter. If'you want to consult an attoniey,you should clo so imniecliately. *For Additional Warning See Reverse Side of'This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i. am now, and at.all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in M-artinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Date ''moi l JOHN CULLEN, CLERK B Deputy Clerk • ���.., •11. [!,��:�e L _,:,-Pd �,� '' �' �` ^!iE'�9E"'JT BO_A-U OF SUPERVISORS OF CQI`f' R-i COSTA COUNTY r'STRUCT1oNs TO cL.4IlYL NI' A. A claim relating to a cause of action for death or for injury to person or to personal property or gro-sving crops shall be presented not laxe�r than sLx months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not late: than o year after the accrual of the cause of action- (Gov. ction(Gov. Code b 91 l.2.) B. Claims must be pled w-ith the Clerk of the Board of Supervisor., at its office in Room 106, Court-)-Adinion Building, 651 Pine Street,M.artLez; CA94553). C. if claim is against a district go veroad by the Board of Sapen-isors, rather than the County, the name of the District should be filled in. D. If th.e cLaim is against more than one public entity; separate claims mast be filed against each. public en:dl . E. Fraud. See penalty for fraadulent claims, Penal Code Sec. 72 at the end of this fb= MRAs as own KK am to Eta t■ tta[a RK a a a at ac Sat gat as Rang a Sam am K ata a Kala t I M as tat a rams LC a a1 Fes: Cumin By: Reserved for Clerk's fYmg stamp SANDRA DEW0 KEN ) a Y►A6m Against the County of Conga Costa or District) caft JUS 1 ?008 (Fill in the name) > cvb R°c°Q`g P'RVis STA CO ORS The,mdersi=ed claima-zt hereby makes claim against to County of Cour-ra Costa or the above-named district is the sum of S 100MA and is support of this claim represents as follows: 50 ,000 .0 1. When did the damage or igjuy occa.,? (Give exact date and hour) 6/7/08 Around 7 :30 p.m. 2. Tylere did the damage or injury occur? (Include city and county) Bay Point, CA - On the pole right outside the shopping center wka where La Finca Restuarnat is located. see photos attached hereto 3. How did the damage or injurer occur? (Crive full details;vjse e. tz�pa er�#lre u -� There was a loose wire cable from the po e an at s a was exiting the shopping center, the cable caughtSer handle bar 6&P%A She �pp� K`0 . rhe, �i Mt�pardcular act or omission on the part of cd +tn),or district offa=s; sen acts, or emplovees cawed the injury or damage? Failure to maintain public property is a safe Hind condition for the public. The broken cable is open and obvious. 5 What are the names of coup y or district officers. servants, or employ;es causing the danage or injury? PUBLIC Works Dept. JJ... CC•1 i, 2Qf CtI r; '�1A'daCE'+I P;T �' C� =E;h 6. '�ct a age or injuries do your claim resulted.? (Give fitll extent of jvr+_es or datr aa(Is chimed. Attach two e-dmaT=•s for auto damage.) fracturted skull. lacerations, hospitalization 7_ How vms the amount claimed above computed? Clacludc fn., estimated am.ouat of an)- prospective injury or damage.) Based on 5 days hospitalization, scar, brain injury and the. like. S. Names and addresses of witnesses, doctors; and hospitals: Sutter Delta Medical Center,' Pittsburg Medical Center and others' 9, List the 4x'pendi.tu es you made on account of this accident or iJM,: DATE TIRE ANT AA Medical expenses of any unknown amount- bills have not been receive�X. a OR NSA s e s s R■a R■■than KNEEN on R s a■a s a s i s s s s a a s s a t R a■a■s s s s s a r o■■■a■s■s s■e s MR ■■■a a s a e.s■■! .Gov. Code Sec. 910.2 provides "The claim shall be si=,d by the claimant or by some person on his behalf." SEl,,,TD NOT ICES TO: (Attorney):r Namz and address of Attorney- ) l Farley S. Tolpen, Esq- 339 sq.339 Lowell Avneue ) (Claimm�t's Si Mill valley, CA 94941 118 Hill St. (Address) Bay Point, CA. 94565 TCA. phone No. 41r;-389-88119 ) Telephoak No. Ka■■rUs■r■■■ssaa■sE s Musa■a■a■WARNER sasse■aea■■xd a an r■Non as an s s IF Ken a s sfR a■■■a■ala[Kati PUBLIC RECORDS 1�'OTICE: Please be advised that this claim form, or any claim pled v6th the County under tate Tort Clams Act, is rabject to public disclosure under the California Public 1Lc4rds Act (Gov. Code, ss" 6500 et seq.) Furthermore, any attaclnants, addendums, or supplements attached to the claim form. including medical records, are also subje(;,L to public disclosure. MV N s a■■■r s N■■■a■R r r MAN as a am s s s■cat■R■■■r■r rdab M s s s e s a R R s a t a■a■■a r r■■r s■AN a I L e R R r■I i NOTICE: Section 72 of the Penal Code provides: Ever; pennon who, with iatert to defrau►� presents for allowance or for payment to any state board or of[i :.r; or to my county, ei or district board or o:5cer, authorized to allow or pay the same if quina, any fare or :.audul--at claim9 bill, account voucher, or uniting, is punishable either by imprisonmeut in the Co=ly jail for a period of not more than one year, by a Tine of not---xceedi g one thousand dollars (51,000.00), or by both such imprisonment and fine, or by irnprisonmmt in the stat.:. prison, by a fine of not e%:e-.d-s g ten thousand dollars (S 10.000), or by bosh mc'a imprisomnent and fine. :5 �� � F s wl► ff. _ - I 4 yk.._ I.. 1 1 { t �1 J , FARLEY.S. TOLPEN ATTORNEY AT LAW July 12, 2008 Mij JUL 1.3 CCERNBO" CONTRA COS q C®VISORS Clerk of the Board of Supervisors CONTRA COSTA COUNTY 651 Pine Street Martinez, CA 94553 Re: Claim of Sandra DeWorken Dear Sir/Madam: Enclosed herewith please find an original and one copy of the filled out claim in the above referenced matter. If you would be so kind as to file the original and have the file-endorsed copy returned to the undersigned in the enclosed self-addressed envelope, we would appreciate it. . Thank you for your kind courtesies and attention to this matter. If you should have any questions, please do not hesitate to contact the undersigned. Very truly yours, F ey S. Tolpen FST':lk Enclosures Cc: Client 339 LOWELL AVENUE MILL VALLEY CA 94941 ph ( 4 1 5 ) 389 - 88 1 9 fax ( 41 5 ) 389 - 8848 f s t o l pen @ a o l c o rn farleytolpenlaw.com ^ � -ao"di o� \ \ . • �� � �O � � � ± � \ � } . \ . � ± � G . \ y2 fzw ` ` J \\ . CLAIM -' BOARD OFSUPIEItVI.SORS .OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 : Claim Against the County;or District Govemed by ) the Board of Supervisors, RoutinNOTICE TO CLAIMANT Endorsements, ) and Board Action. All Section references are to ) � Tile 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 Supervisors. (Paragraph IV below), given Pursuant to Government Code JUL 7 6 Section 913 and 915.4. Please note all AMOUNT: $498.00 °Warnings". COUNTY COUNSEL CLAIMANT: MARY HOWARD MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: JULY 16, 2008 ADDRESS: 1626 BARRUS.AVENUE, BY DELIVERY 7'0 CLERK ON: JULY 16, 2008 PITTSBURG, CA 94565 BY MAIL POSTMARKED:BY FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of tine above-noted claim. JULY 16,- 2008 JOHN CULLEN -1 r Dated: By: Deputy I.I. FROM.: County Counsel TO: Clerk of the Board of S pervisors ( 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. Tile Board cannot act for. 15 days (Section 910.8). Claim is not timely filed. The Clerk should retui7� claim on ground that it was filed late and send wai•tning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: / S By: Deputy County Counsel i11. 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). l V. OARD ORDER: By unanimous vote of the Supervisors present: (• This Claim is rejected in full. ( ) Other: I certify that this is a true and con-ect copy of the Board's Order entered in its thinutes for this date. Dat / z�ogoi iN CULLEN, CLERK, By Deputy Clerk WARN1. G (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 nud.1 to file a couil action on,this claim.See Government Code Sectioih 945.6.You may seek the advice of'an attorney of your choice in connection with this matter. If'you want to consult an attonhey,yon should clo so inhrh►ecliately. *For Additional.Warning See ileverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1. !m now, and at'all times herein mentioned, have been a citizen of the United, States, over age 18; and that today 1 deposited in the United States Postal Service. in Martinez, .California, postage fully prepaid a certified copy of.this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. ,Z.000PIJOHN CULLEN, CLERK. By ,Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented no later- than the 100`u' day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. 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 claire is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claire by ) Reserved for Clerl 's filling stamp �.� ®�. Against the County of Contra Costa or ) �F9�eo b 2 r�(9Gti a ) ooyTRoo� 008 Fi 1 in na e avj�fthistrict ) ROCU UCO� ( ) ) is0 y The undersigned claimant hereby makes claim against the County of Contra Costa or the above- named District in the sum of S ��8, `' and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) OZ> 00 ll� 2. Ntherc did the damage or injury occur? (Include city and county) LIZ" A(J.P C."'.-cg' (a 1 69 , /9&'r &,�; F/ c AF ' 3. How did the damage or injury occur? (Give full details; us extra paper if required) - 4. Whaf particular act or omission on the part Wf cour r district officers, servants or employees caused the injury or damage? (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? wilw'e, 0�b 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed.) Attach two estimates for auto darnage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) ' 8. Names and addresses of witnesses, rs and hospitals. 9. List the expenditures you made on account of this accident or injury: ./ ® �. DATE ' ITEM AMOUNT J" Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO : (Attorney) or by sonic person on his behalf." Name and address of Attorney (C1ian ' Signature) 1,7 Y:5; (Address) Telephone No. Telephone No. - <1-7,3 9�1pP 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 on thousand (S1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a .fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. ) i , 17_/65-1 -oda - -1�1-1-e G /tA ----------- - r - _ . - ------------ �% � `e - ---- - r � y ,"se, --.._....... :_. All- _...... ..._:..:.. ._.._ _.._........ ...... ......_. _... ... ,% -r J�k - ....._.. if.. _...._.__. .. - JJ �I p r L O1 M $ 5.0 — LO U Q N LO (? 5 m LO Q UN N b � O C � v o �cn 1� RF N LL y' � 1 �X oy\ ev,, f � J JI f. Ile,9o Z7-A had, n - _ere-, m ----------- - .rl -----:--.___--__e.��-f d ----- --:_tea- !2 �� /�oo�n .....-- oe u--��aC e._-_. tick__-- --= -, -o _ - ,y y . - n S14/ : Gigin- 4. 49-1 • oo . ....., ........: ...... ....... ..... ...........:...... ... ..... .. ..... .:..:. y� D r � 4 i ___. 1. ._.....t�.. ....f�l �1 DG)lv............ ..._..:._...:....:.,.....�..,...�,..._c�_.___.°�r.�_d_��_.:..-•'--. ... _.�'1L�._��?dt�_-._._.:6? ._ �Z��l.-�r_Cj�!Lr S AV�Zr'�2�: ; ri t '7 7. yoqp E6 _ ka C ' -�1./f. /��I—+r�l4.c.i='..' Y�--L...�J�./t� �f:►�Ii":�`� l���f. a " _.-...._..._ _ ?t-----r"L - ... .. ........ . O f - i /f •t�p froOF 3. tv '�T4`+'4p�/�` Y �t rel •F�.u�ez�+ry'�x�tiway qp�!r�'"y*y�¢*�yt Y���'ix� ` y�'71 ` � �. r��, .i'Rrc�,�•,"f a ,.pan.,'��>ay�t� � nKjS�.*�'py � - M� / d 4 r i-�•�•1`i�• �- � NSoil {a'y.�'+i�q. i �� » s uypmAa a� � - , t .[fA�t$aXl'�,y�a� ♦ oA nr k** * �v F-�� K a J ili A ff�i,Y �t�YSt k t. 7a':, i Ate.., • yp .3°.2"'Y1:�,:`!�$.- .FI; eR:'i • .`F E +{i�. ::`'S.� e,�A'.y�.l` if;' f ai. :• s � :r:y. :.�`' ,:j '` . fir. %.j.; i•` _ - •�:ros:?�ss' sk'•. . .y .;...�;•,i,.:�,. ....'Rai.� .1 "„•s. I Y�'M,.'•„ '-s��.i»�.m. :� •:elf .:yM''1'' ,��,r. .;ya '. , may ,. �,. d, 1: +, � ::t:.•.. nA ir. fur. #i ,fir 71,0 «: •r. is' : CLAiM • BOARD OF SUPERVI:SO.RS OF.CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 . Claim Against the County, or District Govemed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section re �� The copy of this document mailed to California Government Codes. you is your notice of the action taken JUL 6 2008 on your claim.by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code MARTINEZ CALIF AMOUNT: IN' EXCESS OF, $10,000.00 Section 913 and 915.4. Please note all °`Warnings". CLAIMANT: DORI C;,:AWFORD ATTORNEY: TERENCE D. EDWARDS DATE RECEIVED: JULY 16, 2008 BRANDI LAW FIRM JULY 16, 'L008 ADDRESS: 354 PINE STREET, THIRD FLO RY DELIVERY TO CLERK ON: SAN FRANCISCO, CA 94104 BY MAIL POSTMARKED: BAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached:is a copy of the above-noted claim. JULY 16, 2008 JOHN CULLEN, er Dated: By: Deputy IL FROM: County Counsel TO: Clerk of the Board of S ei•visors (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. Tile .Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 91. 1.3). ( ) Other: Dated- 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). IV BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dat -l"91F611N CULLEN, CLERK, B Deputy Clerk WARNAG G (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 nwil to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attonrey of your choice in connection widr this matter. If you want to consult an attorney,you should do so inunetliately. *For Addidaial Warning See Reverse Sick ofThis Notice. AFFIDAVIT OF MAILING [.declare under penalty of per jury 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, hostage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dat 41111,01-IN CULLEN, CLERK By eputy Clerk a JUL. 15. 2008 1 :41 PM CCC RISK MANAGEMENT N0, 901 P. 2 =? BO. OF SUl'[[ERIVISOT3�yry�7OF CONN COSTA COUNTY INSTRUCTIONS ��7 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 aoonml of the cause of action. A claim relating to any other cause of action shall e, presented not later than ore year afte-r the accrual of the cause of action- (Gov. ction(Gov. Code§ 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in RODM 106, County Administration Building, 651 Pine Street,Martinez,CA 94553. C. If claim is agaiwt a district governed by the Board of Supervisors, rather than.the County, the nmme 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 mflty. F. Fraud. See penalty for fraudulent claims,Proal Code Sec. 72 at the end of this form. REms Y'rk YtR[[[[[RacYREUR*c=YYY[RckcctR[Rcc[[cic=tY■\R RtY■\LCYc[[YRRRZY[[RR[\S[YIto RE: Claim By: Reserved for Clerk's Ming stamp DORI CRAWFORD '104 Against the County of Contra Costa or. DOB - --- D]„5i27.Ct} COhT9q co T�c AV/S CHI in the name) The Mdersimed elaimaut hereby makes claim against the County of Contra Costa or the above-named district is the sum of$in excess of and in support of this claim represents as follows: 3. 'When did the damage or injury occur? (Give exact date and hour) January 25, 2008, approximately 7:45 p.m. 2. Where cId the damage or injury occur? (Include city and county) Richmond Parkway approaching Hilltop Drive, City of Richmond, County of Contra Costa, state of California. 3. PIow diel the na�aae or injury occur? (Give full details;use extra paper if required) Please see attached pages.. 4. VVbat pardouk act or omission on the part of county or district officers, servants, or employees caMed the injury or damage? Please see attached pages. 5 What are the names of cD mty or district officers, servants,or employees causing the ri=a or injury? Please see attached pages. JUL. 15. 2008 1 :41 PM CCC RISK MANAGEMENT' N4. 901 P. 3 6. wiiat d=age o: miudes do Your Claim resulted? (Give full extent of injuries 01: damages claimed.. At=h two es=aAtes for auto damage.) Please see attached pages. 7. How was the amount claimed above mmpifted? (Include the estimated amo=t of MY prospmtIve injury ar damage.) Please see attached pages. 8. Names and addresses of wiftesses, doctors,and hospitals., Please see attached pages. 9. List the empenditmes yo-a made oa account of this accident or injury; DATE ME, AMOUNT Please see attached pages. a no KRA as KaRMAZU a Koff A mad am a MR No I I saw Rd a a IN SWERNNN as RAN A a Rd ad MR a A F allff MEN A PIK a A In xKkK5 WIN I Gov. Code Sea. 910.2 provides"The cldm shall be signed by the daimant or by some person on bis 9END NO'T'ICES TO: (AttomeyA--,--1 Name and address of Attorney TERENCE D. EDWARDS BRANDI LAW FIRM TEREP94VPF 'affigffebN BEHALF OF CLAIMANT 354 Pine Street, Third BRANDI LAW FIRM San Francisco, CA 94104 i4 ne i-rpt-j- - Thirtj Flonr (Address) San Francisco, CA 94104 -1800 No. 415 989-1800 Tole- No.-415 989 Telephone mks ex"Nowl TWA%Zug%OAK a wxAXNNRN IN Nut a*XEMNSANta ass TWA K ff UZ IRS VNK*I PUBLIC RECORDS NOTICE-.' Please be advised that this claim form,or any claim Sed with the County imdw the Tort Claims Act, is subject to public disclosure under the California Public Records Act (Gov. Code, §5 6500 et seq.) Furthermore, auy allw.,jlments,addmdumg, or supple ediwJ r=rd are mants=Ghed to The claim form,inGlu6jug m s, also sa bjeot to public disclosure. Is I ff Emig am K a Walla a a It a a a UK Nx%TR ff mkuYr as ff x WEN KAN ban ff so Zx ass Oman Rua NXIERNM ff a--JN to a X.C.Mrs a E NOTICE: Sealion 72 of the Pe?za Code provOeS: Every person who, with intent to defic�presents for allowance for to tuy state board or officer,or to any county, city, or district board or offi=, authorized to allow or 9ELy the same if rnuine MY false Or fraudulent claim, bill, a==voucher, or writing, is pm3ishable either by i 'sonmmt in the County jail for a m1?n period of not more than one,year, by a flne, of not exceedipg on.-,thousand dollars ($1,000-00), or by bath Such irqprisoa,m=t and fine, or by iprisoument LU the state prisch, by a fine of not eXCUdincor tan thousand dollars 10,000),or by both Bach irnpd50nmf,-nt and fmc. THE 13RANDI LAW FIRM THOMAS J. BRAND[, #532-08 TERENCE D. EDWARDS, #168095 354 Pine Street, 'Third Floor San Francisco, CA 94104 (415) 989-1800 Attorneys for Claimants: DANII_,L CRAWFORD, DORI CRAWFORD, and ANDREW CRAWI;'ORD CLAIM OF: DANIEL CRAWFOR..D, DORI ) CRAWFORD, and ) ANDREW CRAWFORD ) CLAIM FOR PERSONAL INJURY AND PROPERTY LOSS Claimants, ) [Government Code §910] THE STATIC OF CALIFORNIA, COUNTY ) OF CONTRA COSTA, CITY OF ) RICHMOND, ) Defendant. ) TO THE COUNTY OF CONTRA COSTA: Claimants DANIEL CRAWFORD, DORI CRAWFORD, and ANDREW CRAWFORD (hereafter"Claimants") claim damages from THE STATE OF CAl_.II-'ORNIA, COUNTY OF CONTRA COSTA, and the CITY OF RICHMOND (hereafter the "PUBLIC ENTITIES"), (a) Claimants' post office address is: c/o The Brandi Law Firm, 354 Pine Street, 1 Third Floor, San Francisco, CA 94104. (b) The post office address to which Claimants desire notices to be sent is c/o The (Brandi Lav Firm, 354 Pine Street, Third Floor, San Francisco, CA 94104. (c) This claim is based on the personal injuries sustained by DANIEL CRAWFORD, DORI CRAWFORD, and ANDREW CRAWFORD. On the evening of January 25, 2008 at approximately 7:45 p.m., DANIEL CRAWFORD was driving a white 2004 Lexus SUV northbound in the #1 lane of Richmond Parkway approaching Hilltop Drive in the City of Richmond, County of Contra Costa (hereafter the "ACCIDENT SITE") with DORI and ANDREW CRAWFORD as his passengers. At said time and place, Reginald Lewis was driving a white 1998 GMC van southbound on Richmond Parkway approaching Hilltop Drive. The Crawford vehicle lawfully proceeded straight through the intersection because it had the green light in its favor when the Lewis vehicle made a left- hand turn from Richmond Parkway onto the IIilltop Drive in front of the Crawford vehicle causing, a collision. All claimants suffered serious physical injury and loss of personal property. The accident was caused by the PUBLIC ENTITIES and/or their employees for reasons including, but not limited to, acts and/or omissions which resulted in: • failure to warn of, and/or prevent and/or correct a `'dangerous condition" (a condition oi�property that creates a substantial [as distinguished from a minor, trivial or insignificant] risk of injury when such property or adjacent property is used with due care in a manner in which it is reasonably foreseeable that it will be used) on, or immediately adjacent to, public property; • failure to provide and/or maintain proper signs, signals and devices at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of 2 the Crawford vehicle; • improper setting and synchronization of lights and signals at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle; • failure to provide and/or maintain adequate, safe, and proper lane markings, and traffic channelization at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle; • improper- setting of speed limits approaching the ACCIDENT SITE which caused the vehicles to be travelling at an unsafe speed for the ACCIDENT SITE: • failure to provide and/or maintain adequate signs, signals, devices, chanrlelization, pavement, and striping at the ACCIDENT SITE; • fai lure to provide and/or maintain adequate sight distances at the ACCIDENT SITE; • failure to provide a safe and reasonable geometric alignment of the roadway at the ACCIDENT SITE; • failure to provide and/or maintain adequate drainage, pavement grooving, and and hydrological devices at the ACCIDENT SITE which caused the accident by making the roadway surface slippery and unsafe; • failure to adequately warn of the dangerous and unsafe conditions set forth above. The PIJBLIC ENTITIES had actual and/or constructive notice of the dangerous condition and a sufficient amount of time prior to the accident to have taken measures to have protected the public against the dangerous condition. 3 (d) As far as is known at the time of the presentation of this claim, Claimants claim darnages for personal injuries, pain and suffering, hospital and medical expenses, lost wages and loss of personal property. (e) The name or names of the public employee or employees causing the injury, danlages or loss is unknown. (1) The amount claimed exceeds ten thousand dollars ($10,000) as of the date of the presentation of this claim. The jurisdiction over the claim would rest in Superior Court which is also known as the Court of Unlimited Jurisdiction. Date: ,July 15. 2008 THE BRANDI LAW FIRM By: TERENCE D. EDWARDS Attorney for Claimants 4 Jan 31 2008 3: 33PM Min 510-835-0685 p, 2 STATE OF CALIFORNIA p�ry� DS.- TRAFFIC COLLISION REPORT RE 13}1P_:,555 E'e9C 1(ReV.7 03) ON -1 - _ �• FPECV.L CON]ITLOY�i Hv..tfcR Nia0.H CfTY .. -JUMIAL DISTRICT LCCILRFP0RrILO1d4ER"•'. .:. _ ti..: •,�<,- _ � _ �l `:,, :mss "' Gr ' ' .. - .. ...:... :. .. W �to r.i.d HKR:EJ[RtuFJ<h COUNTY REPORTIHO DSTRIOT BEAT 4R - a - T COLLFEIOiiobCL,F3LE00.4 ._ M0.• OAYI'EAR TWEl7Eotry .1Jr:LCie�;:. :. •.• OFFICE♦yR I� /./`:,;`,:'•: DAY OJJA -.- J ,: �ta�BLsgcrwvY+TH (/ STATEMJ eL ^ w(�G�G/� �/�L rip OCA �� CO � OR! :FrvnrtiD . DP e Q� C.P' .PARTY DA14'=itS LIC77sENlF#3ER: GTATI CU16S AW e'I :.Wi•..: t! ,'S:1lxA3,'E7i STATE Incas Lysr1. ,; /:..:... L. .. .. 49 - EGIi�/, G�01v 15 .... : Vh'VE46H 'JE AS DRIVER-. d'• c }ARZED OtTYf3TATE.tY ..... _ - vagric ' 1 GI+POs1TH:N OF YtI?CLE 014OW.-RBOF; (� . f�OFFICER ttvEit C)TkR CUSY SIX LVJR•"?; ..-: ES ttEJGHT (wT •"` FRRjTLDA E •,i RACE .... ,.: ,.. _. .. I .. _. - P.^SOFLIAECIfAHICALDEFEV(o. NOV[AFI'AREljj TO ILARRATNE f . . _ , 1 , -OTH.7L W-VA5 1-1�\ .. . CCSiui:cL hH-NE: -,� - YF7tGiE DEFiI�P�CAT10N tPJSReR: .� U_ '.. .•_,..i i,'•:•. _ -VERICLETYPE• TO VEHVV-DQAAG: ..... SHADELV DyAACEU ARCA e;;Ergs r�;c�LLR=li POLZY NLQABER i U . _.. MOD.., 1 i R BULL-OVERtil �G AQt .... .._.. . ' :-:xR'4F 71?x\'Fl Otl6jl�t.�.T Oft FF1c.t!.IAY —' 6Y[�ll Lt'A[f _ .: ::•: I (�^`' CAL-T —4; V STATE IC15ZSArtBAC :S MEOLRP, IMLYEAR W,H•.V.ODalCOLGR 0.VVBR h,11E.(Ff T.AL .ST)' (YFRlEj;etl luta_ 'TaoN 5T A[7DIiE5'a ;.. ADCRESS ..--:yy . GV\9TS Y.&WE'AS.DRIVER'` El. vp ; Aad YaI PAILKEO CTYLSTATEMP .. . . Kl . ._..Oda ON ORDERS R;• OTF�OFF[C.r5E].QMVERQER May, " EMU HELGT %EIOKT SiRTHDATE RACE CIIST _ a v�l1.' � i/iPa �W aq OTH:TI HC; Y DVE' guautl:rwrrt7AL t5FFECT4:''. I h`F MEtfT REFfR TO NAHAATt.YE,. WHICIE DEIMFICAYMI'WSHi: n .. .:-. 1•••J . . ...^: :: .: Vaiid.E TYPG DESCIiEst ITeFi1SYE MAAGE: _ tliU.�1C�?N?EA..._ fl:R GFTR�VFi 01l sTfiE ET UZ{iGFfXAY SPEE.DLVARCA - DOT : . PARTY LR2IVER:i LL^..EN+E hTlLllfEr(: STATE 4AS3: ..`.VR LlAO :SAFETYEQUWi' Vat '• Uwmp Aw>-LACOLOR, .. LfCE1i5E ftbiSJt.. STATE pxvol taleEFLrasr,leOatt rtsT). ........................................ ; .Gtti tomes NAL_: El. SA►aE hS bRNER PEDEr, sTRL:ErA?ORESS .. ..' .... -- ... .. ... -0MIER'SADDRESS SA►AEASDRMR VP�KW CITYISTATE;w . - o15POsrtwn OF v-HOLE ON ORDERS CF: . OFFI^FJi❑DRIVER❑OTHER BICY' LEIC JIVJR. EYES jK5GWr EX*11 MRTFLDATE FLACE CUT 1de..�—D+y-"•Yem:...: _ _ -- - _ _ -_ PRIM VACFLWICAL C CTT6 - REFEi TO WYAATPr. -GTlIOL HOME PWME sIRFSSMONM vEpCLE YiCATiDF11JUt.3 R: ' VEI:CLElf1fP6 DESCRN.E VQiICIL-GMGE *cwc-IH WAGED AREA vsuRAvcEeARaEeL TC.LCYAULIficR i �UHK E1110NE MINOR' oM00.'❑IAAJOIZO ROLL-0VER DVL OF iRAwrl ON STREET OR H:CHVlAY EPEED LNK� CA .i MIT •� _... • CAL4 TcP�psG uCrt1>L(_ PRE VA N' E p:CpATCHHUTnm Rl=llIEV.FR•S �� L�.'_EA.''THREETS 12 QATT Ie YES NO NIA .•.:.::.iy.•;t;,i.. L :;T' ' 1:655 703.frD Jan 31 2008 3:33PM CSAR. 510-835-OG85 P. 3 STATE OF CALIFORNIA - TRAPFIC COLLISION CODING CHP 555 Page 2(Rev.7-03) OPI 061 DATEOFCOLLW(+l(-..--Y --W T,f&Ct oo)•- - NCICe OFPWIER LD. MJM%R ot OMtEflB l:c+E .. DIYVERb'ADDRESa .. NOTIFIED PROPERLY= c. ��` :;t, :zs' \"',�.t°3� YES [] .No pi4MAGE' DwcP.PTICNDFDAMADS S15ATING POSITION.' '•'''SAFETY EQUIPMENT INATTENTION CODF-S . OCCUPANTS 7 ^� -'L•AIR BAGDEYLOYEO 141C[319CLE-HELMET •A-CELLPHomHANOHEw , A-NO`7EINVF_H4 I M:AIRBAGNOTOEPLOYED Q{�NE& PA:_SEgGER__ _ 8-CELI,PHONEHANP•SfREE`: �� B-UNKNOtN. ::.` N-OTHER �-NO� \C. �Dy ��j,iCIRONICEQL'IF!fJIENf C-LAP.BELT USF , P NOT KEQUI.2C-D W„�� �*'•U- �� U-CAPAaTNOTU5[o - fSD E-IT/DI /CD 1 2 3 .1"DRMER'`;. E=SHDULDERt ESSUSEb:,.:�:: .. _ ��)�:' t'i �� F-EAT] 1ARt4. b;r;.••....,.. 2TO6-PAS btNt",I:•RS� F-SHOULDERFW2 SSNOTUSED: -n-•,-Cti11DRE6fRAIN1"�:j`.'+t}' G;CI'IILC EN . 4 5-,6-. 7- '. C�=L ISHOULRERN! tE85U$ED ° O•INVERIOLiluSt=�J•`r(�'h�� - H-{Sf�IA. y:--:�.,.> �' 8-R�AROCC.tKK'ORVAN H"-LWSfibLf0Ei4HAhizt�sixtOsED R-INVEIi1C ENOTIFSE[7�,t •� r TEO 1•PE1iS0 til.HYGYE- 7 ,9-P(aS{TIONUNKNOVh! J-PASS MERESMUTUSED ,S-INVFJiIC US_UNFR,`jlj �• PARTIALLY EJECTED d.13.7.m IE-PASSIVERESTRALy7NOTUSED_'_. ..:T-INVEHIC _SMPROPE E. 3-UNt0401", :r_ 1 -'i1-NONSiN1 ICLE. ^:� .- h ��` :;7• ITEMS MARKED MOW FOLLOWED BY AN ASTERISK V) HR6ILA PEAMED W THE NA PRWARYCOL.LIS!ON.FACTOR. - :•:.TRAFFCt:OFITROLDE1110ES' SPECIAL DF... N• :,r-•I MO}'EMG 'PRECEDING' LJSYNUNBER i OPPARTYATFAULT '• ..�; 1. '2 3 ; - 3-3"'-''-,::.�•"Y;0 ON - A v a-n nvwutra, u,to YE5 CONTROLSFU31C110tSNG HAZARDOUS �. A STOPPED CONTAOLS.NOTF.UNC'66NING' CELLPH04EE�6{91�i1�r3E 1' r 13:.PROGEEpIIjGSTRAIGHT' B- PcR DRWING'G': G CO`tTROiB OBSCURED v-: CELL-PNQr A LWA5SFRE£IN US[. �.,.FWS OFF ROAD ... D.NO CONTilckkWRES� TY �'r 10R^^` D..cELu PHONE NOT N USE, R iAAKING RIGHT TURN- C O7HERTH/J'lDRRIER' - -}a: TYPE DBCOL.USION'•...-' E'SCFi00EewltLLl�7ED7'. `: -- ' �C 4'�`MAK{Nd-t r•.1'URIf '.` :.. D UNKNOY.N vzv •.-\..', ,v., :'' ` F MAKINGU TURN � ti i•:�'A';N�;_Ot4 ' F 75 FT A70TORTRUCICcd1190'- .. .... •':' 1�.:6CD�C.1Yl1;3E•. .. _ Ci 32 FT?RNLER COMBO• -- l3 BACKktifl .5• , t C REARE H H SLCMAWISTOPPINGi WPATHER :ARKITO2ZMS .0. OA,. I'•PASSU4GOTHERVEHICLE A CLEAR E 3f(.OBlF.CT ,J`.i'�,�;'1'''.3:r;':�t l't •.._.,,,\.�,,-r'`:`, �.CHANR•1G1ANE5 . �j R CLOMP F OVERTURNED . _ i !K: K`PAE2Kwc KANEINER RAINING G VEHiCLEIP[D7=STTt1Ah1 '++ L's.ENiER1 L_L _`tel f _ '• '•- INGTRAFF7CC 'No NI"DY F.RIff)SAfE1�1Rti1N0 , E`FC�dI4TSIBILITY" ' ''"FT ."...`.• N - -- NwNGIt QOPP0S14GLAHE tit F d :`. T ks:� O?S1R7(EA� _ `••.�.t'� � .4DTo.R.vF.rilcl:�li�bt:9> ,rrtTH.;" Ovt S'O - - ',+ A'NON-COLLISION . PMERGING .:LIGHTING - B PEDeSTAIRN Q.TRAVELINGWRON3WAY A DAYUGHT C''OTHERitDTORVEHICLE f i 2 3 OTHERASSOCIAW-6*,ACfdR{$)r'' '1' ",f�OT}ILR•''-11"\• 'y. B DUSK-DA%%' D MOTORVEH16LEONOTHERROAUVIAY {A4U4XITOVTEMS) :••- ,xsrtiTuxwutra+ cte \• ; V - . C:DARK-STREET L]GHTS E PARKEU ht0'}R VC-i11CLE'. ,<,-. �'A �� ,'.i,�:•,�r:' s C;1 5 aC3Yfs. D DARK•NO STREET LIGHTS F 7RA1t4 - •y RD F BARK•M.EETUGHTBNOT a BICYCLE T: a Ba s�MA"144. F_UNGTIGNING'=...•; H JWRAAL L. 4 Vr�l;_Jrio c..._, ',l `-... I ROADWAYSORFACE cnE0 �.� _ SQSttIEtl'�dRUG' a- $•.: `1 G YES 1 2 $ PHYSICAL A DRY _ I F{YiEDogi-ecT: . . +I- iTg� C1' i` ND e St S (6f1tRf(A10 2/TEMS} 8.tYEY: :•..: }s_s, - D "aS �� r - ?� A TiAD NOT BEEN DRfNK4tG C SNOV✓Y:=.ICY. �C :', f}`�.L' S� f17.Ef�Or;tECT: E VISIONORSCURMEM: _ B'HBD-UNDERINFLUENCE� Ip.SLIPP�RI'b'ItFDDY OILY EfC.. - F INATTENTION•: C HBO-NOT UNd kI PLOENCE•. ROADWAY CONN TIONf$I STOP&UUTRAFFIC ' D HBO-O,IPAIRMEN7U- NICNOWN' (URR�(T02/TFA1S} ' PEDESTRIAN aACTIOYS _ H E14TERINGILEAVWGR,V,tP _E VNDERDRLF'INFLUENCE• �3'A'HOLES.DEEP RUT* 3G A NO Pt bESTRilAN3 INVOLVED _ I PREVIOUS COLUSi0t4 F IMPAIRVIENT-PHYSICAL'• _Y B. LOOSE GIATERIALONROAp'NAY' 13 CROSSING IN CROSSWALK- .) Euil AMLIARWITNROAD GtMPArRLVIENTNOTKNOYt'N C OBSTRUCTIONONROADWAY* - ATINTERSECTION !• _ K-OE ECTNL°'VEl{;•EOG1R•�)`L'j• , •-.'.:-ti::�^-}{.t,lp•DAGf?UCA9LE ' :•'�D CONSTRUCTION=kEPA1R7.ON£ ° C CROSSINdINCKOSWfALK-NOT•:.••-. � � YES 1 SLEEPY/FATIGUED• > r•• F REDUCED ROADWAYV✓IOTH ALTINTERSEOTIQN F FLOODED' D CROSSING-NOT IN CROSSWALK `-`L,UNINVOLVED.YEHICI G OTHER-; E IN ROAD•INCLUDES SHOULDER M OTHER` —G H NO U14UNALCONDITIONS F NOT IN ROAD . 4 N N NONEAPPARENT _ G APPROACFUNO I LEAYING SCHOOL BUS O RUNA%VAYVFJl1CLE SKETCH - MISCELLANEOUS . LNDtCATeeroam - V-1 `a t OSP 03 78147 - - Jan 31 2008 3: 34PM CSnFl 510-835-0685 p. 4 STATE OF CALIFORNIA INJURED/WITNESS!PASSENGERS CHP 555 Pane 3 0w.8-872 OPI 042 P°a° °� ' •OAiEor cOlil:l>;i VC. DAY YEAtC TUE f ` 0 �• �Y 77107 W . rdw PASSENGER Tr EXTENT OF INJURY("X"ONE) -I....giiM)WAS 1"V ONE) PARTY st:AT w9w OHIY Cl/LY AOE SEX TATAI 6L'bTRE OYNERiMMLS CokwLwr NVNDEft F"*. EDUIP. >acCZED PJJURY IN711RY INS-M OF PAN ORNER r,tisa, P.D. 61GW-L.UT MCA G 7 Nt ❑ ❑ ® Q.19101 ❑ JEJ a. INAf1�1Q 0.9./A8DRE59 Tti£PH7k1E AA el_CMa41524) .1 d U LZ�tY�'N�/1119 RLl !sd 9 q�r ft (LYAFiED OrLTRAI'S�ORTEO FSY J/`y� T,U(..,,TC: �a/YiV !•_1•SLIL�L�f�!(J��CG.�?E/�_ DFs:FIDEowRrEs �'/J�" -` '�oLrt+rcR rrork'TED im:r�ra.o.o.rnocr�ss .1" !, � JE El ©o,�► ��Ati tF� rpahl��,�r,4 ��� � CM—E,ED CUM TRINSPCRII'i1�HY Ate- TAKEtiTa DESLR6E RUUEiF6 � � �'• ✓' �i„•..•••'•''•~�� ❑MTV DF VI”rCRQJF NOW)EC ❑#s K L 7 M ❑ ❑ ❑ Ja 10101 ❑ I C I 2 1G NN O.0.6-/ [.S IELEs'NJNG C/Z1 V&-A-n 1 oo !4.444e HI Z94 .217 pruwSGotl»rxMSPOR�naY:^ TAKE7+ro- II—X&I 1"fli /tFt DESLR3e p;,tualEe !'7 VICTIM OF=LEN•r C7051ENOTIP7EC {1NlJREbGOHL!!Y)�TRAN••(,�5'JSQM-Df.Y�F TAKEN 1 R e14 -c Deb•LpaE UitJFifEa - DNOTfdOF;0011.N WjW,NDMRM - CJ ❑ D ❑ NAAterD-O.B./ADDR68 rE7EPIiDIIE (YiA1F5y QALY)TUNSPORTED GY; TAKEH To DFS:RIREtNA1RES - - . - V1CTIr.IOFYIOLEHf C.R1ME ti0TIAtJ ❑# ❑ ❑ ❑ ❑ ❑ J ❑ ❑ ❑ ❑ ❑ wa�rao.a/AeDr<Ess rlsaPNorrF WU;r=DMY)TRA.45P0RlEDBY: TAKENTO: DESCRIBE ftMAMS . _ - �VICTRn Or ViOICHY GteLE HOTtflED PREPAROMNAIIE In.NULDCIt UO. OAY Y2Alt REVIMER•SNARIE - NO. GAY YE/A Jan 312008 3: 35PM CSFIR 510-835-0685 P. 5 STATE OF CALIFORNIA NARRATNE[SUPPLEMENTAL PACE --�� DATE OF INCIDENT 11MB NCIC NUMBER OFFICER I.D. NMIBFR 1/25/08 1945 0710 1445 08-7522 I NOTIFICATION: 2 On 8/25/2008, at approximately 1945 hovers, I responded to a call of an injury traffic 3- collision with an ambulaince.responding at Richmond Parkway and Hilltop Drive. I 4 responded from Moyers Road and Parker Drive and arrived on scen..e.at�? r y 5 1950 hours. All time, speeds;measurements in this.' ti1 '4 �tte 6 Measurements-were taken b a acini except where indiE l'.4 1.01 11j?UCATED Y P g� p TO 13�D . 8 SCENE DESCRIPTION: 9 At the scene of this collision,Richmond Parkwayis.%m1J ib ' sou bound vided,�. 10- eight lane-city street. Hilltop Drive is a six lane northbound/ s819` eltTs`freet 11 Both the surfaces.are composed"primarily of asphalt.�f Iie posted speed limit is 50 miles 1.2 per hour-on Richinoad Park tiVay. Engine 468 and ANI.responded to the scene to treat 13 all of the pdrrties' iiijuries. 14 15 Parties: 16 17 Party #1., (Lewis was located at the scene shortly after my arrival. P-1 was identified , 18 by his valid California Drivers License. P-1 was placed as a party by the.following: 19 20 Driver statements, physical evidence,possessioli of the keys, solo occupant. 21 22 Vehicle # I White GMC Sayana was located in the#1 lane of northbound Richmond 23 Parkway on all four wheels. The vehicle suffered major front end damage. 24 25 Party#2, (Crawford) was located at the scene shortly after my arrival. P-2 was 26 identified by his valid California Driver's License.P-2 was placed as a party by the 27 following: 28 29 Driver statements, located.in the driver seat, passion of the key and the registered owner 30 of V-2. 31 32 Vehicle#2 White Lexus 470 was found on all wheels, facing northbound on the 33 northeast cornier of Richmond Park way and Hilltop Drive. V-2 suffered-major front.end 34 damage. PREPARER'S NAME I.D.NUMMR DATE REVIEWER'S NAME K Palms 144 Jan '31 2008 3: 35pM CSAR 510-835-0685 p. 6 STATE OF CAUFORMA NARRATIVE/SUPPLEMENTAL PACE DATE OF INCIDENT TIME 'IdCIC NURgiER OFFICER I.D, NUMBER 1/25/08 1945- . ` 0710 1145 08-7522 . 1 PHYSICAL EVIDENCE: 2 3-- Vehicle debris and fluids from.both vehicles were located at the scene. 4 5 STATTNIENTS: 6. Party 41 (Lewis)' _ 7 Refer to Officer Kaiser's suppleinental report for P.1.' t t e i �1Ck 17TPARIM�N'1` i Ct3 I i4.(3LIED pOCtIMEN r 9 Part�2 (D. Crawford).was traveling northboun in the��l lPLtCATFD and of Riclunond 10 Parkway approaching-Hilltop Drive. P-2 watched In he#1 11 LaneofRichmond.ParkwyP-2connuedthouZheese-rielrh use e ada j� r 12 green light in his direction. As P-2 entered the intersection P4,00d��e�-1 ' 13 (east)'tum onto Hilltop Drive from the left hand turn pocket_on southbound Richmond 14 Parkway. P-2 attempted to brake to avoid colliding with P-1, but was unsuccessfitl due 15 to the wet roads..P-1 struck P-2 on the left front side of his vehicle. P-2 complained of 16 . pain to his back and neck and had.difficulty breathing. P-2 believed he was traveling at 17 approximately 40-50 miles per hour. 20 Witness#1 (A. Crawford) was located at the scene shortly after nay arrival. IV-1 was 21 the right front passenger inside of V-2:W-1 saw that the light was green for northbound 22 . traffic on Richmond Parkway as they entered the intersection. W-1 never saw P-1 enter 23 the intersection. He only saw P-1 after they collided: -14 25 Refer to Officer Brownlee's supplemental report for additional witness statements. 26 27 OPINIONS AND CONCLUSIONS: 28 29 Summary: .30 P-1 was traveling southbound on Richmond Parkway in the#I lane approaching 31 Hilltop Drive. P-2 was traveling northbound Richmond Parkway approaching - 32 Hilltop Drive. P-1 made a sudden left turn against a red arrow and collided with 33 P-2 causing major damage to the both vehioles: P-2 attempted to brake to avoid 34 colliding with P=1 but was.unsuccessful. PRPPARER'S NAME I.D.NUNMER DATE REVIEWER'S NAME K- Palma _ 1445 1/2.572nng Jan 31 2008 3:36PM CSAR 510--835-0685 p, 7 STATE OF CALIFOMIA . NARRATIVElSUPPLEMENTAL PACE f I)ATF OF INCIDENT TUVIB NCIC NUMBER' OFFICER I.D. NVIVaER +� 1125/08 1945 0710 1445 08-7522 1 2' P-1 suffered chest pain, shortness of breath and blacked out after the crash.P-2 3 suffered moderate back pain, neck pain and had difficulty breathing. W-1. 4 suffered back pain., neck pain and a possible broken nose. NV-2 suffered neck . 5 pain, bazk pain and blacked out. All four were transported to John Muir Medical 6 Center in Walnut Creek by AMR: _r,__.:.. :.�.�.... :.._._.�....._ .:.,...._ 7 i�C3�I+/It}i�t�i =�i�LIGE DEPAk�i; :.s.•:.- °' : . CONTROLLED DOCUMEN i• 8 V-1 'and V-2 were towed by.me.per CVC 22651 '(W ffffiP8'M"1TR forms for 9 additional vehicle-information. TO:— � -- 10 -- 11 Atex oflmpact: DATE:.. 12 The A01 is approximately 54 feet west 6f the eas`M-IT pro7.ongatlon OMFO l_nond 13 Parkway and 69 feet north of the south prolongation of Hilltop Drive. Established by 14 statements and physical evidence_. 15 16 Callse: 17 P-1 caused this collision by failing to stop for a red arrow, CVC 21453(c) 19 RECOMMENDA'IIONS 20 I'recommend'that P-:1-be found at fault for the collision. Route to Traffic. 'PREPARER'S NAN E LD.NUMBER DATE REVIEWER'S]'.'AMB . K. Paima 1445 .119,519,008 . Mar OS 2000 10:28811 CSAR 510-035-0585 P,1 REODS STATE OFCAUFORNIA r]Z �L� („� f HARRATlVOSUPPLEMENTAL Olf/7 Y0 ! PAGE I OF Z, DAT£OP WC@ENT TO.rs .?:CIC nUM M OMUR LD. NU6IIJF$ 0 01/25/05 1945 0710 1421 ; 08-7522. 1!, 10 1 STATFMFNTS- 21 2 ' y 3 WITNESS> 1(JEiv1UNs) jU . 4 Jenkins stated that he was the driver of a vehicle driving directly behind Party#2's h>3 5 vehicle.According to Jenkins he was approAmately 40 feet behind Party#2's vehicle. !w° 6 Jenkins stated he was traveling northbound along Richmond Pkwy.As Jenkins' �W 7 approached Hilltop Dr he saw that the traffic light at Richmond Pkwyl Hilltop Dr was 8. green for Northbound Richmond Pkwy 1raiic.Jenkins continued traveling northbound on 9 Richmond Pkwy when he noticed Party#1's vehicle begin to make an eastbound turn 10 onto Hilltop Drive.from southbound Richmond Pkwy.As Party III's vehicle was making 11 the turn it struck the front left portion of Party#2's vehicle causing Party 91's vehicle to 12 spin out in the northbound lanes of Richmond Pkwy,Party#2's vehicle continued straight 13 and came to rest at the northeast confer of the Rictunond.Pkwy/Hilltop Dr intersection. 14 Jenkins approximated the-speed of Party Q's vehicle prior to the collision to be 50 MPH. 15 fenk-in's.0aled he is nDsitive his lip-lit and Party#2's liglnt was green so Party 1/1 must 16 have run the red light.Jenkins was unable to approximate Party O's speed, 17 Jenkins'contact information is as follows. 18 Anthony Lawrence Jenkins 19 1 Shores Ct 20 San Rafael,CA 94903 21 HM:415-4914744 22 CELL:510-693-3938 23 24 WITNESS 42(GARCIA) 25 Garcia stated that Drior to witnessing die accident he had been driving his•vehiele 26. westbound on Hilltop Dr-towards the intersection of Hilltop DrAbchmond Pkwy.As 27 Garcia reached the intersection he stopped for a red light.White Curia was coming to a 28 'complete stop he saw Party flys vehicle begin to make an eastbound tum onto Hilltop 29 Drive from southbound Richmond Pkwy.At the same instant be was watching Party#1's 30 tum,Garcia realized that Party#2's vehicle was traveling Northbound on Richmond 31 Pkwy at approximately 40 MPH and was going to be hit by Party 41's vehicle.Garcia 32 watched the collision and thought he would be struck by Party#2's vehicle after it was 33. shuck by Party#1*s vehicle.Garcia saw the front left and center portion of Party Ill's J4 ve. lUle 3n1Ge we lront ierL pur pon or frilly 4.4 s YGwwo.Aiwwa Gown nut esutuate tarry F?MAFY,X9 NAME I.D.NUMY" DATE REV1hWM'$XU19 \V_�rS3llWNr.F.F. 1421 •01/24/r1R LT.A.THREETS.1217 STATE OF CALIFORNIA NARRAnVEISUPPLEMENTAL, PAGE Z of 2_ DATE OP INCIDENT TPAR NCIC NUMM GynCtiR SIX NUMBU 01/25!08 1945 0710 1421 08-7522 1 41's speed and stated he was unsure what color the northbound/southbound Richmond 2 pkwy traffic lights were at the time of the collision:Garcia's.vehicle was not struck 3 during or after the collision. 4 Garcia's contact information is as follows: 5 Juan Aguilar Garcia 6 1945 22nO Street 7 Richmond,CA 94804 8 HM:510-237-17I6 9 10 FORWARD TO OFC K.PALMA'S.PRIMARY ACCIDENT REPOR E . ,r CLAiM 71 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 Claim Against the County, or District Governed by ) the Board of Supervisors, Routird ) NOTICE TO CLAIMANT and Board Action. All Section r 111, The copy of this document mailed to California Government Codes. JUL1 6 2008 you is your notice of the action taken on your claim by the Board of COUNTYOO Supervisors. (Paragraph IV below), MARTINEZ CA A�.� given Pursuant to Government Code AMOUNT: IN EXCESS OF $10,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: ANDREW CRAWFORD ATTORNEY: TERENCE D. EDWARDS DATE RECEIVED: JULY 16, 2008 BRANDI LAW. FIRM ADDRESS: 354 PINE STREET, THIRD.FLOCRY DELIVERY TO CLERK ON: JULY 16, 2008 SAN FRANCISCO, CA 94104 BY MAIL POSTMARKED: RAND DELIVERED FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 16, 2008 JON CULLEN, er Dated: JOHN Deputy II. 1. ROM.: County Counsel I;O: Clerk of the Board of Su ei•visoi•s i ( 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 clairnant. The" Board cannot act for 15 days (Section 910.8). ' O Claim is not timely filed. The Clei-k should return claim oil ground that it.was filed late and send waming of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ( � By: Deputy County Counsel 1.11. FROM: Clerk of the Board T0: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. OARD ORDER: By unanimous vote of tl�e Supervisors present: (✓f� This Claire is.rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for. this date. Dat / 404AHN CULLEN; CLERK, By Deputy Clerk WARN1. G (Gov. code section 913) j Subject to ccitain exceptions,you have only six(6) months Froin the date this notice was personally served or deposited in the nWil 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 tlo so inrinerliately. *For Additional Warding See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that 1. aur 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 Ntartinez, California, postage I'ully prepaid a certified copy of.this Board Order and Notice to Claimant, addressed to the.claiman.t as .shown above. Dated. ��°m' JOHN CULLEN, CLERK, By _Deputy Clerk JUL- 15- 2008 1 :41PM CCC RISK MANAGEMENT NO 901 P 2 BOARD OF SupERWSOP6 OF COYrP.A COSTA COUNTY ` INSTRUCTIONS TO EXT 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 Ir= than one year after the accrual of the cause of action- pov. Code§ 911.2.) B. Clams must by filed with the Clezk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez,CA 945 531 C. If claim is against a district governed by the Board of Supervisors, rather than the County, the navne of the District should be filled in. r . D. Lf the claim is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for frauxdulent clsim_s,Penal Code Sec. 72 at the end of this form. Ross fkkkaffCKf=AERNanRRfINXLki[Rcit■ came RE. Claim By: Reserved for Clerk's faiug sump ANDREW CRAWFORD RECEIVE® ,JUL 1 Agai=t the County of Contra C�asta or ) 6 2008 CLERK BOARD OF SUPERVISofis District) CONTRA COSTA CO. (Fill i a,the nam e) The lmdersigned claimant hereby hakes claim against the County of Contra Costa or the above-named distiat in the sum of din excess of and in support of flus claim represents as follows: . UU I. When did the damage or inJury occur? (Give exact date and hour) January 25, 2008, approximately 7:45 p.m. 2. %ere did the damage or injtuy occur? (Include city and county) Richmond Parkway approaching Hilltop Drive, City of Richmond, County of Contra Costa, State of California. 3• How did the damage or injury occur? (Give fiz11 details;use evtra paper if required) Please see attached pages. 4. 'mat particular act or omission on:the part of county or district officers, servants, or employees caused the injury or damage? Please see attached pages. 5 %st are the names of cotmty or district officers,servants, or employees Gausi-og the d map or injuuy? Please see attached pages. JIJL. 15. 2008 1 :41PM CCC RISK MANAGEMENT N0. 901 P. 3 ti 6. VJ�ai damage or mjudes do your claim resulted? (Give full exa mt of injuries or damages claimed. Attach two estates for auto damage.) Please see attached pages. 7. How was the amount .claimed above computed? (Include the estimated auaotmt of airy prospective injury or damage-) Please see attached pages. S. Names and addresses ofw:ttnesses, doctors, and hospiWs: Please see attached pages. 9. List the expenditures you made on account of this accident or iajury: DA's TTME AMOUNT Please see attached pages. Mmiff"titttRia=ERESIN R+dtt CCU fAatfsfay atafsftKkitfRKEN afttt[ataf Rtlfatall FINNIC 11 199ktf■111 );-Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on bis behalf." SAID NOTICES TO: (Attorney) 1 Name and address of Attorney ) TERENCE D. EDWARDS ) BRAND I LAW FIRM ) P*�anta�e) 354 Pine Street, Third Fl) __: :.-.. TEAS N BEHALF OF CLAIMANT San Francisco, CA 94104 ) BRANDI LAW FIRM • )- — 354 Pine S rPPt+ Thi• rrl F1 nor - (Address) San Francisco, CA 94104 ) 'Felephane No. 415 9 8 9-18 0 0 _).Telephone No. 415 989-1800 ftfs 4 SKURtWtfafa RRt as a k a On ea■Rt[if1lt=t=saftfflR=tYCREW ttkfdff■fRksta tf■ft t ff It i ftf A kfkl PUBLIC RECORDS NOTICE: Please be advised that this claim forza, or any claim filed-%ith the County=der the Tort Claims Act,is subject to public disclosure under the California Public Records Act (Gov. Code, §5 6500 et seq.) Furthermore, auy auw,-hments,addeudums, or supplements attached to the claim foFm,inclining medical records, are also sabject to public disolosure. R IN am AR■a=Y s ORAa Ina EWc da a am KK k t%gas IN Was K z k t a MERE=t i a t a f am R U e f a f E a N a a■as a t■t s t a.=t f a a 1 NOTICE: Sealion 72 of the Penal Code provides: f 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 distil} t, board or offiou, authorz_ed to allow or pay the same if pnuim, any Else or Emidulent cLtim, bill, account voucher, or writing, is punishable either by imprisonment iu the County jail for a period of not more than one year, by a fine of not eno—eding one thousand dollars ($1,000.00), or by both such imprisoaaaent 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 f=_— "ITIE 131ZANDI LAW FIRM THOMAS .I. BRANDI, 45.208 TERENCE D. EDWARDS, 1/168095 354 .I.'ine Street, "Third Floor San Francisco, CA 941.04 (415) 989-1800 Attorneys for Claimants: DAN IEEL CRAWFORD, DORI CRAWFORD, and ANDRF:;W CRAWFORD CLAIM OF: DAN1EI. CRAWFORD, DORI ) CRAWFORD, and ) ANDRI"W CRAWFORD ) CLAIM FOR PERSONAL INJURY AND PROPERTY LOSS Claimants, ) [Government Code 5910] V. ) THE STATE OF CALIFORNIA; COUNTY ) OI- CONTRA COSTA; CITY OF ) RICI-(MOND, ) Defendant. ) TO ]"HE COUNTY OF CONTRA COSTA: Claimants DANIEL CRAWFORD, .DOR.I CRAWFORD, and ANDREW CRAWFORD (hereafter"Claimants") claim damages from THE STATE OF CAL11"ORNIA. COUNTY OF CONTRA COSTA, and the CITY OF RICHMOND (hereafter the "PUBLIC ENTITIES"), (a) Claimants' post office address is: c/o The Brandi Law Firm, 354 Pine Street, 1 Third I lour. San Francisco, CA 94104. (b) "flee post office address to which Claimants desire notices to be sent is c/o The Brandi Law Firm, 354 Pine Street, Third Floor, San Francisco, CA 94104. (c) This claim is based on the personal injuries sustained by DANIEL CIZAMIFORD, DORI CRAWFORD, and ANDREW CRAWFORD. On the evening of January 25, 2008 at approximately 7:45 p.m., DANIEL CRAWFORD was driving a white 2004 Lexus SUV northbound in the #1 lane of Richmond Parkway approaching Hilltop Drive in the City of Richmond, County of Contra Costa (hereafter the "ACCIDENT SITE'') with DORI and ANDREW CRAWFORD as his passengers. At said time and place, Reoinald Lewis was driving a white 1998 GMC van southbound on Richmond Parkway approaching Hilltop Drive. The Crawl:ord vehicle lawfully proceeded straight through the intersection because it had the green light in its favor when the Lewis vehicle made a left- hand turn from Richmond Parkway onto the Hilltop Drive in front of the Crawford vehicle causinY a collision. All claimants suffered serious physical injury and loss of personal property. 'Elie accident was caused by the PUBLIC EN'I TIES and/or their employees for reasons including, but not limited to. acts and/or omissions which resulted in: • failure to warn of, and/or prevent and/or correct a "dangerous condition" (a condition of property that creates a substantial [as distinguished from a minor, trivial or insignificant] risk of injury when such property or adjacent property is used with due care in a manner in which it is reasonably foreseeable that it will be used) on. or immediately adjacent to, public property; • failure to provide and/or maintain proper signs, signals and devices at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafety in front of the Crawford vehicle: ° improper settln`._T and synchronization of lights and signals at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle; • failure to provide and/or maintain adequate, safe, and proper lane markings, and traffic channelization at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle, • improper setting of speed limits approaching the ACCIDENT SITE which caused the vehicles to be travelling at an unsafe speed for the ACCIDENT SITE; • failure to provide and/or maintain adequate signs, signals, devices, chanlclizatioii, pavement, and striping at the ACCIDENT SITE, • failure to provide and/or maintain adequate sight distances at the ACCIDENT SIT E: • failure to provide a safe and reasonable geometric alignment of the roadway at the ACCIDENT SITE; • failure to provide and/or maintain adequate drainage, pavement grooving, and al.ld hydrolo0cal devices at the ACCIDENT SITE which caused the accident by makim, the roadway surface slippery and unsafe; • fai]ure to adequately warn of the dangerous and unsafe conditions set forth above. The PUBLIC ENTITII S had actual and/or constructive notice of the dangerous condition and a suifficicnt amount of time prior to the accident to have taken measures to have protected the public against the dangerous condition. (d) As lar as is known at the time of the presentation of this claim, Claimants claim damages liar personal injuries, pain and suffering, hospital and medical expenses, lost wzw,cs and loss ot'personal property. (e) Tlie name or names of the public employee or employees causing the injury, damages or loss is unknown. (t) The amount claimed exceeds ten thousand dollars ($10,000) as of the date of the presentation of this claim. The jurisdiction over the claim would rest in Superior Court which is also known as the Court of Unlimited Jurisdiction. Date: Jule 15, 2008 THE BRANDI LAW FIRM By: _ TERENCE D. EDWARDS Attorney for Claimants 4 Jan 31 -2008 3:33PM csAri 510-835-0685 p. 2 STATE OF CALIFORNIA TRAFFIC COLLISION REPORT RE"ORMI. �:}JP,555 Ps9C 1(R©y.7-03).,OPI 651 npF,C1V.00N]ITIOHPi lgAgER RTa RtH C,R'y' .. JLQIClSL DSTRICf LOLL REPORTICfV.9ER'" . Wnwotmy. R1ia Pui COLRii'i . .. MPOAnw DISTRICT AF•AT • -..- IaL0EL1EIhC1El .. '�.. b&LW=04.` ._ M7. DAY YEEM TWEC24M Ye.,, la usEe er'rl.of vAnui.. �- 1YF. t ' O_' Ari!rrEGnotmT+ (/ff �• �y 6TATErff. EL- `_' -T t-/!�•l SGA A�e•� .. .r-�••�( � G � OEC ..FEEiIMILP- OF �JY� •QO GA� - .NO . PARTY[itIL�AS LIGF'13E HUMBER: oTAT_E CL1Gs A1R,FA"r 11 - •:. - :{M'.;. )ALMSEe STATE' �1 /L+JE6=BiTiT.STAbCx'i[tS'..... .. -----� �. •... _ _ _ - : V .MA h wtE SDRIVER: .. /� �sPa$Rh:NOF VtJrCLEOriORIixR3Ofi` --'� — �—rG 07NER r &OF Eft.❑{�-.,-..L.� FIC W.GY- SEX LKRi 'CUSP : x Day. &r �NP.I1.LZl3._L•'_-"�-�-... _ -_'. _ .. .n /1/..�•'?�.... i •{1t- )) :"P•�vORllECfiilxLALDEFtZTI�: .:,.:._ f'L'ARENT �:6E%'�R TO ILA4RATPad OTHEA FiD.4<PFG7:�.... .. ... -.. OLC!!tA tiiO!IE:.�_.-. VF}ttiIE DEHTF�G+,TIOH tAJSiihli�r rr����rr��r .;.!..::: ':`::..:i:..:•. yEHICLETYAE. DEiCVEt11CT.E LSAN.cG :... 61iADE 4V DUMGEU AAEA . Rtot.k !Y'.-cARiaElf POLA:YAU,Y,RER .'} UNlC� El ❑h! ORQ�RD R 7AJ l:L•OS%E �R TCti STRE;f;L(Ai;itGY.YIAY 6PeETI L!MIT CA - . Aw ... fitl7ti'k'5`3 LIG�1.'3=Eltx.:.i=R; 10TATc CLA68 ARDAC IGN'E:TV ati uP; LSL.NCAA VAR,.VODFIX.OLOR .....:' LlCiiiSE thRi6ER. S,TATE-.:. . . .. .. ALE '.' . .P�•'ra WOE AS - . TMAN El. .. ._. _ _. .. SAOG C oD f � A R - artirA' �-y .• � GAIAE'A8 DRNFR OP ED.C"YMATEOP .. .. Y'�f •. .., _ ... .... .. ..�.Vii. �Q :. t'OSITICN DPP.KAIGLE ON OROVIS CY:. ��i CEI adFll-VE oQ-- _ &CYCIR ... _. ,. •,. C1tST ! - ISAC}: - F,— H-ZnT LLEtGfiT -6h2TEfDATE Yo:r - :.,..._. _...-....:__::__•. ::.: .; ./ . r Ua Ds 1 J ! `,• -.l3[a -.. U V G ' ( / .{ :. PludRv�rwir�u DEP[CIC:' f UNEFPPARRIT HEFFR TO NAARA l}E, UT!£R HDUE FFiD.4E -_ dU3CiE§S FHDh6E %f.8:CIE IDEhnFICAT0fKJUBER: `J"� -,tJ��f P ter ... ..•• .:,.:_..':' ...,;., '•-. ..: SCrrFsr VE -•;.:..'•..`.: _4G4k�.l�ME!1... VCL TYPE bE H1LYE .E'• � lireEa .P.CLICYIAMER ❑UHK ❑NOLSE. �MirJOFtiI fl:R OFTR.AVEL rAl STRc_ET o;Zimmky ..6AEF,DLYIR DOS - .. CAL-T ��.TCPPSC�_ A1GA%' PARTE VFA^u LICETisE AVi SEt TAM- Mx sa: AIR MO ;SAFETYEDUW: %'Pi YEAR 'UAkT-JMO�LCOLAIi LMFJ CE f:(Y IN�Ji gTALE ......'......:........................... ____ 'OrcV[A !L\L'�jflR OLE LASTJ. -•. . ... ..... ................... _ a,}NFi talk= . ❑ _ wir-AS DRM1rR Pf r- STAEET/SR7RESG - - .... __ ❑•••: .'THUH- 05YIER'SAPDRESS ❑ _ SlJAfl AS DR1VcR PAWED OITVMTA'MOP ❑ - .- DtSPOsfT:al:OP Vp'}UCI.ONaROC-E:SDF: . DFFICER❑DRIVER bTHER BIGY• t77C WVR EVES {{13:7c.iT NEE3FiT LC4TM]ATE RACE ( ' PR1oAUECRLiMALb7�67& It0NEAPPARENf i�WERT0!MAT1vc .OTHEit HAVE Prk+riE USINE:S Piiat.c VEWGLE R ATL0.4 NJL'�A. VfJCCLE`T,YPE DE3CAf'.E VEIi1CLE OA.MOC - SHADEIH DAI•AGCC AREA !' OUNK ❑iiONE ❑MINOR ti3UPAVCE CA4R1'cfi POLICY NLMER ❑KAJI)R❑RUII"-OVER i DuioFiPAV=.1 ONSTRUTORH:CHWAY 'SPEED Lt&ifr CA Oar CAL-T TCP$g0 ...LIGlIE7(_T___ PREPAfi N E D:CFATdi Hili FLED REVIEu'ER'6�h�h!8j� i,THREETS ��2 ` , lit . YES NO NIA 0555 7C1tm Jan 31 2008 3:33PM CSAR 510-83570685 P. 3 STATE OF CALIFORNA '' r.- ::-'-• TRAFFIC COLLISION CODING' CHP 555 Pae 2(Rev.7-03) OPI06i DATE 04 Gm LM0Y C-1,=UAY YEA[�� TV+E{i100f' ' NCICC OFfIGER LD. - FAM9ER . —� ow:rErtar:ctr< . . .. ' ati:ux'aAooRe� .. Wo7+fTE° PROPERL>', �` _- YES NO .. -. `sem:..' ... SMTINI POSITION'.'. `". ..'SAFETY EQUIPMENT INATTENTION CODFS . -AIR d4G DEPLOYED U I C BICYCLE•HELM A-CELLPHONE HANOHEI,D; A-H04EIVVEHiCLC 64-AIR BAG NOT DEPLOYED. O,F,IVER PASSEyGER .B,=PHOHERMDSfREl' s-UNfUtpYaN. :: ': .4-OTHER !t'NO~ (. tl> • " l�TF�f 3i CTRONIC EQUl*FNT C-L4P.EUTUSED, P-NOTKEOUIRF� L,V•:Y-•&•/".' - RL?.�"V-IV+Di /CD —_� R•W RaT NOT UBED .- - .?:-•• •..- f� \., r +�` '�' E-$N, G _ ` .-1-DRA'tT;; E=SHOULDERFIARNESSGED:;: ..µ.-.: .. I?'v:.-•-:-:'.::... "'P,•!{:�'.4.i�1� .i 2 3 2706-pA^,'EtNu1R5: F-SHOtnDJtf{AlthiESSNOYUSFny�:: :,-,CtiiLtiRF.6 t 4 5•,S 7-STArfO;,i Lt/1,G�17•gF1.R .=1f.��S}IOtt}RE•R tl.g.3)JESS US.-D ° O-IN VEHI u^7=6•`rri 'h+1��S N-#t�11A! :t.-..; t'_• H'-LAP1SRbUU3EKHATWE$SNOTUSED R•fNVFJiIC ENOTlISE9 ,. {�• EO I�I,'Q- t'SO TiYG'ENc'~ 8-REAROCC.tR}Z'OR VAN J-PASSIVE RESTRAUIT USED S-INVEHIC�-USE UNf(1,'Ll4f�� •r Z•PARTIAI.LYFJFCTEO 9•POSITION UN Q�OYtN R Lj 7 K-PASSfVE RESTRA NOT USED ., T-IN VENiC IMPIiOPE SE. 3-UNKN0IV(! ;'tC=ATTY,E,f} �./ C•O HER : i ':U-NOILEINI ICLE. ^:� ;! .l ITPMS CdARKEi3 BELOY FOLLOWED BY AN ASTERISK(`) IL tRDOjl�PrATNED iN THE NA _ PRiMARYCOLUs!ON FACTOR• ;7RApRG t HTROL CELICtS"''` SPECIAL L N- -'� f ;NSOLEbG PRLCEpIt(G' . LlSYVURBER 1 OFPARTYATFAULT Pa; { -'2 3 .;�•""LOLLISOf - A V?u�M+xSnolA,rn; cnto" _ COftTROLSFUVCTIOIS;NG 1;AZARDDUS T ' Yea nSf. .r+• ASTOPPED .. ...B CONTFtOLS.NO7E.UNCTIONIFk;' CELL PHONE 1' 'i i BPROG EWAG'STRAICHT'— �B EK IN.�ROPcR D WING': . , G OO4TROLf.OsSCUREC fN Use. - -G^iifU�i.OTF Roa'} .. -. DIto Ci>NTtiOCSPRE$ T'7t- .��Utt"�•= Moat:MONE NOT MI USE, �• MAIOTRIGHT TURN ... CORIEf2fiHht7UftNER' "::4: TYPE Dr 06LOSIOfi.:..:-' E'SCHODCBUS>'.1FLlYTFA�:`.: _ 1 �' 4' 'kta,mkoL .,TUNH -. R A';HE/ds; F 76 FT R10TORTRl1CfCCUf.180'_ F fAAKIf:GUT1JRf1 '- _ ,T �.; H-.SIO si4 E•,,..-• .. - - (3 32 Fr.TWLER ccwBO' G SACKLtiG .t . , .. C_R[AR END H ,'.-•'':.:.:... H SLOWA4(�f STOPPIIiG '. WEATHER ;ARK1 T021TEMS -U ©ROAOTI M.•, r _ , _ _ ItiYASStIiGOTHERVEfIiCf.£ Il A CLEAR .. - E'. rh008lECT �,J :" ', :.`tt!'t :+,\•., -� .:� -Cr" '�'.._211 CLOUDY _F OVEMRNEo'. ; r K. IC PAEtI<R;�FAAtf=WER kg RAINING G VEHiCLEIPEDtTftIAM ! t'L sflovnNo_ .........'.. .._ N..D �..:.._:,....:.. :... ....:.... . • Mme"-- - !' ;�,L'•.Eh1TERI aTIL4FFlCC _ �_ M''—oYf�E�•Ut�sas=>�iktiiNo ' N)ONG II OPPOSMIG O LFtiE t dT�iER:r, a fis ,n-{'i� �.i,Pati .!-0OTOR•yENICLII:VUSL'Od,YATH.; - O ?S1R YA]D A NON-cowsION _ P MERGING .:LIGHTING - B PEDESTRUcN _- n Q,TRAVELINC WRONG WAY A OAYL1GfiT _I :0�OTHEKIg0T04VEHICLE 1 2 3 OTHERASSOL7A7FDFlfCTQft{5{ ,' ''' R $ DU6K-DA:Yf{' Q MOTORVCHICLEONOTfiERHOAUYlAY fktAwITO2f7EMS) C16AM<-STREET LIGHTS --E PARKED MOTOR VEHICLE'. � F wsccnx+wurrw. crteo• `• ;.G. �'J '� .` I'�-j"-'"" D DARK-NO STRFET LIGHTS F TFA I! E_D/•RK-.M.EETLIGHTBNOT _G BICYCLE u -r G trovr„cuwa". " .. ' `'�� .v:ccorra,svwn�c Vcc.n:;fc"QIL3i'Its } WAAL ROAOWAYs _: ,y�s,j�SO'•TiPdiIlYtS.f C.A-liL. 3 ilUG' A.DRY I Fi,:oGE cr: . ? _'! r' t` '�,L INo , ' . S (11MV,�To2 Ais) B.4t.T': :' :.' - D `? NAME: ' -a >��o A-7 LAD N07 BEEN DRINI9NG C sAov¢Y:=Ic.Y t'_ f j.�.>;--'; ';UJ q{ OWEC7: . E VISION DSSCUREAit-W: F3 Hl3D-UNDER INFLUENCE J . p.51tFP il'tS,uooY OILY ETC.). - F fRATTEN-tION'_ C HBD-NOTUNd a1 FUlENCE•. ROADWAYCONDITION(SI f{!AR!t/702/TEI15j G STOP&GOTRAkTIC Bts-QIPAIRMENTUNKNOM' mlSACTIONS H ENTERING/LEAVINGRPAP E VNDERbRLIG`'fNFLVENCE• 4%40LES,DEEP RUT' 5e A'ffO 04DFSTOIANS INVOLVED — d PREVIOUS COLLISION F IMPAIPMENT-PNYSfCAL- _S.LOOSE NATER1AL ON ROADWAY' "N CROSSWALK- J UNFAMLIAR VM ROAD 0 MPArRINENT HOT KNOM C ORSTRUOTIONONROADWAY` - � ATINTER$ECTIGN ' - K-OcCEC7NE�+EI{;•EOTJIP�'1`CiT>'L�. - ^ I{_N�1�APALiCABLE_ D CCNSTRIICTION=fiEPJ41R7.ONE C"CROSS1NG1tYCROB_C1Y/AI.K-NOT:-.•'.•'' : EIYFa ! SLEEPY/FATIGUED' _Ir REDUCED ROADWAY wwTH AT INTERSEOT6 n� _F FLOODED' �D CROSSING-NO.TINCROSSLtiALK L.URINVOLVED.VEHICLE f F ' G OTHER': E IN ROAD•INCLUDES SHOULDER - IVU OTHER' �G H NO U14UWAL 00NOITIOHS. F NOT IN ROAD AS N NONE APPARENT , -- C APPROMHING I LEAVING SCHOOL BUS O RUNA4V.kY VPJiiC'LE SKETCH MISCELLANEOUS MWTENORTH eW 6SP0378147 Jah. 31 2008 3:34PM. CSAR 510-835-0685 p. 4 STATE OF CALI FORMA INJURED I WITNESS I PASSENGERS q p CHP 555 Pane 3 May.8-9n OP J042 P� �J .' DATEWCOU)SIMO. DAY YVA10 Tug 4707 N=s ' .- Yvmtcsa. PA33EN60 EXTENT OF INJURY("X"ONE) -t....utiED WAS(")VONE) PARTY SEAT aAF¢Tr �OHLY GAY ASE SIX PATAL 6CI7E0.E OTHE"Jay .0 COWIJIV(T HIlMBETZ P178. EOt/'.P. £.EGTFD wJ)nY INJURY INJURY oc vA!! aarrEn PAS. rea 5)cYttLYT amen NW'Z I0.0.B.)ADDRESS TELVP 0'7 rt/ ;6&4 LuAt"" A0 "/Aly�/ ill 9 Sl (LYAPZD ON.IT TRVVPORTE.T BY: TAY. ITD: 1DESCRGElwuREs o. ,•f o /I/c5 C a6? t 10 1 El l;At:El D.0,0.lAbORE38 L yy� �c+• n 1" � [2 � £ OFJE C�,*TRA.NRT Uf�I' vxet7 T0: �/• 1J Di"scarsaa,�ra ff f� r� gyp:�,...-• i.�....•••+`."` ❑NCTPA Or YIOtENT CRpJE NOT'FIEO ET LQ c C-AdTCLUMM IrAr�D.an.,Aa •ss l2 aa -/i�lX Q)RJCREC Oth.Y)TRW^vPDR cD Bf: �A � 7AKE*J TO: lwR�' DEiCR3E 4JLR7E8 ' . Y.CTIAI OF TALENT Pave WiTIME0 myeg R.l ADZLRE 3 T1:TEPHONE c.� ggac y Olel/�s t ry�C QNA)REDONLY)TRWSPMTED6Y: TAKEN TM I' !='i OESCfitBG RiJ.JWEo . ❑wcruor+vlolFinai.lAENonF�D ❑? ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 'fDS-O.B./ADDRES - CftAJPwoMV)10%MRTEDDY; TAKEN TO -- DES[RIEE INJJR�.S - . VICTIM OF VAXENT ORWE NOTMD ❑# i ❑ ❑- ❑ ❑ ❑ ❑ ❑ ❑ a ❑ MkW. ID.0.B,l ADDRESS TELEPHONE (I"V1 0-CMY)7RA4'SPORM EY: TAKEN TO: DESC tIBE INJURIES _ ❑V1Cf 10FViOCCM'CRb!✓;xoT•WEO PREPARBi's NMIE ID.MJ4'EGS 1.50. DAY Y'c.AR JAVIE3&VRV.NAJJC N0. DAY YFM Jan 31 2008 3: 35PM CSAA 510-835-0585 P.5 STATE OF CALIFORNIA NAJRRAT(VE(SUPPLEMENTAL PAGE Sf� DATE OF MIDENT TIMB NCIC NUMBER OFFICER I.D. NUMBER 1/25/08 1945 0710 1445 ' 08-M2 1 NOTIFICATION: 2 On 8/25/2408, at approximately 1945 hours, I responded to a call of an injury traffic 3- collision with an ambulance responding at Richmond Parkway and Hilltop Dri'v'e. I 4 responded from Moyers Road and Parker Drive and arrived on scene-ata t 5 1950 hours. All time, speeds;measurements in this. 6 Measurements were taken by a pacing, except where lndif 1�1� ��J)UPL;CXTEU 7 -�-- 8 SCENE DESCRIPTION: 9 At the scene.of this collision, Richmond Parkway is._%- aoaJhba�irm.sout bound-diiftL vided -_. . 10. eight lane-city street:Hilltop Drive is a six lane northb,bund/ s zftyff eet. 11 Botli the surfaces are composed'primarily of asphalt.He posted speed.limit is 50 miles 12 per hour on Richmond Park Way. Engine 968 and AMR responded to,the scene.to treat 13 all of the parties' iiijuries. 14 1.5 -Parties; 16 . 17 Party 91., (Lewis was located at the scene shortly after my arrival. P-1 was identified . 18 by his valid California Drivers License. P-1 was placed as a party by the following:. 19 20 Driver statements, physical evidence, possession of the keys, solo occupant 21 22 Vehicle # I White GMC Savana was located in the 91 lane of northbound Richmond 23 Parkway on all four wheels. 1te vehicle suffered major front end damage. 24 25 Panty#2, (Crawford)w' as located at the scene shortly-after my arrival. P-2 was 26 identified by his,valid California Driver's License.P-2 was placed as a party by the 27 following: 28 - 29 Driver statements, located.in the driver seat,passion of the key and the registered owner 30 of V-2. 31 32 Vehicle##2 White Lexus 470 was found on all wheels,'facing northbound on the ; 33 northeast cornet of Richmond Park way and Hilltop Drive. V-2 suffered major front.end 34 damage. PREPARER'S NAME I.D.NLR4BtR DATE REVIEWER'S NAME K_ Palma 1445 1/25/20(}8 _Jan '31 2008 3: 35PM CSAR 510-835-0685 p. 6 STATE OF CALIFORMA NARRATIVEISUPPLEMENTAL PAGE ( �� DATE OF INCIDENT TIME TdCIC NUMBER OFFICER I.D. . NUMBER 1�2s�as 1945 0710 1445 08-7522 . 1 PHXSICAL'EVIDENCE: 3.. Vehicle debris and fluids from.both vehicles were located at the scene. 4 _ 5 STATE,A ENTS• 6. Party#Lewis) 7 Refer to Officer Kaiser's supplemental report for P-1Vis;stAi It L10E l71;PARTMI✓� I i Co gr-6L[JEDb'JCUMF . r rG>3 3 DUPL[CATF"D 9 Party#2 (D._Crawford) was ttaveling northbound in.th; O-426 of RicMnon'd 10 Parkway approaching.lZilltop Drive. P-2 watched rd.,.1_trave�send the#1 11 Lane of Richmond.Parkway.,P-2 continued througle_intersertierrbecue ie ad a 12 green light in his direction. As P-2 entered the intersection Pllm > �, 13 (east)*turn onto Hilltop Drive from the left hand turn:066i{et on southbound Richmond 14 Parkway. P4 attempted to brake to avoid colliding:with P-1, but was unsllccessfitl due 15 to the wet roads.P-1 struck P-2•on the left front side athis vehicle. P-2 complained of 16 . pain to his back and neck anal had difficulty breathing. P-2 believed he wag traveling at 17 approximately 40-50 miles per hour. 18 19 20 Witness#1 (A. Crawford) was located at the scene shortly after nny arrival. W-1 was 21 the right front passenger inside of V-2:W-1 saw that'the light was green for northbound 22 . traffic on Riclunond Parkway as they entered the intersection. W 1 never saw P-1 enter . 23 the intersection. He only saw P-1 after they collided. .24 25 Refer to Officer Brownlee's.supplemental report for additional witness statements, 26 27 OPINIONS AND CONCLUSIONS: 28 29 Summary: .30 P-1 was traveling southbound on Richmond Parkway in the 41 lane approaching 31 Hilltop Drive. P-2 was travelitig northbound.Richmond Parkway approaching 32 Hilltop Drive.P-1 made a sudden left turn against a red arrow and collided with 33 P-2 causing major damage to the both vehioles. P-2 attempted to brake to avoid 34 colliding with P=1 but was.unsuccessful. PkEPARER'S NAME I.D.NUMEt DATE REVIEWER'S NAME K Palma i 4a s 1 n.5i20OR Jan 31 2008 3:36PM , CSRR 510 -835-0685 p. 7 STATE OF CALIFORNIA . NARRATIVEISUPPLEMENTAL _ PACE I}ATF,OF WCIDENT TIME NCIC NUMBER: OFFICER I.D. NUMBER 1/25/08 . 1945. 0710 1445 08-7522 - 1 2 P-1 suffered chest pain, shortness.of breath and-.blacked out after the crash.P-2 3- suffered moderate back pain., neck pain and had 'difficulty breathing. W-1. 4 suffered back pain,neck pain and a possible broken nose. W-2 suffered neck 5 pain,back pain and blacked out. All four were transported to John Muir Medical G Center in Walnut Creek by AI'vIlZ: �I{1 D iiLIC DrPl�R 7 CONMOLLED DOCUM�N t� 8 V-I and V-2 were towed by.me per CVC 22651forms for 9 additional vehicle information. ------ 10 --- 11 Area:of Iinpact: 12 The A01 is approximately 54 feet west of the ease-u—M pra'longatlon of 'clim'ond 13 Parkway and 69 feet north of the south prolongation of Hilltop Drive.'Established by 14 statements and physical evidende. 15 - 16 Calyses 17 ' P-1 caused this collision by failing to stop for a red arrow, CVC 21453(c) 19 RECOMMENDATIONS 20 I'recommendthat P-.l-be found at fault for the collision. Route to Traffic. 'PREPARER'S NAME LD.NUMBER DATE REVIEWER'S NAMG . KPalma 1449 ' Mnr 05 2006 10:2oRM CSAR 510-035-0685 P,1 RECORDS: STATE OF CIU FORNIA �.�(„j NARRATIVEISUPPLEMENTAL 1 ' r. L PAGE !0 2 DATE OF INCIDOU TD. .TCICM JMIM OFFICER LD. r7I161Dr$ `0 01/2s/o$ 0710 1421 08-7522 Icla 0 1 $TATF.,MEN'PS: 2 a 3 WITNESS#1(JIMUNS) 4 Jenkins stated that he.was the driver of a vehicle driving directly behind Party#2's m 5 vehicle.According to Jenkins he was approximately 40 feet behind Party#2's vehicle, LU 6 Jenkins stated he was traveling northbound along Richmond Pkwy.As Jenkins M 7 approached.Hilltop Dr he saw that the traffic light at Richmond Pkwy/Hilltop Dr was W 8 green for Northbound Richmond Pkwy traffic.Jenkins continued traveling northbound on 9 Richmond Pkwy when he noticed Party It I's vehicle begin to make an eastbound turn 10 onto Hilltop Drive.from southbound Richmond Pkwy. As Party 1fl's vehicle was making 11 the tum it struck the front kelt portion of Party 1#2's vehicle causing Party 41's vehicI6 to 12 spin out nt the northbound lanes of Richmond Pkavy.Party#2's vehicle continued straight 13 and came to rest at the northeast corner of the Richmond.Pkwy/Hilltop Dr intersection. 14 Jenkins approxmmaeey the-speed of Party#2's vehicle prior to the collision to be 50 NVH. 15 fenkins stared he is nositive his liebt and Partv#2's light was green so Party I/1 must 16 have nm the red light.Jenkins was unable to approximate Party#1's speed. 17 Jenkins'contact information is as follows. 18 Anthony Lawrence Jenkins. 19 1 Shores Ct 20 San Rafael,CA 94903 21 HM:415-4914744 22 CELL_510-693-3938 23 24 WIT1uFSS#2(GARCIA) 25 Garcia stated that orior to witnessing the accident he had been driving his'vehicle 26. westbound on Hilltop Dr-towards the intersection of 1lilltop DdRiehmond Pkwy.As 27 Garcia reached the intersection he stopped for a red light.While Gm-cia was coming to a 28 'complete stop he saw Party#I's vehicle begin to make an eastbound turn onto Hilltop . 29 Drive from.southbound Richmond Pkwy.At the same instant he was watching Party#1's 30 turn,Garcia realized that Party 42's vehicle was traveling Northbound on Richmond 31 14cwy at approximately 40 MPH and was going to be hit by Party#1's vehicle.Garcia 32 watched the collision and thought he would be struck by Party#2's vehicle after it was 33 struck by Party M's vehicle.Garcia saw the front left and center portion of party#1's i+ ve)11C1e sauce rile none ren portion or ralay 4e s vewvle.trWwa couru nm esulnate eatzy FRUARER'BNAM I.D.NIURUWA DATF_ RF.VIEVaRSRAME �Q\VhR.AF, 1421 LT.A.THREECS 1217 STATE OF CALIFORNIA NARRRATIVEISUPPLEMENTAL PACE Z OF'Z_ DATE OF MCIDENT TM NCIC-am. lER OFnC:1;4I.D. NUI-MU ol/25/09 1945 Q710 1421 08-7522 I #1's speed and stated he was unsure what color the nolthbonnd/southbound Richmond 2 Pkwy traffic lights were at the time of the collision.Gamia's.vehicle,was not struck 3 during or after the collision, 4 Garcia's contact information is as follows: 5 Juan Aguilar Garcia 6 1945 2220 Street 7 Richmond,CA 94804 8 IM.510-237-1716 9 10 FORWARD TO OFC K.PALMA'S PRIMARY ACCIDENT REPORT. CLAiM. BOARD O.F SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 Claim Against the County, or District Governed by ) the Board of Supervisors, Routin Er 3: r r NOTICE TO CLAIMANT and Board Action. All Section.re j The copy of this document rnailed to California Government Codes. you is your notice of the action taken JUL 16 2008 on your claim by the Board of COUNTY COUNSEL Supervisors. (Paragraph IV below), MARTINEZ CAL given Pursuant to Government Code IN EXCESS OF $10,000.00 Section 913 and 915.4. Please note all AMOUNT: "Warnings". CLAIMANT: DANIEL CRA14FORD ATTORNEY: TERENCE D. EDWARDS DATE RECEIVED: JULY 161 2008 BRANDI LAW FIRM ADDRESS: 354 PINE STREET, THIRD FLOCRY DELIVERY TO CLERK ON: JULY 16, 2008 SAN FRANCISCO, CA. 94104 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 16, 2008 JOHN CULLEN, r 671 Dated: By: Deputy If. FROM.: County Counsel TO: Clerk of the Board of S ervisors (-J'*'I his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FALLS 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 Clei-k should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: mc Deputy County Counsel 1.11. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely:with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous:vote of the Supervisors present. ( This Claim is rejected.in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its.minutes for this date. Dat - ! JOHN CULLEN, CLERK, Byx4&0r=1C=_=Deputy Clerk WARNi. (Gov. code section 913) Subject to ceitain exceptions,you have only six(6) months fi•otll the.date this notice was petsonalfy served or deposited in the mail to file a court action on this claim.See Government Code Sectim 945.6.You may seek the advice of an attorney of your choice in connectim willi this matter. If'you want to consult an _aUonrey,you should clo so Immediately: *For Addilimal Warning See Revel-seSideofThis 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 1 deposited in the United States Postal Service in [Martinez, California, postage fully prepaid a certified copy of this [3oard Order and Notice to Claimant, rr�idressed to the claimant as shown above. Dat JOHN CULLEN, CLERK By Deputy Clerk • JL. 15. 2008 1 :41 PM CCC RISK MANAGEMENT- N0. 901 P. 2 BO OF SUTE��ty T�s�aa TION S O)F�+corr��A COSTA mCon r RqS Aclaim relating to a cause of�.ction for death or for injury to persoa or to permonal property or growing crops shall be presented not later than six monthsafter the accrual of the cause of action. A claim relatlug to any other cause of action shall be pre3ent5d not Wcr than one year after the accrual of the cause of action. pov. Code§ 911.2.) B. Chdins ns must be fled with the Clerk of the Board of Supenisors at its office is Room 106, Co i n_Administration Building, 651 Pine Street, CA 94553. C. if claim is against a district govi ed by the Board of Supervisors, rather Bran the County, the naive of the District should be Mad in. D. If the claim is.aaaiast more than ana public entity, separate claims must be filed agaiEst each public eyutity. E. Fraud. See penalty for fraudulent claims,genal Code Sec. 72 at the end of this form. lEse wwkk=eee}zRBig a as an KORY YaILK NIL unit Zen zzk lalze z e a a a KY it at a kKKKERRANN l KKK WaX e e X RE: Claim By: Reserved for Clerk's filing stamp DANIEL CRAWFORD ) RECEIVE Agailot tht County.of Contra Costa or ) AUL 1 6 2008' 1DiZict) ?CL-FK BOARD OF SUPERVISOfiS CONTRACOSTACO. (Fill!a the name) ) The.-taidersigned ciaimmt hereby makes claim against the County of Contra Costa or the above named distTi ct in the sum of$' est f and in support of this claim represents as follows: 1. 7&en did the damage or injury occur? (rive exact date and hour) January 25, 2008, approximately 7:45 p.m. 2. where slid the damage or injt y occur? (Include city and county) Richmond Parkway approaching Hilltop Drive.,. City of Richmond, County of Contra Costa, state of ,,California. 3. HOW did e damage. or 1p-juiy occur? (Give f M details;use extra paper if required) Please see attached pages. 4. ghat pardcutar act or o-mission oa the part of county or district officers, servants, or employees caned the injury or damage? Please see attached pages. 5 7&.-t are the names of county or.district offimrs, servants,or'employees causiag the damage or injury? Please see attached pages. " . J' L. 1�. 200$ i ;41 PM CCC RISK MANAGEMENT EMENT NO, 901 P. 3 6. W:�tat da`aa.ge or Wmi;es do your claims, resulted? (Cive ftO, extent of injuries or damages clab: ed. A-tt=h two estimates for auto damage.) Please see attached. pages. 7. I-1-ow was the amount claimed move comp+utted? (Inoiude ae estimated amourt of aay prospmtive injury or damage.) Please see attached pages. S. dames and addresses of-%itnesses, doctors, atd hospitals: Please see at `pages. 9. List the exppendmues yo-a made inn account of this accidemt or '-+jury; DATER 'i'IIvIE AMC3D�V I Please see attached pages. amps m ORR ERR Ka KKKK aEnna ann E.KK KK"t WXEKK 111maz,,*KKKlKs"KaisarNwani■""!)RKamuzz it"YttuK K RAkl;Kk! -Gov. Cock Sec. 910.2 Provides"The claim,shall be simod by the claimant or by some person onbis behalf." 9LND N0110ES TO: (Attorneyl � Name and address of Attorney TERENCE D. EDWARDS BRANDI LAW FIRM TERMOPBM., �N BEHALF OF .CLAIMANT 354 Pine Street, Third F.I. San Francisco,, CA 94104 BRANDI LAW FIRM �. - (Address). San Francisco, CA 94104 `I`elephon,hro. 415 989-1800 )Telephone 1 1 o. 415 989,-1800 IN WARN KKKI<fftitlN"Rua amks a#fKKKleusaw Iz=m=kff[nnmKztYlLINXXrYlrf118ww sktlLff4"KullZZKZINlRIL{ PUBLIC RECORDS NOTICE-. Please'be advised that this claim forxa, or any claire filed with the County un ler the Tort Claims Art, is subjeot to public disclos= under the California, Public Records Act (Gov. Code, s5 6500 et seq.) Furthermore, au), at4 c bxmen'ts,addendum, or supplements attached to the claim farm,inoludiug medical records, are also sabject to puVdc disclasum, ilIffaxAam KKYK�■i i IN KK KK if ME a R K"YKK egg ENV ENE'a n*K tKK K"Ki"BIN.")S KK KK i zzan its KK K1 tiSIKKccKtili NV i.iCE: .Se aloln 72.of dze Penal CoA prauzdex. Every person who, with intent to defraud,presents for allowance or for payment to any state board or officer, or to etny county, city, or disftict board or ofsicex,'authoriz-d to slue or pay the sane if genuine, any ase or fraudulent -loon, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not mare than one'year, by a ane of not ex;.:eding one thousand dollars (�I;Oflb.fl(1), or by both such imprisonment and zine, or by imprisoument in the state prison, by a fine of zot exceeding ten thousand doIlaus ($10,000), or by bath such izaprisonmeatand=' a. THE BRAN DI LAW FIRM THOMAS J. BRAND[, #53308 TERENCE D. EDWARDS, it 168095 354 Pine Street, Third Floor San Francisco, CA 94104 (415) 959-1800 Attorneys for Claimants: DANIFJ, CRAWFORD, DORI CRAWFORD, and ANDREW CRAWFORD CLAIM OF: DANIFL CRAWFORD, DORI ) CRAWFORD, and ) AND.RF'W CRAWFORD ) CLAIM FOR PERSONAL INJURY AND PROPERTY LOSS Claimants., ) [Government Code §910] THE STATE OF CALIFORNIA, COUNTY ) OF CONTRA COSTA, CLTY OF ) RICHMOND. ) Defendant. ) TO THE COUNTY OF CONTRA COSTA: Claimants DANIEL CRAWFORD., DORI CRAWFORD, and ANDREW CRAWFORD (hereafter"Claimants")claim damages from THE STATE OF CALIFORNIA, COUNTY OF CONTRA COSTA, and the CITY OF RICHMOND (hereafter the "PUBLIC ENTITIES"), (a) Claimants' post office address is: c/o The Brandi Law Firm, 354 Pine Street, 1 Third Floor, San Francisco, CA 94104. (b) 1'he post office address to which Claimants desire notices to be sent is c/o The Brandi Law Firm, 354 Pine Street, Third Floor, San Francisco, CA 94104. (c) This claim is based on the personal injuries sustained by DANIEL CRAWFORD, DORI CRAWFORD, and ANDREW CRAWFORD. On the evening of January 25, 2008 at approximately 7:45 p.m., DANIEL CRAWFORD was driving a white 2004 Lexus SUV northbound in the #1 lane of Richmond Parkway approaching Hilltop Drive in the City of Richmond, County of Contra Costa(hereafter the "ACCIDENT SITE") with DORI and ANDREW CRAWFORD as his passengers. At said time and place, Reginald Lewis was driving a white 1998 GMC van southbound on Richmond Parkway approaching Hilltop Drive. The Crawford vehicle lawfully proceeded straight through the intersection because it had the green light in its favor when the Lewis vehicle made a left- hand turn from Richmond Parkway onto the Hilltop Drive in front of the Crawford vehicle causiny-1 a collision. All claimants suffered serious physical injury and loss of personal property. The accident was caused by the PUBLIC ENTITIES and/or their employees for reasons including; but not limited to, acts and/or omissions which resulted in: • failure to warn of, and/or prevent and/or correct a"dangerous condition" (a condition oleproperty that creates a substantial [as distinguished from a minor, trivial or insignificant] risk of injury when such property or adjacent property is used with due care in a manner in which it is reasonably foreseeable that it will be used) on, or immediately adjacent to, public property; • failure to provide and/or maintain proper signs, signals and devices at the ACCIDENT SITE which caused the Lewis vehicle-to turn unsafely in front of 2 the Crawford vehicle; • improper setting and synchronization of lights and signals at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle; • fallUre to provide and/or maintain adequate, safe, and proper lane markings, and traffic channelization at the ACCIDENT SITE which caused the Lewis vehicle to turn unsafely in front of the Crawford vehicle; • improper setting of speed limits approaching the ACCIDENT SITE which CLlUsed the vehicles to be travelling at an unsafe speed for the ACCIDENT SITE; • failure to provide and/or maintain adequate signs, signals, devices, channelization, pavement, and striping at the ACCIDENT SITE; • failure to provide and/or maintain adequate sight distances at the ACCIDENT SITE..; • Failure to provide a safe and reasonable geometric alignment of the roadway at the ACCIDENT SITE; • lailure to provide and/or maintain adequate drainage, pavement grooving, and and hydrological devices at the ACCIDENT SITE which caused the accident by making the roadway surface slippery and unsafe; • failure to adequately warn of the dangerous and unsafe conditions set forth above. The PUBLIC ENTITIES had actual and/or constructive notice of the dangerous condition and a sufficient amount of time prior to the accident to have taken measures to have protected the public against the dangerous condition. (d) As far as is known at the time of the presentation of this claim, Claimants claim damages for personal iniuries. pain and suffering, hospital and medical expenses, lost wages and loss of personal property. (e) The name or names of the public employee or employees causing the injury, damages or loss is unknown. (f� 'T'he amount claimed exceeds ten thousand dollars ($10,000) as of the date of the presentation of this claim. The jurisdiction over the claim would rest in Superior Court which is also known as the Court of Unlimited Jurisdiction. Date: July 15, 2008 THE BRANDI I.,AW FIRM By: ` TERENCE D. EDWARD Attorney for Claimants 4 Jan 31 2008 3:33PM Csf(n 510-835-0685 p. 2 STATE OF CALIFORNIA TRAFFIC COLLISION REPORT GaO S. 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' -'' ! _ _ - .:..LJ,..,:.:�...LJ BICY• SIX EWR _S FE]HT V1E73:iT •�'�UIRPIOA �./' RACE ... -... ,... . CUSY far 1Vl P/LWJJ IfEC£fAJBCAL 9E>-tLT[o: 'kOVEA£T'AR.ENTIEUUt TO ILA4RATNE . 'OTH.7L HO.N`£JFIa45:... -. :.. -.. .. . ..... i•:��: ' ... ,... _ .. YFJK(AE DEKTPIC},TIDN tA1LJ3ER:-r• 1:�1:;t G/10 . r► . ...;..:.. ..::..:i_ _ VEH!CLETYPE 065 . .-1Et17CLE LJAA4lGY :._ 6FNDELN Ol1MCED AREA .. q:;Ll 'i. -CxRRK..f! PcAr-Y£:UMBER •i �UNK•'aNOt�£-0h!ItiOR:';:';::'; - • lAOU: 4AJOR ROLL-OVER IXR'9ESfIA\'F1 wJ sTF�'LO:4;itW4�btY LPtr`D L"IT EE I C4 „fir:.:• ... _ '1) '. CAL T P,uiTy 6iiTS 8C3CfF79 FJUNfl R: aTATc CLASS 111AI ;6Ai L-1V EAWP, %01.YrA.4 YIHE IAODELJCOLOR LICi;JBE M1tCiER. ,36 PDA , 6[iATE�. aay.a .tf t '��LtrIL- a&1ULU5 r�..L SAMF_A.S ORR'ER:c?.._...... - e CQ44 L�7 5-sT1it�TYAOORESS .. - . .. - .-. 'TRIAN - -. .... j0kD fRVti+.it'S ADDRESS ASD _ .. ._ QQ - .GAFAE' RIVFR PARKED WNISTATEMP . . . .... - - �. WSFWTION D%V�iICJE ON OIUSF.RS Or:• .. b"- G - OFE£CER •DRIVER;a TTfF1,2. c .. .•. . a,.- - a OU_ - y Si_Y• GE7T''": JiAI�:�'_ EYEa , HidGHT \IF}GFST -&RTHOAT6 - _(�. vfJEAPF WfE REFERTONARRA-M OUST OTH0 ROME Ff aVW :. - l r - ,,.,�f Sl:SttE.§SFFION2 _ VEHK:tP DFX11-ICA•fpfl NJl10L3L' . . .' -(7-. � ..�i, f�•�F. ..: . �, /. '�4 ..• - •-• VO!JCLL-TYi'E DE S<iiBE YEF{1(YE 4QfAp('C. __1Y Q5►y1C�.ARFA_.._ Y4`'rsuRnuc�aVdi1ER f!OiA-Y£AWER �UkK aN4LlE. �lRu�ofYti` 1103.- 0.102ROLL-0VtIt`:? _ [I:R OFTAA1r3.DlJ BTJZrET iTZ IiCHJ:AY - 6PEEAL D LMAIT ' CA DOT C -T. _ TCPtPSC- -` .-:t •.. PARTY OR YFRG LF^.L7JSL ATMat7t AIR 80 ;SAFETYEQUIPJT�YEF UAICEVU6 fCOtARISA1`7 ._ ..._. -... - LI .............: PED".• STRErr?DDRess El ._01VNER'SAOC:RES$: ❑ SAlAB AS DR6R PAtF CITYFSTATFJDP .. . ' .. O£SPOSR!DUOPV3i1CL80PJ ORDER OF: E]OFFICER❑#2NER E]OTHER BICY• sE7i IMR EYSa iT WEIGH1 LTRTMVE RACE - PRRwV4cHVL!-ALapCTs: IJ0.SfAPPARFM RETERTONARUTIYt OTHER HoMEP!ic")E BUM4ESS PHONE vEwcLEpE{rrweAno.4 WMR: El 1-- voce k-'VoE O.SOWEVET'JCLL JXMGP- MkOCRIH MAAGEC AREA NSURAVCE CARRCR POLICY NtXMER DUNK E]TIOHE OMINOR' MOD: IAA1OIt❑ROU. VEA F OtR eP 7R4v.L ON STREET OR H:CHJ'JAY SPEED LMrcCA -� DoT •.:" --.. _• _••., .. 7 CAL-T TCPa'SO LICOl7L_ PRE PA n E (Y.Cs'ATcHHOT FIFORSCYIE44ER'& E CAT T: 114 S 12 YES NO NIA 'r;,.r+; ::.! ;\t 0555 7C31r0 Jan' 31 2008 3_33PM CSRR 510-835-OGOS P. 3 STATEGF CALIFORNA HR5FCOLLISION• 6ODINGI I _ 2;pf Peya -DATEDFCVLLW04 DAY ywo, THR;L()4 NCICF OFfiCERLD. •;.. HUNFJER `- -. 1eve cYV!iE#e!hLTc' .. �l\4c`R'o'ADDFL3'i. .. NOTIFlED PROPERTY, �- .^`,_- sJ''-''=>>� - Yes C] -No 5AMAGE D_if"TK:HOFDAA%GS SEATING PosmoN"' _ -'SAFETY EQUIPMENT INATTENTION CODES_, bcCUPANTS y L-AIRBAGDEPLOYEO IdIC[( CLE•NEjj ( A-CELlPIiOh>rHANOHEID; A-NONEWVEHi'LE �4-AIRBAG O.EZIVEi1' PAI :R -BI0EWHONEfiAFIP,SFf2E>`. ��� f3-UNIUiOrikN. :: 4-OTHER ,L'-JPO tC. ! °"; :, k ELECTRONIC EQLtP►AMT C-IaSP,YLTUSFJ3, P-NOTREQUI.RL-D _.-`.... :1ti,�Yt3•"' �`f�D -WI !CD U-ftp•W3,TNOT tI@ED .. ],JLl -&M ,O .T-DFbVEf;;-;. 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SE i' ?G B;PROFCttOIt1G'STRA1ChTr�_ OPER 6itWNG• G 00NTYtO.IIJ]BSCURED i_, C'CELL-PotU�E llAl71).SFR£EIN USE. C fW!OfF ROAd .. D.NO C0NTROCSPRE F�A�'YUIi^*` D..CkLL'�PI10NE ROT R!USF,-.„ •,I.tAKIN6 RIGHT TU N __.. .. ... .. - --T ---- CQiHEr2THIl4UKIVER' - ':1. TYF•EDF'COl.USfOn " " ESCIi000�lJS�TELFiTf_13� ?� .•z` .`ih1lSR:d .••TURtT ^D UIIKNOWTJ fi }, ',,, ,,:,\i s£C'A;}E1dS:-_O)) F 7bFTA10TORTRl1CKCUAt80 F MAKINGU TURN - B..SIDt:SLti17�E-...�_ G 32 PT T+iAlLER C047B0' 13 BACKLtiG C REf,R ENO H SLOW 40l.8TOPPING '. WEATHM(Y,ARK f TO2ITEEIS) 1',PASSUn OTHER VEIIiCt£ ri'ACLEAR E:JjoTRBJECT _ .J•`•i.t..,R. _•'•)-ri��t` L -.••,\,;.--."-:.`,iIcHA) RJGV+NES' D.CLOUDY F OVERT'URNF.D i K' _ WPAJRKW07MANEUWR p.ArNING - �G VFJIK:LElPEotSTRM . ! l'.L - �.'�t l' _ r`' � Ft . _ H.-OT}{ER'.:.': :.....:.. M. _ I OfTEff1R�5AFEll1{tNIN ..... t)' EFO(`IVISIBILISY'" IT. - N NXING[It iLQOPPOSIUGLANE ::a.1`•',n,{i( •�.i FY4.F4OTOR•}+EHICL�1_t:VOLV1 f3,Y++7H. 't O r•1 4* D ri1�sk1`b 'i't_%' . H S cio 'A NON-COLLISION P MERGING LIGHTING B PEDZSTR1AN _ n Q,TRrVELINGVRON3Y1AY''" A DAYUGirT ff*q!ig_R(AOTOR'VEHICLE 1 2 3 OTi1ERA550CtATrD�ACidR(S) ''' R OTHER•'''-II"ti- 1__). $ DUSK-DA'AW' _ D MOTOR VUHICLEONOTIiERROADWAY (k6WXITO2ITEMS) %'' V.SKTUN YL�UTY7d. CfrEp ` \• '� k r '' _ ` G:,DM,K-6'1'FiEET LIGHTS EPARKED MO 1R VEK.ICLE. �'3 ,-� ,,:�:�,,'�..'- .'•C;1 ' D DARK•140 STREET LIGHTS F YRAD+ f`x"� ❑HD ',' E.b! ..MEETLIGH`rANOT (38SLlCLE `-3,�r,.C' xas.kovsrwuwur.�v r fUNG?IpNiNG'...-,. ANBAAL " rn( ` ys %. 90M lETVrV RUG* ..._ ._ ` _ .ksa,„ ux ` cCtOMMAYSORFACE T 2 3 ' n�1Tc - PHYSICAL A IRY YDDrOT'_ . fFR0 Er. ijMS) ?—)2 A IAD NOT RECNDRINKrNG C SAO\ryYIG.Y L r ��� .L-yu �'tiT•FOIIJECr: E VISIONDRSClRE1iFM: B HB7.UNOFJ2.INFLUENCE p.SLtFPLRY IAUDDY OILY ETC.. - F fRATTUMON': C H8O-NOT UN[S ttl rLUENCE•. ROADWAYCONDITIONISI G 6TOPLGUTFUtFFIC D HOO-PAPAIRIMENTUNKNOM* (k�lR!C(702/TEfIS) w: -pEDF3TR1AfJ9ACTIOHS �HE14TERINGILEAVING EW&P EUNDER DRU INFLUENCE• `A•40LE9,DEF-P RUT• _ A NOPFDE$TRIANS INVOLVED .I PREVIOUS COLUSION _ F. IMPAiMIENT-PNYStCAL•- •_1-B.LOOSEUATERIAL ON ROADWAY' 13 CROSSING IN CROSSWALK- J U F-AMLIAR WITH ROAD Q IMIWIVAENT NOT KNOWN C OBSTRUOTIDNONROADWAY* - ATINTERSECTION__ K=DCkC-CTNCGEIi;ECII'IIRo'1`(,y ^. -.'•, ^- NOT`API'LICA3LE - 7T y_D CONSTRUCTION=REPARZONE C CROSS1NdifItkOSWIALIC AYES ! SLEEPY/FATIGUED' _F REDUCED ROADWAY VADTH _ I AT INTERSLWKW [� �F FLOODED' CI CROSSING-NOTINCROSSWALK L IININVOLVE'DMEHICLE G OTHER': _ E INROAD-INCLUDES SHOULDER M OTHER` { _ 5G-H_NOUNUMIALCONDITIONS. F NOT INROAD . /cS JO N NONEAPPARENT , _ G APPR( !_A.NG/LEAVING WWJDL BUS O HUNAN!,Y VF"J0I.5 SKETCH � MISCELLANEOUS ' . R+OfCAT<t:GRTN . f i` OSP 0370147 - Jan 31 2008 3: 34PM CSAR 510-835-0685 p, 4 6TATE O F CALIFORNIA INJURED I WITNESS I PASSENGERS ? '] Pte° CHP 555 Page 3(12ev.88-97) D 1042 3 w DATEW WU nN•NO, DAY YEAR) TTUE a.7� - . 0710 vRTxESS PASSENGER EXTENT OF INJURY C'X-ONS I.i.urcIZD WAS(90 ONE) PARTY SPAT aAFCTf ONLY OILY AGE SOC FATAL eEYEAE OY)IEA V39teL.f: COiPIAWT HVMDEA POs. EQUIP. �eCiED WJURY fNNRY INJURY OPPALN —Fl IA.se, Pea 6lCVTXAT I OTHER Ib.4L1D.O.EIJADDRESS ^ - ^ TELVlfUl E nD 0.4M CIO-Y)TRJJ'SPORTEt7 BN RQ T TO. �/V1� 14 DESCR-EE Uimms - a sS, 40,04wy O!IZ4*6�5 t; 46eliC/6iJejc k ❑ ❑ ❑ l;Akcl D.O.QfADIYL3$ L`'` is D Ctt h TR/�45PCRfkO HYD T/hTltt T4. DFSC:RGF INJI.l7IED .rQ:�,�..,,�•• ...+" � •,,.J _ . 4,�.....:.-•'.""' � N!-'TVA OF VIOLENT CRIMP HOTFIEO H 0.0.e-tADxea - ----- TEt13'IiDttf! a 10.0 .�M.44'"VZ4.d Al2 /09y4;l yl 04-6 OW-KED ONLY)TRNiGPORTED DY: TAKEN TO,, ) .. � �? !L d .mac DESCRee KAFVES VV=%k OF V;CLETJTm%v-?OTIFlED ❑ �r a �� rt, ❑ i ❑ ❑. ❑ ❑ ❑ ❑ I �'. , !D. AlADJRESS TEW-HO /nfi�r� tErs f 3 �, 1x74,. 8 eco cry ���a yOl �` t �C ORMEDOWO TRAMSmSTE06Y: TAKEN TSR OESCRt3EetJURIf: ' GO Za Cf� S �6�(lI2T__ Li3t. rrJT - - O VK:T{AOFYIOLEITTCR�lAENOTIFl4D ❑# 1 1 .0 1o ❑ El - ❑ ❑ ❑ El.-I ❑ HAAt f D.0.D./ADOR6SB iEiEP'fiOEE p,mF?D Dl1YT TSAUSPDRTEDnY: TAKEN TO OE9—'VBERWRIPS . . VK:TUA(IFYIOIENT CR1ME tiOTSiEJ ❑# ❑ 1 1.. ❑- ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ N+aA�rD.o.6-rAeaaEs3 YaI.ePNONE OKJ.K-CED WA.V)TAAASPORTED BY: TAKEN TC DESCRIBE IN URIE6 . _ VICTL410P V.oI-MY CRWE ROTAEO PREPARBY&NAWE � in.AVLfeCJt � 1lO. DAY YEAR REVIVhERtWJJC ND. DAY YEAR Jan 31 2008 3: 35PM CSAR 510-035=0685 P,5 STATE OF CALIFORNIA NAI2RAT(VEJSUPPLEMENTAL PACE —�� DATE OF INCIDENT 11Mfi NCIC NUMBER OFFICER[.D, Nt AIBER 1/25/08 . 1945 0710 1445 ' 08-7522 1 NOTIFICATION: 2 On 8/25/2008, at•approxilnately 1945 hours, I responded to a call of an injury traffic I collision with an ambulance responding at Richmond Parkway and FElltop Drive, I 4 responded frorn Moyers Road.and Parker Drive and arrNred on scene at RV 41Y 5 1950 hours. All time, speeds;measurements in this.i .ui�} 6 Measu'remebts•were taken'by a pacing, except where lndi ,. Tol-LE o BLE puPL1C � 7 8 SCENE DESCRIPTION: _�___ 9 At the scene of this collision,Richmond Par kway'is. o�batt saittlabound 'vided _ 10 eight lane-city street:Hilltop Drive is a six lane northbound/ sb eft ''street- 11 Pott' the surfaces.are composed primarily of asphalt.Tlie posted speed_limit is 50 miles 12 per hour on Richmond Park Way. Engine#69 and AMR responded to the scene to treat 13 all of the parties' injuries. 14 15 'Parties; 16 17 Party#l., (Lewis was located at the scene shortly after my arrival.-P-1 was identified . 18 by his valid Califortzia Drivers License. P-.1 was placed as a'pai-ty by the,following: 1.9 20 Driver statements, physical evidence, possession of the keys, solo occupant 21 22 Vehicle# I white GTNTC Savana was located in the#I lane of northbound Richmond 23 Parkway on all four wheels. The vehicle suffered major front end.damage. 24 25 Party#2,.(CraNvford)w' as located at the scene shortly'afler my arrival. P-2 was 26 identified by his valid California Driver's License.P-2 was placed as a party by the 27 following: 28 29 Driver statements, located.irl the driver scat,passion of the key and the registered owner 30 of V-2, 31 32 Vehicle_#2 White Lexus 470 was found on all wheels, facing northbound on the' 33 northeast corner of Rlcluno.nd Park way and Hilltop Drive, V-2 suffered major front-end 34 damage. PUPARER'S NAME I.D.NUh1B$R DATE REVIEWER'S NAIXC K 144 Jan '31 2008 3: 35PM CSAR _ 510-835-0685 p. 6 sTA'rE OF CALIFORAfIA NARRATIVE/SUPPLEMENTAL PAGE (t 17 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 1/25/08 1945 0710 1445 08-7522 . 1 PHYSICAL EVIDENCE: 2 3.. Vehicle debris and fluids from.both vehicles were located at the scene, 4 5 STATEMENTS: 6. Party#1 (Lewis 7 Refer to Officer raiser's supplemental report for Y-17s t t eziOL10E Ut;1'ARTM N ` - � Gc)�3'l,�(1l.l,ED DOCt3IvtENT rU}� DUPLICATED 9 Par #2 (D. Crawford) was traveling northbound in the4'�4ane o Party f Riclu-non'd 10 Parkway approaching-Hilltop Drive. P=2 watcheda X-1-txav-e1,e&s oun 1n the#1 11 Lane of Richmond.Parkway.,P-2 continued tllrougl �4e_interst etietrbmau-s—ea ad a 12 green. light in his direction. As P-2 entered the intersection PPI��ild�rr]V - 13 (east)turn onto Hilltop Drive from the left hand tum pocket on southbound Richmond 14 Parkway. P4 attempted to brake to avoid colliding with P-1, but was unsuccessful due 15 to the wet roads.P-1 struck P-Ton the left fiont side of his vehicle. P-2..complained of 16 pain to his back and neck and haddiflieulty breathing. P-2 believed he was traveling at 17 approximately 40-50 n1iles per hour. 19 20 Witness-#I LA. Crawford) was located at the scene shortly after my arrival. W-1 was ZI the right fiont passenger inside of V-2: W-1 saw thaf the light was green for northbound 22 . traffic on Richmond:Parkway as they entered the intersection. W-1 never saw P-1 enter . 23 the intersection. He only saw P-1 after they collided.' 25 Refer to Officer Browiilee's suppletneuta.l-report for additional witness statements. 26 . 27 OPINIONS AND CONCLUSIONS: 28 29 Summary: .30 P-1 was traveling southbound on Richmond Parkway in the#1-lane approaching 31 Hilltop Drive. P-2 was traveling northbound Richmond Parkway approaching ..' 32 Hilltop Drive. P-1 made a sudden left turn against a red arrow and collided with 33 P-2 causing'major damage to the both vehicles. P-2 attempted to brake to avoid 34 colliding with PA but was.unsuccessful. PRFPARER'S NAME I.D.NUMBER DATE RX-VIEWER'S NAME K Palm 1445 1/25/2009 Jan 31 2008 3:36PM CSAR 510-835-0685 p. 7 STATE OF CALIFORNIA . NARRAT4VEISUPPLEMENTAI_ PAGE DATE OF INCIDENT TIME NCIC NtfIMBl R' OE'PICEP I.D. NUMBER 1125/08 1945 0710 1445 08-7522 1 2 P-1 suffered chest pain, shortness:of breath and blacked out after the crash.P-2 3- . suffered moderate back pain,neck pain and had difficulty breathing. W-1 4 suffered back pain, neck Train and a possible broken.nose. W-2 suffered neck . 5 pain,back pain and blacked out. All four were transported to John Muir Medical 6 Center in Walnut Creek by AMR: RICIlNIC3N'v ;'i�L10E llEPAIt i; .as. 7 a� �tcif,Ul;r�acUIr�v 8 -1 'and V-2 were towed by.me per CVC 22651 IPA'WA 'forms for 9 additional vehicle information. To;........ .�_ --_.--- -- 14 ay:�� 11 Area of Impact. 12 The 14_Ql is.' pproximately 54 feet west of the eas�'cu"ur proJlongation aM@iriiand 13 Parkway and 69 feet north of the south prolongation of Hilltop Ddve,'E:stablished by 14 statements and physical evidence. 15 . 16 C14use: 17 P-X caused this collision by failing to stop for a red arrow, CWC 21453(c) . 19 RECOMMENDATIONS 20 I'recon-mendthat P=.1-be found at fault for the collision, Route to Traffic. 'PREPARER'SNAM5 I.D.NUMBER DATE REVIEWER'S NAME . K.PoInia 1445 1/7.5/7,t1(1R Mar OS 2000 10:20fiN CSnfT 510-035-0605 p,1 KOM STATE OF CAU FORMA HARRATIVEISUPPLEMENTAL T ` ! PAGE J of•2- DATE DATE OF INCIDENT TIME .NCICNU)JFM OFFICER LD. N'UKBER .. N 01/25/08 1945 0710 1421 08-7522 i STATEMENTS: 2 �N 3 WITNESS#-I(JENMS1 �U 4 Jenkins stated that he was the driver of a vehicle driving directly behind Party 42's m 5 vehicle.According to Jenkins he was approximately 40 feet behind Party#2's vehicle, W° 6 Jenkins stated he was traveling northbound along Richmond Pkwy.As Jenkins ,U 7 approached Hilltop Dr he saw that the traffic light at Richmond Pkwy/Hilltop Dr was 8 green for Northbound Richmond Pkwy timte.Jenkins continued traveling northbound on 9 Richmond Pkwy when he noticed Party Iles vehicle begin to make an eastbound turn 10 onto Hilltop Drive-from southbound Richmond Pkwy, As Party tfl's vehicle was making 11 the tum it struck the front teff portion of Party 102's vehicle causing Party#1's vehicle.to 12 spin out hi the northbound lanes of Richmond I%vy.Patty#2's vehicle continued straight 13 and came to rest at the northeast corner of the Richmond Pkwy/Hilltop Dr intersection. 14 Jenkins approximated the-speed of Party#2's vehicle prior to the collision to be 50 MPH. 15 Tenlcins stsled he is nositive his 1iAt and Party 42's li0it was green so Party#1 must 16 have run the ted light.Jenkins was unable to approximate Party 1='1's speech. 17 Jenkins'contact information is as follows. 18 Ant holty Lawrence Jenkins 19 1 Shores Ct 20 San Rafael,CA 94903 21 HM:415-4914744 22 CELL:510-693-'3938 23 24 -*YITNF.SS#2(GARCIA) 25 Garcia stated that Drior to witnessing tale accident he had been driving his'vehicle 26. westbound on Hilltop Dr•towards the intersection of Hilitop Dr/Richmond Pkwy.As 27 Garcia reached the intersection he stopped for a red light.While Garcia was coming to a 28 'complete stop he saw Party II I's vehicle begin to make an eastbound turn onto Hilltop 29 DriVe from southbound Richmond Pkwy.At the same instant he was watching Party#1's 30 turn,Garcia realized that Party 92's vehicle was traveling Northbound on Richmond 31 Pkwy at approximately 40 MPH and was going to be hit by Party#1's vehicle.Garcia 32 watched the collision and thought he would be struck by Party#2's vehicle after it was 33 struck by Party#1's vehicle.Garcia saw the front left and center portion of Party#1's ,)4 venrcie strlise u.1e rrUrlL ielr puruocl or?ar y of s vehicle.tiaruin 4uuta nut esuluate Patty FREPARE&SNAMEI.D.h'UMISER DATE REVIEIVERSNALtB FIROWNTFF al 011,25109' LT.A.THREETS 1217 STATE OF CALIFORNIA NARRATiVEISUPPLEMENTAL PAGE DATE OF LNCIDEM TM me Hamm OFFIM 10: NUMBU 0725/08 1945 0710 1421 08-7522 V #1's speed and stated he%vas unsure what color tire northbound/southbound Richmond 2 Pkwy tic lights were at the time of the collision.Garcia's.vehicle.was not struck 3 during or after the collision. 4 Crarcia's contact information is as follows: 5 Juan Aguilar Garcia 6 1945 22mO Street 7 Richmond,CA 94804 S HM.510-237-1716 9 10 FORWARD TO OFC K.PALMA'S PRIMARY ACCIDENT REPOK:I'. i CLAiNI BOARD OF SUPERVISORS OF CONT.i.tA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 Claim Against the County, or-. District Govenied 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 theaction taken W)la V on your- claim.by the Board of JUL 8 ZOOS Supervisors. (Paragraph 1V below), given Put suant to Government Code AMOUNT: $3,017.42 COUNTY COUNSEL Section 913 and 915.4. Please note all. MARTINEZ CALIF. "Warnings". CLAIMANT: AMERIPRISE INSURANCE COMPANY IDS PROPERTY CASUALTY INS. CO. ATTORNEY: FOR: JOYCE OWENS DATE RECEIVED: JULY 18, 2008 - BY: MIYA M. REICHWALD -iTNKNOWN,:' JULY 18, 2008`. ADDRESS: 3500 PACKEREAND DRIVE BY DELIVERY TO CLERK ON: DE PERE; WI ,54115-9071 JULY 16, 2008 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is.a copy of the above-rioted claim. JULY 185 2008 JOHN CULLEN, Cl r•k Dated: By: Deputy [L FROM.: County Counsel TO: Clerk of the Board of Supe visors (. 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). O Claim is not fimely 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-- Dat ed: ther:Dated: �'�O �� By: Deputy County Counsel 1.11. FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: (ve 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- tills ortliis date. Dat / OiN CULLEN, CLERK, By Deputy Clerk Dat4��� WARNI. G (Gov. code section 913) . Subject to certain exceptions,you have only six(6) nionths from the date this notice was personally served or deposited in the mail to file a couit action on this chains.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 shon.ild clo so imnnecliately. *For Additional Warning,See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of pen jury 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 [Wartinez, Califoi-nia, postage fully prepaid a certified copy of this Board Ordei• and Notice to Claimant, addressed to the claimant as shown above. Date m& -eoAO "JOHN CULLEN, CLERK By Deputy Clerk Claim No.: 950884 K305 Policyholder: Joyce Owens Ameriprise Your Insured: Contra Costa County/Driver: Robert Momono Auto&Home Insurance Date of Loss: June 2, 2008 July 15, 2008 3500 Packerland Drive y` ; De Pere,WI 54115-9070 V ameriprise.com/autohome CONTRA COSTA COUNTY z-. CLERK OF THE BOARD OF SUPERVISORS Ameriprise COUNTY ADMINISTRATION BUILDINGInsurance Company CS'JPEP.VISORS IDS Property Casualty 651 PINE STREET, ROOM 106 CONTRACOSTACO. Insurance Company MARTINEZ, CA 94553 Dear Sir or Madam: Our investigation of the loss that occurred on June 2, 2008 indicates that your policyholder is responsible for the damaues incurred by our policyholder. We are hereby notifying you of our damage in the amount of$3,167.42 which includes the following: • Property Damage $3,017.42 . • Deductible $150.00 • Rental/ALE WENDING Please call LIS to discuss liability for this matter at your earliest convenience. Documentation supporting our damage amount is enclosed. Rental supports will be forwarded once that has been completed. If you have any questions, please call the phone number listed below. Sincerely, 911iya 911. 12eic(wafcf Miya M. Reichwald Subrogation Representative IDS Property Casualty Insurance Company 1.800.872.5246,est. 5368 Fax: 888.269.8408 Enc. For your protection California law requires the following to appear on this form: "Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison." Y BOARD(' tiUFERVISORS OF CONTRA C05TA UNT ' INSTRUCTIONS TO CL A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not Iater than one year ager the accrual of the cause of action. (Gov. Coda§ 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should he filled in. D. If the claim is against more than one public eaatity, separate claims must be filed against cacla .-. . ..._. .._ E. E3111 See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. •■O■son ■■■a■■■■■■"m...■■.■sat�t���R\�r���l \�������■���������11�i\IIf \![���e�Y1 RE: Claim By: Reserved for Clerk's filing stamp Qs ) Against the County of Contra Costa or ) District) (Fill in the neune) )' The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give � e�xaact date and hour) . 1X.4& -2, -2-OCA Q-Q UYA Z. 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) �a�., I��°Li o>;~.►7t' �5�� A?1`�.NbD F'o� rt,�u..�T�11LS� 4. What'partieular act or omissio n the part of county or district officers, servants, or employees caused the injury or damage? ;1; ,,SQnC� ,your G►Y10 j� CUArl-)+ �OO L `►n c�1t 6i"Co gets b�f ►'F- V1awe- tao c�-t-�ca~(t 1.:haart old bac k.au# 1�,, ,ouk�ha- SeerL l`11� . 5 What are the names of county or district officers,servants,or employees causing the damage or Wury7` C)-bo x WWe� 01. ����•. damage or injury? O` �-ko MM f of -N &Pt-o_ COS*- - �p .o,gizi U4&-)SG �cwf, : J11,140 0, Eo:d e191 9E:EZ 00-92—Nnf 01 ;o g abed) 6. Y WW- doge or injuriLr do your claim resulted? (Give full exteitE of injuries or dama$cs claimed. .Attach two estimates for auto damage) i Le- quay panel c cn+o, aap-ctn v an W���C���►�a��0� ��/ . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) A*Cfi d ya t So,l - 4 1"3110,42 tote f 150 Dzduch Mf- �ppl i C d g. Names and addresses of witnesses, doctors, and hospitals: 9. List the expetxditums you made on account of this accident or injury: DATE TINE COUNT 0 U I lq I20h QaI(Y)CO f�Y ra■raara.■■■■.■■■aaaaaaaa a■■■raaaea■■■■■■■■■■■■aaaar■■■a6i MEW...i■■r'r6."01Ya�■aie�ra■t .Gov.Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND N'OMES TQ: (A-none--Y) ) Name add address of Attorney ) (Cl is sipatum) (Address) ) Telephone No. )Telephone No. Z-5-) ■agem■■Names mom asoma*an a■■■■■a■aa■*go r.■.■..■.■■a■a■a•rar...■a■a■aaaenv a■■■aa MEN■aa■7 PUBLICRECORDS WTICE: - 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 publie diselosure. aaMEN ONE aeras■on*Raw asons aa■a■ago aago aaasIn*ata IWt■■•raasaa■9.....a a a a a a a a a a a a■a■■■raI NOTICE: Section 72 of the Pend Code provides: Every parson wba, with intent to defraud, pre-gents fbr allowance or for payment to any stat-o beard or cffoer,4r to any county, city, or district board or officer, authorized to allow or pay the some 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 period of not more than one year, by a fine of not=eeding one tliousanedolrars[gr$99.01,or by lot i" cli imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding tan thousand dollars (510,000),or by bath=h impriso=vnt emd fine, b0:d ;X91 9E:ET 00-92-Nnf (y 10 y 96ed) 'Pre Est OWENS 9508843IF Paae 1 of 3 Date: 6/18/2008 09:54 AM Estimate ID: 12062 Estimate Version: 1' Preliminary Profile ID: Amodprise Foreign SIMPLY SUPERIOR AUTO BODY 2110 Market Street,Concord,CA 94520 (925)680-6946 Fax: (925)680-6961 Tax ID: 54-2191707 BAR#: AC251858 EPA M CAD981368590 Damage Assessed By: Rich Lezcano Date of Lass: 612/2008 Deductible: 250.00 Claim Number: 888568 Owner: JOYCE OWENS Address: 9 ORINDA CIR,PITTSBURG,CA 94565 Telephone: Work Phone: (925)432-8550 Home Phone: (925)597-0578 Mitchell Service: 910754 Description: 2002 Toyota Camry LE Vehicle Production Date: 2/02 Body Style: 4D Sed Drive Train: 3.01.Inj 6 Cyl4A FWD VIN: 4T1 BF30K92UO22337 License: 4WTG022 CA Mileage: 61,699 Color: GOLD Options: POWER WINDOWS,POWER DOOR LOCKS,CRUISE CONTROL,AUTOMATIC TRANSMISSION ***SPECIAL PARTS NOTICE: All crash parts on this estimate are "new" orginal equipment manufactured 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 manufactured aftermarket new parts."*** Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 001402 BDY REMOVEIREPLACE UPR W/SHIELD MOULDING 75531-AA020 63.53 0.4 2 001754 REF BLEND L HINGE PILLAR C 0.4 3 005117 REF BLEND L ROOF RAIL C 0.6 4 001762 BDY REMOVEIINSTALL L ROCKER MOULDING 0.5 5 002546 REF BLEND L REAR DOOR OUTSIDE C 0.8 6 002566 BDY REMOVEIINSTALL L REAR BELT MOULDING 0.3 7 002568 BDY REMOVEIREPLACE L REAR DOOR ADHESIVE MOULDING 75742-AA050-EO 55.39 0.4 8 002652 BDY REMOVEIINSTALL L REAR DOOR TRIM PANEL 0.4 9 002686 BDY REMOVEIINSTALL L REAR DOOR HANDLE 0.3 10 002880 BDY REMOVEIINSTALL L ROOF DRIP MOULDING 0.4 11 003014 GLS REMOVEIINSTALL BACK WINDOW 3.6 # 12 003021 BDY REMOVEIREPLACE BACK WINDOW REVEAL MLDG 75571-AA040 91.74 13 003046 BDY REPAIR L QUARTER OUTER PANEL Existing 5.0*# 14 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 2.1 15 003652 BDY REMOVE/REPLACE L QUARTER PROTECTOR 58748-AA010 10.66 16 003165 REF BLEND LUGGAGE LID OUTSIDE C 0.9 17 003223 BDY REMOVEIINSTALL LUGGAGE LID GARNISH 0.6 # 18 003225 BDY REMOVE/REPLACE LUGGAGE LID ADHESIVE EMBLEM 75441-AA050 21.18 0.2 19 003228 BDY REMOVE/REPLACE LUGGAGE LID ADHESIVE NAMEPLATE 75447-AA020 20.41 0.2 20 003231 BDY REMOVE/REPLACE LUGGAGE LID ADHESIVE NAMEPLATE 75442-AA020 22.69 0.2 ESTIMATE RECALL NUMBER: 06/18/200809:42:05 12062 Mitchell Data Version: OEM: MAY-08_A U@raMate is a Trademark of Mitchell International Copyright(C)1994-2008 Mitchell International Page 1 of .3 UltraMate Version: 6.5.017 All Rights Reserved PDF created by SceneAccess.net `Pre Est OWENS 950884.TIF Paae 2 of 3 Date: 6/18/2008 09:54 AM Estimate ID: 12062 Estimate Version: 1 Preliminary Profile ID: Ameriprise Foreign 21 003235 BDY REMOVEIREPLACE LUGGAGE LID ADHESIVE NAMEPLATE 75443-AA100 17.72 0.2 22 003592 BOY REMOVE/INSTALL L REAR COMBINATION LAMP 0.3 23 003623 BOY OVERHAUL REAR BUMPER ASSY 2.1 24 003624 BOY REPAIR REAR BUMPER COVER Existing 2.5* 25 AUTO REF REFINISH REAR BUMPER COVER C 2.4 26 003633 BOY REMOVE/REPLACE L REAR BUMPER RETAINER 52563-AA010 13.40 INC 27 936012 ADD-L COST HAZARDOUS WASTE DISPOSAL 5.00 * 28 936014 ADD'L COST FLEX ADDITIVE 5.00 * 29 AUTO REF ADD'L OPR CLEAR COAT 2.0 30 933003 REF ADD-L OPR TINT COLOR 0.5* 31 AUTO REF ADD-L OPR FINISH SAND AND BUFF 3.1 32 933018 REF ADD-L OPR MASK FOR OVERSPRAY 7.80 * 0.3* 33 AUTO ADD'L COST PAINTIMATERIALS 339.50 * *-Judgment Item #-Labor Note Applies C-Included in Clear Coat Calc Estimate Totals Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals If. Part Replacement Summary Amount Body 14.0 80.00 0.00 0.00 1,120.00 Taxable Parts 316.72 Refinish 13.1 80.00 7.80 0.00 1,055.80 Parts Adjustments 15.84- Glass 3.6 80.00 0.00 0.00 288.00 Sales Tax @ 8.250% 24.82 Non-Taxable Labor 2,463.80 Total Replacement Parts Amount 325.70 Labor Summary 30.7 2,463.80 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 344.50 Insurance Deductible 250.00- Sales Tax @ 8.250% 28.42 Customer Responsibility 250.00- Non-Taxable Costs 5.00 Total Additional Costs 377.92 1. Total Labor: 2,463.80 If. Total Replacement Parts: 325.70 III. Total Additional Costs: 377.92 Gross Total: 3,167.42 IV. Total Adjustments: 250.00- Net Total: 2,917.42 This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair. Insurance Co: AMERIPRISE ESTIMATE RECALL NUMBER: 06118/200809:42:05 12062 Mitchell Data Version: OEM: MAY-08_A UltraMate is a Trademark of Mitchell International Copyright(C)1994-2008 Mitchell International Page 2 of 3 URraMate Version: 6.5.017 All Rights Reserved PDF created by SceneAccess.net Pre Est OWENS 9508847IF Paae 3 of 3 Date: 6h812008 09:54 AM Estimate ID: 12062 Estimate Version: 1 Preliminary Profile ID: Ameriprlse Foreign Cycle Time Information Drop Off Date and Time: 1211/2007 Repair Dates: Start Date: 121112007 Is Vehicle Driveable(YIN)?: Y Assisted With Rental(YIN)?: N ESTIMATE RECALL NUMBER: 06/18/2008 09:42:05 12062 Mitchell Data Version: OEM: MAY-08_A UftraMate Is a Trademark of Mitchell International Copyright(C)1994-2008 Mitchell International Page 3 of 3 U@raMate Version: 6.5.017 All Rights Reserved PDF created by SceneAccess.net mow, �r k x y c din; J � L L� ,m kv u yg'— �.- MVC-001 S.JPG F ..t - lS�e. �,,ww'.��.,iR flFir i': � �a.:�Y�.:.''��:.:��: f'�1--....: - '^•d1:y^.`.,-<..s �;Y: - arx _ ^t ,Y a " _ _ r. T.. MVC-002S.JPG i �ilV, s`.yr�5 : , i f' is .v - = t,x:cz�.�s'. ,•..$,a'd*..:'`'ti`i wY,�,s�r.'a4,- "d'.r,.. PDF created by SceneAccess.net ........... ................... .. ............................................................................................:..... . .......:......................... ....................... ................................................. ........................................ ......................... . ................ ..._ r•t';�2 f..� r .. �l�. !:} _� _��,'�rli ... ........_r..,...11111_ f. ..J.. 1J t _ f._I1,;'J,��:':. .,. ... ......................... . ....................._ ....................._ .. _ .... .... ......... .......... .. File Edit . ...... ...:........ Claimant i0wens.Jayce. #.: .....::::: :':'AX016447$9`' ... .:::::;::x:: Collision 250:': 1200000 Coverage ".. Coverage Deductible .. `:Coverage Liriiit ....... ' ......:::::::::.::.Payment Type::: Pamen Expense Code :: . Address ___... _.... .......... Mail'ta:: :.' __ _ Pay To: JOYCE OGVEtJS AND SIMPLY SUPERIOR AUTO:::::'.:.11a JOYCE:.OWENS- BODY:. ::::.......me'::;; .: . Address dres 1 ]9 ORINDA CIRCLE . ,.. _ ..._............... _ _..................._. .................. { .. .:.. Address :i. _ _ K : _.7..0_7 :.T ;' _... f City, p PITTSBURG,CA 94565 : Tax IDSim I Superior Auto Bod ` ...�. Contact ........... ...... ..... . ... ............._ ..._... . ._.._ .:.:........ .:.::. ;':Check Amount t3D1;7.42 DeduckRedA lies i ....:.::.: Final Payment Manual Pp k . ....:: i Approved TBUCK '` Process Dake 06!20!200$: Check Number ; r 3500 Packerland Drive Ameri rise • � De Pere, WI 54115-9070 Auto&Home Insurance vi il: us. a_ �y�{,-;{}��':"^.i��;-� •ee• •s a '�'•` �•. �_ .�J.:i„'rJ•:.. X i� G = CIA _ r} _ Q G = W = ,a = 7t r €Fi ...t. (Yi JJ r, 01; zy c.► 0n O n C-)M o o•U C:1 C-.)_ a CD w 3500 Packerland Drive Ameriprise ., De Pere, WI 54115-9070 f'g°dj}• 9. cOFCTS? �Qy.dYcD4 Auto&Home Insurance Visit FIs at ameriprose.com/svc JUL 162008 ° US POSTAGE ° p FIRST CLASS AUTO 50 a °3 P.A!I-En FR(7Ml 54115 iP;4rjw Mia! _ W.M� 04R<l00R5003??7 x 7! nl =_ I:y llt _ r W = ,a 2 7P i.i.. .i.- e..i C7 r r: .3 00 :1 Zy Co.)p i I— U);n oo oM ° C=) N n- 9 C` T . r; CLAiM BOARD6.F SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST. 19,...2008. 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 6 on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: UNKNOWN JUL 1 82008 Section 913 and 915.4. Please note all "Warnings". EL CLAIMANT: BEN!AMORELLI COUNTYMARTINNEZEZ CALIF :CF A . ATTORNEY:UNKNOWN DATE RECEIVED: JULY 18, 2008 COAST' ADDRESS: 1874 S. PACIFIC GQAgE HWY-;:,BY DELIVERY TO CLERK ON: JULY 18, 2008 #214 .. RECEIVED THROUGH REDONDO BEACH, CA 90277 BY MAIL POSTMARKED: FAX FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 18, 2008 JOI-IN CULLEN, -lei- Dated: By: Deputy IL FROM: County Counsel TO: Clerk of the Board of S pervis rs ( This claire complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: I By: � Deputy County Counsel 111.. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ') Claire was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: (� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date4 ?JWTOHN CULLEN, CLERK, By. eputy Clerk WARN1.. G (Gov. code section 913). . Subject to certain exceptions,you have only six(6) inontlis from the date this notice was personally seived or deposited in the niail to file a court action on this claim.See Goveininent Code Section 945.6.You may seek the advice of an attorney of your choice in connection widi this matter. If you want to consult an attoniey,yon should clo so immediately. *For Additional Wat-nirig See Reverse Side oflliis 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 Martinez, California, hostage fully prepaid a certified copy of-,this Board Order and Notice to Claimant, addressed to the claimant as shown above. DateZer .2. 10► JOHN CULLEN, CLERK By Deputy Clerk ju l - 18-08 '109- : 06P P . 01 i' Notice 0fC-111 i � Governi-nent Code Section 910 Claimant: Ben Amorelli caNTRq Op ?Q 06 1874 S. Pacific Coast Hwy #214 c�sTq oR`'Scr Redondo Beach Ca 902 r 7 �s 310-686-9487 Agency: Contra Costa County Employees Retirement Association Date of Incident: 6-19.08 Nature of Claim: This action involves a declaratory relief action seeking an order from the cor.ii-t designating the claimant as beneficiary. and successor in interest of Karen Balatti (deceased).for the community property interest in the retirement: of Harrel Dean McNeely. This is solely an action seeking an order from the court defining the rights and liabilities of the parties pursuant to Code of Civil Procedure Section 1060. Other than the retirement proceeds as previously defined by the court in case number 26-29878 (Napa County Superior Court,), there is no potential liabilii.y to the respondeat. All notices shall be directed to the clainnant herein as noted herein. declare under penalty of perjury pursuant to the laws of the State of California that the foregoing is true and correct. Dated: 7-17-08 _ 1.�,,r_. _�_ ae✓ r�e '{L.' B y 1^3.e n A m to re I l i-----.. Clairnant CLAiM + HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19 , 2008 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, wr NOTICE TO CLAIMANT aiid Board Action. All Section references are to- The copy of this document mailed to California Government Cod es. Eli you is your notice of the action taken'.: �y on your claim by the Board of UL 2 2 2o08 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: $9 , 700 -00 MARTINEZ CALIF. "Warnings". CLAIMANT: ELIZABETH McALPINE—BELLIS ATTORNEY: UNKNOWN DATE RECEIVED: JULY 22, 2008 ADDRESS: 2732 DERBY ST. , BY DELIVERY TO CLERK ON: JULY 22, 2008 BERKELEY, CA 94705 BY MAIL POSTMARKED: JULY 21 , 2008 FROM: Clerk of tine Board of Supervisors T0: County Counsel . Attached is a copy of the above-noted claim. JOHN CULLE �1 Dated: JULY 22, :2008 By: Deputy. 1I. FROM: County Counsel TO: Clerk of the Board of uperv'sors (0/1'his claim complies substantially.with Sections 91.0 and 910.2. . ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. 'File Board cannot act for 15 days (Section 910:8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: /7' 7 Deputy County Counsel I11. MOM: Clerk of tine Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. OARD ORDER: By unanimous vote of the Supervisors present: . (✓� This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dat Q� /I� •9���HN CULLEN, CLERK, By uty Clerk WARN1.. G (Gov, code section 913) Subject to certain exceptions,you have only six(6) nnonths 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 wide this matter. ff you want to consult an attorney,you should clo so innnrecliately. *For Additional Warning See Reverse Side ofThis Notice AFFIDAVIT OF MAILING. I declare under penalty of per jury that 1. am 1101v, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of.this Board Order and Notice to Claimant, addressed to the claimant as shown above. Date �J JOHN CULLEN, CLERK B Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COU-4TY t r INSTRUCTIONS TO CLAMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or groi' na crops shall be presented not later than six months after th-. aecnW_Q _the_cause__of action. A claim relating to any other cause of action shall be presented ns - Wyew after the accrual of the cause of action. (Gov. Code § 911.2.) JUI._ 2 2 2008 B. Claims must be filed witli the Clerk of the Board of Supervisors atCftF6ffi ►A& 'SF@g, County Administration Building, 651 Pine Street,Martinez, CA 94��3. 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 entd y, 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. ■■aaaaaaa9aaaaaaaaaaaa•■a3v0aaaaaaaacaaa01a0a11a0aaaaaa2a0aaa■'aaeaaaaa9aaaa0eeaXI RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) District) (Fill in the name) } The undersigned claimarnt hereby Lakes claim against the County of Contra Costa or the above-named district in the sum of$ Ck1W• 0 and in support of this claim represents as follows: I. When did the damaae or injury occur? (Give exact date and hour) VI" 06, Zw�-.. 2. 'Where did the damage.or injury, occur? (Include city and county) 3. How did the damage or injury occur? (Give fiull details;use extra paper if required) off+NVQ V&"C : CR-AJ f,-IQ— tAW tt_ 0 TV faJ 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? . 6r-1 TV Q o c 5 are the names of county or district officers; servants, or employees causing the damage or injury? 6. Vi L L daLnage or injuries do your claim resulted? (Give full extent of injuries or damages .claimed. Attach two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) p� ��, L��-�,� t-t,�S, p� ^�ag� s� . 9. Names and addresses of witnesses; doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE THAE AMOUNT ■ aaIsosaaaasaaaaaaaaaaaaasaa5aaaaaaaaaaIataaaataaaaaaaaaaaaaacaasaaaaaaraaasaa>iaaa,aal ..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). l: Narne and address of Attorney ) ,l )�( (Claimant's Signature) (Address) 9` Telephone No. ) Telephone No. ■a so a on a t a a t a a a a a a a a a Box R a M a a a a a a a a a a a a a a a a a a a a a t a a a a a a a a a a a a a a a e t R s a a a a a a a WE a a s a a a 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 seq.) Furthermore, any :attachments, addendums; or supplements attached to the claim form, including medical records,are also subject to public disclosure. maaaaaaaNunn aatasaaaasasaaaaaSUN aaaaaaaanSaaaaaaa2aaaaNunn asaataaaaaaNOW aNOR aacaaaael NOTICE: Section. 72 of the Pen&Code provides: . Ever) 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.genui*ie, 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 afine of not exceeding one thousand dollars ($1,000.00), or by both sucb imprisontrient and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonrnent and fine. Elizabeth McAlpine-Bellis 2732 Derby St. Berkeley, CA 94705 July 1, 2008 To Whom it May Concern, Enclosed with this letter is a claim I am submitting against the county of Contra Costa for damages sustained in a traffic accident May 18, 2008 on Bear Creek Rd in Orinda, CA with an Orinda police vehicle. Officer Lirio made an . unsafe U-turn into oppossing traffic and struck my motorcycle causing damage. My claim for compensation is for $9700. 00. It is itemized as follows: • totalled motorcycle $4500. 00 • aftermarket exhaust system $350. 00 • helmet $150. 00 • leather jacket $200. 00 • loss of extended warrenty $500. 00 • loss of use $3000. 00 • loss of work $1000.00 TOTAL, $9700. 00 At this time I am not seeking compensation for medical costs, punitive damages, or pain and suffering. If this claim is' resolved quickly I will waive all further claims and any future costs associated with this accident. Respectfully, Elizabeth McAlpine-Bellis uj LD a: Cu co 11;-) 8.Fl- oc>-M -Z C=2 x000) x V) LLJ J2 o -� L) LLJ Ln C, zz T i •J 17.1 ' •t:a'3SS�' w o rVVNN+ xrz t ' � d CLAiM BOARD O.F SUPLRVi.SO.RS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST ,19., 2008 Claim.Against the County, or District Govemed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE`1'O CLAIMANT and Board Action; All Section references are.to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken on your clairrr.by the Board of �gII� Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $2,640 000 000.Eli UL 2 5 2008 Section 913 and 915.4. Please note all COUNTY COUNSEL "'Warnings". CLAINI.ANT: ICRISS MIRANDA MARTINEZ CALIF. ATTORNEY: LAWRENCE MANN DATE RECEIVED: JULY 25, 2008 ADDRESS: BOURffIS & MANN BY DELIVERY TO CLERK ON: JULY 25, 2008 a 1050. BATTERY .STREET, SAN FRANCISCO, CA 94111 JULY 24 2008 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLE ,l r' Dated: JULY 25, 2008 By: Depu'ty iI. FROM.: County Counsel TO: Clerk of the Board of S per-vi ors �6r-h cz 1 (: his claitWornplies substantially with Sections 910 and 910.2. ( ) This .Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim oil ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O,KOther: " lGlt ►Yl lr7 ©n + rV1e_C .lcAalr-Y, OCGU;_ri Z`_-E_, 1oo `7r (Cit►-r,Stor. a , foo=� '� DateDeputy County Counsel III.. FRONi: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I ceitify that this is.a true and.correct copy of the Board's Order entered in its minutes for. this date.' Dato4 XAAJIiN CULLEN, CLERK, By Deputy Clerk tzp� WARN1. G (Gov. code section 913). Subject to certain exceptions,you have only six(6) ninths front the date.this notice was personally served or deposited in the int ail to file a court action on this claim.See Government Code Section 945.6.You may seek theadvice of an attorney of your choice in connection wide this matter. If you want to consult an; .attorney,you should(to so immediately. *For Additional Warning See Reverse Side 61711is Notice. AFFIDAVIT OF NIAILING I declare under penalty of perjury that 1. ant now, and at all times herein inentioned, have been a citizen of the United States, over age 1S; and:that today I deposited in the United States Postal Scrvice in Martinez, California, postage. fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to,the claimant as shown above. Date �JOHN CULLEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL SEAL SILVANO B. MARCHESI 0 COUNTY COUNSEL COUNTY OF CONTRA COSTA Juvenile Division P.O.Box 69 SHARON L. ANDERSON Martinez, California 94553-0116 CHIEF ASSISTANT (925) 335-18300.1 v - A'm�a GREGORY C. HARVEY �:•:_.:.;:':a» ,.`'fl •'"' i VALERIE J. RANCHE (925) 646-2461 (fax) ' '� ASSISTANTS 'q C'6U1`Z�� NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Lawrence Mann, Esq. Bourhis & Maim 1050 Battery Street San Francisco, CA 94111 RE: CLAIM OF KRIS MIRANDA Please Take Notice as Follows: In regards to the claim you submitted on July 24, 2008, on behalf of Kriss Miranda, portions of the claim are timely and portions are untimely. The portions of the claim prior to July 24, 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 91 l.2, because they were not presented within one year after the event or occurrence as provided by law. .Because the portions of the claim prior to July 24, 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. SILVANO B. MARCHER COUNTY COUNSEL Y Monika L. Cooper Deputy County Counsel Lawrence Mann, Esq. Re: Claim of Kriss Miranda August 11', 2008 Page Two CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013x, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On August 11, 2008_1 served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, C".alifornia addressed to Lawrence Mann, Esq., Bourhis& Mann, 1050 Battery Street, San Francisco, CA 95111, as set forth above. .l 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. Cathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Claimants, individually and as a class of persons set forth below, make claim against the State of California, including the California State Board of Equalization, and the Counties of Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, EI Dorado, Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Los Angeles, Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Orange, Placer, Plumas, Riverside, Sacramento, San Benito, San Bernardino, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne, Ventura, Yolo, and Yuba. 1. KRISS MIRANDA, files this claim on her own behalf and on behalf of all residents of California ("Claimants") similarly situated. 2. Claimants purchased residential properties located in the State of California between January 1, 2004 and December 31, 2007. 3. The total number of residential properties purchased as set forth in item two above is in excess of 2,080,447 properties. The total price paid for the aforementioned properties is in excess of$1.074 trillion. The total property taxes that have been assessed per year on the aforementioned properties, based on the approximate tax rate calculated by 1.1% of the purchase price of said properties, has been in excess of$11.82 billion per year. 4. The Constitution of the State of California, Article XIII, Section 1 provides: § 1. Taxable properties; Assessment basis: Unless otherwise provided by this Constitution or the laws of the United States: (a) All property is taxable and shall be assessed at the same percentage of fair market value. ... Despite this mandatory requirement that property be assessed at its fair market value, Claimants' properties were and are not being assessed at their fair market value. 5. The Constitution of the State of California, Article XIII, Section 18 provides the following mandatory duties of the State of California Board of Equalization: § 18. Equalization by State Board RE-CENED JUL 2 5 2008 1 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. The Board shall measure county assessment levels annually and shall bring those levels into conformity by adjusting entire secured local assessment rolls. ... 6, Section 15606 provides the following mandatory duties for the State of California Board of Equalization: § 15606. Powers and duties of board The State Board of Equalization shall do all of the following: (c) Prescribe rules and regulations to govern local boards of equalization when equalizing, and assessors when assessing, including uniform procedures for the consideration and adoption of written findings of fact by local boards of equalization as required by Section 1611.5 of the Revenue and Taxation Code. (d) Prescribe and enforce the use of all forms for the assessment of property for taxation, including forms to be used for the application for reduction in assessment. (e) Prepare and issue instructions to assessors designed to promote uniformity throughout the state and its local taxing jurisdictions in the assessment of property for the purposes of taxation. It may adapt the instructions to varying local circumstances and to differences in the character and conditions of property subject to taxation as in its judgment is necessary to attain this uniformity. (h) Bring an action in a court of competent jurisdiction to compel an assessor or any city or county tax official to comply with any provision of law, or any rule or regulation of the board adopted in accordance with subdivision (c), governing the assessment or taxation of property. The Attorney General shall represent the board in the action. . 7. Pursuant to the tax laws of the State of California, property taxes are required to be calculated based on the current value of the properties in question. 8. It is unlawful for the State of California and for County Tax Collectors to require property owners to pay property taxes in excess of the taxes owed on such properties. 9. Claimants allege that under threat of fines and other penalties Claimants have been compelled by County Tax Collectors and the State Board of Equalization, to pay property tax bills in an amount averaging over 20%, or $11.82 billion, above and in excess of the values of their properties. 10. Claimants further allege that County Tax Collectors and the California Board of Equalization have failed and refused to establish reasonable mechanisms for reducing property tax assessments and have failed and refused to adequately advise Claimants of the fact that the property tax assessments that have been and are being levied against them were and are excessive, unreasonable, and incorrect. 11. Claimants further allege that because California Counties throughout the State did not and do not have the resources necessary to reassess their properties on an individual basis so that the taxes calculated on said properties would be accurate and fair, said Counties and State Board of Equalization, rather than instituting reasonable across the board appraisal and tax reductions, concealed and ignored the fact that the tax bills which Claimants were required to pay under threat of fines and penalties were excessive and unlawful. 12. Claimant information is as follows: Kriss Miranda, Bourhis & Mann, 1050 Battery Street, San Francisco, CA 94111, Telephone No. (415)392-4660. 13. Attorney Representative Information: Lawrence Mann, Esq., Bourhis & Mann, 1050 Battery Street, San Francisco, CA 94111, Telephone No. (415)392-4660. 14. Dollar amount of claim: $2,640,000,000. If the amount is more than $10,000, indicate the type of civil case: Non-limited civil case (over $25,000) 15. Location of Incident: In County receiving claim. 3 16. Description of.the specific damage or injury: Excessive and unlawful property tax assessments. 17. Wherefore, Claimants hereby petition California County Tax Collectors and the State Board of Equalization to: a. Provide refunds to them in the amount of$2.64 billion, plus interest, said figure representing the excessive taxes collected to date; and b. establish uniform, reasonable and fair procedures for the calculation of future property tax assessments, consistent with any future diminution of property values in this State. DATED: July 18, 2008 Respectf 17 ubmitted, BOUR S MAN Ray Bour is, Esq. Lawrence Mann, Esq. Attorneys for Claimant KRISS MIRANDA 4 `\ w a cT o w d� U 0 <a cr r-u. 00 a 0 .2 0 0— — a i 1 \ o .\ Lf) 0 cd4.0 `! v r kN ct -� 1-0 G v � s N d � O �n o C LA.1.M BOARD O.F SUPERV.IS0.1.1S OI. CONTRA COSTA COUNTY BOARD ACTION:.-AUGUST lea, 2008 \' Claim Against the County, or District Governed by ) the Board of Supervisors, Routing ► 2 NOTICE TO CLAIMANT' and Board Action. All Section refer a1'e t� T� The copyof this document mailed to }},, California Government Codes. JUL. 2 5 ZUD$ You is.your notice of the action taken on your claim by the Board of COUNTY COUNSEL Supervisors. (ParagraphIV below), MARTINEZ CALIF. r given Pursuant to Government Code AMOUNT: IN EXCESS OF $27.3000.00 Section 913 and 915.4. Please dote all "Warnings CLAIMANT':.. ANTHONY DUMAS ATTORNEY:' MATTHEW J. FREGI DATE RECEIVED: JULY 21, 2008 ADDRESS: 1136 HENRIETTA STREET, BY DELIVERY TO CLERK ON: JULY 25, 2008 MARTINEZ, CA 94553 RECEIVED BY JUNE BY MAIL POSTMARKED: Mr-JUTFROM MATT FREGI. _ _ FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 25, 2008 JOIIN CULLEN, C •k Dated: By: Deputy I1.. f-RONI: County Counsel TO: Clerk of the Board of Su} rvisors (h is 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 clainiant. 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 off cllaimant's right to apply for leave to present a late claim (Section 911.3). (Other: 7 I r ►e— Ay)-'loc:h Pot i Ce- bc.p r,,+ -15. ;-1P o s 4_ : f 1 S c S-e c ' Dated: -7 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). IV. BOARD ORDER: By unanimous vote of the Supervisors present: �) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for. this date. Dat N CULLEN, CLERK, By �a�Deputy Clerk WARNI. (Gov. code section 913). Subject to certain exceptions,you have only six(6) months ii'om the date this notice ryas pelsonalt served or deposited in the nail to file a coot t aiKI m on this claim.See Government Code Sectim 945.6.You may seek the advice of an attoMey of your choice in connection with this matter. 1. yon want to consult an attorney,you should do so immediately. *For Addidotral WanrirW"Sce Reverse Site ol"Mis Notice. A17 IDAVI I' OF MAILING 1 declare under penalty of pet jury that I. am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in [Martinez, California, postage fully prepaid a certitted cony ofthis Board Order acrd Notice to Claimant, atitiressed to the claimant ars shown above. Dat OI IN CULLEN, CLERK By Deputy Clerk MATTHEW J. FREGI, State Bar No.239525 I Attornev at Law � '-�'� � 1 136 Henrietta Street 2 Martinez, California 94553JUL < 1 2008 (925)565-3456 3 CLERK BOARD OF SUPERVISORS ATTORNEY FOR CLAIMANT CONTRA COSTA CO. d ANTHONY DUMAS 5 6 ANTHONY DUMAS, 7 Plaintiff, 8 vs. GOVERNMENT TORT CLAIM BY 9 COUNTY OF CONTRA COSTA-. ANTIOCI-I ANTHONY DUMAS 10 POLICE DEPARTMENT; OFFICER MARTINEZ JR. (#3460); OFFICER (Government Code 910] $. 11 JOANNIDES (03346); OFFICER AVITABILE (#2724); OFFICER MEDINA Action Filed: Suit Not Yet Filed 12 (44353); OFFICER AMEZCUA (#3071); Trial Date: None Yet 13 OFFICER MELLONE (#432_33.); OFFICER KINT (#3652); and DOES 1 O 100, 14 inclusive. 15 Defendant. / 16 17 18 I. CLAIMANT 19 ,o ANTI IONY DUMAS 2 301 Candlestick Drive 21 Antioch, California 94509 22 ll. PERSON TO WHOM NOTICES ARE TO BE SENT 23 MIRIAM DUMAS 24 2301 Candlestick Drive25 - Antioch, California 94509 26 11I. DATE, PLACE, AND THE TIME OF THE OCCURRENCE 27 Early morning hours of February 16, 2008 28 Fitzuren Drive Antioch, California, County of Contra Costa l GOVERNMUN'T TORT CLAIM t IV. OCCURRENCE 2 In the early morning hours of February 16, 2008, officers of the Antioch Police Department i responded to a report about a white male adult with a firearm who was attempting to break into a 4 home. The home was located on Fitzuren Drive in Antioch. 5 The first officers arrived on the scene at approximately 2:15am. Upon arrival, the officers noticed a Hispanic male adult standing in the driveway of the residence. The man appeared to be 6 flagging the officers down, but retreated back into the residence when the officers stopped. At this time, there were at least five officers on the scene. Present were Officer Martinez, s Officer Joannides, Officer Mellone, Officer Avitabile and Officer Amezcua. 9 Officer Martinez began to order the occupants of the residence to exit the house. Moments to later, the Hispanic male adult exited the front door with his hands raised in the air. He was ii followed shortly thereafter by a IIispanic female adult. 12 Seconds later, an individual matching the description of the gunman emerged from the t residence. Although the officerspolice reports were conflicting, Officer Amezcua testified under Jath at Mr. Dumas' preliminary examination that Mr. Dumas exited the residence with his hands 14 in the air. 15 As Mr. Dumas exited the residence with his hands above him, Officer Avitabile deployed 16 his electric control device (ECD) taser. The taser struck Mr. Dumas in his inner left thigh and 1.7 Lipper chest. Officer Avitabile activated what he approximated to be a five second burst, causing I's Mr. Dumas to fall to the ground. 19 Once upon the ground, the remaining officers swarmed Mr. Dumas. This is where the 20 officers' account varies from that of Mr. Dumas and the witnesses. In an attempt to justify the 21 beating they inflicted upon Mr. Dumas, the officers claimed that Mr. Dumas was struggling with 22 them. A couple officers even utilized the term "fighting", although rather curiously. Mr. Dumas 23 was not charged with resisting arrest or assault on a peace officer. 24 It is Mr. Dumas' contention that as he lay on the ground, still incapacitated from the 25 tasing, one of the officers placed him in cuffs. Another officer demanded to know where the gun was, but before he could answer, he was struck with a closed fist. Before lie knew it, all of the 26 officers present were beating on him. He could not tell which officer was doing what, but he 27 remembers being struck in the face with a blunt object other than a fist, and remembers their 28 repeated demands to know where he hid the gun. 2 GOVERNMENT TORT CLAIM It was little surprise to discover, after reading the various officers' police reports, that 1 Officer Martinez was the one responsible for the majority of the blows. Officer Martinez offers the euphemism "distraction strike" to describe the six times he struck Mr. Dumas's face with a 3 closed Gist. Keep in mind that these are the times he actually admits to in his own police report. 4 We are all too familiar with Officer Martinets unacceptable propensity for violence, along with his reputation for being unprofessional in his affairs. This reputation is corroborated by various 6 substantiated citizen complaints along with several pending lawsuits. 7 Blurring the distinction between the good guys and the bad guys, the Antioch Police x Department once more crossed the line, inflicting a merciless beating upon a physically inferior 9 drunkard in the aftermath of being lased. Then, with the utilization of creative, though highly 10 implausible, police report drafting, they attempt to justify that which clearly was not. 11 Mr. Dumas was severely beaten at a time when Mr. Dumas claims he was subdued, and 12 in any event, at a time when any police officer trained in the effective use of the ECD taser should have easily subdued him. This being said, the beating lasted, in the police officers' own 13 admission, a matter of minutes. In fact, the beating only stopped after the victim herself went 14 and retrieved the gun, for the purpose of.making them stop. In one of the officer's own words, as 1' spoken to Mr. Dumas, that particular act on the part of Mr. Dumas's victim, likely saved his life. 16 Mr. Dumas's treatment subsequent to his beating also warrants mention. Mr. Dumas, for 17 good reason, was transported from the scene to the Intensive Care Unit at Sutter Delta Memorial 18 Hospital. As aforementioned, this was early Saturday.morning. Despite spending the entire 19 morning and the remainder of that day in the Intensive Care Unit, early Sunday morning, 20 Antioch Police officers literally walked Mr. Dumas out of the emergency room, placed him into a squad car, and transported him to Martinez County Hospital. By 8:30pm Sunday evening, 21 against the advice of his treating physician, Mr. Dumas was transported to and booked into Martinez County Detention Facility. 23 24 V. PUBLIC EMPLOYEES CAUSING INJURY OR DAMAGE 2; Claimant identifies the following members of the Antioch Police Department: OFFICER 26 MARTINEZ., JR. (#3460); OFFICER JOANNIDES (#3346); and OFFICER MELLONE (#4323) 27 as the officers whom in fact inflicted the beating. OFFICER AVITABILE (#2724) was the officer 28 who deployed his ECD taser which struck and successfully incapacitated Mr. Dumas, knocking 3 GOVI.-AW:;NI'TORT CLAiM hire to the ground. OFFICER MEDINA (44353): OFFICER AMEZCUA (0071); OFFICER 1 K1NT (#3652) all permitted the unjustifiable beating to occur, and subsequently lied in their 2 police reports to cover up for their fellow officers" use of excessive force. Claimant reserves the 3 right to identify further employees as their identities become known. 4 VI. DAMAGES 6 Mr. Dumas incurred hospital and doctor bills in excess of $27,000.00. His nose was 7 fractured in six different places. In addition, he suffered a severely deviated septum, which will 8 -equire surgery to repair. IIis jaw was fractured, and Mr. Durnas was advised that a plate might 9 need to be installed in order to facilitate his recovery and avoid aggravating his condition. He also 111 Suffered several broken and bruised ribs. 11 VII. UNLIMITED CIVIL JURISDICTION 12 The extent of claimant's damages exceeds $25,000.00, so this action would properly be 13 within the unlimited civil jurisdiction of the State Courts if the action is filed in State Court. The 14 :ietion will also be within the jurisdiction of the United States District Court for the Northern 1' District of California. 16 17 Dated: July 21, 2008 Respect f subm' d, 18 19 TT W J. FRE I 20 Attorn it ANTHONY DUMAS 21 22 23 24 2i 26 27 28 4 GOVERNMENT TORT CLAIM Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 Officer ID: AMEZCUA #3071 REPORT - 1 Supervisor: MOREFIELD #3320 d ]=Other VERA, JACKELIN Race: Hispanic/Latin/ Sex: F DOB: e: 2 Type: PERSON Mexican Height: 200 , Weight: 30 Hair: Black Eyes: Brown ADDRESS INFORMATION Address Type: Phone: Address: Time at Address: Comments: School: "Grade'#: Occupation: '.,t Employer:to ow Ion `�' P Y "��,,y ,• g: Work Firs: Language: SPANISH Clothing: Crime Type: .64 Suspect Status: Additional Info: Comments: n. �1L NARRATIVE On 2-16-08, at approximately 0214 hours, I was dispatched to lWitzuren Dr. along with other officers for a report of a man with a gun.trying to break into a house. As I arrived on scene, I heard officeMartinez advised over the air that the house was next to Skipilini's. As Officer Martinez was approaching the house on foot, I drove onto the.Ariveway. As I was pulling into the driveway, I saw a HMA (Later identified as Vic. Rafael Vera) flagging us down, holding a cell phone in one hand and pointing inside his house with his other hand. Before I exited my patrol vehicle, Rafael went back inside his house and closed the door behind him. I exited my patrol car and.I identified my self as the Antioch Police Department. Officer Martinez ordered the people out of the house and Rafael exited the house. A few seconds later, a HFA (later identified as Vic. Isabel Vera) exited the house and she stated that a white male was still inside the house with a gun. A few seconds later, a WMA (Later identified as A'rr. Anthony Dumas) came out of the house flailing both arms in the air stating, "Do what you have to do." Dumas continued to walk towards us without complying with our commands. Officer Avitabile deployed the ECD. Officers Martinez, Joannides and Mellone placed Dumas under arrest. See their supplemental reports for more details on Dumas' arrest. As soon as the arrest team moved to place Dumas under arrest, I went inside the residence to clear the house. As I was clearing the house, I found a HFA (Later identified as Wit. Marta Islas) sitting on a chair in the family room holding a two year old girl (Later identified as Oth. Jackelin Vera). While we were clearing the house, Officer Kint located a loaded semi auto hand gun in the kitchen. After he Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 4 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 Officer ID: AMEZCUA #3071 REPORT - 1 Supervisor: MOREFIELD #3320 NARRATIVE (Cont'd) secured the hand gun, he contacted Vic. Isabel and he got a statement from her. See officer Kint's supplement report for more details. When I went through the side door, I noticed that the door's frame was cracked and there were shoe marks on the door. Sgt. Morefield arrived on scene and he took several photos of the damaged side door and the hand gun. The photos were later booked into evidence at APD. I then contacted Vic. Rafael Vera and he told me the followirTg in summary: On 2-16-08, at approximately 0210 hours, Rafael and his wife were sleeping when they were woken up by someone kicking the side door of their house. They both got up and they walked to the kitchen to see who was kicking the door. Rafael called the police froAhis cell phone as they walked to the kitchen. When they got to the kitchen they saw Dumas in the kitchen holding a silver gun in his right hand. Dumas pointed the gun at them and told them that he wanted his bicycle back. Rafael told Dumas that he did not have his bicycle and that he did not know what Dumas was talking about. Dumas thea pointed the gun at his wife's head and Rafael's head. Dumas told them that if they did not give him his bicycle he was going to kill them. Rafael then hang up the phone by accident. Rafael walked out of the kitchen to the family room and he called the police a second time. Isabel stayed in the kitchen with Dumas. Rafael then exited the house through the front door and he saw the police driving up to the house. Rafael flagged the police down and he then went back inside the house to be with his wife. When he got back to the kitchen, Dumas told Rafael that he made a mistake and he asked Rafael to help him hide the gun. Rafael told Dumas that he did not want to be involved. After that, he heard the police tell them to exit the house. Rafael then exited the house through the side door and contacted the police. Before he exited the door, Dumas was still holding the gun. Dumas did not say anything else to him. Rafael then saw Isabel exit the house and a few seconds later, Dumas exited the house. Rafael does not know Dumas and he has never seen hien before. He wants to press charges against him for breaking into his home with a gun and threatening to kill him and his wife. Rafael did not have any more information to give me. Rafael did not suffer any injuries. I then contacted Wit. Marta Islas (Spanish speaking only) and she told me the following in summary: On 2-16-08, at approximately 0200 hours, Marta was sleeping in her bedroom with Jackelin, when they were woken up by someone pounding on the door. Marta grabbed Jackelin and she walked out of the bedroom molding Jackelin in her arrns. When she got to the family room, she heard Rafael and Isabel arguing with someone in the kitchen in English. Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 5 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT No: 08012959 CA0070100- 300 L Street(925)779-6900 Officer ID: AMEZCUA #3071 REPORT - 1 Supervisor: MOREFIELD #3320 NARRATIVE (Cont'd) Marta did not understand what they were arguing about because she does not speak English. Marta sat on a chair in the family room holding Jackelin. She was very scared and Jackelin would not stop crying. From where she was sitting, she could see Rafael and Marta in the kitchen and a WMA arguing with them. She never saw a gun, but she saw Dumas pushing Isabel from her chest. Marta then heard someone outside the house yelling and everyone stepped out of the house except for her and Jackelin. They were too scared to move. She then saw the police walk into the house. Marta could not give me any more details. Marta did not suffer any injuries. Marta was too upset and scared to make any further statement. When she saw me, she walked up to me and held my hand. She would not let go my hand until I calmed her down. Jackelin was holding Marta and she was scared. I tried to get a statement from Jackelin,but she was too scared to tell me what she saw. I then drove to SDMH to interview Dumas. I was not able to interview him because the medical staff were working on him and he had tubes in his mouth. Dumas suffered multiple facial fractures. I checked Dumas for wants and warrants and he was clear. I checked him in RMS and found no contacts with APD. However, I found Dumas in RMS under the AKA of Violette;Anthony. I found 8 contacts with APD. One of these contacts was for PC 459 and another one was for PC 245. I also ran a rapsheet on him and found that he had priors for PC 69. At the time of this writing, Dumas remained in custody at SDMH for PC 459, PC 422, PC 496 and PC 136.1. I took no further action. Printed 02121/2008 13:05 Data911 -Version 1.0.107 Page 6 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 REPORT - 2 SUPPLEMENT Officer ID: MELLONE #4323 Supervisor: DEE #2475 NARRATIVE SUPPLEMENTAL REPORT On 16-Feb-2008, I was working as PACT- unit P33, in full-uniform, and driving fully-marked car#1218. At about 0219 hours, I was dispatched tofftFitzuren Road, on a man with a'gun. Dispatch advised, on an open-line 9- 1-1 call, of a male, wearing a gray sweatshirt, armed with.a gun at the location. Dispatch advised the male possibly broke-into the residence and had the gun underneath his sweatshirt. I arrived, along with other officers, at about 0225 hours. I deployed my rifle and approached on-foot. The location was a single-story residence situated along the south-side of Fitzuren Road. Two occupants emerged from the residence pleading for help. A white male, subsequently identified as (ARR) Anthony DUMAS, also:emerged in the doorway. DUMAS was wearing a gray sweatshirt, and initially refused police commands.to put his hands in the air. DUMAS shouted "do what you gotta do!" While officers were attempting to place him in a high-risk prone detention position, he repeatedly refused their commands, and would not go to the ground. While he was waving his arms in the air, and acting belligerent, I saw the bottom-potion of a brown holster suspended from his right-hip. I shouted my observation to other officers, in fear that he was armed with a gun. Officer Avitable deployed his Taser.electronic control device (ECD), which was successful in bringing DUMAS to the ground. Once on the ground, DUMAS positioned both of his arms to the front of his waistband. I knew, based on my training and experience, that the waistband is an area commonly used to conceal weapons. I shouted several times, "put your,hands behind your back! Stop fighting!"but DUMAS did not comply. Officer Martinez and Joannides were struggling to get him to put his hands behind his back, but he kept both his hands/arms in the front of his waistband. This caused me to be in extreme fear for my safety, and the safety of my fellow officers, because of the reported incident(man with a gun), and my observations of the holster suspended from DUMAS' hip. I believed.he was armed with a gun and could potentially use that weapon against us. I struck DUMAS twice in the face with my Streamlight UltaStinger flashlight. Despite doing so, he continued fighting with officers and refused to submit his hands/arms: I was unable to be of much assistance with the ground struggle, as I was armed with a rifle, and I feared that a close-quarters struggle would place my weapon at- risk. I kicked DUMAS approximately three times across the right-side of his rib cage. I did so in an attempt to distract his resistance and gain pain compliance. Upon doing so, and with the assistance of other officers, I was able to gain control of his right-wrist. DUMAS continued to maintain his left-arm/hand underneath his body, and officers had to struggle with him for several more moments to gain control of this arm. DUMAS was handcuffed to the rear without further incident. Refer to primary report for additional details. OFFICER MELLONE#4323 Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 7.of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT No: 08012959 CA0070100-300 L Street(925)779-6900 REPORT - 3 SUPPLEMENT officer ID: JOANNIDES #3346 Supervisor: MOREFIELD #3320 NARRATIVE On 021608 at approx 0221hrs, I responded tcAMFitzuren Rd, Antioch for a report of a man with a gun call. The call described the responsible.as a bald male wearing a gray sweatshirt and jeans with the pistol under his sweatshirt. Upon arrival, I drew my AR-15 rifle and walked up to the residence. As we began establishing contact, ARR- DUMAS hastily exited the west side kitchen door wearing the described clothing. I took aim at Dumas and then I heard Ofc Martinez giving verbal commands to put his hands up and lay down on the ground. Dumas did not follow any Officers' orders. He tucked his hands under his sweatshirt (where the gun was supposed to be located) and yelled out, "Do what you gotta do..." Dumas was subsequently detained by means of an electronic control'device (Tazer). Dumas went to the ground from the incapacitation of the ECD. Ofc Martinez attempted to run up and gain control of Dumas,but Dumas still did not comply. Dumas began to actively resist and fight Ofc Martinez. I suddenly heard Ofc Martinez yell out that Dumas had an empty holster. Dumas still had his hands underneath his torso and near the holster. Fearing that he might have the firearm in his hands and that he might use it on the Police, I kicked Dumas 3 times on the rear right hip area in an attempt to help distract him as well as knock him face down into a prone position to assist Officers who were trying to gain control of his hands. Dumas was finally detained after a couple of more minutes of fighting Officers. This concluded my portion of this report. Refer to attached reports for further. Joannides#3346 Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 8 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT No: 08012959 CA0070100 -300 L Street(925)779-6900 REPORT - 4 SUPPLEMENT OfficerID: MARTINEZ, JR #3460 Supervisor: MOREFIELD #3320 NARRATIVE On the listed date and time I was dispatched along with several other Officers to itzuren Rd on a call of a man with a gun. While enroute to the call dispatch advised that the responsible was wearing a gray sweat shirt and had a gun under his sweatshirt. On arrival, I saw a Hispanic male wearing black jeans and no shirt standing in front of the residence talking on the phone. I had my duty pistol out in the low ready position since the Hispanic male stated that there was a white male in his house with a gun. I ordered him to get to the ground until we could further investigate this incident. The Hispanic male, later identified as Rafael Vera, ignored my commands and instead of complying he ran back into his residence. I then gave more verbal commands to the residents to come out of the house not knowing who was still inside or if the responsible was still in the house. Vera then came to the door way and I ordered him out and instructed him to put his hands up. He then complied and was escorted to the side of the house. Vera continued to say in Spanish) that the responsible was still in his house and had a gun. I gave more verbal commands in English and Spanish for everyone in the house to come out. I then saw a Hispanic female wearing a black sweatshirt, later identified as Isabel Vera, come to the doorway..After several verbal commands she came out of the house and was also escorted off to the side of the house. She was crying and appeared to be terrified. As I gave more verbal commands ordering the occupants of the residence to come out, I then saw a white male wearing a gray hooded sweatshirt standing in the doorway of the house. I ordered him several times to come out with his hands in the air. He stood at the doorway and refused to come out with his hands in the air like he was directed to. I saw that the subject, later identified as Anthony Dumas, was concealing his right hand since he was only sticking his head and shoulders out of the doorway making it hard for me to see if he.was still armed. After several commands he came out of the house and stood in the center of the driveway. I ordered Dumas approximately 6-8 times to put his hands in the air. He ignored my verbal commands and instead started approaching me. He also yelled, "Do what you gotta do motherfucker" repeatedly as he continued to advance on me. Dumas did not comply with any of my verbal commands and was advancing on me. At that time, it was still unknown if he was armed with a gun. Officer Avitabile deployed his ECD on Dumas who then fell to the ground after approximately 4-5 seconds. I quickly approached Dumas while he was on the ground so that I could secure his hands and arms just in Printed 0212112008 13:05 Data911 -Version 1.0.107 Page 9 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 REPORT - 4 SUPPLEMENT officer ID: MARTINEZ, JR #3460 Supervisor: MOREFIELD #3320 NARRATIVE (Cont'd) case he was armed. As I tried to grab Dumas' left arm he started reaching under his sweatshirt with his right hand. I also noticed Dumas was wearing an empty brown pistol holster around his waist. Since the holster was empty I was concerned for my safety and the safety of my fellow Officers. It was my belief that Dumas was possibly trying to reach for the gun with his right hand. I had Dumas' left arm secured but not his right hand so I gave him 2-3 distraction strikes to his nose and to tie left side of his face. I also advised the other assisting Officers that he was possibly reaching for a gun since he had an empty pistol holster. After the distraction strikes he still refused to show me his right hand and instead Dumas rolled over onto his stomach and tucked his right hand under his sweatshirt near his front waist band. I continued ordering Dumas to show his right hand but he refused and continued reaching for an unknown object in his waistband. I gave him 2 more distractions strikes to the left and right side of his face to gain compliance. With the assistance of other Officers I was able.to handcuff Dumas and was able to finally search his person for weapons. During my search of his person I did not locate any weapons on Dumas who only had the empty holster around his waist. Officer Kint advised a short time later that he located a .45 cal pistol in the residence. I had APD dispatch call out AMR Code 3 so that they could treat Dumas for his injuries. Sgt Morefield was also on scene and took photos of the scene and Dumas' injuries. While we waited for AMR to respond, Dumas.spontaneously stated we were arresting the wrong person, and that we should be arresting "them" referring to Isabel and Rafael. He stated "they" were "dope dealers" and that they had sold "dope" to his little sister. He then stated he was angry that they sold "dope" to his sister and he came to their house with a gun and was going to "cap" them (street slang for shooting someone). He was later transported to Sutter Delta IIospital. I took no further action. See the other supplemental reports for details. Officer Martinez Jr Printed 02121/2008 13:05 Data911 -Version 1.0.107 Page 10 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 REPORT - 5 SUPPLEMENT officer ID: KINT #3652 Supervisor: MOREFIELD #3320 NARRATIVE (Cont'd) door at the listed location and was carrying a gun. Upon my arrival on the scene, other Officer's and I had surrounded the house and were requesting all the occupants to exit the house with their hands in the air. Two subjects (later identified as Isabel Vera and Rafael Vera) had exited the house and were frantically pointing to the interior portion of the house, leaving me to believe that the subject with the gun was still inside the listed location. A white male, later identified as Anthony (Dumas) Violette, had exited the house and was yelling out loud, "What are you going to do about it" or "Do what you got to do." Anthony was wearing a gray sweatshirt and fit the description of the subject with the gun. Anthony did not listen to any verbal commands and fought with Officers on scene. Refer to supplemental reports for further information on Anthony being taken into custody. I conducted an interior/welfare check of the listed residence. I located an elderly lady holding a small child (later identified as Jacqueline Vera) in the living room of the listed location. There.were no other subjects located inside4joitzuren Road. A firearm holster had been located on Anthony. I collected the holster and entered it into evidence (see attached). I received information from Rafael Vera that Anthony had placed a gun in a drawer in the kitchen area. I located the stainless steel .45 caliber handgun in a drawer in the kitchen area. The serial number on the firearm wa I observed that the listed firearm was ready to fire, there was one round in the chamber, and the hammer was locked back. I rendered the firearm safe and collected it for evidence. There were no rounds of ammunition located in the magazine. An AFS inquiry on the listed firearm revealed that it was registered to Scott Reaves, out of Elk Grove, California (see below). I later entered the firearm into evidence (see attached). I made contact with one of the residents at%Fitzuren Road, Isabel Vera, and she related the following information in summary: She was sleeping in her bed, when she heard loud banging at her front door. She then heard her young daughter (Jacqueline Vera) talking to someone in the kitchen area. She got up out of bed and walked to the kitchen. She observed an unknown white male (later identified as Anthony Violette) standing in the kitchen talking to Jacqueline. Anthony was holding a gun in his right hand. She started crying and pleading with Anthony not to bring any harm to her or Jacqueline. Anthony then pointed the gun at her and yelled, "Where's my bike, I know you have my bike. She did not understand what Anthony was talking about and she told him that they didn't have any bike. Anthony repeatedly threatened to kill her and Jacqueline if he did not get his bike back. Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 13 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 REPORT - 5 SUPPLEMENT Officer ID: KINT #3652 Supervisor: MOREFIELD #3320 NARRATIVE (Cont'd) The police had arrived and surrounded the house. Anthony started to panic, and he threatened to come back and kill Jacqueline if she said anything to the police. Anthony then hid the gun in a kitchen cabinet and ran outside towards the police. She has never seen Anthony before in her life. Isabel was very emotional and cried through the entire interview. Isebal was frightened for her life during the entire incident. She did not receive any injuries as a result of this incident. I attempted to make contact with the owner of the listed firearm via telephone. I spoke to the registered owner, Scott Reaves, and he related the following information in summary: He does own an AMT .45 caliber handgun. He went target shooting with the listed firearm yesterday in Citrus Heights, California. As he was leaving the target range, he pulled into a gas station. The listed firearm was stolen from his vehicle. He has not filed a report yet for the stolen firearm. I made contact with the Elk Grove Police Department dispatch, and requested a patrol unit to respond to Scott Reaves house in order to make a police report. Refer to Elk Grove Police Department case#08-1570 for further information. No further information K.Kint #3652 2/16/2008 Supplemental Report IG CA0070100 RE: SER/1322166 RESPONSE TO QG INQUIRY DATA IN AFS. * LOCATED STOLEN LOC TED Y CA0070100 ANTIOCH P 080216 A08-1666 SER/11100MMAKJAMT ARCADIA MACHINE TOOL CAL/45 TYP/PI PISTOL SEMI-AUTOMATIC MOD/HARDBALLER DOT/20080216 ENT/1 ORI/CA0340H00 OCA/08-1570 NOA/N MIS/EMP-1117 -- GUN TAKEN FROM ELK GROVE - ANTIOCH PD RECOVERED ALREADY - APD CASE 08-16666 FCN/0530804700166 IMMEDIATELY CONFIRM WITH CA0340H00 ELK GROVE PD MNE/DLKT TELEPHO CHECKING NCIC END AFS RESPONSE. Printed 02/21/2008 13:05 Data911 -Version 1.0.107 Page 14 of 19 Combined Case Report CASE NO: 08001666 Antioch Police Department EVENT NO: 08012959 CA0070100-300 L Street(925)779-6900 Officer►D: AVITABILE #2724 REPORT - 6 SUPPLEMENT Supervisor: MOREFIELD #3320 NARRATIVE I was called to this location to assist fellow officers in a man with a gun call. While outside the house Arr- Dumas ran out from the front door screaming and yelling at us. His fists were clinched and face was red in color with rage. It was tough to understand what he was yelling at us, and why he was yelling at us. A HMA resident of the home who ran out first yelled to us "That's the man with the gun" as he pointed towards Dumas who was 5-10 feet away from him. Myself and fellow officers yelled at Dumas numerous times to get on the ground and show his hands. It was then that I noticed a brown leather pistol holster hanging form his belt, on the left side of his waist band. Dumas was continuing to ignore our commands to get to the ground. I was in fear for the safety of myself and my fellow officers. I deployed my ECD on him from approximately 20ft away. It struck him in the inner left thigh, and the center of his chest. Dumas fell to the ground. I had my ECD activated approximately five seconds. I then stopped it so fellow officers could take him into custody. I took no further action. 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".....•..,.,r: .,. -;:- - i... .C ....ri.t. c '�,:. r .r ..: f.,^,.,r.. ... ...... ...:..... ..t.....,.V. .,:..... �•J,,•.,�.',_ +:i.'r;�,7;•:*x:��':..;.. e.:^.v..-.•.. ;. :..:..x.,:.. .,3.� < ...:;. :,- .-.:..f....�:..: :t....�...*7 Mk....r::�;,.J.. ., .:li• 3... .-::'L''si tc.x.. ld..!#.:_.>g`.C. ..._.d � 1 ..,.........,,,,,+.u......•_..:-....r,.....-.cry 161 A �= Sutter Delta Medical Center 3901 Lone Tree Way Master card❑ Discover❑ Visa❑ American Express❑ Card Number Exp.Date(Required) Antioch CA 94509 Signature Amount Statement Date 3/4/2008 Balance: 23 , 687 . 70 d Toll-Free (866) 50772195 I ACCT.*00041907981 Pay This Amount 23 , 687 . 70 SHOW AMOUNT PAID HERE:$ ADDRESSEE: REMIT TO: 6060000 419079813# # Sutter Delta Medical Center #6060000 DUMAS , ANTHONY File 74430 2301 CANDLESTICK DRIVE P . O . Box 60000 ANTIOCH CA 94509 - 6409 San Francisco CA 94160 - 0001 Please detach along perforation-And return with remittance. BALANCE DUE NOTICE Thank you for choosing our facilities for your medical needs. This statement represerits.charges.that are due from you.Please remit your payment in full or contact Patient Accounting for any assistance we can provide. Uninsured Patient Discount:Sutter Delta Medical Center offers a 20%discount off of hospital:charges at the time of billing and another 20%.discount if your account is paid in full within 30 days of your bill'date:. Charity Program:Uninsured patients who have an inability to.pay their bill may.be eligible for charity assistance. The eligibility.for charity is based on income and family size.If you have any questions or:need a copy of our Charity Application,please contact the Business Office at 1-866-507-2195. AVISO DE SALDO PENDIENTE Gracias por escoger nuestros servicios para sus necesidades de salud.Este estado de cuenta representa su saldo de pago pendiente.Nuestro sistema indi que tiene pendiente el pago de seguro medico.Por favor remita el pago en totalidad o.11ame a nuestro Departamiento de Cuenta Financiera de Pacientes para cualquier asistencia que puedamos proporcionar. Descuento a pacientes sin seguro:Sutter Delta::Medical Center ofrece un 20%de descuento sobre los cargos de hospital al momento de facturar y otro 20 de descuento si liquida su cuenta en los siguientes 30 dias apartir de la fecha de su factura. Programa de Caridad:Pacientes sin seguro que tengan un impedimento para pagar su factura pueden ser elegibles para asistencia caritativa. Eligibilidad para Caridad se basa en el ingreso y en el tamano de la familia.Si bene alguna pregunta o si necesita una Copia de nuestra aplicacion para Caridad,por favor Ilame a nuestra oficina al 1-866-507-2195. ..�e...� �?I .::.f:111��!'±�`+7..•�.''.. !: tt...>?zDUMAS, ANTHONY ���' L'�::,t�7 �:;;::•::�: �8�1�t~:::.::;;;;::.:::::.::::::.::::;.:.. Sutter Delta Medical Center ` l .I '# 1flEUiff`:`:f+�# t3lt€`' tEd#1 00041907981 2/17/2008 E. ...:t. .:4f1't Rf`7 .......... 2 9, 6 v 9. 2 .............:............... ..............,......•.:::::..:,:..,.,.,..... . 0 . 00 23, 687.70 23, 687 . 70 .. rt�erl.€.>E3e3 . .i�� ..E� c�..... . ...... . . . . ...... Upon Receipt Toll-Free 86 6 507 -2195 0 41 07 0 0 9 981 M n- urs 8am-8 m PST Phone Hours: o Th h p Friday8am-4 m PST Saturday 9am-1 m PST ...................................................................................................... p v P WE ACCEPT PAYMENTS OVER THE PHONE > I4It$CIIIi#> , .', 1it �pit:; Sutter Delta Medical Center :.:.I :::::;:::•::::::::::.: Aceptamos pagos por telefono <:'•:'•:•,•• :`::` :<::#<:>:;:>:;::::>::>;: File 74430 If payment in full has been recently made,Thank you. P.O. Box 60000 o r i ntemen a Gracias i:ii'vk4iii el or Com let ec e t ana pago Sisled ham d do , u P P 9 P San Francisco CA 94160-0001 I AT.;i;Oi,I N- ra 'niF..Ft i DATE OF STATEMENT I j IF PAYING BY MASTERCARD OR VISA FILL OUT BELOW. [NH04125A08--...—'--'-- - - _..._.:_,. - -- PA(Ii":_.PONE NUMBER PATIENT'S .O:B. � � _! CARD HOLDER `'•ECURII"Y%;OPE `.....-92-5...7.5.7..__685.7 OSO-9 -7-S-- --- - i:fv!t'LG'tEil PRIMARY INSURANCE i CARD NUMBER I::.'.P.i?i+:TE I ADMISSION CA"TE I SECONDARY INSURANCE i...SIGNATURE-----------........_....--.- .__......_..... _... _....._--. .. I-AMOUNI PAID ----- ! PHONE 925) 296-7156 -81-9.-{)�-..._-------------- MAKE CHECK PAYABLE TO: LTL TO: 002 00392 BAY IMAGING CONSULTANTS MED GROUP II�IuJnI�I�I�11n�I�In�IIn�1nIlln�lilnllnnnllnllrl PO BOX 31455 DUMAS , ANTHONY WALNUT CREEK CA 94598-8455 2301 Candlestick Dr 11.1.11 gill pill IIIIIIrIII hIIII IIIIII IIIIII IIII IIII IIIIII gill Antioch, CA 94509-6409 V OET.ACH HERF AND HFIURN TOP PORTION WITH YOUR PAYMENT USING THE RETURN ENVELOPE ENCLOSED. QI !._I PLEASE CHECK BOX IF ABOVE:ADDRESS IS INCOARECI ANTI INDICATE CHANGES ABOVE. DESCRIPTION O--SERVICES. DIAGNOSIS ! AMOUNT 02/16/08 I 70450 26 CT HEAD/BRAIN W/O CONTRAST 959.01 253.00 02/16/08 I 72125 26 CT SCAN SPINE CERVICAL W/O CO 959.09 282.00 02/16/08 I 71010 26 CHEST 1 VIEW 786.50 37.00 02/16/08 ':I 70486 26 CT MAXILLOFACIAL W/O CONTRAST 802.0 247.00 PENDING INSURANCE PAYMENT: .00 ' k:,..,...-..��:,......�.�;z:..;;�:�:�:s:'.:�:�:i:�:e:eL�e:�*�4'.r�t��ir�Y�:e4•k•ka�;;�:-.�.�t�',••kx::a�.�.#�:..�.is:. �sY:. °t For questions, to update your insurance information, or for °t Notice of Privacy Practices, phone us at (925) 296-7156, fax: us! at (925) 296-7174 or email us at billing@bmmi .net. Please include your account number in the email or on the check. P :.._.................._—......_......._...at-a:`•- AI `sb-t.- =:.- �..�:--aY,�k #a.- 0-�:-NT AN N A NEW "'tDU(NAS ;;,' A[�TIiONY ------------ --.._._._-- -'- Q0154=8 A 7iA!� HFeRti�Nc;sERV(c:F --819.9TJ TFM ENI DATE_. — I .. _. _..._. _ _. SUTTER DELTA MEDICAL CENTER LEE, B 04/25/08 - --------------------.—._..__... _.._.. _....... __..._....__...__..MESSAGE- � REFERRING P!i Y,�.:l•';IAFJ ' .................._.__..... ....---.._.._.. - .-..------------.._._...---''--'---._._....----r'---------------------------.._ .._._. _-----------'—'-J I I I :.... ---SUGARMAN;----T.—.._.._... - -' ........-- .._.._._._...._.-..__........_._..._................ - ..._.... BALANCE IS NOW DUE. PLEASE MAIL BAY IMAGING CONSULTANTS MED GROUP YOUR PAYMENT TODAY, TO AVOID PO BOX 31455 FURTHER COLLECTION ACTIONS. WALNUT CREEK CA 94598-8455 i IRS#94-2965646 PHONE 925/296-7156 • ACEOF SERVICE ! ! I HOSPITAL FMRJ"-FINPT _ � .�J�C�n1fl7F� �AI![:N — gr)tn i. it'fC:i 111$:1 o0l do..e:l;!Ci•.Irl ukrig a c!:fi:n!oi YoUI nOB$R Io511!'aISCe,,)e(lei{tti,piea6e G0I11pIC7e thio i01III and felJlil A 10 ow;111wx..fatiwe.!I rewm Illi:!.';:fill;i,1?0(;:a'x.i4Il'J PIa'+:CS'pu tui paV^.a+:;;,;!full. 2. !:mill,•i IU !m Ii>.:�:oal:ir:;lvanCC,COMP;MV.please maw^.a wi.tocopy e:this MatePleni.Ihi!a c^nlphe.w !ne iur:,l fol each in:;a;i!;:'!;'.:nniel Return all forms to our office. 1. Po:;tm;to w n Me op;)InD!I}!IP'.,!i lih(1 fllr ISr hnliR: _r each f0rII!SWIMI U:(I AUTHORIZATION:I IIf:I:I:A"Alii IJr1171.?i:111E PRO'VINJI SHQA'N ON IiilS I(M.-7 10 fIFI.i.A.S ill A!'i �. ..,.i. ,i.,.� l MIJ.,v.'l;AMA, ..O,I. U SS II, IN. ,.. 1 Poi;:,.N ,. .. .. .. l�rnup No.:... ... AUTHORIZATION: �I:li%:I; .iv�:1!'I'i:ll,:l� .,O,iI!_i�.,.fi If";;!!;A"Ci ,•,`I'!II!iI';. !!!Ri:i;rL�'!()i:;G t'RflVlllil i;;h(iViN(IN iHi I'f!Ii!A n;lv f'.i:IJI Tiil;(`Ili_N(.IIN!;t!:.ngti•I.•J;;URApICI:PLA S ! !'J;::ili� ;n ,ri:.�;,:;;;. e I'i:).'. ...... AG i i it I r r BA11,�r,i.(IF i.?PF!JSES NU'r'i�lir;iici7ci!Iris ill.," - _ .." �._.._.__._.._... STATcA'1LNT DATE FAG DUE DATE Pre{pared by ` Rand04/07/08 1 of 1 05/05/08 r7g2nt5 for: PATIENT NAN11=- BALANCE DUE !rn:;li,,ri hdlin� ANTHONY DUMAS S369.50 BAY PATHOLOGY MEDICAL GRP, INC AMOUNT ENCLOSE-o ACCOUNT NUMBER SUTTER DELTA MEDICAL $ B-59-41907981 ; 1633 ERRINGER RD 1ST FLOOR --'T—� ----- — SIMI VALLEY,CA 93065-3557 TAX ID NUMBER: 68-0425104 805.578.8321 888.582.3397 n;.A:l.'NC;P7!Il! PAI i':NT oR GUARANTOR: :.,4.1.f376() 1 AT 0.3,34 72_57051 t.rp1 STMT MAKE CHECK PAYABLE TO: ��1�111�11�1�1�1�1111�1�111��111�11���111�1�11��111111�'I1��1� ��I�Ilfl��l��llil�'lilf l�lll'�Il�l�lt�l'1�111���111111��1��11� ANTHONY DUMAS BAY PATHOLOGY MEDICAL GRP, INC 2301 CANDLESTICK DRIVE 1633 ERRINGER RD 1ST FLOOR ANTIOCH CA 94509 SIMI VALLEY, CA 93065-3557 ; T �;;" N-r Di:TA:t_MAY BE V;r�%/rD ONLINE AT WW.V.P.ANOBIL!_ING.COM. O U�n.A?'E Y(::Ja I c l:.i!nlrr nirnr;�nnI n i ��.Cf_�ennr Ei:=r;n, :K '= St ATEMENT T BAY PATHOLOGY MEDICAL GRP, INC _ TAX ID:68-0425104 RETURN ABOVE PORTION W1?H PAYMEN i. f/ J P "i-PRING PFiYS";!ANPAI1 F.N'r NA,,AF. .— _^ AC.COL;Nr NLlM_?;=n BASSEM SAID M.D. — ANTHONY DUMAS B-59-41907981 i j I 02/16,108 8704026 CULTURE,BACTERIAL,DEFINITVE;BLOOD 36.50 02/16/08 8205526 ALCOHOL(ETHANOL) 4.00 ' 02/16/08 8004826 BASIC METABOLIC PANEL 28.00 02/16/08 8255326 CREATINE KINASE,MB FRACTION ONLY 42.50 02/16/08 8255026 CREATINE KINASE (CK),(CPK);TOTAL 4.00 02/16/08 8005326 COMPREHENSIVE METABOLIC PANEL 52.00 02/16/08 8373526 MAGNESIUM 4.00 02/16/08 8448426 TROPONIN,OUANTITATIVE 40.00 02/16/08 8010026 DRUG SCREEN; MTPL DRUG CLASSES, EACH 42.00 I 02/16/08 - 8502526 HEMOGRAM AND PLATELET COUNT,AUTOMATE 22.00 I 02/16/08 8501426 OTHER THAN SPUN HEMATOCRIT 1.75 ` 02116/08 8501826 HEMOGLOBIN 1.75 4 02/16/08 8561026 PROTHROMBIN TIME 14.50 02/16/08 8573026 THROMBOPLASTIN TIME,PARTIAL(PTT) 22.50 02/17/08 8004826 BASIC METABOLIC PANEL 28.00 I 02/17/08 8373526 MAGNESIUM 4.00 02.%17/08 8502526 HEMOGRAM A.ND PLATFI.ET COUNT,AUTOMATF 22.00 i I i i i I NS(:RAN"E i—� 05/05/08 369.50 140"E": THESE CHARGES ARE FOR PROFESSIONAL PATHOLOGY SERVICES.THIS FEE IS SEPARATE FROM THE HOSPITAL INSURANCE INFORMATION CHARGE. WAS NOT RECEIVED. PLEASE REMIT BALANCE. F1ano Medical Biiiiny PO Box 10016 Van Nuys CA 91.110-0076 P1-,ore.80!-)-5)78-8321 of 888-582-3397 I PATIENT NAME ACCTA ANTHONY DUMAS E21 343963 ' IF PAYING BY MASTERCARD OR VISA,FILL OUT BELOW. CA EMERGENCY PHYSICIANS 'DELTA CHECK CARD USING FOR PAYMF..N PO BOX 582663 STE D-21 MASTERCARD M4 MODESTO, CA 95358-0046 CARD NUMBER 3-DIGI I ON BACK i AMOUNT ADDRESS SERVICE REQUESTED SIGNATURE FX.P.DAiE Y IF SERVICES WERE RENDERED AT THE HOSPITAL, /08 STATEMENT DATE PATHIS AMOUNT PAST DUE I THIS BILL IS SEPARATE FROM YOUR HOSPITAL BILL. 04/21 566.00 � 05/09.0 ADDRESSEE. TO: ANTHONY DUMAS 18958 2301 CANDLESTICK DRIVE PAYABLE CHECK CA EMERGENCY PHYSICIANS 'DELTA ANTIOCH, CA 94509 PO BOX 582663 MODESTO, CA 95358-0046 Ej Please® it address or insurance information has changed.Make changes on reverse side. ------------------------------------------------------------ -- - - ---- ;'_-PLEASE DETACH AND RETURN'.tHt'TO'R'RORTI0' N-.0F THIS STATEMENTWITH YOUR PAYMENT -.RETAIN THE BOTTOM PORTION FOR YOUR RE4 PLEASE MAKE COPY OF ENTIRE PAGE IF NEEDED FOR INSURANCE THERE IS A $10.00 SERVICE CHARGE FOR ALL RETURNED CHECKS BILLING OFFICE HOURS: 8 AM ' 5 PM Phone► 800 498-5346 Tax ID.# ► 942494000 Para Espanol► 1-800-952-8351 Attending Physician No. SUGARMAN, THOMAS, M.D. Referring Doctor Do- SUGARMAN,THOMAS, M.D. Account Number► E21 343963 Service Provider► CEP SUTTER DELTA MED CT Patient Name► ANTHONY DUMAS Statement Date► 04/21/08 DATE POS DIAGNOSIS DESCRIPTION OF SERVICES AMOUI I' 02/16/08 23 959 .0 99284/25 LEVEL 4 EMERGENCY, PHYS 306 . 6 02/16/08 23 959 . 0 99053 SERVICE 10 :00PM & 8 : OOAM 27 .( 02/16/08 23 959 . 0 12011 LAC/SIMPLE UP TO 2 .5 CM 233 . 1 j rI YOUR ACCOUNT IS 30 DAYS PAST DUE. PAYMENT ON THIS ACCOUNT IS YOUR RESPONSIBI=,IT`,' SU CUENTA ESTA 30 DIAE AL COBRO. EL PAGO ES SU RESPONSABILIDAD. FOR IMPORTANT INFORMATION :MPLOYER PRIMARY INJURY DATE ADMISSION DATE I DISCHARGE DATE INSURANCE SELF PAY/NO INSURA 02/16/08 POS (Place of Service Codes) tf x = I9094t9R# @91044 fil k1egpftl 4 = g®+r m Of#ie@ 4 _ Em@qlan '� I PATIENT NAME ACCT.a j ANTHONY DUMAS A88 14066 IF PAYING BY MASTERCARD OR VISA,FILL OUT BELOW. rALEN INPT PHYS INC DELTA = n CHECK CARD USING FOR PAYMENT � PO BOX 582663 STE D-88 MASTERCARD vl= MODESTO, CA 95358-0046 CARD NUMBER 3-DIGI1 ON BACK AMOUNT ADDRESS SERVICE REQUESTED SIGNATURE EXP.DAIE IF SERVICES WERE RENDERED AT THE HOSPITAL, STATEMENT DATE I PAY THIS AMOUNT PAST DUE DA"THIS BILL IS SEPARATE FROM YOUR HOSPITAL BILL. 03/03108 320.00 03/21/08 ADD- - • 28089 ANTHONY DUMAS 2301 CANDLESTICK DRIVE MAKE CHECK GALEN INPT PHYS INC-DELTA ANTIOCH, CA 94509 PAYABLE To PO BOX 582663 MODESTO,CA 95358-0046 Ej Please N if address or insurance information has changed.Make changes on reverse side. ---------------------------------------------------------------------------------------------------------------------------------------- PLEASE MAKE COPY OF ENTIRE PAGE IF NEEDED FOR INSURANCE THERE 1S A $10.00 SERVICE CHARGE FOR ALL RETURNED CHECKS BILLING OFFICE HOURS: 8 AM - 5 PM Phone► 800 548-5158 Tax ID.# ► 94-3342387 Para Espanol 00- Attending Attending Physician► AKBAR,JAMILA, M.D. Referring Doctor ON- AKBAR, JAMILA, M.D. Account Number► A88 14066 Service Provider 10- GALEN INPT PHYS INC-DEL Patient Name► ANTHONY DUMAS Statement Date► 03/03/08 DATE POS DIAGNOSIS DESCRIPTION OF SERVICES AMOUNT 02/16%08 21 7850. 99254 INPAT. CONSULT. LVL 4 320 .00 PAYMENT OF THIS ACCOUNT IS YOUR RESPONSIBILITY. IF YOU HAVE INSURANCE, PLEAS—v CONTACT THIS )FFICE. THANK YOU EL PAGO DE ESTA CUENTA ES SU RESPONSABIL IDAD. SI TIENE SEGURO MEDICO, POR FAVOR LLAME A NUESTRA OFICINA. EMPLOYER PRIMARY INJUR7DATE ADMISSION DATE DISCHARGE DATE BALANCE DUE INSURANCE " SELF PAY/NO.INSURA 02/16/0 320.00 •• POS (Place of Service Codes) I = iti 1*111"mitAl ®RtPRti%Rt 4moki 9 _ 40ralom®ff c% 4 - Emerpncy Room a 2 t �' WA - 11IC uy � v _ c F, 4if h - 1t Pr yt� ' gym d a �1. r is •, r •fit -. .'s 'r - ,;y:'�•rijp?-'fit;"`"�.:':':: is n.• .. ... . ........ . ... . . gni:::. .. _R�,s. M� x e _ �my : .ij -Rl— r� . •s Ad i .77 v� +r i ;7 r .:. .:.... . .: ... . NCR ------------- Ao ... ..:ter.:...! ..;.. ....: ........:..: ..4.:..�:: :.: ....:.. : 6. .r, .I A. _ .r - 3. r, c` ..:.:. - Try;....: .. ....... . :.. CLAiM BOARD OF SUPERVi.S011S OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008'e Claim Against the County, or. District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sectionreferences are to ) The copy of this document mailed to California Government Codes. • you is your notice of the action taken oil your claim by the Board of Supervisors. (Paragraph IV below), JUL 8 2008 given Pursuant to Government Code MAMOUNT: UNKNOWN Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: ALLEN L. HARRISON ATTORNEY: UNKNOWN DATE RECEIVED: JULY 28, 2008 ADDRESS: 512 DEVONWOOD BY DELIVERY TO CLERK ON:JULY 28, 2008 ` HERCULES;, CA. 94547-3616 RECEIVED FROM RISK BY MAIL POSTI✓IARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JULY 28, 2008 JOHN CULLEN, r Dated: By: Deputy iI. FROM.: County Counsel TO: Clerk of the Board of S. ervisors . (Tis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and e`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 acid send wai-ring of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 7.-2.9 r-O9-- By. _ eputy County Counsel 1.11. 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). IV ,B'OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) -Other: I certify that this.is a true and correct copy of the Board's Order entered in its minutes.for. this date. Dated-_V�/Y, JAPAN CULLEN, CLERK, By ' Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) nionths fronn the date this notice was personally served or deposited in the mail to life a court action on this claim.See Gover nine'nt'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 inanietliately. *For Additional Warniixg See Reverse Side of'This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that 1. 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 Martinez, California, postage fully prepaid a certified copy ol- this Hoard Order and Notice to Claimant, addressed to the claimant as shown above. m. Datedt�i J�oOHN.CULLEN, CLERK. By eputy Clerk JUL-24-2008 THU 01 :59 PM CCRMC STAFFING FAX N0. 9253705154 P. 02 JUL. 21. 2008 1 : 59PM CCHP MEMBER_SERVICES WU 69 F. 4' Allen L. Harrison 28 JUNE 2004 512 Devonwood Hercules, CA 94547-3616 Phone; 510-964-0184 PMB 8 325 City Of Vacaville Ambulance 123 -Estudillo Avenue PO Box San 94 Leandro, CA 577 Sacramento.)CA 8592&9110 RED Run r.08-94376 EIVED Balance: $14454.55 - JUL 2 8 ALCOA Billing Canter Northl3av Healthcare 2008 3429 Regal Drive 1300 Oliver Road,Suite 340 CLERK BOARD OF ALCOA,TN, 37701-3265 Fairfield, CA 94533 CONTRA COS coV►scRs A=#.- 32386240-514-9058 For VacaValley Hospital Balance- $729.00 Client ID, 003301059 Balance: $8998.24 Dear Contra Costa Health Services; On 17APR 08, 1 was taken to Vacaville's VacaValley Hospital for Emergency Medical care based upon a Low Blood Pressure condition that was diagnosed by the EMPs who were called to my workplace folkrwing my physical collapse. This Life Threatening Emergency was caused by an inappropriate prescription that was prescribed by one Dr.M. Florian of Contra Costa County Health Services on or about 1S APR 08. The Doctor prescribed a daily dose of 5 MG of Terazonsin_ He did so in spite of the fact that he was looking at my medical record when he prescribed it. bir. Florin KNEEW wrlh clear and utter medical,cartainty that I was already taking the follov ng daily Blood Pressure Rxs:• Verapamil ER 240 MG Tablets Lisinopril,20 MGTablet, and HydroclorothiaMe 26 MG Tablets Or.Floriian's prescription of an additional 5 MG of Terazonsln nearly killed me. It created a Life Threatening Emergeneyl It made my trip to the nearest medical facility(Vacavllle's VocaVailey Hospital) via ambulance necomry. It is my position that Contra Costa Courtly M6dical Center created my Life Threatening Medical Emergency by inappropriately prescribing excessive, additional Blood Pressure reduction medication. The problem is that I ant being held financially responsible fvr more than$12,000 in medical expenses as a result of my Life Saving, Emergency Medical Treatment at VacaValley Hospital.It Is my contentlun that contra Costa County is moraity and financially responsible for this debt;for it was their action that made my Emergency Medical Rescue and bwatrnent necessary. The names of the medical debtors,their billing amounts and account numbers are listed above.Copies of their bills to me are enclosed.Please act with all possible alacrity to pay:them the amounts required to absolve this debt on my behalf_ Please confslctm=est I DO NOT want Contra Costa County's Prescription ERROR in this VERY NFARLY FATAL,unfortunate affair to have a neptive impact on my personal credit rating. Sincerely, , len n MRS 00283764-7 Jli L44 0ZUW Wt02UW;JU FCCKlUfl UNI) MV, KLUUKUS FhAX O,U.9b1UZ3113b1 F, 02 COf4TRA CpSTA HEALTH SERVICES- ;: • M A R A j g ON ALLEN 7.007/1948 510 964 -.0184 RICHMOND HEALTH CENTER , AC OUTPATIEDIT NOTES, P E P-PEA* 'D A V i 0 110 MAR T riil'R 10 2008 .DATE Prinnr ► r� Date, Z nn n Makin, X: tin rev _ rarmeriy„ never Pain: N z' 4-o D o-V � 40, Mudd 14 _77- R 51 MR-1-RHO-2 { 103} side t OUTPATIENT NOTES J'UL-23-2008 17;37 5142315351 96% P.02 JUL-24-2008 THU 02:00 PH CCRHC STAFFING FAX NO, 9253705154 P. 04 PATCOM # MR#. M002937647 NAME: HARRISON,ALLEN L FAMILY PRACTICE NOTE DOB: 07/07/48 SEX: M PCP:. PCs. CONTRA COSTA HEALTH SERVICES-MR#: 2937647 ccRMC, Richmond Health Center (RHC) -NAME.- Harrison,Allen L loo 38th Street, Richmond, CA 94805-DOB: 07/07/1948 FAMILY PRACTICE NOTE DATE- 04/10/2008 This 59-year-old African American man presented to the Richmond Health Center with complaints of several days of 'a painful left great toe. He claims he often has ingrown toenails and has to go to nail salons where he gets pedicures and they sometimes pull the nail out from under the skin. PAST MEDICAL HISTORY: includes Chronic pain. Patient takes Vicodin ES and methadone 10 mg twice a day.per RXM PATIENT HAS NO KNOWN DRUG ALLERGIES. EXAM: Patient is a well-developed man with bilateral pincer toes wearing pointed toe shoes, presents with left lateral great toe with edema and erythema. The nail is ingrown. ASSESSMENT: Ingrown pincer toenail of the left hallux. PLAN: . Procedure note: the patient was informed that he could have his toenail cut off to relieve the pain. The patient gave verbal consent to the procedure. A digital block with I percent lidocaine mixed-with 0 .5 percent Marcaine both plain, buffered with sodium bicarbonate was achieved after Betadine prep to the entire toe and interdigital web spaces.The lateral toenail was excised. Dry sterilel bulky dressing was applied over bacitracin ointment. The patient was informed to remove this after 48 hours. The patient was given a podiatry followup to offer him preventative care to avoid future problems with the toenail of both feet which appear to be pincer nails with a great risk of recurrent ingrown toenails. of note, the patient asked for pain medications prior to leaving. I informed him that he had refills on his Vicodin Es prescriptions that were just given to him on 03/21 by Dr. Pepper and that he should just take the regular medications that he has already had and did not need anymore. Signed by Howard Shaw, FNP. on 04/18/2008 Howard Shaw, FNP. HS/mt513 D: 04/10/2008 19:15:37 T: 04/11/2008 05:54 :17 job: 2224430 285932 Shaw,Howard,FNP DICTATION: 04/10/08 191537 TRANSCRIPTION: 04/11/06 05541SPI FAMILY PRACTICE NOTE Contra Costa Regional Medical Center (PCI: OE Database CCS) Runt 07/23/08-15i52 by ABRAM,CYNDY Page 1 of 1 JUL-24-2008 THU 02:00 PM CCRMC STAFFING. FAX NO. 9253705154 P. 05 PATCOM # MR#: M002937647 NAME! HARRISON,ALLEN L SPECIALTY CLINIC NOTE DOB: 07/07/48 SEX: M PCP: PCs: CONTRA COSTA HEALTH SERVICES-MR4: 2937647 ccmc, Martinez Health Center-NAME: Harrison,Allen L 2500 Alhambra Ave, Martinez, CA 94553-DOB: 07/07/1948 SPECIALTY NOTE DATE: 04/14/2008 This 59-year-old finds he noticed L TJTS; and in mid 12/2007, his PSA was noted to be elevated to 8.5. According to the referral note, he has had another one ordered but that has not been done as.yet. Patient' s main complaint is that of his urinary hesitancy. He is actually not having to get up very often at night. His health has been good. He does not recall ever having had a PSA determination done previously. There is no family history of prostatic carcinoma. Examination of the abdomen and external genitalia are unrewarding. DRS reveals enlargement of the prostate. The gland is nontender and is symmetrical. it appears to be about a 35-gm size. A free PSA will be drawn on this patient but I for one admit, in view of the previous . elevation a few months ago, that in all likelihoodhe will require a prostatic biopsy. The free PSA will be chart checked to me, and we will let him know if he needs to come in for a prostatic biopsy and we will have him covered with an antibiotic. in the meantime,. we will try him on alpha-blocker at bedtime to bee if his prostatism symptoms improve. Signed by Peter R. Mallen, M.D. on 06/02/2008 Peter R. Mallen, M.D. PRM/mtF55 D; 04/14/2008 16:40:58 T: 04/15/2008 06;45:14 Job; 2229113 287209 MALLEN,PETER R DICTATION: 04/14/08 164058 TRANSCRIPTION: 04/15/09 �064514SPI SPECIALTY CLINIC NOTE Contra Costa Regional Medical Center (PCI: OR Database CCS) Run- 07/23/08-15;52 by ABRAM,CYNDY Page 1 of 1 JUL-24-2008 THU 02:00 PM 0000 STAFFING FAX NO. 9253705154 P. 06 ' . RUN DATE: 07/23/08 Contra Costa Rxm **LIVE** PAGE 1 RUN TIME: 1,613 RXM PRESCRIPTIONS BY DATE RUN USER: N.HORT 01/01/08 thru 87/23/08 Rx#- 0000000640 Date: 06/10/08 Motrin. 600 MG lbuprofen 600 MG SIG: 600 MG PO QGH PRN PAIN. TAKE WITH FOOD. Comments: QUANTITY 90 REFIL� 3 Status: AC Provider: PBPPER.DAVID.MO Not a Prescription Rx# 0000000639 Date; 06/10/08 Phenergan-Cod Syrup (Per 5ML) ' 6.25 MG/1 Prometh-God Syrup (Per 5ML) 6.26 MQ/10 MG '— SIG: 6 ML PO Q4'6H PRN cough (for Sarcoidosis) Comments; QUANTITY 240 REFILL 2 Status: AC Provider: PEPPEQ.D4VID.NU x^� Not u Prescription Rx# 8000000630 Date- 08/10/08 Nystatin, Triamcinolone Cream. 0'1 � Nystatin, Triamcinolone Cream 0.1 * APPLY SMALL AMOUNT TO AFFECTED AREA (beneath foreskin) nightly TOPICALLY QHS Comments: QUANTITY 15 REFILL 3 Status: AC Provider: pEPPER.DAVlD.M� Not u Prescription °^^ Rx# 0000000637 Date: 06/10/08 Hytrin. 5 MG Terazosin G HG SIG: 6 H& PO UD for 90 days. Cnmmentu� - QUANTITY KEBLL 5 Status: AC Provider: PEPP[R.DAVIU.MD ' JUL-24-2008 THU 02:00 PM CCRHC STAFFING FAX N0, 9253705154 P. 07 RUN DATE: 07/23/08 Contra Costa RXM **LIVE** PAGE 2 RUN TIME: 1613 RXM PRESCRIPTIONS BY DATE RUN USER; N.HORT _ 01/01/08 thru 07/23/08 FIR S0 i ALLCN:`:1>''<°c;;:;>' ':<;`<>" ;�..�:• I R' *** Not a Prescription *** Rx# 0000000636 Date; 06/10/08 Methadone. 10 MG Methadone 10 MG SIG: 10 MG PO BID DO NOT DRIVE, WORK OR OPERATE HEAVY MACHINERY WHEN TAKING THIS MEDICATION. DO NOT COMBINE WITH ALCOHOL. Comments: ; QUANTITY 60 REFILL (NONE) Status; AC Provider: PEPPER,DAVID,MD *** Not a Prescription *** Rx-# 0000000635 Date; 06/10/08 Hctz. 25 MG Hydrochlorothiazide 25 MG SIG: 1 TAB PO QAM Comments: QUANTITY 60 REFILL 5 Status: AC Provider: PEPPER,DAVID.MD *** Not a Prescription *** Rx# 0000000634 Date: 06/10/08 Vicodin Es. 7.5 MG/750 MG . Hydrocodone-Acetaminophen* 7.5 MG/750 MG SIG; 1 - 2 TAB PO Q6H PRN PAIN CoTmcnts: QUANTITY 180 REFILL 3 Status; AC Provider: PEPPER.DAVID,MD *** Not a Prescription *** JUL-24-2008 THU 02;00 PM CCRMC STAFFING FAX N0, 9253705154 P. 08 RUN DATE: 07/23/08 Contra Costa RXM —LIVE** PAGE 3 RUN TIME: 1613 RXM PRESCRIPTIONS BY DATE RUN USER: N,HORT 01/01/08 thru 07/23/08 MISRx# 0000000001 Date: 04/14/08 Hytrin. 5 MG Terazosin 5 MG SIG: 5 MG PO UD for 90 days. Corr�t�2n'Cs QUANTITY REFILL 5 Status: DC 06/10/08 Provider: MALLEN,PETER R ** Not a Prescription *** Rx# 0000000104 Date: 03/21/08 Methadone. 10 MG Methadone 10 MG SIG: 10 MG PO BID DO NOT DRIVE, WORK OR OPERATE HEAVY MACHINERY WHEN TARING THIS MEDICATION. DO NOT COMBINE WITH ALCOHOL. Corfonents: QUANTITY 60 REFILL (NONE) Status: DC 06/10/08 Provider: PEPPER,DAVID,MD *** Not a Prescription *** ,Rx# 0000000103 Date: 03/21/08 Hctz. 25 MG Hydrochlorothiazide 25 MG SIG: 1 TAB PO QAM Comments: QUANTITY 60 REFILL 5 Status: DC 06/10/08 Provider: PEPPER,OAVIO,MD *** Not a Prescription ' * Rx#- 0000000102 Date: 03/21/08 Vicodin Es. 7.5 MG/750 MG Hydrocodone•Acetaminophen* 7.5 MG/750 MG SIG: 1 • 2 TAB PO Q6H PRN PAIN corments: QUANTITY 160 REFILL 3 Status: OC 06/10108 Provider; PEPPER,DAVID,MD JUL-24-2008 THU 02:00 PM CCRMC STAFFING FAX N0, 9253705154 P. 09 RUN DATE: 07/23/08 Contra Costa RXM **LIVE** PAGE 4 RUN TIME: 1613 RXM PRESCRIPTIONS BY DATE RUN USER: N.HORT 01/01/08 thru 07/23/08 :iAR' r so 00 R.:.. ................ �M :2 9. *** Not a Prescription *** JUL-24-2008 THU 02:01 PM CCRMC STAFFING FAX N0. 9253705154 P. 10 ............. . . . .................... ... . .................... ... .. . 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EtfFjjgitp ;Pr Id Pla BHGFIMC 002937 47e1' ' I. l .I....,.i:.:i. .� I' '�EridDa a�'��� I.G?ou'!.�;; '�Plan'�'��'i l..�.'•., .Status.•I;IGayere d :I, , Rim,,; Status::Aal',j.Ye ' 5/1/2008 10/31/2008 BACCC BHCRMC A E 1118/2007 4/30/2008 BACCC BHCRMC A E IIITi 7 1 CC " 1!1 '200 1 !2007 BA C BAC I E 1 r 7 i; • .I �::•: .... .:. :..:::. :I' i ..��.'... :�I�i :'�I:li!" :�;�� i;; .::I:�!ii�.j. r.l�.;i�i�i!!;�i�:l,� "�I' 'I I''I ..i. 'iI: :iI•I�'I... il. iiilili li:�:. ::i�.�'I•,I !•:I' 'il:'��'.i".I;.:i. :...I,I'•I 1!I:' !' :•I. �I• I I lilt. r. : Co tacttt;: S'enSltl rtt PorsonRofe:'' CiiriEtjctb`9tt3 I iTar etD'af `CloseDat®:;1:;1:1,T:' e' :I n tn 199922 1 Caller 7/8/2008 7/8/2008 OCC bfe193177 1 Caller 6/4/2008 6/4/2008 INQ kklLL; 28076 1 Caller 7/20/2004 7/20/2004 INQ rwatkir:i', ;,`j 'I 10805 1 Caller 2/3/2004 2/20/2004 APL kfrost Vi. ; ;'', 10805 1 Subject 3!2004 / 004:,r ;. I! ..I I.I ::G.i,l I :' L /2012 PL A 1''.:.:.:::.........:... I / I ! i'ii� I''Fi 'I" :'I i 'I '�• ,'mac I• e'' t'I' �ixit '�I._. I:..I. ..!. t'. '•II':i.. ::II=_ I `.j : ... Vs Thank youl -5m,-a L4,* &ta5 Member Services Representative 595 Center Avenue,Suite N100 Martinez,CA 94663 Tel: 926-957-7255 axt 7560 Fax: 92S-913-6047 Contra Costa Health Plan-A Culture of Caring for over 35 years ' I [1j,:I:'II I I III �L- C:O'NTM.COSTA. FRALm PLAN Tulita Ochoa/MedSry/HSD/US it `III TOW II�ill����� 1:410. �' Ochoa/MedSry/HSD/US To Belkys Fernandez/CCHP/HSD/US@HSD �. JUL-24-2008 THU 02:01 PM CCRMC STAFFING FAX N.O. 9253705154 P. 11 AUL. L I U V 0 I 5yrivi 6.mr iviuvIdtIt� Au jd9y' 'l:,'!' •^!'.li' •� I.T.Q.. �.•�.i!i, ,f. .. 'frt1111h■1W1WI�N1II1�1p11�1W�1�1II111�1IYi111�� ::' .r'. ,�,:,i:,��:7fr'y%{.• .:1•, ';f,:••'S,_.. "Y 'i�'•,:e.,..f.,,, - 'i!'r.'!'�M.;'�^ Ni,,.�"i" ,.�:• ":t y�:�.a 't4•::'+�F `,','+�.'.+�/!Vi•. - :1 •7. '�, ���'� F1:: `�,.•I•.►•�, '� r•�• �. 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JUL-24-2008 THU 02;01 PM CCRMC STAFFING FAX N0. 9253705154 P. 12 JUL 11. 1UUB 2:01PM CCNN_MEMBER_SERVICES N0, 589 P. G- P.O.BOX 271910 ~` SACRAMENTO,Ca WIVe June M.2008 Rertwn service Paquamd 7d7 PERSONAL AND CONMDENnAL CREDITOR: VACAVAt,LEY HOSPITAL. Il�lurl�rlJ�l��lrtlludullrrlrleallrll�mdl.�l�l.�ll�l CLIENT ID: 008301059 TOTAL DUE SM9024 ALAN HAFIR ISON 512 DEVONWOOD HERCULES CA 945473516 h'Iteetse tbU us ff we a7�t+inong. Your.payjmnt.oEAW.questionaabouid be d¢edWJo this office-b ehsure proppaccreditio.yousaccountema mok707-20$41M,if you are unable 10 pay rho balancerin iuk-payments rney be-arranged ptowieca11 im ao we can quany you - for repayment terrrts. if you have advised us of your insurance coverage. we have prepared a bill and sent it to your insurance co►rier for you. Insurance ooverags is an estimate:any edjuus5tnnxinta or refunds will be made afW the insurance has paid Patient Waimea are due and payable upon receipt This deta8ed bili is for your records, taco purpoass. or baling arry other insumnee not assigned to the hospital. Please note that your mcount has been assigned to us by Northbay Medical Center/Vaca Valley HospW for assi4iance in collection of this deb. Failure to remit payment promptly could result in assignment of your balance due ID a traditional collection agency. Unless you notify this office within►30 days after receiving this notice that you dfspute the validity of this debt or any portion thereof.this offtce will assume this debt is valid. If you noW this office in writing within 30 days imm receiving this notice, this ofnce will obtain verification of the debt or obsain a copy of a judgment and mad you a copy of such judgment or verification, if you tegtmt this offroe in writing within 30 days atter reaelving'grist notice,this office w111 provide you with the name and address of the original creditor,if diffowt from the current creditor. !Mpartant Notice: This communication has been sent to you by a debt collector. Fedmal.law requires wo inforrtr you that this is an atterriM to collect a debt and any i norrratbit obtWned vn'0 be used for that purpose. SEE REVERSE SIDE FOR ADDITIONAL,®ISCLOSUAES Please retract this paxtioa of the nat=with yourpay ueet t0 cusrae xqPa odic (� Enclosed is paymeat in full. (� Enclosed is iammWe iufcamation. Fla=call ate at to dict w the above am mm C—J Please Cbwgv ray (_)MASTERCARD C_)VISA Dollar Amount Card d Exp.Date Cardholder's Naaue Address city.Stste.,Zip Al2 N S12 DE DEVONWOONWUOA trlient ED*003301059 IMMULE.S CA 94547-3S16 NORTHBAY FtEALTK CARE Aicsoaat B41mm.$8998.24 P.O.SOX 39000 Dept 05221 C hAtar_YACAVALLBY HOSPZrAL SAN FRANCISCO.CA-94139 ClimA X16 003301059 =o,ao* JUL-24-2008 THU 02:01 PM CCRMC STAFFING FAX N0. 9253705154 P. 13 C"',WQL. [ I. [uuol,L [: u i r47ir+ u',mr_ivitiviGtn_�tKvmu INV- 70N V. I ClrktoF vAcnviue:AMBULANCE L J 'PO BOX 269110 SACRAMENTO CA 95=1354110 FOR&LUNG INCUIRIE9 CALL.- 1(800)coos e= PaCITM Standard Time-evown m 4'9opNn 08-G4376 6/19/2008 7/312008 $1.464.6G RUN NO: 08-J4376 INCIDENT NO: 254908 S DATE OF SERVICE:4117=08 9 7,570-71 =0 ��0 •f7N80620A ASD N=W'AADC 926 $1Q11i00700/9*376//90 {7000061292 01.0006_01129 1292/1 11t1tttl����Itl�u�t�i��t���ltuul��n��l�t�lllt�l��ut��t��� 1'1{111111111t1t11t11111111111t111111/�11��111/11111111111111 CITY OF VACAVILLE AMBULANCE ALAN HARMON PO BOX 269110 612 DEVONWOOD SACRAMENTO CA 9587.6 91 t 0 HERCULES CA 94547-3516 , P6EASE R MRN THIS PORnON V&N YOUR PAYNNER17 SEE REWMIE SIDE FOR AUDMONAL INFORMATION P&ST ®UE INCIDENT NO. 264908 Page 1 of 1 RUN NO. W-94375 DATE OF SERVICE: 4117/2008 DESCRIPTICIN . ' auANT1w-cosi PER uurr TO?AL CHARGE Advanced Ambulance Service 1 1,310.00 1 A10.00 Mileage 3 20.00 60.00 74.00 74.00 Nasal Cannula 1 0.60 0.60 4001V NS 1000ct 1 203 2.05 303 IV Tubirriy1�Mand Drip 1 1158 3.58 301 Angiocath 7 232 2.32 201 Eleamdes Set 1 .200 2.00 - - - 1CIQUP LOCATICN:6W MERCHANT STREET DROPOFF LOCATION Vapvsillcy Nospkal "$1, 7 Phis balance Is now past due and mquirms your attention, 9 you have questions about this balance or need to set up a Xayment plan,please contact our billing office ImmedlMy. Thank Youl CITYOF VACAVILLE AMeui.ANCE PATIENT: HARRISON,ALAN saok Ere CA 95826a110 BIRTHDATE:7!7/9948 FOR WAJN61NWRMS CALL 1(900)9068552 POT 8.Q0am-4.30pm. YOU rar alae sUb1111t IMW=n=InftWmaftn at httpWWWW.WEWLLEMS.COMISECURE JUL-24-2008 THU 02:02 PM CCRMC STAFFING FAX N0. 9253705154 P. 14 )IVVL. c I. cvvUj% < .v i i wLK vvrlr ivvvi6in_%)[nv It.,L0 IVV. Ddj r. u 3429 REGAL OR DeYy. H AND RETURN THIS COUPON WITH AL.COA TN 37701-3265 'J THE REVERSE SIDE COMPLE9'EQ TO PAY BY CREW CARD,TO PROVIDEINSURANCE INFORMATION OR FOR CHANGE OFADDRESS, Naterd wnv ALAN HARRISON MAT DM-SM.00 C+eelt®iA d■apss►■Io aippsar oc`T am NsaMh' VWM=M SERVICES FAMER11M ATz VACAVAL LEY HIMP M 31t OI1011p11�IN111DIU�IHAII1lllUpl�llllllallfllB SOLANO GATEWAY MEDICAL GROUP DEPT,A 136 Q C D(chock oft-we rvvem) i ALAN 40 BISON 8 .3M REGAL_4R ALAN HARRISON 7176 PI-PS/46795 512 DEVON740M ALCOA TN 37701.3265 HERCULES CA 94547.9516 lull/L/arra■lll■■mdl■.llnrl/�/ll►//1/L■r•l■ll.l■.■hl■L ll■1UalIll/1a]/►1n11/./L■/llrrl■LFocal 1111Nrnll/■111■►11►1 018000323882407034-S144333809058BE)DD 7290047 Ste ..... ... ....T .. ............... - .1.gg:.......-----.---.... .. . .... ag ..... D�Idr WYee 4M2'= 7MOnO 001RGIDICY DEPT VISA ' tam MDOMM"B 728AD THIS Is YOUR PHYSICIAN SERVICSS BI_L AND IS SEPARATE FROM THENOSPRAL BILL .P• A�Y•�' 1Y.4M.M r' jVw■Y�ar�^!r /1�1V4`pV7- .t'•/1��1LGIY�� \( •�' i :V•:�..�ft,�1 Y✓4 i••; 7''.Ai;:' U(f'CI Er,�,7{h'k L,!!A MAVE YOU OVE-IMOOPMO VIX1R PAYMEIM YwR AOCQUNT IS PAST DUF--W AV010 FUPfTHER ACTION ON YOUR ACCOUNT,PLZAIM MAIL Y011 PAfIIMF TODAY OF VISIT OUR VVMWM AT W W W TEAMHEALTN COM TO PAY BY CRED[7 CAM. For 84Mg Imwkles,cW1 I-SOS4524M on Monday through Friday,Tram ftm t1,epm and Saturday frDm 10am to Spm Eastem Time- SEND ime_S ND US YOUR QdFORMAT XM OVER TIME WE81 You may now provide Insumm mfo matron and make credh cmd payor ms at www taamhealth.Gcm ... .............. . ...... .. PAYMENT COUPON-RETURN WHEN PAYING 8Y CHECK OR MONEY ORDER •, ,+ r�-� ..�.:• -� .,, : e -+ � .nom�.n w. :�,. n. rt::;• ,., �,9. •-s;:,. 41:•�, s 'is%r�?',,°.. .1N'7::--,�.�sy`�;., � a •,.. POVSICIAN SUMACGS RENDOW AT: VACAVAIJ"HOSP E'D' OAR A196 O�RD�R 701�'H19�U Cl1NECK Q CHECK HIME FOR CHANGE OF ADDRESS MAKE CHEM PAYAOR.E TO. 9eeZao•SSM905e 514 Alan Harrison SOLANO GATEWAY MEDICAL GROUP ' 512 Devonwood PO BOX 740025 Hemules CA 94547-3$16 CINCINNATI ON 48274.0023 I/L//L■L■L/■/�/ll/a/Lr1a1111//r11/■■r■L/lilllu►L/L//llrlr/L/L 018000323882407034S1493338090S820007290047 JUL-24-2008 THU 02:02 PM .CCRMC STAFFING FAX N0, 9253705154 P. 15 jug. Zi. Lvun 2:uiriw Umr_ivLIMLK_�tKVKL; N0. 589 P. 9 CONTRA COSTA HEALTH PLAN 595 Center Avenue.Suite 100 Martinez,California 94553 CONTRA COSTA Member �Number;�77.313-6000 . HEALTH SERVICES Provider Call Center.1-877-800-7423 July 8, 2008 Se Habla Espanol Allen Harrison 512 Devonwood Hercules, CA 84513 Re: Basic Health Care (8HC): Benefits Exclusion Dear Mr, Harrison: This letter is to inform you that Contra Costa Health Plan (CCHP) Member Services Department received your letter dated June 28, 2008 wherein you explained that on April 17, 2008, you were taken by ambulance to the nearest hospital because you had passed out and now you were In no way able to pay for the emergency room and ambulance expenses. Thank you for bringing this to our attention. We understand your concerns for your health and lack of finances. During April 2008, you were not a member of CCHP. Instead, you were a recipient of a county program called Basic Health Care. This program helps low-income people, who live in our county and have no health insurance. BHC, however, is not "health insurance" and it has limitations and very specific requirements. As you are aware, emergency room outside of Contra Costa Regional Medical Center(CCRMC) and ambulance services are excluded for payments (see copy of limitation or exclusion services). SHC does not cover care at private physicians or hospitals like NorthBay Healthcare, Sutter Delta, John Muir/Mt Diablo and ambulance services. To our knowledge, there is no other charity program available to you if you do not qualify for state Medicaid Assistance program. If you would like to file a grievance against Dr. Florin for prescribing you an inappropriate medication, please do not hesitate to contact CCRMC patient Relation Department at (925) 370-5144. They can assist you with this process We sympathize with your situation. However, CCHP will not make any payments for these excluded medical services. We encourage you to work directly with the billing department for the providers involved in providing you this care to see if you can come to some agreement on how to cover, reduce or write off your bill(s). Most providers are willing to write off their charges once they know that there is an inability to pay by the patient. Sinc"Servi B I MemCounselor Contra Costa Health Plan Auachmmt BHC inclusionVFxclusions GenCa CQV3 Alcohol ane Other Dogg Snkxs•Conya Cvsla Emergency AteoiaAl 8avlcas-Contra Costa EnYronmerttel Hearin •Conva Coale Hearm plan- Contre Costs Hazardous M3W41s program,•CanVO Cogm MGW Noallh•Centra Coate P,IpIIC He=•COMM Cora Regional Medical center•contra each Hea;ul Cenl•rs- JUL-24-2008 THU 02;02 PM CCRMC STAFFING FAX N0. 9253705154 P. 16 • vyL, ci. cvvu [. V[Iiri v,.nr_ivi:iriocn_01RVLkC0 IVU. 7tf`1 N. IU CONTRA COSTA HEALTH SERVICES BASIC HEALTH CARE AND HEALTH COVERAGE INTITIATIVE PROGRAM Contra Costa Health Plan (CCHP) provides the healthcare benefits of the Basic Health Care and Health Coverage Initiative (BHC/HCI) Program for the County. Under the supervision of a Primpry Care Provider (PCP), the following services are covered only at Contra Costa Regional Medical Center(CCRMC)& Health Centers or at some authorized community clinics. ❖ Physician Services and medical office visits ie Hospitalization •o• Prescription Drugs from an approved list Lab Tests •y Outpatient Medical Services ❖ Specialist Care •:• Short-term Outpatient Rehabilitation&Physical Therapy ❖ X-rays ❖ Emergency Care at CCRMC only ❖ Dental Treatment for children, ages 5-14 ❖ Basic Dental Services Ifyou have questions about SHC/HCI eligibllity,please call 1400.771-4270 to speak with a Financial Counselor. YO . - Under the BHCIHCI program, you must get ALL of your care from Inpatient hospital services are provided when ordered by your PCP or providers at CCRMC unless you are assigned to a PCP at an specialist and authorized by CCHP. authorized community clinic. SERVICES THAT ARE OR r If you receive medical care somewhere else-without prior approval Services that are NOT COVERED by CCHP under the 131H Cl from CCHP it will NOT be covered, and will NOT be paid for by the program include those listed below. BHCIHCI Program or by the County. Ambulance charges!Emergency transportation Cosmetic surgery Your medical record will be kept at the Health Center where you Eye glasses receive care. Emergency care outside of CCRMC . Hearing aids -OM YOUR _ Hemo dialysis or peritoneal dialysis You may select a PCP from our staff of Family Practice providers and Home health services Family Nurse Practitioners,or one may be assigned to you. • Hospice Investigational or experimental procedures,drugs or therapy Your PCP provides your routine care,arranges for necessary specialty Long-term physical therapy care and hospitalization, follows up on your progress and supervises • OBIMatemity care all the care you receive to make sure you receive quality care. . Mental Health Services Your PCP is part of a tears of health care professionals and other ' Sribstance Abuse Services specialists that includes family nurse practitloners, technicians, and • Most non-prescription drugs nurses to care for you. • Prescription drugs for non-covered services • Prescription drugs filled at a non-contracted pharmacy • _CIAL ARE. a Services in a skilled nursing facility or an intermediate care facility Transportation Specialty services are provided for you at one of the Countys Health . Weight loss program and prescriptions,obesity surgery Centers when you are referred by your PCP. Specialty services . Whole blood transfusions(not self-donated) include Lab tests, X-rays, Orthopedics, Ophthalmology, Urology, please call 1-877.661.6230 (press 2) for more Information, or if you Dermatology,Allergy,and others. Women may go to a gynecologist at have any questions about care that may not be covered in the a County Health Center without a referral. gHClHCI'program. URGENT MEDICAL IF-YOVARE SICK O. If you are sick or hurt and need to be seen the same day,or it you are not sure what to do, call the County Advice Nurse at 1.877-661-6230 .1 . - :CALL THE,ADVICE NURSE.UNIT. . (press 1).The Advice Nurse will help you get the care you need. - ' " • Bask PC"Cwc/f"101 Cavmv Iu 14t;va Pfau= ConM►Costa Halth Sw ices Rovisr;d o�ma+oe JUL-24-2008 THU 02:02 PH CCRHC STAFFING FAX N0. 9253705154 P. 17 L I. LVVO c: vcroi 1,nr_ivitivio1:9_J1:KVIt tJNU. 50 P_ 11 - BASIC 1•'"UTH CARl:/MMTH UOVERAGE IMITIAT%,_,PROGRAM `fir kFORN14fl.01NI'l-AS81 ♦ ♦ r ♦ r ■ If you have questions about getting services at the County Health PerformRx provides pharmacy services for BHC/HCI recipients. You Centers or for hours of service and locations,please call the Health can get a prescription filled at any one of the following twelve (12) Centers'Information number at: Walgreens pharmacies in Contra Costa County- If you have current 1.977.9054645 prescriptions from any other pharmacy,please call the Walgreens store that Is most convenient to you from the list below and have them transfer If you have a complaint about services you received from your PCP the prescription, or any provider, first try to discuss the problem with them. If the problem is not fixed and you are at the Health Center,please ask to Walgreens Store 04724 Antioch,CA 925-978-8000(PHONE) speak to a Clinic Coordinator or other Manager who can take your _3416 Deer Valley Road_ 94531 925-978-4209(i=A complaint. You can also call the Patient Relations Coordinator at Walgreens Stere#6871 Brentwood,CA 825-513-4056(PHONE) 925-370-5144, mail your complaint to Attn- Patient Relations 4,520 Balfour 94513 925.516-9544(FAx) Coordinator,2500 Alhambra Ave., Martinez, CA 94553 or come by Walgreens Stole#3164 Concord,CA 925.574-9477(PHONE) In pemon to see the Coordinator at the her office at CCRMC in 1800 Concord Ave 94520 925.674-9256(FAX) Martinez -- If you have a complaint or question about the refusal of any Walgreens Stoic 43770 EI Cerrito,CA 510-234-9300(PHONE) 11565 Sen Pablo Ave 94530 510-234-8986(Fox) medical services or denial of payment for medical services, you Walgreens Store#6101 Martinez,CA 925-3720337(PHONE) may call CCHP's Service Center at 1-877-661-6230(press 2). ) 3655 Alhambra Ave 4553 k&372-6018 Fax) EMERGENCY C Walgreens Store#7376 Pittsburg,CA 925-439-8675(oHoNE) Under the BHC/HCI Program, emergency medical care is paid for 2901 Railroad Ave 94565 926439-1558(Fox) only when provided at CCRMC in Martinez. If you have a life- Walgreens Store#2506 Richmond,CA 510-236-5748(FHONE) threatening emergency such as severe chest pain,acute shortness 1150 MacDonald Ave 94801 510.236-5287(FAX) of breath, or uncontrollable ble ing, call 911 or go to the nearest hospital. Even though BHC/HCI does not pay for these services, Walgreens Store#9978 Brentwood,CA 925-240-6043(PHONE) every local hospital is required by law to provide emergency 6570 Lone Tree Way 94513 925-240.6134(Fox) services to everyone even if they cannot pay. Walgreens Store 05864 Pleasant Hill, 925.944-1592(PHONE) County 24 hour emergency services are provided at: 721 Oreggry Lane CA 94523 925_944.5976(Fox) Contra Costa Regional Medical Center Walgreens Store#2435 San Pablo,.CA 510-233-9467(PHONE) 2500 Alhambra Avenue,Martinez,California 13751 Sen Pablo Ave 94806 510.233.6467(Fox_ CARE' Walgreens Store#11861 MENTAL,kEALfH 2455 San Pablo Dam San Pablo,CA 510-235-0810(PHONE) Mental health care is not covered under the BHC/HCI Program,but Road 94846 510-235-0106(FAX) care may be provided as necessary by Contra Costa Heaith Walgreens Store#4026 Walnut Creek, 925-933.0307(PHONE) Services'Mental Health Division..For resource information call: 2900 N Main Street CA 94596 925-933.0559(FAX) 1.898.678.7277 RE CARE'FOR DRUG AN0.ALG0H0LA6U§E Substance abuse care is not covered under the BHC/HCI Program, DENTAL-CA but care may be provided as necessary by Contra Costa Health CHILDREN from the ages of 5-14 enrolled in the 8HC/HCI Program Services'Alcohol and Other Drugs Division. Call the Community receive the following dental services at Contra Costa County Health Substance Abuse Services Access Unit at: Centers: . 1-800.846-1652 Limited Care' Examinations X-Rays Filings Extractions Preventive care,including leanings&sealants rHER •L�TH' INSURANC& The SHC/HCI program provides basic dental services ONLY for persons cbokbe • = over the age of;14. Dental we covers only examinations, permanent You have the responsibility to use any other health care insurance fillings,x-rays,extractions and emergency dental work given through the you have before using your RHC/HCI Program benefits. Dental Department at the County Health Centers in Martinez, Richmond, The 6HGHCI program is a program of last resort The County will or Pittsburg. NOT pay for any services that could be provided by any other Basic dental services do not rover procedures such as dentures, root medical program or insurance plan including Medi-Cal and canals,treatment of major tooth injuries,gum treatment,cleaning,or any Medicare, services not provided at a Contra Costa County Health Center. Buie Haaldt Com/Heal&Coverap W iauve Proinz Contra Costa ETcarth Services lkayi=d 07/08103 % JUL-24-2008 THU 01 :59 PM CCRMC STAFFING FAX N0. 9253705154 P. 01 ■ %MAAAAJ MOVED ' s LIAM 13.WALKER,M.D. C ONTREL COSTA f1ralth Services Director JEFFREY V.SN(ITR M.D. JUL 2 "ti �� 12EGIONAL �xecutivc Diractor 20 M7'DICENTER CONTRA C O S ICI RK BOARD OF SUPERVISORS 2500 A1Uatr+bra Avenue ONTRA COSTA CO. Vfaainez'CA 94553 0-5100 HEALTH SERVICES Fax(e9�5 2)5)37 Fax 370-5138 FAX COVER LETTER DATE: SHARON HYMES-OFFORD TIME: JUL 2 ► 2008 TO: FAX: FROM: j This is Page one of 1-7 pages. Notice: The documen.t being faxed is intended only for the use of the individual or entity to which it is addressed, and may contain infonn.ati,ou that is privileged, confidential, and re- disclosure. is prohibited. If the reader of this fax is not the intended recipient, or is the employee or agent responsible for delivering th.e fax to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this coirunuwucation is strictly prohibited. If you have received this con-unwiication in error, please noti.fy us immediately by telephone and return the original fax to us at the address above via the United States Postal Service. Please call us at 925-370-5144 if you have any questions. 925-370-5 (FAX) COMMENTS: Contra Costa Substance AbLISO ServicesContra Costa Emergency Medical Services'contra costa Environmental Health'Contra Costa I loalth Plan Contra Costa Hazardous Materials Program•Contra Costa Mental Health'Contra Costa Regional Mod+cal Center Contra Costa Health Centers I I C LA i.i1'1 HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: AUGUST 19, 2008 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 )C • The copy of this document mailed to California Government Codes. you is your notice of the action taken 5 , 1 ' on your claim .by the Board of �► �64, Supervisors. (Paragraph IV below), AUL 2"'684, ZQQB given Pursuant to Government Code COUNTYOOUNSEL Section 913 and 915.4. Please note all AM.OUNT:,,:• $4,836.65 fWARTINEZ CALIF. \ "Warnings". CLAIMANT: GEICO SUBROGEE FOR: SHERI and RICHARD GANVA l` ATTORNEY: UNKNOWN DATE RECEIVED: JULY 28, 2008 JULY 28, 2008 ADDRESS: 14111:DANIELSON STREET, BY DELIVERY TO CLERK ON: POWAY, CA 92064 BY MAIL POSTMARKED: JULY 24, 2008 FROM: Clerk of the Board of Supervisors T0: County.Counsel Attached is a copy of the above-noted claim. JULY 28, 2008 JOHN CULLEN, C rk Dated: By: Deputy IL FROM: County Counsel TO: Clerk of the Board of S ervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( whis Claim FAILS to comply substantially with Sections 910 acid 910.2, and we are so notifying claimant. The. Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: e7� By: Deputy County Counsel 1.11. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ). Claim was returned as untimely with notice to claimant (Section 911.3). IV.,BOARD ORDER: By unanimous vote of the Supervisors present: (� This Claim is rejected in full. ( ) Other: I certify that this is a true and coi -ect copy of the Board's Order entered in its minutes.for this date. Dated: gf CULLEN, CLERK, By _ eputy Clerk WARNI.N (Gov. code section 913) Subject to certain exceptions,you have only six(6) nrontlis 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':a n attorney of'your choice in connection wide this matter, If*you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of'This Notice. AFFIDAVIT OF MAILING I declare wider penalty of perjury that 1.. ann 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 iii Martinez, California, postage fully prepaid a certified copy of.this Board Order and Notice.to Claimant, addressed to the claimant as shown above, Dale 'o JO 4(JOHN CULLEN, CLERK ByDeputy Clerk OFFICE OF THE COUNTY COUNSEL SILVANO B. MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building F== t 651 Pine Street, 91h Floor �� ' -\,a - � SHARON L. ,ANDERSON Martinez, California 94553-1229 �� - -- ? x s CHIEF ASSISTANT (925) 335-1800 GREGORY C. HARVEY (925) 646-1078 (fax) `�� `� VALERIE J. RANCHE ASSISTANTS S7A_ coU'Z fl` NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM August 8, 2008 TO: GEICO SUBROGEE FOR: SHERI and RICHARD GAMBA 14111 Danielson Street Poway, CA 92064 RE: CLAIM OF: Sheri and Richard Gamba 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 Govermnent Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] L The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ] 3. The claim fails to.state the date, place.or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. 1� [ V] 6. The claim is not signed by the claimant or by some person on his or her behalf. [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ ] 8. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel. CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On August 8, 2008, I'served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to GEICO SUBROGEE FOR: SHERI and RICHARD GAMBA, 14111 Danielson Street, Poway, CA 92064, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U:S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on August 8, 2008, artmez, California. Liliana R6tzscher Enclosure cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 i j BOARD OF SUPERVISORS OF CONTRA COSTA.COUNTY INSTRIJ CTIONS TO CL-4BLA NT „) f 0/ 3 2��yo - 07 �7 �s 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 C177 5. 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. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the nage 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. KENN K f!K!i K I!!!■K■!!K K■KIK EXCE URN K K!!X K l!K!K'K i K i C K K K C K X■K t K K;■R!K X i K!!R C Stott RE: Claim By: `U? Reserved for Clerk's filing stamp Against the County of Contra Costa or ) C<19 District) d, (Fill in the name) )' °sTq o9�iso9 � s The undersigned claimant heraby makes claim against the County of Contra Costa or the above-named district in the sum of$i-' 93 C, [,5•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) ay1c"' CA 3. How did the damage or 4ajury occur? (Give full details;use extra paper if required) 4. %at'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? 6. 'W~:a damage or injuries do your claim resulted? (Give iull extent of ii�juzi.es or damages claimed. Attach two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 6, 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE 'ITME AMOUNT Kum xxkxxx Kx■aK■x In ax x Kula Kx xxx on xax xa a Kxaxax Box xxxuxmown xxa xa Kxx■x xxx xt x K x K x x Kamm on xl .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. ■x It RIKINXXXXXX Known MEN UK UK x NO R t t K x[x K x x x t!f K x x t R 7 t t x K t K x x x x x K x x x x x x x Kum go K t x CEREWN KKI 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 retards, are also subject to public disclosure. ■a K x a x x x x x x x x x x a Knox Knox x x KKKKNEKRXINKNVNKNERR a am a K x x x t a x I K a x x t K i x x t x x MRS own K x x x NCR 91 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. Claim # 0113358400101065 This loss keurr-id on 5/11/2008 at approximately 1:00 pm at the intersection of Pacheco Blvd and 2nd Ave in Pacheco, Ca. Mr. Richard Gamba was stopped at a red light then the light turned green and just a Mr. Gamba was proceeding forward Mr. Jose Beltran rear ended Mr. Gamba at the intersection. Page 1 of 9 T 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 12F71CPJ GEICO CONTRA COSTA NORTHERN CALIFORNIA VISIT US AT GEICO.COM P. 0. BOX 10601 PLEASANTON, CA 94588 (510) 520-8677 ESTIMATE OF RECORD WRITTEN BY: BRIAN TOROK 06/26/2008 01:44 PM ADJUSTER: FCC: 03 (510) 520-8677 INSURED: SHERI GAMBA CLAIM #0113358400101065-01 OWNER: SHERI GAMBA POLICY #0108926106 ADDRESS: 2214 BEGONIA CT DATE OF LOSS: 06/11/2008 AT 12:00 AM PITTSBURG, CA 94565-4424 TYPE OF LOSS: COLLISION EVENING: (925) 432-7584 POINT OF IMPACT: 6. REAR BUSINESS: (925) 550-8945 INSPECT MIKES AUTO BODY DAY: (925) 432-9910 LOCATION: MIKE ROSE AUTO BODY DRIVE-IN 3001 N PARK BLVD PITTSBURG, CA 94565-0000 REPAIR MIKES AUTO BODY-PIT BUSINESS: (925) 432-9910 FACILITY: 3001 N. PARK BLVD 3 DAYS TO REPAIR PITTSBURG, CA 94565 . LICENSE # 942621349 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: VIN: 5GZCZ63455S838524 LIC: 5NT2930 CA PROD DATE: ODOMETER: 46858 AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL INTERMITTENT WIPERS KEYLESS ENTRY THEFT DETERRENT/ALARM REAR WINDOW WIPER DUAL MIRRORS FOG LAMPS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER MIRRORS AM RADIO FM RADIO STEREO SEARCH/SEEK CD PLAYER ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG CLOTH SEATS BUCKET SEATS RECLINE/LOUNGE SEATS AUTOMATIC TRANSMISSION 4 WHEEL DRIVE ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PANT ------------------------------------------------------------------------------- 1 REAR BUMPER 2** REPL RECOND BUMPER COVER BASE 1 244 . 00 1. 4 0. 0* 3 REPL LT REFLECTOR 1 13.08 INCL. N 4 REPL ENERGY ABSORBER 1 102. 67 0. 1 5 LIFT GATE 6 REPL NAMEPLATE "VUE" 1 23.05 0.2 7* REPL QUAL RECY PARTS LIFT GATE +25% 1 625.00 4 .2* 3. 9* 8 ADD FOR CLEAR COAT 1. 6 9 REPL NAMEPLATE "AWD" 1 29. 60 0.2 file://CADocuments and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Page 2 of 9 10 RE W NAMEPLATE "V6" 1 13.49 0.2 1 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 12F71CPJ ES'T'IMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- ll# RPR COLOR MATCH 0.3 12 OTHER CHARGES 13# E.P.C. 1 3.00 ------------------------------------------------------------------------------- SUBTOTALS =_> 1053.89 6. 6 5.5 LINE 4 CALLED KEYSTONE AND KAPA-NOT AVAIL A/M LINE 7 SUPPLIERS PART DESCRIPTION: LID -4SW, 0702, 000, -RED ------------------------------------------------------------------------------- PRIOR DAMAGE NOTES: NONE PARTS 1050.89 BODY LABOR 6. 6 HRS @$ 72.00/HR 475.20 PAINT LABOR 5.5 HRS @$ 72.00/HR 396.00 PAINT SUPPLIES 5.5 HRS @$ 32.00/HR 176.00 OTHER CHARGES 3.00 ---------------------------------------------------- SUBTOTAL $ 2101.09 SALES TAX $ 1226. 89 @ 8.2500% 101.22 ---------------------------------------------------- TOTAL COST OF REPAIRS $ 2202.31 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 1702.31 "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " file://C:\Documents and SeWngs\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Page 3 of 9 THIS IS NOT AN AUTHORIZATION TO REPAIR NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. 2 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 12F71CPJ ESTIMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER 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 P_LGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O�=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMEN'1 MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. file://C:\Documents and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Page 4 of 9 3 06/26/2008 AT 01:56 PM 0113358400101.065-01 49795 i2F71CPJ ESTIMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ALTERNATE PARTS DISCLAIMER IF QUALITY REPLACEMENT PART (QRP) APPEARS ON THIS ESTIMATE, IT INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, WE PROVIDE THE FOLLOWING: **** OWNER LIMITED WARRANTY **** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFECTS IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS THE COST OF THE PART, LABOR TO INSTALL; AND INCIDENTALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR LOCAL GEICO REPRESENTATIVE. NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. RECYCLED PART COSTS BASED ON INFORMATION PROVIDED BY CAR-PART.COM. FOR ASSISTANCE, CALL CCC AT 800-637-8511. file://CADocuments and Settings\u79155\Local Settings\Teinp\pdi\Ol 13358400101065-0... 07/23/2008 Page 5 of 9 4 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 12F71CPJ ESTIMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L7FI 4D UTV SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR8ID02, CCC DATA DATE 06/01/2008, 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, SPr;CIAL, 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 L•KQ, 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 file://C:\Documents and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Page 6 of 9 NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 5 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 1.2F71CPJ ESTIMATE. OF RECORD 2005 SATU VUE 4X4 6-3. 5L-FI 4D UTV SILVER INT: RECYCLED PART •SUPPLIERS LINE LINE DESCRIPTION PRICE 7 QUAL RECY PARTS LIFT GATE +25% STOCK NO. : V70660 $ 625.00 LKQ - WEST (866) 557-2677 AZ, NV,CA, UT SANTA FE SPRING, CA 90670 file://C:\Docum.ents and Settings\u79155\Local Settings\'Temp\pdi\0113358400101065-0... 07/23/2008 Page 7 of 9 6 06/26/2008 AT 01:56 PM 0113358400101065-01 49795 12F71CPJ ESTIMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ALTERNATE PARTS SUPPLIERS 2 R!"'-COND BUMPER COVER BASE PART NO. GM17.00655R PRICE 244 .00 KEYSTONE - COMPLETE (800) 264-7560 3615 NE. 109TH AVE (360) 260-8400 VANCOUVER, WA 98682 KEYSTONE - COMPLETE (800) 421-7866 2530 LINDSAY PRIVADO #C (909) 986-4586 ONTARIO, CA 91.761 file://C:\Documents and Settings\u79155\Local Settings\Temp\pdi\Ol 13358400101065-0... 07/23/2008 Page 8 of 9 KEYSTOUlE - CUMPLETE (800) 263-9727 1627 ARMY COURT (209) 948-1101 STOCKTON, CA . 95206 7 06/26/2008 AT 01:56 PM 0113358400101065-01- 49795 113358400101065-0149795 12F71CPJ ESTIMATE OF RECORD 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ALTERNATE PARTS USAGE. AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST file:HC:\Documents and Settings\09155\Local Settings\Teinp\pdi\0113358400101065-0... 07/23/2008 Page 9 of 9 NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 OPTIONAL OEM PARTS OPTIONAL OEM SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL OEM PART WAS AVAILABLE: 0 NO. OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 RECONDITIONED PARTS RECONDITIONED SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE: 2 NO. OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 RECYCLED PARTS NO. OF TIMES USER WAS NOTIFIED THAT A RECYCLED PART WAS AVAILABLE: 5 NO. OF RECYCLED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 8 file://CADocuments and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Photos for claim no U 1 1-5-5Ji54UU 1 U 1 U6J-U 1 gage 1 of / Photo 1 from Estimate for Claim no 0113358400101065-01 Photo date:.26/06/2008 13:42:26:00. Size: 28573 . Description: Insured: GAMBA, SHERI. Policy—no: 0108926106.. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian Torok ...... . .... .......... O's :or .............................. g - t= ............::..:. ......:...:. .......... ...............: .......... Cil .. ;;. :....:..... .. a^ 4. A -I.. L w , .x� ... ................... ......:. :...:.:::..:... i= l ::........::..: ... .......; ................... r.... x ::..:..::. . • F ........... h:l` M A A :...:. ..:hi:.t3 A: ° w.... .... .. .. ....,n."x.. L.•VV°. _ = P ,r TOR i... .*E .......... ... .... .... ... �..>,. ... Air.: �';.` '. - _ . . .. . ..... . .:5x .. .......... ... .,:....,... .., ....... ........... Po„. ... . . . x: ..�.....:k. ,,. Via: j+ ¢ w. yx -OC K EYS V,111 � 04 j y� -F�x .... ...,•i:L3 .. ...r. . ... .:. xx55yq' '] ... 3..,. ,.....x .: ., s:,:.:..';.:.. .•G:. n,'..Y"� �,'.•:• ..t�t�F�' Lei�� wFjAa'£.F' - 14 :..... .. ..:'.;< x 04 A. - « ;:' 5?AT E!}i„G Lid pF1ia §-� �x;- .•tee��:�� ..... ... :e ,..q d 9e"1� !. X01 ��i�T.'• y �ge�^ei�a�r�rp, sf+s4M17#i3.4i�x+�T! r ,:n"ayyS-> 3.. ERSE S![1E-IMF R7 �1�.•Y i4r::... Photo 2 from Estimate for Claim no 0113358400101065-01 Photo date: 26/06/2008 13:42:27:00. Size: 30777 Description: Insured: GAMBA, SHERI. Policy no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian Torok rile://C:\:Documents and Settings\09155\Local Settings\"hemp\pdi\01 13358400101065-0... 07/23/2008 Photos for claim no U 1 1.33.)64UU 1 U 1 U6-*)-U 1 rage Z of �.� :..x._.. c " Y::.F s 3 77. r � `sY r+ �.••:•.:e�xe..f:_, r`+•i.:fb' ...�:. r�g 'fl �..I ti��fU'F+ e�i�it '�..: wq.:33 <�,�i� ''� p�< �'- •<: t. � gay.�: � ���' i::.2ffi.e '.: :ice'• "'F;'>.k`�. :SA:::.�:S.m:�.:. }..i.,. � �. •aF`•p"�- i�.$.�.,sKi ,��...,f3.> 3 d � 'Vti;xf:n, � 4 . d '?::. it�Y,. �. �>.2'��%<t.Y..S� _e<'Y:. ¢y rA�?o•^e6'3a`". .�5„�' £r tl7.z x'K i �nSwa Photo 3 from Estimate for Claim no 011.3358400101065-01 Photo date: 26/06/2008 13:42:27:00. Size: 23246 Description: .Insured: GAMBA, SI-IERL Policy—no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian Torok f le://C:\Documents and Settings\09155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Photos liar claim no 1.11 133M400 U1Ube-U1 Page J of / _. .............. ml e, liR�C 1, .i- - ,,.... �- ,tet..t..4;:'....... �z ..,:L-. f.:;•�-'` =' a a . .q. F �'. .. � ._.. P: ,. .: ..:.. r•;tea ria;. ��..:.�£�' x. :r. e - Photo 4 from Estimate for Claim no 011335840010:1065-01 Photo date: 26/06/2008 13:42:27:00. Size: 23038 Description: Insured: GAMBA, SHERI.. Policy_no: 0108926106. Claimant: . Vehicle: 5, SATU, VUI 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian'Forok file://C:\Documents and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Photos for claim no U1 133)64UU 1 U 1 U65-U 1 Page 4 of / M: ems. ' I ....0:' M <e Y .. 4 k0s w tz ti. ..dy���� ��il ill Illi I�'I.,, ",��„ri-,f'A`s#� r� ..?�,�„�.»«• :�.;� ... cel': I r: V la a 1P : 4 • Photo 5 from Estimate for Claim no 0113358400101065-01. Photo date: 26/06/2008 13:42:27:00. Size: 17342 Description: Insured: GAM13A, SHFAU. Policy_no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ.63455S838524. Loss (late: 06/11/08. Estimator: Bi-ian 'forok file://C:\Docum.ents and Settings\09155\Local Sett1ngs\Tejn1i\pdi\01.13358400101065-0... 07/23/2008 rnotos for claim no u t 1 s_iD64UU 1 U i UoD-U i rage D of i Xk ft A� r , r: , T s y.e I. a �i .f rr{1;• "P ti,r g., �3 }v. 1'. - 3f'•. 1 :.:.: .,tet, .......:Y.„.. ... p: Via:::•: ,:'.. .,:.:#*.. a. t� L.' 0.i: :::...: :.X .:x..::.:..:.... .¢..n ......,.y l.v[:a M- ...r,> ..;r.:... ..... v;E ra. ,`tai: r.. ......:.: .. ,. ,..,.... .z€..,...:..,�•��; ;;x�:;-:::-.t:"r'-:,±:r >:rc::;� ...,<' .9 ..a..:�.::.....e?C x.,.., .Y.:�? .:.t3 r< ^::':aka -�'.•vN..!,:x 'E�.:.#, i L� a.ti:.. .•<:.¢.ceq'kr,°<:': k yw....:: ...,N�.:• ... ..�t.• vc#.: `s"an', ::.Xz xx..x '''��• 4c :'�'::::- `Y> ir.:4.. 2 3 v*5 ,..Sa•{.r. :F 1 x; "t• 5 .a�l. �.._r.._r. '.. - ,. ..... ..r..... . .. pqbZz.�_.. r "6 3 a'°w x Photo 6 from Estimate for Claim no 0113358400101.065-01 Photo slate: 26/06/2008 13:42:27:00. Size: 14203 Description: Insured: GAMBA, SHERI. Policy_no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GLC763455S838524. Loss date: 06/11/08. Estimator: Brian Torok file://C:\Docuinents and Settings\u79155\Loca1 Settings\Temp\pd1\0113 358400101065-0... 07/23/2008 r11otos for claim ilo U1 1 j.i_)2S4UU l V I UOD-U 1 rage o of / e. ....... ...... ... .. .... ... .e..... ...ir... ... .... ..... :R A ... .. ... .............. r ..::.:........ ....� ..... ...... .,rel.• ........ ...:..:.. M 04 Aj :aX r. - a' r' g r : W. r n p g :.:-..... ._.&'.L.....Wim. •�'.. :.y. '.<; ...:. _�c? `�r:i&;':5:,, :�ksYr%:. ,....A•'�>',� :..a"-F - D Photo 7 from Estimate for Claim no 0113358400101065-01 Photo date: 26/06/2008 13:42:27:00. Size: 20329 .Description: Insured: GAMBA, SH..ERI. Policy—no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/1.1/08. Estimator: Brian Torok f le://C:\Documents and Settings\09155\Local Settings\Temp\pdi\01.13358400101065-0... 07/23/2008 Fhotos for claim no U11»JS4UU.IUIU.bJ-U1 Yage / ol. / 'All K] gg j ..Y...... .w... Aq a n y <:.'�'c''.:ks?::.~.:<�w. hti'...� � � n..it�;'.�r t�;.`;i:;yy"':::<1:�:.:1,;. i'x� .'•d Q� :a M .......... :_ r •+r::x file://C:\Documents and Settings\09155\Local SettingsV.remp\pdi\0113358400101065-0... 07/23/2008 Page l o1: 16 07/09/2008 AT 12: 30 AM 0113358400101065-01 1330 12F'71CPJ GEICO CONTRA COSTA NORTHERN CALIFORNIA VISIT US AT GEICO.COM P.0 BOX 509060 SAN DIEGO, CA 92150 (925) 698-2672. SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: ROBERTO ALCALA 07/09/2008 12:24 AM .ADJUSTER: FCC: 03 (510) 520-86'1'7 INSURED: SHERI GAMBA CLAIM $0113358400101065-01 OWNER: SHERI GAMBA POLTCY ##0108926106 ADDRESS: 2214 BEGONIA CT DATE OF LOSS: 06/11/2008 AT 12.:00 AM PITTSBURG, CA 94565-4424 TYPE: OF' LOSS: COLLISION EVENING: (925) 432-7584 POINT OF IMPACT: 6. REAR BUST-NESS: (925) 550-8945 INSPECT MIKES AUTO BODY DAY: (925) 432-9910 LOCATION: MIKE ROSE AUTO BODY DRIVE—IN 3001 N PARK BLVD PITTSBURG, CA 94565-0000 REPAIR MIKES AUTO BODY-PIT BUSINESS: (925) 432-9910 FACILITY: 3001 N. PARK BLVD 3 DAYS TO REPAIR PITTSBURG, CA 94565 LICENSE ## 942621349 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: V:IN: 5GZCZ63455S838524 LIC: 5NTP930 CA PROD DATE: ODOMETER: 468.58 AIR CONDITIONING REAR DEFOGGER 'TILT WHEEL CRUISE CONTROL INTERMITTENT WIPERS KEYLESS ENTRY THEFT DETERRENT/ALARM REAR WINDOW WIPER DUAL MIRRORS FOG LAMPS CLEAR COAT PAINT, POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER MIRRORS AM RADIO FM RADIO STEREO SEARCH/SEEK CD PLAYER ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIF, BAG CLOTH SEATS BUCKET SEATS RECLINE/LOUNGE SEATS AUTOMATIC TRANSMISSION 4 WHEEL DRIVE ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 S01 O/H REAR BUMPER 1.8 N 3* S01 REPL BUMPER COVER BASE 1 375. 93* INCL. 0.0* N 4* S01. REPL LT REFLECTOR 1 23. 62* INCL. N 5'**S01. REPL QUAL REPL PARTS IMPACT BAR 1 161.26* INCL. N 6* S01 REPL RT ENERGY ABSORBER RETAINER 1 3.00* INCL. N 7* S01 REPL LT ENERGY ABSORBER RETAINER 1 3. 00* INCL. 8* S01 REPL ENERGY ABSORBER 1 148.88* 1NCL. 9 LIFT GATE f le://C:\Documents and Settings\09155\Local Settings\Temp\pdi\01 13358400101065-0... 07/23/2008 gage L oI to ld 10* S01 "REPL NAMEPLATE "VUE" 1. 40. 14* 0.2 1 07/09/2008 AT 12:30 AM 0113358400101065-01 1330 12F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3. 5L-FI 41) UTV SILVER INT: ------------------=------------------------------------------------------------ NO. OP. [.DESCRIPTION QTY EXT. PRICF. LABOR PAIN'.L' ------------------------------------------------------------------------------- N 11* SO_l REPL QUAL RECY PAR'T'S LIFT GATE +25<, 1 631.25* 4 .2* 3. 9* 12 ADD FOR CLEAR COAT 1.. 6 N 13* SOl REPL, NAMEPLATE "AWD" 1 49.26* 0.2 N 1.4* S01 REPL NAMEPLATE "V6" 1 25.02* 0.2 15#; RFP. COLOR MATCH 0. 3 16 S01 REAR BODY & FLOOR N 1-7* S01 REPL REAR BODY PANEL . 1 329.17* INCL. 1.2 18 S01 OVERLAP MAJOR NON-ADJ. PANEL -0.2 19 SO1 ADD FOR CLEAR COAT 0.2 "o 501. ADD FOR INSIDE 0. 6 N 2.1* S01 REPL REAR CROSS BAR 1. 2"76. 12* 10.0. N 22* S01 RPR LT CORNER REINF 1 .5* 23 SO1 R&I TRIM PANEL ASSY NEUTRAL FROM INCL. VIN# 3S876565 24 S01 R&I RT CORNER TRIM INCL. 2.5 S01 R&I LT CORNER TRIM INCL. 26 S01 R&I RT TRAY NEUTRAL, INCL. 27 S01 R&I LT TRAY NEUTRAL INCL. 28 S01 QUARTER PANEL 29 S01 R&I RT QTR TRIM PANEL 0.2 30 S01 R&I LT QTR TRIM PANEL 0.2 31 S01 PILLARS, ROCKER & F'LOOL? 32 S01 R&I RT ROCKER MOLDING BASE 0:7 33 S01 R&I LT ROCKER MOLDING BASE 0.7 34 SOI ROOF 35 S01 R&I REAR HEADER TRIM 0.3 36 SO1 RESTRAINT SYSTEMS 37* S01 R&I RT SEAT BELT ASSY * 0.4* NEUTP.AL--LOOSEN 38* S01 R&I LT SEAT BELT ASSY NEUTRAL * 0.4* --LOOSEN 39 SOl WHEELS 40 S01 R&I SPARE R&I WHEEL M 0. 1 41# S01 RESTORE CORROSION PROTECTION 1 10.00 0.2 42# SO]. SET UP & MEASURE FRAME 1 1.5 F 43# S01 FULL TO SQUARE REAR BODY 1 2.0 44 OTHER CHARGES 45# E. P.C. 1. 3. 00 --------------------------------------------------------------------------------- =-> 2079. 65 25. 1 7 . 3 SUBTOTALS 111e://C:\.Documents and Settings\09155\1:,oca1 Settings\Temp\pdi\0113358100101065-0... 07/23/2008 Page -3 of 16 LINE 3 OEM APRVD DUE TO OEM TXTR AND PART COMES PAINTED. LINE 4 PPI LINE 5 PUSIIED IN LINE 6 A/M NOT COST EFFECTIVE. PPI LIFE 7 A/M NOT COST EFFECTIVE.PPI LINE 10 PPI LINE 11 PPI SUPPLIERS PART DESCRIPTION: LID -4SW, 0702, 000, -RED 2 G 07/09/2008 AT 12: 30 AM 01133584001.01065-01 1.330 12F7I.CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 .SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: LINE 1.3 PPI LINE 14 FPI LINE 17 PUSHED 114. PPI LINE 21 PPI LINE 22 DEN'I'ED IN W/REAP, BODY ------------------------------------------------------------------------------- PRIOR DAMAGE NOTES: NONE PARTS 2076. 65 BODY LABOR 23. 6 HRS @$ 72.00/HR 1699.20 PAINT LABOR 7 .3 HRS @$ 72. 00/HR 525. 60 FRAME LABOR 1.5 HRS @$ 72.00/HR 108. 00 PAINT SUPPLIES 7.3 HRS @$ 32. 00/ITR 233. 60 OTHER CHARGES 3. 00 ---------------------------------------------------- SUBTOTAL $ 4646. 05 SALES 'TAX $ 2310.25 @ 8.2500% 190. 60 ----------------------------=----------------------- TOTAL COST OF REPAIRS $ 4836. 65 ADJUSTMENTS: DEDUCTIBLE 500.00 --------------------------------------------- ------ TOTAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 4336. 65 "WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILT, CAUSE THE DAMAGED VEHTCLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHFIR THP,IT AS STA'T'ED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERTENCF A PROBLEM 11g1'I.'H T13E REPAIR OF YOUR VE'f-3TCLE, PLEASE CONTACT US IMMED.IATFILY FOR ASSISTANCE. " f lc://C:\Documents and Settings\u791 5 5 Tocal Settings\Temp\pdi\O 1133158400101.065-0... 07/23/2008 1'age 4 of 10 TH1S IS NOT AN AUTHORIZATION 'TO REPAIR I,10 SUPPLEMENT WILL BE HONORED, UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPEP,LY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGIIT EQUIPMENT 'TO REPAIR YOUR VEHICLE. 3 07/09/2008 AT 12: 30 AM 01133584001.01065-01 1330 12F71C:PJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES T14E FOLLOWING TO APPEAR ON THIS !"ORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE. PAYMENT Or' A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN S'T'ATE PRISON. THE; FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOL'S 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 TABOR 'TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUC'T'URAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AU'T'OMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST--ESTIMA'T'E EXT. PRICE=UNIT PRICE MULTIPLIED BY TEE QUANTITY .T.NCL-INCLUDED MISC=MISCELLANEOUS NAGS==NATIONAL AUTO GLASS SPECIFICATIONS NON-A.DJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPI, PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R.-REMOVE AND REPLACE R.PR=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 PAR'I'S EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE 01' CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANI]FACTURER OF YOUR MOTOR VEHICLE. ANY WARPA141FIES APPLICTIBLE 'TO TEESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER 'THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. fide://C:\Documents and Settings\u79155\1.,ocal Settings\'Temp\pdi\0.113358400101065-0... 07/23/2008 Page 5 of .16 4 07/09/2008 AT 1.2: 30 AM 01133584001.01065-01 1330 12F'71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SA1'U VUE 414 6-3. 5L-FI 4D UTV SILVER INT: ALTERNATE PARTS DISCLAIMER IF' QUALITY RF..PLACFMEN'1.' PART (QRP) APPEARS ON 'PHIS ESTIMATE, I'T' INDICATES THAT THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE; OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFAC'T'URER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, WE PROVIDE THE FOLLOWING: *** OWNER LIMITED WARRANTY **** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PAR'I'S (PARTS NOT MANUFACTURED BY THE MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF DEFEC'T'S IN MATERIAL AND WORKMANSHIP AND MEET GENERALLY ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMATE. THIS WARRANTY COVERS THE COST OF THE PART, LABOR TO INSTALL, AND INCIDEN'T'ALS SUCH AS PAINT AND MATERIALS AND. IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAT IS UNRELATED TO DEFECTS IN THE QUALITY REPLACEMENT PARTS. THIS IS NOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CONTACT YOUR LOCAL GE-[CO REPRESENTATIVE. NO SUPPLEMENT WILL BE IIONORFD UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A.MIG WELDER FOR f le://C:\Dociunents and Settings\u791.55\Local Settings\Temp\pdi\011 3358400101065-0... 07/23/20.08 Mabe 0 of t0 PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGHT EQUTPMENT TO ]ZEPAIR YOUR VEHICLE. .5 07/09/2008 AT 12: 30 AM 0113358400101.065-01 1330 12F71CPJ SUPPLE'MEN'T' .OF RECORD ]. WITH SUMMARY . 2005 SA U VUE. 4X4 6-3.5L-FI 4D UTV SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. ' UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GU:CDE DR8ID02, CCC DATA DATE 06/01/2008, 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 COME' REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCR7:BED AS L KQ, QUAL REC`i PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECOND. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICiES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS. LABOR OPERATION TIMES LISTED File:/C:\.Documents and Settings\u791.55\Local 8ettings\Temp\pdi\0113358400101065-0... 07/23/2008 Page I of 10 ON THE LINE WIPP THE NAGS INFORMATION "ARL•; MO'T'OR SUGGESTED LABOR OPERATION TIMES. NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN Q) 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 ESTIMATOI? 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. 6 01/09/2008 AT 12.: 30 AM 0113358400101065-01 1330 12F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -,------------------------------------------------------------------------------ ------- CHANGED ITEMS------- 2 REPL L1' REFLECTOR 1 -13.08 INCL. N 4* S01 REPL, LT REFLECTOR 1 2.3. 62* INCL. 5 REPL NAMEPLATE "VUE" 1 -23.05 -0.2 N 10* S01 REPL NAMEPLATE "VUE'' 1 40. 14* 0.2 6* REPL QUAL RECY PARTS LIFT GATE -x-25% 1 -625. 00 -4 .2* -3. 9* N 11* S01 REPL QUAL RELY PAR'I'S LIFT GATE +25` 1 631.25* 4 .2* 3. 9* 8 REPL NAMEPLATE "MWD" 1 -29. 60 -0.2 N 13* S01. REPL NAMEPLATE "AWD" 1 49.26* 0.2 file://C:\Docun.1en1s and Settinglu79155Tocal Settings\Temp,dhOl 13358400101065-0... 07/23/2008 Page 8 o1 16 9 REPL NAMEPLATE "V6" 1 -13.49 -0.2 N 14* S01 REPL NAMEPLATE "V6" 1 25.02* 0.2 ------ DELETED ITEMS------- 2k+ REPL RECOND BUMPER COVER BASE 1 -244 . 00 -1. 4 0.0* N 4 REP1, ENERGY ABSORBER 1 -102. 67 -D. 1- -------- ADDED I'T'EMS ------- 2 S01 0/11 REAR BUMPER 1. .8 N 3* SOI. R1iPL BUMPER COVER BASE 1 375. 93* INCL. 0.0* N 5**SO1 REPL QUAL REPL PAR'I'S IMPACT BAR 1 161.26* INCL. N 6* S01 REPL RT ENERGY ABSORBER RETAINER 1 3.00* INCL. II 7* S01 REPL LT ENERGY ABSORBER RETAINER 1 3.00* INCL. 8* SO! REPL ENERGY" ABSORBER 1 148.88* INCL. 16 S01 REAR BODY & FLOOR N 17'` S01 REPL REAR BODY PANEL 1 329. 17* INCL. 1.2 1S SOl OVERLAP MAJOR NON-ADJ. PANEL -0.2 19 SOl ADD FOR CLEAR COAT 0.2 20 S01 ADDFOR INSIDE 0. 6 N 21* SO]. REPL REAR CROSS BAR 1 276. 12* 10. 0 N 22* SO]. RPR LT CORNER REINF 1.5* 23 S01 R&I TRIM PANEL ASSY NEUTRAL FROM VIN# 35876565 INCL. 24 SO] R&I RT CORNER TRIM INCL. 25 S01 R&I L'T' CORNIER TRIM INCL. 26 SOl R&I RT TRAY NEU'T'RAI, INCL. 27 SOl R&1 LT TRAY NEUTRAL INCL. 28 S01 QUAR'T'ER PANEL 29 S01 R&I RT QTR PRIM PANEL 0.2 30 S01 R&I LT QTR 'PRIM PANEL 0.2 31 SO]. PILLARS, ROCKER & FLOOR 32 SO]. R&I RT ROCKER MOLDING BASE 0.7 ?3 SOl R&I LT ROCKER MOLDING BASE 0.7 34 SO1 ROOF 35 SO]. R&I REAR HEADER TRIM 0. 3 36 SOI. RES'T'RAINT SYSTEMS 37* S01 R&I RT SEAT BELT ASSY NEUTRAL--LOOSEN * 0. 4* 38* S01 R&I LT SEAT BELT ASSY NEUTRAL --LOOSEN * 0.4* 39 S01 WHEELS 7 07/09/2008 AT 12: 30 AM 0113358400101065-01 1330 12F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY. 2005 SATU VUE 4Y.4 6-3.5L-FI 4D UTV SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 40 S01 R&I SPARE R&I WHEEL M 0. 1. 41r S01 RESTORE CORROSION PROTECTION 1 10. 00 0.2 42r S01 SET UP & MEASURE FRAME 1 1 . 5 F 1i1e://C:\D0cu.ments and Settings\u79155\Local Settings\Temp\pdi\Ol 133584001.01065-0... 07/23/2008 1'age J of 16 4311 S01 PULL TO SQUARE REAR BODY 1 2.0 ------------------------------------------------------------------------------- SUBTOTALS 1025.76 18.5 1.8 LINF, 4 PPT LINE, 5 PUSHED IN DINE 1.0 PPI LINE Fi A/M NOT COST EFFEC'1'IVE. PPI LINE 11 PPI SUPPLIERS PART DESCRIPTION: LID -4SW, 0702, 000, -RED LINE 13 PPI LINE 1.4 PPI LINE 3 OEM APRVD DUE TO OEM TXTR AND PART COMES PAIN'T'ED. LINE 5 PUSHED IN T.,INE 6 A/M NOT COST EFFECTIVE. PPI LINE '7 A/M NOT COST EFFECTIVE.PPI LINT; 17 PUSHED IN. PPI LINE 2.1. PPI LINE 22 DENTED IN W/REAR BODY ------------------------------------------------------------------------------- PRTOR DAMAGE NOTES: NONE PARTS 1025.76 BODY LABOR 17.0 HRS @$ 72.00/HR 1224.00 PAINT LABOR 1. 8 HRS @$ 72.00/HR 129. 60 FRAME LABOR 1.5 HRS @$ 72.00/HP, 108. 00 PAINT SUPPLIES 1. 8 HRS @$ 32.00/I-IR b7 . 60 ---------------------------------------------------- SUBTOTAL $ 2544 . 96 SALES TAX $ 1083. 36 @ 8.25000 89. 38 ----------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $. 2634 .34 NET COST OF SUPPLEMEN`! $ 2634 .34 ESTIMATE 220.7..31 BRIAN TOROK SUPPLEMENT S01 2634.34 ROBERTO ALCALA ------ TOTAL ADJUSTMENTS $ 500.00 WORKFILE TOTAL $ 4836. 65 NET COST OF REPAIRS $ 4336. 65 8 07/09/2008 AT 12:30 AM 0113358400101065-01 1.330 1.2F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUF 4Y>4 6-3.5L-FI 4D UTV SILVER INT: file://C:\Documents and Settings\u79155\Local Settings\Tcnip\pdi\Ol 13358400101065-0... 07/23/2008 Yage 10 of 1.b "WE ARE PROHIBITED BY LAW FROM REQUIRING -THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE; REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. " THIS IS NOT AN AUTHORIZATION TO REPAIR NO SUPPLEMENT WILL BE HONORED UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN .THE VEHICLE. MAKE SURE YOUR SHOP HAS THE RIGH'1. EQUIPMENT TO REPAIR YOUR VEHICLE. 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 EINES 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 LABOI? 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=WI'T'HOUT 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. 9 file://C:\Documents and Settings\09155\Local Settings\"1'emp\pdi\011335840010106.5-0... 07/23/2008 rage 1 1 oT 1 o 07/09/2008 Al' 12:30 AM 0113358400101065-01 1.330 12F71.C'PJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3.5L-FJ. 4D UTV SILVER INT: THIS ESTTMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF FOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THE:SE REPLACEMENT PARTS ARE PROVIDED BY THE [MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. ALTERNATE PARTS DISCLAIMER IF QUALITY REPLACEMENT PART (QRP) APPEARS ON ]'HIS ESTIMATE, IT INDICATES THAT `PHIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF ONE OR MORE CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN 'THE MANUFACTURER OF YOUR MOTOR VEHICLE. WARRANTIES, IF ANY, APPLICABLE TO THESE REPLACEMENT CRASH PARTS ARE PROVIDED BY THE PART MANUFACTURER OR DISTRIBUTOR RATHER THAN BY THE MANUFACTURER OF YOUR VEHICLE. *** IN ADDITION TO ANY SUCH WARRANTIES, WE PROVIDE THE FOLLOWING: **** OWNER LIMITED WARRANTY **** WE WARRANT THAT ALL QUALITY REPLACEMENT BODY PARTS (PARTS NOT MANUFAC'T'URED BY THE' MANUFACTURER) IDENTIFIED ON YOUR ESTIMATE, ARE FREE OF' DEFECTS TN MATERIAL AND WORKMANSHIP AND MEET GENERALLY. ACCEPTED INDUSTRY STANDARDS. THIS PARTS AND LABOR WARRANTY WILL BE IN EFFECT FOR AS LONG AS YOU OWN THE VEHICLE DESCRIBED IN THE ESTIMA'J'E. THIS WARRANTY COVERS THE COST OF THE PART, LABOR TO IPSTALL, AND INCIDEN'T'ALS SUCH AS PAINT AND MATERIALS AND IS SPECIFICALLY LIMITED TO THOSE ITEMS. THIS WARRANTY DOES NOT COVER LOSS OR DAMAGE THAI' IS UNRELATED '10 DEFECTS IN THE QUALITY REPLACEMENT PARTS. 'PHIS ISNOT TRANSFERABLE. IF ANY QUALITY REPLACEMENT PARTS ARE DEFECTIVE IN EITHER MATERIAL OR WORKMANSHIP, CON'T'ACT YOUR LOCAL GEICO REPRESENTATIVE. NO SUPPLEMENT WELL BE HONORED UNLESS AUTHORIZED NOTICE: NEW HIGH STRENGTH STEELS MAY REQUIRE THE USE- OF A MIG WELDER FOR PROPER REPAIRS. NEW DESIGNS REQUIRE MEASUREMENT TO PROPERLY ALIGN THE VEHICLE. MAKE: SURE. YOUR SHOP HAS THE RIGHT EQUIPMENT TO REPAIR YOUR VEHICLE. file://C:\Documents and Settings\u79155\Local Sett1ngsV.Femp\pdi\010358400101.065-0... 07/23;2008 Page 12 of 16 10 07/09/2008 AT 12:30 AM 01133584001.01065-01 1330 12F'71CPJ SUPPLEMENT OF' RECORD 1 WTTH SUMMARY 2005 SAT'U VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR81D02, CCC DATA DATE 06/01/2005, AND THE PAR'I'S SELECTED ARE GEM-PARTS MANUFAC'T'URED I3Y THE VEHICLES ORIGINAL EQUIPMENT MANUF'ACT'URER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. OPT OEM (OPTIONAL OEM) OR ALT OEM (ALTERNATIVE OEM) PART'S 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" PAR'I'S PROVIDED 13Y ORM'S '.THROUGH OEM VEHICLE: DEALERSHIPS. ASTERISK (*) OR DOUBLE:. ASTERISK (**) INDICAT'ES THAT THE PAR'I'S 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-1NC.LUDED LABOR OPERATIONS. NON-ORIGINAL E'QUIPME'NT MANUFACTURER AE'TERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMI'ET'ITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RELY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECORD. RECORED PAR'I'S 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. E'OR 'THOSE VEIIICLES, 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. iile://C:\Documents and Settings\u791.55\Local Settings\-remp\pdi\Ol 13358400101065-0... 07/23/2008 gage t j o t t n ].1 07/09/2008 AT 12:30 AM 0113358400101065-01 1330 12F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: RECYCLED PART SUPPLIERS LINE TINE DESCRIPTION PRICE 1.1 QUAL RECY PARTS LIFT GATE 4250-c STOCK NO. : V70660 $ 631.25 LKQ - WEST (866) 557-2677 AZ,NV,CA, UT SANTA.FE SPRING, CA 90670 file://C:\Documents and Settings\09155\Local Settings\'.Cemp\pdi\0113358400101065-0... 07/23/2008 Page 14 of 16 12 0"1/09/2008 AT 12:30 AM 0113358400101065-01 1.330 12F71CPJ SUPPLEMENT OE' RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3. 5L-FI 4D UTV• SILVER INT: ALTERNATE PARTS SUPPLIERS 5 QUAL REPL PAR'I'S IMPACT BAR PART NO. GM1106573 PRICE 161.26 KEYSTONE - COMPLETE (800) 264-7560 3615 NE. 109TH AVE (360) 2.60-8400 VANCOUVER, WA 98682 KEYSTONE - COMPLETE (800) 421-7866 2530 LINDSAY PRIVADO #kC (909) 986-4586 ONTARIO, CA 97.761 KEYSTONE - COMPLETE (800) 263-9727 1627 ARMY COUR`.I' (209) .948-1101 STOCKTON, CA 95206 file://C:\D0CLlMC17tS and Settings\u79155\Local Settings\Temp\pdi\0113358400101065-0... 07/23/2008 Page 15 of 16 13 07/09/2008 AT 12: 30 AM 0113358400101065-01 1330 12F71CPJ SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 SATU VUE 4X4 6-3.5L-FI 4D UTV SILVER INT: ALTERNATE PAR'I'S USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST . NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 9 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 OPTIONAL OEM PARTS OPTIONAL OEM SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL .OEM PART WAS AVAILABLE: 0 NO. OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 RECONDITIONED PARTS RECONDITIONED SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE: 8 NO. OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 file://C:\.I)ocunnents and Settings\u79155\Local Settings\"I'emp\pdi\0.113358400101065-0... 07/2-3/2008 Photos for claim no U 1 1 J-iJ 64UU l U l UVJ-U 1 Page 1 of J Photo 1 from Estimate for Claim no 0113358400101065-01 Photo date: 08/07/2008 12:44:18:00. Size: 28272 Description: Insured: GAMBA, S.HCRI. 1'.olicy_no: 0108926106. Claimant: ° Vehicle: 5, SA'I'D, VUC 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian Torok .a ...:N. :�Yt. r.o-.•:.' a: g < d i.. " i Ilial ,d y — �..a< W: r' i < N ` 'Q u A v. .f •. .�`:.?.S r ..<". e:ru S""�M' �.�'N:iw .:,+nas��'0..e 'riA...-:''�^:": �.*:.(.:. ....:r:..:a ..:3'109%::..:., " :eet4,.x .°F. #r��ix'••..a:':'.:.•x�N a%'4"�R,.v.� �✓, n.... �::Poya>:. ..3 ,,,. .::..+„✓..<'�' ...>x:..`Y$x..is:$�' '<.j'S.,.ix .��rY� ::mss�: 0;'}.°u .Ys:..°:d= .ta"s< ..:.<:.xrx.s.c.,.°t &. sf >".,7:e,.. ..,"„�:r.� R..4�s'A.•y';x.': e. ..ai' ..-.. .. ..:. n .>.m.<. .. :w )..°.r:. °.<am.:.r.. ,... ...°..-°b'.tx3K". ri :.'��'� g ::.,,,`• :; B "/-.. e.... ..`s ...-.<- ..@m...x�. <:.}......,. .. ...x :^.::: .. .. ..w:>y".,.,g i:'� _ ...1e..:'.:.,•�'. '.a� .Y +,x�:.��''O'(d'itev^'•�µ~ .. .. ..yR•:.t xani:.t•:..L • ..�.x .n' ..',v A,.t......,..tw. Photo 2 from Estimate for Claim no 0113358400101065-01 Photo date: 08/07/2008 12:44:18:00. Size: 27707 Description: Insured: GAMBA, SHCRI. Policy—no: 0108926106. Claimant: . Vehicle: 5, SATU, VUC 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian "Torok file://C:\Documents and Settings\u79.155\Local Settings\'I'emp\pdi\OI.13358400101065-0... 07/23/2008 1'11olos for claim no U 1 1.i j N14UU 1 U I UOJ-U 1 nage G of J ... 5. W r A �aN ru r n. C IK •h �Y� �r x .;.:. . ....t x: t^ x x e.: n ,p..r ..... .x� x.. ,rax ..:........:. ,r�.. Photo 3 from Estimate for Claim no 0113358400101.065-01 .Photo date: 08/07/2008 12:44:18:00. Suer 26514 Description: Insured: GAMI3A, SHERI. Policy_no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZCZ63455S838524. Loss date: 06/11/08. Estimator: Brian Torok file://C:\Documents and Settings\09155\Local SettingsV-Femp\pd1\O1 13358400101065-0... 07/23/2008 Photos lor.clann no.U1 133--)84UU1U1U6J-U1 Yage 3 of4. 5 " IleeiSfW E SI�;� IWI I f7r! ...-: C}}57 . 411 ..:. .....i ....... ..... .•.':?y' •�}g.. ..Via" ,5�. ...},..,,, ,' _ ..:.. fir.-. d.;: %S`:•F, 'er •s*x'.' Z. , ,V y .fie.. :., ... .M F.i.. .+�&s.:' ...:.::K..- ...8.. ...°.°�`,:..,..�r.,h�'°:,, _ ''w�;.'� :.fie`,.':�•� ,?-Tg?Y`x1+&. ..gym... ..> .. ... .....:... ��_§ "2x .. .. .., ... �: ., ....� 'f:, "' ..:..:+• 0'.3W �:^u;-si",'.�':'� sem: ' .. .. .q..,F ...: .sr. :•a:. , .. : .� :.:. ..,•K. ....y�..._� ..:e'?a r:. � .:..:..s�...'' ,��8f 'P :b .... �L?Y.j;::r"� ':%',:.c� .,�..&..;.y .... x. Photo 4 from Estimate for Claim no 01.1335840.0101065-01: Photo date: 08/07/2008 12:44:18:00. Size: 28410 Description: Insured: GAMBA, SHERI. Policy_no: 0108926106. Claimant: . Vehicle: 5. SATU, VUE 4X4. VIN: 5GGC763455S838524. Loss date: 06/11/08. Estimator: Brian Torok file://C':\Documents and Settings\091.55Tocal Settings\'I`emp\pdi\0113358400101065-0... 07/23/2008 Yholos for claim 110 Ul 1-3.J64UU10100J-U1 Page 4 01 J ::5: 'fix :'�:. � ... '�'. ..£:c�'r ��;� 'il�'�i _ :;;•.::' � . .. `y , " �4 1/ R ^J _ x. ......... .: �pga.�yy 4' p Y;: ' k t r.. r x�z• per"' L• 1 ,.` '1lt_ x mw rF`f% Photo 5 from Estimate for Claim no 0113358400101065-01 Photo date: 08/07/2008 12:44:.18:00. Size: 23660 Description: Insured: GAMBA, SHERI. Policy—no: 0108926106. Claimant: . Vehicle: 5, SATU, VUE 4X4. VIN: 5GZ,CZ.63455S838524. Loss date: 06/11/08. Estimator: Brian Torok f lc://C:\Documcnts and Settings\09155\Local Settings\"hemp\pdi.\0113358400101065-0... 07/23/2008 Photos for claim.no U 1 1 a3J84UU l U l UOJ-U 1 Page J ol: J M... A On A I file:%/C':\Documents and Settings\u79155\Local Settings\1.'emp\pdi\U113358400101065-0:.. 07/23/2008 Lj= l :J P.O. Box 509119 San Diego, CA 92150-9119 j:::i ^I : r' AY 1:/.1 W20!:,3 T_�.r.-._._�...__._.�.,-..T-_..:.�..-,...r�-nT�.-r^Fri--:.4^^^�^.--1;-•-��T .., ^",-]-' r :3 - :� . Xt 1141 47-7 i'� i_t,�, _.. i' _til S-.1_ {.• � ..,. .. :: ., ../f.�!• ,a 1.'� �1`•. -' , .Fr l.l':ii 1-r ' •, _ gip• - � -��'3''..�p t' ?�.•�\j:1 ����1 f / ( 'r� � ... - c p , i • E-326(09-06) P.O. Box 509119t' ' San Diego, CA 92150-9119s?'ter_,_ 21S P`1�0 Contents Merchandise—This parcel may be opened for postal inspection if necessary. • MINION — 14111 DANIELSON STREET,POWAY,CA 92064 Km CIS !�'G -�,e, ��G'f•'G� '- 1 n-e S7 04�q�& a' ?oo — 0-103-AWW(08-04) RETURN AND FORWARDING POSTAGE GUARANTEED COSTq CO L�SOgS , _ 1 CLAi.M BOARD O.F,SUPE11V.1.SO.RS OF CONTRA COSTA COUNTY BOARD ACTION:. AUGUST 19, .2008. Claim Against the County, or. District Govenled by ) the Board of Supervisors, Rout ing.Endo rsernents, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim.by the Board of Supervisors. (Paragraph IV below), JUL 3 0 2008 given Pursuant to Government Code AMOUNT: UNKNOWN Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: MARY KATHLEEN REMLEY ATTORNEY: UNKNOWN DATE RECEIVED: JULY 30, 2008 ADDRESS: P.O. BOX;971 BY DELIVERY TO CLERK ON: JULY 30, 2008 OCCIDENTAL, CA 95465 RECEIVED THRU FAXED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN .1 Dated: JULY 30, 2008 By: Deputy - fl. FROM.: County Counsel TO: Clerk of the Board of Slupervisors (1/J""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). (Y 0. Vi c+ �� (v)-Clairn ts-i timely .fled. - i-nincy rd__r_tniMai1t'S right tQ apply fbi-lea-,,,e4a present a late e1zlin (SUM-MY i I (✓Y Other: e I } '- �rv-� e�.-� o��l � !'C ' eA/' to -Iqh f 7� c�•� s f c. l 1Se Oc E C i.►,. Dated: 7-30-OS- By: - /)l`)0 qjq:,� Deputy County Counsel ilL FROM: Clerk of the Board TO: County Counsel (]) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). l.V.,, OARD ORDER: By unanimous vote of the Supervisors present: (vlf This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Hoard's Order entered in its minutes for. this date. Date / •l"JKHN CULLEN, CLERK, By Deputy Clerk WARNi.. G (Gov. code section 913) or Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the .pdviee of an attorney of your choice in connection widr this matter.`If'you want to consult an attoniey,you should do so immediately. *For Addidanal Warnir;;See Reverse Side ofrhis Notice. AFFIDAVIT OF MAILING declare under penalty of perjury 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 IN'tartinez, California, postage fully prepaid a certified copy of.this Board Order and Notice to Claimant, addressed to the clainran.t as shown above. Dat r �i '?'did JOHN CULLEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL gESILVANO B. MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building �;•'-_ -_���,� 651 Pine Street, 9'h Floor % ' _` ��.p SHARON L. ANDERSON / _ Martinez, California 94553-1229 a f, _ �fe CHIEF ASSISTANT (925) 335-1800 A� .• "— *'_•�.• 'a' ' GREGORY C. HARVEY �• .•,i° i�1 P (925) 646-1078 (fax) ..... �`^ VALERIE J. RANCHE ASSISTANTS STATUTORY WARNING PURSUANT TO GOVERNMENT CODE SECTION 911.3 July 31, 2008 TO: Mary Kathleen Remley PO Box 971 Occidental, CA 95465 RP: Claim of Mary Kathleen Remley Please Take Notice as Follows: The claim you presented to the Contra Costa County Board of Supervisors on July 30, 2008 was reviewed by County Counsel. The portion of the claim prior to .January 30, 2008 was not presented within six months after the event or occurrence as required by law. Because you allege late discovery of the claim, the claim is "timely on its face" and will be reviewed and acted upon by the Board of Supervisors within the statutory time period. To preserve the rights of the County, its departments and employees to challenge the validity of your late discovery claim, you are warned pursuant to statute that if your delayed discovery argument is improper, your claim is late, and is being returned because it was not presented within six months after the event or occurrence as required by law. (See Gov. Code, §§ 901, 911.2.) Because the claim may not have been presented within the time allowed by law, we warn you that to preserve your right in the event your claim is determined to be late, your only recourse at this time is to apply without delay to the Contra Costa County Board of Supervisors for leave to present a Late claim. (See Gov. Code, §§ 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances, leave to present a late claim will be granted. (See Gov. Code, § 911.6.) Page 1 a 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. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On �( �� , I served a true copy of this Statutory Warning Pursuant to Government Code Section 11.3 by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Mary Kathleen Remley, PO Box 971, Occidental, CA 95465, as set forth above. 1.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. ,7 Ka hleen O'Conne cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 May 27 08 05: 33a P. 1 .. C17/70/1-02'-3 p:19 MNTR=i ';STF{ i_C' '7' CLERK i,i- THE ..,''E1?871__.... I•!f `� a � BOARD OF SL'PER� I50R5 OF CONTRA COSTA COIi3ti1TY NSTRL'CTIONS TO CLAITIMAN"r 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 moaths after the accrual of the cause of action. A claim relating to any o'.aer cause of actiCL shall be presented aot later than one yezr after the accrual of the cause of action. (Gt�v. 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 govcrned by the Board of Supervisors, ;at2rer than the Co=y. Lhe name of the District should be filled in. D. If the claim ie against more than one public entity; separa-e claims must be filed against each public et►tity. E. Fraud. See penalty for fisudulent claims,Penal Coeie Sec. 2 it!The cud of this form. us aMovv.6..v....■...04198e•.v.•r.top......a....y.....a.......0...r.ae0..0....... RE: Claim By: F.eserved for Clerk's filing stamp /V Against the C:otmty of Contra Costa or ? C '1414 3 �Fq 4 Ci District) �o�ggp ?QNB (Fill in the name) C -ems. 3 NTgq oST�CgV�s The undersigned claimant hereby makes cle.irn against the County of Contra Costa or the abov c:-named district in tht: sum of$ and in support of this claire represents as follows: 1. V,Thcn did the damage or injury occur? (Give cx ::t date and:tour) S' /, �Gcc- d e5 _ : /Z, Z-G 2. Where did the damage or injn-y occur? (Include -ity and county) id 3. How did the datuage or injury occur^• (Give full df-Lai Is-, use c.7ctia paper if required; /ZLyySJFd.fCL- lLt�ll.�C'-• SG'�ir�i�CdLa!C�•u�I, 1G'S'� - .SLGf:%���t.��rf %fit /Z�G�Z sKtG�.9`" /'2 SGL/f:.Q� i�c_ .�x�(•.ss�C. Gi.:.Flce S �✓u- �� y..EQ'.f� �1 r l' 4. What particular act or otntss;on on the cart of county or distfict Officers, servants, or emplhyees� - ,,caused t: a injury or damage. _0f- ✓7E/AA,,-'-J �SC-tet/f_L'1;, ��'`�•t f'i,.-Est!-b'�. .s�,.>/% �C�l. �•��,ti It— ;jX �fes,•-j t �.s ��E 1- ��% 5 V&t are the names county or di=af OM Ctrs, servants, ar emp oyees cuustng dansage or injury, !�/~• Jae-�ic_P�J Ge.Fir•zt,,ryF_�'' i c. -���..�tiw �" Ip Z24J-kC_ May 27 08 05: 33a p . 2 �7 ';0f2ChL18 ?.0:19 CONTRA C DSTA i=OLRJ"( _LERK ^F. I � ND..':i 5 Dr02 r, ' :.1 'O; 1219. I 6. Arhez damage or injuries do yaw claim rest:lted? ( give fu'] extent of injures o: damages _ claimed. Attach two estimates for autoclams e. — g ) -.L G��2t,t.�. �ti �/E'er(-G•G�.. �•'Ltl-L� ��G c2 • f�C �L� /� f>` !r_ tz Al' � �hx✓�-z a�1. �vx��� � ��t G c c 7. Host was the mount claimed above cornputtd? (Welude the estimated emotint of any r p:ospertive WWY OT damage.) �o 8. Names and addresses of witnesses, doctors, and hospitals: 9. t ist the rxpenwdtiwe y u eon acro t or this or injury: I ATE TIME AMOLKIT -� i •60160■•es/rNO....s•se..a•.•..■OO•■.&.■•so•ars69S•■oe4one vW•\Csearriss*won s.w•ses•..■.I ) Gov. Code Sec. 910.2 provides"The claim sball he ) signed by the clairn—Ant or by some person on his ) behalf. SE/v�ICES TO: (Attorney)---� Name.and address of Attorney } 1� } (C`laimant's 5igminlre) Telephone No. }Telephone No. ago a..I.aaa DV•ttGOOae.&We a a e 0.6009 a WrDOG SIR 96•I DO%N WWW .0•46600■.De a ON IF VMS GOO BWV.a■a.e., PUBLIC RECORDS NOTICE: Pleasc be advised that this claims form,or any claim filed with arc County wider the Tort Claims Act,is subj=1 to public diw4osm under the Califomia ;<rublic Records Act. (Govt. C'.o&. 5g 6500 et vq-) Fu:tlrerrrorr-, any momenta.addmdums,or mWlementt:attached to the claim form, inchx ing mcdicat rwords,are also subject to public disclosure. ■s■eesstssesa.•►sesoes.■.ass••..■asses..••.•s..•sssa.los.11*F•.d..s.s•■.ssass age■.r.s. NOTICE- Section 72 of the Penal :ode provides. Every person who.with iiamtst to defiand, pre8mts for allowance or for ;raymaat to any state board cr officer,or to any county, city, or district board or officer, authorized to tllow ar pay the same if omnine, any false or fraudulent Claim, bill,account vomher, ar writing, is punishable either by imprison meat in the County jail for a period of nut more than one year, by a fiat of not exceeding one thaussnd dollars (S1,000.00), or by both such impriwnmcnt and finer or by ittiosor umt in the state prison, by a fine of not exccading ten thousand dollars (S 10,000),or by both mx% imprisonment and fine. I Ma'd 2? 08 0-:: 33a P. in:1.9 -1ST! LEIi,' 17F THE F10i RE 'Y BOARD OF SUPERVISO 30F CONTRA COSTA COUNTY A T NSTRUCTI QNS TO C1 DA)0' A. A al[&a relating to a cause of action for deaf-r., ar for 'unjiaw to person or to pi-.rsona). propervi or pro-vvinU w-ops shall b� prrsented not later ;.han S"'.x i'lloaths 'after th.c- aCCMal Of the C;O.Use of action. A claim relating to any other cause of&CAR-IM. ShO be ptescntcd Got Iwa:r than one: Yvas utterthe accrual of thezusr,of action. (Gov. Code § M 1.2.) B. Clai=3 TrIISt be flied with the Clerk of the Board of"Super%lsorg at its offic,,-- in Room 1106, CowAy Admizistration Building,651 Pinc Stroet,Nl.iInez,CA 94553. C. I'claim ;s ar I -,ainst a diitri..:;t goverucA by the. Bowd of Supe btr than they. Coun�y. the narne of The Distric, should beElled its. D. If the claim is against more than oxlr;: public ttatity, ge�jjr.,3.1e. clai-,11s Tila, I)e.. fled ag-in..' f car-i public entity. E. Frauzi. Set,p-malty fbT fraudulent claire s,Penal Code at The tud of this fonvL. ac Iz a 1)0 a q;Ga..vv oo n o00 C,Got 0 ID a 0 0.1 P 0 r U RE Claim Renerved for clerk's, fibug Stamp C Against the County of C-onza Costa orduz cz 17 0 o08 (Fill in the narne) The mijersigned claimant hereby makes cla,irli arminz the Cotmtv of Conza Costa or t1we abo,,c-nanned district in the :;um oJ'$— and in support of Ibis claim represents as: follow5: I. Whem did the: damage or injury ozcw? t dl.-vc awi hour) did the dwnage or injury occur? (Inchidt!i:--ity aud c"mirty) 3. (Give full dwAiji, --i;-,xu-a p-- er if re LI How did th:dxnap,-. ar injury occur'. P quirtfl.) 4. ',,Vh,kt partictilar act or omission on ilie part of county or disI.ISGI oL-5cers, servants, or CUI-01")Yees/, caused.the injury or damage? /2,1- 7�<, 14) 4 5 What are the aawas LircoulITY or da,tricu 0 Cars, 3tTv!UIIS. =,Ipf ye--,eS musing e damagear k1ltry, Ma;, 7 08 05: 33a '00B 10:19 .._�JTrP COSTOCy.�1.J...`• .'1...�: 'J }.� i'rCt;' +?y�� hJf IV ... ' i - G. What damage or injwu es do your clam resulted?. (C?l Vt gull extent of injuries or darnaf:ies claimed. Attach two estates for aw.6:e~:uina e , 1' --�-CG.i(2'G�� 4,L�-�. a GtG- � f'�` i ;t. ,�/ l•'_';`- l�'v��.���•�.S";7r-1. �.'!_t� �' .� -Y 7--.Li.C�.-� 7. How was ,be amount claimed ahoy; co.nputrd? (Inuludc ibe estimated eminunt ,:)f any p:osPet've iajIZ~ ' OT daruage.} S. Names and addresses of mritnesses, doctors, and}xo5plta?5: !- _i�..J'��',I �>:�i.u.}se.f�, 1l"�ti ;`":t';r>j•::r~!� ��,.:. l.�-s�l�s.L)`" 9. r ist the a nenditur�s you a on accoUht of 6.iS acclCi`aatit ur i:.jury: j)ATE TIME AMOUNT N a Do Pnew at 7a1 6 v 0 ae Do.".a a 0 van ab*02 0P asm OD0Ca V Dona..ab lit,a t7 vs,Soon 9192a0 a%D2 p V c,RD f.+a aw.an f } Gov. Cod—.Ser.. 913-21wov'ides"'11c,claim shall be } signe'd by for of by some;parson on i;is j behalf:" Name and adctess of Attorney � / / `_',LTL.. r '�J ;C.la�tzant°s SigtetJ:ttare} ' Tel home No. }Tele hone No. n CJ6 V.e,¢a a q n Tad QEI C'OCm 0600461,T a®O q e a►v O11.06*11Da a 11000,006013 acre.a q is 0 as PMLIC RWORDS M1Tfi'j.E- Pleme be advised that this claims formoar any clahn filed with the County under the pore Claims Act,is subjc ce to public disclostim under ,4w Caelifbmia 'F►.ablic Records AJI. (Galt.. Cerci., rF 6500 ei sect.) Fus4erTnore., ,eny nuachmexits. ae3&ndww,or supplame nts artncW to tete claire format incl gEng TrIv 4ics.l recaetls,are atscy sul�cct to Dtiblic disclosure. D a pqD a ORODa gagb PBn DO a P o©V a DDe...0130 0 emo.^r..e�pagqa peponn•en a a mmvP u abov fil ngvtlapga PR Da mug=zoo.w e.l Section 72 of the Pena?Code provides.- Every person who,with intetst to defraud, pru=nzz for allriwaanw or i'rer payment to any nau bounrd cr offi ,cu to any c¢ae nq-, city, or distrivt board or officer, authon zed to cllovv 3:r pay the &wne if gmiuim, any false or fraudulent claim, bill,ac coudt woo her, or writing, is punirhablo eitlr.,e:r by impTiso-amera in the County jail for a period of nut more them ono year, by a fme of not cx�ing one thnnsiwd dolleas (S1,00.00). or by lro9:b sur..b imprisonment &M fine„ or by itatprieotuesent in tbe: rs4ate: prison, by a flare of not ex=iding,ten thousmid dollars (S 10,000),or by both Mbch i np isonment MW fine:. f APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA'COUNTY, CALIFORNIA BOARD ACTION A., AUGUST 19, 2008 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.) 1 given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING"below. Claimant: HENRY J. RAY Attorney: UNKNOWN JUL 1 '8 2008 Address: 1405 LILLIAN STREET COUNTY CALIF. CROCKETT, CA 94525 Amount: 8,000.00 By delivery to Clerk on: , JULY 18, 2008 I Date Received: JULY 18, 2008 By mail, postmarked on: JULY 17, 2.008 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 18, 2008 JOHN CULLEN, Clerk, By: DEPUTY I1. FROM: County Counsel TO: Werk o theiBoard 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 -4 -09 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. DATEHN 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 apk�cation for ler 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(2ag# .d54060"' JOHN CULLEN', Clerk, By: DEPUTY V. - FR I: (1) County Counsel (2) County Administrator T Clerk of the Troard of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By: County Administrator, By: APPLICATION TO FILE LATE CLAIM Henry).Rey JV2009U 1405 Lillian St JUL Crockett,CA 94.525 CONT ,.•',t A CO. r � A The Board of Supervisors Contra .john Cullen Clerk of the Board f Costa ""`I County Administration Building County Administrator 651 Pine Street, Room 106Count (925)335-1080 Martinez, California 94553-4068 John Gioia,District I Gavle 13.Uilkema,District II "z _ Mary N.Piepho,District III Mark DeSaulnier,District IV Federal D.G.Iover, District V off` ,spa-coun't'I June 23, 2008 TO: Henry Rey 1405 Lillian Street Crockett, CA 94525-1356 RE: CLAIM OF HENRY REY 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 May 29, 2008, has been reviewed by County Counsel and is being returned to you herewith because: 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 Govermuent Code sections 901 and 911.2.) X. Your claim relating to a cause of action for anything other than injury to person or to personal property or growing crops was ;got 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 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.) BOARD OF.SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CL_BIANT 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.) r =�B. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 65.1 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the naive of the District should be filled-in. D. If the claim is against snore 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. •man ENSEERESENERNMEaMEsaw MMUNUKKNER0WEENEKSKINERMaMUREMERVERMEKNENUNNNERMieee ■t RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) 'v ` If District) (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. VYrien did the damage or injury occur? (Give exact date and hour) 2. Rrhere did the damage 6r injury occur?. (Include city and count-) 3. Hu", did the damage or.injury occur? (Give full details; use extra paper if required) f 4. What particular act or omission on the part of count' or district officers, servants, or employees caused the injury or damage? 5 "What are the names of county or district officers. "servants, or employ--es causing the damage or injury? r 1. . 'E A 1l .. - p4 . J;�yt J C ti ro U