Loading...
HomeMy WebLinkAboutMINUTES - 01281992 - 1.17 /, P7 'f ,+ CLAIM Af E 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 Januar—y 26,—1992 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: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CHRISTMANN, Amanda RECEIVE® ATTORNEY: Anthony G. Ratto, Esq. JAN ,f 1992 Law Offices of Duda, Rahim & Rattmate received COUNTY ADDRESS: A Professional Corporation BY DELIVERY TO CLERK ON JanuarpAA;INLsF 385 Grand Avenue, Suite 201 . Oakland, CA 94610 BY MAIL POSTMARKED: December 30, 1991 via County Counsel I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. January 7, 1992 PpHHIL BATCHELOR, Clerk DATED: 8Y: Deputy _ JM11 0/ AL J 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: ( !c(Z BY l� •.f 1 , %� �• �,,� 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 { vDOThis 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: JAN 2 2 192 PHIL BATCHELOR, Clerk, 6 Q4=Of 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: JAN 2 $ 1292 BY: PHIL BATCHELOR by 0(� Deputy Clerk CC: County Counsel County Administrator RECEIVED errithew JAN 6 10,192 emorial COUNTY COUNSEL MARTINEZ, CALIF. @WDURL AND CLINICS TO: Office of County Counsel DATE: January 2, 1992 Contra Costa County FROM: Mark Finucane RE: CLAIM Health Service Director Christmann, Amanda Record #55-70-28-8 The attached claim for the above named patient was received via certified mail by Merrithew Memorial Hospital on January 2, 1992. SP Attachment RECEIVED � cc: Risk Management Departments JAN 71992 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. RM-2 z Contra Costa County A COIlt7'CY A-301A (3/87) LAW OFFICES • LILA M. ABDUL-RAHIM DITDA, 11AHIlM & RATTO FAX (415) 4443604 ANTHONY G. RATTO A PROFESSIONAL CORPORATION 385 GRAND AVENUE OAKLAND, CALIFORNIA 94610 (415) 444-4600 x':,.J-i+144 CERTIFIED RETURN RECEIPT REQUESTED December 30, 1991 Merrittview Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 Re: Our Client: Amanda Christmann DOL: July 1991 Dear Sir/Madam: Enclosed please find the Government Claim form for filing with your office. Please file the original and return the endorsed filed copy in the envelope provided. Thank you for your assistance. If you have any questions, please feel free to call me. Very truly yours, LAW OFFICES OF DUDA, RAHIM & RATTO A Professional Corporation ANTHONY G. RATTO AGR/jgw Enclosure Ille i CLAIM AGAINST MERRITTVIEW MEMORIAL HOSPITAL IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS 910 ET SEQ. * NAME AND POST OFFICE ADDRESS OF CLAIMANT: Amanda Christmann 1849 Lacassie Avenue #1 Walnut Creek, CA 94596 POST OFFICE ADDRESS- TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT: ANTHONY G. RATTO, ESQ. LAW OFFICES OF DUDA, RAHIM & RATTO A Professional Corporation 385 Grand Avenue, Suite 201 Oakland, California 94610 DATE, TIME AND PLACE OF OCCURENCE OR INCIDENT: July, 1991 DESCRIPTION OF OCCURRENCE OR INCIDENT AND ANY INJURY, LOSS OR DAMAGE INCURRED: Claimant sought medical care and emergency medical care at Merrittview Memorial Hospital beginning July, 1991. Medical care received was negligently provided and was below the standard of care, which proximately caused plaintiff's injuries. The injuries are for personal injury damages, emotional distress and other general and special damages, including wage loss, loss of earning capacity, permanent injury, and medical expenses. NAME(S) OF EMPLOYEE(S) CAUSING THE INJURY, LOSS OR DAMAGE, IF KNOWN: Dr. Hobart, Dr. Michael Baker AMOUNT CLAIMED AS OF THE DATE OF PRESENTATION OF CLAIM AND THE ESTIMATED AMOUNT OF FUTURE CLAIM, IF KNOWN: Exceeds jurisdiction of Municipal Court DATED:December 30, 1991 SIGNATURE: ANTHONY RATTO *CLAIM MUST BE PRESENTED WITHIN ONE HUNDRED EIGHTY (180) DAYS OF THE INCIDENT IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS. I 1 i ..i k'h,Yr,S b y Q rr Ln C3 _ rU r I m D ni Er x CLr-1 Ln ti �4 � rn 44 j 0 Ln 0 o W Z r Q N o? a W Z u o Q O L o �^ i z J u J "r N toW p Z a � J a x Q � O Q a '. m ' �: m � . 0 � . . 0 e CLAIM 2 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFOR 146 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT January 28, 1992 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 takW oin 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: CHRISTMANN, Amanda RECEIVED Anthony G. Ratto, Esq. ATTORNEY: Law Offices of Duda, Rahim & Ratto JAN 7 1992 A Professional Corporation Date received ADDRESS: BY DELIVERY TO CLERK ON Janua R�F � 385 Grand Avenue, Suite 201 ur, Oakland, CA 94610 BY MAIL POSTMARKED: From Risk Management 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppIHi gg DATED: January 7, 1992 BYjL DeputyLOR, Clerk a. 1-11 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 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: 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: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA t Claira Against the County, or District governed by) BOARD ACTION the Boara of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT January 28, 1992 and Board Action. All Section references are to ) The copy of this document mailed to you i3 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: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CHRISTMANN, Amanda Anthony G. Ratto, Esq. ATTORNEY: Law Offices of Duda, Rahim & Ratto A Professional Corporation Date received ADDRESS: 385 Grand Avenue, Suite 201 BY DELIVERY TO CLERK ON January 7, 1992 Oakland, CA 94610 BY MAIL POSTMARKED: From Risk Management 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. gg DATED: January 7, 1992 gy]L 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: BY: 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: 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 1 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 errithew emorial.. Pon 04"1 AND CLINICS TO: Office of County Counsel DATE: January 2, 1992 Contra Costa County FROM: Mark Finucane44VI6.11.0 RE: CLAIM Health Service Director Christmann, Amanda Record #55-70-28-8 The attached claim for the above named patient was received via certified mail by Merrithew Memorial Hospital on January 2, 1992. SP Attachment _ RECE E cc: Ra s.k;6Manageme'n't' Qe•p,artment' JAN 11992 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. RM-2 C E. C Contra Costa County 'j C') Y'Cl A-301A ,3.'871 LAW OFFICES LILA M.ABDUL-RAHIM DUDA,RAI-IIM & RA7rTO FAX:(415) 444-3604 ANTHONY G. RATIO A PROFESSIONAL CORPORATION 385 GRAND AVENUE OAKLAND, CALIFORNIA 94610 (415) 444-4600 CERTIFIED RETURN RECEIPT REQUESTED December 30, 1991 Merrittview Memorial Hospital 2500 Alhambra Avenue Martinez, CA 94553 Re: Our Client: Amanda Christmann DOL: July 1991 Dear Sir/Madam: Enclosed please find the Government Claim form for filing with your office. Please file the original and return the endorsed, filed copy in the envelope provided. Thank you for your assistance. If you have any questions, please feel free to call me. Very truly yours, LAW OFFICES OF DUDA, RAHIM & RATTO A Professional Corporation ANTHONY G. RATTO AGR/jgw Enclosure c ; CLAIM AGAINST MERRITTVIEW MEMORIAL HOSPITAL IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS 910 ET SEQ. * NAME AND POST OFFICE ADDRESS OF CLAIMANT: Amanda Christmann 1849 Lacassie Avenue #1 Walnut Creek, CA 94596 POST OFFICE ADDRESS TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT: .ANTHONY G. RATTO, ESQ. LAW OFFICES OF DUDA, RAHIM & RATTO A Professional Corporation 385 Grand Avenue, Suite 201 Oakland, California 94610 DATE, TIME AND PLACE OF OCCURENCE OR INCIDENT: July, 1991 DESCRIPTION OF OCCURRENCE OR INCIDENT AND ANY INJURY, LOSS OR DAMAGE INCURRED: Claimant sought medical care and emergency medical care at Merrittview Memorial Hospital beginning July, 1991. Medical care received was negligently provided and was below the standard of care, which proximately caused plaintiff's injuries. The injuries are for personal injury damages, emotional distress and other general and special damages, including wage loss, loss of earning capacity, permanent injury, and medical expenses. NAME(S) OF EMPLOYEE(S) CAUSING THE INJURY, LOSS OR DAMAGE, IF KNOWN: Dr. Hobart, Dr. Michael Baker AMOUNT CLAIMED AS OF THE DATE OF PRESENTATION OF CLAIM AND THE ESTIMATED AMOUNT OF FUTURE CLAIM, IF KNOWN: Exceeds jurisdiction of Municipal Court DATED:December 30, 1991 SIGNATURE: dAA�mz - /z,�� ANTHONY GU RATTO *CLAIM MUST BE PRESENTED WITHIN ONE HUNDRED EIGHTY (180) DAYS OF THE INCIDENT IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS. CLAIM AGAINST MERRITTVIEW MEMORIAL HOSPITAL IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS 910 ET SEQ. * NAME AND POST OFFICE ADDRESS OF CLAIMANT: Amanda Christmann 1849 Lacassie Avenue #1 Walnut Creek, CA 94596 POST OFFICE ADDRESS TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT: .ANTHONY G. RATTO, ESQ. LAW OFFICES OF DUDA, RAHIM & RATTO A Professional Corporation 385 Grand Avenue, Suite 201 Oakland, California 94610 DATE, TIME AND PLACE OF OCCURENCE OR INCIDENT: July, 1991 DESCRIPTION OF OCCURRENCE OR INCIDENT AND ANY INJURY, LOSS OR DAMAGE INCURRED: Claimant sought medical care and emergency medical care at Merrittview Memorial Hospital beginning July, 1991. Medical care received was negligently provided and was below the standard of care, which proximately caused plaintiff's injuries. The injuries are for personal 'injury damages, emotional distress and other general and special damages, including wage loss, loss of earning capacity, permanent injury, and medical expenses. NAME(S) OF EMPLOYEE(S) CAUSING THE INJURY, LOSS OR DAMAGE, IF KNOWN: Dr. Hobart, Dr. Michael Baker AMOUNT CLAIMED AS OF THE DATE OF PRESENTATION OF CLAIM AND THE ESTIMATED AMOUNT OF FUTURE CLAIM, IF KNOWN: Exceeds jurisdiction of Municipal Court DATED:December 30, 1991 SIGNATURE: �. ANTHONY W RATTO *CLAIM MUST BE PRESENTED WITHIN ONE .HUNDRED EIGHTY (180) DAYS OF THE INCIDENT IN ACCORDANCE WITH GOVERNMENT CODE SECTIONS. r - ...... ......... ..... ........................ .. ... .............. ...... ................. .... .. ........ ... ............. ...... ....... .. ....... . ..... ............... . . ................. . .......... ....................................... .... .. ....... .... . ............. . .. ... ... . .. ........... ..... .... . ................. . .... ............ . ............................... ............... .. ..... .. ........... ....................... .................. ........ .... . . ....................................... ....... .............. ...................... .:::: .. ........................................ .................. . am .4 t a u'► m.0 .............................. RJ M a. s ti x° cr G (4 (fir M 'F• F - iLn - EL t'1 ; w 4J Poi o (1) Lr) � � N ; � O down aD0 ZQ WZ u a v ly J o o � Z a (Y) Q Q Y O 1 � n i n j /P7 CLAIM RECEIVED 3, - BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ' JAN 9 1992 Claim Against the County, or District governed by) BQARD ACTinN the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT J d n Ud r �� p. 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: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: FUNG, Don C. ATTORNEY: Andrew H. Meisel Attorney at Law Date received 1992 ADDRESS: Meisel &Sherman BY DELIVERY TO CLERK ON January 8, 456 Montgomery Street, 18th Floor From Risk Management San Francisco, CA 94104-1251 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: January 9, 1992 ga1L BAATTCtyLOR, Clerk o __ aw 00 11. FROM: County Counsel TO: Clerk of the Board of Supervisors 1�t•) 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 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 ( V1, 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. 0 Dated: JAN 2 $ 1992 PHIL BATCHELOR, Clerk. 8y a; 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: JAN 2 8 1992 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Y • w LAW OFFICES OF MEISEL & SHERMAN 456 MONTGOMERY STREET, ISTH FLOOR SAN FRANCISCO, CALIFORNIA 94104-1251 (415) 788-2035 FACSIMILE Direct Line: (415) 288-4038 RE FILE NO: (415) 398-4366 December 16, 1991 BIC-4599-1AW Legal Department Contra Costa County Fire District 2010 Geary Road Pleasant Hill, CA 94523 Re: Our Client(s) : Don C. Fung Your Driver: Buck Terry Lynn Vehicle License No: E202891 CA D/A: November 23 , 1991 Dear Claims Representative: Please be advised that this office represents Mr. Don C. Fung with respect to injuries he sustained on November 23, 1991 when he was struck by a vehicle driven by Mr. Buck Lynn. Our investigation has revealed that your driver was at fault for this accident. Personal injuries have been sustained by our client as a result of the negligence of your insured. Enclosed for your review is a copy of the police report on this incident. Please contact my legal assistant, Ms. Anna Wong, at (415) 288-4038 at your earliest convenience to discuss this matter. Please refer to our file number on all correspondence. Very trrgly yours", Andrew•' eisel Attorr'ey at Law Enclosure: Police report {�� RE EIVED JAN 8 !9092' CLERK BOARD OF SLIPCF'-:i:'�9S CONTRA COSTA CO 4 � Mull w T RAFFIC CO psm R PORT .ECIAI.C.ANi� lc I J. 8 R CI1V JUDICIAL DISTRICT NO. yam. FELON WALNUT CREEK WC MUNICIPAL q1Q ",.REPORT Mlso. CONTRA COSTA COUNTY Rt Z �}-�"' U,0Z' (J COLLISKJ'n; ,;ED ON RIVATE PROPERTY MOS DAV` viii IME(2x00 NCICr OFFICER I.D. LOC. Q 007t2 G AT INTERSECTION WITH �/ ❑ WET STATE HWY REL TOW AWAY PHOTOGRAPHS BY: OR: V FEETNAIL9 /�' OF e, -CRY n YES O rYES NONE PARTY DRIVER'S LICENSE NUMBER STATECLASS SAFETY VEH.YR. MAKE/MODEL/COLOR LICENSE NUMBER STATE E P. - DRIVER NAME(LAST.FIRST,MIDDLE) OWNER'SNAME ❑SAME ASDRIVER -DESTRIAP STREET AD RES OWNER'S ADDRESS ;] SAME AS DRIVER Z3 z� Y� -- 'ARKED ITYSTATE BIRTHDATE SEX RACE DISPOSITION OF VEHICLE ON ORDERS OF: ❑ OFFICER ❑ DRIVER E; OTHER EHICLE 1640. DAY r iICYCLIST F{D%S ONE -7 `loer mnr p��HONE `? ❑ (( (T�b� J PRIOR MECHANICAL DEFECTS: O NONE APPARENT ❑ REFER TO NARRATIVE OTHER INS CE CARRIER POLICY NUMBER 1 H I VEHICLE HA I N DAMAGED AREA 6 ` ,- '�-� ❑ LINK. ❑NONE ❑ MINOR DIR.OF ON STREET OR HIWAY SPEED PCF ICC O ❑MOO. ❑MAJOR O TOTAL , TRAY . �Ily1�T �/ PUC ❑ ((JJ CHP O DARTY IVE 'S ENSE STA7E CL S SAFETY VEH.YR. MAKE/MODEUCOLORR C,EN^SEN NUMBER ST TE y / EQUIP. '1W �� ;RIVER EI NER'SNA E ❑ SAMEASDRIVER v L, � DESTRIA STREETESS OWNER'S ADDRE O S AS DRIVER :zs Z4070 -.1914L,907- rej :RKED CITY STATE BIRTHDATE SEX RACE DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER - DRIVER O OTHER ,YCLIST HOME PHONE /y/[ 8US16NESS PHONE MECHANICAL DEFECTS: ❑ NONE APPARENT C] REFER TO NARRATIVE cS70 ZS'�,— f q33 ISA _ss00 )THER INSURANCE CARRIER P ICY NUMBER VIOLATION CHARGED DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA O 60-7-4 1,,,S ❑ LINK. NOONE ❑ MINOR DIR.OF ON STREET OR HIWAY SPEED PCF K:C O O MOD. ❑MAJOR O TOTAL ' TR ��` IMIT ...�. PUC O 'i'Gb 6 ❑ %RTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH.YR. MAKE/MODEUCOLOR LICENSE NUMBER STATE $ EQUIP. iIVER NAME(LAST.FIRST,MIDDLE) OWNER'S NAME p SAME AS DRIVER ESTRIAP STREET ADDRESS OWNER'S ADDRESS O SAME AS DRIVER ❑ RKED Cily S A BIRTHDATE RACEDISPOSITION OF VEHICLE ON ORDERS OF: O OFFICER Q DRIVER ❑ OTHER RK LE mo DAY YR. fCLIST HOME PHONE BUSINESS PHONE ( ' ) PRIOR MECHANICAL DEFECTS: ❑ NONE APPARENT ❑ REFER TO NARRATIVE THER INSURANCE CARRIER POLICY NUMBER VIOLATION CHARGED DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA ❑ ❑ LINK. Q NONE ❑MINOR DIIRR.EL ONSTREETORHIWAY `PIED PCF ICC ❑ OMOD. ❑MAJOR ClTOTAL ' PUC.0 ❑ KETCH f TYPE COLL A.HEAD-ON B-SIDESWIPE C-REAR END 1 D.BROADSIDE E.HIT OBJECT F-OVERTURNED I G.AUTOiPED. H.OTHER INDICATE NORTH SPEC GOND 1.CITU PROP.INV. Q.MUNI LOT 8 LOT NO. 3.BICYCLE INV. 4.PEDESTRIAN INV. 122 PCF J"• -0,Z>ZNTER VC SECTION OR U.UNKNOWN D.DRIVER ERROR CASE STATUS P.PENDING C-CLOSED 1 C S.SUSPENDED U-UNFOUNDED CLOSED BY ID a COPIE TO ' INDEXED BY: 'g.I(Rev,4189) FIC COLLISION CODING ,ACE %.1X•QN TYt}24001 NCC MJ ." OI NIG[,/0^ DAY .[.,GI/ /I US CA0071200 �• olvolIITE NAYI rADOK[ff - T / 7 ©� Nonwto TY �,[ N E o[fcwrnoN Do DAMAGE ATING POSITION SAFETY EQUIPMENT fd IC�BICYCLE HEIMFT EJECTED FROM VEH. OCCUPANTS I•DRIVER A•NOW IN VEHICLE L-AIR BAG DEPLOYED 0-NOT EJECTED 2 TO 6•PASSENGERS B.UNKNOWN Y•AIR BAG NOT DEPLOYED DOVER I-FULLY EJECTED 7•STA.WGN.REAR C.IAP BELT USED N•OTHER V•NO 2.PARTIALLY EJECTED ••AR.OCC.TRK_OR VAN D•LAP BELT NOT USED P•NOT REQUIRED W•YES 3-UNKNOWN •-POSITION UNKNOWN E•SMOULDER HARNESS USED 3 0•OTHER c.SMOULDER HARNESS NOT USED CHIS RFe_TR_►_INT PASSENGER j G-LAP T SMOULDER HARNESS USED 0•IN VEHICLE USED X-NO ' H•LAP/SMOULDER HARNESS NOT USED R•111 VEHICLE NOT USED If•VES J•PASSIVE RESTRAINT USED 2 An VEHICLE USE UNKNOWN K•PASSIVE RESTRAINT NOT USED T•M VEHICLE IMPROPER USE U•NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK I•I SHOULD BE EXPLAINED IN THE NARRATIVE AMORT COLLISION FACTOR TRAFFIC CONTROL DEVICES Tref OF VEHICLE t 2 3 MOVEJfNT PROCEDING 'JMBER 1.1 OF PARTY AT FAULT � Z 3 ' VC SECTION VIOLATED: c loss A CONTROLS FUNCTIONING A PASSENGER CAR I STA WGN. COLLISION /J a CONTROLS NOT FUNCTIONING• 8 PASSENGER CAR W i TRA1lER A STOPPED OTHER IMPROPER DRIVING C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER 8 PROCEEDING STRAIGHT D NO CONTROLS PRESENT I FACTOR' D PICKUP OR PANEL TRUCK C RAN OFF ROAD OTHER THWN DRIVER' TYPE OF COLLISION E PICJIUP I PANEL TRK W)TL0. D MAKING RIGHT TURN UNKNOWN A HEAD-ON F T,4UCK OR TRUCK TRACTOR E YOKING LEFT TURN FELL ASLEEP 8 SIDESWAPE GrTRIL I TRK TRACTOR W I TLA. F YOKING U TURN C REAR ENO SCHOOL BUS G BACKING FEATHER(MARK I TO 2 ITEMS) D BROADSIDE I OTHER BUS H SLOWING/STOPPING •CLEAR E HIT OBJECT J EMERGENCY VEHICLE I PASSING OTHER VEHICLE CLOUDY F OVERTURNED K NwY.CONST.EOUIPMENT J CHANGING LANES RAINING G VEHICLE I PEDESTRIAN L BICYCLE K PARKING MANUEVER SNOWING H OTHER•: MOTHER VEHICLE L ENTERING TRAFFIC FOG I VISIBILITY F7. MOTOR VEN:CLE INVOL VED41IN N PEDESTRIAN M OTHER UNSAFE TURNING OTHER-: A NoN-_ Us+oN O MOPED N KUNG INTO OPPOSING LANE ,3 WINO 8 PEDESTRIAN Q PARKED LIGHTING C OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VEH.ON OTHER ROADWAY OTHER ASSOCIATED FACTOR O TRAVELING WRONG WAY 8 DUSK•DAWN _ E PARKED MOTOR VEHICLE (MARK 1 TO 2 ITEMS) R OTHER.• C DARK-STREET LIGHTS F TRAIN A VC UC TION VIOLATKYL alto D DARK•NO STREET LIGHTS G BICYCLE OWES NO E DARK• STREET LIGHTS NCT H ANIMAL: B YC SAC"ON VIOIATKO.I. aTTO FUNCTIONING'ING• O W E f ROADWAY SURFACE FlXEO OBJECT: 0� PHYSICAL A DRY I C Vc we ION VIOLATION alto �r OWES (MARK I TO 21TEMS 1 :BWET J OTHER OBJECT 0-0 A HAD NOT BEEN DRINKING C SNOWY.ICY D D SLIPPERY(MUDDY,OILY,ETC.) E VISION OBSCUREMENT : B HBO•UNDER INFLUENCE F INAT7ENT10N• C HBO•NOT UNDER INFLU.• rrr,DWAY CONDITIONS G STOP A GO TRAFFIC D►�D•IMPAIRMENT LINK' AARK I TO 2ITEMS) PEDESTRIANS ACTION E UNDER DRUG I►FLU.• A No PtoESTRKAN INVOLVED H ENTERING I LEAVING RAMP F IMPAIRMENT•PHYSICAL" F -:. S,DEEP RUTS CROSSING IN CROSSWALK ( PRE NOUS COLLISION B J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN 8 LOOSE MATERIAL ON ROWr AT INTERSECTION H NOT APPLICABLE I(DEFECTIVE VEH,EOUIP.: anD (;OBSTRUCTION ON ROADWAY' C CROSSING IN CNOSSWALK•NOT OYES I SLEEPY I FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION ONO SPECIAL INFORMATION E ABDUCED ROADWAY WIDTH D CROSSING•NOT IN CROSSWALK L UNINVOLVED VEHICLE A HMIAROOUS MATERIAL F FLOODED* E IN ROAD•INCLUDES SHOULDER M OTHER': G OTHER': F MOT IN ROAD N NONE APPARENT H NO UNUSUAL CONDITIONS G APPROACH/LEAVING,SCHOOL BUSS/ Q RUNAWAY VEHICLE Ir-1 r v �• 7�F ��`' C✓3C-L = �UlIS� � L.S �CR l/,�L = 1o07 - V. 8 y . 3• v iS (,�T /cif /S .,rlco,gFgC NAA1E I.O.NUMBER MO. DAY YR. REVIEWEDBY: ` n11� {{/-'' O. DAY YR. ,UREO / WITNESSES / PASSE ;ERS PA.E 3 IyC_OLI{SI OI'•' U° TIME,/0 � NCIC NUMBER CA 0071200 PASSENGER (/ T,]IFICIR I.O. SS P �,)) ( EXTENT OF INJURY ( "X" ONE ) INJURED WAS ( "X" ONE ) PARll.T 'Al : ONLY AGE SEX NUMBER POS. EOUI P. [JEt TED Y FATAL SEVERE OTHER VISIBLE COMPLAIN INJURY INJURY INJURY OF PAINDRIVER PASS. PED. BICYCLIST .-I.. . ❑ ❑ ❑ ❑ ❑ 1 ❑ Pstl ❑(LAS I.FlMi I'miuULE) LAM ❑ _ "' �(/ O C, U 7 - - jzq S9-v ��/YLl ,UREDONLV)TA /7yF• g�1��a��r�I� /) ENT : sIBE INJU S A p /�GW7C Z1 ���F�� ,Ok• DyJQit'S• 1 ❑ 1 147 1 ❑ ❑ 1 ❑ 1 ❑ I ❑ I ❑ 1111cl lol I I FMUNL Oh i LAS SOS .FIRS I.M11JULL)ov- - LAJO v )RESS _ )I HANSPORTFD BY: TAKEN TO: T SCRIBE INJURIES 1 a 137 ❑ ❑ ❑ ❑ ❑ ❑ 101 ❑ 101 � s 3 rii• �/ � G J HE U ONLY)T HANSPOY: IAKFN 10- -SCRIBE INJURIES i ❑ I I I ❑ 1111 ❑ 1 11 111I ❑ 1010101 I ! ,ME'(LA5I.FIRST,MIUUCET )DRESS 'IJUONLY)TRANSPORTED BY: TAKEN TO: =SCRIBE INJURIES 1 m I I I o ❑ 1 0 l ❑ I ❑ I ❑ l ❑ l ❑ AML(L bI.FIHbI.MIUULE) )DRESS IQURED ONLY)TRANSPORTED BY: TAKEN TO: %ESCRISE INJURIES �� I ❑ I I ❑ I ❑ I ❑ ❑ ❑ 1111 ❑ ❑ :aarRsr. LOWTEcr PHONE — — DDRESS INJURED L ►TRANPORTED BY: TAKEN TO: )ESCRIBE INJURIES ,.�R'll�� �'J]//lA/ II.Y.M1� 1/• `� _ �j I WLM7 Jay - 555-Pg.3 kRev.4/89) NARRATIVE/ SUPPLEMENTAL WALNUT CREEK, CONTR., .:OSTA PAGE -•ATE 0;_ ORIGINAL INCIDENT TIME (2400) NCIC NUMBER L ,C/ CASE+ 40./1 DAY YR.�/ Aj Q0712 RECLASS�UISSIFI'ATION / CASE UNFOUNDED ci PENDING J 16 NARRATIVE SUPPLEMENTAL STATUS �✓ ❑SUSPENDED LOSED 2. I 3. 5. v G 6. . �='/ ' mac, �,. 19 iQ /L w L. .�/ 9. 42- 04 y ' 15w rflo9Comte 12. 14 15. 16. 17. tb. ,9. 20 21. '.3. � f •�� � ���4f �Qw� �F � w /=v ff� /51 72 /70 Z-/ 70) S),cX-' a TU I 4 � s � A c, sc� /tee S i� Mfr s , ac? �/-2 . S c' S v 2U �i fs 14tat1 w ARER'S NAME I.D.NUMBER MO. DAY YR. REVIEWER'S NAME MO. DAY YR. g.4 (Rev.4/891 a. NARRATIVE! SUPPLEMENTAL WALNUT CREEK,CONTR MSTA. PAGE S 'DATE OF ORIGUeAL INCIDENT TIME (2400) NCIC NUMBER CLA71171 _ CASE 4 NO. �/ """��� • V / j `DA YR:q// 00712 RECIASSCLASSIFICATION0 El NARRATIVESUPPLEMENTAL CASE [3 UNFOUNDED PENDING STATUS ❑SUSPENDED CLOSED S S I/ mal ff L 4. 5. 1/,":v CAI CIEfes,- 7A '. - v v 9. &4 10. 11. 30. 31. 32. 33. 34. GUST . 35. •REPARERS NAME I.D.NUMBER MO. DAY YR. REVIEWER'S NAME MO. DAY YR. . S - :5•Pg.4 (Rev.4169) i• d //Z 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 January 28, 1992 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: $602.59 Section 913 and 915.4. Please note all "Warnings". RECEIVED CLAIMANT: KAUFFMAN, Gary and Tina by ALLSTATE Claim No. 675 040 8995 JAJ ,JAN 7 1992 ATTORNEY: Market Claim Office Date received COUNTY COUNSEL 757 Arnold Drive Ste C JandAVPIVA1992 ADDRESS: Martinez, CA 94553 BY DELIVERY TO CLERK ON BY MAIL POSTMARKED: From Risk Management 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. January 7, 1992 PpHHIL BATCHELOR, Clerk v DATED: BY: Deputy CL -0-12 44 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: i Dated: I 11Z 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. 0 Dated:—JAN 2 $ 1992 PHIL BATCHELOR, Clerk, ByQ6= ° , 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: JAN 2 $ 1992 BY: PHIL BATCHELOR by M odd4&(0 d Deputy Clerk CC: County Counsel County Administrator AIM dq ie (pZ�3I /C11 MARKET CLAIM OFFICE 757 ARNOLD DR STE C MARTINEZ CA 94553 415-372-5000 RECEIVED JAN 3199 C /ti SORS CR �fDAAI COSOK�p Mloo r _. . A9 rrN-' `lu lc e o U m Our investigation indicates that your insured was responsible for this loss. Since we have already made a settlement with our policyholder, the claim has been assigned to us. Copies of the final papers relating to the loss are enclosed. Please accept this letter as notice of our subrogation claim. Your prompt payment will be -appreciated. Thank you. Sincerely, n �d/V,5 Ont Allstate CBP:G Claim Department Your File No. Ufi Kq Our Claim No. & 7S d 1/0 �j�GS GAJ Your Insured: 7hf1^u C65s l.6zt��jl Our Insured: Gmry Qnd JiVA K4UFFfi0/*1/ Accident Date: / a -/- ?/ Location: W/llou/ "'ass KV 4W6 (lne/o Q Amount of Loss: �f,. . t, � 7Ativ � � , .. _ �... CL CZ) (D 0 LU O Z C3 N y Boz cc tti C::) < Q LL Co LU C3 C 0 0 W Lu GO Cl) 0 O-Z�Tm O C= z �- Z 0 LU zZ K C3 El 0 C-) D 7 Le El =3 ' 0 z P: LL z u 0 cc 0 :D 0 0 WO c; c-> to+•, C3 "i - Z L) z z < 0 Lu 0 z z c'i Lu Z z T...-O-P, :-� �- ;5 < t cr 9 2 Z- LU =:) ,cn cn 0 < CO) 0 < Z dY ,w c) -. — 0 -J (5 :jz�< IL u z LU El<ElQ cc 0 u fP -1 Lf ZLL -i LV 0 U) D LL > W Lu :L ti > LLij 0 z z < ATZSTATE rNSURM- CE 30476 757 ARNOLD DR. C MART-INEZ, CA 94553 LARGEST SHOP IN TETE BAY AREA 28 YEARS OF SFRVICE BAR #AJ37114R 2520 MONUMENT BOULEVARD CONCORD, CA 94520 (510) 689-6117 Fax: (510) 689-7836 EST�MAT ° ' # JL 0476 lay .TOfTN PTCKKIT Date; 12-12-1991 Time: 12:36\, Date Written11.2-12-91 KAUFFAW Froo - e -83 .Tns. Co. ;AL1 STA".TE TNSIJftANCh: RennaAr Ics 1 l'1dj�.�stiPr 1 CONCORD CA J,icense 1 U64358 A 1"'I -se; DEL 1654-9091 Ser # 1101'DC1.4rMJ51.761,1. C1aiwint Nice I Rate CrAe;ALTO Tnstared , 83 G M C PICT( UP N'LEETSTDE In/Out Mi154358.5 Policy #ICNTRT, # 12-6 Style I "Pt- 11 Dedi.acti bi I $150.00 Claim # M50408995 995 # WSCRIPTION PST PRICE 1 TABOR ; 'PA LNT 1 LKq NGW REAR STEP BUMPRR-E I ?.20.Q0 1 i 2 RENOIR RT 1/4 CORNER0.5 ; 1 .5 3 ,REPAIR LF 1/4 CORNER � 0.5 1 1 .5 4 TINT AND BLEND I 0.5 5 CLEAR COAT t 1 ; 0.8 F,.S'J.'IMAT)w ** S11MM111:tY r,alaorDescri� " rtive�Tttxna PAINT Lq 3. " .� 0y'PART-Lir--I" ' �0 B01aY 1.4 2.B 44.00 123.2.0 I MA'T RIAT, 68.,40 FRSAE LA 0.0 44.00 0.00 ` SUPPLIES 0.00 MSCH LA 0.0 44.00 0.00 HAZARD WASTE 0.00 0.0 0.00 0.00 ; OUTSTOE CJ-K•3S .0.00 0.0 0.00 0.00 1 AX)VANCI✓ CHCS 0.00 0.0 0.00 0.00 ; STORA08 =.s 0.00 0.0 0.00 0.00 ; GLASS PART @-10% 0.00 0.0 1 0.00 0.00 ; SUB PARTS 220.00 6.6 ,a-Jor hrs. i t,a- 09 - ':4U Labor 290. 40 SiA)tot al 578.80 ax q-0825 Grand Tota] 02.5 tttttttttttt�Aklfff Part Prices Subject to Invoice ftttffttttfftftttftff AUTNORNED AND ACCCPTED: You are hereby authorized to make the above Rpecified repairs. J understand that paybient in ful will be due upon release of vehicle, including Additional supplemental damage chargges, and hereby grant you and/or your employees permission to operate the car, trunk or vehiele, herein described on REr(:A, highways or elsewhere for th Purpose o esting and/or inspection. An express mechanic's lien is hereb acknowledged on abnve rar, truck or Vehicle t. secure the amount of repairs thereto, You will not be held responsible for IosR or damage to vehid( or articles left in vehicle in case or fire, theft, accident or any other cause boyond your control OLD PAPTS ARB ,TANKED 1IN1,858 INSiRUCIIEDI ESTIidATB 'h authorized PARTS PRICES SUBJECT TO INVOICE . . . . . . . . . NO CREDIT 1rN,2I)S �0pb A-1/ l ZII , i / i ,� - CtAIM 1,17 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION Ve Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT January 28, 1992 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: $272 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: RECEIVE® tiJESTMAN, Scott ATTORNEY: Date received JAPE 7 110192ADDRESS: 120 Berrellessa Street BY DELIVERY TO CLERK ON JanaQ�= cbWNSh992 Martinez , CA 94553 MAXIINU, CALOR BY MAIL POSTMARKED: Hand delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHH1l ATCHELOR, Clerk L4) DATED: Jangar;Z 7 , 1992 8Y: 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: 1� Dated: /'I_ BY: I _ i Deputy County Counsel 0 - -_ \P 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 ( 1/f 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: AN 11 1992 PHIL BATCHELOR, Clerk, By O00&_1Deputy 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:—JAN 2 8 1992 BY: PHIL BATCHELOR by OLc) Deputy Clerk CC: County Counsel County Administrator r la t,„nBOARD 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 iling stamp ) RECEIVES + Against the County of Contra Costa ) .IMI 7 1992 or ) District) OF SUPERVISORS Fill in name ) A CO. !� The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ a` 2 .0 b and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) -------C C C!q�L-----------------_------------------------------------------ 3. How did the damage or injury occur? (Give full details; use extra paper if required) ! J q i'L c o5 4 q ( Ifl-i 'y C (o4 L,,S A ti n .1 Wc-v+- 4w/Sq c K 4o if c, _ ���; f 1.�y 5� 9 f t re c fl,io v+ MS q �n 1.F .(L c.y 0#*P U 4 41,C­10 ,ll..c+" -fl.cy wOuid PGy Vh� , 4L c1,� Z Qc-lu(.�(_r +a c 4L_ SGi I �U �c GeV-\ , VZ �Jl j` _1�__�A_t .. f�c tl� -�� . �. fi Of c�Z 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? nn �oz ke-`/ v � S4404LCJ my 0_ 10 I.,,cS CEJcuO )9--- QccA Q^-' 0 CA4 ��.L_ `SG I k. Cu L0. S ke� QS (N e C � u L. S �Cl 1 r I°,v g q l?>00 ' (over) '' --. ' � �`� -,,,- ;', �; _... ..... a,�:� ,. ��e �; _w�-xva���,xr�gm�Er�rr+2� ,-". �: s I I ;:5. ,,What are the names of county or district officers, servants or employees causing the damage or injury? -__- _ ►_� - -1- -------------------------------------------- 6. What damage or injuries 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 damage.) C �� L,`5------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. 1 _____________________________________________________________________________________ 9. List the expenditures you made on account of this accident or injury: DATE ITE AMOUNT q'l2a1,1 Iu�ss3�,�sr�ss���is o6 �ox�rs 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 Claimant's Signature 12p 5c rrC_I JcSS A 54- rlg 2J►A&z (Address) Telephone No. Telephone No. S??-- V !?-- d 3 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.