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HomeMy WebLinkAboutMINUTES - 12121995 - C9 CLAIM � 9 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unlanown � 13�a' S�eation 913 and 915.4. Please note all "Warnings". CLAIMANT: Melvin De Van Daniel ) 2 ATTORNEY: COU{ TY COUN1S'SI- MHRTIVEZL��I'r• Date received ADDRESS: 901 Court Street, B-8 BY DELIVERY TO CLERK ON November 20, 1995 Martinez, CA 94553 BY MAIL POSTMARKED: NovPmhPr 14 1905 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. �qIL BATCHELOR, Clerk DATED: November 27, 1995 � : Deputy__' 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ,YThis 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: L-2WJ10 BY: �_� Deputy County Counsel II1. 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 (V/) 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: (et• 12, — /9 9 S PHIL BATCHELOR, Clerk, By J 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: r��� 2 IS, BY: PHIL BATCHELOR b _ D uty Clerk CC: County Counsel County Administrator r L � xv: RECEIi�E t y ICU 2 U 1995 OF SUPERVISORS ---- CO (RA COSTA CO. m 1 - ­V.0 l ----- ....--------- -_ .0-... -- ----- c, c crz a C1 1�----- _._ �r-c Vis l J t ---- -- ---- e---_c__f �d cl_s�� �1--- ! _ ��1 1\ _ �-� -----�_--_�- _Vit_�-�----C`_�..�.�_ W Vit_`�-___'�--2SZ ��____�.le'4,�-�� '• - ---- .. _) -- ---------- --- ----------- -- -=----- ------- --------- ------ --------------- - - ----- t-n- -�-` - ----- ------ OFFICE OF THE SHERIFF - Warren E. Rupf vFu SHERIFF Contra Costa County . Cusbudy Servix=Burwu ,� Russell F.Pitldn mr Undersheriff 1000•Ward Street Martinez,California 94553 (510)646-4860 V. Cpl 9 COs% To-: Inmate Melvin Daniel Date: October 26, 1995 B-Module Martinez Detention Facility From: Lieutenant Ray Rodrigues Subject: Grievance/Appeal re: MDF Commander alleged Deputy Conduct. Regarding your inmate request pertaining to a female Deputy working B-Module on the evening of October 21, 1995. When I responded to a previous request I was not aware a Reserve Deputy was assigned to work with Deputy Mariner. Reserve Deputy Stacy Ellis was the assigned female you are referring to. I have interviewed all concerned and have determined you were called aside by Deputy Ellis in a professional and respectful manner. Your grievance/appeal indicates you were somehow sexually harassed or insulted in a sexual way. Since you fail to provide a detailed description my interviews concluded you were requested to explain your decision to constantly stare at Deputy Ellis for hours before finally being taken aside to determine your concerns. I am satisfied you were treated politely and professionally. Letterhead Form R 1193 SBH AN EQUAL OPPORTUNITY EMPLOYER ry LUul w y Z W 00 a c s $ c ti � 3 �{ t� xLU W �. Z 4 ` L W �w Ir cr LL UH Z cc �W V LU" Cc i aNTR, TABOUNTY C. ION FACTLI'TY . RETE . :: .Q ( INMATE REQUEST FOR INF.ORMATIOW`. ( )`MEDICAL REQUEST; From.Clt1 \ n \tri. �c s. #�`J �- -- Date: /q Housing Assignment: lU- AoRB Check One: ( )Request ( ) Grievance ( APP eal ( )Other I Request: \ Cit CtC2 ` - n 0" e ttArl�it r�,. a Date Rec'd: / / Recd B : �. Routed To: Aetz.ties(/ ANSWER: ( ) APPROVED ( ) DENIED_-(state reason) Dat . BY: Ye Reply to Inmate white To Booking Pink:Kept by Inmate DET 024: 1/2/91 s � .tL.�a.�: ro.��, r•'"'� of `� �tJ �. r � j G � � r CLAIM ` f BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4. Please note all "Warnings CLAIMANT: Melvin De Van Daniel ATTORNEY: Date received ADDRESS: 901 Court Street, B-8 BY DELIVERY TO CLERK ON Novemh,-r 2.nd lQg9 Martinez, CA 94553 BY MAIL POSTMARKED:__.._._!___ _Nbinx.1l 1 qq5 __- 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppN IL UTCHtELDR, Clerk DATED: November 27, 1995 81�: Depu y__. 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: //1-2 b— �J/ BY: Deputy County Coun! T II1. 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 (V/) 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: 141- 12, — 10101-90 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (6ov. 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 went to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of Th.'s Notice AFFIDAVIT OF MAILING _ I declare under penalty of perjury that I am now, and at all times herein meh ioned, m ve been a citizen of the United States, Over age 18; and that today 1 deposited in the United States Postal Service in Martinez, California, postage fully prepaid a Certified copy Of this Board Order And Notice to"Claimant, addressed to the claimant as shown above. Dated: 12 ••/��_� g 9_� BY: PHIL BATCHELOR b4 uty Clerk CC: County Counsel County Administrator M Q td,J o a U w a t c a mo 04606 of pa Cl) H ` � U � N w MSH a �+ r� L v C4 N p p r E7 '`c0 dam' } N � tun) Cc: G �D -n Y,c 00 '�l (2 , 9 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995/ Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: $250,000.00 Section 913 and 915.4. Pi easete alb"Warni�qs'« CLAIMANT: Andrew Castillo M t1 r��I 2 tJ uadJ ATTORNEY: Tyler A. Shaw, Esq. COUNTYCOUNISEL Jacoby & Meyers Date received MARTINEZ CALIF. ADDRESS: 100 Bush St. , Ste. 700 BY DELIVERY TO CLERK ON November 20. 1995 San Francisco, CA 94104 BY MAIL POSTMARKED: Not Legible I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHH g DATED: November 27, 1995 BI�II 6epuLyLOR, Clerk n 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: s BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with nu :ice 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: /2— 19-— 19911— HIL 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: 9 9.� 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 1060 County Administration Building, 651 Pine Street, Martinez, CA 94553- C. If claim is against a district governed by tie Board of Super.isars, a.:t::er the County, the name of the District should be filled in. D. AIf 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 Andrew Castillo ) RECEIVE® Against the County of Contra Costa ) NOV 2 0 1995 or ) District) CLERK BOARD OF SUPEWSORS Fill in name CONTRA COSTA CO. ) ° The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 2 5 0, 0 0 0. 0 0 and in support of this claim represents as follows: - 1. wnen did the damage or injury occur?? (Give exact, etc -nd hoer) June 26 , 1995 9 : 05 P.M. 2. . Where did the damage or injury occur? (Include city and county) At the :.intersection of Carlson Blvd. and Cutting Blvd. , Richmond Contra. Costa County�j, California 3. 'How did the damage or injury occur? (Give full details; use e paper if required) Due to malfunctioning traffic signals and the negligence of the other driver, a collision occurred injuring claimant. 4. What .particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Failure- of the appropriate Contra Costa County public entity to patrol and maintain traffic signals. (over) 5. What are the names of county .or district officers, servants or employees causing the damage or injury? Including but not limited to: Officer Gagan; Richmond police department; Contra Costa County and the division of Contra Costa County responsible for the maintainence of traffic signals. ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Substantial property damage. Claimant sustained severe injuries including but not limited to: facial contusions, hematoma, scapular pain and a _--1 aYa ti.cui-tc—the_f a ce_hemLow-the-1 e ftt-eye.-------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Discovery is continuing ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. INCLUDING BUT NOT LIMITED TC Mr. Yoshi Tomimatsu, 2356 Carquinez Ave, E1 Cerrito, CA; Mr. & Mrs. Robert and Doris McKillican, 6200 Laquinitas Ave, El Cerrito, CA; WCC Radiology, 305 Lennon Lane, Walnut Creek, CA; Brookside Hospital, 2000 Vale Road, San Pablo, CA; Richmond Health Center, . 38th & Bissell, Richmond, CA. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT INCLOI5- G-B.UT,,..N�LIMITED TO: 6-26-E95=' ¢" P;iribulance $708 . 00 6-26=95 ­--Br6bltsMde Hospital $2 ,996 . 00 6-27.-95.,, . WCC Rad4iol� $993 .00 Gov. Code Sec. 910.2 provides: .{. _',a... "The claim must igned by the claimant SEND NOTICES TO: (Atrtorney) or A some p on n his behalf." r Name and Address of Attorney Tyler A. Shaw, Esq. C i is Signature) l/ `s ��� Jacoby & Meyers 100 Bush Street, Ste. 700 San Francisco, CA 94104 Address Telephone No. 415-399-8951 Telephone No. N O T I CE 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. JACOBY MEYERS t LAW OFFICES PERSONAL INJURY UNIT 100 Bush Street,Suite 700,San Francisco,CA 94104 415/399-8951; FAX:415/399-1939 PROOF OF SERVICE I, Indira' Chakrabarti, declare: I am over the age of eighteen- years and not a party to the within action. My business address is 100 Bush Street, Suite 700, San Francisco, CA 94104 . On November 15 , 1995, I caused to be served the within Notice of Claim by placing a true copy thereof in an envelope- with adequate postage, and depositing same via certified mail item. no. Z 426 745 073 in a U. S. Mail receptacle, addressed as .follows: The Clerk of the Board of Supervisors County Administration Building, room 106 651 Pine Street Martinez, CA 94553 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this fifteenth day of November, in San Francisco, California. i We use recycled paper. PARAMEDIC AND d NON-EMERGENCY AMBULANCE SERVICE 07/ 14/95 PAYIEN•T. IVAME ANDREW CA'STILLO ACCOUNT NO. : 1076356o DATE OF ;SERV 06/26)95 AMOUNT DUE 708166 ANDREW CASTIL.LO 1641 SANTA CLARA ST Fi I CHMGill D , CA. 944 04 *I F .YOU HAVE ANY QUESTIONS PLEASE ' *CALL OUR OFFICE AT (5 1 0) 657-9999* *ASK FOR: CUSTOMER SERVICE A. DEAR: ANDREW CASTII_I_O PLEASE PROVIDE U'S INSURANCE INFORMATION, IF YOU ARE NOT INSURED PLEASE CALL US. WE NEED TO HEAR FROM YOU WITHINV4 DAYS FROM THE ABOVE DATE. ####################### 4##"4 ::;L,,;4 a 4 :l##rt#####u:###INSURANCE INFORMATION#############.########### 0###################### INSURANCE COMPANY ANY NAME (COPY OF CARD) : AND ADDRESS: : •:;1' E OP INSURED: 13ROUR #: EMPLWER ' S hAME AND r=gni=iii_`,-, RELATCENSHIP OF PATIENT , IF P,(r'mE OF INSAND/i R GUARANTOR IS - 1 i E._�1 L r:r't- P••!U C';_'`_.ice:,. i.(-!.-�-_ " ? -------- -------- � --_-- MED I--CAL NO. (COPY OF CARD OR POE, FOR MONTH OF (SERV I CIE) INDUSTRIAL INJURY? YES,,,,,NO. 1 IF YES, EMPLOYERS NAME AND ADDRESS g I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY FROM ANY SOURCE TO PROCE'E,`_:; MY CLAIM FOR PAYMENT. . I AUTHORIZE MY INSURANCE CARRIER, HEALTH PLAN, MEDICARE OR MED I•—CAL TO PAY SAID AMBULANCE INCE COMPANY FOR THE SERVICES PROVIDED. I UNDERSTAND 'L HAT HE BILL FOR TI--IiE SERVICES IS MY RESPONSIBILITY AND THAT THE AI`11_+l!I_ANCI_: COMPANY IS BILLINO ON f`i`r` BEHALF AS A COURTESY. INSURED SIGNATURE PATIENT ' S SIGNATURE- -----THAN(:: YOU 41300 Christy Street • Fremont,California 94538—P.0.Box 7780 • Fremont,California 94537-7780 STATEMENT 8/07/95 WCC ,RADIOLOGY MED GP:-- INC 305 LENNON LANE WALNUT CREEK CA 94598 510-945-0755 EIN# 94-1700773 PATIENT REFERRED BY . . . Robert Mandiberg SERVICES PROVIDED AT . . . BROOKSIDE HOSPITAL RENDERING PHYSICIAN (S) . . W. GREG WIERZBOWSKI , M #02 ---NO INSURANCE BILLED-- --ACCOUNT#-- If you have insurance , ANDREW CASTILLO WC0000916910 please . return this bill 1641 SANTA CLARA STREET with a completed insur- RICHMOND CA 94804 ance billing form and/c your insurance ID card . zxzxxxxxxxxzzxxxxzxxxxxxxxxxxxxxxxxzxzzzxxxxxxzzxxxxzzzzzzzxxxxzxzz * * ** * *IMPORTANT NOT'ICEx** * * * We do not have insurance information for you . You. * _ may use this statement to bill your insurance if * you have insurance coverage , or you may send us * your insurance information and we will bill for * you . Please send your payment by return mail . PROCEDURE PAYMENTS DATE PATIENT DR# CODE DESCRIPTION DIAGNOSIS CHARGES ADJUST_E -------------------------------------------------------------------------------- 6/26/95 ANDREW 02 7015026 FACIAL BONES 3 7840 42 . 00 6/26/95 ANDREW 02 7102026 CHEST TWO VIEWS 78650 37 . 00 6/27/95 ANDREW 02 7416026 CT ABDOMEN W/CO 78900 289 . 00 6/27/95 ANDREW 02 7045026 HEAD WO 34610 221 . 00 6/27/95 ANDREW 02 7219 = 26 CT PELVIS WCO 78900 273 . 00 6/27/95 ANDREW 02 99052 AFTER HOURS CHARGE 78900 131 . 00 •--------------------------------------------------------------------------------- ov�; CVE_: OVE_. OVER Tor 0 �.. _ S 90 DAYS 60 ..SFS 30 DAYS CURRE\: Di._ �0 . 00 . 00 . 00 993 . 00 993 . 01- ### 93 . 01### To insure proper credit , please write your account # W00000916910 on your check or return lower portion with your remittance . ### If you were seen in a hospital setting , you will -receive two bills this one from your physician and a separate one from the hospital . 5% SUPER REPRODUCTION SERVICE Hospital Record Photocopy Main Office: 953 Mission Street,Suite 31 Mailing Address: P.O.Box 2718 Medical Records San Francisco,CA 94103 Daly City,CA 94017 Attorney Services 415-546-0951 FAX:415-546-7439 Name of Patient: Andrew Castillo Date Of Birth: 04/18/57 Date of Accident: 06/26/95 File Number: Claim Number: Doctor/Hospital Name: Brookside Hospital 2000 Yale Road San Pablo, CA 94806 Records Requested By: Jacoby & Meyers Law Offices 100 Bush Street Suite 700 .San Francisco,CA 94104 . � :3 f tr C:) - s rri _ 3 r it '.'� -1 m Z O 1, r ri.G. ..m CL !y f F. z �1 r O o 0' O co - = z n r i > m t-DETACH AND RETURN WITH YOUR PAYMENT D [n Z-0 Z C1 A n W-4-4 O Z �Z m �; m mxx C D m-a �o o i 03 ZDV Z c >> 3 I w 1 Z D \_ "L' o=Di D m Z IT m Z O 9�m O O 37 N _rZ D r < 1c) p0 • _ ohm �p?D p 2 Z _ m 0 ATn X ... •, _. . ... gx wDD-I N co Q �_ 7z D > D -to r >m > ATTORNEY OF RECORD Jacoby and Meyers (415) 399-8951 Case Number Law Offices 100 Bush Street, Suite 700 San Francisco, CA 94104 DECLARATION OF CUSTODIAN OF RECORDS PLAINTIFF: DEFENDANT: DEPONENT: Brookside Hospital RECORDS REGARD: Andrew Castillo DEPOSITION DATE: I, the undersigned, being the duly authorized Custodian of Records or other qualified witness, and having the authority to certify the records declare the following: the records were prepared in the ordinary course of business at or near the time of the act, condition or event, and that: CERTIFICATION OF RECORDS COPIED CERTIFICATION OF NO RECORDS ❑ All of the records called for in the subpena or ❑ A thorough search of our files has been carried written release are in my custody and have been out under my direction. Based on the copied by this Deponent. A true and legible copy information provided for identification, no or of said records are submitted herein. documents, records or other materials called for in the subpena or written release exist in All of the records called for in the subpena or our files. written release are in my custody and have been released to a Super Reproduction Service SELECT REASON representative for the purpose of copying. ❑ All records for the time period in question have been destroyed pursuant to our AIlliLLING RECORDS (if requested) document retention policy. ng records are produced herein. ❑ Records do exist, but none within the time ❑ We do not have billing records as requested. period called for in the subpena or written release. X-RAYS (if requested) ❑ A complete and thorough search has been ❑ X-Rays and/or other films are produced herein. conducted and no such records were ❑ We do not have x-rays or films as requested. found. ❑ Other: PATHOLOGY (if requested) ❑ Pathology materials are produced herein. (if more space is needed, please attach additional sheet.) ❑ We do not have pathology materials requested. I declare under the penaltyofpurjury thattheforegoing is true and correct. I Executed on (date): ! — �`� at (city,state • Print Name:- 'v/ Signature: DECLARATION OF PROFESSIONAL PHOTOCOPIER (BPC Section 22462) 1 declare that I am the attorney's representative and that I made true copies of all the original records delivered to me by the Custodian of Records of the within named location, and these records will be distributed to the authorized persons or entities. Executed on at ,CA. Signature• SUPER REPRODUCTION SERVICE DECLARATION OF CUSTODIAN OF RECORDS _ . °a , ��, fQ SRO®KSI ®E eOSPITAL j . L, 2000 Vale Road o San Pablo, CA 94806 . . a k a4tLiQc CA5T1Ll. f@,�cy�Ci 74',Y7- 9U 6 9 10 � FDIG®Il�:o s be ,ROM a�. 111111 1 1111 D o 0' r. 12to4 I y � G 1�! W'r!? bl � ?[ '�;' 1n! f7 0",U1 ()LCV I.Aid F3w'R ;,, �'l1 ?..`? T 1) JG { Cf , ANt-Dvt :S L iSTT LL,-', 11 Cut" S I 0�F «,'i r'- :`1t 1 �f �, i.•t5,^:.i`J. y _ PERRIP,m, rt. 0f1}k '' 2 77 7y: SOLUiTOM S r R : 4.i 'Lw`7V Ctj� 7 or,, n . .r. !vSF'I �A arr"' Y T ":: KATY 'rS .Ci 46yj'1 i f-1d 11 tR _NT LH A G " 7 9 911;- ,1' i 11LA;:t aEASE REFER TO PATIENT NUMBER ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY CHARGES ON ALL INQUIRES AND NOT POSTED WHEN THIS BILL WAS PREPARED. OR IF INSURANCE CORRESPONDENCE. CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN. FORM 8530-136 1.93) IMPORTANT*INSU PLEASE A NON PROFIT ORGANIZATION PHONE{510) 235-7006 COVERAGE IS - SEO.1449 REMIT TO 'aaal¢�cdeod� e IRS N0. 94-6003145W X2154 ESTI•HATE AND,110 DEPT.1479 P.O.BOX 61000,SAN FRANCISCO.CA 94161 BROOKSI ®E 1- ..:)SPITAL ST L L 2000 Vale Road ® San Pablo, CA 94806 ROMEr �4 o e o e !:l Z / y�. 4'7 ;6 i� I Z L , ti``... 14 1 16/5 7 u l�4l it`s{ Ct l r.A'a :-'"�:� q�G R 0 R 1 f; T Nhtuc": aSTTaI sH"I Erin i:T( Hi'9!1�rtyG:;14 a w aril.:i Y 1,(115 ;}"�! .! .6i° n 22 C 00 2c; 1 wC TN 50Mu' fr Y P[iC D 4713-11 raj i3 ? > 3 i tt1 T-i'F 7 a e Y! 0 R a Li 1. t ! P ?SJ'fi'T 19 is 3.4 .:-.1 U 3 4.+1 0 F' a( TA U 3 ;*IES 4 G4 5-j Zlffw^'�% cI. t� 1if CSL 4>:3 ` 75;f 1c8 C-;u 1?_„Q0 >! .'? ji, A '. nC' 1� :347.7 03 4 (} .^G 4 .;.1 C 9 b3 •0 1 ij 6 3 a L+0 � I-11”! �' r' I-i:- L ti ,(� .�.:.4 t:�� - s'�o s f`ii �;ti. +,j 0 - - x �G ! i .. J7 L� _I,aT 4 . i`=w11 05 . veU cl PLEASE REFER TO PATIENT NUMBER ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY CHARGES -, ON Al L INQUIRES AND NOT POSTED WHEN THIS BILL WAS PREPARED. OR IF INSURANCE ccRaESFordDENCE. CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN. FORM 8530-136 '/.. MPORTANT INSURA (1"93) PLEASE Fnaa&ede T C1Q G�`GL� ANON PROFIT ORGANIZATION PHONE-510 235-7006 E IS SEQ.i4=6 REMIT TO IRS NO.94-6003145'x! ( ) X2154 ESTIMATE AND NOT Fit DEPT. 1479 P.O.BOX 61000.SAN FRANCISCO.CA 94161 SUPER REPRODUCTION SERVICE Hospital Record Photocopy Main Office: 953 Mission Street,Suite 31 Mailing Address: P.O.Box 2718 Medical Records San Francisco,CA 94103 Daly City,CA 94017 Attorney Services 415-546-0951 FAk 415-546-7439 SHREM ol� �KSl ! - DS ITAL FINAL 07/01 /95 0 6 TL L 2000 Vale.Road ® San Pablo, CA 94806 • ` p 4' a'e.Y Oil9010 ` . a }.,.,. i DA;i, �7 r11TTtt ;I r�. j "�Q n R 06 20/ �i r� 2c 10 0112 :.}/`t5 21 : 42 Oz= / 1WI57 0000 01)'001 ill 4N'D 2! 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PLEASE - / �J� A NON PROFIT ORGANIZATION PHONE(510) 235-7006 COVERAGE ISOU.- SEQ.14'6 REMIT TO DEPT. 1479 B �PC00,SAN`GZe o IRS NO.94-6003145W X2154 ESTIMATE AVD NOT- DE, !. 747„P.O.r C.6GX 61000...AN FRANCISCO,CA„4161 FLNaL �'`?/-01 /95' 1 BROO SIDE [,. -,DSPI TAL j , ;.L 2000 Vale Road San Pablo, CA 94806 attiiR w- Ca ST'. '_L U 660 74;;75 `i 1. b9 iP, L L`r/ ZC?/ SUPER REPRODUCTION SERVICE Hospital Record Photocopy Main Nice: 953 Mission Street,Sub 31 Mailing Address: P.O.Box 2718 ' Medical Records San Francisco,CA 94103 Daly City,CA 94017 Attorney Services 415-5460951 FAX:415.546-7439 I MEDICA L. BROOKSIDE HOSPITAL 2000 VALE ROAD SAN PABLO, CA 94806 " ' , - F AT GCT# C>74U7,� MED ;REG# 91 b9 10-- b2 (510) 235 7000 ATOM DA fiE b Cb 95 $VCS'CD EMR ADM TIME 2s.40 SPT TYFE'a E READMIT # 1351006 : ESRC CD:' FC F :41 b/ 6/9c ACTIVE OUTPAT I ENT EP,ARTMENT VIP'a {V PATIENT INFORMATION NAME b A S"T"I LO, ANDREW SEX M RACE H MS S ' DOB 4 `i$ 57 AGE 3B �1bDR' ib41 SANTA :CLARA ST RRIOf 4 H'OSPVTAL CITY R I CHMOl ST CA PRIOR' STAY c' s I P :�94804" PH �1 A=5^4--3b��� SMS � REL I G TON ANO F'FtEFERE�tCE r� � - PHYSICIAf�LMl �" r�� /E� F!-1vSICIAN ATTENDING FrIYSIGTAtu FRIMAF�Y GAFFE �35i=7nt�� P SICIAN , 1 510/ 35--70t'1G s. 1 PATIENT EMPLOYER NEAREST RELATIVE EMERGENCY CONTAuT NONE MOTHER MOTHER CAST,ILLO,t IUA` s CASTILLO, ILIA 1b41 SANTA CLARA ST 1b.41 SANTA :.GLAA ST -. R I CHMONLf ' CA ;.. .: N 9484 510 524 3b5z 948:04 510524 3652 GUARANTOR GUARANTOR EMPLOYER OTHER SELF'; NONE �4 n RM zSS# GASTILLQ�' ANGREW SU 1700 TE EMPLOYED 1641SANTA CLARA =ST UR flGENCY : _ ICHM0ND CA _ AUTi#a 4804 5.10 54 3652 GONSERUA'TOR• ' -M-.,. -..e,. .. :.- ' ., ,^.. .: .•4::.e vpS„ V.x .-. _.:. -...- - . '=-1t ,o _ .:S'.G'w -..... a .. ...._-.... r....s_, ..._. PRIMARY INSURANCE SECONDARYINSURANCE TERTIARY INSURANCE �'°� -� GROUP POLICY CLAIM GROUP-POLICY-CLAIM GROUP POLICY �AIV 2 5b Sf t k a � n O� r Y 4 � �;QiNS N - � �• M` ADMIT DIAGNOSIS HEA63INJURY ®! 6 �b 9� r�L1T0. ACCIDENT eROUGiT r } RELATIVE HERE`: Y N CIRCLE . ,ONE. � —2 b —95 r, ( �) D0 OR WILL CAL! �— �' 9 (r ) P :D NOTIFIED HISTORY/COMMENTS F 0 INS REFNDER TREATMENT r ERRED TO ED WI ( EL`BY x - POLICEOFFICER NAME AND NO h CLERK INITIALS 8560-300(7/93)SEQ.1389 (1�' 1NlA1 _nn AlnT DCRAMIC C IIA f%UAD T' UNUUMbIUt r1VJYI I AL tMtZHL3tN;-Y MtIjIUAL Flr-% WU IIJ Triage DU enta Pon San Pablo,CA 94806 DATE: ❑ Unscheduled Return Within 72 Hours Name(La �- c�(CI. b 2 0-1401 91'b �1 M x Age DOB� � Ins rrier Prio' ET iCA5.1$�.L�3e "W �� It3 I III FT THOD OF 141 Ambulatory ❑EMT ElW/C PMD L P ARRIVAL PM E-1 Other I LR,2, � 316 1W TRIAGE TIME EXAM RM TIME POLICE NOTIFIED? SOCIAL SERVICES �'/ � �'J'1` 2- Q ❑Y S ❑YES Chief Complaint VA \9 OD—OS— PMH IMMUNIZATIONS YES NO I IMMUNIZATION UP TO DATE? ❑ ❑ INFORMATION GIVEN ❑ MEDICATION Non �c� ,_ LNMP G_ - P— AB LAST TD L O ^ ALLER ES 1-- n-�^ N KA }P�. P SUB/OBJ DATA z23� ��' 1 _ — R TX:ICE[I _ WT _ DRSG: LJ M.D.TIME DICTATED INTERPRETER LANG FAMILY/FRIENDS ❑YES ❑FOLLOW UP HISTORIAN IN WAITING RM ❑NO Signature: H+P SH: FH: j^ PMH: a L PROCANTERP. C S ❑ SEE PROGRESS NOTE: Consulting Physician's Name m Iled Time Responded Time Arrived LAB TIME X-RAY TIME MD ORDERS INSURANCE AUTH ❑ TIME ROUTE SITE SIGNATURE ORD INITIAL ORD IN TIAL ER Panel" �4 Cx R ❑ BC Abd X-R _ ❑Lytes / ❑ pine ❑ P TT— - � ❑ Old Record .� ❑BICX ❑EKG Condition: ❑ Improved ❑Stable ❑Critical ❑ ExpiredG S , DISP: ❑ADMIT SERV RM TIMEDX 1. �, PMD ACCEPTING 3 �C/ J rV�S ❑ TRANS TO: TRANSPORT BY: 1:1 BLS ❑ ALS ED/DC TIME HOME MD/SIG ' -M CHART COMPLETE % 7015-103A(1/93)SEQ. 1354 MEDICAL REC RDS —� ED NURSING FLOW SHEET ILI DATE: NAME: 1 :f$ .: . A. V.4, . ... 02 Umin El Cannula []Mask Cardiac RhythmJ* f 1 2 3 4 5 6 7 8 9 Pupil Guage(mm) . o i PEDIATRIC START AMOUNT RN HYDRATION/MUCOUS COLOR ACTIVITY LEVEL TIME AMT PARENTAL FLUIDS/BLOOD SITE ABSORBED SIG. MEMBRANE ❑ lk Irnla yful e❑q ❑❑Dull❑ ry c ❑Poor Skin Turgor GENERALASSESSMENT CARDIAC RESP - EENT TRAUMA .V6R Reg. ❑Oual.Normal ❑No Deficit ❑Nothing Visible ❑HR Irreg. Near Bilah- ❑Deficit maceration ❑Chest Pains ❑Laboredf r7f SKIN ❑Palpitations C1 /Rhonchi Warm ❑Edema ❑Rales ❑Retractions 0 Cool ❑Burns ❑Wheezes ❑Diaphoretic ❑Puncture ❑JVD ❑Pale ❑GSW Gt ❑Rash �/A ❑Deformity ❑Soft X$welling ❑Bowel Sounds ❑Bruising LASGOW CO SCALE cYrv11Y infants Children and Adults ❑Tender INPUT OUTPUT ❑ROM Decrease EYE Spontaneous Spontaneous OPENING 3 To speech or sound To speech ❑Distended IV URINE ❑ 2 To infutstimuli Nonein ❑Riged PO EMESIS VERBAL 5 Appropriate words or sounds; O anted social smile;fixes and follows 4 Cries but consotable Confused 3 Persistently irritable Inappropriate words OTHER OTHER j None Restless; Incoemprehensiblewords MOTOR3 Spontaneous movement Obeys commands Localizes to pain Localizes to pain 4 Withdraws Io pain Withdraws to pain 3 Abnormal flexion(decorticate) Abnormal flexion decortca F Abnormal extension(decerebrate) normial exte)tension decerebrate 1 None(flaccid) one(ffa=4 -- Adapted from Teesdale.G.,6 Jennett,S.(1874).Lancet z 81.84;and James,M.L.(1968).Pediamc Annals,15(1).17. TOTAL SIGNATURE ' TIME: PUPILS: Size R NR 3 Size R NR TIME 8P P RESP T P OX E GCS NURSING PROGRESS NOTES I On Lk 'J.a,..,. 1,) Gam-,, C1.+ 1 -5 C I o t c � C METHOD OF DISCHARGE: DISCHARGE DISPOSITION TIME:_ / AMBULATORY ❑W/C ❑CARRIED [I CRUTCHES ❑CRUTCH WALKS WELL ❑AMBULANCE ADMIT PT.BELONGINGS: ❑PATIENT ❑FAMILY ❑SAFE ' LIST ITEMS: MEDS TO PHARMACY RN SIGNATURE 7015-105(6/94)SEQ.1426 naGrltf^at oc��one wow BROOKSIDE HOSPITAL # - EMERGENCY DEPARTMENT NURSING FLOW SHEET #7015-105(9/92) DATE NAME RN TIME --4SITE SIGN. t. TIME BP P RESP T PULSE L E GCS NURSING PROGRESS NOTES c.Q,.,_k C I v � ..� �. Nva C�-:.o _ �•— �.....� 7` 0 6 c_e Z L8 6 m l6 D / -Aze—c-- S 'A - 15-41/0 16 rAL BROOKSIDE HOSPITAL 2000 VALE ROAD SAN PABLO, CALIFORNIA 94806 TELEPHONE (510) 235-7006 x 2892 WEST CONTRA COSTA RADIOLOGIC MEDICAL GROUP INC R. W. JANG, M.D. M. M. LAPP, M.D: E. M. TAO, M.D. W. G. WIERZBOWSKI, M.D. REPORT OF ROENTGEN EXAMINATION, OF CASTILLO, ANDREW 38 916910 Name Age Patient Number REFERRED BY: DR. ROBERT MANDIBERG X-RAY NO 12-41-82 DATE: 06/26/95 ROOM NO: ER 06/27/95 CT OF THE HEAD, ABDOMEN, AND PELVIS 6/27/95 • The studies were performed on an emergency basis beginning at approximately 0144 hours . 5 mm contiguous axial sections were obtained through the posterior fossa with 10 mm contiguous axial sections obtained to the vertex of the head without contrast . The scans demonstrate prominent swelling over the left frontal scalp extending to the left periorbital region. There is no evidence of fractures . The intracranial contents appear unremarkable. There is no evidence of mass effect , midline shift , or intracranial hemorrhage . 10 mm axial sections were obtained at 15 mm increments from the level of the hemidiaphragms to the symphysis pubis utilizing oral and intravenous contrast. The scans demonstrate a normal liver , gallbladder , spleen, kidneys , and pancreas . The visualized bowel appears unremarkable . There is no evidence of organ laceration or hematoma. CHEST AND FACIAL BONES , 6/26/95 • Two frontal and a single lateral view of the chest demonstrates clear lungs . The heart and pulmonary vasculature are normal . CONTINUED. . . . CHART BROOKSIDE HOSPITAL 2000 VALE ROAD SAN PABLO, CALIFORNIA 94806 TELEPHONE (510) 235-7006 x 2892 WEST CONTRA COSTA RADIOLOGIC MEDICAL GROUP, INC. R. W. JANG, M.D. M. M. LAPP, M.D. E. M. TAO, M.D. W. G. WIERZBOWSKI, M.D. REPORT OF ROENTGEN EXAMINATION OF Name Age Patient Number REFERRED BY: X-RAY NO DATE: ROOM NO: CASTILLO, ANDREW PAGE TWO X-RAY NO. : 12-41-82 DATE: 06/26/95 & 96/27/95 Five views of the facial bones demonstrate no evidence of fractures or skeletal lesions . Soft tissue swelling is noted over the frontal scalp and left zygomatic region. I Vv WGW:mw W.G. WIERZ M.D. June 27 , 1995 PF : NEW CHART c • • 2000 ® r:,. • CLINICAL LABORATORY Page 1 . . REPORT , BROOKSIDE HOSPITAL 2000 VALE ROAD•SAN PABLO,CA 94806 JOHN G.POPPINGO,M.D..DIR. (5 10)235-7006•EXT.2576 K.H.WOODRUFF,M.D. NAME CASTILLO , ANDREW Area EMERGENCY DEPT Account ID 41 916910 Status OUTPATIENT Adm Phys ER MDS ID #2 000062074075 Class Req Phys INVALID CODE Collected 06/26/95 22 : 40 DOB 04 /18/57 Sex M Received 06/26/95 23 : 00 Accn 157307 Reported 06^f26/95. 23 : 09 Test' Results "NORMALI HIGH" Normals Units - ' .-Tec <<(<(HEMATOLOGY) ) ) )) HEMATOLOGY TESTS WBCV 7 . 25 I I * I 14 . 3 - 11 . 0 X10"3 GT RBG ` 2 ,;;X10";6 G,T HGB 14 . 6 I I ,; ) I 14 18 G/DL GT HCT- =- 41`=2 40 54 ,� �T �.' . MCV 85 . 8 I I * ( 180 — 94 FL GT MCH.:; 30'c 4 �. .., :'> .,,.. ! :.L. 26 33 'PG GT MCHC ,. 35 . 4 I I * I ( 31 - 36 G/D.L. .. GT PL"T<^- 2.2.2 375 'GT_ RDW 47 . 3 I I * I 137 48 FL GT NE'UTRpRM ��S .. :42 75 GT LYMPHOCYTES 32 . 7 I ( * I 121 — 51 % GT . MON 7. 4 .„� EOSIOCY°N 2 . 1 I. I , _ *. I I 1 .._ 3.-% GT BASQPHI.L '1 5 ”„ :H. � �.... , �,�` „ �.. .0 1 , % GT p - ------------------ - -- ----- Signature Name CASTILL0 , ANDREWCHART COPY Reported 06/26/95 23 : 09 ID #1 916910 ID #2 000062074075 Collected 06/26/95 22 : 40 Area EMERGENCY DEPT Req Phys INVALID CODE Adm Phys ER MDS • CLINICAL LABORATORY Page 1 REPORT BROOKSIDE HOSPITAL 2000 VALE ROAD i SAN PABLO,CA 94806 JOHN G.POPPINGO,M.D.,DIR. (510)235-7006•EXT.2576 K.H.WOODRUFF,M.D. NAME CASTILLO , ANDREW Area EMERGENCY DEPT Account ID #1 916910 Status OUTPATIENT Adm Phys ER MDS ID #2 000062074075 Class Req Phys INVALID CODE Collected 06/26/95 22 : 40 DOB 04 /18 /57 Sex M Received 06/26/95 23 : 00 _Accn 157307 Reported 06/26/95 23 : 26 fest';= -,• Results, ;.F,AB LOW NORMAL+ HIGN Normals — Units: Tech < << <<CHEMISTRY> >>>> CHEMISTRY TESTS GLUCOSE 189 H I I * 65 — 115 MG/DL GT BLOOD UREA,-NITROGEN- 6 Lw.,I " I , ;. ( I. �:,.... 22 .MG%.DL <a;GT. CREATININE 0 . 7 * 10 . 5 — 1 . 2 MG/DL GT SOD`; `UN_ 145;MMOLJ,L'.. . GT. POTASSIUM 3 . 9 I I * I 13 . 6 — 5 . 0 MMOL/L GT ' CHLO,RIDE.' 1.1.1,u.:MMOL;/L,..- G<L )TOTAL CARBONATE 27 I I * 121 31 MMOL/'L GT T PHOSPHORUS 3 . 4 I * I 12 . 5 - 4 . 5 MG/DL GT GT TOTAL PROTEIN 7 . 4 I I * I 16 . 1 — 8 . 0 G/DL GT ALBUMIN 3,..9 . , ( ,.. .. I; * =.) I 35 :15 ;0, GJDL GT: AMYLASE 50 * I 130 — 130 U/L GT -_:AST (SGOT) .r -., . ...,.,, .a.... .. LACTATE DE HYDRO GE NSE 175 I I 195 — 1754U"/L GT ALKA 1NE.' PHOSPHATASE ; 1 37; H GT.. TOTAL BILIRUBIN 0 . 9 I I I 102 1. 2 MG/DL GT CH0LEST.E:ROL 238 H: I. . I ,,. '�_, ,. I "11@ ,. 2@0 '7G/DL GT --------------------- -- --- i Signature Name CASTILLO , ANDREWCHAR IM ppYY Reported 06/26/95 23 : 26 ID #1 916910 ID #2 2074075 Collected 06/26/95 22 : 40 Area EMERGENCY DEPT Req Phys INVALID CODE Adm Phys ER MDS 06/27/95 (03:56) BROOKSIDE HOSPITAL Page 1 of 1 BROOKSIDE HOSPITAL EMERGENCY DEPT. 2000. Vale Rd. San Pablo CA 94826 (510) 235-7000 Discharge Instructions HE:A D I N J U R Y (w/ wake—up3 You have had a head injury which does not appear serious at this time. Sometimes symptoms may appear later which could be a sign of amore serious problem. Therefore please watch for the WARNING SIGNS listed below: repeated vomiting -- severe or worsening headache -- severe dizziness -- unusual drowsiness, or unable. to awaken as usual -- unequal pupils -- confusion or change in behavior or spe.ech -- convulsion (seizure) HOME CARE During the next 24 hours you must stay with someone who can watch you for the above warning signs. This person should WANE YOU UP EVERY TWO HOURS to see check on your condition. FOLLOW UP with -your doctor or 'this facility if your current symptoms do not begin to improve over the next 24 hogs. RETURN PROMPTLY or contact your doctor if any of the above warning signs occur. y vt 06/27/95 (03:57) 'BROOKSIDE HOSPITAL Page 1 of 1 BROOKSIDE HOSPITAL EMERGENCY DEPT. 2000 Vale Rd. San Pablo CA 94806 (510) 235-7000 Discharge Instructions ME:D I CAT I ON VICODIN (Hydrocodone) You have been prescribed a GAIN MEDICATION called VICODIN (generic .= HYDROCODONE) . It is also available under. the trade names: LORTAB and ANEXSIA. Vicodin is a narcotic, and may cause drowsiness. Be sure to . take it only as directed. DIRECTIONS FOR USE: Vicodin may be irritating to the stomach. To minimize this problem, you may take this medication with food. Pain medication should be taken only if needed at the times prescribed. If you are not having pa.in, do not take the medicine. WHAT TO WATCH FOR: Contact your doctor or this facility if .any of the following occur: POSSIBLE SIDE EFFECTS include: dizziness, drowsiness, nausea, vomiting, and constipation. These effects may be minimized by. taking a smaller dose (for example, breaking a pill in half or taking it less often) . ALLERGIC REACTION: consists of rash, itching, swelling, trouble breathing or swallowing. *�► *** �► IMPORTANT * ***�►�►* Do not drive or operate dangerous equipment while. taking this drug. Prolonged use of this drug can be habit-forming. f . DRUG INTERACTION < < � Alcohol, Barbiturates, Cimet� ne (Tagamet) will increase the drowsiness caused by thi s 6rug. 06/27/95 (03:57) 9ROOKSIDE.H0801TAL Page, 1 of 1 BROOKSIDE HOSPITAL EMERGENOY DEPT. . 2000 Vale Rd. San, Pablo CA. 94806 (510) `235-7000 Discharge Instructions CONTUS ION, SOFT TISSUE A CONTUSION is a bruise with swelling and some .bleeding under the skin. This may take from a few days 'to a few weeks to heal, ". depending on. how severe it; is.. HOME CARE: 1) Keep the injured part elevated. to reduce pain and swelling. This is especially important during the first 48 hours. 2) Make an ice pack (ice cubes in a plastic. :bag, wrapped in a towel) and apply for 20 minutes every one. to two hours the first day. You should continue with ice packs three to four tines a day for the second and third days. After t:he. first three to _.four days, hot "soaks or hot packs .three to four times a daywill. . be helpful. 3) You may take aspirin, Tylenol'. or. Advil for pain, unless another pain medicine was prescribed. FOLLOW UP with your doctor or this facility if you are .not improving within the next five days. . RETURN PROMPTLY or contact your doctor if any of the following_ occur: -- Fingers or toes become swollen, cold, blue, numb or 'tingly -- Pain increases -- Signs of infection appear: local .redness or ' red streaks, warmth, or increased pain BROOKSIDE HOSPITAL 64D15 CONDITIONS OF SERVICE 91-b9-j SAN PABLO,CALIFORNIA CA.S7I LL4, ,lwiEW 1.CONSENT TO MEDICAL AND SURGICAL PROCEDURES Ob Pb of The undersigned consents to the procedures which may be performed during this hospitalization or P on an outpatient basis,including emergency treatment or services,and which may include but are not $�j 9s�' limited to laboratory procedures,x-ray examination,medical or surgical treatment or procedures,x- 38 ray examination, medical or surgical treatment or procedures, anesthesia, or hospital services rendered the patient under the general and special instructions of the patient's physician or surgeon. 2.NURSING CARE This hospital provides only general duty nursing care unless,upon orders of the patient's physician,the patient is provided more intensive nursing care.It the patient's condition is such as to need the service of a special duty nurse,it is agreed that such must be arranged by the patient or his/her legal representative.The hospital shall in no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fact that said patient is not provided with such additional care. 3.LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN All physicians and surgeons furnishing services to the patient,including tfie radiologist,pathologist,anesthesiologist and the like,are independent contractors with the patient and are not employees or agents of the hospital.The patient is under the care and supervision of his/her attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physician.It is the responsibility of the patient's physician or surgeon to obtain the patient's informed consent,when required;to medical or surgical treatment,special diagnostic or therapeutic procedures,or hospital services rendered the patient under the general and special instructions of the physician. 4.RELEASE OF INFORMATION Upon inquiry,the hospital may make available to the public certain basic information about the patient,including name,address,age,sex,general description of the reason for treatment (whether and injury, bum, poisoning, or other condition), general nature of the injury, bum, poisoning or other condition, and general condition. If the patient or the patient's legal representative does not want such information to be released,he/she must make a written request for such information to be withheld.The patient or the patient's legal representative may obtain a separate form for this purpose upon request. The hospital will obtain the patient's consent and his/her written authorization to release information,other than basic information,concerning the patient,except in those circumstances when the hospital is permitted or required by law to release information. The undersigned agrees that,to the extent necessary to determine liability for payment and to obtain reimbursement,the hospital may disclose portions of the patient's record,including his/her medical records,to any person or corporation which is or may be liable,for all or any portion of the hospital's charges,including but not limited to insurance companies,health care service plans,or workers'compensation carriers.Special permission is needed to release this information where the patient is being treated for alcohol or drug abuse. 5.PERSONAL VALUABLES It is understood and agreed that the hospital maintains a safe for the safekeeping of money and valuables,and the hospital shall not be Gable for the loss or damage to any money,jewelry, eyeglasses,dentures,hearing-aides,documents,furs,fur coats and fur garments or other articles of unusual value and small size,unless placed therein,and shall not be liable for loss or damage to any other personal property,unless deposited with the hospital for safekeeping.The liability of the hospital for loss of any personal property which is deposited with the hospital for safekeeping is limited by statute to five hundred dollars ($500.00) unless a written receipt for a greater amount has been obtained.from the hospital by the patient. I do not have items/valuables to lock in the safe 6.FINANCIAL AGREEMENT Patient/Parent/GuardianConservator initials The undersigned agrees,whether he/she signs as agent or as patient,that in consideration*'of the services to be rendered to the patient,he/she hereby individually obligates himself/herseff to pay the account of the hospital in accordance with the regular rates and terms of the hospital.Should the account be referred to an attorney or collection agency for collection,the undersigned shall pay actual attorney's fees and collection expenses.All delinquent accounts shall bear interest at the legal rate. 7.ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorizes,whether he/she signs as agent or as patient,direct payment to the hospital of any insurance benefits otherwise payable to or on behalf of the undersigned for this hospitalization or for these outpatient services,including emergency services if rendered,at a rate not to exceed the hospital's regular charges.It is agreed that payment to the hospital, pursuant to this authorization,by an insurance company shall discharge said insurance company of any and all obligations under a policy.to the extent of such payment.It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.The undersigned assigns to providers of care or hospital based physicians any insurance or health plan benefits as described above. 8.HEALTH CARE SERVICE PLAN OBLIGATION This hospital maintains a list of the health care service plans with which it has contracted.A list of such plans is available upon request from the financial office.The hospital has no contract, express or implied,with any plan that does not appear on the list.The undersigned agrees that he/she is individually obligated to pay the full cost of all services rendered to him/her by the hospital if he/she belongs to a plan which does not appear on the above mentioned list. 9.NOTIFICATION OF BILLING Services provided(either inpatient or outpatient)at this hospital may generate more than one bill.One bill will cover your hospital charges.Other bills may come from:Anesthesiologist, Pulmonologist,Cardiologist, Pathologist,Radiologist or any other physician,or reference laboratory services.If you are being'Admitted.to Observation',please know your physician has ordered an outpatient service.Although you will be in a'regular hospital bed',you will be considered an outpatient(by Medicare regulations).You may be responsible for a 201/6 co-pay. The undersigned certifies that he/she has read the foregoing,received a copy thereof,and is the patient,the patient's legal representative,or is duty authorized by the patient as the patient's general agent to execute the above and accept its terms. Date Patient/Pareni/Guar arv'Consermtor If other than patient,indicate relationship: Time waness(es) Financial Responsibility Agreement by Person Other than.the Patient,or the Patients Legal Representative:I agree to accept financial responsibility for services rendered to the patient abd to accept the terms of the Financial Agreement,Assignment of Insurance Benefits,and Health Care Service Plan,Obl'igation Provisions above. REASON FOR NOT SIGNING(Document date/time/signature/reason not obtained): FararcWly Responsible Parry A COPY OF THIS DOCUMENT IS TO BE DELIVERED TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT. 8560-106(10/93)SEO.829 "" .. PLEASE NOTE: The examination and treatment tht you have received in the Emergency Department has been given on an emergency basis only, and is not intended to be a.substitute for complete medical care. It is.important-that you be checked again as instructed. If an x-ray or EKG has been performed, it hasbeen;read on a preliminary basis only;:and will be reviewed by a radiologist or internist with24 ho r . You will be no ified if additional findings are noted. YOUR.ESIAGNOSIS IS: N1rL / . LJ res. �� ' � �tv�,�l ctc F � 1 5'S' I1 �f TRAUMAS ADULT PEDES GYN-GU Laceration/Puncture ead In]' Viral URI Pneumonia/Bronchitis Fever Control Otitis Media Miscarriage,Spont. pip Sprain/Strain Gastroenteritis COPD/Asthma. Viral URI Otitis/Extema Miscarriage,Threaten Ovarian Cyst BuMAbrasi Neck/Back-Pain Ulcer/Gastritis Tension Headache Gastroenteritis Pneumonia/Bronchitis Irregular Vag.Bleed Curettage 5pu�si�o (/ Comeal Abrasion' Esophagitis' Hypertension,New 'Pharyngitis,.Viral' Asthma' Vaginitis' Menstrual Pain' uur Abscess' Seizure,Recurrent' Biliary Colic Pharyngitis,Strep' Poisoning,Pedes` Cystitis,Fem. Kidney Stone' Ca Splint Care Cellulitis Abdominal Unknown No Complications Chicken Pox Febrile Seizure' Pyelonephritis' GC/Chlamydia' Suture Removal- Animal Bite Alcohol W/D Synd. Migraine Headache Conjunctivitis' Allergic Reaction Scabies No Complications Chest Wall Pain Diabetes Chest Pain-Non Cardiac Croup' Sinusitis, PRINTED INSTRUCTIONS PROVIDED: indicated above other: PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW. ADDITIONAL INSTRUCTIONS: p Cr 6�►-- tee cls .,e : v= �E s`6-y) I For.the health of your child follow up with yo4y docto ensure that your child I 'f 11 immuni VCal(235-7006 x 2100 on for the results of your test: YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS BEEN: `U 1A 4--s D ries P.Kivela D.Mendelson E.Nipomnick II.Ahwah !J.Rampulla J..Evans R.Turner C.Freye' ij L. .Hodgson D Evans M O'Connor If you notice any worsening of your symptoms, return to hospital immediately,or if you notice no improvement of your symptoms within 24 hours call your referred MD promptly or return to the hospital. I have received and understand the instructions outlined above. X X � � � 1 ta Patient or Representative ff - r Datb � D//C Time ' fi ` � a > �� --�yT' —,— � _ -------------------- 77 �.HUSPI_TAI+�I�IiC�t'IS , (� 5�_7 .a� - #` z' � � �J �� '" K,': :. ,ice... ` � a W'�Sr�se i .n I,Jt `NY Ill 01611`6$mould b'0'a,a t `Ietll�i`Ct o wa aeh filou�>x st ctlo -""'s ,j ° i� , "exa �^!+ ,¢ ^�.., ���.���s��.��.� �..: ci`Li'a��"^�` EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mgt. Dis . Sig' ❑ Do not drive while taking medication. physician Printed ❑ Do not substitute. Signature Name ❑ Spanish Instructions. M.D. P.Kivela D.Mendelson E.Nipornnick I.Ahwah.J.Rampula J.Evans R.Turner C.F . anfte L.H.Hodgson D.Evans M.O'Connor o BROOKSIDE HOSPITAL ED 2000 Vale Road San Pablo,CA 94806 LSA j 8 t W S 6 9 Z 9 0 Saw �3 EMERGENCY DEPARTMENT M3. V 4'IZ115VO DISCHARGE INSTRUCTIONS MEDICAL RECORDS 3 FORM p7015.107(REV.3/95)SEQ.790 I I , NOTES SUPER REPRODUMIGN SERVICE Hospital Record Photocopy Main Office: 953 Mission Street.Suite 31 Mailing Address: P.O.Box 2718 Medical Records San Francisco,CA 94103 Daly City,CA 94017 Attorney Servioes 415-546-0951 FAX:415-546-7439 co -4 C) 0-1 .p W 11 - `U 07D O > z z z - t Z T D O0 m D m tn M3 rr*m m Z m m -0 O .. m }., F) _ m o z� � o m m M C: { n o n mLo m TI > -i 5 n -nTI r Tl D '� z z m n s m� z z z 3) D� n z D o Cl =O zl m z mo p a 3 Om �i En A a • �!ti 3 3 n 3 r "s 3 17 C7 3 D v _ a? z 0F �� )' D arn o m .D CD -4 -{ 0 D r z 9 .. X -n C m n) .D ro Cr D c: K o 1CR %DD Ln 7CJ ?mJ 0 r-n Ln O Or . mm i >33"' n .D r .. .. .. < D X) :D D 1 f x7 �7 3 3 3 O> 1D z z z D1 z 1 c� c7 a a r-� � , '-—''"FORNIA - 1, '.1-:.COLLISION REPORT PAGE / OF 3 SPECT• - ANS - NUMBER jHTT&R I JU. DISTRICT - NUMBER ` INJURED FELOe • J. NUMBER HIT.RUN COUNTY— r>�'. .;� REPORTING DISTRICT BEAT 7 �/ V/{ J( ) KILLED MISD a ;�•. ( U COLLISION OCCURRED ON - - - - MO. DAY YEAR TME(24CO) NCIC It OFP.CER t : C las o --------- - --- - ------------------------------•---- MILEPOSTINFORMATION DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: F Q FEET/Aacc OF MILEPOST BATAT F S Y-YES El u n Qff l—INTERSECTION WITH C(�77%, /<C�!} STATE HW REL �I�}y�'',��� ❑OR: FEET/MILER OF /'--` JUN 2 � ❑YES �. Ipr„-SNE PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY Y0. _ MAKE MOOEL l COLOR LICENSE NUMBER SATE ll EQUIP. DRIVER NAME(FIRST,MIDDLE,LAST L65-14r--o ��� ct PEDES STREET ADDRESS OWNER'S NAME SAME AS DRIVER TRIAN PARKED CITY I STATE ZIP OWNER'S ADDRESS SAME AS DRIVER - VEHICLE ❑ F_L C BICY- SEX HAIR EYES MEIG///}}}777T WEIGHT BIRTHDATE RACE DISPOSITION OF VEHICLE ON ORDER OF: ❑OFRCER DRIVER ❑OTHER CU❑ST �� M� DAY YEAR �j�1 OTHER HOME PHONE L`` (LLL/0000 BUSINESS PHONE �/ PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER 70 W.3AATVE , ❑ (S�o )X33_ Z ( ) � � ( CHP USE ONLY ::LRIOE VEHICLE DAMAGE SHADE IN DANA ED AREA VEHICLE TYPE INSURANCE CARRIER POLICY NUMBER NONE ❑MINOR ❑MAJOR ❑TOTAL DIF.OF ON STREET OR HIGHWAY SPEED PCF `-'••.�� ICC ❑ - T'c` LIMIT PUC ❑ CMP ❑ PARTY DRIVER'S LICENSE NUMBER STATE I CLASS'l SAFETY VEIL YR. MAKE.MODEL!COLOR LICENSE NUMBER STATE C E 2 miT.P�C DRIVER NAME(FIRST,MIDDLE,LAST / PEDES STREET ADDRESS - - _ -OWNER'S NAME SAME AS DRIVER o C I( PARKED CITY/ ,ATE!ZIP OWNER'S AODRESS SAME AS DRIVER VEHICLE BICY- SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE OISPOSTICN OF VEHICLE ON ORDERS OF: ❑OFFICER FIVER. ❑OTHER CLIST MO. OAY YEAR ❑ h'1 SSS l� `( l� f0 OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT �- REFER TO NAARATIVE ❑ -❑ ($�� 3� (�,J ) / -� CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE W DAMAGED AREA VEHICLE TYPE INSURANCE CARRIER - POLICYNUMBER ` ❑UNK. []NONE MINOR 12�.OD. E]MAJOR ❑TOTAL DIR.OF ION STREET OR MIG AY ISPIED PCF ICC ❑ TR Ay EL � r� L�= PVC Cl AVL CMP ❑ PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEIL YR. MAKE.MODEL/COLOR LICENSE NUMBER STATE EQUIP. 3 DRIVER NAME( ,NIDD E, A '�, T.ENG STATE CORP. ❑ -J PEDES STR _ - I I OWNER'S AME ❑ AME AS ORrvEA c Twa UNIF CA?T S.S. CAPT PARKED CITY I STATE;IIP 7�IL ADDRESS (—�SJk•E AS DRIVER .- VEHICLE �f 11 1 BICY- SEX MAIJ STT• HE MT MT Mf`. RTD TE N OF VEHICLE ON ORDERS OF: OFFICER DRIVER (—i0�^ER - CLIST P. OTHER HOME PHCN - S PHONE1 man '- fpRIOR HANICAL DEFECTS: NONE APPARENT ❑ REFER TO NARRATIVE IJ ❑ ( ) ( ) CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA / VEHICLE TYPE INSURANCE CARRIER POUCY NUMBER .._ ❑UNK. ❑NONE ❑MINOR _ _ ._. ...- ;- ❑MOD. ❑MAJOR ❑TOTAL--] _--�II DIR.OF ON STREET OR HIGHWAY _ SPEED PCF cc C] ' - ----- - 4 TRAV EI LIMIT _ PUC ❑ GNP ❑ PREPARER'S NAME DISPATCH NOTIFIED fl EWER'S NAME"• - - - -. ATE REVIE'NED 1ar4 � �$ O NO ❑ NIA f �. U R2 7jw CHP 555-Page 1 (Rev. 7-87)OPI 042 -- -._ __ 87 4 STATE OF CALIFORMA TRAFFIC.COLLISION CODING i ;. PACE JCr3 DATE OF COLLISION TME(2400) 1 NCIC NUMBER OFR-Ell I.D NUMBER MO. DAY NEAR V OWNE.."NAME/ADDRE S j vCii R E, PROPERTY I YES w DAMAGE . ' DESCI PTION OF DANA i SEATING POSITION OCCUPANT s SAFETY EQUIPMENT M I r.BICYCLE ,MET EJECTED FROM VEH. � I-DRIVER A-NONE IN VEHICLE L-AIR BAG DEPLOYED D-NOT EJECTED �► 2 TO 6-PASSENGERS B-UNKNOWN M-AIR BAG NOTDEPLOYED DRIVER t-FULLY EJECTED 7-STA.WGN.REAR C-LAP BELT USED N-OTHER V-NO 2-PARTIALLY Ej ECT ED d-RFL CCC.TRK_OR VAN D-LAP BELT NOT USED P-NOT REQUIRED `N-YES I 3-UNKNOWN 9-POSITION UNKNOWN E-SHOULDER HARNESS USED j 1 2 3 0-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER I I 456 G-LAP/SHOULDER HARNESS USED t0-IN VEHICLE USED X-NO H-LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES Z- J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-1N VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK( )SHOULD BE EXPLAINED IN THE NARRATIVE i PRIMARY.COLUSION FACTOR TRAFFIC CONTROL DEVICES 1 2 3 TYPE OF VEHICLE 1 2 13 MOVEMENT PRECEDING UST NUMBER(s)OF PARTY AT FAULT COLL154CN 0 A VC SECTION VI TED: CITEDEg CONTROLS FUNCTIONING A PASSENGER CAR/STA.WGN. �y Q NO B CONTROLS NOT FUNCTIONING- B PASSENGER CAR W/TRAILER A STOPPED s -B OTHER IMPIROPERl C CONTROLS OBSCURED C MOTORCYCLE/SCOOTER B PROCEEDING STRAIGHT D NO CONTROLS PRESENT/FACTOR* D PICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP/PANEL TRK.W/TLR D MAKING RIGHT TURN D UNKNOWN' A HEAD-0N F TRUCK OR TRUCK TRACTOR E MAKING LEFT i URN x E FELL ASLEEP- B SIDESWIPE G TRK./TRK.TRACTOR W/TLR. F MAKING U TURN i C REAR END H SCHOOL BUS G BACKING WEATHER(MARK t TO 2 ITEMS) BROADSIDE 1 OTHER BUS H SLOWING/STOPPING CLEAR E HIT OBJECT ,J EMERGENCY VEHICLE 1 PASSING OTHER VEHICLE B CLOUDY- F OVERTURNED K HWY.CONST.EQUIPMENT J CHANGING LANES I C RAINING G VEHICLE/PEDESTRIAN L BICYCLE K PARKING MANEUVER D SNOWING H OTHER': MOTHER VEHICLE L ENTERING TRAFFIC E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M OTHER UNSAFE TURNING F OTHER': A NON-COLLISION _ O MOPED N XING INTO OPPOSING LANE G WIND B PEDESTRIAN O PARKED LIGHTING OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VEH.ON OTHER ROADWAY OTHER ASSOCIATED FACTOR I IQ TRAVELING WRONG`NAY B DUSK-DAWN E PARKED MOTOR VEHICLE 1 2 3 (MARK t TO 2 ITEMS) R OTHER:' DARK-STREET LIGHTS F TRAIN AVC SECTION VIOLATION: CITED D DARK-NO STREET LIGHTS ('�BICYCLE ❑NOS E DARK- STREET LIGHTS NOT H ANIMAL: B VC SECTION VIOLATION: CITED FUNCTIONING' ❑YES SOBRIETY-DRUG ROADWAY SURFACEFIXED OBJECT: ONO PHYSICAL 1 C VC SECTION VIOLATION: CITED 1 2 3 A DRY ❑YES (MARK i TO 2 ITEMS) B WET J OTHER OBJECT- D ❑NO A HAD NOT BEEN DRINKING C SNOWY-ICY B HBD-UNDER INFLUENCE E VISION OBSCUREMENT D SLIPPERY(MUDDY,OILY,ETC.) C HBD-NOT UNDER INFLU. F INATTENTION D HBD-IMPAIRMENT UNK.' _s%,.tROADWAY CONDITIONS G STOPS GO TRAFFIC (MARK t TO 2 ITEMS PEDESTRIANS ACTION E UNDER DRUG INFLU.• A NO PEDESTRIAN INVOLVED H ENTERING/LEAVING RAMP F IMPAIRMENT-PHYSICAL' ON A HOLES,DEEP RUTS 1 PREVIOUS R WITH ROAD G IMPAIRMENT NOT KNOWN B CROSSING IN CROSSWALK � UNFAMILIAR WITH ROAD B LOOSE MATERIAL ON RDWY.• AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE C OBSTRUCTION ON ROADWAY' CROSSING IN CROSSWALK-NOT ❑YES I SLEEPY/FATIGUED D CONSTRUCTION-REPAIR ZONE C'AT INTERSECTION - ❑NO SPECIAL INFORMATICN E REDUCED ROADWAY WIDTH D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOUS MATERIAL F FLOODED- E IN ROAD-INCLUDES SHOULDER ` - M OTHER•:' FE I G OTHER': F NOT IN ROAD N NONE APPARENT NO UNUSUAL CONDITIONS G APPROACH/LEAVING SCHOOL BUS _ O RUNAWAYNEHICLE - - MISCELLANEOUS 5 ETCH 'C{..�-' It— A'E^^ s I � - Y I 1 � i s /—(,J—/ / i—A K STATE OF CALIFORNA _ r)�A T �'.71,t� 'INJURED [WITNESSES / PAS r-,.UERS3or- P4GE D riE OF COLUSIO TIME(21 NER O R NUMBER' - S 1. CIC NUMB r . . I;�S lS EXTENT OF INJURY:(..X ONE ) I��R`Eq ,s ( "X" ONE ) WITNESS PASSENGER I - PARTY SEAT SAFE Y ONLY ONLY AGE SEX .—.ER POS. EC::IP. E:eCTEO FATAL' SEVERE OTHER VISIBLE COMPLAINT INJURY INJURY INJURY OF PAIN DRIVER i PASS. PED. BICYCLIST ❑� ❑ 3 YYI ❑ ❑ ( Fs!i- ❑ ❑ ❑ ❑ I ❑ I I r — G NAM /D.O.B./A00 RESS _ TELEPHONE (INJURED ONLY TRANSPORTED eq�77//4 ^ TAKEN TO: /7 DESCRIBE INJURIES S( L�-z l VICTIM OF VIOLENT CRIME NOTIFIED ❑ o ❑ 101 ❑ ❑ I CO I ❑ 1 ❑ ❑ 6 1 C NAME I D.O.B.!ADDRESS TELEPHONE J (INJURED ONLY)TRANSPORTED 8Y: - TAKEN DESCRIBE i VICTIM OF VIOLENT CRIME NOTIFIED ❑# �- ❑ ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ ❑ 01 SCC NAhif8.0.8.I ADDRESS / - LEPN� QNJURED OQONNLCLYY))TT/RANT Sl(PO J^�DD BY: (_ TAKEN TO: DESCRIBE INJURIES - VICTIM OF VIOLENT CRIME NOTIFIED ❑ -Z) 17 1 tl 1 ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ 10 1 ❑ I ❑ I C G NAME I D.O.B.I ADDRESS / TELEPHONE (INJURED ONLY)TRAW TSD BY: T N TO: DESCRIBE INJURIES ` - J/v ❑ VICTIM OF VIOLENT CRIME NCT'FlED ❑# ❑ I ❑ I ❑ I ❑ ❑ o To I Eil ❑ lol NAME:C.C.B.:ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NC—,.7-,E:) 1 . ❑ ❑ ❑ ❑ I ❑ I ❑ I ❑ ❑ ❑ I ❑ a 1 1 1 1 NAME I D.C.&I ADDRESS TELEPHONE 1 ONJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES I ❑ VICTIM OF VIOLENT CRIME NOTIFIED 1 PREPARER'S NAME,:T 11.0.NW BER MO. YEAR REVIEWERS NAME IMO. 04f YEtii b/ I ( rE OF CALIFORNIA - — kRRATIVE/SUPPLEMENTAL +; P,556(ReV 7-90)CPI 042' Pace rE OF INC:CEMTr_=^,'RFENCE i iME(424cO) NC:C NUMEER OFFICER LC.NUVEER NUMGER 6/26/95 I 2105 hr5 . 0710 I 1224 I 95-15882 ONE x oNE i PE SU=?L_4IENT.IL rX•APPLICAELE ]Narrative I 0XCcIIISIcn reper L_! EA update ❑rasa; C Hit and run update i Supplemental ' ❑Other: ❑ Hazardous materials C Sc`Cci tus X C other: YXCUNTY/JUC:C1A'_MSTAICT REPORTING CISTRiCTiSEAT I CITAT:C`."wVc"cR Richmond;"Contra Costa/Bav 'ATIO WSUBJECT STATE HIGHWAY RELATED Carlson 31 . & Cutting Bl . ❑Yes Chi The approximate POI was 33 ' W of the ECL of Carlson Bl . and 36 ' N of the SCL c Cutting Bl . i On 6/26/95 at 2105 hrs . , I was dispatched to the intersection of Carlson Bl . anti Cutting Bl . for a report of a vehicle collision that had just occurred. I arrived at 2108 hrs . The intersection of Carlson Bl . and Cutting 31 . is controlled in all four directions by traffic control signals . At the ti--me of this collision the traffic control signal for straight N and S/B traffic o Carlson Bl . was stuck on green, while E and W/B traffic for Cutting Bl . was hely with a solid red signal . The traffic control _ signals were locked on this configuration due to a malfunction of railroad crossing gate for railroad track! that traverse 'Cutting B1 . N to S approximately 50 ' W of the WCL of Carlson BlI Both the safety gate W of the tracks and the .gate E of the tracks were in thl down position blocking E and W/B traffic on Cutting Bl . although there wasn' t train crossing Cutting Bl . at the time. With the safety gates down vehicles were still able to cross over the tracks by circumventing the gates , although thf, traffic control signal remained solid red for E and W/B traffic on Cutting BlI Officer Gagan had already been on scene approximately ten minutes prior to th- time of this collision and he was attempting to notify Southern Pacific RailroaF so they could respond to his location to fix the malfunctioning railroad crossing gates . Officer Gagan heard this collision but did not witness it . Officer GagaII told me he -was walking the railroad tracks just N of Cutting Bl . checking fo� metal obstructions which may have been the cause of the malfunction at the time of this collision. �I On. scene i met Yoshio Tomimatsu, who identified himself to me as the driver of V-1 . The driver of V-2 was not present upon my arrival . Tomimatsu told me char the driver of V-2 informed him that he was going to use a nearby pay phone to call his girlfriend since it was her vehicle that D-2 was driving- at the time of the collision. Tomimatsu told me the following had occurred. Tomimatsu told me that prior to the collision he had been driving V-1 E/'B c-I Cutting Bl . prior to the railroad tracks W of Carlson B1 . Tomimatsu told me that as he approached he saw that the safety gate arms for the railroad crossing tracks appeared to be stuck in a downward position with the red lights on the arms flashing and the bell sounding. Toitiia su told me that as he approached the railroad crossing, he was driving behind a black marked Highway Patrol vehicle: Tomimatsu told me that as he and the Highway Patrol vehicle approached the safety arms, still W of the railroad tracks, he saw what appeared to be a police officei standing near the tracks directing E/B traffic on Cutting Bl . through the safety arms and over the railroad tracks . Tomimatsu told me that he followed behind t��e a 'T T SEC T ENG STLi COR_ ( R P.LE� tP7L C1?_^ CZB CAr SS CA.2T DA A.X` L3 CA{ TOTAL ( ASS:GS� 5-T , I I � Term-- I 'PA.RER'S NA.`L•' A.'SD ID HUDL3ER r DA's? 1 ='V'_N: DAT3 i BRUCE 1224 6/29/95 js tc OF CALIFORNIA` -• - �RRAT'IVE/SUPPLEMENTAL P 556(REv 7,,-90)OR 042 Face c OF INCICE1JT,CgCI?R'n�NCE TIME/Zs CC) NC:C NUMB-Fi CFF;CER LC.5UM2E; NUMSER 0'/26/95 l 2105 hrs,. 0710 I 1224 ( 95-15882 Pa. 2 CNE 'X-CNE —i =c SUPPLEMENTAL rX-APPLICAELE' -- flarrative LX Cellis"Cn reper, _1 SA update C Fa'--' ( Hit and n n update Supplemental ❑Other, -1 Hazar cus materials C S `col mus X ❑Other: . Y;CCUNTYIJUDICIALCISTRICT (REPCRTINGOISTRICTlEEAi CIT AT:C`. .,;ME" Richmond/Contra Costa/Bay , :ATION/SUBJECT STATE HIGHWAY RELATED Carlson Bl . & Cutting Bl . ( 01 Yes CNc black Highway Patrol car as it circumvented the safety gate and then crossed the tracks . Tomimatsu told me that he followed approximately 10 ' behind the Highway Patrol car and safety traversed the railroad tracks at which time he stopped,; still on Cutting Bl . just W of Carlson B1 . between the railroad crossina and Carlson B1 . Tomimatsu told me that as he approached the intersection of Cutting B . and Carlson Bl . , he looked and thought that all traffic control signals showed reg for all directions of traffic . Tomimatsu told me that he remained behind the Highway Patrol vehicle for "a couple of minutes" at which time he saw the H=ghwau Patrol vehicle cross the intersection and continue E/B on Cutting Bl . against a red traffic control signal . Tomimatsu told me in seeing the Highway Patron vehicle cross the intersection, he felt. that it was a " signal " .that E/B traffic on Cutting B1 . was to proceed behind the Highway Patrol vehicle. Tomimatsu told me that he also thought that this meant it would be safe to cross thq' intersection. Tomimatsu told me he was traveling between 10-15 mph when he began to crow Carlson Bl . in an E/B direction on Cutting when he saw V-2 approach his location N/B on Carlson Bl . Tomimatsu told me he saw V-2 immediately prior to th4 collision and he was unable to avoid the collision. Tomimatsu told me that id appeared that V-2 was traveling fast, but Jae could not estimate its speed. Tomimatsu told me that his vehicle and V-2 collided in the intersection cil Carlson Bl . and Cutting. Bl . Tomimatsu told me-�that the Highway Patrol vehicle continued E/B on Cutting B1 . and did not stop-after the collision. Tomimatsu told me that after the collision he parked V-1 on Cutting Bi . E oy Carlson at which time he exited his vehicle and contacted Andrew Castillo, the driver of V-2 . Tomimatsu told me that after he contacted Castillo, Castillo stated that V-2 was not Castillo ' s and he was not sure if there was insurance on the vehicle. Tomimatsu told me that Castillo then told him that Castillo Headed to make a phone call . Tomimatsu told me that Castillo then walked away E/B along the NCL of Cutting Bl . Tomimatsu told me that Castillo appearedslightlydazed at the time Castilla walked away. It was shortly after this„th'at I arrived. i Tomimatsu told me that he was uninjured in the collision. One of Tomima_su ' s passengers, Doris McKillican, who was seated in the rear right passenger seat,j complaint of slight soreness to her nose. McKillican told me that as a result. of the collision she was thrown forward at which time her nose struck the bac'.k of the front passenger seat of V-1 . McKillican denied medical attention and tol T I T SEC I T =tiG I STA';n COZY I R ?IL( UNI? CAPT� C:9 C;_n SS Ca?T DA ADH I IA. C\1 TOT:.I. ASs:GS= ?XRZR•S NXILZ AN-D ID NUH3cR r Del='_' I RLJ:=ncR-S NAY DA= ' BRUCE 1224 6/29/95 js I � I ,TE CF CALIFORNIA ' 4RRATIVEISUPPLEMENTAL , IP 556(Rev 7-90)OPI 042 Pace ,TE CF INC:CE :C c�;;"ENCZ TWE ri C) NC:C NUMB=1 CFFfCER 1.D.NUMBER NUMBER 6/26/95 12105 lies . 0710 ( 1224 I 95-15882 Pc. 3 'CNE 1-X-CNE I i P=_SU, =LEMENTAL rX-APPLICAFL=j � I i Narrative CKI Ccllisicn recce; ! ..�A uccate ❑Fatal ❑Hit and run ucdate i Supplemental ❑Other: I ❑ Hazardous materials C S hccl bus X ❑Other: fY CCUNTY/JUCIC::.L CISTRiCT REPORTING CIS-,niCTiSEAT I CITA'.C`. Richmond/Contra Costa/Bav CATICN1SUBJECT STATE HIGHMAY RELATED Carlson Bl . & Cutting Bl . I ❑Yes E::'*1 me that her nose was only slightly sore and not broken. McKillican did ncu sustain any visible injury as a result of this collision. No other persons is V-1 were injured. Upon my arrival I had located V-1 parked on Cutting B1 . approximately 50 ' o Carlson_ E-1 . I - saw that V-1 , a 1985 Toyota Cressida, license 1NAP159 , had sustained moderate damage to its front end and left front quarter panel . %7-1 was later towed from the scene by ?AA Towing per Tomimatsu ' s request . After speaking with Tomimatsu, I located and then spoke with Castillo w'--c had returned to V-2 . Castillo told me the following. Castillo told me that he had been driving V-2 N/B along Carlson Bl . in the =1 lane just prior to th collision. Castillo told me that he approached the intersection of Carlson B1 .11 and Cutting Bl . between 25-30 mph. Castillo told me that as he approached the intersection he saw that his traffic control signal for N/B Carlson B1 . was green and he continued into the intersection. Castillo told me that after he e--r�<terea the intersection, V-1 struck. his vehicle on the left front. side. Castillo told me that prior to the collision V-1 had been traveling E/B on Cuttina Bl . Castillo told me that he barely had time to see V-1 just prior to the colli sio and he was not able to take evasive action in an effort to avoid the collision. II _ I saw that Castillo had sustained major swelling to the area around and directly; above his left eye. Castillo also had a small laceration below his left eye.; Castillo additionally complained of pain com'i'ng from the center of his back.!. Castillo was transported to Brookside Hospital for evaluation and treatment by American Medical Response Ambulance Service, crew =18 . V-2 was towed from the scene per Castillo' s request for a non-specific to-.J. V-2 was removed from the scene by A and D Towing. There were no passengers in V-2 at the time of the collision. Upon my arrival I had located V-2 parked N/B on Carlson B1 . approximately 10 ' of Cuttina Bl . V-2 , a 1988 Mercury Tracer, license 2h7fiB306 , had sustained moderate damage to the front and left front quarter panel ._ i CLOSING STATEMENTS : The railroad safety gates were repaired and traffic reg-erred to normal approximately one hour after this collision. Officer Gagan tcl' d me that he had not directed traffic through or around the railroad crossing prior to or during the time of this collision. J i (T T SEC T ENG smN= COR-1 F. ?=? UNI? cis =-'.2 SS C1-T Dn eL7H I 1A I G I I TDi.11 I :SS=CLIA I I I I I I ?PAR➢R'S NAIL. AND ID NUM-B3.R r DA 3 I R-:✓_En_2.5 NA DATE BRUCE 1224 16/29/95 js I Irl. a*• {[ ,tea ` a#�."sa 4 Z 1s'f K'{{ S'i ;- r �t E > r s (Y ;u)11� P r� } t P 1. 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't'E $ ,s 4 rx - :i -i .. + .�i r c 1 L a�f x k L` T tf " 'Y t f, ' i314 Ly , 1LT •� r� B" S Xr J s C 't r'#1: !,; a . � 4�N� 1I 3 ! $ ,rt �J as K #1 f V � 0 ',_ {7 d h S yt s l� a t ?- - rix>�� '; N �^O 0 a s, j r J i '} w r } 4"rx ?r a ^�Y J,vet r !r; ` °{ s E mtF r > { {rt �} 1 c x{ a lg t'r' ., 1 xt W,-, "' 7 r � ° �`-,M, +}a �" - tail# ' �i t r� W U ��/�U r{ x` .1 IY 'r Ykr , .,a t r ( µ,t 1t P ,,t,t ' ars , 5 n.r ^VI �Q r 5 r ��a F a t s t r , 1 a t fa CJI '# r �t �. :-. [ t a 9} "� x t r �� U) r I �r1 Y b ye q .' I J t 1"➢ " >• t1' ,, y a "' „4 i t a t, 'i T y�'� m - r r d e J ;, >r n Y�` f "r 411 r , rxt. W I/1 Z -4-) _ A y,FI t 3{.t{ q( tf 1@ �" A41 r r 5 O = Q W 4 A J ! /y� r�'yy (� err d t i Y c F?7L r Ft } s, t 3 t U O W LJ.. �I-1' rt r :d _r+' s .w ,, rtS IA O O •��i U v� t :t e =�., _ F' f 4 s `£ ,Aq � ;i ^ VMS ,,F J i Fj , I Y�I O Z e-i •^ tz ` . s ^: I '� }j e r r a s'` '' ' s W^4 �-I N N I e ," - u a ra t 97 _r #r r >,I - HU �o `,i 't _ K y -.�,..r - -_ _ ____ _ 3 F . rL',",,�_,-, .� - " - -, ,. -� �---_.� - , .1. I , �- I� ­ -. .- j: k:. . . . _ _ F .. C_ , q CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1955 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4. Please note all "Wa.rn.i.ngs' ,. CLAIMANT: Bettye Barnes Heffernon ATIORNEY: Date received r�flUNiy ADDRESS: 824 San Carlos Ave. BY DELIVERY TO CLERK ON November 22`, 1995 Albany, CA 94706 BY MAIL POSTMARKED: via: Risk MPmt. 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, ppH gg DATED:_ November 27, 1995 e�Il Depuiy OR, 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: 55, BY: Deputy 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 ( M ) 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: 95 PHIL BATCHELOR,'Clerk, B +01.� , 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein fwitioned, 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. JJDated: /,Z - /,3 /9 9S BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator r. RECEIVE® City of Richmond NOV 2 2 Office of the City Attorney Risk Management Division CLERK BOARD OF PERVISOR8 P.O.Box 4046 CONTRA COSTA CO. Richmond, CA 94804 FAX NUMBER: (510) 620-6811 Vu0" FACSIMILE TPUXIL S. ISS_ON COVER 5c�T TO: rl koxve-�d C.C. `R,"s DATE: I i - D`d - q5- =� = G) � � e Cir � o =� � ee. Cts-acyl, eA L) �� ernon rr� COPY [ 1 WILL FOLLOW BY MA?_. [ l WILL NOT FOLLOW BY MA.11 1. -2"GR7AWT/CaVF:DGlMl- Th;s zm=9w is fircanded only for :he use aF --to individual cr antty m A"= It is' addr =ad This a:tssage CnC27M fnroralacian from =?Ts af=ics ri1T4zh may bw pr-ivi leged. q�Ti�errcYai ars! exalgltz from dlselanov under eaaiioole la.. tf c5e reader of this amage is ncc i^ ead rtac;*piertt, or Cite employee. or agrasuonsfble for delf.Krrnq tete message ca the n�noed recipigtrc, yav aro hereby *Deified :Aar any dlssennac an. dfstritutfon. or C=yfnq or rTTs �°�^yC77iTgn is Sa-rly pranibTted. (f,ym have remised chis c2rmuni4=1* in error, A41Se no rTy cos iarneaY�cely az Aur Biednone mmmer see mr," &)ova. we .,1? of .UCDY = arrange ror =jr C'tis aaM=29e uS vfa CM UAlteC Stares F==1 $erv?ca 3C 17C car tu you. i= T'►NS•`22SSZ0N IS NOT PROPERLX RECEIVED, pLZASZ CAr•r• NOU-08-1995 13 17 P.01 NOU-08-1995 13:20 RISK MANAGEMENT P.02 $11j� hN b- y� f ,racnneme s. _. Y (� .Ik ', r4))t'�'dP7: ts. •• _N.._ PRODl10ER PAdCN a Ent) OCCURRENCE DATE OFOCGIRAflICFANDTBrE AM DATE OFCLAIREPORTED T EPORTED NU'ftCE OF C[AIM 09-28-95 PM ES No Risk Management Division EffECTIVE DATE EXPIRATION DATE POLICY TYPE RETROACTIVE DATE c/o City of Richmond I 10CCURRFNCE CI.AIMSMAOF P. O.Bax 4046 COMPANY MISCELLANEOUS ANEOUS INFO(SIW 6 lovadon cad*) Ricbmo CODE: SUB CODE: POLICY NUMBER REIR:RENCE NUMBER AGENCY i CONTACT INSURED 1'' g" j NAME AND ADDRESS NAME AND ADDRESS WHERE TO CONTACT City of Richmond PUBLIC WORKS P. 0. Box 4046 Richmond, CA 94804 WHEN TO"CONTACT RESIDENCE PHONE(AIC,No) BUSINESS PHONE(A/C.No,a0 RESIDENCE PHONE(AIC,(ArC,No) BUSINESS PHONE(ac,N4 E>a) III INBORN M, LOCATION OF AUTHORITY CONTACTED OCCURRENCE pnclad<ahll,rrxe) Appx, 100 yds. (north) before Market & 3rd St. , Richmond DESCRIPTION OF Bump in roadway allegedly caused claimant to hit manhole, damaging her oil pan. OCCURRENCE Use reverse eld$. Irrocesaary) 1 p4.Y COVERAGE PART OR FORMS(tneerl form M and e4111en daNS) GENERAL AGGREGATE PROD/COMP OP AGG PERS Li AOV NJ EACH OCCURRENCE FlRE DAMAGE MEDICAL EXPENSE DEDUCTIBLE PO Bt UMBREL UMBRELLA EXCESS CARRIER: LJafiS: CLAIM OCCUR PREMISES:INSURED IS OWNER TENANT OTHER: TIM OFPREINISIES OWNER'S NAME 6 ADDRESS of not Insured) ou►NFJas PNOI� PRODUCTS_INSURED IS MANUFACTUAFRVENDOR OTHER: TYPE OF PRODUCT MANUFACTURER'S NAME A ADDRESS (It not Insured) MANUFACT PHONE WHERE CAN PRODUCT SE SEEN? OTHER LIABILITY IN- CLUDING COMPLETED OPERATIONS(Explain) ISMS NAME$ • PHONE WC,No.EM) ADD( 1�Imer) Bette Barnes Heffernon, 824 San Carlos Ave. , Albany, CA 94706 (510) 526-7726 AGE SEX OCCUPATION FWLOYERIS PHONE(AIC.N4,M NAME 6 AODREbS _ DESCRIBE INJURY WHERE TAKEN WHAT WAS BIyURF�D0o6? FATALITY _ DESCRIBE ESTIMATE AMOUNT WHERE CAN WHEN CAN PROPERTY BE SEEN? PROPERTY PROPERTY (type,model,etc) BE SEEM? NAME b ADDRESS iBLMNESS PHow(AIC,Ne,M RES 000E PHONE(AIC,No) REMARKS REPORTED BY REPORTED TO SIGNATURE OF PRODUCER OR INSURED Claimant Cit Clerk Louise Gi liotti, Risk Manager NOU-08-1995 13: 19 P.02 NOV-06-1995 13:21 RISK MANAGEMENT P.03 Office of EULA M. BARNES City Clerk City of INTER-OFFICE MEMORANDUM DATE: October 10, 1995 TO: FINANCE DEPARTMENT, LOUISE GIGLIOTTI FROM: CITY CLERK, EULA M. BARNES SUBJECT: CLAIM(S) AGAINST THE CITY By BETTYE BARNES HEFFERNON The attached claim(s) (listed above) against the City will be placed on the City Council's agenda when so advised by your office. Attachment 2600 Barrett Ave. P.O. Box 4046 Richmond California 94804 telephone: 415 620-6513 NOU-09-1995 13:19 98% P.03 NOU-08-1995 13:21 RISK MANAGEMENT P.04 3 ursuant to CoYernaant Coda 1 92 •t seq.) �I bass f iv �w(rh�5 1� e- C` ri:,!'r t14 Phone I9CJ ,tdd=e.. '�C AcG A-►�1 ,,�f�-f' .,1 _ r `t,'t -1 h ,n r , .r�.1�- ,(L �1J�j>tlts�_0Z11hON'Alit MOTICtS MCt—R"Xc C,AIM 999.W !_ LPNT i Masa f` 4d- f�r t f�i�Nr� u�.r F=•�.�na�-' !hens !22) Sx C -ri'7�C /� � �r•YYYY� , "zess �� ""+ . ..l rt �! Li. "7.�1� A- K)-/nL i . /1 — ^II�YYwwI�rwwYYYw,r�,IYYI�YYY�YY�YYr�lr��� �ox�.�t�Yom. eyltt s�ta� �1l��JA'"" lia,.�l,,,_a.>,. �;%/,�,�la,.■. SoC WCW C Ice Ar AeIJ- IIIY��IwI IrwY�YYYYwp�wY.YYlrw�nY�rw D ION Or 143S. lb""GE ORS Y3 ,fret l L-J t f�i(r�/•%-! � fr.�t'.�,%�- !�%-•r`t �.l r,�/._ 4-iJ?"t�.'� "17 ' , t ASLO! CITY IJKP�(S) CACSING LOSS. DAMAGE OR IIi�Y.XT„�110wi1t: VA?[G5}—aiai'D ADDRESSES OT ANY MSTNLSSLS, DOCTORS AND/OR 80ST�%LS,t �1l 171"'/•G-`T fi�'- ✓��1.=1r . ti mss AXOMT CLAIM 19 s10� ,000 Oltt LISS, P ZASS IIMICATS T= BASIS rOR Sw mom" CLAIM. V TBx &HO ST CZtaS� 00.*000, VIJAZ `AMICATt T'EL JURISDICTION vast Sw CLAlm. I I XMI IPAL COU ,44�'tTtLRIOR COURT O/WX� A'Z�/' gnatosaiFCIAIS"t Or person acting on his be a K MUST BL I2CMD BY CL>LZNAXT OR�R ON AC?IN 'an t�-t Delmer or sail toi City Clerk, ity of Richmond 0 96 P.O. box 40 6 tr 1 .I 3600 Barratt Avanne, BoOm 302 GO ���'M -0 All) It thmond, CA 94#01 :i: ` - . . NOV-08-1995 13:19 99% P.04 NOV-08-1995 13:22 RISK MANAGEMENT P.05 JR lu loft 4•_•C.•t.•.�i.,�.v'�.F,�'Y.':`�;:: ..�1 - < f �'!� �i.•tR',.tdE+. 'tuu ,�'iy.:'7='a..'.v;•' , 29:SanabbAAve. S LI B AFi U l Y/�LBANY.:CA 94708 RO No., ' CALIF lS.A:H - 'it r 1 �' _, • • 'AL189634 �•,�yr r R1 +1 'a O. NAMEOF Y �' RES.PHONE ADDRESS ' f'=? ` %, L pf BUS.• '' r PHONE IN BY �•-.i97 ER ,xpa L:f_ is PHONE YEAR MAKF MODy�- _ 40R.: UC.NO. BODY PROD.'DATE = '.COLOR'j -TRIM: ' IMLD©.•N0:"�"�a:MII,F.AOE SERUIL NO. A. PART ='PARTS.NECESBARY AND EBTIAfIATE OF,LBOR REQUIRED SUBLET LABOR COST _PARTS COST NUMBER .....� .,.':�, ...--•. ESTIMATE ESTIMATE :Yn xf-9 L44", •. 71 `J %• : . i r _ `Fay '•+ •< �. THE ABOVE IS AN ESTIMATE BASED ON OUR INSPECTION AND DOES NOT COVER.ANY ADDITIONAL LABOR AS. Q AT>f PARTS OR LABOR WHICH MAY BE REQUIRED AFTER E WORK••HAS'BE OPENED UP, ILE OCCASIONALLY AF7ER"THE woRK HAS STARTED DAMAGED OR BROKEN PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT ppN THE FIRST INSPEC11bN.;^ ' ?�.rr�t .d , '? a�;r, ''> % PAR79. LESS % P PRI S ARE 3U8JECT TO INV 1 ra .. ALL WORK CASH UNLESS OTHERARRANQEMENTS WOE IN ADVANCE .': : SUBLET . -YOU AAE HEREBY AUTHORIZED TO u&U TN9 ABOVE SPECIFIED F40AIRS.-' TAX SIGNED - DATE TOWING uwmm"cawc, uUjim)472-moz -jwswom JTNO.213133 . : ' -mTAi NOU-08-1995 13:20 99% P.05 NOU-08-1995 13:23 RISK MANAGEMENT P.06 oq lzo , 112 q I vs 'o e,c e• Z i 4o 3 o I 'L LAJ w cm /2 ui O o e rm .2, cc La a P3 �► m eta d i r c°'a v w o d °A m: ❑ ❑ hl .p frig O cl cq h Nd �, � fJ � 3 0 •a c ` t G ry `�. ra :ft 10 loom LU vp FE U) \ .' I/• /} WWeg c Wl Gi •I' r �i7 Y �i I` <r 0 N m 1 r y ; aIL L12 4L 9L I K r' ` Lui o .O 1. N W �' .�► Q ' • Q 2 W e uj o ' r E W Y� z;.'; ; ' ;�. 'fir,.. c c :v E o = w o co Z h u d v °. ; •. w O ° •'—° (7 r- a oc x ? Pu`5 a`c TOTAL P.06 NOU-08-1995 13=21 98% P.06 C , 9 "AIXEMED" CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ; December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: $1,547.00 Section 913 and 915.4. Pleas.e,moteyalVl;'„Wa:rn`.ings" } �'r ' .. CLAIMANT: Adele Chase Hollander ATTORNEY: coU41-Y Ccji ,1 Date received I;hrt't1,vELt ,e ir' ADDRESS: 501 Cliffside Ct. BY DELIVERY TO CLERK ON November 21, 1995 Point Richmond, CA 94801 BY MAIL POSTMARKED: November 20, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. `� IV BATCHELOR, Clerk DATED: "T 1 n,,..n.4-X t ed R-7- 199-L Bl�: Deputy 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). (L/Y Other: &4 4b PJ 6JG4 d4f,IG4* ✓ Dated: /I —7,Y— �7 s BY: t' 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: 12• !Z — 1 9 9_, ' PHIL BATCHELOR, Clerk, ByJJ ♦ 10 d. 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over,age 18; and that today 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: 1 '��,7 /`� BY: PHIL BATCHELOR byd4A"puty Clerk CC: County Counsel County Administrator Maim '.o: 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 Rom 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 ageinst more than -)ne public entity; ser%ArRte Maims n,et- be film acai.nct eat+.h null i.ct entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. It RE: Claim S� AS AMENDED BY ) Reserved for Clerk's filing stamp ADELE CHASE HOLLANDER ) RECEIVE® Against the County of Contra Costa ) or ) NOV 2 1 19% _ District) Fill in name ) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 1_ s47 nn and in support of this claim re resents as follows: .F. T C T-' L2 J_�. ��LTE_ -- 1. When did the damage or injury occur? (Give exact date and hour) The carnage occurred over the period between„ Feb t5 199 2. Where did the damage or injury occur? (Include city and county) At 4655 and 4655 Appian Way, E1 Sobrante , CWITPA COSTA COUNTY, CA Between the street, up to and including the front gate at said address . 3. How did the damage or injury occur? (Give full details; use extra paper if required) See attached explanation. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? See attached explanation and causes alleged. Q (over) 5. What are the ,names of county or district officers, servants or employees causing the damage or injury? I , . The damage was caused by the inadequate engineering, specifications , and plan under which the area in question was graded and pavdd in 1992 and in 1993 (repairs) . 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Large holes and lumps in the asphalt paving developed, as described herein and in "the pictures enclosed. I _ _ 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See estimate of repair by Mark Raine Paving Co. $1 , 547 .00 8. Names and addresses of witnesses, c �tx�, � 94803 C. Jay Hollander, Mark Raine , Joseph Farrell , 335 Hat Ct . , E1 Sobrante Roark Raine , 437 Rincon Lane , El Sobrante , CA 94803 Larry Delorifice , 4655 Appian Way , E1 Sobrante , 94803 Victor Nozzillo; 4655 Appian Way, E1 Stobrante, 94803 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT NONE YET. Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: ''(Attorne ) or by some person on is behalf," Nt3me and Address of Attorney • J,tai;_.�.•„ !, �u C.p Cp'L Claimant's Signature / 501 Cliffside Court , Pt . Richmond; CA 94801 Address Telephone No. Telephone No. 2 3 3- 7 7 8 8 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. ... .. f � DX ,.R y�,�,,:- mss; t� �'� � *� +s :.A }.t �� "_ <•� • *i: „ k �� "'as ���,,,✓ '�.G� � � € �� �-'�t 1 Y .'� � .:� .. - .. rs*�... � n 3 [x b. � � ♦ .� P� � tt .al•' .2 A' � * 1 € T • r c f �*'�" �e# } a s: e e � � L Fes, � { 'a 3 .i - -. r f � - { i � r_•. � � a i Y k 4, - •• + '. 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C:t i...t..s i. ;. � , <.l J. �: to {»c:. „�:.k ,.k:#, 'i::i „t:. i:. :ir it-i t:.i .., ,.F# .#'• ...4:::t., ..i :� .t k i >.} t:,t`.. .t... ,:i, i ,: ...'•f i s:i{:`t i., ,.: o t»t ,> v..t.(J., n vi i e c::i::,}a}1 c.': e»:.xs•,i�t,� i--E':.; d�a{a'.i g{:...1:..c.i . . . . It is tho� opinion of several paving contractors that the new driveway installed by Gallagher and Burke was not only inadequate in base rock an� paving for the use we have made of that property .t. but must be totally redone with a complete lowering of the grade and with required side wall protection. It would be a better use of funds if , since you must re- construct this driveway in a major way soon � it would be 1:3 to do it in the final form with proper grades and sidewalk now. As owner of the above building , I hereby make claim against the County of Contra Costa, its Department of Public Wcs and Engineering and Gallagher and Burke, its contractor. Wherefore, demand is made upon the Ccuu�ty for the sum of One Thousand , Five� Hundred and Forty-seven ($1 ,547. 00) Dollars damage ` to the property of the undersigned. In the alternative, the County of Contra Costa must redesign this driveway, cut down the grade and reconstruct it , with alignment to the final grades you established for Appian Way and its sidewalk. This t twoproperties east of ours where the sidewalks are in place. Verification I , Adele Chase Hollander , Trustee, declare that I am the owner of the property at 4655 and 4653 Appian Way, El Sobrante, Contra Costa County, California, the claimant in the foregoing claim; that I have read the same and know the contents thereof ; that the same is true; and that it contains, a correct statement of my demand. I further declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. | Executed on October 21 , 1995 at Point Richmond , California~ _........ .. __ , -- --- Owner of 4655-4653 Appian Way El Sobrante, California My address is: 501 Cliffside Court Pt~ J.-k- CA 94801 / ! ` file12/CLAIM. DAM ' ' � ■ ^ � z\� . 2 CA4 / m\ \ \ �Q@e oo ® mO > eo e E o e « @ o g � 2c3 7 Gc3 r» o $ o£ sww ISI o @ j u §+ o cuer ) dome & . o .. q2 »/ % ) � % / \ W 2 0 m _ E . m $ £ . m + U £ + / ; $ / w . w c \ \ \ i | : e � t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4, y.pase-note`aA-lea"W&rnings". CLAIMANT: Faustina M. Dohermann Lavalsiti V 8 ""_3 S'5 ATTORNEY: David J. Byron Date received [AAATli�iEL COUNT`i C_U it�`L vtiaRi;kLii=. ADDRESS: 39111 Paseo Padre Pkwy, Ste. 220 BY DELIVERY TO CLERK ON November 20, 1995 Fremont, cA 94538-1615 BY MAIL POSTMARKED: November 18, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PPMt�IL BATCHELOR, Clerk , DATED: November 27, 1995 B1: Deputy �,�QQa II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( Vf'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: / l Z�� 9 BY: Deputy County Counsel II1. 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 (✓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: 12 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: 1'1,-,1 - 19 CJs BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator DAVID J. B,YRON ATTORNEY AT LAW 39111 Paseo Padre Pkwy. Ste. 220 Fremont, CA 94538-1615 Telephone 510-792-9297 Fax 510-79.5-6111 November 17, 1995 RECEIVED CLERK BOARD OF SUPERVISORS COUNTY OF CONTRA, COSTA NOV 2 O F 651 PINE STREET MARTINEZ CA 94553 CLERKCp TRA COSD OF TA CO.AR ISORS Re : Claim. of Faustina M. Dohermann Lavalsiti Date of Incident : 6-25-95 Ladies/Gentlemen; This is a claim pursuant to Government Code section 911 . 2 . Claimant is ,Faustina Marchand Dohe'rmann Lavalsiti; Claimant' s address is 4885 South Point, Byron, CA 94514 Any notices regarding this claim should be sent to Claimant at 4885 South Point, Byron, CA 94514 . The date, place and other circumstances of this incident are : Claimant was arrested by Deputy D. G. Dunlap #40845 for resisting/interfering/obstructing (Penal Code § 148) . Dep. Dunlap came into contact with claimant while she was parked in the parking lot of Mission Bait and Mart, 1541 E . Cypress, Rd.',, Oakley about 0535 hrs . ,' June '25, 1995 . Claimant had stopped there because. she was too sleepy to drive., She was on a medication that , she had not, gotten fully used to yet. Claimant was contacted by Dep. Dunlap. Claimant was not aware of what was happening. Claimant believes Dep. Dunlap was reaching into her cart she became frightened. She reached toward Dep. Dunlap, not knowing what he was trying to do. Dep. dunlap yanked claimant out of her car and handcuffed her. During the process Dep'. Dunlap kept telling claimant to hold still . Although' claimant was not moving, ' he kept telling her to be still . He behaved very violently and used far more force ' than wast necessary. Claimant characterizes him as being out of control . Claimant was placed in the . rear of a police car. d:\95c1ient\dohermann\c1aim.1tr November 17, 1995 Page 2. Clerk, Board of Supervisors County, of Contra' Costa Claim of Faustina M., Dohermann Lavalsiti November .17, 1995 Dep. Dunlap •cited claimant for resisting arrest and . unhandcuffed her and told her to. go home. There were fire and paramedic" personnel present . One of these per urged claimant to .go to the Sheriff' s Station and inform them that she was being mistreated.. These persons indicated that they would support her. Claimant drove off extremely upset . She probably should not have been allowed todrive off . However, she went -to the Sheriff' s Station to made a complaint against Dep. Dunlap. She was again Confronted by Dept . Dunlap who` attempted to talk to her. Apparently Dep. Dunlap has accused claimant of scratching him; but claimant does not believe that she scratched him. She had no fingernails at the time with which to scratch the deputy. . Claimant suffered much distress over this incident; claimant has been charged with a crime by the " District Attorney' s Office (battery on a peace officer, Penal code § 242/243 (b) and resisting, obstructing or delaying a .public officer, Penal, code § 148) . As a consequence claimant has incurred attorney fees to defend herself in this action. At the present moment claimant' s losses include attorney fees of three thousand dollars ($3 , 000) , process service costs ' of two hundred seventy five dollars ($275) and investigative fees which will likely be seven-hundred fifty dollars ($750) , and whatever further costs and further fees - are necessary to defend against these criminal charges . The enclosed materials may assist in providing information about this matter. Your consideration of claimant' s matter is appreciated. Very truly your , David J. By n Attorney at Law Encls : Copy of criminal complaint, Docket No. 095878-5 , with attached copy of police reports - (Contra Costa , County Sheriff' s Dept . , report (DR No. 95-17327 and Contra."Costa County Sheriff' s Dept . report 95-15647) d:\95c1ient\dohermann\c1aim.1tr November 17, 1995 Page 3 Clerk, Board of Supervisors County of - Contra Costa Claim of Faustina .M. Dohermann Lavalsiti , November 17, 1995 Copy, of Personnel complaint; Copy of letter from David J. Byron, Attorney at Law to the District Attorney, dated Oct . 17 , 1995 , ' seeking dismissal of these charges. i d:\95c1ient\dohermann\c1aim.1tr November 17 , 1995 1 � (per E :JUL 26 19J5 MUNICIPAL COURT OF CALIFORNIA, kS'COUNTY OF CCOON[�+-1n)�?n-Cp J� - DELTA JUDICIAL DISTRICT ' r '� THE PEOPLE OF THE STATE OF CALIFORNIA, NO. ' 095878-5 DA 'NO. C 95 008200"-8 vs., COMPLAINT - MISDEMEANOR FAUSTINA MARCHAND DOHERMANN, 01) PC 242/243 (B) DEFENDANT./ 02 ) PC 148 The undersigned states, on . information and belief, that FAUSTINA ,MARCHAND DOHERMANN, Defendant, did commit a misdemean'or, , to wit: violation of PENAL. CODE SECTION 242/243 (b) (BATTERY ON' PEACE OFFICER, committed as follows, to wit: r On or about June 25 , 1995, at Oakley, , in Contra Costa County, the Defendant, , FAUSTINA MARCHAND DOHERMAN"N', did wulfully .and ulawfully use force or violence upon the person of Officer D. 'G. DUNLAP, a peace officer, who was engaged in the performance -of his duties; and the Defendant, FAUSTINA MARCHAND DOHERMANN', knew and 'reasonably should have known that Officer -DUNLAP,"was a peace officer,- engaged in the performance of his duties . COUNT TWO: r The undersigned further states, on information and belief, that FAUSTINA MARCHAND DOHERMANN, defendant, did 'commit a misdemeanor, to wit; violation of PENAL CODE SECTION 148 (RESIST, OBSTRUCT, OR .DELAY A PUBLIC OFFICER) , committed as follows, to wit: On or about June 25 , 1995, at Oakley, in Contra Costa County, the Defendant, FAUSTINA MARCHAND DOHERMANN did wilfully and unlawfully resist, delay, and obstruct a public officer in the discharge of and the 'attempt to discharge a duty of his office. COMPLAINANT REQUESTS THAT DEFENDANT(S) BE DEALT WITH ACCORD>ING TO LAW. I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. DATED: July 175 1995 AT CONCORD, CALIFORNIA G. WARD ----�_ , COMPLAINANT JENNIFER URBANSKI/ms ^ DEPUTY- DISTRICT ATTORNEY CONTRA COSTA COUNTY SHERIFF .'ti (gFacAP,age CONTRA C,.,-,rA COUNTY SHERIFF'S DEPARTMENT,G-j070000 Beau_ /(JGonenuation P.U. Box 391, Martinez, Cd(ifornia 94553-0039 Supplemental ❑HRO NJ Arrest CSI 1.OR No. 2.Gity Gode 3. Crime/Classification 4.Detail 1 5.More 1'�� rf D 1 `T A ;L'- -S 1 �'t+J G r OFF( C-k�iZ 2. -Z Persgns 6.Day/Date/Time of Occurrence 7.Dale J Time fleg rted 8.Employee No. ■ Q �4 ��.(� ' 1 9.Reclassi_ -fication 10.Adds ss/Location of O urren e ❑ 2P-1VA"[-Q- C�`C' i 'f t - 11. K PRI C VIC C WIT ❑MSP C RUN C SUS []LEAD C Other 12.Name(L,F,M): 13.Race/Sex/Age 14.DOB 15.Driver License No. L [A /J F G� F [o ? 16.Address (Zip Code) 17.Home Phone 18.Employed By or School 19.Work Phone 20.Hair 21.Eyes 22:.HL 23,0L 24.AKA!Maiden Name 25.Social Security No. 26.Further Description(Scars,Tattoos,Mannerisms,Clothing,Etc.) 27.Booking or Cite No. 28. ❑PRI ®VIC ❑WIT _ ❑MSP = ❑RUN ❑SUS C LEAD C Other 29.Name(L,F,M) 34.Race t Sex t Age 31,DOB 32.Driver license No. PEa r 33.Address (Zip Code) 34.Home Phone, ( ) 35.Employed By or School 36.Work Phone 3Z.Hair 38:Eyes 39.H,. 40.Wt. 41.AKA/Maiden Name 42.Social Security No. 43.Further Description(Scars,Tattoos,Mannerisms.Clothing,Etc.) 44.Booking or Cite No. 45.'• []PRI (]VIC ❑WIT C MSP C RUN a SUS ❑'LEAD C other 46.Name(L,;F•M) 1 47.Race,/Sex/Age A8.D08 49.Driver License No. b 1=.,2..h-1 A 1=A v `rI nJ' Q G N 1 L� � S4.Address (Z p Code) 51.Home.Phone Y ( > 52.Employed By or Schpol 53.Work Phone 54.Hair 55.Eyes 56.HL 57. t. 58.AKA t Maiden Name 59.Social Security No 0 14d " A--JAU-5 )`T- FAL3611^3At H:A2.GNAAD 60.Further Description(Scars, attoos,Mannerisms.Clothing,Etc:) BJl q'G SI-EV S 61. Cite No.' ASy c.R oo �tY f 2Y .!E ►J 5 a` x P ,e �5 f�T a.0-- 40 1`7 14 !o 62.Veh./fres 63 Lic.Nd(State) 64.Year 65.IAake 66. odelt 67.Body Style 63.Color Top _-A1-) INS C V ict ( 73 F- ( `7 a Bottom 69.Status 70.Registered Owr�erl 71.R.O.Address Left n >_. . 1301. ZIM4 gL 6A C]lmpound 72.Towed to or Released t 73.Who LA keys? Stored A bo H E jptj A to A-) H 74.Evid, CD Yes 7S.F/P C es 76.Oispo of Evidence 77.$Missing 78.$Da ed IN No X No � � � 79.Brief Synopsis of Incident MCEPoY r-OAJGE O Ati3 A'A.) (2) F G t t3) C t� ti S (4) C (5} (7) 80.Distribution 81.Additional Routing . CB C]C CDA (jDE CL C]o CSR CV C Investigation Vicef C Narcotics CJuv 0 Coroner, 82.Reporting Deputy(Print) 83.Date/Time Written84.Dispo. Property Ck. ACS C Intell. [JR.O., C SHG 1 a' Q E,,Q 0.2.E d C 1.C1 C]Patrol Captain Compl.Ole. C Marine Patrol 85.Approving S .(Print) 86.Supv,No. 87.Date 88.Page Other. G- . o "4 FORMA (Rev.1/89) /0Fac;ePage CONTRA G.. ,TA,COUNTY SHERIFF'S DEPARTMENT GMJ07000'0 Beat._s5,�,._ :!aContinuation P.O. Box 391, Martinez, California 94553-0039 • ❑Supplemental ❑HRO I9,Arrest ❑SI City Code 3.Crime/Classification 4.Detail t 5.More C 2. 7 oa Persons 6.Day/Dale/Time of Occurrence 7.Date i Time Reported 8. mpioyee No. Q� 9.Reclassi- 10.Address j Location of Occurrence ' fication 11.. 0 PRI VIC WIT ❑MSP ❑RUN 0 SUS ❑LEAD Other 12.Name(L,F.M) 13.Race/Sex-/Age 14.DOB 15.Driver License No. It.Address (Zip Code) 17.Home Phone' 16.Employed By or School 19.Work Phone i. G 1 20.Hair 21.Eyes 22.H, 23.Wt. 24.AKA/Maiden Name 25.Social Security No. 26.Further Description(Scars,Tattoos,Mannerisms,Clothing,Etc,) 27.Booking or Cite No. 28. 0 PRI O VIC IJ WIT ❑MSP t. ❑RUN SUS LEAD ❑Other 29.Name(L,F,M) 30.Race 1 Sex t Age 31.DOB 32.Driver License No. A ��L 33.Address (Zip Code) 34.Home Phone 35.Employed By or School 36.Work Phone c 0 ^-3 e t { ) 6-11 9`9 37•Hair 38,Eyes 39.Ht. 40.Wt. 141.AKA/Maiden Name 42,Social Security No. 43.Further Description(Scars,Tattoos,Mannerisms,Clothing,Etc.) 44.Booking or Cite No. 45. PRI VIC ❑WIT ❑MSP RUN SUS []LEAD Other 46.Name(L,F,M) 47.Race/Sex/Age 48.DOB 49.Driver License No. $0.Address (Zip Code) 51.Home Phone ( ) 52,Employed By or School 53.Work Phone ( ) 54.Hair. 55.Eyes 56.HL 57.Wt. 58.AKA t Maiden Name 59.,Social Security No 60.Further Description(Scars,Tattoos,Mannerisms,Clothing,Etc.) 61.Booking or Cite No. 1 , 62.Veh J Ves 63.Lic.No.(State) 64:Year 65.Make 66.Model{ 67.Body Style 63.Color Top S ❑Vict Bottom 69.Status 70.Registered Owner 71.R.O.Address ❑ten Q impound 72.Towed to or Released to 73.Who has keys? Stored 74.Evid. ❑Yes 75.F/P ❑Yes 76.Dispo of Evidence 77.$Missing 78.$Damaged 0 No 1 ❑No 79.Brief Synopsis of Incident {t} (21 (3) {5} ' (6) (7) $0.Distribution 81.Additional Routing OB ❑C ODA ODE ❑L ❑O ❑SR ❑V 0,Investigation O Vice D Narcotics ❑Juv 0 Coroner 82.Reporting Deputy(Print) 83.Date/Time Written 84:Dispo. 0 Property Ck. F�ACS ❑Intell. 0 R.O. 0 SHC Date 88.Page Q Patrol Captain ❑Compl,Olc. [�Marine Patrol 85.Approving Supv.(Print) 86.Supv. Other ar 4-ot ORM A: (Rev.1/89) Continuation`, CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT CA0070000 Beat_ ❑Supplemental P.O. Box 391, Martinez,California 94553-0039 0 HRo 0 Arrest OSI 1.DR No. 2.City Cade 3.Grime`Cfassiticatian 4.Detail 1 t 5.Reclassi- --) Gf-= 2, ticabon 6.Victim Name(L.F;M) 7.Date Orig,Report 8.Employee No. 9.Address/Location o1 Occurrence 10.Suspect's Name(L;F,M) 11,Properly Description: Impounded,Recovered,Found,Last,Stolen-item Number,Article,Ouantity,Brand/Make/Manufacturer's Model Number,Serial Number,Miscellaneous Description,Location Where Taken,Value,Include Total Loss LIST IN FOLLOWING ORDER:A)Currency,Notes;B)Jewelry;C)Clothing,Furs;D)Vehicles;E)Office Equipment;F)Radio;TVs,etc.: G)Firearms;H)Household Goods;1)Misc. 12.Recovered Property$ 13.Narrative/Statements ,v (2) t✓E " 40i- ,0.tis (3) A t Y o (4) (5) (6)UPa at2 r..J �' G .t .c. . (7) C- �Q:t7,_� Sa) C- .33 h A r„0 n2!1 FewQ-4bAh - 1 (9)C c Y' Y N t. b t t tJ o cZ as { (12) (13) (t5)--6P A�b C I (16) (17) 1 `M1 i18) Gtc A (19) p C4,E (2 1) 1 tJ G.- A FaZI G.A I'F3 AS.rt= .Q t,t_ CSe F~ "' (22) (23) (24) (25) . 14,Distribution 15.Additional Routing (]B OC ODA ODE OL OO OSR ❑V Investigation O Vice ❑Narcotics O Juv O Coroner O Property Ck. []ACS O Inteil. I]R9. O SHC 16.Reporting Deputy(Print) 17.Date/,Time Written 1a.Dispo. Patrol Captain O Compl.Oic. O Marine Patrol j1 C.J1 O Other 19.Approving Supv.(Print) 20.Supv,No. 1.,Date .22.Page FORM 8 (Rev.1./89) IN Continuation CONTRA COSTA CdUNTY'SHERIFF'S DEPARTMENT CA0070000 Beat �3( P.O. Box 391, Martinez, California 94553-0039. , arrest s( Supplemental HRCT ❑ Q . 1.OR No. 2.City Code 3.CrimelGlassification 4.Detail 1 t 5.Rectassi- -" - 17(=3�i�A 12 1= 1 t nSG_ C 2. lication 6.Victim Name(L,•F,M) 7,Date Orig,Report 8.Employee No. ❑ 9.Address!Location of Occurrence 10.Suspect's Name(L,F,M) 11.Property Description: Impounded,Recovered,Found.lost.Stolen-Item Number,Article,Quantity,Brand/Make/Manufacturer's Model Number,Serial Number,Miscellaneous Description,Location Where Taken,Value,Include Total Loss-LIST IN FOLLOWING,ORDER:A)Currency.Notes;B)Jewelry;C)Clothing,Furs;D)Vehicles;E)Office Equipment;F)Radio,TVs,etc.; G)Firearms;H)Household Goads;l)Misc. 12.Recovered Property$ 13.Narrative/Statements (2) (3) N u Fl>V .5 b E `7' {s} 0 1 _E0 1J O (6) o (7) uE I a AJ - M 7 ,1 GA Q . {f)1 c^ I~ tea " a Ec cD (9) A iJ (10) (111 (12?-- ' t'14 f Cj (13) s E a. (14) (15) ' C "' �t t Y1 HAY (16) E "A-TrF-H;PY1Y,)C "Tn 8 A P-11-i A F= ZSELE r (n) c 5t A - Y `{" 1 (16) Alf F J) 8AC (19) LJ E (22) G- .7- IJ- -- '1 !d.) (24) G 1 G G J AN r..3 (2 5) 14.Distribution 15.Additional Routing ❑B ❑C ODA []DE , OL ❑O []SR ❑V [:)investigation ❑Vice ❑Narcotics []Juv ❑Coroner ❑PropertyCk. E]AGS ❑Intell. ',[Q R.O. ❑SHC 16.Reporting Deputy(Print) 17.Date t Time Written 18.Dispo. ❑Patrol Captain []Compt.Otc. R Marine Patrol D ❑Other 19.Approving Supv.(Print 26.Supv.No, 21.Date .Page FORM,B (Rev,1/89) �CoMinuationCONTRA CuSTA COUNTY SHERIFF'S DEPARTMENT CR0070000' Beat ❑Supplemental P.O., Box 391, Martinez, California 94553-0039 ❑HRO E]Arrest ❑SI ffVictim 2.City Code 3.Crime/Classification 4.Detail 1 �� 8 S.Reclassi- ' 17 7 CL i A r 5 1 J`' .� G— O r=F/.GC�_ 2. tication Name(L,F,M) 7.Date Orig.Report 8.Employee No. ❑ s/Location of Occurrence 10.Suspect's Name(L,F,M) 11.Property Description: Impounded,Recovered,Found,Lost,.Stolen-:Item Number,Article,Quantity,Brand/Make/Manufacturer's Model Number,Serial Number,Miscellaneous Description,Location Where Taken.Value,Include Total Loss-LIST IN FOLLOWING ORDERA)Currency,Notes;8)Jewelry;C)Clothing,Furs;D)Vehicles;E)Office Equipment;F)Radio.TVs,etc G)Firearms;H)Household Goods;1)Misc. 12.Recovered Property$ 13.Narrative/Statements (1) . S S (2) F P e t o G, (3) 1 Ik.3 r 2. 5 n��r - v ts) - Y c k E Vid- (7)Y FA p P-E- PapI - G E3�.iE G U (12) (13) GL — E (14) P _ (15) t t (16) p 17 8 PC / f ^3c--. o C 3 — (19)o'S _ (20) (21) (��) q P (23) `, `- A' (24) Q (25) 14.Distribution. 15.Additional Routing 08 ❑C ODA ODE ❑L ❑o ❑SR 0 0 Investigation ❑Vice ❑Narcotics ❑Juv ❑Coroner Property Ck. ❑ACS ❑'Intell. ❑R.O. ❑SHC 16.Reporting Deputy(Print) 17.Date/Time Written 18.Dispo. ❑Patrol Captain ❑Compl.Ofc. ❑Marine.Patrol F]Other 19.Approving Supv.(Print) 20.Supv.No. 21 Date 22.Paqe dG-,d of FORM B, (Rev.1/89) .. 71, .y. ..• , M=p..Moxa Ou:'moss Forms,fnG, PalonLs J,O18 JD8 J,428.83'i`` - DIGI-CHEK COUNTY OF CONTRA COSTA S DEPARTMENT SHERIFF' ; MISDEMEANOR NOTICE TO APPEAR;' 2QTIME DAY QK17 8 6 Co -01 199 ' M v NAME(FIRST, DDLE.LAST) RESIDENCE/BU I ESS ADDRESS CITY - $� C� EVIDENCE Of INANCIAL RESPONSIBRITY - DRIVERS LICENSE NO. - STATE CLASS BIRTHDATE - i SEX HAIR EYES HEIGHT WEK.HT RAGE OTHER DES. T 12 'VEHICLEL N NO. - STAT , F w . Q CY.(V.C. 1521Ob) '-' YEAR Of YEFL MAKE MO 82 STYLE COLOR PASSENGERS - Y n^ y� ❑H.M.-(V.C.353) rC_V M F REGISTERED OW ER OR LESSEE ❑ SAME ADDRESS OF OWNER OR LESSEE ❑ SAME VIOLATION($) F� SECTION CODE DESCRIPTION - Y INFRACTION _ RE O IREO BOOKING O KING jj Dismiss on proof of Correction if - E] RADAR checked,Here(A06}0 B CVC) APPRO%.SPEED FIF MAX.SPEED VEK SPO.LMT SAFE SPD. CITY OF OCCUR. RADAR - CONE FORM ISSUED LOCAAON iO'f VIOLATIONS} s - . . - .COM TS:(WEATHER,ROAD;6 TRAFFIC CONDITIONS} OFFICER'5 DAYS Off - ACCIDENT S M T W TH F S- OFFENSE(S)NOT COMMITTED IN MY PRESENCE CERTIFIED ON INFORMATION AND BELIEF,i CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING 15 TRUE AND COR CT EXECUTED ON THE DATE SHOWN ABOVE AT SERIAL NO. ISSUING OFf C�A�ER t9ucE) CALIF, NAME OF ARRES G OFFICER-IF DIFFERENT FR ABOVE SERIAL NO, - VACATION DATES y TO WITHOUT ADMITTING T,I ISE T APPEAR AT THE TIME AN�PLACE CHECKED BELOW. X SIGNATURE flEFORE AIUDGE ORA ERK F THE 11NICNAL COURT N 017 JUV NILE OUR7 TRAFfK DNISION DATE TIME - WIRSIN - 19 9 ,A M IS DAYS FORM'APPROVED BYZEJUDICIAL OUNCIL Of CALIFORNIA REV.1/1/77 VC.ROS 0(B)40513(8)P.C.857.9, SEE REVERSE SIDE L` FORM V-56 6/90 QI ^. 1_ 1 'J ■ scwpi d COn rRA COSTA COUNTY SHERIFF'S DEPAATmEN r CA00T0000 � [1 ca,oamen h P.O. Box 391,Ma � W rUttiez,CaliforniaGalNornla 94553-0039 O HRO ❑Arrest ❑8k I . 2 CCisods 3 Gir,r/ 4 OesM 1 6.Mae S G�7 v� 2. Penorr b/Tkno d 7.Dab Tins Rporbd a Em No. - / G• •9 8 71 Z 9.P,Ka"i- /Loc.eon of Ronson / w c,J ❑ vtc vYrr p MSP p RUN p sus p LEAD O 01tw 12. F. t3 Rsw/8.x/Age 14.008 16 Dr1wr Lkeme No. GcJ 1&Address (Zip Code) 17.Home Phar 18.Er plo 6y or Scholl 19,Work Phone 20.Mair 21.Eyes 22.FR 23.WL 24.AKA/Maiden Name 25.SOCW Secuft No 2&Further Dow"on(Bean.Tsttooe.Mrxwisms.Clothing.E1c.) 27.BookkV or Gla No. 2& ❑PF4 OVIC Wil MSP RUN 0 5113 n LEAD Mother 29.N (L,F.4 � 30Rao*/Sex Jr Aga 31.D08 �� W.Dr1wr Uow%"No. - 3, eee WP Code) 34.Horns Phone AIMMA w [.r✓ o E / X Employed By or School 3&Work Phone v �2• q 37.Mair 3&Ey« 39.HL 40.Wt 41.AKA/Maiden Naar 42.$OCw$sctrlQr No. 5 • . 43,Further Deeoriptlon(Scan.Taboos,Mannerisms,C"hkV.E1ca 44.Booking or Cho No. 45 QPN Vic DWIT 0 MSP, ORA 5119 LEAD Other 4&r;4,vz,q1 .F.let) 47.Race/Sax/Ape 48.006 4Q iva L1cw"N0L . AwN, STiW �QCfIA O . F o G• . / 57 6Q __ll hit � /QO N WP Cods), 51.Ftoer 52.Emp( By«Sdad $3.Work Phone 5l HZ 55.Eyes 5&ML 57.WL 58.AKA/Maiden Name 59.Social Sec N.oy� 60.Furttw Description(Scars,Tattoos.Mannerisms,Cto 44i E1c3 41.BookxV«CW 82.Veh/Ven n Lk:,No.(Sate) t14 Ysw .Maiu EA Model 67.Body S" d3.Calor Top 06 Vk 1 Bosom, 69.Status7M Rpislared Owrw 71.R.Q Ad&"& C]LAj&/ ❑I-pound 72.Towed Io or Released to 71 Who hes keys? SW6d 74.Evid. ❑Yea 75.F/P ❑Yes 7 of EYidence 77,S Missing 78 =Dameped No No 76..Brt noesis of kicidertt (1). t2) L A. N (3) AAA 1V (` !� Me- c U, AND Aor� A4i.'r- cs) Dbt►butlon 61.Additional Rouing O8 OC ❑DAIBgE pL 00 DSA IJV ❑Investigation �,o we ❑N&M0tcs O JuY p cor«w 62 Dwuty as 0a* 54.Di". O Property .8' ❑inWl. O RA: [-).%4C - `, , t✓ 3 oe,.r Capain4 Otc. ❑Mark,.Petra P1 0 eb Approvkp �k+9 11&supv.No. 87.Der M Poo FORMA (Rev.1/89) see,CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT CA0070000 7C4,ndnuation P.o. Rax%oi,MwrtL^,wx.Gllk>rttia G4663-0039 p pN n LLII eupy vnwnr /j + 1. "1 ti 2.Cxy� ns &CrW / 5cu o0 4,Dew I. re a:Mo 2 PO*orw &Dey/Deft/Tkns of OoCuc»nd 7.Davis J Tk+M PWpon ! E EM10 y"140. { 0.Recu". 10.Addrw/Location of Occurreno. p . 11. 0 Pw Vic OVAT p t tsP OWN C3 sus t EAD 12 NArrLIL.F.M) 18.Rscs/sax/Ag* ll 008 16.DrKW Uomnss No. 1&Add - (Zip Cods) 17.Hans Phone 1&&npbyed By or Sohool 10.Work Phone t ! 20.Hair 12 1.Eyes 22,Ht 23 wt 24.AKA/Maiden Name 2S.SocW Gook* y No., 26,Further Desaip 00*cars,Tattoo*,Marw»rwmk Cbd i%.EW4 27.BOOWV or CAS No. 26. p PW Vic 0 WfT nmsp OWN p SUS Cl LEAD WOW 29.Na (L,F.M) '7 30.Rom/Sax t 31-DOS 32.DrNw Lkerae No. 33, (Zlp Code) 34.Hots Phone / 35.Employed By or schOai 36.Work Phone t ! 37.Hair 3a,Eye* 1 30.Ht 40,Wt 41.AKA/Maiden Nang* 42.soc1M BaCwly No. 43,Furfw Descr"oo(scan,Tattoo*,k4vvwbma,C•k*wvg.DO 44.BooWq or Clot No. 45. C PRI OVIC WIT 0 MSP 0 RUN sus LEAD 00 46.Na t1.,F.M! 47.Rana!Sex 48.D06 40.Ww License No.- NN. JR ! Z-"Q 50. e s Wp Codd 51.Horn*Phone GaC�» d ( ! 82.Errs{"Od By or.sohooi 33.Work Phone 54.Hek 56.Eyes 56.}k 67.VEL 58,AKA/Maiden Name So.60061 Security No . 60.further Deoalption(Soars,Tasom Marwtarbm*Clothing.Etc.! 8i.Booking or Cie No., 82.Veh/VO4 63.Lk-No,(Sabi) 84.Year 66.Melee 66 MO" 87.Body sty% 83.CObr lop ps Ovid Boom . ea.saki 70.Registered Owner 7t.R O.Addree* p Leu C k pound 7Z Towed to or Released to 7A Who hes key*? stoced 74.Ey d. C Yee 76.F/P p Yea 7&Dispo Of E ' 77,f Misskrg T8 i Demaged No No 70.8ried 8ynopskf of Incid4xX . (1) t2! 01 (4) (S! t6! $0.DfttribWon 8t AddWorW Rotttirig 08 CC ODA ODE OL CJD CJS+ OV p klvMdgsMon p Vks p Nwoodcs p Juv p C"(Kw 82. b3 Deb/Tkna V►titwl p Property Ck p ACa p Ir t un. p RO. p&4C ..1d irV •P` ,Z'C� p Patrol Captrin p Gon+W Ofc ❑►Aartna Patrot M.Approvfnp&tpk(Prsr,Q a6.suprc Na 87.Date 86. ao,.r FORMA (Avw.1/Bp) r' •e• • • I-. •WILYA � �iw�•��� .. rii`dl�1l � 11.Prop" DoecrObwt • FOLIDMNO•-♦ ♦. • o • G) e. � I-. 1 ��M � rr,. L e Iit • • rrr 'ty't i 11...: t S ear i..�f . # L' • � Itr. a r. 3� / ' j i '"�, t# w• # t • L•�• I MOM.: • � .:. r=sem'' :�- t� sir= 4�..:� � _- . • a Al 11111F11' F� dw • S+� rr/' J.'r: r v �.i.w. . �..lrli ��.aiL•i L� 1's A s w �. � r�•�,j #.aI`�Yr / i II w �L •' l�a.�i r r . ff T. MrA• fir � / ' �rr �•r #1J�i �a .1 � �� • II ./' (�I rr'r�r t rr'• .t- I r ■•. OWN ; �� •• Place Stamp Here WARREN E. RUPF, SHERIFF CONTRA COSTA COUNTY Post Office Box 391 Martinez.,California 94553 So ro d E y o+ a•M oc Q is t R ro „' o c. -� y'C7 « c . � O ^o a' M rJ. C n J'C7 U1 . in p ro � � 5 .D � d �. ;;,, o -� � �- .�•_.. 'C ,O�s G t�9 ,C( �.� � „� . n• Cb, .b7po C •rt. OwC oryd' Nrn• 'r C on 'pro aK^ °S: O.CC•7., ^ti: p ofir CW O_,�Mn.„ �_ S« ryO .'r�u, ,fMO,..'^ nN '�tD• C af9• nO yO. ycq O 3w CQ fuO °: S m Q' _, y.ro'C1 b C. Ce N •'ri ,Mj .0.,� @ �, w ry 5 � ry < �� m'n d �• n o .p ." �. JC.'S' 't G' r-• .`r7+ ,� �. '� ry y fdro 'O w f�9 d 'bS n 0 d,•p-n d ^ .M. N Co C. 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DAVID J. BYRON ATTORNEY AT' LAW 39111 Paseo Padre Pkwy. Ste.. . 220 Fremont, CA 94538-1615 Telephone 510-792-9297` Fax 510-795-6117 October 17, .1995 OFFICE OF THE DISTRICT ATTORNEY 3024 WILLOW PASS ROAD ROOM 202 5107646-5335 CONCORD CA 94519-2577 FAX : 510,64`6-5467 Re: People v. Faustina Marchand, Dohermann Delta Municipal Court Docket 095878-5 DA No. C95 008200-8 Next appearance : . 10-26-9511 : 30 PM Dept Two ,Pre-trial 4 Ladie's/Gentlemen, I represent the defendant, Ms. Dohermann- She presently uses her maiden name, Faustina M. Lavalsiti . I think this matter ought to be dismissed for the reasons that Ms . Lavalsiti. did not by her actions purposely resistor assault the officer. It is our position that. . shewas man-handled by , the officer and that her response ought to be viewed as a reaction to inappropriate conduct of the officer,. not as assaultive or resistive behavior toward the officer;. " It is nay understanding that on the date of this. incident Ms Lavalsiti was driving and became sleepy. She was taking medication that she had not yet become accustomed to this medicine, lithium. She had not long before this incident been hospitalized and ' , diagnosed as bi-polar and hypoglycemic . Thus, the medication. A, grocery store clerk apparently, became concerned about Ms . ' Lavalsiti' s welfare, so called 911 . Deputy Dunlap of the Contra County Sheriff' s .Office responded. The Knightsen Fire Department also responded. Deputy Dunlap treated Ms . Lavalsiti extremely roughly, 'He pulled her out of her _car .and threw her to the ground, Ms . Lavalsiti was cited for 148 'PC, . but was ultimately released at the scene . Apparently Knightsen Fire Dept . personnel intervened on her behalf . The pills the officer was concerned about .apparently. proved to be prescribed lithium. „ d:\95c1ient\dohermann\da1.1tr October 17, 1995 October 17, 1995 Office of the District Attorney re: ' Faustine M. Dohermann' ,(Lavalsiti) Delta Muni Crt Docket . 095878-5 After being released, Ms .. Lavalsiti drove to the ,Sheriff' s Office to 'complain about Deputy Dunlap' s conduct . Before she could speak to anyone about the ,complaint,' Dep. Dunlap arrived and apparently r tried to dissuade her from doing so . Ms . Lavalsiti did make a personnel complaint against' Dep'. ,Dunlap. She provided an. account of the incident to Sgt . Hatehett,:-and- Dek ngland I am told that the Knightsen Fire. Dept . personnel at the scene will confirm Ms . Lavalsiti' s complaint -about. Dep. Dunlap-Is rough ' , handling of her. The names ofsthe fire personnel were provided to the Sheriff' s . Dept . by Ms . Lavalsiti when she made her complaint . I understand. the Kniglitsen Fire Dept . personnei are : Asst Chief Bob Pastor. (625-3360) , Capt . Albert Bello (625-3553) and Capt . Scott Pastor. You may want to make inquiries of your own between now and the pre trial 'date . Your attention to this matter is much appreciated. i r Ve truly , David J B on. Attorney at Law. S - 40 d:\95c1ient\dohermann\da.1tr October 17, 1995 Q t V' r y r 1 i i rrt� �1 f rt ------------------- N U) ZO 5 � o j s }U" D H i � rYQ p4 En ; O cr- ' Zwcr OLL W E -� 44 H W --Ty � OLLv Ozw O W O ' a ¢ O v) U O �•y ._ r. O O W n1 0 rw as z LL >4Hz M ^4 H W H W z E- WW' r` a o Ln .A _u U 1 rd N i 5 t r' YI u- I'® C . q f CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4. Please note all 'Warnings". CLAIMANT: Cecelia M. Pierott ATTORNEY: V4 2 *, COU,iYCOUNSEL Date received ADDRESS: 1409 Rice St. IV1Fk1�1-INFZ`%ALIF. BY DELIVERY TO CLERK ON November 20, 1995 Vallejo, CA 94590 BY MAIL POSTMARKED: nTot__Legible= 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 27, 1995 Bl: Deputy �Q 4� 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: /// / �! 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: /2- PHIL BATCHELOR, Clerk, By 1J 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: /,2 - / — BY: PHIL BATCHELOR b, 0A deputy Clerk CC: County Counsel County Administrator Clai!- to: BOAP,D 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, 988, 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 5911.2.) vB: Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. R£: Claim By ) Reserved for Clerk's filing stamp JU ell' a, d RECEIVE® Against the County of Contra Costa ) NOV 2 U or ) CLERK District) CONTRA g 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: �_ � ��- �noc� YA-0- 4'-r+oa t- Z-1�� e� 1. When did the damage or injury occur? (Give exact date and hour) C/ 30 ex� P 1;0�� 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage r inj occur? (Give full details; use extra paper if , required) �ZG�c,c SQi p pY►Z �u-,�� onty a.s ._G. ruo�-s' S(puJi�.q�} �Cowl'1 ....� ,Z tc�a-� p✓Yr )� 5�e�-e 4 9voa d- SO✓ ze)2 e_ k' � _�i-tS lira._- S 92- e 4. What particular act or omission on the part of county or district officers, 16 servants or// employees caused the injury or damage? 9L lye- eeul !?0 7` GliYv wp,.S ni cC ✓De �OYn eO�2.2 G� � - ,J ne te-, i✓1 or4 S' what are �ri tvA5 0 cis Kl o s lv 3� employees A,5 l fgrn • na-�es o1 couAty or dlstrlct/ �r , eing he da age or injury? �u Gua S -ScE.r 2r.,--�� 's 5. What damage or injuries'doYyou 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.) 8. Names and addresses^of witnesses, doctors and hospitals. f Lt - ine1ft ,s � 3c5 �'�2 - 3 o t13 9. List the expenditures you made on account of this accident or injury: DATE ITEMAMOUNT _L h AV2.� ?.� s fir v .a ,�vt� �c� O !k 14 it 1F iE iF IE 01 74, V.. 0 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TOi (AttrSe or by someperson on his behalf. Name and Address of Attorney Claimants Signature C/ elC1— � ' Address. Telephone No. Telephone No. (?� �^ ' ' " if 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 ($10,0{10, or by both s--,ch imprisonment and fine_ i • � � �-s vim- '� �1 � -- -- - hu--t___-_r;�-f ------ _----- jj., _ s4�Lfc --------------------------- /07 4- --- _._ �_ - � •—_l�—___0�2�-_e�,-_-__mom�----i-n _c,�,,- ��,_____.___ - _ ----�- Cv� �f'______moi��"z.- ___-_o_v►_•_ ----�----���-- - /on v� 1 l t �[ . . - ' MaIRL - RepairKhmisch's Inc. collision Repair Specialists PAINT/MISC 0.00 55.00 55.00 —~guarantee all~workmanship performed—'our--' - PAINT LABOR 0.00 A48-06 120. 120.00pany for one full year, up to the manufacturers origi ,MECHLA R� 94k.---'I warranty. We certify that all structural repairs to your TOW 0.to 00 vehicle are based upon vehicle manufacture's recom- DETAIL 0.00 0.00 0.00 mended , specifications. ` repair are "" ="e" p= the manufacture's written� ~" rant ` _yChips,dents_and scratches, ^ are not covered by this guarantt. DEDUCTIBLE' 0.00 0.00 Repairs completed CUST.PAYS 0. ' I hereby authorize the above repair work to be done along with the necessary material.I agree that you are not responsible for loss or damage to vehicle or articles left in � 'he vehicle in case mfire,theft or any other cause beyond your control or for any delays caused by unavailability of parts or delays in parts shipments by the supplier or � transporter.I herby grant you and/or your employees permission to operate the above vehicle on streets,highways or elsewhere for the purpose of testing and/or inspection. A'express mechanic's lien lhereby above vehicle~secure the amount~'`~~ agree 'fees and ' acknowledgecourt costs in the event legal action is necessary to enforce this contract. parts,labor,handling and diagnosis and agree that,if closer analysis finds that additional repairs are necessary, I will be contacted for authorization if the amount I must pay /be increased. � Accepted By Date Received By == . ..ER~~. ...~..,E. For consideration—repairs —this_vehicle,I_hereby ER_— ATTORNEY—sign—endorse any_checks_and/or drafts made payable to me,and any release thereto,as settlement for my claim for damage to this automobile. Authorized by X Date / _ K11MISCh's Inc. 285 Couch Street Vallejo, CA 94590 - Collision Repair Specialists (707) 643-2519 • FAx (7 07) 643-9642 CEC:EL IA M. PIEROTTI =ER 1 i99=, R. 0_ # = : LZ C = v -ai tF3'y iiARiCi9y _a I _ s; .9 U E _Ii=Eic.E, CL'L_yL N =a:it=l= J+ S c4 i mil H `':N No ! lr �!!5 y '_:5ri s M A H,3 075-134 E {l. 4 1rK E T tiE; N NS pE ui.` . I a1 'Ey_r! R —."4 .1_'�+T hri /� aii ,t-N; E ! E P. - --- .. MILEAGE, iN4O'y , !y:y(94r, r i�L.T?qlF i =`E3 L;'diT No -LiCiNE No. ;707) 864-8830 J rX.T. EXCELLENCE THROUGH TRAINING VISUAL DAMAGE i Elements of this estimate preceded by 'C' are EZEst Certified-based on MOTOR CRASH ESTIMATING CIIDE. � A F ' Parts Legend - OEM=Orlgnal Equipment W=After Market. LKQ--Like Kind Quality N` t I C OrH REAR BUMPER [REAR BUMPER] C* OEM-REPLACE BUMPER COVER (BLACK) rPEAR BUMPER] G OEM-REPLACE RT PAD [REAR BUMPER] C OEM-REPLACE LT PAD [REAR BUMPER] 22 77" r> - MISCELLANEOUS BODY MATERIALS (AUTO) PAINT MATERIALS (AUTO) @.�. **** *at***�** **+�**atm+�*���•**+i•**;�++��+�**t•� ��t��+[m � *�*tet **#*#*** REVISIONS G* OEM-REPLACE BUMPER COVER (BLACK) [REAR R WER7 d+ 85 0.80 c. ; t Part price decrease, orifi. 398.27-revittd,'is,., 398.22 ) F ` ' Paint Iabor hour(s) increase, oris 0:8 rev is, . 2.5 ) NE'd REAR BUMPER STEP PAD - 25.85 ( Part trice increase, orig. 0.Wrevised is 25.85 ) PAINT MATERIALS (AUTO) 55.0+ t M sc. P[,ce.increase,_orig. 0.09 revised is 55.8@ ) � x 1 I i I � ....... ;,edaese-i 465.69 N A.0 i.6 TOTALS Klimisch's Inc. PARTS N1111 uvoicE W Collision .Re'pa.ir Specialists !; PAINT/MISC _ = SUBLET �+,00 8,iN B Repair Guarantee BODY LABOR _.:°A ; .._•z {+ - a."�� FRAME LABOR 0 0 48.2>3 We guarantee all workmanship y i PAINT LABOR -- g p performed b our cpm- pany for one full year, up.to the manufacturers original MECH LABOR B,0h @W.BN 8,00 B,.0G warranty. We certify that all structural repairs to your TOW I STORAGE i�. D.28 vehicle are based upon vehicle manufacture's recom DETAIL ',4th ,.3r? mended specifications. Parts and materials used in the repair are warrantied per the manufacture's written war !I TpX = s r o � = O Qj �' CLAIM c BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ; December 12, 1995, Claim Against" the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4. Please note all "Warnings". IF CLAIMANT: Alvin G. Medvin c( V, i w ATTORNEY: Ronald D. Rattner 1998 Broadway, #1204 MART�k,� '-;% " Date received ADDRESS: San Francisco, CA 94109 BY DELIVERY TO CLERK ON November 16. 1995 BY MAIL POSTMARKED: via: County Counsel November 15, 1995 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November 17 1995 PpHHIL BATCHELOR, Clerk DATED: B1: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors (lamK 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 (d ) 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: /,Q.J Q -f 9 9s 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of .the United States, over age 18; and that today 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: j29_< BY: PHIL BATCHELOR by, ` AM A eputy Clerk CC: County Counsel County Administrator 9_-�, ';' c . � (� ""�' � �. �','s ��'"" � c� ... - ..� ._..- ti V � �" ,e� .,, � � r �� .� Vl© `"ak'+� n � .�. �dJJ � �'7.) . O � J � O' � � � r f'� �"1 � r cel � ;;= m �-- o a �, ; � � -� ''Z � � ..- �^,_ �, -� ►y N `` C A�y, �d U ���d � �7 j. � c %�� d a' Clair to: WARD OF aM] RVISORS OF CONTRA COSTA CO[JNTY 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.) H. 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 nane 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 f orm. R£: Claim By ) Reserved for Clerk's filing stamp L(o S �--A S RECEIVED -E � L ) �' • Against the County of Contra Costa_ ) V�N►QV 6995 or ) A o District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 0 Qy_vo Lv itJ t' and in support of this claim represents as follows: T H-l S T 0(G 1. When did the damage or injury occur? (Give exact date and hour) �cr ��� IgIs 11;30 �Fm 2. Where did the damage or injury occur? (Include city and county) OA-LU UT- 0:?-�_E_Kc e00T r-A (!,OST-A Go, 3. How did the damage or injury occur? (Give full details; use extra paper if required) cPA-I-L - 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? l�V�6'tt✓l�r 00AT �-1 l,� SGL p 0 � v-)A PV (- (S L_ ASD t �. wnat are the na-jes of' counLv or district officers, servants or employees causing he da:aage or injury? . 5. What damage or injuries-do-you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. -?-0�)T- '4�-7(c q e L E 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) _ 3A-0C v5 Nr- ( -did LO� A-F `Fly l i 1�E B. Names and addresses of witnesses, doctors and hospitals. VA �R-F7M�� 1�0� a� �.tr�—vim b -, G q14 9. 9. List the expenditures you made on account of this accident or injury: DATE ITEM: AMOUNT Gov.gCode Sec. 910:2 provides: , , • F"Thp claim must be signed by the claimant SEND NOTICES T0: (Atta*^ne } �. a or by someerson on his behalf." Name and Address of Attorney Claimant l s Signature ( - - - Address. Telephone No. IV1 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 010,000, or by both su--h im-prisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995.. Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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: Unknown Section 913 and 915.4. Please not�aljA Warningsf.,� ; CLAIMANT: Andrea Margaret Rowbotham and Brian Rowbotham NOV 171939 ATTORNEY: Thomas G. Beatty, Esq. COUNTY COUNSEL 1211 Newell Ave. , Second Floor Date received MARTINEZ CALIF. ADDRESS: Walnut Creek, CA 94596 BY DELIVERY TO CLERK ON November 17, 1995 BY MAIL POSTMARKED: Hand Delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. p BATCHELOR, DATED: November 17, 1995 (�IL Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( &Or 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: 01 --1-1—`-IS 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 (V ) 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:/Q HIL 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. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: q 9 jr BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator NOV-06-1995{ 16:18 FROM CCC RISK MANAGEMENT TO 99390203 P.01/02 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLADiW A. Clai.:s relating to causes of action for death or for injury to person or to per- sonal property or growing brops and which accrue on or before December 31, 1987, must be presented noy tater than the 100th day atter the accrual of the cause of action- Claims relating to causes of action for-death or for injury to person • or to personal prjperty of ging 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 $wilding, 651. fim street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the Comfy, the Warne 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 f or-- # RE: Claim By ) Reserved for Clerk's filing stamp ) ANDREA MARGARET ROWBOTHAMRECEIVED �„•�,�,„,�,.,..� BRIAN ROWBOTHAM ? . Against the County of Contra Costa , �1 orNOV 1996 SHERIFF' S DEPARTMENT ) pK BOA D OP SUPERVISORS will in n.,me } CONTRA COSTA CO. The undemigned claimant hereby makes claim against the County-of Contm Costa or the above--named District in the sum of $ see attached and in supports of this claim represents as foil ows: 1. When did the damage or injury occur? "(Give exact date and hour) See -attached, page ' _three. 2. Where did the damage our injury occur? (Include city and county) At or about So. Main Street, Walnut Creek, CA, at or about the intersection with. Interstate 680 . See attached Complaint. 3. Now did the damage or injury occur? (Give full details; use extra paper if required) .See attached Complaint. 4. What particular act or omission on the part of county or district officers, se-^vaczts or employees caused the injury or damage? Claimants refer to and incorporate by reference, as if fully set forth herein, the allegations of the plaintiff in the attached Complaint. On information and belief, it appears that the County of Contra Costa, Sheriff 's Department, � or other agent of the County maintained or allowed to maintain a dangerous (see attached page three) NOV-06-1995 16:19 FROM CCC RISK MANAGEMENT TO 99390203 P.02/02 5. wnaL are tne r,--nes of county or district officers, servants or employees causing a=- dge or njku--y*.� h Sheriff 's Department; specific individuals unknown at this time. Discovery is1continuing. 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto da=ge. See attached Complaint. 7. Bow was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached Complaint. 6- Names and addresses of witnesses, doctors and hospitals. Unknown; discovery is continuing. List the expenditures you made on account of this accident Or Wur-Y-* DATE ITEM AMOUNT Not applicable since claimants are seeking appropriate equitable or , other indemnity rights. Gov. Cooe Sec. 910;2 provides: hTheim t� me z signed by the claimant SEM NOTICES TO: (Attorney) or Wit An his bebalf. Name and Address of Attorney J � JV Thomas G. Beatty, Esq. t 3 Signatui-el) I McNAMARA, HOUSTON, DODGE, .McCLURE & NEY 1211 Newell Avenue, Second Flo ) Walnut Creek, CA 94596 �(Address) Telephone No. ( 510) 939-5330 Telephone No. N 0 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 genuinet any false Or fraudulent' claim, bill, account,, voucher, or writing, is punishable either by imrisonmnt in the county jail for a period of not mere than one .year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisoruapant in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such lmprisonnernl, and fine. TOTAL P.02 Board of Supervisors of Contra Costa County Page 3 to Claim Form Re: Andrea Margaret Rowbotham and Brian Rowbotham 1. On or, about October 28, 1995, Claimants Andrea Margaret Rowbotham and Brian Rowbotham were served with a Complaint for Damages for Wrongful Death on behalf of Diana Darnall Beer, Executrix of the Estate of Muriel H. Darnall, Deceased. Said Complaint arises out of a multi-vehicle incident which occurred on or about January 30, 1995. 2. condition of property and/or acted negligently or otherwise improper with regard to the subject incident including, but not limited to, creating or allowing a dangerous condition to exist and/or failing to provide adequate warnings or post adequate warnings regarding the conditions of the time, or otherwise directing motorists in a negligent or improper manner, causing or contributing to the alleged damages asserted in the attached Complaint. 01.9 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA December 12, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT 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 toy Government-„Code Amount: $423.57 Section 913 and 915.4. Please nbte all „Warnings110 CLAIMANT: State Farm Insurance Companies ` ?) 2 P3 F":i1a Lynn Bills, Claim Specialist COUNTY C' UNCE ATTORNEY: *05-6761-516 MARTINEZ(;kLih. Date received ADDRESS: 6400 State Farm Dr. BY DELIVERY TO CLERK ON Nn�Tamhar 71 r ��,�5 Rohnert Park, CA 94926 BY MAIL POSTMARKED: Nnvamhar 9n, 1 Q25 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH g DATED: November 27, 1995 BtII Deputy OR, 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: //— Z� — �? 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: 12.41-/99,5- PHIL BATCHELOR, Clerk, BROMPMMA 17 yy 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. * For Additional yarning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 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: /-2-/,3-M 9.4 BY: PHIL BATCHELOR by Dpiuty Clerk CC: County Counsel County Administrator ' STATE FARM State Farm Insurance Companies we INSURANCE RECEIVES Northern California Office November 17, 1995 µ i 6400 State Farm Drive ' ,.i Rohnert Park,California 94926-0001 NOVFNOV 2 1 i Contra Costa County ' 651 Pine St Room 106 (:LER BOAR BUPr St, CONTRA COSTA--'., -' Martinez, Ca 94553-1290 ****IMPORTANT**** PLEASE WRITE OUR CLAIM NUMBER* ON YOUR REPLY OR PAYMENT THANK YOU RE: Claim Number: *05-6761-516 Date of Loss: October 3 , 1995 Our Insured: Regina Wand Dear Claims: State Farm Mutual Automobile Insurance Company on behalf of Subrogee, Regina Wand hereby makes claim for $423 . 57 and makes the following statements in support of claim: 1. Notices concerning this claim should be sent to: State Farm Insurance Companies 6400 State Farm Dr Rohnert Park,Ca 94926 2 . The date of accident occurring on October 3 , 1995 at Tasajahara Rd, past east gate of Blackhawk, Danville 3 . The circumstances giving rise to this claim are as follows: Cal Trans left very large bump in road, insured came around curve, unable to see it to allow time to slow down before hitting it and damaged oil pan & underside 4. The injuries reported consisted of none. 5. Our total claim is as follows: Company's Net Payment 173 .57 Insured's Deductible Interest 250. 00 Total Property Damage 423 . 57 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 STATE FAR M 5t1a e Sqr m oInsurance Companies00 / INSURANCE Page 2 November 17, 1995 Northern California Office 6400 State Farm Drive NOTICE: Rohnert Park,California 94926-0001 This form is to provide notice of our claim for damages in accordance with the day statute. If this form is not acceptable for compliance with the statute, please rush the necessary form to my attention for proper filing. State Farm Mutual Automobile Insurance NOV 171995 ( ai& Dated: By:_ LAA _ Em oyee Name Em loyee Tifab Employ a Phone Number Enc: Supporting Documents cc: Sepe 2263 09 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 PAYEE DATE 11/08/95 REGINA WAND AMOUNT $*******10. 00 120,ALLEN WAY PLEASANT HILL CA 94523-3218 COVERAGE TIN MAILEDRENTAL REIMBURSEMENT 501-1 $10.00 REMARKS N 0VO 1995 , Q CREATED BY Diana L Thornton '•'�'••- STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 02 883172 J NORTHERN CALIFORNIA OFFICE BANK OF AMERICA NT & SA 11-35/1210 ROHNERT PARK, CA CUSTOMER SERVICE AMERICAS 1233 DATE, 11/08/95 ws++•�« CA Danville 02-221 CONCORD, COVERAGE RENTAL REIMBURSEMENT CLAIM NO 05-6761-516 POLICY NO 1477-776-05B CLAIM UNIT 16B 501-1 $10.00 LOSS DATE 10/03/95 INSURED WAND, REGINA ***************************************************************************EXACTLY TEN AND 00/100 DOLLARS Pav to the Order of: REGINA WAND 120 ALLEN WAY PLEASANT HILL CA 94523-3218 TIN Aur ER APPROVED BY CLAIM NO 05-6761-516 POLICY NO 1477-776-05B LOSS DATE 10/03/95 DRAFT NO 1 02 796997 J PAYE? DATE 10/12/95 REGINA WAND AND KUNIO'S AUTOMOTIVE REPAIR AMOUNT . $******163 . 57 120 ALLEN WAY PLEASANT HILL CA 94523-3218 COVERAGE TIN 05-942915427 COLLISION (LOMV) 400-1 $163.57 REMARKS CREATED BY Lucy NEWMAN S•. ••M STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 02 796997 J NORTHERN CALIFORNIA OFFICE BANK OF AMERICA NT & SA 11-35/1210 © ' ROHNERT rARK, CA CUSTOMER SERVICE AMERICAS 1233 DATE 10/12/95 ���+•�<" Pleas Hit( Auto 02-103 CONCORD, CA COVERAGE COLLISION (LOMV) CLAIM NO 05-6751-516 POLICY NO 1477-776-05B CLAIM UNIT 16B 400-1 $163.57 LOSS DATE 10/03/95 INSU',IED WAND, REGINA *******************************************************EXACTLY ONE HUNDRED SIXTY-THREE AND 57/100 DOLLARS *! <?k ?+ 3 Pay to the Order of REGINA WAND AND KUNIO'S AUTOMOTIVE REPAIR 120 ALLEN WAY TIN 05-942915427 PLEASANT HILL CA 94523-3218 AUTH DMORR APPROVED BY co r >Cf) cf) m -n 71 >Z m rr. -> m 7 73 C :z �7 ecj V,v r T!f- Q T"I oc� 10 .7 V1, 1.;)0 Z> T 11, 11 11r"IR-1 J�)'Tf-*"- J",:.j".1 1.1 C.F. 1-,' -1; .0 i 1[--' 0 S3 0,E T Ii: f,"!'A D 'o rr r-I E�s M Ij Dcai\ z> >^ <n ' Elofi � . . - > � � File #1W �8�-8006i2� E1 � _ >� � ��� ��� � ���� ������� ������ � �� L[KE A GOOD NE[GH8GR STATE FAJM I� THERE � ' � � 333 CIVIC DR1VE �� - PLEASANT HILL CA 9�5�] �� � '5-1 0-41@0 �- .. - � ESTINATE CF RECORD �- � B� : �. W{�6TON 1�9/�6/95 \0� 31 a. m. � '�l �im Rep� DONNA MORRIS it (510) < _ �rsure� � REGIN4 W�ND Cl�im #Q5-6761-51601 - Policy # ` '�ddress � �2� A�LEN AAY ' — PLEA5ANT HILL, CA 94523-321� Dat* cf Loss � 10/ af Loss / COLLlSI '� Othe51Q> 932-8673- Pnint Of [mpact : 1� FRONT ��- 0 ^ nc�tion � Fie�d > � � - � m - �epair K�NTO' S AUTOMOTIVE (510) 676-2255- � iity : 1855 A CONTRA COSTA 8LVD PL�ASANT HILL, CA 94523 License # 0, :Z � c �6 F�RD THUN[ERBlRD ��D BED MAROON 6-3. 8L-FI lFA8P46366H2|002t Lic. # : 1RBNQ92 CA Prud, De0/� � - � � seats Recline/lcunge seats Po*er steering � - � o�er brahes Spe� imauldings al - � REPR/ PART > � REPL DESCRIPTION OF DAMAGE Q�Y COST LABOR �AI�T MISC ' --- --------------------------------------------------------- ----- -'--------'--- � ENGINE �* Rp1 Oil pan w/o sensor ]* DRA[N L. 1 5 0^ � 0^ � � Repl Oil pan gasket i i�, 35 0. � 0. 0 ��_ OIL AND GASKET GLUE z ____ ��5W. O > _______'__--__-____-___-__-_-------------------- -- ----- ---------- --------�r � » � � - >� � � �zz � . c ' - _� - _ . Z> � � ' E-O > >Cf) 77 C: -0 M -n m mm 86 FORD THL.)HOERBIRD Z> -i 77 > ij 'C. t T t i C`l i C.0 71 C" CCV3*F > JIEWED Blf SH%, ;-:71TIMfiTE REVIEWED T( FESTINT"UP. 9-i"PPLEMENTS" IR-QUIRE PP10pi AWROVAL BY A STATE FARM REPRESENTATIVE. M< ;lstigate based On VTOR CPASH ESTIMATING GUIDE. Non-ast.erj5k-l'+) iters are derived frena the Gu:6e DE2JE,",3- Database fiat, 7'rq : Drilibie mteri:k(*4) itudi indicate part supplied bv a supplier other than Vis? origii.nal equipt?nt 30.nufac'�irer. EZEst A product of CCC Tinforsation. ServiceIne, > 77 7r, Z > 0 11 `.+a d_ n\ y�S�'i 1t � • T y p. •;S� � / �?_>i�? 1-mow ,�... � 'y -T Vis, .,a:: � � res • I ,Fri .r-• .�` ..� rye -0 r�- rP y • _ 1 rla f Nmv ILI i,` ' 3 � u r ' r � 5 i � T i � Y �. c''yeti y,• � � a. P.G.S. FORS/! 200" �ir�l=�?Sc !:; HIES, P.O. BOX 1348, .AS8IJR`( P^, i+�, i, +J� C3 ;i `i +GS 919-7319 �f � . f ) � «, . t y �•� 4' 00�/ \. 10 _J - n,§ - \ � _ w�� � . . \ \ � : \ r 22 0 7 G k Cl) \ Zoe u o % « wmy � . C /7 $ cu . Cc 2y % z 7 k 0 ) co L / % m . / \ ± 7. } maG <