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HomeMy WebLinkAboutMINUTES - 12121989 - 1.24 • r • CLAIM i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 121, 1989 and Board Action. .All Section references are to The copy of Jhis document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 9134nd 915.4. Please note all "Warnings". CLAIMANT:. -ANDREWS ,. Mary , 443 S . 24th St. , Richmond, CA 94804 ATTORNEY: Leandro H. Duran Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, p gg DATED: November 14 , 1989 BgII DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (� ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: r Dated: BY: I� J- Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated©E C 1 2 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code sect on 913) iubject to certain excektions, you have only six (6) months from the date this notice was personally served o� ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. fated: DEC 12 1909 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator F-nNOCEIVEDTOXIC TORT CLAIM V 13 1989 P�HIL BATCHELOR This claim is submitted against CONTRA COSTA COU TY y q "P�RosoRs to Section 910 et seq of the California Government Co menu 1 . Claimant (name & address ) : MARY ANDREWS, 443 S. 24th St. , Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 ,Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity 's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of .its regulatory function and public safety responsi- bility to the public, the community, and to claimant , respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) .Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( 1 ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (�O Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (X) Medical expenses ( ) (X) (x) Pain & suffering ( ) ()K) ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown S . Amount claimed at present , including estimated amount of any .prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 . Signature of Claimant or Person Actina on Claimant ' s Behalf : 2 L DRO . DURAN, Esq. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:---BROWN, Porschea M. , 1602 Lincoln Ave . , Richmond 94801 ATTORNEY: Leandro H. Duran " Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. QQHH Bg DATED: November 14 , 1989 BYIL DepuLyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). (. ) Other: i Dated: 11 114 29 BY: I �, Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORD 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: nE—C J PHIL BATCHELOR, Clerk, By ' Deputy Clerk WARNING (Gov. code section 913) ;ubject to certain excep_tions, you have only six (6) months from the date this notice was personally served o� leposited in the mail to file a court action on this claim. See Government Code Section 945.6. 'ou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult n attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. rated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk C: County Counsel County Administrator RECEIVED • k l TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA COUTY CLERK GOAH;LBATCHELORERV15OR5 pursuant to Section 910 et seq of the California Gove nment CQT6d TA o. 1 . Claimant (name & address) : PORSCHEA M. BROWN, 1602 Lincoln Avenue, Richmond, CA 94801 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15, 1989 through June 19 , 1989 . 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS, Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant , respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) r ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( L4' Eye irritation/inflammation ( ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( t,YHeadache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) Muscle spasms ( ) ( ) Nausea ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) { ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) { ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( tX Medical expenses ( y� Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : . Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature. of Claimant or Person Acting on Claimant ' s Behalf: LEANDRO H. DURAN, Esq. 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA h Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4., Please note all "Warnings". CLAIMANT:.-BROWN, Thelma, 317 S. 18th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13 , 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 'I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 14 , 1989 all DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and•send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: i Dated: (I lig BY: J11 V J ` Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (kl 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk Ar WARNING (Gov. code sect 3) Subject to certain excejW*ons, you have only six (6) months from the date this notice was personally served o� ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING -declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator 4 SEC-IVSD TOXIC TORT CLAIM1989 M4V 13 This claim is submitted against CONTRA COSTA OUNTY9044ttsoxs to Section 910 et seq of the California Government ode`. C NTRA ° ACo De ur 1 . Claimant ( name & address ) : THELMA BROWN, 317 S . 18th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting . such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant f' ( ) Anemia/chronic fatigue ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( } Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) (X) Diarrhea ( ) (X) (X) Dizziness ( ) ( ) Drowsiness ( ) ( ) ()() Eye irritation/inflammation ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) (X) Sore throat ( ) O ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( } Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (k) Medical expenses ( ) (X} (J() Pain & suffering ( ) Reduced market value , real ( } ( ) property 7 . Name( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount .claimed at present , including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California) Date of Claim: November 7 , 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf : —A/bfl 2 DURAN, Esq. CLAIM �� Y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOAR_ D ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors • (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..-DAVIS, Jamayla, 2367 Clinton Ave . , #C, Richmond 94804 ATTORNEY: Leandro H. Duran - • Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHH BATCHELOR, DATED: November 14 , 1989 BYIL DepuLyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present { This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec on 913) Subject .to certain exce&*ons, you have only six (6) months from the date this notice was personally served or ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING [ declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk ;C: County Counsel County Administrator RECEIVE NOV 13 1989 TOXIC TORT CLAIM PHIL BATCHELOR CLERK BOARD OF SUPERVISORS COO NSTA CO. This claim is submitted against CONTRA COSTA COUN ... °eU pursuant to Section 910 et seq of the California Government e. 1 . Claimant (name & address) : JAMAYLA DAVIS , 2367 Clinton Avenue, Apt. C, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 -- through-June- 19-f-4-989 . - --- 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS, Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances, or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered pers.onal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding , nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) (Glisters ( ) ( ) Breathing difficulty ( - Cold & flu symptoms ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( -KChest pain/angina ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ..KEye irritation/inflammation ( ( ) ( ) Fainting ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) ( ) ( W Loss - of appetite ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( LY' Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) Stomach cramps ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( W'Medical expenses ( ) ( U Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: LEANDRO H. DURAN, Esq. 2 CLAIM /1.11 y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:...DAVIS, Noel Jr. , 2367 Clinton Ave . ,, #C , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. QQHH gg DATED: November 14 , 1989 BYIL DepuLyLOR, Clerk 61 II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: T�� I`I q BY Q� /J Deputy County Counsel f V III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: QE C. 1 2 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se ' n 913) Subject to certain exceions, you have only six (6) months from the date this notice was personally served o�c.� deposited in the mail to file a court action on this claim, See Government Code Section 945.6. Vou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. 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 inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, .alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator r 0 0 RECEIVED F TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA COUNY pursuant to Section 910 et se of the California Gover me } rr,��.�F�T WOR p q r'4,,_-HL�W r.HSUPERVISO RS i -.nt,!TleqC TA CO. 1 . Claimant (name & address ) : NOEL DAVIS , JR. , 2367 Clinton Avenue , Apt. C, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone:. 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through-June--1-9 ; -1989-.---- 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site, within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) n ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) 1isters ( ) ( ) ( L' Breathing difficulty ( Cold & flu symptoms ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( CKChest pain/angina ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( -KEye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) ( ) (-�L-oss--of—appet ite - - ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) uscle spasms ( ) ( ) ( y' Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) (v)' Stomach cramps ( ) Vision impairment ( ) ( ) ( ) Vomiting A ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( -KMedical expenses ( ) ( yKPain & suffering ( ) ( ) Reduced market value , real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8. Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: LE DRO H. DURAN, Esq. 2 •- �.. CLAIM • BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..-DAVIS, Noel Sr. , 2367 Clinton Ave. , #C , Richmond, 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHH BATCHELOR, DATED: November 14 , 1989 BYIL DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: - (q BY: 7 S- / Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:F�1� 19$9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ion 913) subject to certain excegU ons, you have only six (6) months from the date this notice was personally served oc_ ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult kn attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Jnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. sated: DEC 12 1989 BY: PHIL BATCHELOR by oma-- Deputy Clerk :C: County Counsel County Administrator FRECCEIVED TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA COLrnm&H PHIL BATCHELOR pursuant to Section 910 et seq of the California Gov ' � UPco'ORs e ut 1 . Claimant (name & address ) : NOEL DAVIS , SR. , 2367 Clinton Avenue , Apt. C. Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15, 1989 ----- through--June 1-9 ; --19894-- 4 . -1989 .4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant' s body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant , respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal. injury and/or damage as a proximate result of the above-described occurrence as i.s hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) � ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( vKBreathing difficulty ( Cold & flu symptoms , ( ) Constipation ( ) ( ) ( ) Coughing ( )✓ ( ) ( -4' Chest pain/angina (✓, ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( Eye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) (--,)-,-L-os s-of-app-e t i t e ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( vY Stomach cramps ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) . Business loss ( ) ( ) ( W Medical expenses ( L4'Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown .8 . Amount claimed at present , including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date ,o.f Claim: October 13 , 1989 Signature of Claimant or Person Acting on Claimant 's Behalf: LE DRO H. DURAN, Esq. 2 i CLAIM ! ." BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. DAVIS, Phyllis , 2367 Clinton Ave . , #C, Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Pp 8g DATED: November 14 , 1989 BIL DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: J Deputy County Counsel I11. 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 OR By unanimous vote of the Supervisors present ( ) This Clam is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sect' 913) Subject to certain exceRU ons, you have only six (6) months from the date this notice was personally served ocd deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. 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 inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, .alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: Mo 1 P 1989 BY: PHIL BATCHELOR by Deputy Clerk ;C: County Counsel County Administrator R RECEIVED NOV 13LeV'S TOXIC TORT CLAIM rKL B CLERK GOARDS This claim is submitted against CONTRA COSTA COU Y CO pe or pursuant to Section 910 et seq of the California Government de. 1 . Claimant (name & address ) : PHYLLIS DAVIS , 2367 Clinton Avenue , Apt. C, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond , CA 94806 3 . Date when damage or injury occurred: April 15, 1989 through June 1.9 , 1989 . 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances , including claimant, either by direct physical contact with claimant' s body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation. of said entity ' s duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant , respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage /Loss Which is : Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) "Bleeding , nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( � Breathing difficulty ( [4-'Cold & flu symptoms ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) (U-' Chest pain/angina ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( Eye irritation/inflammation ( vY ( ) ( ).. Fainting ( ) ( ) ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) ( ) (-O--Loss--of--appe-t i t-e ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (Nausea ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) { ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) (� Stomach cramps ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( .) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ('Medical expenses ( Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any: prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature of Claimant C or. Person Acting on Claimant ' s Behalf: LEANDRO VIDURAN, Esq. 2 CLAIM 1 -241 * BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against/she County, or District governed by) BOARD ACTION the Board o` Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph. IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT.-..HOUSLEY, Ellamae , 438 S . 25th St,. , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel .Attached is a copy of the above-noted claim. Ball p gg DATED: November 14 , 1989 DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors �) 'This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: S Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD OR ER: 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code sec on 913) Subject to certain exce0 ons, you have only six (6) months from the date this notice was personally served oma- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING [ declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the lnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, .alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: DEC 12 19 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator M ECEIVED TOXIC TORT CLAIM NOV 13 1989 FHR BATCHELOR This claim is submitted against CONTRA COSTA COUN Y !:_12"l SORS to Section 910 et seq of the California Government Cod B . . oe 1 . Claimant (name & address ) : ELLAMAE HOUSLEY, 438 S . 25th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15, 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS, Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood- were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding , rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ! ) ( ) ( ) Breathing difficulty ( ) ( ) (x) Cold & flu symptoms ( ) (X1 ( ) Constipation ( ) ! ) (X) Coughing ( ) (X) ( ) Chest pain/angina ( ) ! ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) (x) Drowsiness ( ) (X> (X) Eye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ! ) (X) Headache ( ) !X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ! ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (a() Medical expenses ()() Pain & suffering ( ) (X) ( ) Reduced market value, real property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8. Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 1/, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf:;:� ` ANDRO H. DURAN, Esq. 2 CLAIM y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA a Claire .yainst the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..HOUSLEY, Ellamae N.. , 438 S . 25th St. , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 14 , 1989 IVIL �ep�tyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors �) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: c Dated: BY: I ) - z Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code se 913) Subject to certain exceRU ons, you have only six (6) months from the date this notice was personally served oma- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. )ated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator Fmov IVSD 1 31989 TOXIC TORT CLAIM PHIL BATCHELOR CLERK BOARD OF STA CO D.This claim is submitted against CONTRA COSTA COU TY pu Af Deu to Section 910 et seq of the California Government Co s 1 . Claimant (name & address ) : - ELLAMAE N. HOUSLEY , 438 S . 25th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station ) , City of Richmond, California. 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant . Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances, or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance, or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss, damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( } Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) (x) Cold & flu symptoms ( ) (X) ( ) Constipation ( ) ( ) (X) Coughing ( ) (X) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) (x) Drowsiness ( ) (X) (X) Eye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (�() Headache ( ) (1C) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( } Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ()() Medical expenses (�() Pain & suffering ( ) ()C) ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 3(, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: LEANDRO H. DURAN, Esq. 2 CLAIM �- BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA the County, or District governed by) BOAR_ D ACTION of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 .d Action. All Section references are to ) The copy of this document mailed to you is your notice of urnia Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.- HOUS LEY, Maryella, 438 S . 25th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - ' I Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PP ss DATED: November 14 , 1989 Ba?L DeputyLOR, Clerk I1. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: II (�( l BYJ Deputy County Counsel U 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORD 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se on 913) Subject to certain exceZions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 19 9 BY: PHIL BATCHELOR by ,� Deputy Clerk CC: County Counsel County Administrator ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) (x) Cold & flu symptoms ( ) (}n ( . ) Constipation ( ) ( ) (X) Coughing ( ) (X) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ()() Drowsiness ( ) (x) (X) Eye irritation/inflammation (X) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (X) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (X) Medical expenses ( ) W) 00 Pain & suffering ( ) (X) ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed. at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in . the Superior Court of California] Date of Claim: October 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf- > LEANDRO H. DURAN, Esq. 2 ' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors. Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.--HOUSLEY, Ronald, 438 S. 25th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Pp 8g DATED: November 14 , 1989 BIL DepuLyLOR, C1er II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: 11 (`( BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: n F C 12 1989. PHIL BATCHELOR, Clerk. By Deputy Clerk WARNING (Gov, code se i 13) 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. Vou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. 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 inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, .alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: C E C 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator 4 ' 0 RECEIVED TOXIC TORT CLAIM NOV 13 1989 PHIL BATCHELOR fSUPERVISORS This claim is submitted against CONTRA COSTA COUN Y ¢#f ' bSTACO. to Section 910 et seq of the California Government Codh. oe 1 . Claimant (name & address ) : RONALD HOUSLEY, 438 S. 25th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity ' s .duty to control a public nuisance , or , if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss, damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant 4 ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) Breathing difficulty ( ) ( ) (X) Cold & flu symptoms ( ) Constipation. ( ) ( ) (X) Coughing ( ) (X) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) (x) Drowsiness ( ) (X) (X) Eye irritation/inflammation ()() ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (X) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ). Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (x) Medical expenses (}() Pain & suffering ( ) ()C) ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October V, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: ANDRO H. DURAN, Esq. 2 CLAIM Oft BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..-HOUSLEY, Sylvia, 438 S. 25th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 14 , 1989 EVIL BATCHELOR, Clerk g: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: I j Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDE • 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. DEC 12 1989 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se n 913) Subject to certain excejW*ons, you have only six (6) months from the date this notice was personally served o deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. 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 Jnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, 'alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator NOV 13 1989 TOXIC TORT CLAIM PH!L BATCHELOR CLERK BOARD O.F SUPERVISO GONT!A COSTA CO This claim is submitted against CONTRA COSTA C eu1 to Section 910 et seq of the California Government Code. 1 . Claimant (name & address) : SYLVIA HOUSLEY, 438 S . 25th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3. Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of .South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical -contact with claimant' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss, damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/.Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) (X) Cold & flu symptoms ( ) Constipation ( ) ( ) '(x) Coughing ( ) (X) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) (x) Drowsiness ( ) (X) (X) Eye irritation/inflammation (X) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (X) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( } Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) Business loss ( ) ( ) (x) Medical expenses ( ) DO (x) Pain & suffering ( ) (X) ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : Unknown S . Amount claimed at present , including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 3l , 1989 Signature of Claimant or Person Acting on Claimant ' s Behal LEANDRO H. DURAN, Esq. 2 x CLAIM �' y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..HOUSLEY, Reverend Thomas , 438 S . 25th St:-, Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gATCHELOR, Clerk DATED: November 14 , 1989 : Deputy 1I. FROM: County Counsel TO: Clerk of the Board of S&perllisors i ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: r Dated: II Iii BY: aUA Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec n 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served oc_�- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR byC�KDeputy Clerk CC: County Counsel County Administrator 0 RECEIVED TOXIC TORT CLAIM NOV 13 1989 ? PHIL BATCHELOR This claim is submitted against CONTRA COSTA COU Y SUPERVISORS g .5 to Section 910 et seq of the California Government Co oe 1 . Claimant (name & address ) : REV. THOMAS HOUSLEY, 438 S. 25th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing , and in violation of said entity 's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant 1 ti A ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) { ) ( ) Breathing difficulty ( ) ( ) (x) Cold & flu symptoms ( ) ( ) Constipation ( ) ( ) (X) Coughing ( ) (X) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ()() (X) Eye irritation/inflammation (X) ( ) ( ) Fainting ( ) { ) ( ) Fever ( ) ( ) (X) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) { ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) { ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (x) Medical expenses ( ) 00 OO Pain & suffering ( ) (X) ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 3/ , 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: LEANDRO H. DURAN, Esq. 2 CLAIM a y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:...LYONS, Jerry L . , 1602 Lincoln Ave . , Richmond 94801 ATTORNEY: Leandro H. Duran Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13 , 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 14 , 1989 IVIl Dep�tyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (v ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ( I(I ICA BY: �. / J_ Deputy County Counsel V �_0 - \U 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) ;ubject to certain excgXtions, you have only six (6) months from the date this notice was personally served or ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. DEC 12 1999 sated: BY: PHIL BATCHELOR by ,L_ Deputy Clerk 'C: County Counsel County Administrator or 0 0 RECEIVED H TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA COUN Y PHi,BATCHELOR CI",PH", RK .0ARD OF SUPERVISORS pursuant to Section 910 et seq of the California Gover ment " o Aco. 1 . Claimant (name & address ) : JERRY L. LYONS , 1602 Lincoln Avenue , Richmond, CA 94801 2. Name & address of person to whom any notices concerning the claim should be -sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15, 1989 through June 19 , 1989 . 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss, damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of .the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( L-)' Eye irritation/inflammation ( ( ) ( ) Fainting ( ) Fever ( ) ( ) (t>' Headache ( ) Laryngitis ( ) ( ) ( ) Loss- of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( } ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( 'Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( } Vision impairment ( ) ( ) ( ) Vomiting { ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (44' Medical expenses ( ) ((c-Y" Pain & suffering ( ) Reduced market value, real ( ) ( } property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature of Claimant /L or Person Acting on Claimant 's Behalf: LEANDRO H. DURAN, Esq. 2 CLAIM ?' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. -LYONS ,, Maple 1602 Lincoln Ave . , Richmond, 94801 ATTORNEY: Leandro H. Duran - Attorney at Law Date received .ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH BATCHELOR, DATED: November 14 , 1989 Btil Clerk I1. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: JUL:) Deputy County Counsel I1I. 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 OR By unanimous vote of the Supervisors present L ( ) 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. -DEC , 2 1989 Dated: PHIL BATCHELOR, Clerk, ByDeputy Clerk WARNING (Gov. code sec n 913) Subject to certain exceZJ ons, you have only six (6) months from the date this notice was personally served omc_.�- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR by _ Deputy Clerk CC: County Counsel County Administrator / TOXIC TORT CLAIMdV 1 31988 FH1 BASF SUP RVISORS This claim is submitted against CONTRA COSTA COU TY CLFRKCOST pursuant to Section 910 et seq of the California Gove nment` 1 . Claimant (name & address) : MAPLE LYONS , 1602 Lincoln Avenue, Richmond, CA 94801 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3. Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site , within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and - fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( vYEye irritation/inflammation ( y' ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( Headache ( ) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) vision impairment ( ) ( ) ( ) vomiting ( ) ( ) ( ) vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( [a Medical expenses (tom' Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7. Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 13 , 1989 Signature of Claimant ' or Person Acting on Claimant 's Behalf: LEANDI%el H. DURAN, Esq. 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOAR_ D ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.--PROCTOR, Maiyah, a minor, c/o Mary Andrews , 443 S . 24th St. , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PPi�t} g DATED: November 14 , 1989 61IL DeputyLOR, Clerk 04 s II. FROM: County Counsel TO: Clerk of the Board of Supervisors _'(v ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ci BY: I Q / Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code sectio 3) Subject to certain excekU ons, you have only six (6) months from the date this notice was personally served oc..�. deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. DEC 12 1989 Dated: BY: PHIL BATCHELOR by _Deputy Clerk CC: County Counsel County Administrator RECEIVED TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA C UNTXERp�',Jj $CAv1soRS to Section 910 et seq of the California Government qde. �0 TR OSTACO. DQ 1 . Claimant (name & address ) : MAIYAH PROCTOR a minor c/o MARY ANDREWS , 443 S. 24th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances, or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by .said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant J ~ , I ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) (x) ( )_ Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (�O Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( j Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) Business loss (x) Medical expenses (X) Pain & suffering ( ) (x) ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present , . including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 Signature of—Claimant or Person Acting on Claimant ' s Behalf :, ; //, 2 LAND H. DURAN, Esq. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ast the County, or District governed by) BOARD ACTION P.Joa rd of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 rd Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:...PROCTOR, Taailah, a minor, c/o Mary Andrews , 443 S . 24th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. QQ 8g DATED: November 14 , 1989 BIL DeputyLOR, Clerk 'I1. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: r Dated: BY: I �. Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( 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: b E G 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ' 913) subject to certain exceptions, you have only six (6) months from the date this notice was personally served ov- ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. lou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. sated: DEC 12 1989 BY: PHIL BATCHELOR by OF_ Deputy Clerk ;C: County Counsel County Administrator 13ECEIVED TOXIC TORT CLAIM NOV 13 1989 PHIL BATCHELOR This claim is submitted against CONTRA COSTA CUNT411RLlPEgYISORs to Section 910 et seq of the California GovernmentN °e 1 . Claimant (name & address ) : TAAILAH PROCTOR, a minor, c/o MARY ANDREWS , 443 S . 24th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent : LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS, Inc. , .a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated-urban- neighbor- hood , opulated urban neighbor- hood , in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public , the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant ( )" Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) Laryngitis ( ) ( ) ( j Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( } (X) Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) { ) ( ) Skin rash Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (X) Medical expenses ( ) DO (X) Pain & suffering ( ) (k) ( ) Reduced market value , real ( ) ( ) property 7. Name (s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in tine Superior Court of California] Date of Claim: November 7, 1989 Signature of Claimant . ADIR or Person Acting on Claimant ' s Behalf : 2L DURAN, Esq. CLAIM / a BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.-.PROCTOR, Tami , 443 S. 24th St . , Richmond, 94804 ATTORNEY: Leandro H. Duran Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gATCHELOR, Clerk DATED: November 14 , 1989 : Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: It liq �1 BY: Deputy County Counsel [ll. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). [V. BOAR�This ORDER- By unanimous vote of the Supervisors present ( aim 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: _ DEC 1 2 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code secti 3) ubject to certain excekions, you have only six (6) months from the date this notice was personally served ora.f *Posited in the mail to file a court action on this claim. See Government Code Section 945.6. ou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult n attorney, you should do so immediately, AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the nited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to he claimant as shown above. ated: DEC 1 2 1999 BY: PHIL BATCHELOR by.26Deputy Clerk C: County Counsel County Administrator _ RECEIVED TOXIC TORT CLAIM NOV 131989 EMIL B'ICMELOR U ERvr RS This claim is submitted against CONTRA COSTA COLNTYQ co. to Section 910 et seq of the California Government C pe 1 . Claimant (name & address ) : TAMI PROCTOR, 443 S . 24th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct- physical contact with . claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant Li ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) (X) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (X) Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (x) Medical expenses ( ) (X) (X) Pain & suffering ( ) OC) ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present , including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 Signature of Claimant or Person Acting on Claimant ' s.-Behalf : 2 2. D DURAN, Esq. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOAR_. D ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.--SALAAM, Bashir, 443 S . 24th Street, Richmond, 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9, 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk &,,.. DATED: November 14 , 1989 &V: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: r' Dated: �� �` � q BY: Deputy County Counsel 1I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). V. BOARD ®RIEBy 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. q 19 oo Dated: DEC 1 2 9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 913) ubject to certain excegtjons, you have only six (6) months from the date this notice was personally served oxo eposited in the mail to file a court action on this claim. See Government Code Section 945.6. Du may seek the advice of an attorney of your choice in connection with this matter. If you want to consult I attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the sited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ilifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to ie claimant as shown above. ted: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk County Counsel County Administrator RECEIVED NOV 13 1989 TOXIC TORT CLAIM PHIL BATCHELOR CLERK BOARD OF SUPERVISO S This claim is submitted against CONTRA COSTA CO I Y pu T1 .an'Tt-C . to Section 910 et seq of the California Government Co e. 1 . Claimant (name & address ) : BASHIR SALAAM, 443 S . 24th Street, Richmond , CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt. at the above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and e.nforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said. excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding , oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( } ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (X) Headache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (X) Nausea ( ) OO ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( } ( ) Sore throat { ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (X) Medical expenses ( ) (x) (X) Pain & suffering ( ) Oo ( ) Reduced market value , real ( ) ( ) property 7 . Name( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 Signature of Claimant or Person Actinc on Claimant ' s Behalf : LDRO 2 . DURAN, Esq. CLAIM ^• ; ; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOAR_D ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..-SALAAM, Laila, a minor, c/o Mary Andrews , 443 S . 24th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pF gB DATED: November 14 , 1989 BIL DeputyLOR, Cler II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: ly BY: ,� Deputy County Counsel [II. 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 ORDE By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated: D F C 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk 7 7- WARNING (Gov. code se�tt 6n913) subject to certain excekW*ons, you have only six (6) months from the date this notice was personally served or.. leposited in the mail to file a court action on this claim. See Government Code Section 945.6. 'ou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult n attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the nited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to he claimant as shown above. ated: DEC 12 1989 BY: PHIL BATCHELOR by �.� Deputy Clerk C: County Counsel County Administrator RECEIVED TOXIC TORT CLAIM NOV 1 31989 PHIL BATCHELOR This claim is submitted against CONTRA COSTA COU Y pn�" TAcoSORS to Section 910 et seq of the California Government Co 0 1 . Claimant ( name & address ) : LAILA SALAAM, a minor, c/o MARY ANDREWS , 443 S. 24th St. , Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone : 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt- at the above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical- contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal. injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding , oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding , rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (X) Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( } ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting . blood ( ) ( ) ( ) Business loss ( ) ( ) (x) Medical expenses ( ) (X) (x) Pain & suffering ( ) (k) ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown S . Amount claimed at present , including estim-ated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf : 2 Z- LEANDA�. URAN, Esq. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Inst the County, or District governed by) BOAR_ O ACTION d of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 ,,a rd Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,.000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:..SALAAM, Munir, 443 S. 24th St . , Richmond, 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 31SO Hilltop Mall Rd. #S8 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. gg DATED: November 14 , 1989 JqIL DepuiyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: 1�°► BY: Deputy County Counsel V III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER- By unanimous vote of the Supervisors present �Thislaim 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk 7 77 WARNING (Gov. code sect(1-0413) 913) Subject to certain excejjons, you have only six (6) months from the date this notice was personally served o— leposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult kn attorney, you should do so immediately. AFFIDAVIT OF MAILING f declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the lnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. ►ated: D E C 12 1989 BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator :NOVXIC TORT CLAIM 1 31989 • :! 9RTCHEIOR +- Of SUPERVISOR This claim is submitted against CONTRA COSTA COUNTY pursuaw 0;T CO. to Section 910 et seq of the California Government Code. 1 . Claimant (name & address ) : MUNIR SALAAM, 443 S . 24th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances, or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ) :Anemia/chronic fatigue ( ) ( ) ( Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) ()() ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (X) Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (X) Medical expenses ( ) (X) (x) Pain & suffering ( ) (x) ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present , including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: November 7, 1989 Signature of Claimant or Person Actinc on Claimant ' s Behalf : 2 L DRO . DURAN, Esq. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10 ,000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:...SALAAM, Naimah, a minor, c/o Mary Andrews , 443 S . 24th St . , Richmond 94804 ATTORNEY: Leandro H. Duran - Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, pp gg DATED: November 14 , 1989 BIL DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: i 11 Dated: (1 I'{ � BY: J_ JA Deputy County Counsel [II. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). N. BOARD �01DI 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. DatedD E C 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk 011 WARNING (Gov. code secon 913) ubject to certain exceW*ons, you have only six (6) months from the date this notice was personally served or eposited in the mail to file a court action on this claim. See Government Code Section 945.6. ou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult n attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the nited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to he claimant as shown above. ated: DEC 12 1999 BY: PHIL BATCHELOR by Deputy Clerk .. County Counsel County Administrator . R.ECEI' EI� TOXIC TORT CLAIM NOV 13 1989 This claim is submitted against CONTRA COSTA COUN Y �rK$r.�tenT SUPWISoas to Section 910 et seq of the California Government Cod CONT, ° Aco. e � 1 . Claimant ( name & address ) : NAIMAH SALAAM, a minor, c/o MARY ANDREWS , 443 S . 24th St. , Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H . DURAN Telephone : 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances, including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic andhazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant (` ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding , oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( } Drowsiness ( ) ( ) ( } Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (x) Headache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) (X) Nausea ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss (X) Medical expenses ( ) ()C) (X) Pain & suffering ( ) 00 ( ) Reduced market value , real ( ) ( ) property 7 . Name ( s ) of public entity employees causing the injury, damage or loss : Unknown 8 . Amount claimed at present , including estimated amount of any prospective loss : [Exceeds $10 , 000 -- Jurisdiction is in the Superior Court of California] Date of Claim: 'november 7, 1989 Signature of Claimant or Person :acting on Claimant ' s Behalf : j 2 L DR H. DURAN, Esq. /.sy ' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. .All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: exceeds $10,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:.-WILLIAMS , Earlene , 740- 18th St . , Richmond 94801 ATTORNEY: Leandro H. Duran Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Rd. #58 BY DELIVERY TO CLERK ON November 13, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: November 93, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL gATCHELOR, Clerk DATED: November 14 , 1989 �a: Deputy II. FROM: County Counsel TO: Clerk of the Board of ervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: G BY; 1 �'' S Deputy County Counsel n T III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). - IV. BOARD OR 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: DEC 1 2 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sect 913) iubject to certain excep_tjons, you have only six (6) months from the date this notice was personalty served o ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. lou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. Iated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk ',C: County Counsel County Administrator NOV 13 1989 TOXIC TORT CLAIM PHIL BATCHELOR CLERK GOARD OF SUPERVISORS This claim is submitted against CONTRA COSTA COU I'� CONTRA C. TACO. DeDuty pursuant to Section 910 et seq of the California Government C e. 1 . Claimant (name & address ) : EARLENE WILLIAMS , 740-18th Street, Richmond, CA 94801 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15, 1989 through June 19 , 1989 . 4 . Location of occurrence: A vacant lot at the southeast corner of 23rd Street and Downer Avenue, City of Richmond, California. 5. Circumstances of occurrence: PWS, Inc. , a California corporation, deposited toxic-contaminated dirt upon the above- described site, within a populated urban neighborhood and in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighborhood were exposed to these substances, including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The depositing of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation of said entity 's duty to control a public nuisance, or, if not so approved and authorized by said entity, said depositing should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsibility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant (Anemia/chronic fatigue Y ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( ) Diarrhea ( ) ( ) ( ) Dizziness ( ) ( ) ( WDrowsiness ( ) (vY ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( ) Headache ( ) ( ) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( •,KSkin rash ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( 0' Medical expenses ( ) ( La`Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California) Date of Claim: October 13 , 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: LEANDRO H. DURAN, Esq. 2 I i I 3 bd+d¢t+t P+ i CC tri 3 P,e . aWcc COM f , Qt I c r f,v 'o' j � SL , z tu0 M Vag '. < ma W J � •) ul 0 �C Y S'� > Q)s w ¢'z rt � M i6 U- CJ) �" in Ln v= CO Gz, O 4J d' 0� � 0 U Q) J ra -S 4+ u v C>0 a O mu 0 N a x� � a � Wr. r-4u a O >n rd UUs� 5M t nA � rn ti p 0 a a Q" Ln CLAIM �• `� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or D'istrict governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant tod,BvynRmVen4(� Code Amount: $140.00 Section 913 and 915.4.. Please note alll "Warn gs'�URS@' NOV 17 1989 CLAIMANT- CAPOTE, James Douglas _ . ATTORNEY: Martinez: CA P4,%3 Date received ADDRESS: BY DELIVERY TO CLERK ON November 15, 1989 (via Clerk's 5609 Hoffman Ct. , #4 Office) San. Jose, CA 95123 BY MAIL POSTMARKED: October 4, 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: November 17, 1989 BY: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: ). Deputy County Counsel \VQ III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (!i) 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: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 3) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR bDeputy Clerk 77 CC: County Counsel County Administrator ,.^,LA1-A1kJJ, TC?-'. . BOA, OF SUPERVISORS OF CONTRA10eptur�i� i i�i�1a Iicationt0, PP r.' OST r� _'� Instructions to Claimant Clerk of the Board IPSO. Box 911 A. Claims relating to causes of action for death or torninG uryn o,533 person or to personal property or growing crops must be presented not later than the 100th day 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 of the cause f of action. (Sec. 911. 2, Govt. Code) { B. Claims must be filed with the Clerk of the Board of Supervisors j at its office in Room 106 , County Administration Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a district governed by the Board of Supervisors, j rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps j E C V ED Against the COUNTY OF CONTRA COSTA) NOV 1 51989 or - D1STRIC: ) PHit.'BATCHELOR (r-ill 1n name) ) ^EFK EOARD OF SUPERVISORS T.n COSTA CO. De ut . The undersigned claimant hereby makes claim against he County of Contra Costa or the above-named District in the sum of $ _ and in support of this claim represents as follows : ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) �1v5us-f- 23, .7-o 2-9//99 - i hgre � t}ha---mage or injulry nrrrTii_r? (Tnc:liade city and countyl---- J l 04, 3. How did the damage or injury occur? (Give" full details, use extra sheets if required) /-A T2:OC �vI�C� �s� �/ f�ersblil.�+� _/O MAPT1 NF_Z vQ:i � an Coun When T go-1- Picked OF by SAA-TA C +`I °� -2_9-�I They Cdolel F-ivid way P-ers0VIAI beloA�1, 9 so .G Lam - _tea)4H + --r --------- ------- ----------- -------------------- 4 . What particular act or omission on the part of county or district officers , servants or employees caused the injury or uamaye? -rA.e-y didr)14 uip_14e my persona I i� r��.�� Q e NMeP, bcoLvl ,5HfF T sa +k o tis� roy ITEM. (over) iat. ar.e._the..naV* of county or district o -icers , servants ur` I` j, employees causing the damage or injury? ifs , A-1 l o Mr��Tirtl�Z JAI /4� ��5 �s b/� '' '" ------------------------------------------------------------------------- 6 . What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) 'FAR, LOST rAV �f4Bg:S ) ;3'1\ k,19 -ri WA 11E-r be-h'_ avId ire . SuCh GS- Ctg5ere.Hs end brocIF-4 r,66ter ---------------------------------------------r•--------------------------- / 7 . How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) d, ----------^--------------------------------------------------------------- 8 . Names and addresses of witnesses , doctors and hospitals. ------------------------------------------------------------------------- 9 . List 4he expenditures you made on account of this accident or injury: DATEITEM AI OUNT TAre HESE 00 So JAC6� ry- 'Ar. a 0 WHFa w.a I I r, Kcvs , 6��' 176 Iv.6 o P,�r co.� Govt. Code Sec. 910. 2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorne y) ors me oerson „on his behalf. ' Name and Address of Attorney Rf, Claimant' s jSig,nature Addres-s, Scui �o� C'o . 9 s_l 2 Telephone No. Telephone ( . 2-(o6—!?562- 7d 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, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bill , account , voucher or writing , is guilty of a fe,lony. " ©PERTYCLOTHING-RECEIPT w;'ONTRA COSTA C:Ol1 Y J Qbv No a`'NE• . DATE: � RACK :<K, MD9' *.t .. CLH Sox1 WCDF, y . NAME . BOOKING NBR: � ' ` �r s OTHER _ msµ. CASH: ❑ SHIRT/BLOUSES —1, ESS , COAT/-JACKET__ ❑ TEf CARF�, El SHO.RTOANTFES ®�'�'JEUiJARY SOCKS/NIYL;ONS, ❑� SWHTSWATOH BELT _ r ❑"I5ApTS/SKIRT . ___,S/BO ❑.T-SHIRT/BRA -- u WAL4T .HAT/PURSE. ER KEYS F_1'KNIFE ❑GLASSES F1Z1 OTHER P4° - 7;�,aL v� 6.t b A9'-. i f-C ` BKG OFC: X JN ATE SIGNATURE . I: have received all of my per- DATE: I'sonal property and clothing. REL OFC: r INMATE SIGNATURE ;PRORERT'1fCl_& NG REC�'IF'T CONTRA COSTA ,C0_NTY 4 EC"';'Nd. DATE: ' . CLH BOX CDf*e�, .:r• ' 807E VL�I'C '�t' NAME: c-11 .l' A. D `. 'OTHER, 1 BOOKING NBR: 4 ,. CAS H: $ .:�. ❑"SH IRT/BLOUSE ❑ DRFSS• v j, } COAT/JACKET '-') ❑ TIE/�CARF� t r x. ..17+ (� SHORTS7PA„IVTIE9 JEi .EILRY__.��"` t ; 1Cs' j _.❑ SOCKS/N`6ibNS ...'. SWEATER/SWT. SHIRT ❑ WATCH P. <' BELT ` a I . } ®ASH&%00TS — ❑I.TSHIRT/BRA a , [ I WALkT HAT/PURSE C KEYS "r j ❑TKNIFE El GLASSES OTHER BKCi OFC; X— .INMATE SIGNATURE f have received all of my per- I h, DATE: Anal property and clothing. ��aClz REL OFC: X INMATE SIGNA'T'URE i h, t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: (in excess of $10,000) Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. TAYLOR, Earl, Vanessa, Taifa, Kamihla and Dominique County Counsel ATTORNEY: Colman, Reisman, Bourdon & Bourdon rr d u 13 1999 861 Bryant Street Date received Martinez. CA n45,53 ADDRESS: San Francisco, CA 94103 BY DELIVERY TO CLERK ON November 9, 1989 BY MAIL POSTMARKED: November 8. 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 13, 1989 gtIL DepputyLOR, Clerk II.\FROM: County Counsel TO: Clerk of the Board of Supervisors (� ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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���S � � BY: I` / Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD OAR-D-E'R: 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: D E C 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain excep-tjons, you have only six (6) months from the date this notice was personally served oe_.�__- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk .2,6 CC: County Counsel County Administrator CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant Return original application"tc. Clerk of the Board:,,:, 651 Pine St:. Room:106 Martinez. CA 94553 A. Claims relating to causes of action for death or"for injury to person or to personal property or growing crops must be presented not later than the 100th day 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. (Sec. 911. 2, Govt. Code) 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, California 94553. C. If claim is against a district governed b the Board of Supervisors !..':..',,�'.ti�;�'. 9 9 Y P + rather than the County, the name of the District should be .F. ,f+f � J i•. D. If the claim is against more than one public entity, separate claims must be filed against each public entity m E. Freud. See penalty for fraudulent claims, Penal .Code Sec. 72 at end,,-,' 6yry of this form. :.. tt�RrkRtitf*Atk*�**TkMir*�RtrtR,t�*trrt�rk��*�,kik**ir**xrk,k�,t**�*��t*rt,t***�t*tkR*irw.*t�*ftlt.:.;.a�';;':f.•.. �'��; f RE: Claim by Earl Taylor, ) Reserved for Clerk's filing stamps; Vanessa Taylor, Taifa Taylor, Kamihl)a Taylor, Dominique Taylor ) RECE +� Against the COUNTY OF. CONTRA COSTA) NOV 91989 or DISTRICT) PHL BATCHELOR I CLERK aOARD OF SUPERVISORS (Fill1n name ) c CoSTACO. The' undersigned claimant hereby makes claim agains the County of Contra,",,f Costa or the above-named District in the sum of -''K". $ (in excess of 81 n . nnn,l and in support of thin claim represents as follows: J I f� L. When did the damage or-ln3uzy occur? 7Give exact date-and houzj • jy'fi'rjrt I �; August 30, 1989., 10 : 30 a.m. '�. inlhe-re did-tie damage or injury occur? �Inc�ude city-and countyf �,r ,; West Pittsburgh, Contra Costa County 3. How did the damage or in3ury occur? (Give �uI,I-details, use extra.,;;;,.;;,:..,: , •,, a sheets if required) i Police illegally detained, searched, falsely imprisoned, assaulted, ' ,'' battered and threatened claimants with weapons . ----'• ---�.--. -------- —�.---T--- —art—pr� ^k .� i '�'; 4. what particular act or omission on the part of county oz distr�ctr,;.?�,�,+; • I � officers, servants or employees caused the injury or damage? w Plfc=e i.tlegall'y d°eta "ned -searched, falsely imprisoned, assaulted, jll battered and threatened claimants with weapons. v,3 (over) K 5. What are :the names of county or district officers, servants; or' .employees causing the damage or injury? r : 1) Kenneth Buchanan, Oakland Police Department 2) Tinknown police officers employed by the county of Contra Costa & Alameda 6. What Clamage or injuries do you claim resulted? ZGive full extent 77, of inj ries or damages claimed. Attach two estimates for auto ; damage , Emotional Distress; trespass --- H---ow----------------amount--------claimed-------------------------------------- 7. was the above computed? (Include the estimated f amount of any prospective injury or damage. ) K' The number of claimants and the degree of emotional distress suffe're'd °". 3. 8. Names and addresses of witnesses aoctors and hos itals. J. List the expenditures you made on account of this accident or in3urya_ !' DATE ITEM AMOUNT N/A Govt. Code Sec. 910.2 provides,: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. '" Name and Address of Attorney -lex : Colman, Reisman, Bourdon & Bourdon Cls ant s Signature 861 Br ant; Street Y 283 Sandy Cove Lane :,.. San Francisco CA 94103 Address West Pittsburgh, CA 94565 Telephone No. (415) 626-5134 Telephone No. (415) 45R-9S1if'"`'' 'J NOTICE A, • 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, town, city : ` '° district, ward or 'village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, ;,: or writing, is guilty of a felony. " t� ,,i . 1• .k . . . � .� $ £ � 110, � � 0 \ & .7e @ � � y . ` ! . � \� / r' .. \ + � G �-- �_ � �` � fi _,,,., ��,,,,,,,,, 'tt��kJV kfi . 'iy I � `_,�� C `vU l t' ¢ i ., � i ��S v-� .-� �,` �., �� � � ��� �. �� � � .,,.'a ,� LAW OFFICE OF COLMAN, REISMAN, BOURDON & BOURDON 861 BRYANT STREET SAN FRANCISCO,CA 94103 NANCY COLMAN TELEPHONE ALEX REISMAN (415)626.5134 CHARLES R BOURDON FAX VICTORIA L. BOURDON (415)626.5257 November 16, 1989 ®_ Clerk of the Board .Ed � �� Contra Costa County 651 Pine Street, Rm. 106 NOV 2 01989 Martinez, CA 94553 rlq fnrCHELOR ATTN: BARBARA CL.`�c0�'>G OF SUPSpRS g Co.CO 7A CO e ut Re: Earl Taylor, et. al. Dear Barbara: I am writing you this letter to confirm our conversation on November 16, 1989, wherein you informed me that you had received the Taylor' s claim on November 9, 1989 and that the Board would review the claim on December 12, 1989. You further informed me that you would send me a copy of the claim with the clerk' s stamp indicating its receipt. Thank you for your cooperation in this matter. Sincerely, Law Offices of COLMAN, REISMAN, BOURDON & BOURDON DON SCHAEFER Law Clerk DS:rc 0 'y 9 a �•: �W ya ,I � O Y :• f`� N �1 c Cti Y u,O tri t'' ;s � ct ,� 75' N p fi CD O ct 31r' ON Yi a 1 i f CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA y Cla4m Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $2 .1240 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. VAN VOORHIS , Thomas trustee for the Van Voorhis Inv. Trust ATTORNEY: Thomas Van Voorhis r P.O. Box 2299 Date received ADDRESS: P.O. t Creek, CA 94595 BY DELIVERY TO CLERK ON November 13 , 1989 WalnBY MAIL POSTMARKED: November 9 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, ppHH gg DATED: NovemhPr 14 , 1989 BYIL DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: 11 IN ' �, BY: Q _ Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated:DEC 12 'N69 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceW ons, you have only six (6) months from the date this notice was personally served oK.� deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: i)EC 12 �g$J BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 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 per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property 'Or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the .Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp THCIMAS VAN VOORHIS, TRUSTFF- OF j THE VAN VOORHIS INV. TRUST ) II ,..ECEI Against the County of Contra Costa ) or ) NOV.-13 1989 CONSOLIDATED FIRE PROTECT.District) PHIL BATCHELOR K BOARD Of SUPERVISORS Fill in name ION ) CLERK c cosTn co. De u The undersigned claimant hereby makes claim against the CWMty of Contra Costa or the above-named District in the sum of $ 2240.00 and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ON OR ABOUT JULY 7, 1989 2. Where did the damage or injury occur? (Include city and county) -_- AP# 188-080-048-5 & 188-080-049-3 TO THE REAR OF IUTJJ.J&N.UL_C_L_1'YALL.LT-CREEK, CA. ------------------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) FIRE DISTRICT ORDERED WEED ABATEMENT AND FAILED TO SUPERVISE CON- TRACTOR WHO WORKED ON WRONG PARCELS, DID EXCESSIVE WORK, CHARGED FOR HOURS NOT WORKED, WAS PAID MORE THAN THE REASONABLE VALUE, AN EXCESSIVE SUR CHARGE WAS ADDED AND CLAIMANTS IRRIGATION AND SOLAR SYSTEM WAS DAMAGED. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? SEE #3 ABOVE (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? INSPECTOR MCKISSICK AND CONTRACTOR ED RICHARD. ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach'two estimates for auto damage. $2040 FOR WEED ABATEMENT CHARGE, AND $200 FOR DAMAGE TO IRRIGATION SYSTEM ---- AJSD-aQ1A1LayS3:EW-------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) WEED ABATEMENT AT COST, BALANCE FIVE HOURS LABOR AT $40 PER HOUR. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. N/A ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some personot his behalf." Name and Address of Attorney, ' THOMAS VAN VOORHIS P O BOX 2299 Claimant's Signature WALNUT CREEK, CA 94595 (415) 933-3109 P O BOX 22 Address Telephone No.(415) 933-3109 Telephone No. Q 933-3109 N O T I C E 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 ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. DATEN.O.V.....9.,...1.98.9...........................................1111...................... ❑ URGENT THOMAS VAN VOORHIS ❑ SOON AS FOSS/BLE P.O. Box 2299 FILE NO. 1_Q..1.0.3.3........................................................................................ ❑ NO REPLY NEEDED WALNUT CREEK, CALIFORNIA 94595 ATTENTION .............................................................................................................................................................................................................. (415)933.3109 • Fax(415)933.3110 TO SUBJECT .................CLAIM....(..G.O.V....'_T.....CODE....§.9.1..1..2)........................A............... CLERKOF THE BOA D ISO.R.S.......................__.... ............................._................................................................_.................................................._.............._._...._............._............_..........._...........................— _..........._..............................._...._........_..............._..........................It..............Q.F...._.8.U..P.E..R_V. ROOM 106, ADMINISTRATION BUILDING 651 PI MARTINEZ, CA. 94553 MESSAGE PLEASE CAUSE THE ENCLOSED CLAIM TO BE FILED RETURNING A.._F.ILE.....S.TA.M.P.E..D.................................................................. ............................................................................................................................................................................................................................................................................................................................................................................................................................................. COPY TO ME IN THE ENVELOPE ENCLOSED.._FOR.TH_AT.PURP E. ....... .. ...... ......................................Q.S.. ................ ................................................................................................................................................ RECEIVED .. .. .................. ......... N:QV 1 3 1989 .. f H:t BATCHELOR $/GNE ......................... .............................................................................:.............................................................................l-RK BOARD..OF..SUPERYf50 5.......................................................... REPLY T ............................................ DATE OF REPLY......................................................................._................................................................................._................................ ....... ............................................................................................................................................................................................_...................................................................................._...............................................................................................11.11.......... ...... .................................................... ......... ..... ..... .............. ..111.1. . ........... . ........... ..............................................................I'll......................................_... ............ . . .. ................. ... . _...................................................................................... CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 1,2 ,' 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $100 ,000 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. GLUECK, Margaret Anne ATTORNEY: Mr. Harvey A. Hyman, Esq, . Law Office of Harvey Hyman Date received ADDRESS: 22 Battery St . , Suite 333 BY DELIVERY TO CLERK ON November 13 , 1989 San Francisco, CA 94111 BY MAIL POSTMARKED: November 8 , 1989 Cert . # P057 484 965 I. 'FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gATCHELOR, Clerk DATED: November 14 , 1989 : Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: 1 Dated: _I.1 �I�( I �cy BY: I 0 Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is.rejected in full . ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 913) Subject to certain exceW ons, you have only six (6) months from the date this notice was personally served o deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. DEC 12 1989 Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator LAW OFFICE OF HARVEY A. HYMAN ATTORNEY AT LAW SUITE 333,22 BATTERY STREET SAN FRANCISCO.CALIFORNIA 94111 + _�� TELEPHONE (415) 788-2362 RECEIVED November 8 , 1989 NOV /3 1959 PHIL 9ATCMELOA Board of Supervisors CLERK BOARD OF SUPERVISORS Government Tort Claims UnitCONTRA COSTA CO. Uy— 651 Pine Street, Room 106 Martinez , CA 94523 RE: Claim of Margaret Anne Glueck Dear Gentlemen: Enclosed herein please find an original plus one copy of the claim of my client Margaret Anne Glueck. Please file the original and mail back the copy stamped received. If you have any questions please do not hesitate to call me. Thank you for your cooperation in this matter. Very truly you s , 7Ha)rveyTHym 1 HARVEY A. HYMAN, ESQ. Law Offices of 2 HARVEY A. HYMAN 22 Battery Street, Suite 333 3 San Francisco, CA 94111 Telephone: (415) 788-2362 4 Attorney for Claimant 5 6 TO: COUNTY OF CONTRA COSTA - EAST 7 MARGARET ANNE GLUECK, hereby makes claim against the COUNTY 8 OF CONTRA COSTA - EAST in the sum of $100 , 000 and makes the 9 following statements in support of the claim: 10 1 . Claimant ' s post office address is : 11 807 Cheyenne Drive 12 Walnut Creek, CA 94598 13 2 . Notices concernina the claim should be sent to: 14 HARVEY A. HYMAN, ESQ. Law Office of Harvey A. Hyman 15 22 Battery Street , Suite 333 San Francisco, CA 94111 16 3 . The date and place of the occurrence giving rise to 17 this claim are : 18 DATE: June 9 , 1989 19 PLACE: Camino Diablo Eastbound approximately 1 . 4 miles east of Vasco Road in an unincorporated 20 area of the county known as the Delta. 21 4 . The circumstances giving rise to this claim are : 22 Claimant was driving alone in her 1984 Mercedes Benz 23 300 Turbo D automobile eastbound on Camino Diablo in the location 24 indicated above. Her car flipped over when she drove over a 25 section of road in which loose gravel was covering oil and 26 asphalt . The county road department had recently done work in the 27 area and had left the loose gravel behind without posting any 28 signs , cones or barricades to warn approaching drivers of the 1 I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: D E C 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sect(on 13) Subject to certain excep- tions, you have only six (6) months from the date this notice was personally served or - deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: p E C 12 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator MARTIN, RYAN & ANDRADA RECEIVED A Professional Corporation Ordway Building, Suite 2275 1989 One Kaiser Plaza NOV 9 , Oakland, CA 94612 11,GO P.m. (415) 763-6510 PHIL BATCHELOR CLE 8U D OF SAJPERVISORS CO! A CO Attorneys for Claimant B uI SAFEWAY STORES, INC. CLAIM AGAINST CONTRA COSTA COUNTY HEALTH DEPARTMENT TO: CLERK OF THE BOARD OF SUPERVISORS, 651 Pine Street, Room 106, Martinez, CA 94553: SAFEWAY STORES , INC. , hereby makes a claim against the CONTRA COSTA COUNTY HEALTH DEPARTMENT and makes the following statement in support thereof: 1. Claimant ' s post office address is: SAFEWAY STORES , INC. , 201 - 4th Street, Oakland, California 94607. 2. Notices concerning the claim should be sent to Gerald P. Martin, Jr . , Martin, Ryan & Andrada, One Kaiser Plaza, Suite 2275, Oakland, CA 94612. 3 . The date and place of the occurrence giving rise to this claim are as follows: On or about May 11, 1989 SAFEWAY STORES, INC. , was served with a complaint by Annabelle Taylor v. Safeway Stores, Inc. , et al. (Case No. 651128-1) . The action was filed in the Superior Court of California, County of Alameda. 4. The circumstances giving rise to liability are as follows: SAFEWAY STORES, INC. , owned and operated a distribution center warehouse at 2900 Hoffman Boulevard, City of Richmond, County of Contra Costa, State of California. On July ll, 1988 , -1- / may CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12. 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $318.50 Section 913 and 915.4. Please note all "Warnings" County Counsel CLAIMANT:. BENAVIDEZ, Ignacio Galvan f �1 ry j 1n89 ATTORNEY: 1 •7 Date received Martinez. CA ADDRESS: 1091 Virginia Lane #4 BY DELIVERY TO CLERK ON November 9, 1989 (hand delivered Concord, CA 94520 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk DATED: November 13, 1989 BY: Deputy L / 1I. �FROM: County Counsel TO: Clerk of the Board of Supervisors (� ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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 �I� BY: Deputy County Counsel XJ I1I. 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 ( LI 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: D E C 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code section 913) Subject to certain exce�W ons, you have only six (6) months from the date this notice was personally served or_.�_- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately, AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator �t } 4 k d 0 C,A fir® ...a.Z m } 1` 1 t f t w �x Y. x Lo q � w0 ON Z mit 1� O 6 01 I. f� � p O Q 217►{' "� d �" H p _, Tk µ Y= LYS t W ' Ul 4 w K �@rt i tt ,d rt. ' N � � tti 00 i N cA S� � r Pi N-) C»� � r)-13 (1CP �Z1Ii � • J '' ^LAIN,% TCS• BOARD OF SUPERVISORS OF CONTRA CO i T .y`. eturR2tiit5�i application to, Instructions to Claimant Clerk of the Board P.O.Box A. Claims relating to causes of action for death or M oroin�urynto4533 person or to personal property or growing crops must. be presented not later than the 100th day 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. (Sec. 911.2, Govt. Code) B. Claims must be- filed with the Clerk of the Board of Supervisors at its office in Room 106 , County _Administratiun Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a district governed by. the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Reser-, g stamps RECEIVED �t(002WMd /o; .3 Against the COUNTY OF CONTRA COSTA) Nov e? PHIL BATCHELOR or DISTRICT) CLERK BOARD OF SUPERVISORS (Fill in name) ) CO"R COSTA CO. B u . The undersignedclaimant hereby makes claim against 1 ouf Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: --------------t--------------- -- --------------------------------------- 1. When did he he a or in •uryoccur (Give e Actvdate and hour) CM �rn ---------- ---------------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) --------------------------------------------------------------`---------- 3. How did the damage or injury occur? (Give full details, use extra sheets if required)— Ali equired)A 4. What particular act or omission on the-part of county or district- �offfficers , servants or employees caused the injury or damage? (over) '.:5..:,:• zat are...the..names of county or district officers, servants or i • �' ' j emplo -. ca sing the damage or injur� � `- --� - -- - ---- ---------- --------- - - ----� 6. ,at damage or inju ies do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) -------------------------------------------- --------- 7 . How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damAcTe� ----------- ----------------------------------------------------------- 8. Names an addresses of witnesses , doctors and hospitals. ------------------------------------------------------------------------- 9 . Lis:t,�the-...expea .tureis you made on account of this accident or injury: DATE I 1TEI4 MMOUNT �W vV PC) t. ode Se "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some nerson' on his behalf. " Name and Address of Attorney C ant' s Signatur i D w z . Addres Telephone No. -.x Telephone No. -77 NOTICE Section 72 of the Penal Code provides: "Every person who, with intert to defraud, presents for allowance or for payment to any state', or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bill, account , voucher , or writing, is guilty of a felony. " CLAIM Z Y BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Cl;im Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section 913 and 915.4. Please note all "Warnings" ounty CiOUCISl CLAIMANT:. KASPRZAK, Adam I'M q 3 198O9 ATTORNEY: Christopher A. Kerosky l J iS Byrne, Igleheart, Kerosky & Byrne Date received ��:'t�11EZ �'A i94 ? ADDRESS: 785 Market St. , Suite 820 BY DELIVERY TO CLERK ON November 9, 1989 San Francisco, CA 94104 BY MAIL POSTMARKED: November 7, 1989 (Cert. #P055-915-171) I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pH DATED: November 13, 1989 gYIL BATCHELOR, Clerk eputyII. FROM: County Counsel TO: Clerk of the Board of Su cors �(v ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: II 1349 BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:__rlrp �. 959 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 13) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served oc� deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown abave. Dated: DE C BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 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 per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp Adam Kasprzak ) RECEIVED Against the County of Contra Costa > NQV. 9 1989 and ) PHIL BATCHELOR HAN;Sa , SIMIOR , FiTZHUCH, DeMglk, FUQUA CLERK BOARD Of SUPERVISORS anti other Dexxar_tnent members District) s c �- cosrAco. —Dep�1 Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) July 18 , 1989 , approx. 2 - 6 p.m. ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) --_- 1779_Wilbur Avenue, Antioch, California, and Sheriff' s De2artment_ --------------------------------------------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) See attached. ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? See attached. (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Contra Costa Sheriff' s Department Kenneth_ Hansen, _Doug Sizemore; Dave Fitzhugh Deputy DeLuna, Deputy'Fuqua, other department menbers ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. See attached, including two estimates for auto damage. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached. ------------------------- Names and addresses of witnesses, doctors and hospitals. See attached. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT See attached. Gov. Code Sec. 910.2 provides% "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney Christopher A. Kerosky Claimans Signature BYRNE, IGLEHEART, KEROSKY & BY E 785 Market Street, Suite 820 fl. San Francisco, CA 94103 Address 6V�47 Cp Ceo2l Telephone No. (415) 777-4444 Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent 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 ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. FRECEEIVED CLAIM OF NOV 91989 PWL BATCHELOR ADAM KASPRZAK LCLERKBOARD OF SUPERVISORS 'P COSTA CO. De u v. THE CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT, KENNETH HANSEN, DOUG SIZEMORE, DAVE FITZHUGH, DEPUTY DELUNA, DEPUTY FUQUA AND OTHER UNKNOWN MEMBERS OF THE CONTRA COSTA SHERIFF'S DEPARTMENT [Govt. Code Section 900 et seq. ] 1. NAME AND ADDRESS OF CLAIMANT Adam Kasprzak 1731 Adelaide St . , #205 Concord, Ca. 94520 2. ADDRESSES TO WHICH NOTICES ARE TO BE SENT Christopher A. Kerosky Byrne, Igleheart, Kerosky & Byrne 785 Market St . , Ste. 820 San Francisco, Ca . 94104 3. DESCRIPTION OF CLAIM On July 18 , 1989, claimant Adam Kasprzak [ "Claimant" ] was leaving his place of employment at the Gaylord' s Container Corporation site at 1779 Wilbur Avenue , Antioch, California . As claimant was exiting the building, he was first the subject of threats and verbal abuse by a mob of protesters , many of whom were intoxicated. Claimant is a political emigre from Poland and a former member of Solidarity labor union. The mob reacted to a Solidarity bumper sticker on his automobile and for that reason, subjected him specifically to Strong threats and verbal abuse. The Contra Costa County Sheriff' s Department ["The Department" ] and five of its individual officers, Lt . Sizemore, Sgt. Fuqua , Dep. DeLuna, Dep. Hansen and Dep. Fitzhugh failed to protect claimant from the crowd in any way. None of the violent protesters were arrested or restrained in any way by the Department. By their own admission, later quoted in the local newspapers , the officers lacked any control over the situation. Nonetheless, the officers failed to take any action to seek additional help or personnel to assist in controlling the violent mob. The claimant was directed by one or more of the members of the Department to drive his vehicle through the plant gate into the waiting mob. No effort was made by the Department to move the mob so that employees could pass. No efforts were taken to protect claimant from physical damage from the mob. No alternative means of departure were suggested or even permitted by the Department . Soon after the claimant reached the gate, his car was surrounded by the mob of protesters. The verbal threats increased. His car was severely damaged by the crowd with bags of nails and possibly other foreign objects . Several individuals, apparently intoxicated , jumped onto his vehicle and began jumping up and down on his hood and roof. One such person was photographed and identified in the local papers , jumping up and down atop claimant' s vehicle, yet no action was taken against her at that time or later by the Department . When claimant attempted to exit his car in fear, he was prevented to do so by the crowd and the Department. At no time did the Department take any action to prevent the destruction of claimant ' s car or to stop the physical threats and physical imprisonment of claimant . Unable to leave his vehicle, Mr . Kasprzak remained in his vehicle until both the front and rear windows in his car were broken . At that time, Mr . Kasprzak pulled his car forward away from the crowd. The members of the Department pursued him, pulled him from the car and pinned the claimant against the ground. No warnings were given. The claimant was arrested and dragged through the crowd to a Department vehicle. The claimant ' s car was left unprotected by the Department and sustained further damage by the mob. The claimant was taken to the Department headquarters and booked on charges of "Attempted Resisting Arrest" . He was injured in the violent confrontation at the plant , but he was not provided any medical attention by the Department. The claimant was kept at the Department in the jail until his bail was met . Charges were brought against the claimant , but later dismissed. The Department failed to arrest any of the members of the mob which had incited the violence occurring at the Gaylord plant, threatened and assaulted several employees of the plant including claimant and caused thousands of dollars in property damage. 4. LEGAL BASIS OF THE CLAIM The actions of the Department and the individual members named above create causes of action for the claimant under the Equal Protection and Due Process Clauses of the U.S. Constitution; 42 U.S.C. 1983 and other federal civil rights provisions; the California Constitution; Government Code 815 .2 (a) , 820 (a) , 845.6 and other provisions of the Government Code; provisions of the California Penal Code; and common law principles of false arrest and imprisonment; negligent and/or intentional failure to protect claimant from mob violence; negligent and/or intentional failure to provide necessary medical attention; negligent and/or intentional failure to provide police protection; assault and battery; and intentional or negligent infliction of emotional distress . 5. DAMAGES SUFFERED BY CLAIMANT Physical property damage to claimant' s vehicle in the approximate amount of $4 ,000 ; Medical bills of at least $200 but in an undetermined amount according to proof ; Pain and suffering, emotional distress in the amount of $100,000; and punitive damages; Attorneys fees according to proof. 6. JURISDICTION OVER CLAIM Jurisdiction over this claim will lie with the U.S.District Court for the Northern District of California. 7. RESERVATION The claimant reserves his right to revise, amend and/or supplement this claim or any portion thereof . DATED: !I. f q /&W,6 CHRISTOPHW A. KEROSKY BYRNE, IGLEHEART, KEROSKY BYRNE 785 Market St. , Suite 820 San Francisco, Ca. 94104 (415) 777-4444 J & C BODY SHOP, INC. Jack Arman 2535 Monument Boulevard Randy Armas Concord, California 94520 ��//�}} 825-3800 �7 �i Natne 2g /�� _Gf Phone N� rere Y Date / 2— Address J7Insured by Year &Make Styl cense Motor No. Serial No. Mileage Symbol FRONT Labor Park Symbol LEFT Labor Parts Symbol RIGHT labor Park Bumper Bumper Brkt. Fender, Frt. Fender, Frf. Bumper Gd. Fender Shield Fender Shield Frf. System Fender Mldg. Fender Mldg. Frame Headlamp Headlamp Cross Member Headlamp Door Headlomp Door Stabilizer Sealed Beam Sealed Boom Wheel Cowl Cowl Hub Cap Windshield Windshield Hub&Drum Door, FrontC7 Door, Front Knuckle Knuckle Sup. Door Hinge Door Hinge Lr. Cont. Arn►Shaft Door Glass Door Glass Vent Glass Vent Glass Up. Cont. Arm-Shaft Door Mldgs. Door Mldg. Shock Door Handle Door Handle Spring Center Post Center Post Tis Rod Door, Rear Door, Rear Q Steering Gear Door Gloss Door Glass Steering Wheel Door Mldg. UDoor Mldg. Horn Ring Roder Panel Roder Panel Gravel Shield Rocker Mldg. Roder Mldg. Park. Light Floor Floor Frame Frome Rod. Grille Dog Leg Dog Leg Quar. Panel Quar. Panel J^ Quar. Mldg. Quar. Mldg. Quar. Gloss Quar. Glass Fender, Rear Fender, Rear qO p') Fender Mldg. Fender Mldg. Fender Pad Fender Pod Name Plate REAR misc. Horn I ZoBurnper Inst. Panel Baffle, Side Bumper Brb.,hW 1 14 A Jrrl I Front Seat Baffle, Lower Bumper Gd. Front Seat Adj. Baffle, Upper Grovel Shield Trim Lock Plate, Lr. Lower Panel Headlining Lode Plate, Up. Floor TopI TO 1947FE IV Hood Top Trunk Lid Tire % Worn Hood Hinge Trunk Light Tube Hood Mldg. Trunk Handle Battery Ornament Tail Light int Rod. sup. Tail Pipe Unde Rad. Core Gas Talc , Anti Freese Frame 3,501t < W. Hoses Wheel PARTS b 3b Fan Blade Hub&Drum Fon Belt Axle TAX Wafer Pump Spring TOTAL Motor Mts. Clutch Linkage ADVANCE CHARGE GRAND TOTAL$ A—Align N-Now OH-Overhaul S-Straighten or R i nge RC-Rechrome U-For Used Park Signed: W ESTIMA EXPIRES 30 DAYS FROM DATE m �o Wq m CCs m H c >•qD a E a c� ul m In O O F' >ti 0 i rt 5 �j rt 4 NM (D f-h q Lo 5 ft t� n m x+ (D r• ro (D En ° O > m • Pi Ft < t n rt t1, Ln r• V) n w O O z ( n O !1 Z � n M r N Yy F- (D o �C O ¢ C a R° I UI � � 'n � Ln O Z D I�y STA. Ln 0 a h C,63 O _ uar� O0Y CD '� 0 "�. YV� O�Q Q0 Q< 00 AAA"I A'A f.Atft F::� U (l `C4. v P AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section 913 and 915.4. Please notGeijn*►Gaonse1 CLAIMANT: SUBIA, Patricia Nov ( n 1-90 ATTORNEY: Joanne Brown - Maftnnoz, CA 04451 Molesky $ Brown Date received ADDRESS: An Association of Attorneys BY DELIVERY TO CLERK ON November 21 , 1989 ()Lia 80 Grand Avenue, #600 Counsel) Oakland, CA 94612 BY MAIL POSTMARKED: no envelol2P 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gAT%LOR, Clerk DATED: November 22 , 1989 : Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2; and we are so notifying claimant. The Board cannot act for 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: 11 7 BY: 1 J . Deputy County Counsel 0- 11I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) , Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator J ' t Joanne M. Brown AMENDED CLAIM Molesky & Brown 80 Grand Avenue, Suite 600 Oakland, California 94612 Telephone: (415) 987-7500 Attorneys for Claimant TO: Clerk of the Board of Supervisors County of Contra Costa Administration Building, First Floor 651 Pine Street Martinez, California 94553 AMENDED CLAIM AGAINST: County of Contra Costa CLAIMANT'S NAME: Patricia Subia CLAIMANT'S ADDRESS: 1423 Chanslor Avenue Richmond, California 94801 CLAIMANT'S TELEPHONE NO. : (415) 987-7500 AMOUNT OF CLAIM: In an amount in excess of $100, 000.00; permanent physical damages have to be assessed; medical treatment is continuing. JURISDICTION: Superior Court ADDRESS TO WHICH NOTICES ARE TO BE SENT: Joanne M. Brown Molesky & Brown 80 Grand Avenue, Suite 600 Oakland, California 94612 DATE OF OCCURRENCE: May 13, 1989 PLACE OF OCCURRENCE: Interstate Highway 580 (westbound) (near the Hoffman Street exit) , Richmond, California HOW DID ACCIDENT OR TRANSACTION OCCUR?: On or about May 13, 1989, at approximately 1: 00 a.m. , a vehicle was stopped on Westbound Interstate Highway 580 in the #1 lane, due a previous collision in the W-2 lane. There was a car stopped in front of this vehicle. A truck collided into this vehicle. Because the driver(s) involved in the original . t . collision could not pull his/their car(s) off the road and due to the absence of an emergency lane, the traffic was forced to merge and change lanes around these vehicle(s) . As a result of the absence of an emergency lane, proper design, maintenance and safety of this section of I-580, including placement of the Jersey wall, a vehicle collided with the car in which plaintiff was riding, causing her car to be propelled ahead and resulting in another vehicle landing on the roof of her car. The force of this collision expelled plaintiff from her seat and threw her twenty (20) feet away, onto the asphalt in a pool of gasoline, which resulted in serious physical injuries to her, loss of consciousness and burns, requiring hospitalization and long term medical care. She also suffered permanent scaring on her face, arms and back. The County of Contra Costa constructed, maintained, operated, designed, and supervised this roadway in such a negligent and careless manner so that it was not in a reasonably safe condition, which resulted in serious injury and loss to plaintiff. ITEMIZATION OF CLAIM: Wage loss, permanent physical disability, medical and psychological treatment costs, loss of economic opportunity. *DATED: November 20, 1989 OANNE M. BROWN Attorney for Claimant PATRICIA SUBIA *Original claim was dated November 9, 1989 • •VICTOR J. WESTMAN Y CONTRA COSTA COUNTY COUNSEL TO '-V 1 P.O. BOX 69. CO. ADMIN. BLDG.. \\\VVVVVIII MARTINEZ, CA 94553 DATE Nv R;- f' a 1 ❑n'^(' ice,: C1 EP :; a or u�=l`:nw,SORS CCINHA COSiA CO. uv D^ O CLAIM t - BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 12 ,, J989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice o California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. SUBIA, Patricia ATTORNEY: Joanne M. Brown, Esq. Molesky & Brown Date received ADDRESS: 80 Grand Avenue , Suite 600 BY DELIVERY TO CLERK ON November 13 , 1989 Oakland, CA 94612 BY MAIL POSTMARKED: November 9 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHH gg DATED: November 14 1989 BYIL DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( } This claim complies substantially with Sections 910 and 910.2. �+ ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: i Dated: BY: I Q S All) Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exce�W ons, you have only six (6) months from the date this notice was personally served oc—.-- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator V � NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Joanne M. rown, Esq. Molesky & BroW 80 Grand Ave. , ite 600 Oakland, CA 946t Re: Claim of PATRICIA SUBIA Please Take Notice As Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code section 910 and 910 . 2, or is otherwise insufficient for the reasons checked below: 1 . 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. x 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10,000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. 6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WESTMAN, County Counsel By: ► A I 1 Deputy C ' my Counsel CERTIFICATE OF SERVICE BY MAIL C.C.P. 99 1012, 1013a, 2015.5; Evid. C. S§ 641, 664) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated.- _ ko \q�J, at Martinez, California. cc: Clerk of the Board of Supervisors (o ginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910. 2, 920 .4, 910 .8) MOLESKY & BROWN AN ASSOCIATION OF ATTORNEYS INCLUDING A PROFESSIONAL CORPORATION 80 GRAND AVENUE, SUITE 600 JAMES MOLESKY, APC OAKLAND, CALIFORNIA 94612 TELEPHONE: 415) 987-7500 JOANNE M. BROWN TELECOPY: (415) 987-7575 November 9, 1989i ,EC�IEi NOV 13 1989 Clerk, Board of Supervisors PFlIL BATCHELOR County of Contra Costa CLERK BOARD OF SUPERVISORS Administration Building, First Floor s Co T. STA Co. oe u 5 1 r .-.t Martinez, California 94553 Re: Claim of Patricia Subia Dear County Clerk: Enclosed please find the personal injury claim of Patricia Subia, resulting from an accident of May 13, 1989. All correspondence regarding this claim should be directed to attorney Joanne M. Brown at the address noted above. Very truly yours, Esther Aviva Secretary to Joanne M. Brown Enclosure 9 Joanne M. Brown 1 i I i Molesky & Brown ``" ��` 80 Grand Avenue, Suite 600 Oakland, California 94612 NOV 13 1989 Telephone: (415) 987-7500 L £K3GAP.DAfCNEVP,-% -`�, Attorneys for Claimant B Ma TO: Clerk of the Board of Supervisors County of Contra Costa Administration Building, First Floor 651 Pine Street Martinez, California 94553 CLAIM AGAINST: County of Contra Costa CLAIMANT'S NAME: Patricia Subia CLAIMANT'S ADDRESS: 1423 Chanslor Avenue Richmond, California 94801 CLAIMANT'S TELEPHONE NO. : (415) 987-7500 AMOUNT OF CLAIM: In an amount to be determined; permanent physical damages have to be assessed; medical treatment is continuing. ADDRESS TO WHICH NOTICES ARE TO BE SENT: Joanne M. Brown Molesky & Brown 80 Grand Avenue, Suite 600 Oakland, California 94612 DATE OF OCCURRENCE: May 13, 1989 PLACE OF OCCURRENCE: Interstate Highway 580 (westbound) (near the Hoffman Street exit) , Richmond, California HOW DID ACCIDENT OR TRANSACTION OCCUR?: On or about May 13, 1989, at approximately 1: 00 a.m. , a vehicle was stopped on Westbound Interstate Highway 580 in the #1 lane, due a previous collision in the W-2 lane. There was a car stopped in front of this vehicle. A truck collided into this vehicle. Because the driver(s) involved in the original collision could not pull his/their car(s) off the road and • due to the absence of an emergency lane, the traffic was forced to merge and change lanes around these vehicle(s) . As a result of the:.:absence of an emergency lane, proper design, maintenance and safety of this section of I-580, including placement of the Jersey wall, a vehicle collided with the car in which plaintiff was riding, causing her car to be propelled ahead and resulting in another vehicle landing on the roof of her car. The force of this collision expelled plaintiff from her seat and threw her twenty (20) feet away, onto the asphalt in a pool of gasoline, which resulted in serious physical injuries to her, loss of consciousness and burns, requiring hospitalization and long term medical care. She also suffered permanent scaring on her face, arms and back. The County of Contra Costa constructed, maintained, operated, designed, and supervised this roadway in such a negligent and careless manner so that it was not in a reasonably safe condition, which resulted in serious injury and loss to plaintiff. ITEMIZATION OF CLAIM: Wage loss, permanent physical disability, medical and psychological treatment costs, loss of economic opportunity. DATED: November 9, 1989 (gbANNE M. BROWN Attorney for Claimant PATRICIA SUBIA oz Z 0 > t-.4 c. z z b 4 tt 9 m o FC o o0 20 z z ~ H H p �1 z Q O . ._. ° w ,4 y N 0 z Q :to nn K N0 G M rt r- O " r•ro :3 rt yc' mew t-' Or^ o W n�t " 0n' 1 C) rt rt 0 ►i fU " r-O Nm 0 :3 r•(D O rt O M ft " f"h O w W H- H O v 'Pct � jl...#r ko U► O -n Ln ► fi ct E✓ t . y O O Ir- CO ar hen V • -�G r � Win �-�`�. xt,... OD O f A"ARRRAAAAAAA AMENDED CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA .2L/ Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT December 1 2 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice bf California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified , Section 913 and 915.4. Please note all "Warnings". CLAIMANT:. Spectrum Emergency Care., Inc . and S . Phillip Moody, M.D. ATTORNEY: Nancy E . Hudgins Attorney at Law Date received ADDRESS: 605 Market Street, Suite 700BY DELIVERY TO CLERK ON November 13 , 1989 San Francisco , CA 94105 BY MAIL POSTMARKED: November 8 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. GATED: November 14 , 1989 ��IL �ep�tyLOR, Clerk Nell II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 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: 1 9 BY: S Deputy County Counsel J I1I. 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 ( his 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. 0[1 Dated: DEC 12 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served oc.�-- deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: DEC 12 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator LAW OFFICES OF NANCY E. HUDGINS 605 MARKET STREET.SURE 700 SAH FRANasco.CAUFORNIA 94105 415243-8118 NANCY E.HUDGINS FAX 418/243.8204 LAURA M.HILLENBRAND SEL November 9 KEVAN 1989 OTT..HUNT X7_0 I NOV' j 189 CLERK OF BOARD OF SUPERVISORS CLF:2t:4GAk,D L SUr'Ei:`/:SC)p,S County Administration Bldg. , Room 106 By • ACOSTA c0. oeul 651 Pine Street Martinez, CA 94553 RE: SPECTRUM EMERGENCY CARE, INC. AND S. PHILLIP MOODY, M.D. Dear Sir/Madam: Enclosed please find an original and one copy of Defendants' Amended Claim Against the County of Contra Costa and Merrithew Hospital. Please return an endorsed copy to our office in the enclosed self-addressed, stamped envelope. If you have any questions, please do not hesitate in contacting the undersigned. Thank you for your anticipatea courtesy and cooperation in this matter. 'Very truly yours, �n? Samara Baumg"arten cSecretary to NANCY E. HUDGINS• 1 � 1 LAW OFFICES OF NANCY E. HUDGINS 605 Market Street, Suite 700 2 San Francisco, CA 94105 3 Telephone (415) 243-8118 [RIEE � Attorneys for Defendant 89 4 SPECTRUM EMERGENCY CARE, INC. AND S. PHILLIP MOODY, M.D.5 RVISORS O. DePW 6 7 8 RE: Amended Claim by SPECTRUM EMERGENCY CARE, INC. ) 9 AND S. PHILLIP MOODY, M.D. ) 10 Against the COUNTY OF ) CONTRA COSTA AND MERRITHEW ) 11 HOSPITAL ) 12 The attached Complaint, Contra Costa Superior Court Case 13 No. 309838, is incorporated herein by reference, as Exhibit A. 14 The attached medical records from Merrithew Hospital are 15 incorporated herein as Exhibit B. 16 SPECTRUM EMERGENCY CARE, INC. and S. PHILLIP MOODY, M.D. , 17 hereby make a claim against CONTRA COSTA COUNTY for equitable 18 indemnity and contribution and medical malpractice for all damages 19 and injuries alleged and referred to in the attached Complaint. 20 The exact amount of the damages are unknown. Defendant S. Phillip 21 Moody, M.D. , was served with the Complaint on this action on April 22 27, 1989 . 23 1. The damage occurred on March 4 and 5, 1987, between 24 approximately 9: 30 p.m. and 3 : 00 a.m. 25 2 . Merrithew Hospital, Martinez, Contra Costa County. 26 3 . See Exhibits A and B. The plaintiff's baby was n 1 alive when she arrived at Merrithew Hospital, but then was 2 stillborn. 3 4. Alleged negligence by hospital personnel. 4 5. See Exhibits A and B. 5 6. See Exhibits A and B. The baby was stillborn. b 7. See Exhibit A. 7 8. See Exhibits A and B. S 9. Their claim is for equitable indemnity and 9 contribution. 10 A claim in this action was previously filed on October 11 27, 1989. This amendment is made in response to the Notice of 12 Insufficiency and/or non-Acceptance of Claim served on November 7, 13 1989. 14 Send notices to: 15 LAW OFFICES OF NANCY E. HUDGINS 605 Market Street, Suite 700 16 San Francisco, California 94105 17 18 DATED: November 9, 1989 LAW OFFICES OF NANCY E. HUDGINS 19 20 By: 21 NANC GINS Attorn s fo Defendants 22 SPECTRUM EMERGENCY CARE, INC. and S. PHILLIP MOODY, M.D. 23 24 25 26 -2- n u I CLYDE I. BUTTS LAW OFFICES OF MARRACCINI & BUTTS 2 1225 Alpine Road, Suite 204 Walnut Creek, CA 94596 J.h. JLSSON. CountyY Uetk 3 (415) 943-1850 .nNTRA COS i A cUUNT 4 LAW OFFICES OF JAMES J. SELTZER A Professional Law Corporation 5 2200 Powell Street, 10th Fl. Emeryville, CA 94606 6 (415) 596-2500 7 Attorneys for Plaintiff 8 SUPERIOR COURT FOR CALIFORNIA, COUNTY OF CONTRA COSTA 9 ANNA GRANT, NO: 3098 3 g 10 Plaintiff, COMPLAINT FOR DAMAGES DAMAGES V. 11 WEST CONTRA COSTA HOSPITAL 12 DISTRICT, BROOKSIDE HOSPITAL, SPECTRUM, INC. ,zi-PHILLIP MOODY, M.D. 1; COUNTY OF CONTRA COSTA, MERRITHEW HOSPITAL, and 14 DOES 1 THROUGH 50, IS Defendants. 1 16 PLAINTIFF ALLEGES: 17 GENERAL ALLEGATIONS 18 1. At all times herein mentioned Plaintiff was and is 19 now a resident of Contra Costa County, California. 20 2. Plaintiff is informed .and believes and thereon 21 alleges that at all times herein mentioned defendant WEST CONTRA 22 COSTA HOSPITAL DISTRICT (hereinafter DISTRICT) was and is now a 23 hospital district organized and established in compliance with 24 California Health and Safety Code Section 32000, et seq. 25 3. Plaintiff is informed and believes and thereon 26 alleges that Defendant BROOKSIDE HOSPITAL (hereinafter BROOKSIDE) 27 is and at all times herein mentioned was a hospital, as defined u-w Oss-CES Of 28 d E 9 nNaw�'f Inti L STi I' f � � 4,�yt m 7r,� 7. :5 AL PINE RO.STE ;6 -1- AH 1{ � _ . ....--°-- i.+uT C of f K.CA 9+. ��"' �1 1 lin California Health and Safety Code Section 1250, located at 2 2000 Vale Road, San Pablo, Contra Costa County, California, 3 organized, operated and controlled by defendant District. 4 4. Plaintiff is informed and believes and thereon S alleges that defendant SPECTRUM, INC. (hereinafter SPECTRUM) was and is now a business entity, form unknown, providing physician's 7 services to hospitals, including defendant BROOKSIDE. Plaintiff 8 is further informed and believes and thereon alleges that 9 defendants SPECTRUM and DOES 26 through 35, and each of them, 10 were and are now in a contractual relationship, form unknown, 11 with defendants DISTRICT and BROOKSIDE, whereunder SPECTRUM 12 provides physicians to work at BROOKSIDE. li 5. Plaintiff is informed and believes and thereon 14 alleges that defendant CONTRA COSTA COUNTY (hereinafter COUNTY) 15 is and at all times herein mentioned was a public entity. 16 6. Plaintiff is informed and believes and thereon 17 alleges that defendant MERRITHEW HOSPITAL (hereinafter MERRITHEW) 18 is and at all times herein mentioned was a. hospital, as defined 19 in California Health and Safety Code Section 1250, located at 20 2500 Alhambra Avenue, Martinez, Contra Costa County, California, 21 organized, operated and controlled by defendants COUNTY and 22 DISTRICT. 23 7. Plaintiff is informed and believes and thereon alleges 24 that PHILLIP MOODY, M.D. (hereinafter MOODY) is and at all times 25 herein mentioned was a physician licensed to practice medicine in 26 the State of California and was and is now an employee of 27 defendant SPECTRUM assigned to practice at BROOKSIDE. At all w oFr$cEs or 28 times herein mentioned MOODY was on duty as the emergency room ,rf iWi r el'TTa P,NE AO_STE.?W —2- r CREEK.CA 9+396 .1 I physician at BROOKSIDE and in doing the acts and things 2 hereinafter alleged, acted with the knowledge, consent, 3 permission and authorization of each of his co-defendants and 4 within the course and scope of his duties as a physician. 5 8. Plaintiff is unaware of the true names and capacities, 6 whether individual, corporate, partner, associate or otherwise of 7 defendant DOES 1 through 50, and therefore sues such defendants 8 by such fictitious names. Plaintiff prays leave to amend this 9 complaint to state the true names and capacities when 10 ascertained. Plaintiff is informed and believes and thereon 11 alleges that each of the defendants designated as a DOE is 12 negligently responsible in some manner for the events and li happenings herein alleged, thereby proximately causing 14 plaintiff's injuries and damages. 15 9• At all times herein -mentioned Defendant DOES 1 through 16 50, and each of them, were the agents, servants and employees of 17 each of their co-defendants, and in doing the acts and things 18 hereinafter alleged, acted within the scope of their authority as 19 such agents, servants and employees and with the knowledge, 20 consent, permission and authorization of each of their co- defendants. 21 22 10. Pursuant to California Health and Safety Code Section 23 32492 and California Government Code Section 910, Plaintiff 24 filed claims against defendants DISTRICT, BROOKSIDE, COUNTY and 25 DISTRICT. Said claims, attached hereto as Exhibit "A" were 26 rejected by Defendants DISTRICT and BROOKSIDE on or about June 27 26, 1987 and by COUNTY and MERRITHEW on or about July 7, 1987. ll. At all times herein mentioned Plaintiff was nearing UW OFFICES OF 28 IIACCIN,&,MITTS -3- � AL oiNE t+0_STE.704 AUT CREEK.to 945" :r I full term pregnancy. On March 4, 1987 . Plaintiff began to 2 experience contractions and a seepage of amniotic fluid. At j approximately 9:00 p.m. on March 4, 1987 the contractions had 4 intensified and were occurring at regular 3 minute intervals. 5 An ambulance was summoned and Plaintiff was transported to 6 BROOKSIDE for the impending delivery. At all times throughout 7 the course of her pregnancy and labor, Plaintiff was aware, 8 through sensory perceptions of fetal movements, that the infant 9 she was carrying was alive and viable upon delivery.. . 101 12. All damages complained of herein are in amounts yet to I1 be ascertained which exceed the minimum jurisdictional limits of 12 this court. Plaintiff prays leave to amend this complaint to 13 state the correct amount of damages when ascertained. 14 FIRST CAUSE OF ACTION 15 Medical Malpractice (Defendants DISTRICT, BROOKSIDE, 16 SPECTRUM, MOODY and DOES 1 through 35) 17 13. Plaintiff refers to Paragraphs 1 through 12, inclusive 18 and by such reference incorporates them herein as though fully 19 set forth. 20 14. Upon arrival at BROOKSIDE Plaintiff was taken into the 21 emergency room and placed in an examination room. Prior to any 22 examination by a physician, Defendants DOES 1 through 5, and 23 each of them, questioned Plaintiff regarding her ability to pay 24 for any expenses that would be incurred as a result of the 25 delivery of her child. Plaintiff advised DOES l through 5, and 26 each of them, that she was unemployed and indigent and that the 2p7 expenses would have to be paid by Medi-Cal. There were no LAW OFFICES OF 28 ..PACI'INI L-111'TT♦ ALPINE RO.STE.204 . .I —4— ti JT CREEK.CA oa596 I further discussions pertaining to payment of expenses. 2 15. Following questioning regarding her ability to pay, 3 Plaintiff was briefly examined by Defendants MOODY and DOES 6 4 through 10, and each of them. At no time during the course of S the examination did Defendants monitor Plaintiff's heart rate, 6 perform an abdominal measurement to ascertain an approximate 7 fetal age, ascertain a fetal heartbeat or place a fetal monitor. 8 Rather, Defendants MOODY and DOES 6 through 10 performed only a 9 cursory vaginal examination, rupturing Plaintiff's water bag and 10 thereafter advised Plaintiff she was not sufficiently dilated for 11 delivery. MOODY and' DOES 6 through 10 told plaintiff to arrange 12 transportation to another hospital. Immediately following the li examination, Defendants DOES 1 through 5, and each of them, 14 advised Plaintiff she would not be accepted as a patient at 15 BROOKSIDE and to seek further care and treatment at MERRITHEW. 16 16. Following the examination, Plaintiff was placed in a 17 wheelchair by Defendants 1 through 25, and each of them, and left 18 in the emergency room lobby to wait for transportation to 19 MERRITHEW. Although Plaintiff advised DOES 1 through 25, and 20 each of them, that she had no transportation or access to 21 transportation, Defendants DISTRICT, BROOKSIDE and DOES 1 through 25, and each of them, refused to provide ambulance service to 22 23 transport Plaintiff to MERRITHEW. Rather, Plaintiff, who had no funds, was told to take a taxi. 24 25 17. Approximately 2-1/2 -hours later, Defendants DISTRICT, 26 BROOKSIDE, SPECTRUM and DOES 1 through 35, and each of them, 27 reluctantly made arrangements to transport Plaintiff to MERRITHEW via ambulance. During this 2-1/2 hour period, Plaintiff received LAW orrlcEs OF 28 [[A(:f:I NI 4 III•y"► -�- y•LPIME RO_SIE ?W NUT CREEK,CA 94596 I absolutely no medical attention, despite the fact she was 2 obviously in the latter stages of labor, in considerable pain j and experiencing intense contractions at regular and brief 4 intervals. Neither Plaintiff's condition nor the fetal 5 condition were checked again prior to Plaintiff being 6 transported to MERRITHEW. 7 18. Plaintiff is informed and believes and thereon alleges 8 that Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 9 through 35, and each of their actions and refusal to treat her 10 arose from an invidious, class based animus against Plaintiff 11 because she was an unemployed, indigent black female with no 12 readily apparent means to pay for hospitalization. 13 19. Plaintiff is informed and believes and thereon alleges 14 that defendants MOODY and DOES 1 through 35, and each of them, 15 negligently breached a duty of care of health care providers by 16 their failure to adequately and properly examine Plaintiff, 17 obtain a fetal heartbeat, place a fetal monitor and prepare 18 Plaintiff for the impending child birth. 19 20. Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and 20 DOES 1 through 35, and each of them, were further negligent in their failure to promptly arrange for Plaintiff to be transported 21 22 to MERRITHEW once it was determined that she would not be 23 accepted for treatment by BROOKSIDE. 24 21. As a direct and proximate result of Defendants 25 DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and 26 each of their refusal and failure to provide medical services to 27 Plaintiff, the fetus, which had been viable throughout the period of time Plaintiff was at BROOKSIDE, was stillborn approximately LAW OFFICES OF 28 •r R wl-cIHI E 91' t♦ 75♦I P'NE PD.STE.704 -6- • L NVT CPEEK,CA 94.596 1 20 minutes after Plaintiff arrived at MERRITHEW. 2 22. As a direct and proximate result of Defendants, and 3 each of their refusal and failure to provide medical services to 4 Plaintiff, resulting in the death of the fetus, Plaintiff has 5 suffered profound shock and injury to her body and nervous system 6 all to her damage, according to proof. 7 23. As a further, direct and proximate result of 8 defendants, and each of their refusal and failure to provide 9 medical services to Plaintiff, resulting in the death of the 10 fetus, Plaintiff has suffered and continues to suffer extreme 11 mental and emotional upset and distress, all to her further 12 damage, according to proof. 13 24. As a further, direct and proximate result of 14 Defendants, and each of their refusal and failure to provide 15 medical services to Plaintiff, resulting in the death of the 16 fetus, Plaintiff has incurred hospital and medical expenses, all 17 to her further damage, according to proof. 18 25. As a further, direct and proximate result of 19 Defendants, and each of their refusal and failure to provide 20 medical services to Plaintiff, resulting in the death of the 21 fetus, Plaintiff has incurred funeral and burial expenses, all 22 to her further damage, according to proof. �3 WHEREFORE, Plaintiff prays judgment as hereinafter set forth. 24 25 26 27 v.w OFFICES OF 28 04.4-t'IN#r a#'rn ALPINE PD.STE 204 —7- UT JUT CREEK.C•94596 1 SECOND CAUSE OF ACTION 2 Violation of Statutory Duty (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 3 MOODY and DOES 1 through 25) 4 26. Plaintiff refers to Paragraphs 13 through 21, 5 inclusive, and by such reference incorporates them herein as G though fully set forth. 27. At all times herein mentioned, California Health and 8 Safety Code Section 1317 was in full force and effect and binding 9 upon Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 10 through 35, and each of them. 11 28. Said Section provides, in part, that emergency services 12 shall be provided to any person requesting such services or care 13 without first questioning the patient or any other person as to 14 the ability to pay, provided that the patient or legally 15 responsible relative or guardian shall execute an agreement to 16 pay for services or otherwise supply insurance or credit 17 information promptly after the services are rendered. 18 29. Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and i9 DOES 1 through 35, and each of them, breached the statutory duty 10 to provide emergency medical services to Plaintiff by refusing to 21 render any emergency medical treatment, other than a cursory 22 examination, during the time she was at BROOKSIDE, despite the 23 fact that Plaintiff was in the latter stages of labor as 24 hereinabove alleged. 25 30. Defendants, and each of them, further breached the 26 statutory duty to provide emergency medical services to Plaintiff 27 by initially questioning her ability to pay for the services vw OFFICES OF 28 9RA4 CINI S.116"s ,AL VINE p0-STE.264 �U?CREEK.CA?x596 r . I prior to rendering any services and by failing to allow Plaintiff 2 to execute an agreement to pay for the services rendered and/or 3 by failing to allow Plaintiff to provide any insurance or credit 4 information. 5 31. Plaintiff is informed and believes and thereon alleges 6 that Defendants, and each of their refusal to provide emergency 7 medical services to her arose from an invidious class based 8 animus because she was an unemployed, indigent black female with 9 no readily apparent means to pay for hospitalization.' 10 32. As a proximate result of Defendants DISTRICT, 11 BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and each of 12 their breach of statutory duty by refusing to provide Plaintiff 1; with emergency medical treatment, the fetus, which had been 14 viable throughout the period time Plaintiff was at BROOKSIDE, was 15 stillborn approximately 20 minutes after Plaintiff arrived at 16 MERRITHEW. 17 33. As a direct and proximate result of Defendants, and 18 each of their breach of statutory duty, resulting in the death of 19 the fetus, Plaintiff sustained profound shock to her body and 20 nervous system, all to her damage according to proof. 21 34. As a further, direct and proximate result of 22 defendants, and each of their breach of statutory duty, resulting 23 in the death of the fetus, Plaintiff has suffered and continues 24 to suffer extreme mental and emotional upset and distress, all to 25 her further damage according to proof. 26 35. As a further, direct and proximate result of 27 Defendants, and each of their breach of statutory duty, resulting in the death of the fetus, Plaintiff has incurred �w OFFICES OF 28 RRA1'f:I NIL 111.77! _�_ At PINE RD.STE.204 NUT CREEK.G 94596 - l I hospital and medical expenses all to her further damage, 2 according to proof. 3 36. As a further, direct and proximate result of defendants 4 and each of their breach of statutory duty, resulting in the 5 death of the fetus, Plaintiff has incurred funeral and burial 6 expenses, -all to her further damage according to proof. The 7 policies and procedures further require that a fetal tone be 8 obtained. 9 WHEREFORE, Plaintiff prays judgment as hereinafter set. 10 forth. 11 THIRD 'CAUSE OF ACTION 12 Violation of Express Policy ( Defendants DISTRICT, BROOKSIDE, MOODY, 13 and DOES 1 through 25) 14 37. Plaintiff refers to Paragraphs 13 through 21, 15 inclusive, and by such reference incorporates them herein as 16 though fully set forth. 17 38. At all times herein mentioned, Defendants DISTRICT and 18 BROOKSIDE had in effect policies and procedures to be followed 19 pertaining to admitting obstetrical patients to the emergency 20 room. 21 39. Said policies and procedures require that all 22 obstetrical patients who present to the BROOKSIDE emergency �3 department at greater than 20 weeks gestation, with any symptoms 24 relating to the pregnancy, regardless of the payment source, will 25 be examined by the Emergency Department physician, referred to 26 the OB/GYN on-call physician and directed to the Women's Center 27 as appropriate. Said policies and procedures further require LAW osf(CES OF 28 U.RRAC(:J%j$I((1•TT 775 AL W►(E RO.STE.20 _10- N-A L NU T CREEK.CA 9459: . i 1 that a fetal heart tone be obtained. 2 40. Defendants BROOKSIDE, MOODY and DOES 1 through 25, and j each of them, breached the express hospital policy in failing to 4 refer plaintiff to the OB/GYN on-call physician and to direct 5 Plaintiff to the Women's Center to prepare for the impending 6 delivery. 7 41. Defendants, and each of them, further breached the 8 express hospital policy by failing to obtain a fetal heart tone. 9 42. Plaintiff is informed and believes and thereon alleges 10 that Defendants BROOKSIDE, MOODY and DOES 1 through 25, and each 11 of their refusal to refer Plaintiff to the OB/GYN on-call 12 physician and direct her to the Women's Center for the impending l; delivery arose from an invidious class based animus toward 14 Plaintiff because she was an unemployed, indigent black female 15 with no readily apparent means to pay for hospitalization. 16 43. As a direct and proximate result of Defendants 17 DISTRICT, BROOKSIDE, MOODY and DOES 1 through 25, and each of 18 their breach of express hospital policy, the fetus, which had 19 been viable throughout the time Plaintiff was at BROOKSIDE, was 20 stillborn approximately 20 minutes after Plaintiff arrived at 21 MERRITHEW. 22 44. As a direct and proximate result of Defendants, and 23 each of their breach of statutory duty, resulting in the death of 24 the fetus, Plaintiff sustained profound shock and injury to her 25 body and nervous system all to her damage, according to proof. 26 45. As a further, direct and proximate result of 27 defendants, and each of their breach of statutory duty, resulting t1w OFFICES OF 28 in the death of the fetus, Plaintiff has suffered and continues . . � •rxi r '75♦l PINE RO_STE 204 •/ •INUT CAEEK.CA 94596 Ito suffer extreme mental and emotional upset and distress. all to 2 her further damage, according to proof. j 46. As a further, direct and proximate result of 4 Defendants, and each of their breach of statutory duty, resulting 5 in the death of the fetus, Plaintiff has incurred hospital and 6 medical expenses all to her further damage, according to proof. 7 47. As a further, direct and proximate result of 8 Defendants, and each of their breach of statutory duty, resulting 9 in the death of the fetus, Plaintiff has incurred funeral and to burial expenses all to her further damage, according to proof. 11 WHEREFORE, Plaintiff prays judgment as hereinafter set 12 forth. li FOURTH CAUSE OF ACTION 14 Breach of Express Policy (Defendants BROOKSIDE, DISTRICT, MOODY 15 and DOES 1 through 25) 16 48. Plaintiff refers to Paragraphs 13 through 21, 17 inclusive, and by such reference incorporates them herein as 18 fully set forth. 19 49. At all times herein mentioned, Defendants DISTRICT and Z0 BROOKSIDE had in effectolicies and p procedures pertaining to the 21 triage categorization of Plaintiffs presenting at the BROOKSIDE 22 emergency room. 23 50. Said policies and procedures require that obstetrical 24 patients presenting with complaints of abdominal pain in 25 pregnancies with greater than 20 weeks gestation, shall be 26 classified as triage Priority I, emergent or immediate care 27 patients. LAW'OFFICES OF 28 tRACCINI L S1'TT% 1-- 5 ALPINE PO.STE.204 .UT CREEK.CA 9459A 1 51. Said policies and procedures require that patients 2 classified as Priority I patients have vital signs monitored and 3 entered on the patient's chart a minimum of one time per hour. 4 Said policies and procedures further require Priority I patients 5 be placed in an emergency department holding bed with vital signs 6 monitored and recorded on the patient's chart and nurse's notes 7 written at least once per hour. 8 52. Defendants BROOKSIDE, MOODY and DOES 1 through 25 and 9 each of them, breached the express hospital policies and 10 procedures by failing to categorize Plaintiff as a Triage 11 Priority I patient, by failing to place her in a holding bed and 12 by failing to monitor hers and fetal vital signs and make 13 appropriate entries in Plaintiff's emergency department chart. 14 Rather than following the express policies and procedures, 1S Defendants, and each of them, placed Plaintiff in a wheelchair in 16 the waiting room, providing absolutely no medical attention 17 whatsoever, as hereinabove alleged. 18 53. Plaintiff is informed and believes and thereon alleges 19 that Defendants, and each of their refusal to classify Plaintiff 20 as Priority I patient and place her in a holding bed arose from 21 an invidious class based animus toward plaintiff because she was 22 an unemployed, indigent black female with no readily apparent 23 means to pay for hospitalization. 24 54. As a direct and proximate result of DISTRICT, 25 BROOKSIDE, MOODY and DOES 1 through 25, and each of their breach 26 of express hospital policy, the fetus, which had been viable 27 throughout the time Plaintiff was at BROOKSIDE, was stillborn 28 approximately 20 minutes after Plaintiff's arrival at MERRITHEW. UW OFFICES OF -AK6A1:1 INI 4 61'771 25 ALv1NE RO_STE.704 -13- ILNUT CREEK.CO 94596 1 55. As a direct and proximate result of Defendants, and 2 each of their breach of express policy, resulting in the death of j the fetus, Plaintiff sustained profound shock and injury to her 4 body and nervous system all to her damage according to proof. 5 56. As a further, direct and proximate result of 6 Defendants, and each of their breach of express policy, resulting 7 in the death of the fetus, Plaintiff has suffered and continues 8 to suffer extreme and emotional upset and distress, all to her 9 further damage, according to proof. 10 57• As a further, direct and proximate result of 11 Defendants, and each of their breach of express policy, resulting 12 in the death of the fetus, Plaintiff has incurred hospital and li medical expenses all to her further damage, according to proof. 14 58. As a further, direct and proximate result of 15 Defendants, and each of their breach of express policy, resulting 16 in the death of the fetus, Plaintiff has incurred funeral and 17 burial expenses, all to her further damage according to proof. 18 WHEREFORE, Plaintiff prays judgment as hereinafter set forth. 19 SIXTH CAUSE OF ACTION 20 Breach of Statutory Duty 21 (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 22 MOODY and DOES 1 through 35) 23 59. Plaintiff refers to Paragraphs 13 through 21, 24 inclusive, and by such reference incorporates them herein as 25 though fully set forth. 26 60. At all times herein mentioned, Title 22 of the 27 California Administrative Code, Section 70751(g) was in full !_AW OFFICES OF 28 ♦ARACCINI r III-rT% -14- i'rt ALPINE 1wY- ALPINE Q0.! .204 NUT CREEK.CA 94596 1 force and effect and binding upon Defendants BROOKSIDE, DISTRICT, 2 SPECTRUM, MOODY and DOES 1 through 35 and each of them. Said 3 section requires that medical records and reports be completed 4 before 14 days after a patient's discharge. S 61. On or about March 18, 1987, Defendants, and each of 6 their refusal to provide medical care to Plaintiff was brought to 7 the attention of the news media. Following the media attention, 8 Defendants MOODY and DOES 1 through 25, and each of them, in 9 violation of 22 C.A.C. Section 70751(g) made ,late and self 10 serving entries in Plaintiff's emergency room chart and MOODY 11 made a late medical narrative report. The late chart entries 12 were made on March 18, 20 and 30, up to 26 days post incident. 13 MOODY's report was not made until March 23, 1987, 19 days post 14 incident. 15 62. Plaintiff is informed and believes and thereon alleges 16 the hereinabove alleged late entries were made in an attempt to 17 and with the intent to conceal Defendant's, and each of their 18 refusal to provide medical treatment to Plaintiff, as hereinabove 19 alleged, and to shield each Defendant herein from liability. ZO 63. As a direct and proximate result of Defendants, and 21 each of their violation of 22 C.A.C. Section 70751(g), Plaintiff has suffered and continues to suffer humiliation and extreme 22 23 mental and emotional upset and distress all to her damage 24 according to proof. WHEREFORE, Plaintiff prays judgment as hereinafter set 25 26 forth. 27 =w OFFICES OF 28 Pi NE AO.STE.104 -T CREEK.CA 94596 '� Y.. I SEVENTH CAUSE OF ACTION 2 Intentional Infliction of Emotional Distress (Defendants DISTRICT, BROOKSIDE, MOODY 3 and DOES 1 THROUGH 35) 4 64. Plaintiff refers to Paragraphs 13 through 21, 5 inclusive, and by such reference incorporates them herein as though fully set forth. 7 65. At all times herein mentioned defendants DISTRICT, 8 BROOKSIDE, SPECTRUM, MOODY and DOES 1 THROUGH 35, and each of 9 them, refused to provide any medical services to Plaintiff, 10 despite the fact that she was at or near a full term pregnancy 11 and experiencing labor pains, as hereinabove alleged. Rather, 12 said Defendants, and each of them, told Plaintiff to seek care at 13 another hospital, as hereinabove alleged. 14 66. At all times herein mentioned, as Defendants, and each 15 of them, fully aware that Plaintiff was without transportation 16 and had no funds, refused to make any arrangements to have 17 Plaintiff transferred to MERRITHEW via ambulance despite 18 Plaintiff's requests that they do so. Rather than make such 19 arrangements, Defendants advised Plaintiff to find another form 20 of transportation, or specifically to take a taxi cab, as hereinabove alleged. Defendants and each of them, reluctantly 21 22 made arrangements for ambulance transportation only after a 2-1/2 23 hour wait, and only when it appeared that Plaintiff could not 24 arrange any other transportation, as hereinabove alleged, and 25 would deliver her infant in the waiting room, if arrangements 26 were not made immediately to transport her to MERRITHEW. 27 67. At all times herein mentioned, Defendants DISTRICT, BROOKSIDE, MOODY and DOES 1 through 25, and each of their LAW OFFICES OF 2g 75 CIr.E AO.STE 70 V IL NUT CQEEK.Ca 94596 1 conduct, as hereinabove alleged, was malicious, extreme, 2 outrageous, wanton and outside the bounds of all decency, 3 motivated by an invidious class based animus toward Plaintiff 4 because she was an unemployed, indigent black female with no 5 apparent resources to pay for hospitalization. Said actions and conduct were undertaken with the purpose and intent of causing 7 Plaintiff to suffer humiliation, mental anguish, severe emotional 8 upset and mental distress and with a complete, conscious and 9 callous disregard for Plaintiff's physical health and mental well 10 being and the physical health of her viable fetus. 11 68. At some point following her arrival at MERRITHEW, 12 Plaintiff experienced a profound sense of shock and emotional 1; trauma and distress when she could no longer sense any fetal 14 movement within the womb. At that point Plaintiff perceived that 15 her baby had died. 16 69. As a direct and proximate result of Defendants, and 17 each of their extreme and outrageous conduct, and the sensory 18 perception of the death of her child, Plaintiff has suffered and 19 continues to suffer humiliation, degradation, guilt and severe 20 mental anguish and emotional upset all to her damage, according 21 to proof. 22 70. The hereinabove alleged acts of Defendants, and each of 2; them, were willful, wanton, oppressious, malicious and motivated 24 by an intent to discriminate against Plaintiff. Such acts 25 justify an award of punitive damages against each defendant in 26 an amount sufficient to punish Defendants and set an example for 27 others. 28 WHEREFORE, Plaintiff prays judgment as hereinafter set Iuw OFFICES OF _ "ACCINI L 111'T7\ _ •LVINE PC.STE.704 -17- +v i CREEK.CG 94396 I forth. 2 EIGHTH CAUSE OF ACTION j Negligent Infliction of Emotional District (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 4 MOODY and DOES 1 through 35) 5 71. Plaintiff refers to Paragraphs 13 through 21 b inclusive, and Paragraphs 65 through 67, inclusive, and by such 7 reference incorporates them herein as though fully set forth. 8 72. At all times herein mentioned, Defendants. DISTRICT, 9 BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and each of 10 them, knew, or in the exercise of reasonable care, should have 11 known that their refusal to provide Plaintiff and her viable . 12 fetus with medical care and treatment, and arrange for 13 transportation to MERRITHEW, as hereinabove alleged, would cause 14 plaintiff to experience severe emotional distress, mental anguish 15 and humiliation. 16 73. Defendants, and each of them, nevertheless, refused to 17 provide Plaintiff and her viable fetus with any medical care and 18 treatment, and refused to make immediate arrangements for 19 Plaintiff's transportation to MERRITHEW, as 'hereinabove alleged. 20 74. At some point following her arrival at MERRITHEW, 21 Plaintiff experienced a profound sense of shock and emotional 22 trauma and distress when she could no longer sense any fetal 23 movement within the womb. At that point, Plaintiff perceived 24 that her baby had died. 25 75. As a direct and proximate result of Defendant's, and 26 each of their refusal to provide Plaintiff and her fetus with any 27 medical care or treatment and the sensory perception of the death 28 LAW O«ICES OF 25-LP-,f Q0..S7,E 104 •k--Uv CCE£..CA 94596 4 `y I of her child, Plaintiff has suffered and continues to suffer 2 humiliation, degradation, guilt and severe mental anguish and 3 emotional distress, all to her damage, according to proof. 4 WHEREFORE, Plaintiff prays judgment as hereinafter set 5 forth. 6 NINTH CAUSE OF ACTION 7 Medical Malpractice (Defendants COUNTY and MERRITHEW 8 and DOES 36 through 45) 9 76. Plaintiff refers to Paragraphs 13 through- 21, 1� inclusive, and by such reference incorporates them herein as 11 though fully set forth. 12 77. Plaintiff is informed and believes and thereon alleges 13 that Defendants COUNTY, MERRITHEW and DOES 36 through 45, and 14 each of them, breached their duty of care as health care 15 providers by failing to perform all procedures necessary to save 16 the life of her viable fetus, including, but not limited to 17 performing a cesarean section delivery rather than a vaginal 18 delivery. 19 78. As a direct and proximate result of Defendants COUNTY, 20 MERRITHEW and DOES 36 through 45, and each of their failure to 21 perform a cesarean section delivery, Plaintiff's child was 22 stillborn. 23 79. . As a direct and proximate result of Defendants, and . 24 each of their failure to perform a cesarean section, Plaintiff 25 sustained profound shock and injury to her body and nervous 26 system, all to her damage, according to proof. 27 80.. As a further, direct and proximate result of Defendants, and each of their failure to perform a cesarean LAW OFFICES OF 28 -AMRAI'('INI lRI•TT! 715 ALPINE AO_STE.2a -19- •ALNUTCPEE^.CA 94596 I section, Plaintiff has suffered and continues to suffer extreme 2 mental and emotional upset and distress, all to her further 3 damage, according to proof. 4 81. As a further, direct and proximate result of 5 Defendants, and each of their failure to perform a cesarean 6 section, Plaintiff has incurred hospital and medical expenses all 7 to her further damage, according to proof. 8 82. As a further, direct and proximate result of 9 Defendants, and each of their failure to perform a - cesarean 10 section, Plaintiff has incurred funeral and burial expenses, all 11 to her further damage, according to proof. 12 WHEREFORE, Plaintiff prays judgments against Defendants WEST 13 CONTRA COSTA HOSPITAL DISTRICT, BROOKSIDE HOSPITAL, SPECTRUM, 14 INC. , PHILLIP MOODY, M.D. , COUNTY OF CONTRA COSTA, MERRITHEW 15 HOSPITAL, and DOES 1 through 50, and each of them for: 16 First Cause of Action 17 1. General damages according to proof; 18 2. Special damages according to proof; 19 Second Cause of Action 20 3. General damages according to proof; 21 4. Special damages according to proof; 22 Third Cause of Action 23 5. General damages according to proof; 24 6. Special damages according. to proof; 25 Fourth Cause of Action 26 7. General damages according to proof; 27 8. Special damages according to proof; Uw OFFICES OF 28 "ARRAt CINI A. NJ- T� _�O_ 75 ALPINE QO_STE 2W -L-UT CQEEK.CA 94596 L I Fifth Cause of Action 2 9. General damages according to proof; 3 10. Special damages according to proof; 4 Sixth Cause of Action 5 11. General damages according to proof; 12. Special damages according to proof; 7 Seventh Cause of Action 8 13. General damages according to proof; 9 14. Special damages according to proof; - 10 15. Punitive damages in an amount sufficient to punish 11 Defendants and set an example for others; 12 Eighth Cause of Action 13 16. General damages according to proof; 14 17. Special damages according to proof; IS Ninth Cause of Action 16 18. General damages according to proof; 17 19. Special damages according to proof; 18 Each Cause of Action 19 21. Cost of suit incurred herein; 20 22• Attorney's fees, according to proof; 21 23. Prejudgment and postjudgment interest; 22 24. Such other relief as the court deems just and proper. 23 DATED: December 22 1987. 24 LAW OFFICES OF MARRACCINI & BUTTS 25 26 G!eIDE I. BUTTS 27 Attorneys for Plaintiff LAW OFFICES OF 28 u♦It 9 AC( IN$l 111'77% :2 5 At.VINE RO.STE 204 X21- ALNUT CREEK.CA 94596 "ISTRATIOW FORM INPATIEV ADM ISSION/OUTPATI ENI P NIT NO PREADMIT BY ADMIT B CONTRA COSTA COUNTY HEALTH SERVICES F r 4 PATIENT NUMBER 71T DATE ADMIT TIME FC PT IWARDIROOMfEYEE) ACC ]SERVICE BIRTH DATE AGE ISEX MAR rEL!GI0N N;-: PATIENT NAME TEL NO. DRIVERS LIC.NO. ETH � ri rn 1 415 PATIENT ADDRESS OWN/RENT HOW LONG DIVIDATIEf"M50 -t j 1*1 N %,- -'. 7 i I)Is f t-'- "PiN P(li'Ll"I L. 4 "'1 I A--.- -:j I J OL, EMPLOYER(NAME OF 004 OW LONGI MP.TEL NO. OCCUPATION PA IE SOC.SEC.NO. EMPLOYER ADDRESS STREET CITY STATE ZIP VETERAN? INDUSENT?TRIAL OUIRY? ACCID fv N DOCTOR NO. DOCTOR NAME REFERRED BY PATIENT'S MAIDEN NAME MOTHER'S MAIDEN NAME 1. 76 P()Nrl . I\fluf3Ei RT "RANT -31<1w SP.-PARTY FIRST NAME &NIT. LAST NAME RESP.PARTY SOC.SEC.140. RESP.P IARTY TEL NO.DAY/EVENINGt. 0 W 0-o 14NA GRANt 5154.�l I 5,141n, All' RESP PARTY ADDRESS STREET CITY STATE ZIP OWN/RENTrONG7 IRELAT.TO PATIENT VALUABLESE TE7 4104.-MISSYON :3T-?44 !3AN' P.ABL.0 CA 94-.0 3 RESP.PARTY EMPLOYER(NAME OF C04 OCCUPATION FLOW LONGI JEMPLOYEE NO. DRIVERS LOC.NO. 40NE NONE ADDRESS STREET CITY STATE ZIP BUIS.TEL NO. REF.(I.E.CREDIT CARD INFO.ACCT.N0) INWRAPOCE CO.NAME SUBSCRIBERS NAME CERT.NOJMEDICARE GR MICARE? CO.NAME SUBSCRIBERS NAME CERT.NO-IMEDICAL GROUP NO. M/CAL? AOmfrnNd DIAGNOSIS PRIOR STAY(WITHIN 60 OAYS9 NAME OF FACILITY • ADMIT DATE DISCHARGE DATE EMERGENCY CONTACT TEL NO... HOW BROUGHT TO HOSP. PRIVATE SMOKER? MED.M ED JUSTIFIED? to,R'c'- 4 ALN I Wau ICD-9,CM CODES DIAGNOSES PROCEDURES . 7 T DISCHARGE WITH APPROVAL AMA DIED OTHER HOSP SKILLED NURS.FAC. INTERMED.CARE FAC. HOMECARE STATUS ❑ TRANSFERRED: . - 0 .o 1-1 El AUTOPYES NO WHOLE BLOOD PACKED RED CELLS . CORONER-S NUMBER OF -84) El EJ ICASE ITRANSFUSIONS T 01(6 CH EXHIBIT . - t A!%11�SION ' MF'v1(.,'.l'` .%`t- i„+ ..•,t ntrrs.cA of psychiatric treatment mcludingX.riyexarrtinstion,laboi I +� my iv,: s:.,:,;'• r„,c icor,.• i •i,.t:.• i •.,.. .I rran•:nsions anti psychiatric testi49 as may be considered advisable or necessary p ”' U,. au,.nn,•,.: n.:•.•.,c:,• . ...,.• •:•r,iyt. ..e... •• ..,iu,t,n.:m.<i:ad studen4%and physician residents-and personnel assigned-by•the..hospua NURSING CARL: 1 unne,st.n d tt,at ties hUprtal I'!;,. Ci—Only aene,at duty nursing care unless the.physici;n orders more intensive nursing care t i be provided for ilie patent o, ,I the patient's conditw•r is sucn as to need the service of a special-duty nurse or attendant:'- - - - -. TEACHING PRUGRAM: 1 understand that this hospital ,s.) teach,ny institution and that unless the hospital is notified to the contrary in writing, may participate as a petieni in the medical education prout.im of this institution. •+ 't PERSONAL.VALUABLES: 1 understand that this Itcisli,tal maintains a safe for the safekeeping of money and_valuablesand.ibai.thehaspital she not be liable for the loss or damage to any"money, jewelry,documents. tuts;or other articles of unusual value or any other pet'sttnel`property U• >, less deposited in the safe. NEWS RELEASE AND RESPONSE TO INQUIRIES. I understand it is the policy of Contra Costa County Health Services to release upon inquir + unless otherwise requested by the patient, parent or conservator,the following information:Patient's name,address,sex,age,reason for admission 'general nature of injury and .. -- - _iiia .. _. __ . ,_. ____; g j y general condition. No information is released for patients being treated (or a-psychiatric condition, or.�•drug al. alcohol abuse unless specifically authorized by the patient. L -.__ __ iiia . ---- -- -- - - - ._ •.;t-r ,.[ :"'4 1. -•�_ y• - _. -- l,/.:,•:p:•.- :.,-.,;,._".'`7,.. .. J :.,i ... - :6-MAN, ; :'i1W. :,.rAL'-i 2A!i' P4:,sCr7�ii4 + CONSENT TO PHOTOG�.APH:The Hospital is permitted.to take pictures of themedical or surgicalprogres introlirirty the Patient and to '+for uieritific,&ducationa�or-Tesearch purposes, ' :` y 'ia•"'n_„ '..�.� .__:'t_-.-�._'t' ''Nc,.;•. ,.,'. .__.. .—_. -. iiia. iiia_ --- T�aHTZ ° ,.ty�-.t783 -'d 's LEAV iNG HOSPITAL AGAINST ADVICE:in the event the Patient elects to leave the.Hospital against-the'adviFe of a physician and the Hospit .__,the PatienLreleases all-phvsiciansand the HospitaLirom all responsibility and any.il"ffecii vii ismaysasultJ1 �,ch action.—,---- S; ::>:-• +. it -t5I ::-I%IA4,bi .:riv)r.pA�.}.ya - DRUGS: It is imperative that the Hospital at all times be aware of the!Patient's intake.Accordingly.;fatientshall neither,tise not keepany'.'drtig' drug appfiancs/apparatvF7ot prescribett by or on:beh;If,ot'the Astending-Physictwn and-disperifold-i3j/'th"otpitM'-durivMPatign1V.CUrr_•, FINANCIAL A EEMENT:-'} mise to reimburse the County-of Contra Costa foran fto a xar ndmedi®I sertiiee vtded a t v r v C' promise Y'. .�,.. not covered by Medicsre;'Medi-,Cal, insurance or other health care compensation carrier. Payment.will bi at the rates established by the Count Board of Supervisors. 1 will use any damages or indemnity due tire,from the injury or illness_which necessitatedthis caree'to reimburse the Cout j _. _. _ . _ iiia. _ -. ... -- — - - • - - - - -- — - -- - - 1 up to the amount'bi}led'but not to exceed the rates set by the Board. �i ,.i,•••:` :;Ll,y�i_c s:+•:.2'.. f ' _RELEASE OF..JNFORMATION FOR.REIMBURSEMENT: 1_give.permission.to Contra Costa.County..Health Services-La.furnish-.informatic, d excerpts from m r ' • p y patient record to the extent necessary to determine'liability for payment and to obtain reimbursement. IhfOimation.mayArM elude that related to drug$alcohol or psychiatric conditions, and may be given to any person or corporation'which is or may be liable foltallol fny portion-of the hospital's eharge;,including but not limited to insurance companies,lreatth care-service plans-orworkers'eclttlpertsatfop:6aRia►{c-� . -' "'AUTHORiZATION TO.-RELEASE INFORMATION AND-CONSENT T0RELEASE1V1ED1-CA1-LA13ELS - _. . 00 1 atth�zt.$optipcf-sta Department gf,'S-ocij§ervmws to release information concerninA�e status of my Medi-:al application,and.to send.aTy h "Medi-Cal labels-To Contra Cosu Health Services Department. +. . ;*f+ ASSIGNMENT OF BENEFITS: I outhtiiiie any insurance company or carrier through which l'may.have•eoveragetO:make dtrtttcf Payrnt3nt of ,;)benefits,to Contra Costa Courcy Health Services,an amount not to exceed the1-iospital's regular charges for this,.-period of service_A Riotocopy.of �yY ? 3his authorization shall:be considered as effective and valid as the original. I authorize the Attorney,Claim Adjustor, Insurance Company or any Person(s),Company or Corporation who may effect a settlement or payment of my claim far damages or indemnity arising from the injury or illness which necessitated this hospital care and)or services to deduct the amount of the charges of these services from'sum due me and to pay that amount directly to Contra Costa County and 1 assign from that amount all or any portion of it which is necessary to pay those charges. I waive the statute of limitations on this matter for a period of 10 years,This agreement and waiver is binding on me,my heirs,assigns,administra- K ., tors,and executors. WHERE MINORS ARE INVOLVED, THE FOLLOWING PREVAILS: . AGE OF CONSENT: : 1. The-consent of a parent or legal guardian is required if the patient is unmarried and has not yet attained kis or her 18th birthday., 2. If a patient under 18 years of age has contracted a valid marriage, regardless of a subsequent divorce or annulment, then the consent of a parent or legal guardian is not required. THE UNDERSIGNED CERTIFIES TO UNDERSTAND AND AGREE TO THE FOREGOING, RECEIVING A COPY THEREOF,AND IS THE PATIENT, OR IS DULY AUTHORIZED BY AND ON BEHALF OF THE PATIENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS i PERSONALLY AND UPON PATIENT'S BEHALF, C \1 w SNATURE OF Pa.Rr%—, UR PAIIENT'S AG .N7 REL 4TIC)NSttty TtlPATI4:r;+t A C::p, n r, .,. .. .. , ... • j• ... �. .. ... ... iiia .. ,• , 1':7'x.:'i! .::•..::I�• r• i;( Tune of sggning Date:... By y INPA 'ENT MEDI-DATA ENTRY FORM Last Name First • Medical Record No. Pa tcom No. Sex DOB �, '7- F-S3 :.. Admit Date Discharge Date I'{ Race y Attending M.Ddin ... ,. g Source of Admit . Admit Type Readmit .. Discharge .a .. Status Autopsy Coroner Transfusions EJB PC Plasma ' Complications k1.) Transfusion` Rx (2) Infection (3) Stillborn t (4) Reoperate/OR Complication IAGNOSFS ICD-CM (5)Adverse Rx Reaction (6) Cardiac arrest resusitated • PROCEDURES (7) Anesthesia , Code Unit Days �,— Tissue PRIM. SERVICE T 01HER SERVICE Tics le OIIER SERVI . o-, . Admitting Tissue w; Resident Consul tan t Tissue Asst. Surg Tissue - k � I Tissue Distribution • Initia ' Dt Original : Data Entry Arra lZed Copy 1 : Chart ® Abstracted ® Amlyzed Entered -363 CONTRA COSTA COUNTY HEA!.TH SERVICES MERRITHEW MEMORIAL HOSP: AND CLINICS D E A T H P R O C E D U R E • PHYSICIAN GUIDELINES, AUTOPSY CONSENT, AUTHORIZATION TO RELEASE REMAINS AND RECEIPT OF REMAINS PLEASE CHECK APPROPRIATE BOX: Q Inpatient Death Q Dead on Arrival _ Q Emergency Room or Fetal Death Patient ID Outpatient Death ti M Record date and time of PATIENT PRONOUNCED: "3 5��� is PM death in Progress Notes Date Time DID PATIENT OR DOES NEXT OF KIN WISH TO MAKE AN ANATOMICAL GIFT? Q' YES Q NO t...: If YES, see Merrithew Memorial Hospital and Clinics Policy No.554a b Form MR-361 fbr guidelines &-consent form. • Coroner's case: Coroner must also consent to anatomical gift. Outlined on the reverse side DOES THIS CASE REQUIRE REPORTING TO THE CORONER? is a summary of the classes of deaths that are required to be reported to the Coroner Q YES: 1. Call Coroner (x2406): AM *Date called Time PM *Spoke with CORONER ACCEPTED CASE? Q YES Q NO Comments NOTE: If coroner refuses case, go to Item Al in 'No" section--b—el—ow. 2. Notify Family: *Name of relative or friend called AM *Date called Time PM 'Time relative/friend will come in NO: 1. Notify Family: If unable to notify family, go to page 0, *Name of relative or friend called AM ,Date called Time PM -When relative/friend will come in 2. Meet with family and request auto s : •If an autopsy is refused, a state the cause of death' on the typed death certificate and b sign the death certificate. 'If family agrees to an autopsy, obtain appropriate signatures on "Consent for Autopsy"--see reverse s1de of thi$ form. Page 1 �3�86) Physici s Signature CHART CLASSES OF DEATHS REPORTABLE 70 CORONER (See also She 'f-Coroner Guide which is on ea ward. ) t' 1. All violent, sudden and unusual deaths. 11. Deaths known or suspected as due to -2. Unattended deaths. contagious disease and constituting a 3. Deaths wherein the deceased has not public hazard. been attended by a physician in the 20 12. Deaths from occupational diseases or • days before death, occupational hazards. 4. Deaths related to or following known or 13. Deaths under such circumstances as to suspected self-induced or criminal afford a reasonable ground to suspect t; abortion, that the death was caused by the 5. Known or suspected homicide, suicide or criminal act of another. accidental poisoning. 14. Deaths reported by physicians or other 6. Deaths known or suspected as resulting persons having knowledge of death in whole or in part from or related to for inquiry by the Coroner. accident or injury either old or recent. 15. Sudden infant death syndrome. 7. Deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug ** In addition to the above provision of addiction, strangulation or aspiration, the Government Code, the Health and X 8. Death in whole or in part occasioned by Safety Code adds another category of criminal means, coroner's cases, namely, "If a phy- ` 9:. Deaths associated with a known or sician is truly unable to state the alleged rape or crime against nature, cause of death, he/she may refer the 10. Deaths in prison or while under sentence, case to the Coroner." - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CONSENT FO. R AUTOPSY I authorize Merrithew Memorial Hospital and its medical representatives to perform an autopsy on the remains of 6.(a,,,tk to confirm the cause tient s name of death and nature of the disease process, and to remote and retain any structure _ or organ, including eyes, for study and diagnosis and other scientific purposes. Tv�c(c.c�(.i v/ �1...-c��+-moo Sv�..-e S-f�-r�-:�r �-•� ..r�L.7 -� �e.,.e�h L dL�,�.�5 The undersigned states that she/he is legally entitled to give authorization for such autopsy on the deceased named above, and hereby releases Contra Costa County, Merrithew Memorial Hospital and members of its staff from any liability arising out of the performance of such autopsy. _ AM 3 - Z'-10 PM \ Date Signature of person giving p rmission Phone consent for autopsy & release 0q,\ r of remains to mortuary must be fol- Relationship to deceased lowed by telegram sent to hospital COLLECT--to Nursing Administration (415) 372-4254 Signature of witness When telegraph office phones in the consent, message is to be heard by two. UT persons, documented on plain paper, dated and signed by both Person notifying pathology) parties and attached to Consent for Auto s . Tele ram will arrive later MR-211 Page 2 (3/86) '` } PATHOLOGY REQUEST 3t fM-CODE. ...;f... / w,-�.. - 'CODE• - �Os�� �• Y ;. i' 3^•f '8 PATIENT I.D.ImWint Area must be readable on al!cools CLINICAL SUMMARY PREOP."DIAG. POSTOP. DIAG. ``SPECIMEN OF f q C Qh 9 r�K A_rIh•e. LJ�k I V�� EXCIMC* -' _ BIOPSY PREVIOUS PATH.NOS. SIGNED M.D w ,t • GROSS DESCRIPTION: Specj=' consistsof a small round placenta measiaing. �� 16 cm-in diameter and 2.2 cm in thiclmess. It vieghs 496 grams. Umbilical cord is attached centrally and 23 ® in. 1 d 1 2 cm in diameter, -t y measures length an x, =Cut surface reveals threevessels. -fie amniotic membrane along the fetal surface appearssomewhat grayish tan opaque and slight yellowisht tan discolortion ,; . consistent with meconium staining is present. Maternal surface is intact, shwoing inksih red matted cotyledon, There is a small amount of retroplacental p ty blood clot weighing 30 grams, approximately. Fetal membrane is grayish tan and Y•�t-'.. scmadiat opaque. Representative section are submitted. �.'.4a.`• .. .; . per.:?•' D: ..3/6 T: .3/6/87 ^AAA ,. : MICROSoOpIC .D1SCRjF=Mi.. Sections reveal texm placenta.mDade up of small nature E r= and well"vascularized chorionic yiilli. . There is diffuse and quite extensive .: neutropblic infiltration associated with fibrin material deposition in, the ,= plate of the fetal surace. ' Extraplacental fetal mP..mbrape Also show ' :.,.;diffuse neutrophilic infiltration. Section of the umbilical coxa.,shows ne:UM- F" • philic infiltrationof all t$xee vessel walls as well as in the adjacent Riarton t$ *jelly, ' r, •• 'Y.._ ..Lit1A7L�W J�7 TEM LIACENTA `, •tl,s {y Aam auRM9141ma= wriH A= .trmiucAL ANGITIS AND CIroHarm PAS=DOE; �37bT* 3/16/87 fIItK:ek�=- '•:`}•f,;fz: :: (`mow CONTRA C09TA.COLINTY HEALTH SERVICES-PATHOLOGY LABORATORY M.O. ^` PATHOLOGIST PATHOLOGIST ,c.�. HYE-KYUNG.1CIt�'M.D. IRCHG 402(s/> ;`' T)P V7V 1 rFiYSIC1AN. ;;;r ` , AUIDP"Y; 6 A 8! GW?Z, BABY BOY (4568437) FUM MI. DOB; 315/87 X 'PROCEDURE-=' '< ' _ ' DAA 316/87 AUTOPSY, GROSS ONLY AUTOPSY, INCL.CNS GROSS ONLY . AUTOPSY, EXCL.CNS GROSS AND MICROSCOPIC _ ►ATIt MT I.O.AntA YYf "t ADAsLt ON ALL COr16 t. :..'' AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC PROSECTOR: _r.,, _J;W;. AUTOPSY,SINGLE ORGAN STUDY Hatmrd.Goldman, M e D% EMW t, _ -. ' ' '-may a t.• .. - 3 i GROSS E � LY`W -No ; E��TERN�,I. M4MIWI0Iq. 7lie Body is ''that..of a ara:ll developed male. te='fetus wei 2.15 k Mere %s lmoldin of the head and facial.ec ses ;. . per. -ticu�y cIa the right side... Ecchygmoses are also prominent nth ri&ht upper _ .. limbs andlateral aspect of the lower .limbs, as well as over the .anterior .chest.. Eyes are urernariCable, as a;ethe ears; there is no Potter. s facies. The bonynose and nares. are well developed;; as are the lips; there is no hare- lip. Opening the mouth reveals normal buccal uccosa and gingiva There. is no cleft palate and the 'tongue is normally.-formed. 'Five normally developed digits are present on both I=ds and.Both feet;;' there is no equinovarus or other lower limb deformi_ty.` The external genitalia are normal, The anus is perforate. There is a nromaTly developed vertgbral colu, :without: ` evidenceof spina. bifida or m)' gomyelocele. '• Il4E M:EX MINATIM. 7r a body:is opened by,the'usual Y-sbaped incision. The:;liver has the usual fetal. configuatim andis otherwise makable. The-7 small..aid::large bowel are-noxmally developed;. there...is no'-malrotation. fter "dissection there is no evidenceof retroperitoneal testis and on pal-, patios, two testes are felt in the scrotum. . The spleen has the usual fetal ` `configuration and on cut section is unremarkable. The stomach is unremark- "; `r'able, Pts are the noreal-appearing head, body, and tail of pancreas. The right.and left kidneys have the usual fetal configuration, with typical fetal adrenal lands • �.-::•. g Sectioning them reveals normally developed left and right cortin®:dullary structures of both kidneys and both adrenals. Opening the rhes t cage reveals a nor=1-appearing fetal thymus with sym- metrical ym- •metrical right and left lobes. The 1 are atelectatic, with-erythematous sings ppleural surfaces. 7hree normal right lobes and two normally developed left lobes,are present. Opening the pericardial sac reveals a normally developed Y.four' ered heart with the usual fetal great'vessels. On opening there is no evidenceof septal defect. A Incising the scalp reveals Opening the skull als no noteworthy scalp hematoma. with oras g Parasagittal dissection reveals no evidenceof epidural, subdural or �TY arachnoid hemorrhages. Neither is there evidenceof Hemorrhage inthe region of the falx. The hemispheres have the usual fetal configuration with normal appearing sulci and gyri. There is no evidenceof microcephaly. Representa- tive" tissue is fixed in the event of future need. CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY l�'� '�N PAGE 2 HYE•KYUNG KIM,M.D.,PATHOLOGIST p IRCHG-403 (5183) PHKSICIAN:; ;; ` AtTMM- 6 A 87 DRAW, BABY BOY (4568937) X PROCEDURE"' �:-s ;,. M.D. AUTOPSY,GROSS ONLY PAGE --2- . AUTOPSY, INCL.CNS GROSS ONLY AUTOPSY, EXCL.CNS GROSS AND MICROSCOPIC •ATICMT I.C.ARM^MUST Wt RtAOA•Lt ON ALL C0.19S. AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC PROSECTOR: .- ?�`'""' AUTOPSY,SINGLE ORGAN STUDY x:.i. , • i. DTAMSTS: ANAZCMIG41LY NMM TEES!ME FENS (STJIILBMH) D: 3/71 T: 3/1-1/87 �.; HG,sk ,.w D. ATHOLOGLST v�;F 4r CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY HYE-KYUNG KIM,M.D.,PATHOLOGIST PHYSICIAN AUTOPSY: 6 A 87 r GWIT, BABY BOY aD. 4568937 X PROCEDUREDOB: 3/5/87 DOA: .3/6/87 AUTOPSY,GROSS ONLY AUTOPSY, INCL.CNS GROSS ONLY AUTOPSY,EXCL.CNS GROSS AND MICROSCOPIC PATI<NT 1.0.AAKA NY{T■■P9AOA8L•ON ALL COPIft. AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC PROSECTOR: _•. rte`- AUTOPSY,SINGLE ORGAN STUDY HC7WdId GOlcn M :D. `•' gib: . E =PR - _ '':;::. . .;. •� ... .,, it-: *MENDED GROSS EXAM NAT33ON thew of_the 2.15 kg weight, this fetus is`tecbaically.prematute. ' X MMED GROSS DIAMOSIS: ANATMaMLY NORMAL PR jv%N -r Mt-r =S (STITiLBnM : _. Di- '3/23 T: .3/23/87 HS:sk y' = ; fHOWARD GIflM`?AN, M.D. PATHOIAGIST CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY HYE-KYUNG KIM,M.D.,PATHOLOGIST IRCHG-403 (5183) S CON'T'RA COSTA COUN'T'Y HEALTH SERVICES Name: BIRTH CERTIFICATE INFORMATION WORM= Baby's Mother's • BABY'S NAME: (Fir ) ( dle) (Last) MOTHER OF BABY Q%*Lldl �� ?-' •=" (First) (Middle) (Maiden, Name) Address• '�•r� City: w: ,. ,} Zi Code• D County: +rxr�+-�- P C� ed State•• w` .'State of Birth• �l.� el.Q� Ager Usual Occupation :E Kind of Business or Industry - y Y • ` FATHER OF BABY ' Name. First). (Middle) ( st) State of Birth- - Ager Usual Occupation: Kind of Business or Industry 4 OTHER CHILDREN OF THIS MOrIfIER NLanber born alive: , (Do not count this baby) Date of last live birth: Number of children born alive but now dead: C7 -; Date of last termination (miscarriage) Before 20 weeks: After 20 weeks,: first day of last normal menstrualperiod• < .:During what month of Pregnancy was prenatal car begun: <: T�'.xF•...SIQQATURE OF MOIHER; -- Other info_rrmant DO NOT WRITE BLOW THIS LTNTE SE{• - DATE OF BIRTH: ` - v~- � DELIVERED BY• f � �✓ 7'12'E OF BIRTH: WEIGHT AT BIRTH: J /� INITIA9 _ t • ., Sta`t,�,*f California—Health and Welfare Agency Department of Health Services SELF-IDENTIFICATION WORKSHEET FOR THE CERTIFICATE OF LIVE BIRTH Name of Child Name of Mother• , "� (ITEM 18) IS THE FATHER (check ONE box): (ITEM 21) IS THE MOTHER (check ONE box): ❑ White ❑ Cambodian ❑ Guamanian O White ❑ Cambodian ❑ Guamanian 1@(61ack or Negro ❑ American Indian ❑ Samoan Black or Negro ❑ American Indian ❑ Samoan C'J Japanese (Specify Tribe) ❑ Eskimo O Japanese (Specify Tribe) ❑ Eskimo O Chinese ❑ Aleut O Chinese ❑ Aleut ❑ Filipino ❑ Asian Indian O Other (Specify) ❑ Filipino ❑ Asian Indian ❑ Other (Specify) O Korean ❑ Thai ❑ Korean ❑ Thai O Vietnamese ❑ Hawaiian O Vietnamese ❑ Hawaiian (ITEM 19) IS THE FATHER OF SPAN ISHJHISPANIC (ITEM 22) IS THE MOTHER OF SPANISH/HISPANIC ORIGIN OR DESCENT (check ONE box): ORIGIN OR DESCENT (check ONE box): . .�<gNo— (Not Spanish/Hispanic) No— (Not Spanish/Hispanic) Yes— Mexican/Mexican-American/Chicano O Yes—Mexican/Mexican-American/Chicano L O Yes— Puerto Rican ❑ Yes—Puerto Rican ❑ Yes—Cuban ❑ Yes—Cub;M Yes—Other Spanish/Hispanic (Specify) O Yes—Othel Spanish/Hispanic (Specify) :a.v' These items may be left blank;however,this information is essential for determining the health problems of these groups within California. Enter This Information On The Certificate Of Live Birth (Form VS 10). VS 108(1182) r CERTIFICATE OF FETAL DEATH STATE'VILE NUMBER STATE OF CALIFORNIA LOCAL R[G14TRATION DISTRICT ANO C[RTVICATE NUMBER IA.NAME-FINST 118. MIDDLE N IC.LAST THIS BABY BOY mmn GRANT FETUS 2. SEX 3A.THIS DELIVERY,SINGLE.TWIN,13B. IF MULTIPUL THIS FETUS 4A. DATE OF DEUVERY--MONTH.OAT, Y[ARIAB. HOUR(216 HOUR CLOCK TIME) ETC. 1 1 ST,2NO.RC. 1 Male Single -- March 5 1987 ' 0212 SA.PLACE OF DELIVERY-NAME OF HOSPITAL 138. STREET ADDRESS ISTR"T.NUMBER.OR LOCAT10N1 PLACE E Merrithew Memorial Hospital 2500 Alhambra Avenue SC.CITY Oq TOWN Tao.COUNTY DELIVERY Martinez Contra Costa GA.NAME OF PATHER-FIRST I BB. MIDDLE 16C.LAST 7.STATE OF BIRTH B. AGE OF FATHER ,. ;`,FATHER Clyde % ' mmn ' Neiley CA 44 ,,. 9A. NAME OF MOTHER-FB1ST 188. MIDDLE IAC.LAST IBMmINAME) 10.STATE OF BIRTH 11.AGE OF MOTHS +rh 11AOTHERAnna ' Ernestine 1, Grant =T7( 33 #t. 124 PHYSICIAN OR BONER-DEGR[[OR TRtJt ANO TYP[p NAM[ 1 128. DATE SIGNED .'� CERTIFICA- I CERTIFY THAT THIS 1.WAS BORN DUD AT THE HOUR.OATS AND PLACE STATSD AND /� 1 ON PROM THE CAUSES STATED. / Sarah t,v M.D. ! �160 6 7 13.DISPOSITION e a i ne for �*E rMONTH.D Y,TEAR NAM D ADD ESS OF E,2y �E ET RY ORS CRE ATORT uNERAL Merrl Tf1ew emori a F os tai" RECTOR Scientific purposes 03/05/1987 1 2500 Alhambra Avenue. Martin 7. CA 94SSI AND 16 NAME OF PUNERAL DRI[CTOR NOR PERSON ACTING AS SUCH) 17.LOCAL REGISTRAR-SIGNATURE 16.DAT[ACCEPTED ST LOCAL REGISTF *-_ LOCAL .REGISTRAR Merrithew Memorial Hospital. 19. FETAL DEATH WAS CAUSED8Y ENTER ONLY ONE CAUSE PER LINE FOR A.8 AND C .Z PETAL OR MATERNAL CONOI- IMMEOIAT'E GAUSS c(iN f/L W1 -///jc/� es` O TION DIRECTLY CAUSING (AI PETALDEATM. VE TO..1 OR ASJA CONSEQUENCE�OF J /' ca CAUSE PETAL AND/OR MATERNAL IB) [,'ICL�L�,tk I//- GOF CONOTTIONS. K ANT. WHICH a'' .i.�t, GAVE MSE TO THE IMMEDIATE DUE TO.OR AS A CONSEQUENCE OF DEATH CAUSE. STATING THE LL UNDERLYING CAUSE LAST. ICI Z" 20.OTHER SIGNIFICANT CONDITIONS OF FETUS OR MOTN[R--CONTRIBUTION TO FETAL DEATH BUT HOT RELATED TO CAUSE GIVEN 1N 19A. 21.AUTOPSY ISPECIFY YES OR NO) yEs 22- RACE/ETHNICITY 23. SPANISH/HISPANIC 244. USUAL OCCUPATION 2410. KIND OF BUSINESS OR INDUSTRY ?.�F�d+ Ys FATHER - i:�G; BlacknQne IVU none NO 1 .' Yt 25. RACE/ETHNICITY 26. SPANISH/HISPANIC 27A. USUAL OCCUPATION 1 278.KIND OF BUSINESS OR INDUSTRY Black 1� ND Homemaker I Home OTHER 26A.RESIDENCE(STREET.NUMBER OR LOCATION) 12810. CITY OR TOWN I28C. STATE 1260.ZIP CODE 126E. COUNTY :� 1410 Mission Street #41 San Pablo CA 94806 Contra Costa 4 " I I I 29A.DATE LAST NORMAL MENSES BEGAN 1298. MONTH OF PREGNANCY PRENATAL 30. BIRTHWEIGHT 31. PREGNANCY HISTORY (COMPLETE EACH SECTIO OAT i YUR 1 CARE BEGIN(t5T.2NO •..8TH.I'll ^ ^7 UNE BIRTHS OTHER TERMINATIONS June 04 ' 1986 S L t`' GRAMS IDD HOT COUNT THIS CHILD E[CLUDE INDUC(D ABORTK ENTER THE APPROPRIATE CODE OR CODES FOR EACH ITEM 32 TMRU 36 32 CESAREAN SECTION HOW UVING NOW DEAD DEFORE 20 AFTER 20 (HUNT) (NU c"I -4 IMUMB[l1) WKS/MUNI FROM THE VS IZA SUPPLEMENTAL WORKSHEET.IF NONE CHECK-NONE L U :;MEDICAL NO w B C 0 D 0 1 D DATA 33. Cr ►U T-N,.OFF'PRE.TGNA�N�CCY�.AND CONCURRENT ILLNESSES 3A. BIRTH INJURY TO CHILD DATE OF VAST ALIVE BIRTH DATE OF LAST TERMINATIO A't xruk .-!r I-/uee OF /.'t�G'pp��������//� M11 I Ov 173AR MONTH 1 YEAR . 0, ❑ NONE �/7/�.. 16 x .:Q, 164( NONE E I 1 F I 35. CONPUCATIONS OF LABOR ANO DELIVER, 36. CONGENITAL MALFORMATIONS OR ANOMAUES OF CHILD <°K: . NONE `• _ NONE G rtk ." A. '.STATE B• G. D. E. F. cENsuS TRACT REGISTRAR v5.12 (REI/ 2-84) PENALTY FOR UNAUTHORIZED RELEASE. 5500 FINE 'OR SIX MONTHS IMPRISONMENT. 31713• 94-81620M' s U P W uri+ ti W p g L V r (n W o 1„ Yc N rAP WO ut 4'1 y x i oOL ,0�5 7E o g 2 '� ► pl d L z$ 0 wCD O�d L V d O p U r• 6 O x �L� x7 g y s • 'iA 'kj; P N Q 4" d+� D O ORu W U d iA, V' u1 • awc N LL <�! W p N W y Z < Z ac rn o. Y D .,. O O • Zop� s < x Nom+ o N O u- • * 2 `•. O L E !6 N W rto O Or k7c:t.� ,. u. � F © w = r O • t ,Tp p Yt u y St a;i:':rae t W i Q O A� Y �+ z Z r • 6 e �i 5' z u •:". ••� ¢ w t o � W u � g s, a •t o W u+ a p W x i, 1� TG ° s 0 5e N u a m D W W d O y e O x r+ S t'• `-' •i V Zk '� Z ? O y_ y 6 W r cc G7 ' O m J SA or 0 CnWr u► m O 2 •e 9 • N • N O to c ✓: ; J• m p p Jd Z 1 d L o e C •r '�' Q IV, w U' Os°s •.. Z Y x W L W °r, W N � d 6 D y^' �/S p'' Y, N t Y a'' /• Y ss W ut OC r r 6 ° y 6• i O �' p• N N++O O O ,y� O d ZN �j Z W P Wo. G G � Z • � C W y s v p � a`c r'•j; .".. 4j y� Y Z Sid 7112Ln 7 x 111 Z a O W W W4' d O • 'O 'Fr 'fj rte, M+ o'n o : ,=_• 0 < V SJ N W p' r p °,. W x ; Z '� • Zf L S+ g o g W ?a !as, a N D % W �i � ,. ' `^ E 4 .� O L O .moi'� a s•.'� t,;:.. � KS G � r S Z r d Z e C �' � • ,n W a V ki u. 1 Q S •. d W �, o 1r t f.' O too W ,"+'-',r.:...-r V fr w L r O W Z W x � � � • k✓ n o d a' Uk x y,1`+ W a V y e • w G Y " 0 P 1G iso t'2;'F". S d 2 G u- ° N W L •S L 44 a d J t J O `,.'ti.°...:. J D r S y 0 N W d • L x .r W V N r' •4;'I..F,tttrk;: y� N Z ♦ `�i y :` r Z 14, L • O q K. _k 1- 10 N < W Z ri:rt O v N m D W a Z U—, 0% O , 3 d 4 Z d ? a p �•, O p 9 d U a °r ° a, W O W G w C1 Q u cfl o .r- n p i1- a% O 61 y W S' W Z PATIENT NUMBER :DUST RIAL M D Er.ENCIENCY I/C MED,CA:RECORDS NUMBEf PRIV J Q o 60143053-1 PIO.ME) EF: MDS . . . 5-93-13 i" CcorPATIENT NAME(LAST,FIRST.MO DATE TIME IN SERVICE PTVFNi a: a GRANT.ANNA E 03/04/8 0 2138 ?�ik O ZADDRESS CITY,STATE,ZIP TELEPHONE SEX RACE MARITAL ST TUS = O 1410 MISSION STREET SAN PABLO CA94806 NONE F B LL RELIGION BIRTHDATE I AGE JBIRTHPLACE SMOKE PREVIOUDSAfESGMARGE LAST HOSPITAL DATE F.C. GHT IN Li N00 07/08/53 33 N P N EMPLOYED BY ADDRESS CITY,STATE.ZIP OCCUPATION TELEPHONE HOW LONG FAA5WE 10111101- EMPLOYED Y OJ NONE YES O NO O d GUARANTOR ADDRESS CITY.STATE.ZIP TELEPHONE RELATIONSNIP g DOCTOR WILL CALL GRANT.ANNA E SAN PABL0 CA 94806 NONE P.M.O NOTIFIED Q QEMPLOYED BY ADDRESS CITY.STATE,ZIP OCCUPATION TELEPHONE -,TOW LONG WILL RENDER TREATMENT m � EMPLOYED NONE O REFERRED TO ED PANEL BY; EMERGENCY CONTACT NAME ADDRESS CITY,STATE,ZIP TELEPHONE RELATIONSHIP PER K I NS.CHARLES C 1FbLQ OFFICERS NAMEINO. i,P�,•r�;;, IM PLAN PRIMARY INSURANCE COMPANY ADDRESS CITY,STATE,ZIP I IDENTWICATNrSS+ GROUP WPOLICY+/LOCAL UNION INSURED r, PATIENT SS IO 553-90-5349 INS PLM/ SECGIN NDARY SURANCE COMPAN:' ADDRESS CITY,STATE,ZIP GUARANTOR SS+ cooE PENDING MEDICAL .553-90-5349 Y IDENTIFICATION=+ GROUP+/POLICY+/LOCAL UNION+ INSURED F 1#-'L DATE TIME REPORTED TO ACCIDENT SITE PATIENTS COMPLAINT CLERKS NAME '. LILL TERM O.B. LN AUTHORIZATION: CONSENT TO ANY MEDICAL OR SURGICAL TREATMENT OR HOSPITAL SERVICES -_, RENDERED THE PATIENT UNDER THE GENERAL OR SPECIAL INSTRUCTIONS OF THE PHYSICIANS. AUTHORITY IS GRANTED TO FURNISH FROM THE PATIENTS RECORD REQUESTED INFORMATION OR EXCERPT TO ANY HEALTH INSURER OF THE PATIENT. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO BROOKSIDE HOSPITAL. CONDITIONS OF ADMISSION: THE UNDERSIGNED FURTHER AUTHORIZES THE RESPECTIVE COUNTY, STATE, AND/OR FEDERAL AGENCY TO RELEASE ANY AND ALL DOCUMENTATION AND INFORMATION RELATED TO MEDICARE ELIGIBILITY AND/OR BENEFITS, MEDI-CAL ELIGIBILITY, AND/OR BENEFITS AND PROOF OF ELIGIBILITY LABELS FOR BILLING PURPOSES, AND BASIC A�ULT CARE AND/OR =v: CONTRA COSTA HEALTH PLAN MEMBER ELIGIBILITY AND/OR BENEFITS, TO BROOKSIDE HOSPITAL .or AND/OR ITS AUTHORIZED AGENTS. 0 J FINANFIAL AGREEMENT: THE UNDERSIGNED AGREES, WHETHER HE SIGNS AS AGENT OR AS PATIENT, F- q THAT IN CONSIDERATION OF THE SERVICES TO BE RENDERED TO THE PATIENT, HE HEREBY O � = U. O INDIVIDUALLY OBLIGATES HIMSELF TO PAY THE ACCOUNT OF THE HOSPITAL IN ACCORDANCE Q a WITH THE REGULAR R ES AN TERMS O THE HOSPITAL. Y m' SIGNATURE X O s a O RELATIONSHIP Cr Z WITNESS X M Q CIVICn t71 CIVV I IVIC✓IV/•�L nL6sV n✓ i •J PATIENT NUMBER PROV. .G/INDUSI HIAL MD EMERGENCY MU MEDICAL RECORDS NUMBER Q - lrnl4qn9q-1 7 PATIENT NAME(LAST.FIRST.MI) DATE TIME IN FC PATIENT TYPE NlA E5a A PATIENTS COMPLAINT LAST HOSP•DATE • AGE SEX RACE MARITAL STAT. coW B/P TET.TOX ALLERGIES: MEDS: � ( PMH R 10 yrs C3 -2— < 7 U 7REG <10 yrs ❑�y �l[ O C�i,,,{ / Given: O m NU $ IS RY O o a TIME T LNMP CCa m co HISTORY DICTATED TIME YES❑ NO❑ •PHYSICAL EXAM .• ^— 0 V PLAN: PHYSICIAN'S ORDERS/RX TIME BY LAB TIME TIME ORD R BY X-RAY RD BY r7 CBC [�CHEST ❑U/A ❑C-SPINE u LYTES NA_ K ��EXT CL CO, L-1LS SPINE L GLUCOSE "SKULL BUN/CREAT. ABD SERIES o ER PANEL EKG m m v r— G . DIAGNCSIS — - — Q 1 Z DISPOSITIOr• _ - Q ✓h ` N I ADMIT TR 'GGFP TO $TMJ(,".IIj N'if.,IVLN IT 1j (I DISCHARGE TIME•DATE SIG 'Yl D SI HECUHU INT NUMbEA pA'c •.ME FLIIEx l SEC-VICE SENO RECORDS TO INDUSTRIAL u0 MEDICAL RECORDS _ 1 YPE CODE 5 EMR r LAST.FIRST,INITIAL BIRTHDATE AGE SEX RACE I • SOCIAL SECURITY NO F.0 LAST TIME AT f n•rvs BROOKSIDE � I '"IRATIONS MENTAL STATUS RESPONDS TO PUPILS SKIN l 1MAL ALERT VOICE EQUAL DRY NORMAL f'',%LLOW CONFUSED ORIENTED ItCONS-TRICTED DIAPHORETIC FLUSHED '--'QRED UNCONSCIOUS PAIN DILATED r.a< NORMAL COOL MOTTLED ,1R _ IA {-•�CZES �' UNRESNPONSIVE UNEQUAL R L WARM PALE t"..*5 RESPONSIVE NOT CYANOTIC CHI FIXED ink Ai. PULSE RESP V POSITION 'tL/RE'TAI 14LOlWAEGTYPE • TPAE (URINE MG.qmw TUBE) AMOIAIT g L/'AIN(MASK.CANNULA) TOFi RHYTHM I IV NUMBER SOLUTIONS MEDICATIONS RATE AMOUNT AM ID IME BP P R MEDICATIONS ASSESSMENTS OBSERVATIONS 1yo 4 CO c� ' 33 A T A M M 1A S T I r 4 P r . 1 1 ' I W I Z. W Y � z Z EMERGENCY PROTOCOL FOR PATIENT TRANSFERS DATE OAT I ENT'S NAME: Grp - }�Yl hO,. CHART NO. —15 q-3 1 SEX: AGE: _ DIAGNOSIS: u4�, a.m. TIME. OF ARRIVAL IN ER: a� LJO. .m. VITALS ON ARRIVAL: T. P�_ R_f_ BP TIME OF DISCHARGE ti a.m VITALS ON DISCHARGE: T � R BP r1$ Z FROM ER: �P.m. YES IV: NO E 1, TYPE OF SOLUTION: AMOUNT REMAINING: AGNOSTIC WORK: EKG: CBC: URINALYSIS: X-RAYS: YES BLOOD TYPE b X MATCHED: IS BLOOD BEING TRANSFERRED WITH PT.? NO MEDICINES GIVEN IN ER: PERSON ORDERING TRANSFER: rr� M.D. OEASON FOR TRANSFER: (CONDITION AT TIME OF TRANSFER: IRGOOD STABLE (? YES US PATIENT AWARE OF REASON FOR TRANSFER? N0BIA IF NOT, GIVE REASON: YES HAS NEXT OF KIN BEEN NOTIFIED? NO METHOD OF TRANSFER: AMBULANCE 21 0 TAXI U PRIVATE CAR o� p 1IF TRANSFERRED BY PRIVATE CAR, ACCOMPANIED BY: Name Relationship 4 HOSPITAL ACCEPTING PATIENT: NAME OF PERSON CONTACTED AT ACCEPTING HOSPITAL: �r M.D. PERSONAL EFFECTS: CLOTHES WATCH : WALLET OR PURSE : MISC.: �. FILLED OUT BY: Name -' / Title SIGNATURE OF PHYSICIAN: / M.D. +'_DICAL RECORDS E PERSONAL EFFECTS SENT WITH: Signature of Responsible Party Title )*:DICAL RECORDS & PERSONA! EFFECTS RECEIVED BY: Signature o Responsible Party Title f,rm 7230, 14 (Rev. 9/80) CONTRA COSTA COUNTY HEALTH SERVICES _ MERRITHF MEMORIAL HOSPITAL INCOMING TRANSrER FORM - EMERGENCY. 57 r0 1 . Date �l`�� ��� Time J1� AM M: 7 F -, - - . 2 2. Is call being recorded? C , "1 S u _ 4 If not, why? azo G1S ��/ �• 3. Patient name Patient f 4. Patient ages_ Sex M 5. Referring Referring facility c .� .c physician 6. Is %his call from one of our clinics? If yes, the one below: Direct admit that will arrive before 5PM. Transfer call to appropriate resident orward staff (Name ). Post form in ER. On arrival, send original to ward. • n Direct admit that will arrive after 5PM. Go to 10. Hn Patient being referred for ER evaluation. Go to 10. • 7. Patient's .permanertt 8. Insurance Medi-Cal /BAC, address •Pc Coverage Medicare None; 'r Veteran (How determined: ) �--1 Other (W cannot accept uninsured out-of-county residents from other acute care _. hospitals.) (Encourage transfer of joinsured eligible veterans to V1 if they are inelligible for both Nedi-Cal and !fedi-Care.) • 9. Is this an inhouse-to-inhouse transfer from another acute care hospital? If yes, transfer call to appropriate resident or ward staff (Name: That person will be responsible for workup of medically elective inpatient _ transfers that arrive after SPM on weekdays, noon on weekends and _) holiday;.) Post form in ER. On arrival, send original to ward. 10. Nurse or Clerk - - - - - - - - - - - - C -� - -�- - - - - - - - � - - - - - - - - -:._ History . - �f P A� b 3V a:. 0 _7 Reason for transfer Mode of transport _ Accompanying information Objections to transfer Distribution: White - Chart eQ MR-144 (7/85) Yellow - ER Director Physician CONTRA ;:c1STA COUNTY F'Rk QH `404Y.7AL CARE FORM II R _ p*CL90007uWAPMOMuIrg2MC TAPE / / DATE �� IME :_�AGENCY < AUTH. M NAME_ �-f- :� A^^ g ' AGE a M l_) ETA�-,L+IOSPITAL�Ll�/ •1�1 �n ej.�i� LOC- 'ION/POSITION h h DISTRESS: ned ild mod severe CHI�F COMPLAINT �`" DURATION: H.P.I. Jn E ir+ COMMENTS: S - P.M.H. 46 �,d.A_4 , A -n d X ;;x MEDICATIONS: � � 0.1 '' �... / ALLERGIES OeA L4 INITIAL VITALS: BP P R FD CP MT- QUALITY OF VITALS: INITIAL RHYTHM: �� c �'`I_t / RESPONDS TO: 'C t ', LO.0: ALERT �� �' SdWRYy''` DIAPHORETICLLSL.COOL 11 6 RM-6.----'HOT elah COLOR: NORMAL ✓FLUSHED M& PALE_:2!�L CYANOTIC A x HEAD' INJURY• �y" `AlRYAY; 642�n PUPILS: PEARL UNEQUAL: RT. LT. EARS: DRAINAGE" n NOSE:`DRAINAW NECK: TRACHEA C/S��TENDERNESS ^J JVD n v CHEST: EXPANSION wti TENDERNESS LUNO`_ ENTRY—f- RALES _ WHEEZES --lo _ ABDOMEN: TENDER `l 'SOFT �'�" DISTENDED �.� PELVIS: TENDER h BACK: TENDER r% EXTREW PULSE x EDEMA -I"' INJURY n lu M/S \= v���no In 4- �� EHL PL Wt. l j . G�L---ASSESSMENT., . . . _. .. .:. _ • MANAGEMENT; •ks.' TIME DONE PATIENT RESPONSE. BP;;..-z: :P..:: �r w :.= i�18-. C � 'r 1.�5!'�',,? -.y: ° : _4 � .;��r"' E.1 n ::ft'+ +��i'.� �e �� 1. �if{�• ,� ar 44 PRIOR MOVEMENT/TREATMENT CODE TO SCENE,_ ;GENE ASSISTANCE -02k ���� INCIDENT LQCATION. y -RANG TO AMBULANCE t< PT.DI POSITIONS( r �1 CODE 1 STWrED PT. PERSON—_r_ A... ✓ RAD/DRIVER :ASE SIGN: BASE FIELD WHITS oopy to raoaiving bospitaZ;YELLOW copy retained by onbaZanoe„ompa7y; Pin to Bass BoepitaZ EMS-2 (4/82) Patient Name as., First. • lei IPatCOm Number Patient's Matoen f CHART SOURCE VISIT a RANT ANNA E15075304 GRANT 4568937-02-0001 Local Address(space/apt)City State Zip ITelepnone Arrival 1410 MISSION SAN PABLO,CA.94806 V'3/05/87 iol120 AU dw Permanent Address(it different from above)Space/apt City State Zip Pt,Type ad Serv. - 410 MISSION ST#4 SAN PABLO CA 94806�7.1.phone 15 0000000 PO E IE'4/R Occupation Soc.Sec.Number Age Date of Birth M/S SexJR&ce Religion ONE 53-90-5349 033 107/08/53 4 F 3 NO Employer(Name oCo.) Employer Address Street City State Zip How Emp.Tel. umber Long ONE. . resenting Problems Mother's Maiden Name• ABOR JASKEW Res .Party Name(Last,First,M.I. Resp.Party Tel.No.Day/Evening Resp.Party Soc.Sec. No. Sex RANT ANNA E 15 000-0000 553-90-5349 Resp.Party Address Street city. State Zip Rant Rslatlonshlp to Patient Occupation 41,0• .MISSION SUSAN PABLO XA 94806 own NONE ... Rasp: artY'ErgDloy*r(Nams of'Co.) — Addreu: Street City State 3 `Zip :r ONEt j _ ItsPayer Source *1 subscriber's Nam*- Group No. Policy No. Cov.Code verlfie f'` �. 1 i Payer Source rt2 Subscriber's Name Group No. Policy No. Cov.Code erlfle x ,.i. n.. Payer Source #3 Subscrlber's Nama Group No. Policy No. Cov.Code Verified ubscriber's Relationship to Patient Nameand Address of insurance Co. Nearest Relative (Not Living With Patientl Relationship Relative Address Relative Tel.Number •• R.&MRS.WALKER AUN&UNCLE. 6814 DELMONTE AVEF'RICH 415 232-4830 may.s `.�:;:- . . _ . . f �;•� ...� t..7 W: l., M1 s. ` DISCHARGE SUMMARY AND ORDERS 1. ADMISSION DATE: DISCHARGE DATE: 3. INITIAL COMPLAINT: PATIENT I.D.Imprint Area must be readable on all copies 4. PRINCIPAL DISCHARGE DIAGNOSIS: (D S pc,,4• ,—tee ou•s ve-S i t (Chief reason for patient's admission) Other Dx O E' 34 —?Lo 5. P OCEDURES PERFORMED/GENERAL TREATMENT MEASURES: DICTATED SUMMARY— YES ❑ NO I� Vk 6. PERTINENT FINDINGS/HOSPITAL COURSE: p �6 y—G�%v�trh� Cys Q SFC�rt-I -S3 to W e,•-f tb t5 S N Lr(-x -4- Cil.-�-�•�`�. '�-c"",� ,f,.,.,� 1-,r.•�C. 4v?--f 4e (tee-►mac. 2 1� "'� Cu c.✓ •.Ow vd�-Imo.-=r. %L—. f•C ,Uj.,A &Ldx .U- t- 4 o_rd`• w;N-z, cam..--�►.ruh -r -1��r.�-d- Z`' ' k' cp- S•fi l I�owr+ cr, rO c,s L-t--13 YL ps11 rC-bt`-c0C'C�' �. CONDITION ON DISCHARGE: f�^{?!J► Le �rv+ , ! v-- LITIA�S� C�^Ve'��"'�� � 8. INSTRUCTIONS TO PATIENT: (Activity,diet,etc. Include medications not being dispensed.) f�1.0-N^+� t:�.. V6+5i'•'-c: � �Q �^'�k3 -' w Sec � (,`..� -f-�t�--�• G�-•!� �,.�� �I,.oL,•t�-.-:�. 12%t Ck-w—rK- 'D�- Fo ie-L.� . V-L-C-L-i c--C4 C.•c APPOINTMENT REQUEST FOR OUTPATIENT FOLLOW UP: CLINIC Primary —LAS Clinic � •�, rm WHEN?NEXT OPENING/OR SPECIFIC TIME PERIOD Doctor �� LOCATION: MARTINEZ � HMOND [a PITTSBURG ❑ BRENTW"63l OTHERIDy c_ �_- SPECIFY). ..,z•-.._Y<r 10. ADDITIONAL APPOINTMENTS: ` DISCHARGE MEDICATION ORDER (DISPENSED) 0 PATIENT I.D. -m rint Area must be readable on all co les aY Q - v , DEA NUMBER (SIGNATURE) 1 CIF rp TY.a=i.7 POc'�J2 3 HI�I!r 'i�?:t.� CONDITIONS OF q� 1 iJN �A is: \8\r7U\C0 �Cr 4 .ri �OJ9Ha MAP, 14(11 :M Ulf: C :.aL;JIiRGICAL TREATMENT PERMIT: 1 give permission for any m`edical.or psychiatric treatment including X-ray examination.labors.' l e.`, f r1lCdt �a►stent a d ton to Ung as may be c d 3. ��dt�1 P nA J :!�1�4 MAe "� pal I AF tio. ,zie,id,lig physician and/or his associates,assistants,including medical students and physician residents,and personnel assigned by the hospit NLOUNG CAME: I AcIPAIA OCZw WQiP9P ovides only"A dutQrRli�rr+;QRTJi=he physician orders more intensive nursing,UAOK br trrvvtopirl for the pat,et,r or if the pm,ent7tanditran is such as to-need the service of#'special duty nurse or attendant:• ., (� uu' TEACHING PROGRAM: I understand that this hospital is teaching institution and that unless the hospital is notified to the Contrary to v;lMA T. i pib... . may paruupate as a patient m the medical education program of this institiltion. 33N, AvggA ' PERSONAL VALU�BLE�Y 1 understand that this hospital maintains a safe'for the safekeeping of money and valuables and that the hosBitaTsha�� . j _not be Iiahlr for the loss or damage to any money; 'ewelr ,document :fate,or otter articles of unusual value or any other persobal pro rty.ut ' less dedos,R AS"� �OU�-QUO �:�; . a Ah14q 1 NA��;;� NEWS R AND RESPONSE TO INOUIRIdSti undeistand.lt is tlie' ' gf�o r CQ'�t� y al e r I nf(�Q�r 1 unless bth Wequested by the patient,parent or conservator,the fohowir��kTnfet=a(rt++t leAMUT�,�edt+adlhll k,. P, i gane�A1 nature of irEjur,7 and general ebnditjon:No informatioh*is rete"-ed for patients being treated for i psychiatric.eood!tion,'or,forrtlrug oe. 1 .ak ohol abuse artless specifically authorized by the patient y 3N� :CONSENT T.O"C'TOGRAPH:The Hospital is Permitted to takepictures of the medical ori:surgical progress involvin4tlge Patient and to use samaf` r! *, C: •ior-! eritiflc,@ducational or research purposes p. L� � F. �r7_.... :' •�..,:'.r.. S - += �j_..'. j• .,, ^ i• a -: ; r `jr ,i � �?LEANING HQSPITAL AGAINST ADVICE':'�n.1hetevent the Patient elects'to leave the Hospital Against the-advice of a physician and the Hospital;'L_ r she Petj¢n3,lplersas all physjciaris and Lhe Hospitpl(resin all responsibility and any_ill effects which may result from such action.. i _ ,iia DRUGS:7f.is iiitperaZive:that the Hospital atall tineas be aware of the Patient s Intake.Accordingly,Patient shall neither use not keep any drug -dr-ul;aP lieifeefapperatus:net that, or-on behalf of:the Attendi P1► tcian:and di r►sed b th HOs el Burin P tiseit's eurrent•ata t' Y. Ps y ^� .lrs ?Pe •.::a 1? R" ri FINANCIAL AGREEMENT. I promise to reimburse the County of Conte Costa for hospital care and medical service provided to me ttujas L! n� c ve 'S1, , re, Med'• i re ort a nt will be at the rat I" �+Be �ofry will us bA EBr�t �r dtsel4ted+KL1tE it eFstlMEls`�11ich necessitated this 't0-rEnTrbUKe tttl�eAgy ,. _.. .. .Is IJ ul lathe amounCbitled,but not to exceed the ratenet by the'Board: —7.- .. ...,RELEASE.OF INFORMATION FOR REIMBURSEMENT: 1 give..permission to Contra Costa County Health.Services to furnish information;..'">1' from my.-patient record to the extent necessary to'determine for payment and to Obtain reimbursement: Infomatlon>may include r :. . related to a.drug,alcohol or psychiatric conditions,and may'be.given jcs any person or'cdrporation which is or may be liable for all or any nor tion of the hospital's:charge,.including but not limited to insurance companies, healthcare service plans,worker's compensation or peer:review <-;r... .. organizations". AUTHORIZATION TO RELEASE INFORMATION AND CONSENT'fO RELEASE MEDI-CAL LABELS rr I,authorize COtitra.Costa Department of Social Services to release information concerning the status of my Medi-Cal application,and to send my 'Medi-Cal labels to.Contra Costa Health Se►yices Department::..,. ASSIGf1lMENT.OF BENEFITS: I authorize any insurance company or carrier.,through which I may have coverage to make direct payment of.'_ / benef its to'Contra Costa County Health Services,an amount not to exceed the Hospital's regular charges for this period of service.A photocopy of this authorization shall be considered as effective and valid as the original. i I authorize the Attorney, Claim Adjustor, Insurance Company or any Person(s),Company or Corporation who may effect a settlement or payment of my claim for damages or indemnity arising from the injury or illness which necessitated this hospital care and/or services to deduct the amount of the charges•of these services from sum due me and to pay that amount directly to Contra Costa County and I assign from that amount all or any i�' portion of it which is necessary to pay those charges. 4t Jr.; .I waive the statute of limitations on this matter for a period of 10 years. This agreement and waiver is binding on me,my heirs,assigns,administra- '`? :,tofs,and executors. WHERE MINORS ARE INVOLVED,THE FOLLOWING PREVAILS: #'t AGE OF.CONSENT: 1. The:consent of a parent or legal guardian is required if the patient is unmarried and has not yet attained his or her 18th birthday. 2. If a.patient under 18 years of age has contracted a valid marriage, regardless of a subsequent divorce or annulment, then the consent orf a parent or legal guardian is not required. THF UNDERSIGNED CERTIFIES TO UNDERSTAND AND AGREE TO THE FOREGOING, RECEIVING A COPY THEREOF,AND IS THE PATIENT. OR IS DULY AUTHURIZED BY AND ON BEHALF OF THE PATIENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS :'EHSCNALLY AND UPON PATIENT'S BEHALF. Cv RELATI T PATIENT cop', of this Da. ::n: ,LA,vw t•d[ ,. P„i:••r �— • Patent undU'� tU ,.11, --- Timebf sign,rty:. CONTRA COSTA COUNTY HEALTH SERVICES..CPT. r•'y - - EMERGENCY ROOM RECORD Patient Name(Last,First,Middle) jPatcom Number Patient-s Maiden Name CHART SOURCE VISIT GRANT ANNA E 5075304 GRANT 4568937-02-0001 Local Address(space/apt) City State zip Telephone Arrival 1410 MISSION SAN PABLO r CA.94806 413 0000000 V`J/05187 TdY9 ZO AU Date of Birth Age Emergency Contact Name Telephone F.C. Pt,TypoMed Serv. 7/08/53 33 R.&MRS. WALKER PO E £/R NURSE ASSESSMENT&PRELIMINARY TREATMENT CCHP YES 11Current Meds(Inclutla 8CP's,ASA, Tylenol,vitamins) "i NO❑ Primary Physician Other Medical Problems Last Tetanus— l Nursing cdritractptibn— I e Signature TimePHYSICIAN ASSESSMENT&PLAN 7e ORDERS B/P Pulse ' Resp.. Temp. Time .Pulse r Resp. ... Temp. .-_.. ..� . Weight. VISUA ? ."?... ACUIT� OS OD Corrected ❑ , i... - Uncorrected ❑ Allergies antative Diagnosis Condition on Release N' PATIENT INSTRUCTIONS DISABILITY Will be able to return to o _ - work or school on: W Restrictions was visit an emergency by MeW-Cal standards? YESO NOO DATE: I have read and understand these instructions PHYSICIAN'S SIGNATURE M-D" TIME: PM Q PATIENT'S SIGNATURE ''ONTRA COSTA COUNTY HEALTH SERVICF- DEPT. EMERGENCY ROOM RECORG Patient Name(Last.First.Meddle( Patcom Number P'atient's Maiden Name CHART SOURCE VISIT Local Address(space/apt) City State Zip Telephone rr Date Time How • Date of Birth Age Emergency Contact Name a' TelephoneFTylenol, Pt.Type Med Serv. �r NURSE ASSESSMENT&PRELIMINARY TREATMENT CCHP YE (tnclutle BCPs,ASA, ❑ mins) AUt1toA2ltt" ❑ rlmarY Physician ;RA!1T, AP:NA E . Other medical Problems _.........- Last Tetanus — AR AS a LMP— Nursing Contraception— - Signature,' Time PHYSICIAN ASSESSMENT&PLAN ^ ORDERS Pulse Resp- Temp. N9-� -o Soo �� ry Time U is FLA— B/P Pulse lie 0&4 Resp. _ --�— C: -, Temp. CD h: Sn, Weight _ !—L�.;—�15_� — ACUIT OSE_ OD Corrected ❑ ty100t7�-- - �S/IO,..Y►�. ._ .=Y'"'�=- - - -- _ ,....--- - —_.... Uncorrected ❑ (1 Allergies —7'entative Diagnosis Co ditlon on Release -:rs PATIENT INSTRUCTIONS DISABILITY Will be able to return to ^.. Work Or school On: Restrictions Was visit an emergency by Meoi-Cal standards? Y S NOO DATE: 'Sr I have read and understand these instructions M.D. TIME: ` `O PHYSICIAN'S SIGNATU cJ� M, PATIENT'S SIGNATURE Contra Costa County .ealth Services I• Merrithew Memorial Hospital EMERGENCY DEPARTMENT— NURSING RECORDE , _ S_3 _ +f� E � LATE ALLERGIES: - 53 Pp �� S 3 011 - 4 S t `� '� TRIAGE STATUS 6 1 S / r ❑ 11 ❑ 111 Patient ID ,w . RRENT MEDS: - PAST MEDICAL WC VISUAL WEIGHT: LAST TETANUS: r , - ACUITY LMP: OS ❑ CORRECTED CONTRACE OD ❑ UNCORRECTED EMEFK3ENCY M VU: 441ULANCE -'[3 WIC..`.- `- ❑CARRIED ❑ POLICE ❑ 5150/5170 ❑ OTHER NURSES'NOTES TIME I TYPE BP P R T• NT - y 2,P h : t+)13 x _ - o - o ADDITIONAL NOTES ❑ 1 IA! MEDICATIONS AND IV SOLUTIONS TIME MEDICATION OR SOLUTION(IV solution bag 4 and rate) DOSE GIVEN/ ROUTE/ RESPONSE INT. AMT INFUSED SITE INTAKE p0 IV DISPOSITION: ❑HOME ❑MHS []JAIL ADMIT--f--L D OTHER HOW DISCHARGED: ❑WALKING ❑W/C ❑GURNE*. ❑OTHER OUTPUT NOTIFICATION DISCHARGED BY: DISCHARGE TIME: URINE EMESIS/NGT OTHER ❑POLICE []CORONER AI c'.i ❑CPS ❑OTHER PM RIGNATUAECAx - CONTRA COSTA CuUNTY HEALTH SERVICES HISTORY AND PHYSICAL EXAMINATION Patient I.D. DATE jj 331 z , r t ,21 j r r C'J J L M11-4 4/81. CONTRA COSTA COUN HEALTH SERVICES I HISTORY AND PHYSICAL EXAMINATION Patient I. D. DATE -14 Pal 4 lad, Ct/ �C� Gc� ctpll'"v l-c.OLtJT�'� ' -� .. -s' •U"G'?�t�i•- ,7 kl` b:l yC1 MR-4 4/81 4M r rr c r`r z •O r v c M z a - a; { X �. P- 10 - w z vs L a p -4 co n a x m ;�^ i N 0 CD + � z x �o at t �a cn c c'1 g A s -_� cn cn M R. M -4 CA \. r a., Z mt- \ O L x k J -o G G c m y -o o d► � I •J: `co C-1 p s� g., 8 v► % s N ,-- N % n � r 92 z � � A tp k � c M y i rn � i � w m rm rn 17mz ca 0 i X 2 1:- °CA _ ci C m3m� �1 ci o. m �d T im{ C ro y X �e> { C A Rk tzt O E-c 2 .I 1 t N � , N % � D Z C ri m sit a .a I f O O"I iN31IVdCA Y Ctl+t m y Z t O • i r • 1 , m MENEM MEMO W- 7- m NS Merrithew Memc it Hospital / I CONTRA COSTA COUNTY HEALTH SERVICES 2500 ALHAMBRA AVENUE • MARTINEZ, CALIFORNIA Patient I.D, FETAL MONITORING HISTORY SHEET REASON FOR MONITORING: 1) ✓ROUTINE SCREENING 3) FETAL FACTORS (Bradycardia 2) MATERNAL COMPLICATIONS Tachycardia Toxemia Irregularity Diabetes Meconium Passage - . Heart Disease Fetal Activity Decreased Anemia Fetal Activity Increased RH Isoimmunization Breech Presentation . Prev. Perinatal Death Prematurity Elderly Primagravida Postmaturity . Grandmultiparity Dx Fetal Viability Other 4) COMPLICATION OF PREGNANCY 5) UTERINE FACTORS Premature Rupture Membranes Poor Progresp: suspected CPD Abruptio Placenta Prev C-Section • Partial Placenta Previa Uterine Anomaly Prolapsed Cord Multiple Gest. Undet. 3rd Tri. Bleeding Oxytocin Augmentation Amnionitis OTocin Induct. , COMPLETE AFTER MONITORING: 1) METHOD USED 2) FHR OBSERVATIONS i_ ?ltrasound Normal 4--tocotransducer Periodic Changes [ piral Electrode Head Compression Intrauterine Catheter Cord Compression U.P.I Acceleration baseline Changes Tachycardia Bradycardia PATIENT INFORMATION: Gravida l Para _� ,3 Gestation Type of Delivery /VSye Sex Q� APGAR Score 4fj / 0 Birth Wt. � /; 1 min / 5 min M.D. White - Mother's Chart MR-156 9/85 Canary - Newborn's Chart CONTRA CGSTA COUNTY HEALTP-ERVICES Obstetrical/Delivery Reco MATERNAL FACTORS Age Gr. P Ab EDCtS. 1A4 ,(y�'B�ood r"' 45,pe Rh Rubella VDRL ' Significant prenatal factors: G Gt./l MOTHER'S I.D. LABOR DELIVERY a.m. Onset Labor (p m. Duration 1st stage hrs. 0-set 2nd stage �13 p.m. Duration 2nd stage �/�� hrs. Membranes Zemksw(F- a.m. = ruptured at AQ/ p.m.. ❑ spontaneous artificially Labor Analgesia: (agent/route) /L1C?1t Delivery Analgesia: (agent/route) 4,421,4= ® 3 S 7 at al delivery can Delivery at ,�- P.M. Date y Unclean Type of delivery spontaneous ❑ operative ❑ elective Indication for operative delivery 'T Forceps: ❑ mid ❑ low type -Placenta 3 P.M. Appearance Cord vesselr s L- Arteries ❑ Episiotomy type laceration �� ,�rlG TL✓�� �d'u , 12C7'/Le,�Da..�(v� • ❑ Cervix inspected cervical laceration(s) Describe any repairs Estimated blood loss cause -if excessive BA , Sex Weight Length Respirations: ❑ spontaneous ® delayed minutes Resuscitation endotracheal ❑ bulb [] gastric aspirate Apgar Resp / cry / color / tone / heart rate / Apgar @ 1 min ,� @ 5 min p ❑ Bilateral breath sounds / abd,. mads/es n cord Rh ❑ coombs Other findings - comments: ST,//�O�,a iGc �GGr-fiY Ilotycin oint, identaban 7F j 0 Fetal Monitor: Int/ernal . hrs. W External hrs. INFANT'S I.D. Medication 1 Findings / c -- -Pc ,L M.D. MR- 6 (4/84) Dist: White - Mother's Chart Yellow - Baby's Chart Pink - Clinic/Baby's Chart CONTRA COSTA COUNTY HEALTH SERVICES CARDIOPULMONARY RESUSCITATION Date 3/q /9-7 • Location Patient I.D. EVENT �1TIME COMKENTS: Unresponsive/CODE BLUE called �� 2 �? m 3y-3(p w k esio,t 1 ot) ma Breathing: -Yes -No rr qq qy- (�t O/0 No Pry-nom 1 Cwr Mouth-to-mouth begun ��1 Ambui Ba 2 begun P4 Endotracheal-tube laced p -E Pulse check: -present ` -absent Chest compressions begun a Monitor EKGi 0 255 :. Initial rhythm 5 t, :.... ;.. I.V. in:place -started C (13(10 Solution :_. (A) = Site F L O W R. E C O R D - STATE MONITOR-RHYTHM TIMEam ID SA E TIME DOSAGE TIME IDOSAGE TIME- DOSAGE DEFIBRILLATION pm MEDICATIONS (I.V.) Soda Bicarb O 3 a- 5CC E rine hrine 1 Lidocaine: Bolus I.V. Drip 'Bretylium Procainamide-' Atropine Isuprel Dopamine Calcium Spontaneous Pulse Blood Pressure S ont. Respirations Arterial Blood Gas Nam^^. cc 2 '18 .Team Members: Physicians: nISPOSITION: n - 1.'� � / J All � Time Recorder's Signatur 3. R. N. 's Signature PLACE MONITOR/EKG STRIPS ON REVERSE SIDE (patient's name, date, time) M. D. 's Signature 027181"1 - Charc •T_�n r. in... T.11ow — Surv."/forward to ►d. Traininr NEWBORN MATURITY RATING and CLASSIFICATION ESTIMATION OF GESTATIONAL AGE BY MATURITY RATING SidE Symbols: X - 1st Exam 0 - 2nd Exam NEUROMUSCULAR MATURITY _ 0 1 2 3 4 5 Gestation by Dates w Birth Date 6- 47 Hour Vit.• �a� � _ ;., a f� �' �:�s• ` _,i APGAR l�nain"T"5 IT a V;o� ;... ra 1 F T a i A MATURITY RATING I' eb° o0g1yM a Scan Wks wwP. r ? r 5 26 a- W .�+'-` r•`'`- = 10 28 C.C. �ig0" s0" <eat 15 30 j/' 20 32 t-_. w.. 26 34 �} { a » _ } 35 36 _ f 45 42 PHYSICAL MATURITY 50 44 Sty o 1 2 3 . 4 5 SCORING SECTION 1st Exam=X 2nd Exam=C z Estimating a Gest Age ,r;1 by Maturity 3 Rating 'Weeks Weeks 4 K� Time of Date Date x" Exam am m Hour3�� pm Hour pm Age at �• Exam Hours Hours '^n Signature of I 3 Examiner - t - i Mead a l l I I NUTRITIONAL DIVISION MERRITFy MEMORIAL HOSPITAL CONTRA COSTA COU,,fY HEALTH SERVICES - PC. PHYSICIAN ' S ANTEPARTUM ORDERS Date 3� 5/ 17 Patient I .D. 1 Wei ht BP FHT TPR on admission. 2 Shower as needed. 3J Clean voided urine to lab. Check for albumin and sugar on ward. 4. CBC VDRL on entry. RH factor and blood t e '3' t�nknown ► :` ::' '' 5. Fleet enema PRN. No enema if premature,- if patient is_ bleeding or if patient is to be sectioned, unless ordered.:.specifically .by s3 doctor. No enema if membranes are ruptured, " 6. Li uids as tolerated if in labor otherwise'diet as tolerated. 7. Notify Resident on service (or call) when patient first admitted to ward. I.V. Fluids 1000 cc Ringers ' Lactate 125 cc. per hour on all �- atients in active labor. * 9. Fetal' Monitor Tracing. C fig: Y� r; M.D. (Signature) MR-23a x.9/85 DATE _ . TREATMENT AND/OR DRUGS jv10-- ` TIME k i-� {SCC fS Z a ° c kok — W Q J l _ m a /} ° m O a ;._. m ! , 3 . m CC WB f � i g5't;'1 a z � St n a SIGNAT RE '. TE TREATMENT AND/OR DRUGS E � .-. rte; . I} J t Z IIAP ' 4 a <a- uj ++Ec ¢ F Ci F `-� '• W . n ;4 SIGNATURE. M.D. }+ DATE TREATMENT AND/OR DRUGS TIME I'- = •,: dX Zrf ��k W � � IL -w w� W W Y mCc 3 dc .. y w a irk" cc u O: Y z:.,' U 2` U) s r U a SIGNATURE M.D. PHYSICIAN'S DRUG ORDERS PRESS FIRMLY CONTRA COUNTY COUNTY USE BALL POINT PEN HEALTH SERVICES - PYMT 05(1/86) MEEK ��/ V * MERRITHEW T�IORIAL HOSPITAL ' - POSTPARTUM PP_YSICIAN'S ORDERS nates Patient ID 1. V= SIGNS: Check fundus, pulse and vaginal bleeding q 15 minutes X 4; _ then q 30 minutes X 4. Record blood pressure on arrival to ward; y• then g 15 minutes X 3 or until stable,- then blood pmssure and temp BID. nflT%: �• 2. ' AMMMATION: Ambulate with assistance PRN. May shower'PRN with assistance. ;, If spinal block: Horizontal in bed X 8 hours,- .then ambulate PRN with assistance. 3. DIET: Regular,with additional. nourishment. 4. CATTM=ZE: In 6 to 8 hours, if unable to void or if distended. If necessary to re-catheterize, insert a 416 Foley to straight, drainacTe. 5. HEMT0CRIT• On 1:)ostpartur6 da 1. .100 mg nembutal po q .hs .PRN, may repeat Y, 1 if necessary. . 7. ANALGESIA c I 2 Tylenol tabs 2-4 hrs PRN Ty q Po 1-2 #3 Tylenol tabs '2-4 hrs po P?N r 1-2 Tylox tabs q 3-4 hrs po PRN 1-2 Percodan tabs q 3-4 hrs po PRN - IF NO RELIEF FROM THE AHDVE MAY GIVE: Dem rol .50 mg and Vistaril 50 mg .IM q .3-4 hrs PRN X 2. S. BOWEMS: 2 Doxidan HS until has bowel rrrnnwient 1 DSS tab po BID PRN Fleets enena .or .Dulcolax Suppository PRAT 9. BREASTS: BreastptarP PRN ✓ Ice bag PRN Lanolin ointment PRI IF NOT NURSING: Deladumone OB 2 cc DI STAT 10. EPISIOTOMY: / Hot sitz bath TID or PRN Ice pack TID or PRNI Dermaplast PRN 4th degree laceration precautions -23_b side 1 (8/85) %r HERRITHE Mr-ORI-AL H05PITAL t PO.S'TPARIUM PHYSICIAN'S ORDERS - continued 11. IV's: Ruda present bottle in hours, then: ! Follow with 20 units Pitocin in RL 1000ec for 5 hours; then DC. IF PATIENT IS HAVING EXCESSIVE ELEEDI G: .'.Keep IV open with . 50 nllitS at 1RL'1000:CP N(7TIFY'.PHYSICIAN. . " } I Methergine 0.2 mg PO q 4 hours X- 6 doses if blood pressure is , not elevated. • � i x • ��. R 12. . Rubella .vaccine`on day of discharge if patient has xiega£ive.-titer... 13. ✓Ferrous ,sulfate 1 aab.daily. = w . f f �. 14. .'::ADDITIONAL ORDERS RHOGAM IF h i': _��. - � y t .� � ` `• _'.t 4 _ L •r moi,. NN r 15. ALLERGIES: v M.D. a PR-23-b. Side 2 (8/85) p S MS• - Patient J1amp , CONTRA COSTA COUNTY HEALTH SERVICES MERRITHEW MEMORIAL HOSPITAL& CLINICS MARTINEZ XRAY ULTRASOUND, y�/ C.T.SCAN AND } ���I��C/�✓ '" ,."' '••` NUCLEAR MEDICINE REQUEST t dab of Request:' Appointment Date Appointment Time Py � EXAMS OU D CONIC INFOR ow.­4 . I ` = ! �.. .. 4. � ,`.. r,' ?st,°.._ .yam i�e,r�T a,.•{y�y�,;`�:;.t. �.f�t ,L e �7 `ti AI.LEFK31ES7 k: PRECaNANT'! YIDS D NO S SKiNATURIE ,# YES Q woo Wt3ii!!f NEKyFTPHYSICIAN yt Pk10NE FIEPORT7 .z•. PFIONE N0. DIABETIC"?. PATIENT STATUS _ w a ri "YES C7 No C) YES❑ NO C7WIC D'• "CiUERNEY f3•,'.x :c. '' RADIOGRAPHIC RZPORT "`- y« DATE _.PATIEMrSNAME•: -- UNTTNUIN R 87 GRANT, BABY`$OY '.. z °�. ` 10453(1',1 L; N : PDRTABLE CHEST, ABDOMEN' '7• � .,A••tii11 �"t'K / .. y' .. _ -.t: r .G t 1 +q , yT , . `m9d trachea. , sre r.* s an endgtrache �ube, term _ ppaquewf th no • r.idence -ofaeration. and :a nonvisible' cardiac silhouette:-because=...: the dense surroun- i.ng,.-,l:eings.- : There ..i.s,gas i n.the stomach and-An. the' fuodenum : r , Q : Otheriseaar:l'Um;_ o the ligament of Veitz. ` i WAA possible;to:exclude or inc. lude .abdomihal It 'masses. There .are 'no ca)`e� icat.ions .. - , . • all the abdolren' An :umbilical arterial tatheter;terminates at thelower:.•.border of. t Z R-l�+.w�.. 4 F. a'� k, <• w '_ }{ 1: �ir.I,- _° k'T_Jt Lr ✓a's' : y4-h > . ONCL�TSiON -'� ,Total iy unaerated lung :fields: ::yMinimal. gas jfaVni ritered ` ew-intestinal tract` and.,this. i s a6norma l ter= noX Ila ode-pending n c - . � �P 9 -D ttie,:age of e` patient, - •.. :- FMF•st FREDERICK LEY, M:D. Y Q D&T: 1/.5/87 :. RADIOLOGISTS: SOLOMON KUPERMAN,M.D. ROBERTS,SKOR,M.D. FREDERICK M.FOLEY,M.D. BRUCE LONDON,M.D. RAMT ni r5JA6t COMA KA CUS 1 A CUUMY MERRITHEW MEML1•;IAL HOSPITAL HEALTH SERVICES LABORATORY R L P O R T AND CLINICS c z m ° 4 3 U3 F7 It WARD c 8 ` tu �z• J ¢ N 1 ` 0ulz r t 0 ¢ c O V , _ c u _ 1'.. I-1_I...-� I.IJ Ire- M 2%0 Xi PATIE t T AREA MU= EADAaLE OM ALL C0►IEf. so 02 :: ' 11 It Q Wifn e O v_�. •: ��' �URINALYSIS 1�� `W CHART 634 •0 o yeti Lfl 0 :x- •vewRITY f .�_pEOUESTEDBr;. 18F9C:00t1EJCTM: U'1 ROUTINE ccc ASAP M.D. _ +R STAT DRAW 'i: tx pAjE S - �:T, u i - 1 STAT r� tY AFTER HOURS - - PJIA. f = 'X'• -':PROCEDURE _�? '� '��1T RE8ULTS,: �' � is.: :•;.. - ABO GROUP/Rh TYPE \/Qr n _ ►) r 1Fo -� <� Du ` r DIRECT ANTIGLOBULIN BS TEST •' J os INDIRECT ANTIGLOBULIN/ANTIBODY SCREEN PATIENT LD.IMPRINT AREA MUST BE READABLE ON ALL CONES Rh t{ 1 r3 �; Rh TTTE R :X PROCEDU1 ;v? r11EEULjs'; W Rh IMMUNE LOT* _ PROTHROMBIN TIME 11-13 SEC SE :`E GLOBULIN $= g .-! ANTIBODY I.D. ARTIAL THROMBOPLAS'TINTIME—29-37SEC SE i " � ASO SCREEN FIBRINOGEN:200400 mg% F MONO TEST FSP.9 10 UG/ML 0RHEUMATOID FACTOR = O i LBMT09 IMMUNOLOGY/COAG 'W CHART j .�C;ct_a S19OIOHltld'O'W'WIM ONnAN'3AH E5SV6'Z1W`3AV VH9WVHIV ooSZ S31NIIO ONV 1V11dSOH IVlllOW3W M3H11atl3W t •r S3:)iAV3S HllV3H A1Nnoo V1SOD VH1NO3 ' #noo ESS►6'Zln"3AV VWBWVHIV OOSZrAldVlWOW3W M3H11HH3W V1S03 VU:1NOD It 3Hlo cc cr 1:131-110 svie A S1SYl8 � dAld � 1jIHS 1:1311dIH$ a3dAH m i id3l a3dAH x =.. OdAH p sl• �►.' :L� . O odAH n avn �. O - • :'sf Oaovw s y oaolw H liz CPO M y. .A-J;• .�,�` "� AL A. oaOlW N - os y.,. 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