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HomeMy WebLinkAboutMINUTES - 02131996 - C20 CLAIM • BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA -FEBRUARY 13; 1996, 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: $3,500.00 Section 913 and 915.4. Please note all "Warnings% CLAIMANT: MATT BUSCEMI ATIORNEY: IRVIN GRANT 1738 GRANT STREET JAN 1 g 1996 Date received ADDRESS: CONCORD CA 94520 CpUN8E1. BY DELIVERY TO CLERK ON JANUARY 17_ 1996 �jdpRTINEZ CAI.1F• BY MAIL POSTMARKED: JANUARY 16. 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: JANUARY 18, 1996 111 �eputy OR, Clerk I1. FR� ountyM: Counsel T0: Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ),__This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying "'claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: ( BY: Deputy County'Couns II1. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (✓ ) 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: 07- 3 "/9 9& 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 Clatter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 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. Dated: BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator RECEIVED BOATWRIGHT, ADAMS & BECHELLI FEB 2 6 0% ATTORNEYS AT LAW CLERK BOARD OF SUPERVISORS DALE C.ADAMS r_1138WW CO. F.JOSEPH BECHELLI,JR. CONCORD,CA 94520 IRVEN L. GRANT TELEPHONE(510)687-9121 FACSIMILE(510)687-4850 Of Counsel: DANIEL E. BOATWRIGHT February 23, 1996 Clerk Board of Supervisors Contra Costa County 651 Pine Street Martinez, CA 94553 Re: Claimant Matt Buscemi Dear Clerk: I am in receipt of a copy of the"Notice to Claimant" addressed to the above individual. A copy of the notice is enclosed for your reference. Please be advised that I do not, and have never, represented Matt Buscemi regarding this matter or any other matter. Very truly yours, BOATWRIGHT, ADAMS & BECHELLI IRVEN L. GRANT ILG/cb I r l G cc: M. Buscemi r Cla;r to:- BOARD OF SUPERVISORS OF CONrAA COSTA COUNTY INSTRUCTIONS TO CUDWT A. Clai:s 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 mouths 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 aecrm�l 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 91553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the nave 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 0. . R£: Claim By ) Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Cosh ) N 17 1996 or District) CLERK BOARD OF SUPERVISORS Fill 'in name ) CONTRA COSTA CO. The undersigned claimant hereby makes clam against the County of Contra Costa or the above-named District in- the sum of $ S5CD6 �, ___._ 2nd in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where id the damage or injury occur? (Include city and county) 3. How did the damage or it jur- occur use extra papeer? (Give full detai�; t:., p° if required) ! 7 t 5 '�- m rD et Lk � � i ya1 F��' �1 �r� yK ' ;/ 4. What particular act or omission on the part of county or district officers, se.^vants or employees caused the injury or damage? VW,L, CtWt G I c eA / ri Ste- UL c 7t e-oC 0 5. what are the na.-aes of county or district officers, servants or employees causing the da:-age or injury? -------_--- 5. What damage or�n uries do you claim a full extent of injuries or S j Y resulted? (Give j .damages claimed. Attach two estimates for auto damage. 7• How was the amount claimed above aomput,.ed?, (Include the estimated amount of any prospective injury or damage.) $. Names and addresses of w tresses, doctors and hospitals. N\M 1E VIA 9. List the expenditures you made on account of this accident or injury: -��T ` rb �c- i?� AUNT t 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 Rut ru 6 R A W- Z1�- Claimant's Signature ( '7 3 g &RIA NT ST , cok(op-o , C Pkl F. Address. Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for Payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. r V'4 Pkv COPy CLks C vw+ S L� c C c ( `��r 3 GtLL O(Z CaWCoa (D) Cl" t6- I • i � s P -, -- - - -- - -- f - --- ----- -- Z C? r n TA 41 (A U3 o VI Cyr NO N ) co Ln _ M - oo °' D 0T ® ' j p ! • ;►> p .. ✓ - _. S 7- 9 Y t i 7'> M O O � {r} 6� dei J Z Co.rr^^�� O 66 4 d 4 � U d N c F L D 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA FEBRUARY 13, 1996 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: $3,500.00 Section 913 and 913.4. Please note all "Warnings% CLAIMANT: MATT BUSCEMI ATTORNEY: IRVIN GRANT 1738 GRANT STREET JAN 1 $ 1996 Date received ADDRESS: CONCORD CA 94520UN8E� Br DELIVERY TO CLERK ON JANUARY 17, 1996 C "TNEZ CALIF• BY MAIL POSTMARKED: JANUARY 16, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PpHHIL BATCHELOR, Clerk v DATED: JANUARY 18, 1996 eputy 11. FROM: ounty Counsel T0: Clerk of the Board of Supervisors_ ( This claim complies substantially with Sections 910 and 910.2. This c44 FAILS io-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: /�� (le BY: __Deputy County Cou 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 (✓) ThisCleYim is rejectedin.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: 99(0 PHIL BATCHELOR, Clerk, By , Deputy Clerk 17 WARNING (Gov: code section M) 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 GO vernwent Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For .Additional Warning See Reverse Side Of 7 is NotiC 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 ir, Martinez, California, postage fully prepaid a certified copy of this Board. Order and %Dtice-to Clais:ant,.addressed to the claimant as.shown above: Dated: a2 y ` �9`�� BY: PHIL BATCHELOR by 1 % 4( 1 )Deputy Clerk CC: County Counsel County Administrator J CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA -FEBRUARY 13, 1996; 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:DEBORAH RAY TQD�C��IIM�� ATI ORNE Y: JAN 18 1996 Date received ADDRESS: 2167 EL SECO CA�TYCOOUNSEL EL BY DELIVERY TO CLERK ON JANUARY 17, 1996 PITTSBURG CA 94565 BY MAIL POSTMARKED: JANUARY 16, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. _ JANUARY 18 IV IL BATCHELOR. Clerk l DATED: , 1996 : Deputy Il. FROM: County Counsel TO: Clerk of the Board of Supervisors (,WThis 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: Gated: ` 2S '—fit ( z 8Y: �-- Deputy County Couns, 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. BOARDD ORDER: By unanimous vote of the Supervisors present (+� ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. I Dated: 02 — 1-3`/9 9 PHIL BATCHELOR. Clerk, By/J Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now. and at all times herein mentioned, have been a citizen of the United States, over age 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. Dated: 02�1���9'9G, BY: PHIL BATCHELOR by puty Clerk CC: County Counsel County Administrator Claim 'tot 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 whieh' accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of aetian 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.) Bo 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 orrD. , 4 ! # a aa a 0 0 4 a a I * 0 a 0 a a 0 � � � � � RE Claim By ) Reserved for,Clerk's filing stamp Deborah Ray ) r RECEIVE® w k gainst the ,t�/,q�f/ lRd�'tl ) JAN 171996 HOUSING AUTHORITY OF_.THE COUNTY. OF - CLERK BOARD OFSUPERvic, CONTRA COSTA 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 sum of $ and in support of this claim represents as follows ..._..... ----------..r_—_����. to When did the damage or injury occur? (Give exact date and hour) 2. 6fieredide damage or injury occur? (Indlude city and county) 3. How did the damage or injury oce ? (Give full details; use extra( paper if required) -�=-- -rte K ---------.--------- ____..w� 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? �q � t mei a r 66 / srorx— �— r �.cK �.e J �" S // d el 0prT_ . 5. What are the names of county or district officers, servants or employees causing the damage or injury? wd Y fC c r L7) c�� ai2 ?L-eA'a- $. Khat damage or injuries do you claim 'resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. Now was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) $. Names' and--addMS3eS Of WivrIeSSCS, doctors and :lospitdls. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AUNT 4 0 g 1 09 0 f 0 0 • f6 3 0 * 0 0 * f 0 0 so AGO 0 i 0 0 � Gov. Code Sec. 910.2 providesz "The claim must be signed by the claimant SEND NOTICES TOs (Attorney) or by some person on his behalf." Name and Address of Attorney (Claimafit's 'Signature) � ss � Address Telephone No. Telephone No. d 4,2 r"3 - es S a- e AJ 0 ! f f f # ! •E 0 � � f !F 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 ($11000), or by both siich. Jmpri3onr)ent and fine, or by .imprisonment in the state prison, by a fine of not e_xceeding .ten thousand dollars ($10,4009 or by both such imprisonment and fine. W'I NTER 'OH'EVROL'E'I' HONDA WHERE COURTESY IS STANDARD EQUIPMENT! 2101 RAILROAD AVENUE PITTSBURG, CA 94565- (510) 439-8222 Owner: GERALD RAY Day Phone: (510) 458-0926- Address : 2167 EL SECO Other Ph: ( ) - - PITTSBURG CA 94565 Deductible: $ N/A Insurance Co . : Phone: Claim No. . Adj . : 92 FORD MUSTANG GT 2D CNVT GREEN 8-5 .OL-HO Vin: 1FAGP45E5NF178856 License: 3BMN759 . CA Prod Date: 0/ 0 Odometer: Power steering Power brakes Power windows Power locks Power mirrors - Power trunk Tinted glass Body side moldings Dual mirrors Driver airbag Positraction Luggage/roof rack - Cloth seats Bucket seats Recline/ lounge seats Aluminum wheels Clear coat paint REPR/ PART LBR PAINT NO. REPL DESCRIPTION OF DAMAGE QTY COST HRS HRS MISC -------------------------------------------------------------------•----------- 1 FRONT BUMPER 2 Refin Cover 1 .3 . 0 3 Add for Clear Coat 1 1 . 2 4 FENDER 5* Repr LT Fender 1 � 2 .0 2 . 2 6 Add for Clear Coat 1 0 . 9 7* HAZARD WASTE DISPOSAL 1 S_ 5.0 8* COVER CAR 1 0 . 5 T •.5 .0, Subtotals =__> 0 .00 2 . 5 7 . 3 10 .0 1 Page: 1 �40 W T w T E R C H EV R 4 L E T H O N DA WHERE COURTESY IS STANDARD EQUIPMENT! 2101 RAILROAD AVENUE PITTSBURG, CA 94565— (510) 439-8222 Parts (Subject to Invoice) 0.00 Labor 2 . 5 hrs $ 50 .00/hr 125 .00 Paint 7 . 3 hrs -$ 50 .00/hr 365 .00 Paint/Materials 7 . 3 hrs $ 23 .00/hr 167 . 90 Sublet/Mise 10 .00; -------------------------------------------- SUBTOTAL $ 667 . 90 Tax on $ 172 . 90 at 8 . 2500% 14 . 26 -------------------------------------------- GRAND TOTAL $ 682 . 16 -------------------------------------------- INSURANCE PAYS $ 682 . 16 Estimate based on MOTOR CRASH ESTIMATING GUIDE. Kwasterisk(x) items are derived from the�kide DR2JC85. Database Date 7/99 Double asterisk(**) items indicate part supplied by a'supplier other than the original equipment manufacturer. EZEst - A product of CCC Information Services Inc: Page: 2 r t - Ga - �\ > vo - S- >, M - o +-) Ln - N C Ln y O •-J cT O 4} 4-1 4-) U Ln N tJ} 4- U O N tS1 ((f •r C i? Z 0. •*- +' S- +> titii O 0 1n 1 Grp 4r h Cf) O a 64 � ooaZc r� coo ' 4 LL O U z N O OrOjto W 0 1=. F a' 0 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA FEBRUARY 13, 1996 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $250,000.00 Section 913 ae all "uarnings% CLAIMANT: SAMATHA URIBE JAN 16 1996 ATTORNEY: MARK V MURPHY ESQ COUNTY COUNSEL 3223 CROW CANYON ROAD STE 350 Date received MARTINEZCALIF. ADDRESS: SAN RAMON CA 94583 BY DELIVERY TO CLERK ON JA_NiJARY 16, 1996 BY MAIL POSTMARKED: JANUARY 12. 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: JANUARY 16 1996 ppNNIL BATCHELOR, Clerk Bl: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( 'This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying Claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: /—17—% BY: Deputy County Couns( III. FRDM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). i IV. BOARD ORDER: By unanimous vote of the Supervisors present (' ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Gated: -/3 '/9 9(e PHIL BATCHELOR, Clerk, By� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING 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 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: /5 9 BY: PHIL BATCHELOR by& ¢�, Deputy Clerk CC: County Counsel County Administrator -- Claim lo: 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, 1987s, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If t::e claim ;s ageinst mncLre thin one public entity. separate claims ?gust be t z' 1- r...}.,i n en m i t•, O�O Lr L, \..0`011 rrwv��v J . 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 SAMATHA URIBE ) RECEIVE® ) Against the County of Contra Costa ) JAN 16 1996 or ) District) Ca ERK BOARD of SUPERVISORS CONMA COSTA CO. Fill in name The undersigned claimant hereby makes clai inst the County of Contra Costa or the above-named District in the sum of $ 50 00. 00 and in support of this claim represents as follows: ` ..�M----------------��.----�_______�_________� ��w._� _ 1. When did the damage or injury occur? (Give exact date and hour) July 27 , 1995 ------------- 2. ------ ---2. Where did the damage or injury occur? (Include city and county) City of Richmond, County of Contra Costa 3. How did the damage or injury occur? (Give full details; use extra paper if required) Claimant was injured when the operator of Laidlaw Transit, Inc. bus closed the bus doors on the claimant. ------------------=----- -- ----- --------------------- --- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Claimant believes the county may participate in the. management and,.control of the operation of the .bus that was involved in the injury to claimant. (over) It 5. What are the names of county or district officers, servants or employees causing the damage or injury? ` Unknown at this time. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. The injuries are as follows: Contusion, left arm, tender. 4th -- 6th ribs, possible rib fracture, chest wall contusion, myofascial pain,. contusion to ' "1'ap����"'a n CL 'fir fesY 7. How was the amount claimed above computed? Include t e estimated amount of an prospective injury or damage.) -_ Amount claimed re injuries: -,,'V250 ,.000. 0,0'., Special damages totalling $832. 95, plus compensation for pain and suffering 8. Names and addresses of witnesses, doctors and hospitals. Richmond Health_ Center Pittsburg Health Clinic 38th .Street 550 School Street Richmond, CA -94805 Pittsburg, CA 94565 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 7/29/95 -10/25/95 Medical Costs $832. 95 V s; Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person jon his behalf." Name and Address of Attorney Mark V. Murphy, Esq. ^ Buchta & Murphy (ClaimantIX y nature 3223 Crow Canyon Road, Suite 31 0 Mark V. Murphy, Counsel for Claimant San Ramon, CA 94583 Address Telephone No. 510) 866-6677 Tei AnhnnE+ *T,,_ re 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. r _ > - �1; DODO Z0 x p r b0 � � L a I . O x �M n , tit N dr, w ' Q o "° `fl to a w W 0 • w E.? S , W N ! n { I 4 Law Offices of BUCHTA & MURPHY Union Bank Building •3223 Crow Canyon Road, Suite 350 • San Ramon, CA 94583 Mailing Address: P. O. 5026 • San Ramon, CA 94583 (510) 866-6677 FAX: (510) 866-9399 Alfred'H 'Buchta T .., Mark V. Murphy "RECEIVE® January 11, 1996 JAN 161996 CLERK BOARD OF SUPERVISORS Clerk of the Board of Supervisors CONTRA COSTA CO. Room 106 County Administration Building 651 Pine Street Martinez, CA 94553 - Re: Samatha Uribe v. County of Contra Costa Dear Sir/Madam: Enclosed please find an original Claim by Samatha Uribe. Please file the original and send a copy back to me in the self-addressed, stamped envelope provided. Thank you. Very truly yours, MARK V. MURPHY MVM:dls Enc. REPLY TO SAN RAMON ANTIOCH OFFICE:1104 Buchanan Road,Suite 135•Antioch,CA 94509•PLEASANT HILL OFFICE:101 Gregory Lane,Suite 42•Pleasant Hill,CA 94523 C . a � CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA FEBRUARY. 13, 1996' 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: $5,000.00 Section 913 and 915.4. Please note all "Warnings% CLAIMANT: SEUK PHONGVONGKEO ATTORNEY: JAN 19 1996 COUNTY COUNSEL Date received ADDRESS: 2966 17TH STREET MARTINEZ CALIF. BY DELIVERY TO CLERK ON JANUARY 18, 1996 SAN PABLO CA 94806 BY MAIL POSTMARKED: HAND DELIVERED V T A• T?T(ZV lVT('M i I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: _ JANUARY 19. 1996 call 6eputy OR, Clerk Il. FROM: County Counsel TO: Clerk of the Board of Supervisors (V This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send` warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: I—I`� — 6Y- �� Deputy County Counsi 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. BOAR ORDER: By unanimous vote of the Supervisors present (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: PHIL BATCHELOR. Clerk. By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file A court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. if you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a Citizen of the United States, over age 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. Dated: BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator Clam to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO. CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person • or to personal property or growing crops and which accrue on or after January 1, 1988, -must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal- Code Sec. 72 at the end of this form. R£: Claim By ) Reserved for Clerk's filing stamp �K F+710tl sV KeQ RECENED Against the County of Contra Costa ) RANI 1 8 1996 or District) CLERK BOARD OF SUPERVISORS Fill in n ) CONTRA cos7A co. The undersigned claimant hereby makes claim aizainst the County of Contra Costa or the above-named District in the sum of $ ?� Po k QJ� and in support of this claim represents as fo1ivws: r 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) me VKo tzi ot t4zx.u1 3. How did the damage or injury occur? (Give full details; use extra paper if required) ae.UA , 4. What particular act or omission on the part of county or district officers, se-rvants or employees caused the injury or damage? D. wnat are the names of counLv or district officers, servants or employees causing the c"amage or AJ.r,j ury? ute_'tan Meyno(U'A t1ad ki 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two .enst�imates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) � (` c� ltd_ l �. !Names and addresses of. witnesses. doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE. ITEM AMOUNT Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name.and, Address of Attorney Claimant's Signature Address. Telephone No. Telephone No. N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if 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 oollars. ($10,000, or by both such i=,riso'Zr.)ent and fine. r D l� � In 4 NO. No.—Clerk eomv°rs eu f 1 - I, 2 t` 5 s � 9 10 11 1. 12 13 14 15 52 f lA Your account stated to date.If error is found return at once. Sengchanh Pongvongkeo (Seuk) 2966 17th Street San Pablo, CA 94806 510-236-1282 To: County Administration Risk Management Division Re: Failure to meet the agreement by the Veteran Memorial Hall The Event Agenda: During the day time on October 21, 1995;we had the "Kator tournament" elsewhere and at night we will have the dance function and presenting the championship trophies to the winners teams at the Veteran Memorial Hall in Richmond, California. ("Kator"is a Laotian traditional sport that plays like a volley ball game but only used of foot and some body parts allowed.") I have signed the agreement with the Veteran Memorial Hall in Richmond regarding the dance party that was planned for October 21, 1995. On Saturday October 21, 1995, we waited for the Veteran Memorial Hall's employee but no one show up to open up the facility. Hundreds of our quest arrived just to see us waiting outside the hall announcing a cancellation of the party for all the distinguish quests. For this matter, I, as the event organizer, have experienced such a humiliation and embarrassment from this action. Attached are copies of receipt of supplies purchased in preparation for the event: Food Purchased $811.88 Hall rental $1031.23 Band $700.00 Soft drinks $194.85 Beer $472.50 Trophies $150.00 Total $3419.96 Expectation of 350 persons to attend the event where admission tickets would be sold for $10.00 per person, beer: $2.00 per can, soft drink: $1.00 per can, food: $5.00 per serving. I was expecting to generate a total of $3500.00 for the sale of the admission tickets, $800.00-for--beers,-$200.00-from-soft drinks-and-$1500.00 from-food. I am asking for $5000.00 for Contra Costa County who should be held responsible for my loss of income and humiliation that I experienced from this matter. Thank you. Your consideration is greatly appreciated. Sincerely yours, Sengchanh(Seuk) Pongvongkeo Date: ©1��= (A) The Reservation Deposit is part of the total sum of the final contract and is not a part of the Damage Deposit, Rental Fee: Damage Deposit (Refundable): ' � = Security Fee: � T- Janitorial Fee: LiauQr Beer C.. Wine Champagne Other: l r In signing this Contact, the Tenant agrees to abide and be held accountable to,the'Verms and Agreements of this Contract. Date of Event: Start Time of Event: 1. Ending Time(Must be off Premises) f Signature`of Authorized Association Representative Signature of Tenant 3 L / , Date. i s Address. Phone Number:.. Hysten's Graphic Designs(510).724-0441 Date: Richmond Veterans Association 968 23rd, St. Richmond, CA. 94804 (510) 236 9764 Rental Agreement This is intended to be a legal binding agreement - READ CAREFULLY This agreement:is entered between Tent and Veteran Me_moni l Hall Association this .;; " ) Day s P—) Month 19 %'G� and they agree to all Terms and Conditions. Terms and Conditions The Tenant agrees to the following: (1) The Event is for the following purpose: <-? i= (2)A. The Tenant has use of the building from <'=": time r-' --'' -X ' date until time --:7f -date. B. The ending time will mean: The�nant rfi`iust=Biit"of the building and off the grounds by the ending time on the contract. C. Should Tenant fail to be off the grounds by stated time of contract a charge of' Fifty($50.00) dollars per hour or any fraction there of, will be withheld from the required. Damage Deposit. (3 j Any Event where.Tenant serves Liquor, Security Guards are required. The Tenant will pay the cost of security. This will include any extra hours the Tenant is charged. (4) The Tenant will be charged a fee for Janitorial Services. (5) The Tenant will be required to post a Damage Deposit, which.will be refundable provided no damage is done. The following defines damages: (A)Nothing will be placed on our Flag. (B) No sign's, markings, letters,tape, push pins or nails will be placed on our walls. (C) The bathrooms are not to be marked up in any manner. (D) The outside of our building is not to be defaced. (6) There will be No Drinking in Cars parked in the parking lot. (7) The Tenant or their Guest will bring no Liquor into our building. (8) All Drinking will occur inside our building. (9) The Tenant of Record will beheld liable for any damages to our building during the length of the contract_ �. (l 0) The Association's General Manager or his/her representative may cancel any Event when they deem it,in the best interest of the Association because of actions of the "Tenant or their Guests. (1 1) The amount deposited as the Damage Deposit will be refunded after management has inspected the building for damages, by Five (5) working days atter the Event. (12) At the time the Tenant signs the Contract,One Hundred (100) Dollars will be required to secure agreed upon date fcr the Event,-as as: sei=vacion Delio�it. b . BOWLERS MART SPOFMKG GOODS 2223 MacDordd Ave. Richmond,CA SM; CUSTOMER'S OROER NO.. DEPT, LATE r, NAME ADDRESS,,. OUT SOLD @V CASH C.O.O. C.AAGE ON ACCT. MO56 A'ETO. IA10 x3 S 1?l�/L� �4 12 r 16 a 17w. r- 18 :' REC D B�' k � J:�+..++''x-�"•Si�-.. ..ac.XY Ftm..Y'Z.'-,3wf'ra3P+•::�'�•GST..e..YHL:.u-i%.ti'J-.J.+YS'=:a.t.�..+•✓ rt�tx tS -KEEP:THRS SLfP. �7 5L32Q/01320„ " n: �. 4 If �7 13 '6 ePatotP� 17 �-000 t 0 VOW hecku`8._, J C7 �� - Eo��pt Qj �!• � � , ovEg'T R • � A�'dUNt " i 19 ci .. /%'�•�; iii;. z�� 3E3 �. No. �l accnuxr Re .No.—Cent :ra+nrn'D 1 8 3 t/ :i"a'�rf f/ _ 8 9 10 11 - 12 13 14 02 15 --._--------- I .ftl?I-FORM„ BL 8O6/07806 - I. mz v �. rn S m oz .M, n. 4 0 I 00 ji r CLAIM ao BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 'FEBRUARY 13 ' 1996 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. Ail 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 VNIsdvk se note all "Warnings". lair CLAIMANT: DANIEL M NELSON AND JOANNNE NELSON SLK JAN 2 5 1996 ATi ORNE Y: DIANNA L ALBINI EWQ COUNTY COUNSEL LAW OFFICES OF JACOBY & MEYERS Date receiWARTINEZOAUF, ADDRESS: 100 BUSH ST STE 700 BY DELIVERY TO CLERK ON JANUARY 25, 1996 SANFRANCISCO CA 94104 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. JANUARY 25 1996 IL BATCHELOR, Clerk ]DATED: �d: Deputy I1. FROM Counsel T0: 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). ( I 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). ( I Other: Dated: Z S �j �-f BY 2�.�Deputy County Couns 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 ( 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: of - 13 PHIL BATCHELOR. Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. A Dated: -2 — I AI g g (o BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator r .. •'L r DANIEL M. NELSON and JOANNE NELSON CLAIM AGAINST CONTRA COSTA, For decedent; DANIEL T. NELSON BOARD OF SUPERVISORS (Claimant) ap,,- RECEIVED VS. FCCILEERKBOARDW� �:&.&. 96 CONTRA COSTA COUNTY,Does 1-50; public entities and RVSORS their employees W� (Respondent) DECEDENT' S DATE OF BIRTH: May 31, 1974 DECEDENT' S SOCIAL SECURITY NUMBER: 554 39 2705 CLAIMANTS ' DATES OF BIRTH: December 28 , 1956 and May 9 , 1958 CLAIMANTS ' SOCIAL SECURITY NUMBERS: 549 25 2907 and 552 06 4091 CLAIMANTS ' ADDRESS: 36 Dunes Way, Antioch, California 94509 TELEPHONE: (510) 757-2923 ADDRESS TO WHICH NOTICES ARE TO BE SENT, IF DIFFERENT FROM ABOVE: Dianna L. Albini, Esq. , Law Offices of Jacoby & Meyers, 100 Bush Street, Suite 700, San Francisco, CA 94104 DATE OF ACCIDENT: July 30, 1995 TIME: approximately 9 : 35 p.m. LOCATION OF ACCIDENT: Marsh Creek Road (2 . 7 miles East of Morgan Territory Road) DIRECTION PUBLIC VEHICLE WAS TRAVELING? N/A HOW DID THE ACCIDENT OCCUR? The Decedent, Daniel T. Nelson was traveling west on Marsh Creek Road when he was struck by Kenneth Barnes due to a dangerous condition existing on Public Property which was created by Respondent. CAUSE OF INJURY OR DAMAGE? Respondent created a dangerous condition on Marsh Creek Road, 2 . 7 miles east of Morgan Territory Road, by failing to properly maintain, control, manage, construct, repair, supervise, warn, design, install lighting and inspect said county road directly causing fatal injuries to decedent. INJURY OR DAMAGE CLAIMED: Wrongful Death of Decedent NAME AND/OR NUMBER OR I .D. NUMBER OF PUBLIC EMPLOYEES (S) INVOLVED: Unknown at this time. CLAIM AGAINST CONTRA COSTA COUNTY Page 2 Damages included, are but not limited to medical and hospital bills, past, and present and future, burial expenses, lost income, loss of earning capacity, and pain and suffering, emotional trauma and general trauma and general damages. Information provided herein is based on that which is available to claimant as of the date of the presentation of this claim. Damages are sought in an undetermined amount, pursuant to California Government Code Section 910, and said damages are well in excess of the minimum jurisdiction of the Superior Court of the State of California. DATE: ! �' DIANNA L. ALBINI Attorney for Claimants CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA -FEBRUARY 1 3, 1996 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: UNKNO[W]N Section 913 and 915.4. PlgrW1 ,;MW% CLAIMANT: GIVORGI.,`:'GIVORGI & GIVORGI #12722-638 JAN 16 1996 ATTORNEY: CARL HUTCHINS, JR COUNTY COUNSEL PO BOX 292 Date received �pRTINEZCAUF. ADDRESS: WALNUT CREEK CA 94597-0292 BY DELIVERY TO CLERK ON JANUARY 12, 1996 BY MAIL POSTMARKED: JANUARY 11, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp g DATED:_ JANUARY 16, 1996 BtII Deputy OR, Clerk Il. 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: 0 �::?ce BY Deputy County Counsf III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (v) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By1& , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as /shown above. Dated: v2 — �`� 5/ BY: PHIL BATCHELOR by7j Deputy Clerk CC: County Counsel County Administrator RECEIVEDt, F CARL HUTCHINS,QTR,. Claim&Loss Adjuster JAN 12 1996 . 7 P.O.Boa 292 CLERK BOARD OF SUPERVISORS Walnut Creek, CA 94597-0292 CONTRA COSTA CO. (510) 934-5908 FAX (510) 934-9399 December 18, 1995 County of Contra Costa Board of Supervisors 725 Court Street v ( Martinez, CA 94553 * Kv Attention: Board of Supervisors Re: Insured: Givorgi, Givorgi & Givorgi Claimant: Vera Noffa Date of Loss: November 30, 1995. Type of Loss: GLBI Claim No. : 12722-638 Our File No. : H 1735 .Board of Supervisors: 'We are the adjusting representatives of Citation Insurance Group. 'Givorgi, Givorgi & Givorgi operate a business at 3721 San Pablo Dam Road in E1 Sobrante, CA. Vera Noffa slipped and fell on an alleged defect in the public walkway in front of PJ's at that location. We have commenced our investigation. We believe that the respon- sibility for the maintenance and upkeep of that public sidewalk is that of the County of Contra Costa. Accordingly, we tender the further handing of this claim to the Board of Supervisors and/or their self-insured administrators or insurance carrier. The claimant is: r County of Contra Costa Page 2 December 18, 1995 Vera Noffa 1640 San Pablo Avenue, #216 San Pablo, CA 94306 Telephone 51-0764-5186. I would appreciate your acknowledging this letter and advising your handling. Sincerely, 414..4 ti 4� - % Carl Hutchins, Jr. CH:pb cc: Citation Insurance Group P.O. Box 6750 Costa Mesa, CA 92628-6750 7 4 cii A °+.ate" C .. - rA c►c2 b4 i A 10 r to � A � '' V1H �nDO%� W -% -1 0� o a W. SIM I �- CA: 04 , on z �n i r as CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA FEBRUARY 1-3,_1996x, 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% ��C��IIMg�i1 CLAIMANT: EVA BREILEIN �J ATTORNEY: ALAN M TALBOT ESQ JAN 2 4 1996 Date received COUNTY COUNSEL ADDRESS: 1990 N CALIFORNIA BLVD #740 BY DELIVERY TO CLERKAWT1� 9-1 1 AAF, WALNUT CREEK CA 94596 BY MAIL POSTMARKED: TANiTARY 91 1 AAA 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IV IL BATCHELOR, Clerk , DATED: JANUARY 24, 1996 B�: Deputy 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: ?,44— CI (r¢. BY: -rte Deputy County Couns 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). Iv. BOARD ORDER: By unanimous vote of the Supervisors present (�) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: e?s /3 -/9 9(o 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 natter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now. and at ail 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 a$ shown above. Dated: oZ - %4 —1 q 9BY: PHIL BATCHELOR by `Deputy Clerk CC: County Counsel County Administrator Claim to:' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 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 §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. `If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim _is against more than one public entity, separate claims must be . filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp EVA BREILEIN . . RECEIVE® Against the County of Contra Costa JAN 2 31996 CLERK ROAR OF SUPERVISORS Fill in nameCONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa .or the above-named District in the sum of $ Amt to be and in support of this claim represents as follows: e ermine 1. When did the. damage or injury occur? (Give exact date and hour) 9/13/95; approx. 7 : 45 a.m. 2. Where did the damage or injury occur? (Include city and county) Alhambra Avenue, in the city of Martinez , County of Contra Costa, CA 3. How did the damage or injury occur? (Give full details; use extra paper if required) See Attachment A. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury.or damage? Michael Weldon Stamps, an employee of the Central Contra Costa Transit Authority, County Connection, caused this accident by following too close, a violation of CVC Section 21703 . (over) 5. What are the names of county or district officers, servants or employees causirg the damage or injury? Michael Weldon Stamps. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Property Damage: $1, 480 . 31; Medical bills: $3 ,017. 00 through 12/27/95, and continuing. Claimant has sustained in]uries to her , neck and back. General damages: to be determined. _Jurisdiction Lies in Superior Court. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached property damage estimate and medical bills through 11/14/95. 8. Names and addresses of witnesses, doctors and hospitals. Thomas R. Donovan, D.C. , 3249 Mt. Diablo Blvd. , #211, Lafayette, CA 94549; #937-2225. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT See attached medical bllls'. Gov. Code Sec. 910.2 provides: "The:,Om must be signed by the claimant SEND.NOTICES TO: (Attorney) or ,b / .me person on his behalf." Name and Address of Attorney ALAN M. TALBOT, ESQ. BROOKMAN & TALBOT (Claimant's Signature 1990 N. California Blvd. #740 /ttorney for Claimant Walnut Creek, CA 94596 1990 N. California Blvd. , Ste. 740 Address Walnut Creek, CA 94596 932-4008 Te" Nc, 932-4008 ' iViVjJLiVLV l.0✓YY. YY A * R N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. '_�'.�—.'�f�—�.�J`aSit'��'S�c�___—___ae1�-_�:.'.-71X.?Xr':.�r'_'. 'L-t-B:.ut C'__a.-..._.v.•....www.se:�e..L-c.�c_—::_im.�m.�._� �__ __ ATTACHMENT A Eva Breilein v. Contra Costa County 3. Claimant was the driver of a 1995 Saturn vehicle, and was travelling in a generally westerly direction in the left turn lane of the exit ramp of Highway 4, known as the Alhambra Avenue exit, in Martinez, California. A certain 1994 Dodge van vehicle being driven by Michael Weldon Stamps, and owned by the Central Contra Costa Transit Authority, County Connection, was travelling in a generally westerly direction in the left turn lane of the exit ramp of Highway 4, directly behind claimant's vehicle. Claimant was stopped for a red signal light and as claimant proceeded to flow with traffic when the light turned green, claimant's vehicle was rear-ended by the vehicle being driven by Mr. Stamps. J i I I a i I 472�4S agi4.70, TOTALS F5d Id_A 65-f;133657. pai tit is Pold-Y S pe c i a'I s ts Wo r k P A JNAVI�C ee- M&T-cAMf'4C63bD-N- PAUNT71 44*%C-.;t to 11 -Mt blo3 ie, uia5l-t-ea N-711'iCt CANN Sk 'Ffl F. N CAJR 11M PM It P-A'NT UL-OR M,ECH LASOR TOW -STOP GF 5 2294 SS.46 FAX(5 10 6-35-1-295 TAX *TOTALEST4 IV-a- f 1!�a c DE -C 118 L E 229 ll. INS,PAYS wrmoe 16�p(--!"a i..so'(. IL_S vo,' I ry vt-,Nv fqgn Ar' . *h..i5 acclicrn ti"-t t;L)r irl";�Ozal&akifra.op lrwlufla�- all Eulm aqye=, ii, Tir-- ,ph .t5,-.2 Ei t.."; te-C'v"'Mctegi for 1he af-noul^A i mvV f)f,.y"Jiil t.3 hrj-0 0 c By L By I-REMIT CARL114S.OP.i:;NIECII 'Waf-1.$4--4 ACCEPTil'.D. i w I F-0'j'VFF;OP �—�Sn--i OF 50A 4ey; 9:x:'r ccn��ictllimlon f I 'of m"I '-6, 'An* :�,v f by x pecoiV6�-j ty WIN, 5 10- 6-81 29.4 MW MAIM STATE FPtW,, -as 13 PqRKweiy rj R 1). BA$ MART I N E Z %i wo PUj 1 45-53 LICEWSE? P-0 0-.J VIN No, t in TH-z Mal 0.DATE POLICY No- --a Cc Dr- NED Bvi SHAJURN A t4o' I M.CODE TNGICE ADJ. COLIN KENDfILL ED Wlyy-k4--"q N NE No 5 1.4� ADJUI-TER UNIT 4a2 2LATM ?NO, EXT. SIEEXTt ROM sgw- — mm MW vm� V k-4 .0 mw� gm k MR- MOV-0-- -r2"- Ml M 32IBB Was. 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' F T t i i t�•.l (ter': 13K ,;; , �:ac :s In---� r•.2 1 .��� .yy -. i-.la '�t�2 Qt S�Cy ../�ac!klui s7ya 'u s#ra i`a.{ •'. 7 sof y �lA-j Ji. d t: r y C+r rT°: I r My ate. 1 '�U �a_v!; t.1 I�T.Pr _3 .. =r. n;1'� ,. • /-. .. . s, `.,1. r,t�:•: lof +s sf� g / C,.v t w;t,� +-' 9f•j•` 7 tyr._ }ir4c•..,.> ::f s � , I T E M I Z E D S T A T E M E N T ----------------------------------- ----------------------------------- CLAIM NO. : 05-6712305 DATE: 11/01/95 ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED' S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic (723 . 1, 724 . 1) Cervical and Thoracic Syndromes With (723 . 4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839 . 0, 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847 . 0) Cervical Strai n/Sprain -------------------------------------------------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- -------------------------------------------------------------------- -------------------------------------------------------------------- 09/13/95 99203- Initial Intermed. Exam 78 . 00 09/13/95 76140- Radiologist Cons/Report 30. 00 09/13/95 72050- Cervical Complete 5 View 125. 00 09/14/95 99214- Intermed. OV & Exam 48 . 00 09/14/95 97035- ULTRASOUND 20 . 00 09/15/95 99214- Intermed. OV & Exam 48 . 00 09/15/95 97035- ULTRASOUND 20 . 00 09/18/95 99214- Intermed. OV & Exam 48 . 00 09/18/95 97035- ULTRASOUND 20 . 00 09/20/95 99214- Intermed. OV & Exam 48 . 00 09/20/95 97035- ULTRASOUND 20 . 00 09/22/95 99214- Intermed. OV & Exam 48 . 00 09/22/95 97035- ULTRASOUND 20 . 00 09/25/95 99214- Intermed. OV & Exam 48 . 00 09/25/95 97035- ULTRASOUND 20. 00 09/27/95 99214- Intermed. OV & Exam 48 . 00 09/27/95 97035- ULTRASOUND 20. 00 09/29/95 99214- Intermed. OV & Exam 48 . 00 09/29/95 97035- ULTRASOUND 20 . 00 09/29/95 97014- Interferential Muscle Th 25. 00 * CONTINUED ON NEXT PAGE I T E M I Z E D S T A T E M E N T CLAIM NO. : 05-6712305 DATE: 11/01/95 I ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED'S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic (723 . 1 , 724 . 1) Cervical and Thoracic Syndromes With (723 . 4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839 . 0, 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847 . 0) Cervical Strai n/Sprain -------------------------------------------------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- CONTINUED FROM PREVIOUS PAGE 10/02/95 99214- Intermed. OV & Exam 48 . 00 10/02/95 97035- ULTRASOUND 20 . 00 10/04/95 99214- Intermed. OV & Exam 48 . 00 10/04/95 97035- ULTRASOUND 20 . 00 10/06/95 99214- Intermed. OV & Exam 48 . 00 10/06/95 97035- ULTRASOUND 20 . 00 10/09/95 99214- Intermed. OV & Exam 48 . 00 10/09/95 97035- ULTRASOUND 20 . 00 10/11/95 99214- Intermed. OV & Exam 48 . 00 10/11/95 97035- ULTRASOUND 20 . 00 10/12/95 99214- Intermed. OV & Exam 48 . 00 10/12/95 97124- Massage Therapy 30 min. 23 . 00 10/12/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/12/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/13/95 99214- Intermed. OV & Exam 48 . 00 10/13/95 97035- ULTRASOUND 20. 00 10/16/95 99214- Intermed. OV & Exam 48 . 00 10/16/95 97014- Interferential Muscle Th 25 . 00 * CONTINUED ON NEXT PAGE. * I T E M I Z E D S T A T E M E NT CLAIM --------------=-------------------- ----------------------------------- CLAIM NO. : 05-6712305 DATE: 11/01/95 ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED'S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic (723 . 1,724 . 1) Cervical and Thoracic Syndromes With (723 . 4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839 . 0, 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847 . 0) Cervical Strai n/Sprain -------------------------------------------------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- CONTINUED FROM PREVIOUS PAGE 10/16/95 97035- - ULTRASOUND 20 . 00 10/17/95 99214- Intermed. OV & Exam 48 . 00 10/17/95 97124- Massage Therapy 30 min. 23 . 00 10/17/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/17/95 97145 MASSAGE/ ADDL 15 MINUTES 13 . 50 10/18/95 99214- Intermed. OV & Exam 48 . 00 10/18/95 97035- ULTRASOUND 20. 00 10/20/.95 99214- Intermed. OV & Exam 48 . 00 10/20/95 97035- ULTRASOUND 20 . 00 10/23/95 99215- Extended OV & Re-Exam 70 . 00 10/23/95 97035- ULTRASOUND 20. 00 10/25/95 99214- Intermed. OV & Exam 48 . 00 10/25/95 97035- ULTRASOUND 20. 00 10/26/95 97124- Massage Therapy 30 min. 23 . 00 10/26/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/26/95 .97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/27/95 99214- Intermed. OV & Exam 48 . 00 10/27/95 97035- ULTRASOUND 20 . 00 * CONTINUED ON NEXT PAGE I T E M I Z E D S T A T E M E N T ----------------------------------- CLAIM NO. : 05-6712305 DATE: 11/01/95 ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED' S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post. Traumatic (723 . 1 , 724 . 1) Cervical and Thoracic Syndromes With (723 . 4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839 . 0, 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847 . 0) Cervical Strai n/Sprain -------------------------------------------------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- CONTINUED FROM PREVIOUS PAGE 10/30/95 99214- Intermed. OV & Exam 48 . 00 10/30/95 97035- ULTRASOUND 20 . 00 10/31/95 99214- Intermed. OV & Exam 48 . 00 10/31/95 97124- Massage Therapy 30 min. 23 . 00 10/31/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 10/31/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 PATIENT NO: 1851C-2 TOTAL THIS BILLING: 2 , 077 . 00 TOTAL DUE ON ACCOUNT: 935 . 00 I T E M I Z E D S T A T E M E N T ----------------------------------- ----------------------------------- CLAIM NO. : 05-6712305 DATE: 11/16/95 ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED'S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic (723 . 1, 724 . 1) Cervical and Thoracic Syndromes With (723 . 4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839 . 0 , 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847 . 0) Cervical Strai n/Sprain , -------------------------------------------------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- -------------------------------------------------------------------- -------------------------------------------------------------------- 11/03/95 99214- Intermed. OV & Exam 48 . 00 11/03/95 97035- ULTRASOUND 20 . 00 11/06/95 99214- Intermed. OV & Exam 48 . 00 11/06/95 97035- ULTRASOUND 20. 00 11/07/95 9712,4- Massage. Therapy 30 min. 23 . 00 11/07/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 11/07/95 97145- MASSAGE'/ ADDL 15 MINUTES 13 . 50 11/10/95 99214- Intermed. OV & Exam 48 . 00 11/10/95 97035- ULTRASOUND 20 . 00 11/14/95 .99214- Intermed. OV & Exam 48 . 00 11/14/95 97124- Massage Therapy 30 min. 23 . 00 11/14/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 11/14/95 97145- MASSAGE/ ADDL 15 MINUTES 13 . 50 PATIENT NO: 1851C-2 TOTAL THIS BILLING: 352 . 00 TOTAL DUE ON ACCOUNT: 930 . 00 I T E M I Z E D S T A T E M E N T CLAIM NO. : 05-6712305 DATE: 11/30/95 i ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740. WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R. Donovan, D.C. 3249 Mt. Diablo Blvd #211 PATI.ENT; Lafayette, CA 94549 EVA BREILEIN - (510) 937-2225 2813PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED'S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic - (723 . 1, 724 . 1) Cervical and, Thoracic Syndromes With (723 .4) Radiculitis With (728 . 85) Paravertebral Myospasm Due To (839. 0, 839 . 1) Cery ical and Thoracic Subluxation Complex Complicated By (847. 0) Cervical Strai n/Sprain ----------------------------------------7--------------------------- - DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- ------------------------------------------------------------------=- 11/17/95 99214- Intermed. OV & Exam 48 . 00 11/17/95 97035- ULTRASOUND 20. 00 11/21/95 99215- Extended OV & Re-Exam 70. 00 11/21/95 97035- ULTRASOUND 20. 00 11/24/95 99214- Intermed. OV & Exam 48 . 00 11/24/95 97035- ULTRASOUND 20. 00 11/28/95 99214- Intermed. OV & Exam 48 . 00 11/28/95 97035- ULTRASOUND 20. 00 PATIENT, NO: 1851C-2 TOTAL THIS BILLING: 294 . 00 TOTAL DUE ON ACCOUNT: 1, 224 . 00 I T E M I Z E D S T A T E M E N T ; ----------------------------------- CLAIM NO. : 05-6712305 DATE: 12/14j,95� ATTORNEY: LAW OFFICES OF BROOKMAN & TALBOT 1990 NO. CALIFORNIA BLVD #740 WALNUT CREEK, CA. 94596 DOCTOR: PHONE: 415-932-4008 Thomas R; Donovan, D.C. 3249 Mt:; Diablo Blvd #211 PATIENT: Lafayette, CA 94549 EVA BREILEIN (510) 937-2225 2813 PARKWAY DR. IRS # 94-2613049 MARTINEZ, CA. 94553 INSURED'S NAME: EVA BRELEIN DATE OF ACCIDENT: 09/13/95 DIAGNOSIS: Post Traumatic (723 . 1, 724 . 1) Cervical and Thoracic Syndromes With (728 . 85) Paravertebral Myospasm Due To (839 . 0, 839 . 1) Cervical and Thoracic Subluxa tion Complex Complicated By Chronic Effects (847 . 0) Cervical Strain/Sprain -------------------------------------------------------------------- DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT- -------------------------------------------------=------------------ 12/08/95 99214- Intermed. OV & Exam 48 . 00 12/08/95 97035- ULTRASOUND 20 . 00 12/11/95 99215- Extended OV & Re-Exam 70. 00 12/11/95 97035- ULTRASOUND 20. 00 PATIENT NO: 1851C-2 TOTAL THIS BILLING: 158 . 00 ,TOTAL DUE ON ACCOUNT: i, 518 . 00 1 PROOF OF SERVICE BY MAIL -- CCP, &2015.5 & §1013(a) 2 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 3 4 That I am a citizen of the United States and over the age of eighteen years; that I am not a party to the within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below I served a true copy of: 6 CLAIM AGAINST CONTRA COSTA COUNTY 7 8 9 by depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed 10 envelope, postage thereon prepaid, addressed as follows: 11 12 CERTIFIED MAIL - RETURN RECEIPT REQUESTED 13 Clerk of the Board of Supervisors Administration Bldg., Room 106 14 651 Pine Street 15 Martinez, CA 94553 16 17 18 19 20 21 At said time, there was regular delivery of the United States Mail between said places of deposit 22 and address(es). 1 23 Executed at Walnut Creek, Contra Costa County, California, on Janua , 1996. 24 25 r 26 SHARON HANNEY 27 28 LAW OFFICES OF BROOKMAN & TALBOT SUITE 740 1990 NORTH CALIFORNIA BOULEVARD WALNUT CREEK, CALIFORNIA 94596-3711 TELEPHONE (510) 932-4008 FAX: (510) 937-1828 January 17, 1996 Clerk, Board of Supervisors Administration Bldg., Room 106 651 Pine Street Martinez, CA 94553 RE: EVA BREILEIN v. CONTRA COSTA COUNTY Dear Clerk: Enclosed please find original and one copy of Ms. Breilein's Claim against Contra Costa County. Please endorse receipt on the copy and return it to this office in the envelope provided. Thank you for your cooperation and assistance. Very truly yours, BROOKMAN & TALBOT Sharon Harney, Secretary to Alan M. Talbot /sh Encl. it O / S Y i 4?• Y. �Y O cn 0.2 O d vO• M , 6� 0 � �1 O "CA 0 s 50 0 A 1Cn a� tt1 o y, V x da a' r N J-A .E� d N � a U o x �