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MINUTES - 01171995 - 1.5
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA January 17, 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: $3,103.34 Section 913 and 915.4. Please note all "Warnings. CLAIMANT: Buck Gregger • 4.v? d � LN.cJ� ATTORNEY Date received -OLINTYCOUNSEL ADDRESS: 216 W. Tenth StreetDecember 13;'1994=zCALI F. BY DELIVERY TO CLERK ON Antioch, CA 94509 BY MAIL POSTMARKED: December 12, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. �qIL BATCHELOR. Clerk DATED: December 13, 1994 : �eputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( Ael 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 —1 3 7 BY: Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( III APSLAM) ( 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: Jmjary 17, 1995 PHIL BATCHELOR, Clerk, By IL � Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States., over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Jmmry 18, 1995 BY: PHIL BATCHELOR by 1�1Deputy Clerk CC: County Counsel County Administrator \\�. « \ \} � \�� � � ` ' $ ■�� s«�.�` / • ���� %%� S 0 9 N � � \ � $ \ # , ' $ m � % 0 to F Cla;-- to: BOARD OF SUPERVISORS OF CONTRA, COSTA CO= INSTRUCTIONS TO CLADVM 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, 19871• 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 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form RE: Claim By ) Reserved for Clerk's filing stamp Buck Cregger RECEIVE® Against the County of Contra Costa ) 3 19 or ) DEC 94 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 $ 3 ;1 03 .34 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 7: 01 am - Tuesday, 11/1./94 (refer to accident report) 2. Where did the damage or injury occur? (Include city and county) 216 W. 10th Street, Antioch, Contra Costa County, CA 3. How did the damage or injury occur? (Give full details; use extra paper if required) Car was parked along curb- accident occured on the street 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Sheriff collided with the unattended parked vehicle **Footnote: Check #C061431 in the amount of $1 ,160. was returned uncashed to Mr. Ron Harvey on 11/21/94 ;,ve D. wnat are the names of county or district officers, servants or employees causing the -Jamage or injury? Officer Patricia Ford 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. County claims adjustor feels vehicle. to be. "totalled" . _Vehicle is now inoperable after, a�Qidgnt 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Attached are receipts for the last -24 months to -identify the cost of. vehicle maintenance along with a copy of the 1994-95 vehicle registration. 8. ?James and addresses of witnesses, doctors and hospitals. None, no injury (only property damage) 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 11/1/94 Filled gas tank on borrowed vehicle: $10. 00 11/4/94 Replaced headlights on borrowed $23 . 79 vehicle ,and filled tank with gas $20 . 00 Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by .some person on his behalf." Name and Address of Attorney Claimant's Si ure 216 W. Tenth Street Address Antioch, CA -94509 Telephone No. Telephone No. 510-706-0568 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 imarisonr.)ent and fine. INVOKE NO. • � . 1757.•. SOLD T SHIPPED TO 4', 6- STREET STREET& NO. _ STREET& NO. CITY STATE ZIP CITY STATE ZIP CUSTOMER'S ORDER SALESMAN TE S F.O.B. D TE LU Z _ r i REDIFORM, ,' 7L721/ , X) 01723 . tij:•7?i, .••lRZ:'l�Nfbid�L''��li(.s:..u'(4:,.:1a:A:;Yi�A..1.::d::►,,-.�.:.x.:.::6iuiu.:u_L-•�.�aul.iu..ti:�li:-:ue:.._:.at.:i.•i>.,..Se'.:J�+:S��+�i_•.ws:.'d`�'u:::.,,iu�:.-..r.. - �.. - O p , • J a.'F— � Q z ::E J o O O LLI ,,,. ..... u W ' a Y m tt'f to Z LLJ vv Ov� UMY o LU bA lz W � � r-tQ r ^° 0 0 _ � CA: .z- r G. � a W O u � z oI m a CEJ p O g CGO N LAJ zi j< �, $14 Trucks CHEVROLET'54 3800 1 ton flat- bed,mint condition,$5000,will i nego.trade 228-3105 CHEVROLET'65 EI Camino,327 4-spd. Excellent mechanical. Clean interior. $3440. Days, ' 932-7722;Eves.937-3783 'CHEVROLET;66 El Camino,Must see! $2750. Please call (510) 606-4376 I CHEVROLET'66 P.U.;all ori&, + clean, new clutch, "diamond in the rough"$2000.689.4698 ;f•;{.;{ I1ffR ;iF14iNJ tf#f#i4 CHEVROLET'68 EL CAMINO i I n 8�1: 115V! %!aft? Black, great condition, $8000. all(510)778-2468. T w` _ 1°)Nt�F1) 'HEVROLET''70 P/U 350 auto, hT shortbed all orig.,prig paint 00 �4 E (1143].1 NSVD alley whis.,11800.243-0349 } + :HEVROLET '71 Pickup Step- 611.Z 5 E I(I 111111.1 t-------------------- Me. Excel. cond., must see to j T F1 r 1 -Xcc .`9 1k1 KV), spprec.$2250/ofr,243-0349 t 916 1e =.IHnf31dtf 311ft�Y,vi t HEVROLET '72 Stepside P.U., t, uii•'.' I�b,O.`: �all`7!)4�f'1 xcel. cond., brand new rims& ires, 1 owner, $2150 firm. r 137-2372 `>��rS;:l K ta11?i.a•1. Z 96/tLf/TT ;HEVROLET '73 Flatbed; Y411 1 on, fresh motor, clean &tight, i 140 14114ri t:34 04q "1•:4 I. 'f I2I SIH.I 40 ;1800.825-4222 + (1.1In1V•:NWl)XIV) 01 .SPIN 5111009 014)101-101 llv ;HEVROLET '76 P:U. 1/2 Ton 106-6f!� (011.0 with 3/4 ton rear, 4 spd. Good 1 X d - 1`1•:141,91 01.(it► "1.13•1JW03 unning cond.$1500.427-4096 CHEVROLET '76 Stepside 454, auto, A/C,dual tanks,tow pkg., , great Gond.$3975.638-9062 FiEGISTFtAFIOI( CARD ��AI_.IIi F Fi(.l1.1� 04/-3,0/94 T'(:): ti4•/=';Cf,'t cJ MAKE YR MODEL YR IST SOLD VLF CLASS TYPE VEH TYPE LIC LICENSE NUMBER G111(; 76 76 BM _12:Fp 1. 1135-31096 BODY TYPE MODEL MP MO AX WC UNLADEN WT VEHICLE ID NUMBER Fl:' G ZD 2 C', s"_}"?86() -FCL-1462504260 TYPE VEHICLE USE DATE ISSUED CC/ALCO DT FEE RECVD PIC STICKER ISSUED 1:.C)MVIERC:IAI_ o4/2-16/94 o7 04/21/9A. 9 650 1390 1 FIFZ EXP DO `T'E: 04/3o/911. REGISTERED OWNER AMOUNT PAID (,fF EGGER CLYL)E. I_EONAFRG 77. ()t_} 1 7 A 1°1 i�lw!.�.A h!11"A WAY AMOUNT DUE AMOUNT RECVD $ 77. 00 CASF•,1 AN'T I[TCF-i CFRDT e (:A 94509 _IENHOLDER F-#w 174• :';t.} (+t)07700 f"}f'} Pc' 11.4riCi r'tiA rz.0n ��L"�"s�`�;o-c-;ah 3 ,x,,y�RR11RRr,yy��Yyy�s,tp.;7R,��.kpy�'vaa[n;�.�e}�'1"�ts�`_���s y}(1N����akw��`4.x��1 e��RyY���..r�..��Y�i..y��H���� S ���5 '` }{,�n `� � •�� - -- — °i 1$ Y �}.,' k} { ��ii+ 1.^8.-..sp�Ry � 1f���. '�t13 ' ^,RM4 w.!✓ '� y� ��{"�iN tHh.. `��'�..W ���(� - �} +—_ -(`�. { �'� G '. h { ixrfdjj�jr"e fj4Et ", n"�Q '"`5 :•t{ r ffa:r �§ttr Vf.`,fi t k�Sr c°f.tku f#�yyt,,rfrS;3 ZvI s( ..•ti x#�\s ,r'r Wsi iN, p $ ,LV7GKf —qLf.v;if'l� t^�idfl:.: 5 r �`- r;ryf�, �:;.a ' i •(�': ' k 'rF imp l T T LJL#,"f , T`,1 4 7 4t Ic�t I -,-BA�t �tEC'x Ply r. ti s ,z f C c )R �rh f' !t �t c3_1�}'ry}g �; r p � �y t t�f` +j {,•; �.t, '� ..VC��`� f.Jr ',�' .,1�� -, L+.» �'Y..:R't 5.,'•... gR,,t p� �R('� t 4 3 �i,;�'tY rtT \, '� :.�+ m">• it z 16 t� 4 (_I r t )1 � lz /.,'MR�,'r{IA"�`!L.ir: ,',1ee1��.+.r. ry,R ,,�41 4t i`,"A:Tf �' ; .,+�4��„L7,• �-t+�- �^S F 3 a,}.r ,7 h?.G F i t '3 .... AI. "h i+' a «Gt i 1 a �z 'sS h'Y'z', �. p'*.ori 1 ,�;.� t Y -+•rr , " .<t s r l�j ,1 a f r 1{1 � _ `id,,, � -,t��r�C�"1`(�+tJ� h'�tf / 4�� : ��;��,'t`��ig� !'�,���#�p'� � �.n� }.f•.� rt y t '�S 't:.,� itsrr ,`5 ,$.tj'". �h�¢ ' i .C6 # i .1ist 1( � 'jS{1(•'i { $ ,,, .F ,... .i-i 0:1 1 t�",'-_.��"'•1 rry�yy �,,�,�^�a ?;C,{ai � D{' 3D�R(A3_t,.�75't,� Ci4}., r 1 ( R4":,5,,N fF� x1 s�><.f,�`8 w( �.k t4�l€�:�N�� �iYk�a�r�t�.i? $i€'.ii:I"��'�"n R � t.`z,, ' • �, g•, � 4 C1C�lE l. . . . . , (`+30) . ;4— .R�is• dE 1� rEsaE .rtt�I ! _ cai`11: '� . R, H 1!~ Fij=1,i!Il`i FEL i_i':t r__i.?, 4 �«E11 L 1 1 ( t I; L..i;,..#, � 1C1F. L'ut "iE=ij f ].};'s�r)`Y6 /I i A ': \.tl..t.�; ,_ (��. .,i. _.i..i i IyJF�!�..1 i t•'/4 [;3'_i U :t 'h,E.11. Etl. ie'( :i•-4'E.�: rv1_ C.COUNT # NE TC CiUST# TYFE{STE;TEi, SQ8449 2 01 109449 0 CA AU -t rgy`,.. _rTIDUC-s CODE ;j't{ _ _ u C in i,i�.`" �i 4 uu c 'a? t:dy`ti sL#:..tJS - ,t' t-"T EN, f ., ..� ( I , Uta + ..i— �iG li.l CA— ". «Y i — ,t: YOU �:S� ` 7" ,. t ,... ,_" �: � r �:1{e t: � i" s:'!-:ir_,. Er.} ii t1f1;v . Ytsu E �,\ t,.,: �, u# u�.}i: i i � 4 N NARTS T;.iiA` .. 218.9J . § aL7. � 5R zRfECAMOUNT i LABOR'TOTAL 93. tt0 ±ig,C Ula CiIJ OL 'TAX 1790il •' UST {i'1 y�R}� 1 ,y �Ft4� BI1Y�tJCi.E'LRNR ,.Atr ar 'r }� ( t;' R Y' IYI $T'AR1D��> tt� 194 y�{ 'd< i CGUNT �..F. w .-^».»�; ...,; .x,,: 3 aix+ '� t3! �'I >." � � YJR'4t'p�,c�' l5 i .t - ¢'7`^` ti �at s�....a�"''4.. �^II'•"IFiTaf, F{ ,75, "#t G"��.IRf' 7i ...hR#F.yG.•I� il. --. p''�; ., '# I ,+xy,` x"T �}� (# {>, ��, �,��7��8" >• ,F+�y\E�t�i�yyyyy J'{, v�'�*x_a.S" {°'�'# a $ � sF F k--., � {" s r;.,, it i +'� ��z ,r a .�t,�'R^��s s x tiY,x { V %'�� r:; r �+�.re R •. d"" �, µ- t ,# 4 i t i, G� } R ,r �': �..�1 st' x �i#f ,;''«r. �*,�t l ti�u^�ra.� ,rA:�'4i,i. 6 z},2s'" i`tip us i, F i' f i s 7 �•�°:� F °'t:,' I �sC�' � �; ted u � a r�t r vwi•{t, 3r;� '21'r-r,.e.R. � �r^ �Aj� t Rs� '.� � I r w, s ��,y „ v'*t�"�'`G: � {„Ycr-''^tt'�`.> °%'c.�Y���, -+^$44...�NAYE A���ES�'IOt�UR-PROBLEM? {EFS �, t �.+;r• r ,�{ ` , .;: + h s; YYa'Ya o-- r ~kt ctlt �"� c a _ _�� 't v x � , � ;f , 3• r� t r' - 1 hereby authorize tie repair work listed hereon,including sublet ' work,to be done along with necessary materials.You and your employees may operate the described vehicle for purposes of testing,inspection or delivery at my risk.An express lien is acknowledged on said vehicle to secure the amount of repairs thereto.You will not be held responsible for loss or damage to vehicle or articles left in vehicle in case of fire,theft,accident or any other cause beyond jl' IL:,;!. u ., h.... Qn(i i)!"hi 11:41: id 4 your control.Customer agrees to pay all collection costs and/or attorney's fees in the event y„ r.• a ! p. default is made in an iF:a II'•II , v. n. �..::: Pill IE::'. '0 I Ilr1lli it!t :.II.: 1 •N y payment due.It automobile is returned to customer without repair' service being performed,a diagnostic and handling charge(including reassembling)will be N:;da, ";jj1.;; 1(,:'. p�i° II;��,: �;..N ..H p h. �•. :•�. -:,;. • !�� L.... made.A 1.5%monthly interest charge,plus a$25 per day storage charge,will be applied to all jobs,beginning one week after completion. 6 5 S CAPITOL A V F: SAN J0`:,'E , CA 99,127 /i PEIONE ( 1408 ) 2.58. 6 0 5 5 CUSTOMER SIGN4T1JV 8 A R f4 A F 9 5 9 5 9 R Q !V,A, 042,153<, ..,,,k.. .s.',.EN(�„ TYL3E :11 35(� ,a..,.,,. .....y. ; �.... ,. NAME,ADDRESS,CITY,STATE,ZIP CODE YEAR/MAKE MILEAGE PURCHASE ORDER BUCK CREG(IER 76 GIyIC 74386' � I �, f `3`,r LICENSE NUMBER C'(l,T0i1R 1; E. OUL .2�i . AD CODE W/R/F 1. F 18TH AN FIM11 CA 945017 lE3',i::309C 4' HOME PHONE WORK PHONE IIODEL I,01"0N {�',. WRITTEN BY (5:.111)706 �i56�3 C 1 �} 4 FLAT �f PRICE t 3I 1 K ,.VEHICLE PROSLEM_STATEMENTS NO. „ �, s;LA80R Of?EHATIO „ ,.. .._.r .. .,..,.,,..,, �, W s�1, _. , ►.N:J Remove & replace Lower hall. 1.1.9. lit LR1 ,joir'It;r, CARL Remove & replace lo1,l r corlt:rol 1.1. 14 CAB L at-in brashirrgs. 0 130 Remova fv replace upper r.orit.rol. 4.1.9 7/i 'CAV,U ;`Irrn burshirigss. 1:A Remove & replace idler arrn. 29 .93 Reriet;) Pi_t.marl arm. 29.93 Oe.ld & repair left frame rail, ;359.21 REcor MENDBosE�vlcE` d,� a I•JI FR Repair, relocate weld friale 0 4,It,4`Id at: ste0_ri.r7gnear`. rTfo1Pub. area r 0 iALFR rei.riforce. as reyifired. GA Af 4 A.I.1 Q!-J f rot-ft. P1-11 Ad j Lrstw 40,00 'AF[ cyst nr camber- & toe. Center I x AFF: 7,Leerifiq Check trackirltl, 0 ESTIMATE OF REPAIRS:Includes all parts,labor,handling and diagnosis.If on closer analysis it is found that additional repairs TOTAL LABOR are necessary,you will be contacted for authorization. Parti ins4allad ar9 not warranted beyond fFat given liy respective manulacfurers No other warranpes are mad$except as listed on this-invoice .,vS"tt,,.�5 w�',�.�.� .^,..",d.w..:a",.,v,.�«.'., a. ...,:3_ .x.1,..3.: ••,c;.s. . C OTY PART NUMBER PART DESCRIPTION AMOUNT m C QTY' PART NUMBER PART DESCRIPTIONu AMOUNT N 2 KE-i1'11 3AI..L 13CITN1 76.+1)0 N 2 K6.137 113U111`4T'1`4C3 61.88 IV 2 K6.1:38 1111Ni("i 45.94 . ..P. _ N 1 K6096 1 U1 F.:; ARM 47.01 �•-b* "fly A,�,T N I KC"143 '"Fr ARA 64.96 VT, C CODE N NEW R, t1EBU�L7, U USED C REFUNDABLE CORE DEPOSIT a I acknowledge notice and Orel approval of an Increase fn 6 or!gmafestimated piece S .t _ _ LABOR . 0i.31,11 . 30 .'J. rry $IGNATURE.OR.INITIALS,. .s J �... PHONE AUTHORIZATION DATE EMPLOYEE NO. ? PARTS 4: Z: 1. �: JUci•a TIME AMOUNT OF NEW ESTIMATE `' DATE •' TOTAL TAX a 1.6j93 rr.r1G.h DONE El SAVE YES ❑ R.O.NUMBER TOTAL CALLED El PARTS: NO ❑ !I 2'_;I. CUSTOMER COPY CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA f5 ' • January 17,'•1.995 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 Amo u^t' 250.00 "' '-Section 913 and 915.4. Please note all 'warnings". CLAIMANT: Donna LeBoeuf ATTORNEY:- co UrT 00seL r�n,�2TINEzCALIF. Date received ADDRESS: 55 Pacifica Ave. , #8 BY DELIVERY TO CLERK ON Dpcembpr 15 1 A94 Bay Point, CA 94565 BY MAIL POSTMARKED: Hand Dplivprpd 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: December 16, 1994 all Depuiy OR, Clerk r 1I. FROM: County Counsel TO: Clerk of the Board of Supervisors ( L4 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: j 7.��q "� 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 III ABSEMNED ( 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:Jarnaary 17, 1995 PHIL BATCHELOR, Clerk, By ( .e X pn , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 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: JaramT 18, 1995 BY: PHIL BATCHELOR by Deputy Clerk ,e_61 81. s CC: County Counsel County Administrator Claim to; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Clams 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 .l, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this f orm RE: Claim By ) Reserved for Clerk's filing stamp REI E® Against the County of Contra Costa ) DEC i 51994 or ) District) CLERK ONRo S �SORS BO 8D CO. O Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ a 51 ,0 Q and in support of this claim represents as follows: l. When did the damage or injury occur? (Give exact date and hour) - Aho 'I/D 14 --NM-MMM-MM-- 2. Where did the damage or injury.occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) �r x,�W-es J,dava i il�llam-o _�e - ---------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 40JLa 6to ") f W, les 50pap- D. wnat are the names of county or district officers, servants or employees causing the c!a :sage 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. 7. How was the amount claimed above computed?, (Includehe estimated amount of any prospective injury or damage.) .5��4 e AWS ���6-t&Vq W1046 a 6. ?James and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT b .. Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorne ) or by some person on his behalf." Name and Address of Attorney Cla mant's Signat AY I Address Telephone No. Telephone * V V Treit * * * �F �E F"i '�E�F'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 ($10,000, or by both such imprisorurient and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 5 January 17, 1995 --1- 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: $210,000,000.00 Section 913 and 915.4. Please note all "Warnipgs". CLAIMANT: Steven J. Doughty Jr.; Micheael V. Doughty; Robert E. Raymer; Donna D. Doughty-and Steven J. Doughty Sr. ATTORNEY Date received C0UN F�'::0''i4`Lw• ADDRESS: 2941 Estudillo St. BY DELIVERY TO CLERK ON December 16, 1994`�� if� Z`" �'`F' Martinez; CA 94553 BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: December 16, 1994 HIL 9ATCHELOR, Clerk C ��f: Deputy 11. FROM: ounty 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: /2— " I ff v `P BY: -�..,. Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (ITT ABSI'ATNFD) 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. n n Dated: JammT 17, 1995 PHIL BATCHELOR, Clerk, By �p el 1l J1 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. 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: JaalarY 18, 1995 BY: PHIL BATCHELOR by ,e�,o.. l��Cr►�/ Deputy Clerk CC: County Counsel County Administrator Clam 3,o: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury ._o 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 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. ' D. If the claim is against more than one public entity, separate claims must be filed against each pubi i c entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this orm. RE: Claim By T a, TR ) Reserved for Clerk's filing stamp w^^�iCG,ekreL v V. Ovyy7 yv , /7- NOr)ha, LIDO S7cyr_n d.�aL;S4 14 RECEIVED Against the County of Contra Costa ) or ) DEC 1 61994 District) 0:60 a•f, . F SUPERVISORS Fill n name ) CLERK ONTR AOCOSTA Cg.___j The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $a10,0 2!a, and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 7 i7,�y 2. Where did the damage or injury occur? (Include city and county) Mul-T-i h zf z Czh 7-"m- Co s-a NN--YN/N- - -- 3. How did the damage or injury occur? (Give full details; use extra paper if required) �-YNM-N--N-NN---- Y-NY-N•--MN-N-YY- 4. What particular act or emission on the part of county or district officers, servants or employees caused the injury or damage? (over) 5. 'What are-the names of county or district officers, servants or employees causing ; the dama--ge or injury? IZe K-,5 KGr� �e��/c� STvf tnf- ('7qr1.1 1/e-7711 Sevt ( FS o,n cl Ua05 1 Th ry 10 0c, (Lc7c) is"Ifv C lLd2 Y"J • .!J - 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages cla d. -Attach two estimate for auto 1lcnGTTvn o� 7-cr?-eal M�ctl- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective yjury-Pr damage.) iF ohm r�r�L✓e t./o v! 7v ti� cr c%/V B. Names and addresses of witnesses, doctors and hospitals. N�MNN-N�-N---NM- MNNMNM NN--- N 9. List the expenditures you made on account of this accident or injury: DATE ITEM! AMOUNT eeeeeeeee • eeeee • feeeeeeeeeeee • feeeefeefeee Gov. Code Sec. 910.2 provides: ° "The claim must be signed_ gne by the claimant SEND NOTICES TO: (Attorney) or bv some person on his behalf." Name and Address of Attorney laimant Signature) POW i tl��4 We:, s-F (Address) r-lgl^,,?r7 C.4 � YSSJ Telephone No. Telephone No. 3 7;� -7Y71 e • s • eee eeeeeeee _ - - xe � 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 falx 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 ($109000, or by Doth such imprisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY. rALIFORNIA / January 17„ 1995 ,7 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: $1 402.91 Section 913 and 91;5.4... ;Please`note all •Warnings". CLAIMANT: Saiid Rezvani t� � ATTORNEY: Date received MARTiNEZOALIF- ADDRESS: 12421 Radoyka Dr. BY DELIVERY TO CLERK ON December 14, 1994 Saratoga, CA- 95070 BY MAIL POSTMARKED: Postage Mark Unreadable I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. iaIL gATCHELOR, Clerk DATED: December 14, 1994 : Deputy �6Y 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ►This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and"910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: /e� 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. BOARDD ORDER: By unanimous vote of the Supervisors present ( III ABSLAIIMD) ( J) 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: Jarnay 17, 1995 PHIL BATCHELOR, Clerk, By _ A� �Q 11a.� , 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 ttorney, you should do so immediately. AFFIDAVIT OF MAILING ire under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Ttates, over age 18; and that today I deposited in the United States Postal Service in Martinez, a, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to �t as shown above. 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PA • a AYE r x ��� S '.�r stt�k4/^�,dy���'��,. s/ r�y £ tt 4�is>Yw/f/ ,/'�,�£�/ 4/v r)i Iry'yx�n\"a�'t'M Y�,��✓' .S �N^GT �i.o" -.. � r `�'�' ,..?:,,,:>,:r:..r�w ,•.,aw..;.�„wr.. :i'µ,a�” sF/t"ya r YP ,"Y! � , � k ,� -2 t 'X'7� 4 s�n`� 9�,,.f 4° vS { q, �E ' :/r.::F,,�`��.nx. {n/::,:,,,�.Ys�u,_Z:t _., 4} 'a r;, srXi ire 4+vri•t :r,;.: r wy^sfn a kvs•,t�dbW acres >a.:'1^.N°yr/A..:t x��,r?s-'' +` y... � 1 7 S. fS tl rr �dR3 u A... tt tA Ls wa `• Y J 4 y F } \ , l yet y* x ag F f s , r/F n r.. � 4 RX%r 1 Y r"',8tr {.,4:s /" h'1 f�'x't..+•'/",ny~4 f` 09/19/94 13:97 FAX 510 919 2750A FIELD OPERATIONS DELTA Z002/002 Claim to: BGARD OF OF OOR= C= 00UM CTIONS TC QrAIMAIZT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or Browing cps and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the soorual 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 aoarual 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. (C;ovt. Code 5911.2.) . B. Claims swat be filed with the Clerk of the Board of Supervisors at its office in i Roam 106, Co;mty Administration Buildings 651 Pine street, Martinez, CA 94553- C. If claim is against a district governed by the Board of Supervisors, rather than the County, the rmw of the District should be filled in. D. If the claim is &OLinst more than me public entity, separate elal muat be filed against each public entity. E. rraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this To. . f �r f e • e e e e e a • * * e f e e e �► * +s e e a e • f f e f e f f f e RE Claim By Reserved for Clerk's filing stamp _ �5A H D - K C- Z VA N l RECEIVE® ) li AgaMf the County of Contra Costa DEC 1 41994 CLERK BOAR©OF SpPERVISORS ! District) CONTRA COSTA CO. (Fill in name The undersigned claimant hereby makes claim against the County of Contra Costa or the above.-named District in the sup of Iand in support of this claim represents as follows: 1. When did the daamge Or injury occur? (Give exact date and hour) 71W f' VW 2. Whom did the damage or injury occur? (Include city and oouaty) 3. Now did the da mage injury oelour3 (Give Lfull details; use extra paper if required) A 6�n art S bOc�� 1�4� ,l✓�`1 e v� v�sz-1 v� o(� 5 i 1 V`lS P.v� c J�P.� �+'e J e✓ems It �s -E�ns�. e� v ��v �F.s (k-f L �• 4.. What particular act ar Mission on the part of qty or district officars, {. servants or employees owned the injurg or, damage? I I ''11 CCS cacl ,n o �Aetett �oc S�, l ( ') :' Neat are the names of County or distriet officers, bervants or employees causing the damage or injury? jat?;r �e �t damage, 6r injuries do you claim resulted? (hive full extent of damages `claimed. ' Attach t, Ie3timates farr a e. Vies or i... Psi f� ✓2 e. 0 c l5Inp S� 4-t,. o (, .e �' v�si i.:.., � � F . 7., How was the .amdunt olaiaaed above Computed? (Include the estimated amount of any prospective W=7 or damage.) LS.ee_, m 8. N=$ and addresses of witnesses, doctors and hospitals. `_ �+nem c� _ -�d�. -f-�.A. v`��e�s o�� �cQc�✓ess e s �s� Q-c/e�,, dv-�- z t . g. List texpenditu�u made on account of this accident or injury: DATE _ AMMT o vie, Gov. Code See. 910.2 provides: ' w1hemust be signed by the claimant ,. SErID xOTIC�S TO-* (attorne ) or sore en his behalf. ame an d of Attabney , E _ cc *s Signature) ;'' _:Teleione No. Telephone No. 7 7 a 7 -,`;:•:::tees ssss essssss • * s !, Section 72 of the penal. Code provides: 02very.person *o, .with intent to defraud, preaemts'for allatance or for P$Y= .to a i?Ute.:b09 d:Cr Officer, or to_any 00unty, 'City or district board or soiY'i oer, autba"ized to.,,a31o+ ar pay the it, eenuira, w t s1m or fraudulent C38i�1,',b311, abCota:t, troucher, or writing.,3a� punishable either by i�oprioonment in `the aaunty ' for a period of not more than ane year, by s rine of not acaeeding - ' one thousand (s1,0D0), or by both such imprisonment and fine, or by imprisonment in the state pris=, by a fine of not exoeedir% tea thousand dollars ($10,000, or by i both ouch tmprisonmeat and firm. aUY,ins.,_'.:u'd*'..i.'E'}.�:'"?. ..L;i.X�z,h,-,.... :r ;:G....r• ...,.,.:,, ::....._t.,. :.. i,, . .... .. ,. RECEIVED l +Ckerk of the Board of Supervisors Room 106 county Administration Building DEC 1 41994 651 Fine Street Martinez,CA 94553 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Date: December 11, 1994 To whom it may concern: Attached,please find a copy of an estimate I have obtained for the damage to my boat caused by a Contra Costa sheriffs boat on the Delta on 9/18/94. I have also enclosed a copy of the original letter from Wes Dodd(Deputy Sheriff)along with pictures that I took of the damaged area. Because hooking the boat to my car and hauling it around town in order to obtain estimates required me to take time off work I am asking for compensation for the one and a half hours of my time that I spent for this purpose. In addition since we(three families)were held up on the day of the accident for a whole hour by the deputies so that another deputy(or Sheriff)could write up the report,I am asking for compensation for this valuable vacation time. The following is an itemized list for my claim: Damage repair $952.91 Estimate time $150.00 Loss of vacation $300.00 --------------------------------------------- Total $1402.91 Saiid Rezvani 12421 Radoyka Dr. Saratoga,CA 95070 (408)-252-7707 Home (408)-894-7455 Work ot Cl 1N� (ff untu of (1outra Crusta `7 (9f fire of #1le '' 14erif f-Qlaranez Warren E.Rupf Sheriff-Coroner September 19 , 1994 Mr . Saiid Rezvani 12421 Radoyka Drive Saratoga, CA 95070 Dear Mr . Rezvani , Enclosed is the claim form we discussed yesterday. Get an estimate and fill out the form. Mail it back to the Board pf Supervisors . If you have any questions feel free to call me at ( 510) 313-2521 . Your truly, wT Wes Dodd-Deputy Sheriff Marine Service Bureau 1980 Muir Road•Martinez, California 94553-4800 LELAND'S MARINE- 601 Reed St., Santa Clara, CA 95050 (408) 988-5130 REPAIR ORDER AS LISTED FOR LABOR AND MATERIALS VERBAL AGREEMENTS NOT BINDING-ESTIMATES FREE OWNER DATE ADDRESS PHONE EST. NO.' INSURANCE CO. "CF"NO. ADDRESS PHONE LICENSE NUMBER YEAR-MAKE MODEL HOURS MOTOR NO. SERIAL NO. I ,iii/-;I 1e-e C QUAN. DESCRIPTION OF LABOR OR MATERIAL PART NO. MATERIAL LABOR 75- 00 49 PARTS PRICES BASED ON,STANDARD CATALOG PROCUREMENT PRICE LISTS SUBJECT TO CHANGE WITHOUT NOTICE. PROCUREMENT AND DELIVERY CHARGES MAY BE ADDED FOR SPECIAL SERVICE ON ITEMS NOT AVAILABLE LOCALLY. OLD PARTS REMOVED FROM BOATS WILL BE JUNKED UNLESS OTHERWISE INSTRUCTED IN WRITING. TOTAL THE ABOVE IS AN ESTIMATE BASED ON OUR INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR WHICH MATERIAL MAY BE REQUIRED AFTER THE WORK HAS BEEN OPENED UP.OCCASIONALLY AFTER WORK HAS STARTED WORN PARTS ARE DISCOVERED WHICH ARE EVIDENT ON FIRST INSPECTION.BECAUSE OF THIS THE ABOVE PRICES ARE / U NOT GUARANTEED. - t.�61 TOTAL LABOR ' BOATS LEFT OVER 5 DAYS AFTER.NOTIFICATION OF COMPLETION WILL BE CHARGED$17.50 A DAY STORAGE. TOTAL MATERIAL NOT RESPONSIBLE FOR FIRE.THEFT.OR DAMAGES OF BOAT WHILE TRANSPORTING TO AND FROM SHOP OR TESTING. ESTIMATE TAX J ESTIMATED BY'`-T l APPROVED BY PAID OUT TOW&STORAGE AUTHORIZED AND ACCEPTED SUBLET REPAIRS BY OWNER OR AGENT DATE { 9 ' " ._CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA January•17, 1995 I , 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: Unlmown Section 913 and 915.4. Please note all *Warnings". CLAIMANT: Sally Fleming (now Sally;Larch) ATTORNEY: Ronald E. Moe- Date received COUNTY COUNSEL ADDRESS: 805 N. Lincoln St., Ste. B BY DELIVERY TO CLERKPONNuDod tuber 14, 1994 Dixon, CA 95620 BY MAIL POSTMARKED: December 9, 1994 1. FROM: .Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp B DATED:December 14, 1994 BIL Deputy OR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( yr 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: �rR15 CLAD✓! 0_6w1PL1J5 wITAf Sfe_XAJs 4/Da4d 4/0.2 4S 70 7"H65L 4ditV15 QC.L'ux(LiNL,- w►t"in) mix MoN7'Ms of r''ic. mr >Nct- C..tAim . Fox JrAa _isr2_ gvsA/T5 , d_L-Ao 14ftJ 1 NtUs?' APPL,4 Ab LTb ?I4s4rv7" A c..AT-rr. C.LAla-1 ((,� 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). 1V. BOARD ORDER: By unanimous vote of the Supervisors present ( III gMUN 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: Jan.mty 17, 1995 PHIL BATCHELOR, Clerk, By . - Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. t— Dated: Jmxwy 18, 1995 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator r �® Ise 0 ,VNV'80 w ww W 1� Q N RONALD E. MOE, State Bar No. 039278 Attorney at Law 805 N. Lincoln St., Ste. B Dixon, CA 95620. Telephone: (916) 678-1612 Attorney for Claimant j ;DOECI 1`"A W i TO: THE COUNTY OF CONTRA COSTA i �E ' VI aC00. Clerk of the Board of Supervisors 651 Pine Street Martinez, CA 94533 SALLY FLEMING (now Sally Larch) hereby makes claim against the County of Contra Costa and the Contra Costa Sheriff's Department, for,an amount that exceeds the minimum jurisdictional limit of the Superior Court and makes the following statements in support of her claim: 1. Claimant's address is 1550 Marenda Drive, Dixon, California 95620. 2. Notice concerning the claims should be sent to RONALD E. MOE, Attorney at Law, 805 N. Lincoln St., Ste. B, Dixon, California. 3. The date and place of the occurrence giving rise to this claim are June 28, 1994, at the (Sheriff's Department Richmond, California). 4. The circumstances giving rise to the claim are as follows: That on said date and for a period of time prior thereto, defendant Sheriff's Department, by and through numerous officials, engaged in a cause of discrimination toward claimant, including, but not limited to, sex discrimination, gender discrimination, sexual harassment, and other conduct that caused an extremely hostile and intolerable work environment that resulted in the constructive termination of claimant. 5. Claimant, SALLY LARCH, has experienced physical pain and injury, and psychological and emotional distress as well as loss of employment as a consequence of the wrongful conduct of the defendants. 6. The name of the public employees that may be responsible for claimant's injuries, include, but are not limited to: Sheriff Warren Rupf; Undersheriff Roger Devine; Richard Rainey; Capt. William Shinn; Capt. Russ Pitkin; Lt. Ray Rodiquez; Lt. Telford Terry; Sgt. Jerry Knutson; Sgt. Russ Sutter.; Sgt. Rich Weckel. 7. The amount and nature of claimant's present and future medical and psychological damages, wage loss and general damages are unascertained at this time. 8. The claim, as of this date, is in an amount in excess of the minimum jurisdictional requirement of the Superior Court in an amount to be provided later. Dated: cl 1994 RONALD E. MOE Attorney for Claimant i RONALD E. MOE Attorney at Law 805 N. Lincoln Street, Suite B Telephone: (916)678-1612 Dixon, California 95620 Facsimile: (916)678-6121 RECEIVED December 9, 1994 DEC 1 4199Q. CLERK BOARD OF SUPERVISORS, CONTRA COSTA Cr,?. Office of the Clerk Board of Supervisiors County of Contra Costa 651 Pine Street Martinez CA 94533 RE: SALLY LARCH v. CONTRA COSTA SHERIFF'S DEPARTMENT Dear Clerk: Enclosed you will find an original and one copie of CLAIM AGAINST CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT pertaining to the above-referenced matter. Please file and return an endorsed filed copy to me in the enclosed return envelope. Should you have any questions, please do not hesitate to contact this office. Thank you for your courtesy and cooperation. Ver truly yours, RONALD E. MOE /gav Enclosures CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA January 17, 1995 1.5 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: $1.00; an apology; a resolution Section 913 and 915.4. Please note all -Warnings". and an agreement CLAIMANT: � iyi 1 Gary J. Balsdon and Vincent J. D'Alo ATTORNEY: _ Aliquot Associates, Inc.— . DEC Date received ADDRESS: 125 Ryan Industrial Ct. , Ste 109 BY DELIVERY TO CLERK ON December 9, 1994 COUNTY v r��, San Ramon, CA 94583 � CALIF. BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. - IV IL gATCHELOR, Clerk ' DATED: December 9, 1994 : Deputy lI. FROM: County Counsel TO: Clerk of the Board of Supervisors { tf�'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 Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present ( III ABS Q\1E)) (✓_ 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. ` D � Dated: Jarni y 17, 1995 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. _ Dated:_ JarD.kazy 18, 1995 BY: PHIL BATCHELOR by , ��� �, Deputy Clerk CC: County Counsel County Administrator A RECEIVED 1jF-9 - 9 1994 ALIQUOT - CLERK BO A€D OF u�€F'ERVISORS a CONTA COSTA q.0. December 9, 1994 Clerk of the Board of Supervisors Contra Costa County 651 Pine Street Martinez, Ca 94553 Re: Claim of Aliquot Associates, Inc., Gary J. Balsdon and Vincent J D'Alo Arising out of Statements by County Supervisor Gayle Bishop To Whom It May Concern: Enclosed please find a claim against Contra Costa County based on disparaging statements made by County Supervisor Gayle Bishop to clients of ours. We have attempted to resolve this problem informally. However, our letter to Supervisor Bishop has gone unanswered and she has refused to meet with us to discuss these issues. We have no choice but to file the enclosed claim with the county. We remain willing to resolve this dispute and are prepared to settle our claims against the county in return for payment of $1.00 along with the following: (1) A written apology from Supervisor Bishop and a promise not to make disparaging statements about Aliquot Associates, Inc., Gary Balsdon or Vince D'Alo; (2) A resolution of Board of Supervisors stating that Supervisor Bishop's conduct was inappropriate; (3) An agreement that Supervisor Bishop shall not vote on projects which we are involved. PLANNERS . CIVIL ENGINEERS . SURVEYORS 3236 Stone Valley Road West #220 . Alamo, California 94507 . (510) 838-5544 I FAX (510) 838-5557 We are a small local business with most of its work here in the County and it is not our desire to punish the County for the actions of Supervisor Bishop. We appreciate your consideration of our claim and this settlement offer. Very truly yours ar Balsdon Vince J. D'Alo �EC E "ED 1 Aliquot Associates, Inc. Gary J. Balsdon DEC - 91994 2 Vincent D'Alo 125 Ryan Industrial Court, Suite 109 CLERK BO OF SU. ERVISORS San Ramon, CA 94583 CONTRA COSTG c0. 3 Telephone: (510) 838-5544 4 Facsimile: (510) 838-5557 . 5 6 7 CLAIM AGAINST CONTRA COSTA COUNTY 8 9 TO THE COUNTY OF CONTRA COSTA: 10 11 Aliquot Associates, Inc. , a corporation, Gary J. Balsdon 12 and Vincent D'Alo hereby make a claim against the County of Contra 13 Costa for damages and injunctive relief for statements made by 14 Contra Costa County Supervisor Gayle Bishop. Claimants make the 15 following statements in support of their claim: 16 1. Claimants' Names: 17 Aliquot Associates, Inc. Gary J. Balsdon 18 Vincent D'Alo 19 2 . Claimants' Address: 20 Gary J. Balsdon Vincent D'Alo 21 Aliquot Associates, Inc. 125 Ryan Industrial Court, Suite 109 22 San Ramon, California, 94583 23 3 . Address To Which Notices Are To Be Sent: 24 Gary J. Balsdon Vincent D'Alo 25 Aliquot Associates, Inc. 125 Ryan Industrial Court, Suite 109 26 San Ramon, California, 94583 1 4. Incidents Giving Rise To This Claim: 2 On or about August 17, 1994, Contra Costa County 3 Supervisor Gayle Bishop made disparaging remarks about Aliquot 4 Associates, Inc. and Gary Balsdon of Aliquot Associates, Inc. The 5 statements were made to a client of Aliquot's who was discussing a 6 proposed project with Supervisor Bishop. Supervisor Bishop stated 7 that because Aliquot Associates, Inc. and Gary Balsdon were 8 involved in the proposed project, she would not be inclined to 9 support the project. She further stated that the reason for her 10 opposition was that Gary Balsdon had opposed her on issues in the 11 past. Supervisor Bishop may well have made similar statements to 12 others that Aliquot is presently unaware of. 13 After learning of these statements, claimants wrote a 14 letter to Supervisor Bishop requesting an apology. There was no 15 response to this letter. Subsequently, claimants made follow-up 16 phone calls to Supervisor Bishop's office to discuss the situation. 17 Supervisor Bishop refused to meet with claimants. 18 As a result of Supervisor Bishop's statements, claimants' 19 reputation in the community has been damaged. Claimants are a 20 small local planning and civil engineering firm with the majority 21 of their business in Contra Costa County. They rely heavily on 22 "word of mouth" . Many of the projects they work on are under the 23 jurisdiction of Contra Costa County. Supervisor Bishop's 24 disparaging statements have hurt claimants' reputation with clients 25 and potential clients and Supervisor Bishop's statements are a 26 2 I direct attempt to interfere with Aliquot's relationships with 2 clients. 3 5. Names of Public Employees Responsible: 4 County Supervisor Gayle Bishop. Claimants are presently 5 unaware of whether any other individuals in Supervisor Bishop's 6 office have contributed to cause damage to claimants. 7 6. Nature of Claim: 8 Claimants' reputation has been damaged in the community 9 and claimants are informed and believe that they have lost business 10 as a result of Supervisor Bishop's statements and conduct and that 11 their relationships with existing clients have been interfered 12 with. There has also been an interference with prospective 13 business advantage as a result of Supervisor Bishop's statements 14 and conduct. The basis for computation of claimants' damages is 15 unascertained at this time. 16 In addition to seeking recovery for damages caused by 17 Supervisor Bishop's conduct and statements, claimants seek a 18 declaration that: (a) Supervisor Bishop's statements were 19 inappropriate; (b) Supervisor Bishop is not to make further 20 disparaging statements about claimants; (c) Supervisor Bishop is 21 not to vote on projects where claimants are involved because of her 22 prejudice against claimants. 23 24 25 26 3 1 7. Amount of Claim. 2 As of the date of this claim, claimants are informed and 3 believe that the amount of their claim would place it within the 4 jurisdiction of the Superior Court. 5 6 Dated: December 1994 ALIQUOT ASSOCIATES, INC. 7 8 By INCENT D'ALO, PRESID T 9 10 11 Y ALSDON 12 13 VINCENT D'AtT- 1A 15 16 faddaim 17 18 19 20 21 22 23 24 25 26 4 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA January 17, 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 Goverment Code Amount: $30,000.00 Section 913 and 915.4. Please note all mWarnings">: CLAIMANT: Charles Ramirez ,I n 13 4 ATTORNEY:Mark V. Murphy COUNTY COUNSEL Date received MARTiNEZCALIF. ADDRESS: P.O. Box 5026 BY DELIVERY TO CLERK ON December 12, 1994 San Ramon, CA 94583 BY MAIL POSTMARKED: December 9, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. December 13 1994 call BATCHELOR, Clerk DATED: , eputy .n s 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( V1 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: 2— — 3 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). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (ARSi'AM) (X 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. - D Dated: January 17, 1995 PHIL BATCHELOR, Clerk, By qd�, _a Q A_ , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; 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. 1995 ' Dated: Jatiaary 18 BY: PHIL BATCHELOR by� puty Clerk CC: County Counsel County Administrator BUCHTA & MURPHY ATTORNEYS AT LAW A LEGAL ASSOCIATION UNION BANK BUILDING 3223 CROW CANYON ROAD, SUITE 350 • SAN RAMON, CA 94583 MAILING ADDRESS: P.O, BOX 5026 • SAN RAMON, CA 94583 • TELEPHONE: (510) 866-6677 FACSIMILE: (510) 866-9399 ALFRED H. BUCHTA MARK V. MURPHY December 9, 1994 RECEIVED Clerk of the Board of Supervisors DEC 121994 Contra Costa County 651 Pine Street, Room 106 CLERK BOARD QF SUPERVISORS CQ. Martinez, CA 94553 CONTRA CQSTA Re: My Client: CHARLES RAMIREZ Your Insured: EAST CONTRA COSTA IRRIGATION DISTRICT Date of Injury: 8/18/94 Dear Clerk of the Board: Please find enclosed a settlement brochure for the above captioned matter. This brochure, contains a demand in the amount of $30,000.00. If this demand is not met within 25 days of the date of this letter, I will proceed to litigate this case on behalf of my client. Thank you for your anticipated courtesy and cooperation. Very truly yours, x�' ' Mark V. Murphy MVM:bkk Enclosure cc: Charles Ramirez REPLY TO SAN RAMON ANTIOCH OFFICE: 1104 BUCHANAN ROAD, SUITE B5 ANTIOCH, CA 94509 (510) 778-5963 PLEASANT HILL OFFICE: 101 GREGORY LANE, SUITE 42 • PLEASANT HILL, CA 94523 RECEIVE® DEC 1 21994 TABLE OF CONTENTS CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. SEMEMENT STATEMENT OF CHARLES RAMIREZ Page Number I. SETTLEMENT STATEMENT 1 - 5 Exhibit Number II. EXHIBIT SECTION A. California Highway Patrol Report A B. Delta Memorial Hospital Treatment records B C. Walnut Creek Radiology Treatment Records C D. Dr. Michael J. Painter Treatment Records and Billing Statement D • 1 MARK V. MURPHY 2 BUCHTA & MURPHY, A Legal Association 3223 Crow Canyon Road 3 Suite 350 San Ramon, CA 94583 4 (510) 866-6677 State Bar No: 83884 5 Attorney for Plaintiff 6 SUPERIOR COURT OF THE STATE OF CALIFORNIA 7 COUNTY OF CONTRA COSTA 8 CHARLES RAMIREZ, ) 9 Plaintiff, ) 10 vs ) SETTLEMENT STATEMENT 11 EAST CONTRA COSTA IRRIGATION ) DISTRICT, GERALD THOMAS BOUDREAU, ) 12 AND DOES 1-10, ) 13 Defendants. ) 14 PLAINTIFF, CHARLES RAMIREZ, submits the following settlement • statement: 15 I 16 LIABMITY/IMPACT 17 Plaintiff, CHARLES RAMIREZ, was injured August 18, 1994 in a truck 18 versus bicycle collision. The collision was caused by the negligent driving of 19 defendant, Gerald Boudreau. Just before the collision, Mr. Ramirez was riding 20 his bicycle on the right of eastbound Sunset Road in unincorporated Contra 21 Costa County near the city of Byron. At the intersection of Sunset and a 22 private dirt road, a water truck driven by defendant proceeded onto Sunset 23 Road. Due to inattention, defendant failed to see Mr. Ramirez or yield to 24 him. Once defendant finally saw Mr. Ramirez and tried to stop, defendant 25 pressed the accelerator instead of the brake pedal and struck Mr. Ramirez, 26 causing his injuries. The California Highway Patrol report is attached hereto • 27 as Exhibit A. 28 • 1 II 2 INJURIES/TREATMENT 3 4 As the result of defendant's negligence, Mr. Ramirez suffered the 5 following injuries: 6 a. Headaches b. Dizziness 7 C. Hip pain 8 d. Chest pain e. Right shoulder pain 9 f. Neck sprain g. Mid back sprain 10 h. Low back sprain i. Radiation into right arm 11 j. Right ankle pain 12 Mr. Ramirez received treatment with the following medical care 13 providers: • 14 15 DELTA MEMORIAL HOSPITAL (8/24/94) 16 FINDINGS: 17 a. Neck pain and tenderness b. Sharp back pain 18 C. Headache d. Right hip pain 19 DIAGNOSIS: 20 a. Lumbar back strain 21 b. Multiple contusions to left side of head and right hip, secondary to bicycle accident 22 23 TREATMENT: 24 a. X-rays, cervical spine b. X-rays, lumbar spine 25 c. X-rays, right hip 26 See Exhibit B • 27 28 1 • DR. MICHAEL J. PAINTER (8/19/94 - 11/22/94) 2 FINDINGS: 3 a. Neck pain 4 b. Neck stiffness C. Chest pains 5 d. Right shoulder pain e. Mid back pain 6 f. Low back pain g. Low back stiffness 7 h. "Pins and needles", right arm 8 DIAGNOSIS: 9 a. Thoracic sprain b. Lumbar sprain 10 TREATMENT: 11 a. Comprehensive examination 12 b. X-rays C. Spinal manipulations 13 d. Electrical stimulation of m)scl.es e. Ultrasound 14 f. Heat treatments • 15 See Exhibit D 16 III 17 SPECIAL DAMAGES ITEMIZED 18 19 A. MEDICAL COSTS 20 1. Delta Memorial Hosptial $1,396.72 21 8/24/94 (See Exhibit B) 22 23 2. Walnut Creek Radiology $ 12.0.28 8/24/94 24 (See Exhibit C) 25 3• Dr. Michael J. Painter $3,264.75 8/19/94 - 11/22/94 26 (See Exhibit D) • 27 TOTAL SPECIAL DAMAGES $4,781.75 28 1 N 2 PAIN AND SUFFERING 3 4 Mr. Ramirez sustained the following elements of pain and suffering: 5 a. Initial difficulty with: 6 1 . Grooming 7 2. Dressing 3. Getting in and out of bed 8 4. Getting in and out of a car 5. Riding in a car 9 b. Difficulty sleeping for 4-5 months, continuing intermittently 10 C. Fear of concussion or brain injury d. Inability to participate in sports and recreational activities 11 such as bike riding and walking 12 13 V 14 RESIDUAL DAMAGES • 15 16 Mr. Ramirez has suffered the following residual damages: 17 As indicated in Dr. Painter's report of 11/29/94, (attached as Exhibit D), the patient has residual occasional low back pain and stiffness on 18 exertion. 19 20 VI 21 CONCLUSION/EVALUATION 22 23 The following factors should be considered when evaluating Mr. Ramirez's 24 claim: 25 A. Multiple Injuries: 26 Mr. Ramirez suffered injury to numerous areas of his body • 27 including his low back, mid back, head, chest and shoulder. 28 1 B. Special Damages. 2 Mr. Ramirez has incurred special damages totalling $4,781.75. 3 C. Residual Damages: 4 As Dr. Painter has stated, Mr. Ramirez is suffering residual injuries in 5 the form of low back pain and stiffness on exertion. 6 In light of the foregoing factors, Mr. Ramirez's claim has a fair 7 settlement value of $30,000.00. Settlement is hereby demanded on behalf of 8 CHARLES RAMIREZ in the sum of $30,000.00. 9 10 11 DATED: 4/- 12 12 MARK V. MURPHY Counsel for Plaintiff 13 • 14 15 16 17 18 19 20 21 22 23 24 25 26 • 27 28 TRAFFICv COLLISION REPORT CHP 555 PAGE 1 (rt?v 2- )'CIPI 042 92 64 PACE / Of SPECIAL cONomow NUMS[R wra RUM CITY _ JUWCIALMSTRICT LOCAL REroRTNwEER NJIM[D FELONY NUMBER NR i RIM COUNTY REPORTING DISTRICT BEAT KILLED MSQ T-774 COL LtpON OCCURRED ON Aim OAT YEAR TIME(x00) NICK:I Of19CER L D. _Y fw f Q ____________ ____ __----___-----MILEPOST NPOIRYAigN DAYOFWEEK TOWAWAr PHOTOGRAPHS BY: t uFEET/M S M T S DYES ND J 0AT SRSIISECiRON 1MTN RAT[NYrY REL MOR: r RSlP/MLE!WOP 402 ❑Yp NO �NONi PARTY IONVOM LICENSE NLMBER fTA CLASS SAFETY VEIL YEAR MAKE I MODEL I COLOR BLU ENSENUMSER STATE DRIVER NAMELFlRS .MIOoLE.LAST) R G 2s PEDES- STREET ADORES[ OWNER'S NAME SAME AS DRIVER 0 S T .✓ A / PARKED CITY ISTATE IZIP OWNER'S ADDRESS SAME AS DRIVER VEHICLE T go ae pcY- fEiC IWR EYE1 IIEIOIiP WENJKT CRTHOATE S.t.^.0 DISPOSITION OF VEHICLE ON ORDERS OP: OFFICER RIORRVER QOTHSM OUST MD. DAY YEAR ❑ f 8 OTHER HOME PHONE BUSINESS PHONE MECHANICAL DEFECTS: NONE AMARENT REFER TO MARRATIVE❑ ❑ _ CHP USE QMLY DESCISiC V[NCL[DAMAGE SHADE N DAMAGED AREA VEHICLE TYPE NSURANC[CARRIER POLICY NUMBER a- QNONE El- e_- QMoo. QMA.gII QroTAL OR OF 10"STREET OR HIGHWAYSPEED I DoT O CA O ICc G PUC OTRAva7 OSr PARTY Dmvgw i LICENSE NUNSSM STATE CLASS I`AIM VEK YEAR ALA"f S-�amp. �A"I MODELI COLOR p/ NUM"It srATE DRIVER NAME(FIRST.MIDDLE.LAST) - &AW TRIAN FTRSIVT ADDRESS - oRwNERs MANE �q SAYE AS DRIVER ❑ o r PARKED CITY/STATE/TIP _ OWNUM ADORES[ SAME AS DRIVEN VEMK;LE ❑ 7 per• SEIrWR tY0 MElGMT MXTMOATS RACE DISPOSITION Of VEHICLE ON ORDERS OF: QOFFICER (grim ❑OTHER MO. . DAY • YEAR �G S- ZJ 3 a' ,�, OTHER HON[PHONE s MINE"P►IOINt PRIOR MECHANICAL DEFECTS: NON[APPARENT RUM TO MAM4TNE❑ ❑ O/ CHP USE ONLY DESCIISE HI VECLE DAMAGE SHADE W D AM AGED AREA ❑. ❑. c]. } '1d:IRANCECARIIERR POLICY NUMSEII rEHICLE Tr.t . �L L-'w ^�•Y MOO. Q MAJOR QTOTAL Dal. ON STREET OR HIGHWAY SST PCF Dar13 CA fl ICC a PUC O , TRAVEL • ' PARTY OmvER'S LICENSE NUYBER (� STATE CLASS SAFETY VEIL YEAR MAKEIIEODEL/COLOR LICENSE MAMSER STATE 3 [OLIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DROVER NAME(FIRST.MIDDLE.LAST) ❑ FECES• TRACT ADDRESS OMMEIPS NAME QSAME AS DRIVER TRIAM ❑ PARKED I CRY/STATE I ZIP OWNERS AOOAESS QSAME AS DRIVER vE/OCLf _...�. I Z. _. � ... pCY- SEI MAR EYES MEANTWEIOJIT pRTHDAT[ RAGE OISPOSITON Of VEHICLE ON ORDERS Of: �OFRCER QORIVEA QOTNEII CUST MO. DAY . YEAR - -� —— ti^ OTHER HOME.HONE BUSINESSPHONE PRIOR MECHANICAL DEFECTS: NONE APPAA04T ROER TO NARRATIVEO Q:J:(-"7-�-.,___"ji ..'_' CW IISE ONLY OtSC1IBEV[HICL[OAMAO[ SHAD E N OAYAG60 AREA C", TYPE INSURANCE CARRIER POUCV NUMBER ❑IAOL 13HOMS QMNOR Ste: ".• i Q El MAJOR 0 TOTAL all OF ION STREET OR MOMWA. SPEED PCF pOTp cAp R«p PUC 13 , TRAVEL _ LIMIT :►A EA AREA S w t DISPATCH NOTIFIED REVIEWER'S NAME DAtt atviEw[o DYES NO u NIA STATEOFCAUFDRNIA TRAFFIC-COLLISION CODIN k PACE aZ DATE OF CCOOLU34ONTYa(1100) NCR:NUMSEII [R L 0 NUYSEII MO. (J DAY YEAR OWNER'SNAME!ADDRESS NZo ED PROPERTY EjYES [:]NO DAMAGE DESC MFnON OF DAMADE EATING POSITION SAFETY EQUIPMENT c HICYCI F.W[[FT EJECTED FROM VEHICLE OCCUPANTSL-AIR BAG DEPLOYED • O_ EJECTED _ A-NONE IN VEHICLE N-AIR BAG NOT DEPLOYED DRIVER 1-FULLY EJECTED e-UNKNOWN N-OTHER V_"O Y-PARTIALLY EJECTED C-LAP BELT USED P NOT REQUIRED W-YES 3-UNKNOWN I-DRIVER D-LAP BELT NOT USED 1 2 $ E-SHOULDER HARNESS USED PASSENGER 2 TO 6-PASSENGERS F-SHOULDER HARNESS NOT USED CHILD RESTRAINT Q S G 7-STATION WAGON REAR Q-LAP/SHOULDER HARNESS USED x-No 0-REAR OCC TRK OR VAN Q-IN VEHICLE USED Y-YES 0-POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED 7 0-OTHER -PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(•)SHOULD BE EXPLAINED IN THE NARRATIVE PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES MOVEMENT PRECEDING UST NUMBER (JJ) OF PARTY AT FAULT Z3 TYPE OF VEHICLE 23 COLLISION ► AVC SECTION VIOLATED: ToEsACONTROl3 FUNCTiONNG APASSENGEA CAR 1 STATION N ASTOPPED .21 Q u' B CONTROLS NOT FUNCTIONING• B PASSENGER CAR W/ R B PROCEEDING STRAIGHT • B OTHER IMPROPER DRIVING•: CONTROLS OBSCURED I IC MOTORCYCLE/ TER C RAN OFF ROAD >913 No CONTROLS PRESENT/FACTOR I ID PICKUP OR PAXL TRUCK D MAKING RIGHT TURN C OTHER THAN DRIVER• TYPE OF COLLISION IE PICKUP/Pjf4m TRUCK W/TRAILER E MAKING LEFT TURN D UNKNOWN• AHEAD-ON F TRUCK 9A TRUCK TRACTOR F MAKING U TURN • E FELL ASLEEP B SIDESWIPE TRUCVj#TRUCK TRACTOR W/TRL.R I GBACKING REAR END H scHqbL BUS SLOWING/STOPPING WEATHER( MARK T TO 21TEMS) D BROADSIDE I O R BUS I PASSING OTHER VEHICLE ACLEAR E HIT OBJECT J RGENCY VEHICLE j CHANGING LANES B CLOUDY F OVERTURNED K HWAY CONST.EOUIPMENT I(PARKING MANEUVER G RAINING VEHICLE/PEDESTRIAN L YCLE EK L ENTERING TRAFFIC D SNOWING OTHER•: THER VEHICLE OTHER UNSAFE TURNING E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH PEDESTRIAN " XING INTO OPPOSING LANE F OTHER•: ANOV•COWSION MOPED PARKED G WIND PEDESTRIAN P MERGING LIGHTING OTHER MOTOR VEHICLE TRAVELING WRONG WAY DAYLIGHT D MOTOR VEHICLE ON OTHER ROADWAY OTHER ASSOCIATED FACTOR(S) OTHER USK-DAWN E PARKED MOTOR VEHICLE Z 3 (MARK 1 TO 2ITEMS) ARK-STREETLIGHTS F TRAIN Avc sfiCT101/v1OLATWN: �E0 D DARK-NO STREET LIGHTS BK:YCIb CYA ON DARK.STREET LIGHTS NOT ANIMAL: BvcSECTIONVIOLATION: CITED FUNCTIONING• LONwo ROADWAY SURFACE S08RIET7-DRUG RJ(EDOBJECT: CvcsECT1ON�Rou TED 1 2 3 PHYSICAL A DRY i (MARK 1 TO 2 ITEMS) B WET J OTHER OBJECT: D HAD NOT BEEN DRINKING SNOWY-ICY E VISION OBSCUREMENT: B HBO-UNDER INFLUENCE D SLIPPERY(MUDDY,qLY,ETC ) HBO-NOT UNDER INFLUENCE• F INATTENTION•: HBO-IMPAIRMENT UNKNOWN ROADWAY CONDITIONS) PEDESTRIAMS INVOLVED G STOP A GO TRAFFIC. E UNDER DRUG INFLUENCE (MARK T TO 2ITEMS) H ENTERING/LEAVING RAMP A NO PEDESTRIAN INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL* A HOLES,DEEP RUT• CROSSING IN CROSSWALK IMPAIRMENT NOT KNOWN UNFAMILIAR WITH ROAD B LOOSE MATERIAL ON ROADWAY• B AT INTERSECTION IH NOT APPLICABLE C OBSTRUCTION ON ROADWAY• I(DEFECTIVE VEH EQUIP.: p CROSSING IN CROSSWALK-NOT oyl I I SLEEPY!FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION LINO SPECIAL INFORMATION E REDUCED ROADWAY WIDTH IDcROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE I I IAKAZARDOus MATERIAL FLOODED• IN ROAD-INCLUDES SHOULDER OTHER IG OTHER•: NOT IN ROAD NONE APPARENT li NO UNUSUAL CONDITIONS APPROACHING/LEAVING SCHOOL BUS I I I PRUNAWAYVEHICLE SKETCH SCELLANEOus OOOT S /� aolcAT><IaRTN � _LCR CRNR w /B 19C CHP .._..._ ESB ____.DA PD.!SO R�✓.fT� CT OTHER — • CHP SSS PAGE 21 Rev 1-")OPI Oat STATE OF CALIfORNrA INJURED tWITNESSES / PASS .aERS R. PAGE DATE OF COLLISION TIME(2400) NCIC NUM8E11 OFFICER I.D. NUMBER EXTENT OF INJURY( "X" ONE) INJURED WAS( "X" ONE )wfiNESS PASSENGER PARTY SEAT SAFETY ��� ONLY AGE SEX NUMBER POS. EOUP. FATAL SEVERE OTHER VISIBLE COMPLAINT [E�� PEO. BICYCLIST OTHER INJURY INJURY INJURY Of PAIN tt ❑ VN ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME D.O.B./ADORE S TELEPHONE L (INJURED ONLY)TRANSPORTED BY: - TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME N07VMD ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME/O.OALI ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I D.OAL/ADDRESS - - TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED TELEPHONE NAME I O,O.IL I ADDRESS gNJUREO ONLY)TRANSPORTED BY: TAKEN TO: iDESCRIBE INJURIES { VICTIM Of VIOLENT CRIME NOTIAEO ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1111 77-7 TELEPHONE —ME;O.O.S.:ADDRESS (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ TELEPHONE NAM[/O,O.L/ADORES$ ONJURED ONLY)TRANSPORTED$Y: TAKEN TO: O F INJURIES VICTIM Of VIOL WT CNM[ROTNm PREPARER"$NAM[ I,D.NWeER MO. DAT YEAR I RFVIFW91019 NAM[ MO. OAY Y CNP 555-Page 3(Rev. 7-87) OPI 042 37 jam/ STATE OF CALIFORNIA ` \ NARRATIVE/SUPPLEMENTAL CHP 556(Rev 7-90)OPI 042 -- Page DATE OF INCIDENTIOCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER .X. 'X'ONE TYPE SUPPLEMENTAL rX-APPLrABLE) ®Narrative 9 Collision report ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental ❑Other: ❑Hazardous materials ❑School bus ❑Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT18EAT ORATION NUMBER LOCATION/SUBJECT STATE HIGHWAY RELATED ❑Yes ❑No 1. /V O - o u 2. u V 3. S 4. 5. - V'/ .J i2/2 / V / 6. W,4 @ J2 I Z 27 12 O 7. .J S .J Sv.•f S 8. w B . 4c.4 vs .4-2 9• T�� 7'/0�.7 �� �L Yo S€E �J - 2 ri9 46 cyG L �i 10. .4,00��,e o,fj J� /C� 0�7 15//s L 1--.�7 � -/ d012 �'s s�DE 27 ©^/;P- 11. S'��.JS E 7" T.Sl .�l Sis u� V -� Pi9 SS ee B Y /ej /- w o.J 7' 40,0c- 12. F12. AR e z7 e=,,, y L 13. es z 7 ' 17o Y � 14. 8�, d A-_ ), y ,4 1-f D B j� 16. V D o Y� �- GtJ 2 �'i5/tr1.J M o U�O rc Yifl tr S,S/d u G D6.e 18. 19- G /-S/ o"o s-= Z2 /3 y Z -/ oe J 20. V/ot� Yio� 4: >',142 F305el'11i�uc "f ie �F 21. Gy.lf � /Va �.(1o3 cU J/o�J /S ��Qy6sY�D Dy4;* }tea A 22 4,4G,tc a ✓/I� E� C E , 23. 24��r..� 7' �F L��•s c 7' w.a S L.r_� / 7"�//� Ti51E' �".9 S�! B o u..�O 25 L.4N E e�F S'c%•�s� y /Z O 26. YiS�E SD v YiS/ LC�7 �� /.�� A.v D �3��.Q v 6�o 27. 4P^2 &�&2 t' ,:"s X4,d X /stiF n B Y Pis/Ys c-�G 128. - ✓/O�.�G'F- - - --- 29. 3 . i (31. PREPARER'S NAME AND).D.NUMBER DATE REVIEWER'S NAME DATE 1.� A& B r_� s I_53 -.;A,0 3_ Use previous editions until depleted_ 90 57547 It P11 DELTA MEMORIAL HOSPITAL 3901 LONE TREE WAY EMERGENCY R0'qM A Sutter Health Affiliate ANTIOCH.CA 94509 510)779-7200 RECORD V _NT—ACCOUNTNO. AUTHORIZATION NO. DAYS REL. ADMIT DATE TIME MED.RECORD NO. 33e953 08/24/94 1023 10076859, NT NAME.._— BIRTHDATE AGE MS jSEXjFC IPT, PE OSP.SVC RACE PHONE TIME 4 1 0 23 OSP. S /9 'TYPE YPE -RAC 61 R j PT T S V' 04-m—K.CHAR L 1-2/30/58 M TO ER E/R 634!--0291 COUNTY SOC.SEC.NUMBER VALUABLES TAKEN MIT-164p6la— p .0 CARIBOU TERRACE BRENTWOOD, CA 945 3 513 "C,4-7-15-5631 n YES NNO OYER ADDRESS PHONE - RETIREMENT DATE P� AD�D Y� 0 1EMPLOYED NRY GUARANTOR PHONE JBIRTHDATE. IARLES RAMIREZ 510 634-0291 ESSRELATIONSHIP 0 CARIBOU TERRACE BRENTWOOD, CA 94513 SELF, ANTOR EMPLOYER TADDRE"s (EMPLOYED NDARY GUARANTOR PHONE BIRTHDATE 51'06340291 ESS 0 CARIBOU TERRACE BRENTWOOD.CA 94513 . NDARY GUARANTOR EMPLOYER ADDRESS !EMPLOYED PHONE RELATIONSHIP GENCY CONTACT ADDRESS 8 ,HN RAMIREZ. 131BETA. COURT- SUITES 'SAN RAMO R,Ck' 9 `516 0-341.5,. BROTHERPS.D.A. bw HOW . DATE I LOCATION TIME DYES 9 NO IANCE COMPANY INSURED AUTH.NUMBER POLICY NUMBER GROUP-RUMBER,- 03*203. RAMIREZ .CHARLES MEDI-CAL 07609547155631 547155631 COMPLAINT REFERRED I BROUGHT BY: M"kPAIN-INJURY TO BACK-NECK HA SELF QR.-CODE __:. EMERGENCY.PHYSICIANDR.CODE,� DR. JUDI WHITEHALL 20071 C UA RAYS M.D.CONSULT: iEm 7 Q C&S EKG DR: lYLASE ❑IV ❑ABG RUM PREGIOUAL]QUANT ❑TET DTmOXIMETER TIME PHONED: E)O, UMIN SAW PT.IN ER TIME orl. lao 2_6 "14N SIGNATURE MEDICl RECORDS CHAR T ii 16 TION ON DISCHARGE: GOOD ❑STABLE ❑FAIR ❑SERIOUS ❑CRITICAL ❑EXPIRED ❑CORONER NOTIFIED ❑POLICE NOTIFIED MIT ❑TRANSFER ❑STABLE ❑UNSTABLE 'URE 9 : 50AM 10100A C CUTHBERTSON DELTA MEMORIAL HOSPITAL 3901 LONE TREE WAY t A Sutter Health Affiliate ANTIOCH,CA 94509 (510)779-7200 T AURWT NO. AUTHORIZATION NO. DAYS ADMIT DATE TIME MED.RECORD(JO. 30953 08/24 /.94 102.3 8076859 . ... NT NAME CHARLES RAMIREZ PHoI`6340291 PAT 547-15-5631 P.T. ER kODREss • 810 CARIBOU: TERRACE S.S.N. TATE,ZIP BRENTWOOD . CA 94513ADMIT TAR NO. CLERK M J D NIEDICAL RECORDS CONDITIO OF ADMISSION TO DELTA MEMORIAL HOSPITAL FL6�Z"(V", � _ MED. RECORD # Name of Patient 4 1. ARBITRATION representative d&s not want such information to be released,he/she must It is understood that any dispute as to medical malpractice,that is as to ! make a writtlsn request for such information to be withheld. The patient or the whether any medical services rendered under this contract were unnecessVy patient's legal representative may obtain a separate form for this purpose or unauthorized or were improperly,negligently or incompetently rendered,will upon request. be determined by submission to arbitration as provided by California law,and The hospital will obtain the patient's consent and his/her authorization to not by a lawsuit or resort to court process except as California law provides for release information,other than basic information,concerning the patient, judicial review of arbitration proceedings. Both parties to this contract,by except in those circumstances when the hospital is permitted or required by entering into it,are giving up their constitutional right to have any such dispute law to release information. The undersigned authorizes release of clinical decided in a court of law before a jury,and instead are accepting the use of data and medical record information in circumstances where the patient is arbitration. transferred to another facility for medical care or to any provider that is expected to provide follow-up care. 2. LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN The undersigned agrees that,to the extent necessary to determine liability for All physicians and surgeons furnishing services to the patient,including the payment and to obtain reimbursement,the hospital may disclose portions of radiologist,pathologist,anesthesiologist and the like,are independent the patient's record,including his/her medical records,to any person or contractors with the patient and are not employees or agents of the hospital. corporation which is or may be liable,for all or any portion of the hospital's The patient is under the care and supervision of his/her attending physician charges,including but not limited to insurance companies,health care service and it is the responsibility of the hospital and its nursing staff to carry out the plans,or worker's compensation carriers. 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 6. PERSONAL VALUABLES or surgical treatment,special diagnostic or therapeutic procedures,or hospital It is understood and agreed that the hospital maintains a safe for the services rendered the patient under the general and special instructions of the safekeeping of money and valuables,and the hospital shall not be liable for physician. the loss or damage to any money,jewelry,documents,furs,fur coats and fur garments or other article of unusual value and small size,unless placed there 3. NURSING CARE in,and shall not be liable for loss of damage to any other personal property, This hospital provides only general duty nursing care unless,upon orders of unless deposited with the hospital for safekeeping.The liability of the hospital the patient's physician,the patient is provided more intensive nursing care. If for loss of any personal property which is deposited with the hospital for the patient's condition is such as to need the service of a special duty nurse,it safekeeping is limited by statute to five hundred dollars($500.00)unless a is agreed that such must be arranged by the patient or his/her legal written receipt for a greater amount has been obtained from the hospital by representative. The hospital shall in no way be responsible for failure to the patient. 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. 7. FINANCIAL AGREEMENT The undersigned agrees,whether he/she signs as agent or as patient,that in NSENT TO MEDICAL AND SURGICAL PROCEDURES consideration of the services to be rendered to the patient,he/she hereby Ondersigned consents to the procedures which may be performed during individually obligates himself/herself to pay the account of the hospital in this hospitalization or on an outpatient basis,including emergency treatment or accordance with the regular rates and terms of the hospital.Should the services,and which may include but are not limited to laboratory"procedures, account be referred to an attorney or collection agency for collection,the x-ray examination,medical or surgical treatment or procedures,anesthesia,or undersigned shall pay actual attorney's fees and collection expenses. All hospital services rendered the patient under the general and special delinquent accounts shall bear interest at the legal rata. instructions of the patient's physician or surgeon. 8. ASSIGNMENT OF INSURANCE BENEFITS 5. RELEASE OF INFORMATION The undersigned authorizes,whether he/she signs as agent or as patient, Upon inquiry,the hospital may make available to the public certain basic direct payment to the hospital of any insurance benefits otherwise payable to information about the patient,including name,address,age,sex,general or on behalf of the undersigned for this hospitalization or for these outpatient description of the reason for treatment(whether an injury,burn,poisoning,or services,including emergency services if rendered,at a rate not to exceed the other condition),general nature of the injury,burn,poisoning or other hospital's regular charges. It is agreed that payment to the hospital,pursuant condition,and general condition. The undersigned agrees that the hospital to this authorization,by an insurance company shall discharge said insurance may also release diagnostic information for insurance coverage verification, company of any and all obligations under a policy to the extent of such 0. payment processing and claims review. If the patient's medical record payment. It is understood by the undersigned that he/she is financially contains references to psychiatric,drug,alcohol or HIV status;this information responsible for charges not covered by this assignment. I request that payment of authorized Medigap benefits,if applicable,be made on my behalf may be released to third party payors. If the patient or the patient's legal to Delta Memorial Hospital for services rendered. C 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 duly authorized by they patient as the patient's general agent to execute the above and accepts its terms. "NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.SEE'. ARTICLE 1 OF TH NTRACT ' ' AUGWitness Patient/Parent/Guardian'60 nservaor q 2 4 1894 If other than patient,indicate relationship t ` Date Time • Financial Responsibility Agreement by Person Other than the Patient,or the Patients! r Legal Representative:I agree to accept financial responsibility for services rendered to the patient and to accept the terms of the Financial Agreement,assgriment of Witness Insurance Benefits,and Health Care Service Plan Obligation Provisions above. Date Time Financi Ily Responsible Party A COPY OF THIS DOCUMENT IS TO BE DELIVERED TO THE PATIENT AND ANY OTHER PERSON WHO SIGNS THIS DOCUMENT, 29-517(1/92) WHITE-Med.Records YELLOW-Patient/Guarantor PINK-Business Office e e ' ee DELTA MEMORIAL HOSPITAL `^ A Sutter Health Affiliate 050 CC: VA EM RGENCY DEPARTMENT - NURSES NOTES _ ,R D.O.B. `Z_,-So_S SEX M O F PRIORITY 1 11 IPOLIC NOTIFIED? YE NO E TIME OBJECTIVE DATA N(� H� y S GLASGOW COMA SCALE TRIAGE TIMEt OO SOCIAL SERVIC S NOTIFIED? ; EYE OPEN#1�tQ; YEAi RFPISE MOTOR RESPONSE METHOD ARRIVAL OF SELF ❑ EMT UNIT ❑ PM UNIT ❑OTHER NTANEOUS 4 ENTED 5 EYS COMMANDS 6 SUBJECTIVE TRIAGE DATA. ❑TO VOICE 3 ❑CONFUSED 4 LOCALIZES PAIN 5 O TO PAIN 2 ❑INAPPROPRIATE WORDS 3 p WITHDRAWS TO PAIN 4 uoftltl _ ❑NONE 1 ❑INCOMPREHENSIBLE WORDS 2 ❑FLEXION TO PAIN 3 p NONE 1 ❑EXTENSION TO PAIN 2 ❑NONE 1 OBJECTIVE DATA: v EXPLANATION: G Q}` $REA!#&3 FAMILY M.D. ►� ORMALORMAL E PERTINENT MEDICAL HISTORY: C)SHALLOW PALE MOIST ❑COLD 22 SECS ❑PINPOINT ❑RETRACTING ❑ASHEN ❑COOL ❑DELAYED O DILATED ❑ CARDIAC/ SEIZURE ❑ ETORONFw ENT ❑FLUSHED ❑HOT >2 SECS ❑REACTIVE ❑ASTHMA / EMPHYSEMA EI CVA L) PSYCH ❑CYANOTIC ❑ABSENT ❑NON REACT. TOPID ❑JAUNDICED TURGOR ❑RA ❑ DIABETES ❑ HTN ❑ OTHER ❑ LABORED GOD I❑L>R ........... ❑OTHER ❑POOR t.. I BP P�`� R� T_SS Z WT—AU-0— DETAILS OF#'S 1 NEURO "N G P AB ❑ 2. HEAD/FACE C-TIRENT MEDS: (w^w11,nose) AM � 3. VISUAL AO OS OD '- ALLERGIES: 4. NECK��Q� A COO _ u✓ 5. CHEST ABN LAST TETANUS TOX: ❑ i 6. LUNGS ABN XX MEDS GIVEN: 7. ABDOMEN ABN 8. BACKSPIN > WNL � ❑ EXAM RM IMMED. ❑ X-RAY ORDERED ❑ ELEV. p p ❑ DRY, STERILE DRSG. ❑SPLINT/SLING ❑ICE 9. PELVIS WNL INTERPRETER TIME CALLED ,�`„_,, ❑ 10. EXTREMITIES A O HOSPITAL O FAMILY ❑ LANGUAGE p HISTORIAN RELATIONSHIP 7c o-M IPA _ C FAMILY/ FRIENDS IN WAITING RM? ❑YES O P{ LIABLE ENVELOPE 1t: f Triage Nurse Signature: C`Jt1�Jl.x� CJ �v • NUBS Date: O ' Z�'C1 ABN normal WNL-Within normal limits -------------- .................... ums -T-T- .......... II Il II II Rif . ........... ............ ],-)s . . .......... ........... ............... -X ... ... ... ...................... .. ..... .... IM 1:1 AMCW I- P: TOTAL INTAKE TOTAL OUTPUT 072 3 4 5 6 7 1L- C. GAGE • 29-147 1/92 mom f P SE RETURN TO � FOR A` FIECK IF NOT MUCH BETTER IN THE NEXT DAY , AND RECHECK AT ONCE IF YOU ARE GETTING WORSE. USE THE EMERGENCY ROOM IF YOUR DOCTOR OR CLININC IS NOT AVAILABLE. WE ARE OPEN 24 HOURS A DAY. he following are specific instructions which you should follow: �lv9 1� . ................ ......................... ........ ....... _ EAD INJURY E] WOUND CARE(cuts,abrasions,burns etc.) i Notify doctor if the following symptoms occur: Keep the dressings or wound clean and dry. 1.Unconsciousness Elevate the wound to help relieve soreness and help speed wound 2.Confusion healing. 3.Unusual sleepiness i 4.Vomiting more than once Use antibiotic ointment daily to wound. 5.Blurred or double vision 1 .Increasing dizziness Despite the greatest care,any wound can be infected.If your wound 6zz \ 6.Fever over 1 zz F. becomes red,swollen,shows pus or red streaks,or feel more sore 8.Inability a move arms or legs instead of less sore as days go by you must report to your doctor 9.Convulsions,fits or seizures right away,or return to emergency room. 10.Colorless fluid or bleeding from ears or nose. Have sutures removed in days. Recheck-if worse. B. Aw in ient every hour a irst 18 ho rs fter the' ju \ check fo ese si s and ake s e hels kno the! nam ,the d t , SPRAIN&FRACTURE,SEVERE BRUISES and where the - 1. Elevate the injured part to lessen swelling This may be comfortably doe with pillows,blankets,etc. 2. Ice packs also help prevent swelling,especially during the first 48 hours\: BACK&NECK INJURY INSTRUCTIONS Place ice in a plastic or rubber bag,with a cloth cover. 1. Use heat or cold on the injured area,whichever seems to help the mo t. 3. If the part swells or gets cold,blue or numb,or if pain increases J Be careful not to bum yourself. markedly,have it checked promptly by physician. / 2. Avoid activity causing pain [��Ifou have an elastic bandage,rewrap it if too tight or to�Ioose. sen 3. You generally feel worse in 36-48 hours after the injury;then 30 minutes at least every eight hours. improvement should definitely begin if you are not aggravating the injury and are following instructions.If not,contact your doctor. ❑ UTI INSTRUCTI N . 4. If you develop numbness and or weakness in arms or legs after A. Empty your bladder after: emergency treatment,notify physician. 2. ottu1.Hottuourse(sex) 3.Bicycle riding - b 4.Bubble bath t`. Time �/\ Physician's v t i, /j /� / ( d 6� i ate Signature /� ►V/l/ �i(JC/¢" `7'" I hereby ackno ledge eceipt of the instructions indicated above. I understand that I have had emergency treatment anAthat I may be released before all.my medical problems are known and tre ed. will arrange for follow-up care as instructed above. Preprinted Afterca a Instructions Patient or Patient's Representative Signature other than above. YES NO XQ ❑ ❑ 7V1113 : 08/24/94., 53Delta Memorial HospitalIREZ CHARLEsutter Health Affiliate 30/58 0tioch, CA (510) 779-7273 EMERGENCY DEPARTMENT AFTERCARE INSTRUCTIONS FORM 29-005 3/92 WHITE-Chart YELLOW-Patient DELTA MEMORIAL HOSPITAL 3901 Lone Tree Way • Antioch, CA 94509 • (510) 779-7200 EMERGENCY ROOM REPORT PATIENT: RAMIREZ, CHARLES DATE OF ER VISIT: August 24, 1994 at 1023 hours, seen at 1130 hours. PHYSICIAN: Judi Whitehall, M.D. CHIEF COMPLAINT: Bicycle accident. HISTORY OF PRESENT ILLNESS: This is a 35-year-old whose brother sent him in for x-rays because last Tuesday he was involved in an accident where he was struck while riding his bicycle. He was hit by a company truck, the bicycle was knocked over with him on it and he complains of lumbar back pain radiating to the neck and some pain in his right hip as well as pain on the left side of his head • secondary to hitting the hood of the car. The patient describes the accident as the car hitting him perpendicularly, knocking the bike sideways so that he landed on his right side, yet he complains that the left side of his head hit the hood of the car. The patient states he was hit by the car on at age 6. He had brain surgery and a metal plate placed in his head. The patient states he has had a headache on the left side of his _ head since the accident. Itstarted a- couple of days after the accident. He has not had any focal findings or complaints such as numbness in one arm or leg, any weakness, or any difficulty ,_. walking. He has had no change in his vision and no nausea and vomiting. The patient states that his pain is in the back, neck, and 'right hip as well as the left side of his head. R' PAST MEDICAL HISTORY: None other than above. CURRENT MEDICATIONS: None. ALLERGIES: None. PHYSICAL EXAMINATION: • .;.: VITAL SIGNS: On presentation, his blood pressure is 116/68 with a pulse of 55, respiratory rate 18, and temperature is 98.2' . GENERAL: This is an ambulatory, 35-year-old who appears in no acute distress. see AIWA • DMH EMERGENCY ROOM REPORT PATIENT: RAMIREZ, CHARLES 26859 PAGE 2 HEAD, EARS, EYES, NOSE AND THROAT: There is some asymmetry of his face with under-development or flattening of the face on the left side compared with the right. The left side of the face appears somewhat smaller. The patient has some asymmetry of the bony structures of the orbits also with the left side appearing somewhat lower than the right. There was no actual palpable swelling or acute deformity, no crepitance, and no change in the skin such as ecchymosis or abrasions and there was no palpable .specific point tenderness of the head. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Fundi cannot be seen. Tympanic membranes are clear without hemotympanum. The oropharynx is clear. There is no facial droop to the muscles on either side. Tongue and uvula are midline. NECK: Supple with a full active range of motion. There is a mild amount of diffuse tenderness of the paraspinal muscles of the cervical spine on the left; however, there is no palpable spasm and no cervical spine tenderness in the midline. There is no thoracic spine tenderness in the midline and the thoracic spine paraspinal muscles are nontender. • LUNGS: Clear to auscultation. CARDIAC: Regular rate and rhythm. LUMBAR SPINE: Tender bilaterally to palpation, especially the paraspinal muscles of the lumbar spine more than in the midline. The patient, however, flinches remarkably with palpation of the muscles of the lumbar spine. He is able to jump away from my hand with good mobility. He does not appear to hold his body as if he were in pain and- does not appear to have any stiffness �or palpable spasm. EXTREMITIES: The patient has some diffuse tenderness of the right hip; however, he has a full range of motion, especially passive range of motion to internal and external rotation of the hip. There is no crepitance of the hip, no bony deformity, and no point bony tenderness. The lower extremities have normal strength and palpable, intact neurovascular examination. ' The patient is able to stand and walk without any ataxia and his Romberg is negative. PELVIS: Stable to compression. J ` EMERGENCY ROOM COURSE: The patient was sent to the x-ray department at his own request for cervical spine, lumbar ;spine, aMd' _ • right hip. films. These were all negative and` `-read by Dr. Keith Tao. DISCHARGE INSTRUCTIONS: The patient was to take Tylenol or Advil as needed for pain. He is to follow-up in clinic if his symptoms . . .continued. . . DMH EMBRG #U—ROOM---REPORT PATIENT-.-RAMIRBZ, CHARL$ 26859 • PAGE continue. He was given head injury instructions as well as instructions for bruises and he is to follow-up in the clinic. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSIS: Multiple contusions secondary to bicycle accident with contusions to the left side of the head, right hip, as well as lumbar back strain. ULJ av JUD WHITEHALL, M.D. /mw25 24/94:8/25/94 cc: ER Physician's Billing Delta Billing Office • a ZA,,__ • g Sim DELTA MEMORIAL HOSPITAL DEPARTMENT' OF MEDICAL IMAGING J.H. FISH, M.D. B.T. LEE, M.D., DMC7rOR K.E.M. TAO, M.D. E.J. SALDINGER, M.D. S. CHOI, M.D. Radiographic Report Outpatient RAMIREZ, CHARLES X-ray No. 90796 Physician: J. WHITEHALL, M.D. Med. Rec. No. 007685 ER Age: 35 Hospital No. 83309 3 Date: 8/24/9 CERVICAL SPINE SERIES: No comparison. Density, stature and alignment of the seven cervical vertebral segments are normal. Disk spaces are preserved. Appendages are intact. Neuroforamena bilaterally are patent. Normal anatomic relationship between the odontoid and lateral masses of C1 is maintained. Prevertebral soft tissue is unremarkable. LUMBAR SPINE SERIES: Stature and alignment of the five lumbar vertebral segments are normal. Lumbar disk spaces are maintained. Appendages are intact' except for the presence of spina bifida occulta at L5 which has no clinical significance. Sacrum and sacroiliac joints are normal. RIGHT HIP: No fracture or dislocation is seen in the right hip. No hip joint effusion is identified. Bony pelvis is unremarkable. CONCLUSION• 1 . Negative cervical spine series. 2 . Negative lumbar spine series. 3 . Negative right hip. KEITH TAO, M.D. /mw1 8/24/94: 8/24/94 _ % ' 1 AKLEY CHIROPRACTIC Michael J. Painter, D.C. 3478 Main Street P.O. Box 8 Oakley,CA 94561 (510) 625-1881 November 291 1994 Mr. Mark V. Murphy Attorney At Law P. 0. Box 5026 San Ramon;' California 94583 Dear Mr. Murphy: The patient Charles Ramirez has treated in my office for injuries he received on 8/19/94. The patient stated he was riding a bicycle about 2 : 30 p.m. when he .was struck by an automobile. . The patient was on Sunset Road in Brentwood, California. The patient' s .original complaints included neck pain. and . stiffness, chest pains, .pain over right chestand right shoulder, mid-back pain, low back pain. and stiffness, and pins and needles into right arm. . The patient was unable to perform his usual and customary job as a. laborer for a roofing company. He was required to lift in excess of 100 pounds and required repeated . bending and stooping. The patient was unable to work for a period of 6 weeks. The patient has treated for the past 3 months on a frequent basis. The patient has shown a gradual improvement from his original complaints. The patient received a final examination on November 22, 1994. The patient has reached pre-injury status with a residual of occasional low-back pain and stiffness on exertion. If you need any. further information regarding this -patient, please feel free to contact me. . Sincerely, Michael J. Painter, D. C. MJP:pp NAME RAMIREZ, CHARLES PHONE 610 ) 634-0291 WK ( ) DOI COMPLAINTS A SYMPTOMS: DATE: ICD 9 1. C' a 1. 2. - . 4. 4. 5. 5. 6. 6. COMPLAINTS i SYMPTOMS: DATE: ICD 9 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. X-RAY COMMENTS DATE: -RAY SERIES DATE 1. -/y / 2. sit CLINICAL PROCEDURES: SUPPLEMENTS DATE • ' C-COLLAR L-SUPPORT PULLEY EXER. SEAT SUPPORT C-PILLOW INDUS. SUPPORT I EXERCISE - CTL SHOULDER _ TAPE TNS - x ORTHOTICS KNEE REFERRAL 2. / DEDUCT COPAY DISABILITY FROM TO 7 MONTH 1121314 51617 819110 11112113114115 16 17118119 20 21 22 23 24 25 26127128 29 30 31 REPORTS. JAN. DICTATED SENT FEB. MARCH APRIL MAY JUNE JULY - AUG. _. SEPT. OCT. _.. NOV. _ DEC. !�rr�r�rirrrir ,�. R�.s• .•wl IN • : rrirrrrrrr • s • � . . nrrrrrMirr� ' * , .. =Now No rte.;*.�r:rr�r_�►��+ r � j � r W� l •.i ./j. t I We F940 • r �r ) •Ito ,® NAME RAMIREZ, CHARLES TREATMENT PLAN DOI SACCT.: 94248-00001 FREQUENCY THERAPY LAST EXAM DATE: DATE GG P+�S IPJ�pP,�O PGQ.� 0 RE-EVALUATION DATE S Pvi I V I THERAPY S)MjATK_ MB1IL8J SI HP CP US THERAP (M iiV e. TR LB i HP CP U 14 — t ""7 THERAPY (MS) C TR MB LB SI HP CP dS 0 - r 0 J ;4- THERAPY -THERAPY (MS) C TR MB LB $62 CP US THERAPY;(Fit) M 19 I D G- THER MS)A, TR, MB LB, SI C , U . 6 ZI THERAPY (MS) C, TR, MB LB, S HP, P, US OC _ a THERAPY (MS) C, TR, MB LB, SI, HP, CP, US 0C ` THERAPY (MS) C TR MB LB SI P CP U ,( W iL THERAPY MS C TR MB LB S HP CP US NO ( � THERAPY (MS) C, TR, MB LB, SI, CP, U NOV1 1 lqqG W THERAPY (MS) C, TR, MB LB, SI, HP, CP, US W OV 16 941 &CL A,a 4d-&6 THERAPY (MS) C, TR, MB LB, SI HP CP US THERAPY (MS) C TR, MB LB SI HP, CP US 1410 INTO MY 111dinch _. r ; r it 1119 WORO SING! K 1119 .1 _. .. . PIPAPAIRD r i � er, MANTPULM IQ! r ji 1 .. .. ,r.: I-. :3 10INS],. INS#! !NS#2 1. i i 10 1 1 C P I 1 NS49 RAM 11 In 7 CHAIT FS 100 CARI BUY 1PRIVA17 ft TJ WY F D I k)::;4 C1094 1-2 91010 MOIST HFA : 18 Q� 1356 11294 T-P W?1 T F/M FXPANDFD WK. 0 . "'D 306 Y: T 14 14 1 -2 77,5 D MyWASCIrd, RKWASK 5 1439 , 7C1 91294 1-2 9/ 124 MASSAGE THCHAPY i3 tO W 1477 h) 93491 1 -2 ivy?1 Q F/P 1-A M 1 IF 11 Fi; "'D C, A 1501 , j() 91494 1 -2 0/010 MOTS1 HKAi V 10 45 T 1526 . 1�:.! lilt'94 1 -7 W120 MASSAGE 1HFRW1Y 1564 . 1 '15 94 V -2 Q n' 1 V MAmmor: mawn 1 1602 . 15 11 194 1-2 1071113 IN 1APORKIND $ 1621 , 1 91994 1-2 992 12 F/M KNITIRD Ff- i') !,:-)C', $ 1657 15 9199A 1-2 91010 MOIST HFAI v 18 , Q� 5 1615 K"I 91994 1 -7 9/250 MYORISCUT, 100 ,R)SP: -i; T 17 0 0 .6 C) 92104 1-2 W?1 A F I M W X 01 No 1 FD f:P �'i C 5 1240 6C), &Q 10 Phi 15 1 WA i 10 , T R 1759 05 92194 1 -2 '0760 MAN V&A A 1 KI! 5 17 9 4 "W:... 9?194 A -2 V7125 MAT057 UIPAWKY 0;C', W 1832 Q,:� 9PI94 1 -2 QJ 12", to-1 PASOLINI A 1851 . U::� 092 1:0 P/M FAVIANHWA) Kh' A 40 0c) 1 18 9 7 W'i POW V NY A01 1(H%] w 193, Ili 1 f� I A 1 99B WD 92694 1 -2 9 1250 FIVA 1100 A Ad- F151 WASI : 2 15 1 A 90394 1-2 07010 MOIST HFAI 0 18 K,�.! A 2209 0:�� 92894 1 5, I J 0! 924h , Y) 27H? W. 100191 1 -2 10 TO 123 F/M FWANDFID VP 5 2327 4:5 -2 97010 MOIST HnAl w 19 W 2341 i C) 1 2414 40 41 11 120 , 1 Cl 1 1J IuRi 1N k, .. I SP, 'S ! FROM 1 IF J CIAN11 U; H 10 CAR 1 80Y Ph;0(0�� 3 1 job SUR 1 W v 11 ON 100094 1 0 A 2464 1 Q] P94 1 -2 F/M FF, 101794 1 -2 9000 MCI I RAM 1 IN] 35 2AW AC) 1 019yo 1-0 Q/0 1 0 oil)1 S-1 1 W A i 101?91 1-2 101204 1 -2 1071213 UWWASCRHIT"; 101794 1-2 1292 17 K/M 1 .111FIVID PKI 0 2040 W., f(TA 1 -2 07010 MOIST HKAI 194 1 -2 97121 MASSAGE WRAW 102594 1-2 9/010 MDTST FUDY, 2140 ,7"1 1CWYA J -21 01124 MASSWIR APPAPY 0 1 0 NOW HOW 11 U1904 1 _0 WOW K)NINT W 40 IOWA 1 -2 QW! 1 PHI - MAYMMAJ P W 2 K 3 . 1 1 !DYA 1-0 970 1O MOKI INY ; 1 1 1AW 9 2 WYSS 054 (A A W 1 ck nn 1 1 TAW 1 —� MASSAW 1 b PKAP, AKY vs 1 1 y2w 1 -2 1.!iNI 0 A 19? 2 QW14 P/M _ DQ001 "T 11-1 6L:1 A 21701 10 BUCHTA & MURPHY ATTORNEYS AT LAW A LEGAL ASSOCIATION UNION BANK BUILDING 3223 CROW CANYON ROAD, SUITE 350 • SAN RAMON, CA 94583 MAILING ADDRESS: P.O. BOX 5026 • SAN RAMON, CA 94583 • TELEPHONE: (510) 866-6677 FACSIMILE: (510) 866-9399 ALFRED H. BUCHTA MARK V. MURPHY RECEIVED October 11, 1994 XT 12 W4 Claims Representative CLERK BOARD OF SUPERVISORS County of Contra Costa - Board of Supervisors CONTRA COSTA CO. 651 Pine Street Martinez, CA 94553 RE: My Client: CHARLES J. RAMIREZ Your Insured: East Contra Costa County Irrigation District Date of Loss: 8/18/94 Location: Brentwood - Delta Road and Sunset Dear Claims Representative: This letter is to advise you that this office represents the above- named person for injuries resulting from the accident indicated above. We understand that you represent the party responsible for our client' s injuries, and we hereby make a claim on our client' s behalf. Thank you in advance for your anticipated courtesy and cooperation in this matter. Please provide my office with a Contra Costa County claim form. Very truly yours, Mark V. Murphy MVM/fmb cc: Charles Ramirez REPLY TO SAN RAMON ANTIOCH OFFICE: 1104 BUCHANAN ROAD, SUITE B5 ANTIOCH, CA 94509 (510) 778-5963 PLEASANT HILL OFFICE: 101 GREGORY LANE, SUITE 42 • PLEASANT HILL, CA 94523 c� o- �¢ #co o s s� W► Go Lo 00 3 H^ co IJ co `n co O fp ON 7¢O b- d 0 rs CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY. CALIFORNIA �,T:anuary_-.17, 199.0 Claim Against the County, Or District governed by) BOARD ACTION � . 5 the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT _ and Board Action. All Section references are to ) The copy of this document sailed 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: $10, 000.00 + Section 913 and 915.4. Please note all •Warnings`. _ CLAIMANT: John Geasaw M J E C 2 ATTORNEY R. Opre Wilson Jr. Wilson Law Offices Date received MA�t*TiY zCALIFL ADDRESS: 1330 Broadway Ste . 1056 BY DELIVERY TO CLERK ON December 21 , 199+ Oakland, CA X4612 BY MAIL POSTMARKED: Dt-_ PmhPr 12 1 9.QZL 1. FROM: Clerk of the Board of Supervisors TO: County Counsel' Attached is a copy of the above-noted claim. December 22' BY: De1994 pp��IL ATCHELOR, Clerk DATED: puty 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 910.6). ( ) 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: /2- 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 (pBSMIlSID) d" y 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: Jaaiary 17, 1995 PHIL BATCHELOR, Clerk, By pd (- A _ mag J , Deputy Clerk YARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) sonths from the date this notice was Personally served or deposited in the sail to file a court action on this claim. See Government Code Section 945.6. You say seek the advice of an attorney of your choice in connection with this setter. If you want to consult An attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under Penalty of perjury that I am now, and at all times herein sentioned, have been a citizen of the United States, over age IS; 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: Jaaity 18, 1995 BY: PHIL BATCHELOR by puty Clerk . ��l . CC: County Counsel County Administrator 4 � � L'\5 why •� 0.3 i� V O .v n O U ul -': wrA 0 .% .vA r ")O"l � N OA O „ t*A N - 0, O0 rA 30 Lo t.t O O '9 LO C- 0 0-40 Cd 0 CO � o Clain: 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, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp JOHN GEASA ) _ ) RECEIVED Against the.County of Contra Costa ) or ). flEG 211994 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 $10 000. 00+medicalsand in support of this claim represents as follows: special'-:.damages 1. When did the damage or injury occur? (Give exact date and hour) August 14, 1994 , approximately 6: 00 p.m. 2. Where did the damage or injury occur? (Include city and county) Bishop Ranch Business Park, City of San Ramon, Contra Costa County at .intersection of Bollinger Canyon Rd. & Broadmore Rd. , dirt parking i; 3. 3. How did the damage or injury occur? (Give full details; use extra paper if required) Fell in manhole. -------------- ----------- ---- - 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Improper manhole CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA;,COUNTY, CALIFORNIA - January 17, 1995 1 . 5 Claim Against the County, or District governed by) BOARD ACTON the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document wiled 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: $60,000.00 Section 913 and 915.4. Please note all -wernings% CLAIMANT: Daniel Imbellino, a minor by his mother Barbara Imbellino - ATTORNEY: James J. Fishel Date received c�at�sv Z,:�c „ UNE, � " ADDRESS: 110 Blue Ridge Dr. , Ste. 1 BY DELIVERY TO CLERK ON December 22, 1994 "���`��tya:zr_�t,��, Martinez, CA 94553 BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors 10: County Counsel Attached is a copy of the above-noted claim. BY: IpV�IL ATCHELOR, Clerk DATED: December 22. 1994 Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 2-'2z —.7 y BY: Deputy County Counsel 111. FROM. Clerk of the Board• TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (ABSM=) (✓) 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: Jaiiary 17, 1995 PHIL BATCHELOR, Clerk, By 0A a 1 Q O.A n , Deputy Clerk VARNING (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 sail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Jmnry 18, 1995 BY: PHIL BATCHELOR byA A� _� Deputy Clerk CC: tounty Counsel County Administrator r .. CC Claim moo: ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of` the cause of'- f action. Claims relating to causes of" action for death or for injury to person ! or to personal property or growing crops and' which accrue' an-or°after January-1, ! 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not. later than one year after the accrual. of the cause of`action. (Govt. Code §911.2:..) B. Claims must be filed with the Clerk of the Board of' Supervisors at its office in Room 1069 County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the: Board of Supervisors, rather than ',- the County, the name of the District should be filled- in... D. If the claim is against more than one public entity,, separate claims must be filed against each public entity. E. Fraud.. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this RE: Claim By ) Reserved for Clerk's filing stamp a(N,i e FREC;EIV;ED 2 21994Against the County of Contra- Costa ) a Ad/or ) �CCLERK BO ARD OFS�SPFRVISORS istrict) CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes' elaim against the County of Contra Costa or the above-named District in the sum of $ Co O, Oo O ,0C) and in support of this claim represents a& follows:. 1.. When did the damage or injury occur? (Give exacts date and hour) { �y S Q C A,�a c�• 2. Where did the damage or injury occur?- (Include city and county) See- 3. ee3. How did the damage or injury occur? (Give full details;- use extra paper ifp ~ required) 4. What particular act or omission on the part.-of county or district officers, servants or employees caused the injury or damage?- i See 7 j (over) 5'. Whit are the names of county or district officers, servants or employees causing the damage or injury? 6. Whatdamage or injuries do you claim resulted? (Give full extent of injuries or damages claimed- Attach two estimates for auto damage. 7 How was the amount claimed above computed? (Include the estimated amount of any prospective. injury. or damage.) 8. Names and addresses of witnesses, doctors and hospitals. 9... List. the expenditures you madeon account of this accident or injury: DATE ITEM AMOUNT e e e * e e * * e e * e e e * * * e e e e e W * Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney JAMES J. FISHEL 's Signature ATTORNEY AT LAW 110 Blue Ridge Dr.Ste. - Martinez,CA 84553 J Telephone No. SW d 9 3S- a O a 1 I Telephone No. s * * ee �t -eeeeeeeeF' eee 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. FISHEL & FISHEL ATTORNEYS AT LAW .TAMES J.FISHEL SUZYN E.FISHEL December 21, 1994 ORIGINALS HAND DELIVERED TO ALL LISTED ENTITIES Attention: Robert F.D. Adams, City of Lafayette 3675 Mt. Diablo Blvd., Suite 210 Lafayette, California 94549-1968 Contra Costa County Board of Supervisors 651 Pine Street Martinez, California 94553 Contra Costa County Sheriff Department 1980 Muir Road Martinez, California 94553 Re: Notice of Claim Against The City Of Lafayette, Contra Costa County Sheriffs Department and County of Contra Costa County pursuant to Government Code § 911 CLAIMANT'S NAME: BARBARA IMBELLINO on behalf of Daniel Imbellino, a minor CLAIMANT'S ADDRESS: 3366 Mt. Diablo Blvd. #404• Lafayette, Ca. 94549 NAME AND ADDRESS OF PERSON TO WHOM NOTICES REGARDING THIS CLAIM SHOULD BE SENT: JAMES J. FISHEL FISHEL AND FISHEL 110 BLUE RIDGE DRIVE SUITE I MARTINEZ, CALIFORNIA 94553 510-935-2021 Page 1 E:\ACLIENTS\6000MBELLINI2-21B.SAM 110 BLUE RIDGE DRIVE,SUITE I, MARTINEZ,CALIFORNIA 94553 PHONE(510)935-2021 FAx (510)935-8484 FtSHEL & FISHEL ATTORNEYS AT LAw December 21, 1994 DATE OF THE OCCURRENCE: JUNE 23, 1994 PLACE OF THE OCCURRENCE: 3234 DEL MAR DR.: LAFAYETTE, CA. 94549 GENERAL DESCRIPTION OF THE OCCURRENCE: Deputy Fitz of the Lafayette Police Department/ Contra Costa Sheriffs Department entered the minor's residence forcefully and without consent. The officer then held the minor by his arm, pulled the minor down the residence hallway and across the living room. The officer also threatened the minor during this occurrence. Deputy Fitz failed to notify Daniel Imbellino's parents of the detention and failed to allow him to call his custodial parent. The deputy failed to advise him of his right to remain silent and his right to counsel. NAMES, IF KNOWN, OF ANY PUBLIC EMPLOYEES CAUSING THE INJURY OR LOSS: DEPUTY C. FITZ of the Lafayette Police / Contra Costa Sheriffs Department NAME AND ADDRESS OF WITNESSES: NAME ADDRESS TELEPHONE 1. Daniel Imbellino contact attorney for minor 2. Sgt. Paul Clancy Lafayette Police Services (see attached) This incident was investigated by the Contra Costa County Sheriff Office and the complaint was substantiated. (See attached letter) NAME AND ADDRESS OF DOCTORS, HOSPITALS WHERE TREATED: NAME ADDRESS TELEPHONE 1. NONE 2. Page 2 E:\ACLIENTS\600MMELLIN12-21B.SAM FISHEL & FISHEL ATTORNEYS AT LAW December 21, 1994 GENERAL DESCRIPTION OF THE LOSS, INJURY OR DAMAGE SUFFERED: Trespass Battery Assault Violation of Federal and State Civil Rights Statutes (USCA § 1983) TOTAL AMOUNT OF CLAIMED: $60,000.00 THE BASIS OF COMPUTING THE TOTAL AMOUNT Claimed is as follows: Damages incurred to date:: Medical: $ Loss of Earnings: $ Special Damages for: Statutory Damages, Punitive damages and Exemplary Damages I/We, the undersigned, declare under penalty of perjury that I/We have read the forgoing claim for damages and know the contents thereof; that the same is true of my/ our own knowledge and belief, save and except as to those matters wherein stated on information and belief, and as to them, I/we believe it to be true. DATED: Barbara Imbellino, mother of Daniel Imbellino DATED: Daniel Imbellino, a minor Page 3 E.\ACLIENTS1600\UvMELLINI2-21B.SAM fly, (Couutu of (luutra nst�t Offire of t4c �fieriff-(IIjartzner Warren E. Rupf Sheriff-Coroner July 14, 1994 Ms. Barbara Imbellino 3234 Del Mar Drive Lafayette, Ca. 94549 Dear Ms. Imbellino: Thank you for contacting this office and sharing your concerns regarding the conduct of Deputy C. Fitz on June 23, 1994. This office welcomes the opportunity to investigate a citizen's complaint, and when appropriate, make changes in our policies, procedures, and training to improve our current level of service. Your complaint was investigated by Lafayette Police Services Sgt. Paul Clancy and reviewed by Lt. Gregg Moore, Police Services Manager. The investigation substantiated your complaint and corrective action was taken. Should you have further questions, please contact me personally or contact Lt.� Gregg Moore, at (510) 283-3680. Sincerely,' Warren Runf, Sheriff !? ^ r Gerald T. Mitosinka, Assistant Sheriff 1980 Muir Road•Martinez, California 94553-4800 (510) 313-2500 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY,_CALIFORNIA January 17, 1995 Claim Against the County, or District governed by) BOARD ACT]", f' f 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: $15,000.00 Section 913 and 915.4. Please note all •warnings". CLAIMANT: Joseph Kevin Graves ATTORNEY Utb $ �1{ Date received December 28, 19�eCOUNSEL ADDRESS: P.O. Box 2192 BY DELIVERY TO CLERK ON �.....� Castro Valley, CA 94546 BY MAIL POSTMARKED: December 27, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. VIL ATCHELOR, Clerk DATED: December 28- 1994 BY: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( }J�This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) 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 —Z o y 8Y: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) { ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (ABS ATNFT)) ( A' 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: Jaruaey 17, 1995 PHIL BATCHELOR, Clerk, By J , Il ,Qp. , Deputy Clerk i1ARNING (Gov. code section 913) Subject to Certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in Connection with this matter. If you want to Consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18: and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Jmiary 18, 1995 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 --o 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 case 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 Roam 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 rime of the District should be filled in. D. If the claim is against more than one public entity, separate claims mist be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this 3orM. RE: Claim By j Reserved for Clerk's filing stamp JOSEPH KEVIN GRAVES BOX 2192 ) RECEIVED CASTRO VALLEY CA 94546 ) saint the County of Contra Costa) DEC 2181994 or ) District) CLERK OAR�OFS SUPERVISORS CONTRFill in name ) The undersigned claimant hereby makes claim against the County of Costra Cotb-.ty the above-named District in the sum of $in excess $15 ,000.=d in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) June 28 , 1994 4 : 25p .m,. .2. Where did the damage or injury occur? (Include city and county) Indian Slough , 400 ' West of entrance to Discovery Bay Marina . Contra Costa County , State of California 3. How did the damage or injury occur? (Give Rill details; use extra paper if r. required) Claimant was passenger in a boat proceeding westbound in Indian Slough that collided with another boat heading eastbound ------ -------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Unknown specifics (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? Unknown 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Severe Physical and emotional injuries . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Full extent of injuries and damages unknown however , damages to date are in excess of $15 , 000 .00 . 8. Names and addresses of witnesses, doctors and hospitals. John Muir HospitalDr . Nang Wong Dr . R . Steiner P 0 Box 30187 Dr . Paul E . Morris Tri-Valley Orthopedic Walnut Creek , CA Dr . Nicolas C. Skaric 5565 W. Las Positas #320 (Dr . William Hoddick Pleasanton , CA --- ------ 9. 'List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 6/28/94 Ambulance $ 1 , 200 . (with interest ) 6/28-6/29/94 Hosp . E.R. & Trauma Rm. 12 , 000 . 6/r 2x9-7/s 8*/9•4* * 1t Lost ostR •Wage;t st-t S1htaAs Co . 700 . 20/94 1otWngeSuetlssest . 25QQ69/94ChPager, Ga . 1t tt x R 11 r 1t • # 1t * * i f 1F f ,. Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorne ) or, by some erson on his behalf." Name and Address of Attorney ; Tn Pro Per �Lba�Lel ( Claimant's Signature ! OSEPH KEVIN GRAVES P 0 BOX 2192 Address CASTRO VALLEY, CA 94546 a T elepnone No. Telephone No. a �t � �t f f �t � f � r s r � f • t� � 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 offieer, 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 ($109000, or by both such imprisonment and fine. u .re ai oc Q7_ � a� oGS �M ICL !A s E G 2 5 0 8 0 7 7 3 6 U S AdOO 33SS380ad emmv I J N m h m-m $ gyp. I O �T a iT I W 50,4«°m° E Wco g 'El E ¢ E0 El El ¢ E -2-E co y.J Z•E ` ca 15 ON cc> O ❑ rL ❑ ❑ w X Z X ymL7w4' ¢ ."• . W.N C ❑ J0411 {aw OL ID c .$ r lL >_�Jmm w qj Y�� I . A o N - a LL a 0;: wo dik N J ca © to ❑}��- w F— ,. Z❑ • ..,;•• K z FT M � �` �., �� � .." i a:��\��d.���•,�w� � ��4 ire.. _ I} 0 oC T ',\ s t m IW 5 a 1w CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA January,: 17, 1995 j Claim Against the County, or District governed by) BOARD ACTI.ON 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 Goirnment Code Amount: $100,000.00 + Section 913 and 915.4. Please note all •yBMi CLAIMANT: Anthony Brennan, a minor ULL Z 8 toss Cou ATTORNEY: Scott K. Zimmerman, Esq. Date received MAIN Rte. ADDRESS: 812 First St. , Ste A BY DELIVERY TO CLERK ON December 27, 1994 P.O. Box 1120 Brentwood, CA 94513 BY MAIL POSTMARKED: December 23, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IV gATCHELOR, Clerk ' DATED: December 28, 1994 eY: Deputy lI. 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 921.3). ( ) Other: Dated: —.q BY: I Deputy County Counsel JII. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) { ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (ABSTAM) {�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• ' ' J 17, 1995 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. Vou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Jarnaary 18, 1995 BY: PHIL BATCHELOR by_ .�2 0A 0 �Deputy Clerk CC: Count Counsel , County County Administrator Law Offices of ' SCOTT K. ZEMMMULAN Attorneys at Law Post Office Box 1120 812 First Street Brentwood, California 94513-1120 Scott K. Zimmerman Barbara E.Scramstad Telephone:(510)6343571 Maureen M.Bryan,C.L.S. Facsimile:(510)634-0781 CERTIFIED MAIL RETURN RECEIPT REQUESTED Contra Costa County Supervisors Clerk of the Board of Supervisors 651 Pine Street, Room 106 Martinez, California 94553 Pittsburg Unified School District N 2000 Railroad Avenue R Pittsburg, California r-- Department of Education DEG 2 71994 for the State of California CLERK BOARD OF SUPERVISORS Superintendent of Schools CONTRA coSTA CO. 721 Capital Mall Sacramento, California 95814 Re: Anthony Brennan, a minor NOTICE OF CLAIM Pursuant to California Government Code Section 910 Pursuant to California Government Code Section 910, SCOTT K. ZEMM4ERMAN of the Law Offices of Scott K. Zimmerman, hereby submits a claim on behalf of ANTHONY BRENNAN, against the County of Contra Costa, Pittsburg Unified School District, Department of Education for the State of California, as follows: A. The name and post office box of the claimant: ANTHONY BRENNAN, a minor c/o Law Offices of Scott K. Zimmerman, 812 First Street, Suite "A", P.O. Box 1120, Brentwood, California 94513. B. The name and post office box of the person submitting the claim: SCOTT K. ZEVIMERMAN, Esq. of the Law Offices of Scott K. Zimmerman, 812 First Street, Suite "A", Post Office Box 1120, Brentwood, California, 94513. Law Offices of ' Scott K. Zimmerman Page:2 C. On December 1, 1994, Anthony Brennan, a minor, was injured while playing on the playground of the Foothill Elementary School, in the City of Pittsburg, during school hours; that Anthony Brennan had fallen and struck his head on the playground asphalt, however, his parents were not informed that he had sustained Any trauma to his head. Anthony's mother, Mrs. Brennan, was informed that Anthony wanted to come home simply because "his head hurt." It was not until Mrs. Brennan picked up Anthony from school that she was informed, by Anthony, of the head trauma. The yard duty teacher/supervisor was aware of the trauma to Anthony's head, but failed to take the appropriate steps to insure Anthony's well being. D. ANTHONY BRENNAN was, is, and in the future shall continue to suffer the long-term effects of the acts or omissions set forth in paragraph "C preceding, to .wit: ANTHONY BRENNAN sustained a right parietal-occipital non-displaced skull fracture and soft tissue swelling in the right occipital region coupled with emotional pain and abuse, and has had to seek medical treatment for the injury, has suffered and continues to suffer extreme mental anguish, and has suffered other physical and mental injuries, the full extent of which have not yet been ascertained. E. The jurisdiction of this claim would rest in the Superior Court of Contra Costa County. F. So far as is known at.the time of filing this Claim, Claimant has incurred damages in excess of $100,000.00 general and special. December 23, 1994 C LLQ'-5'1JA�IITTED, SCO K. IM N Attorney for Claimant CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Jattuary -11, 1,995 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: Jemmette L. Geach ATTORNEY: John Starbuck4 N➢ - 'S Date received yQ ADDRESS: 1404 Franklin St., Ste. 200 BY DELIVERY TO CLERK ON December 16, 19941Ttt'Eiz r,1 `N Oakland, CA 9.4612 BY MAIL POSTMARKED: Hand Delivered via: Risk Mmt. 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JJ Il gATCHELOR, Clerk y 1 DATED: December 16, 1994 : Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( is 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 910.6). ( ) 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: IL'I�'�`� 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 (ABSIAT1VF7)) (✓) 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. �1 Dated: Jmjary 17, 1995 PHIL BATCHELOR, Clerk, By y-� (_' a,�y�� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today l deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. . Dated: January 18, 1995 BY: PHIL BATCHELiR by a , , ,1,(,P Deputy Clerk CC: County Counsel County Administrator OFFICE OF COUNTY COUNSEL DEPUTIES. y PHILLIP S. ALTHOFF CONTRA COSTA COUNTY SHARON L. ANDERSON BRANDON D. BAUM COUNTY ADMINISTRATION BUILDING ANDREA W. CASSIDY + VICKIE L. DAWES P.O. BOX 69 MARKE S. ESTIS VICTOR J.WESTMAN MARTINEZ, CALIFORNIA MICHAEL D. FARR COUNTY COUNSEL 94553-0116 LILLIAN T. FUJII DENNIS C. GRAVES SILVANO B.MARCHESI TELEPHONE (510) 646-2041 GREGORY C. HARVEY ARTHUR W.WALENTA,JR. FAX (510) 646-1078 KEVIN T. KERR ASSISTANTS EDWARD V. LANE, JR. MARY ANN M. MASON PAUL R. MUNIZ December 19 , 1994 VALERIE J. RANCHE DAVID F. SCHMIDT DIANA J. SILVER VICTORIA T. WILLIAMS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Jeannette L. Geach C/O John Starbuck 1404 Franklin Street Oakland, CA 94612 RE: CLAIM OF: Jeanette Starbuck Please Take Notice as Follows : The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910 .2 , or is otherwise insufficient for the reasons checked below: [x] 1 . The claim fails to state the name and post office address of the claimant. [] 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [x] 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [x] 4 . The claim fails to state the name (s) of the public employee (s) causing the injury, damage, or loss, if known. [x] 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10, 000) . If the claim totals less than ten thousand dollars ($10, 000) , the claim fails to state the amount claimed as of the date of presentation, the estimated' amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10, 000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [] 6 . The claim is not signed by the claimant or by some person on is behalf . [x] 7 . Other: Please take note that we must treat your December 15, 1994 letter as a claim against the County. As such, it is insufficient for the foregoing reasons . VICTOR J. WESTMAN, County Counsel By: '?,-, Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a, 2015.5; Evidence Code §§ 641, 664) I declare that my business address is the County Counsel's Office of Contra Costa County, 651 Pine Street, Martinez, California 94553; I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above, sealed and postage fully prepaid thereon, and thereafter was, deposited this day in the U.S. Mail at Martinez, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: December 5,0, 1994 at Martinez, California. CC: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE §§ 910, 910.2, 920.4, 910.8) JOHN STARBUCK LAW OFFICES 1404 Franklin Street,Suite 200 Telephone (510) 763-5300 Oakland,California 94612 FAX(510) 763-8876 December 15, 1994 Contra Costa Municipal Risk Authority ATTN: Liability Claims RECEIVE® 651 Pine Tre Martinez, CA 94553 tl C 161994 Re: Our client: Jeannette L. Geach Your insured: Acalanes School District I-!FRi;30A,RD OF SU -RVISORS Date of incident: 11/02/94 w_C �Th%aCOSTA CO. Y.. ... Claim number: unknown Dear Contra Costa Municipal Risk Authority: This office represents Jeannette L. Geach for injuries and damages sustained in the above-referenced incident. Please direct all further inquiries and correspondence to the undersigned. At your earliest convenience, please confirm the policy limits applicable to this case. Please inform us if there is any question as to coverage; if we do not hear otherwise, we will assume that there is full coverage for my client's claim. If you have obtained a statement from my client, please forward a copy of same. Please also let me know the status of any property damage or other settlement negotiations. Please also be advised that any authorizations for release of information which my client may have signed are hereby revoked. Please direct all requests for documents and information through this office. My client continues to receive medical care and treatment. When my client has sufficiently stabilized to warrant a reasonable prognosis, we shall initiate settlement negotiations. In the interim, should you need any information, please do not hesitate to contact me. Very truly yours, LAW OFFICES OF JOHN STARBUCK By: /. OHN STA K cc: Jeannette L. Geach Enclosure: 2695. 2 (c) authorization JS:mrk •yll C-1 cla C7 �' a tn 00 ON ~.: tsl O �G Wva N ti• • 'p a � •u' � 3 1 O 00 � V t!1