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MINUTES - 12162003 - C15
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA CgUNTY B DAM ACTION•DECDMER 16, 2003 Claim Against the County,or District Governed by } 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 California Government Codes. } notice of the action taken on your claim by the Board of Supervisors, (Paragraph IV below), givex <, Pursuant to Government Code Section 913 and t 915A. Please note all"Warnings". AMOUNT: $7,779.19 CLAIMANT: STATE FARM INSURANCE COMPANIES FOR: JAY B. WILLIAMS ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 10, 2003 ADDRESS: P.O. BOX 64£ 3 BY DELIVERY TO CLERK ON:NOVEMBER 10, 2003 Rol-NERT PARE., CA 949.27--6403 BY MAIL POSTMARKED: INTEROFFICE MAIL FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE EN, Cler <. Dated: NOCEMBER 13, 20013 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Su 1sors This claim complies substantially with Sections 910 and,%,10.2. { ) 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: Bye: Deputy County Counse _2III. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IVB. ,BOARD ORDER: By unanimous vote of the Supervisors present: ( r°' 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: mArl;�/ JOHN SWEETEN, CLERK, By , Deputy Clerk IF WARNING(Gov. code section 913) Subject to certain exceptions, you have only six (6)months from the date this ndtice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seep 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: scar' OHN SWEETEN,CLERK By Deputy Clerk -SAX::5-6 7- Ic( 74 4) a W Lot 5 7T 1 pit :7q 70,P; 51, 1 .7 ZOOM! • .7.x 'fflay 07 A 77� aW 14.1 i Ale 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? TP S. What are the names of county or district officers, servants, or employees causing the damage or injury? I' 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) C.rq r;<:;, r) • 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) r S. Names and addresses of witnesses, doctors, and hospitals. is _. ... :.�� �r'.l.• {S C.�a t X.•, I ; :ih - f'�/�' .. i- �7A.1r.. rf ,.. - U CCT L at T s r v -)r ,•, 9. List the expenditures you made;on account of this accident or injury. } Gov. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf," Name and Address of Attorney } } (Claimant's Signature) (Address) Telephone No. Telephone No. NO nCE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the 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,mount, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not mon than one year,by a fine of not exceeding one thousand($hoot?),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. �� rr CS :1 cr.. x H� Ri R� o t� _ n;. CLAIM BOARD OF S wUPERVISORS OF CONTRA COSTA COUNTY' r n BOARD ACTION: DECEMBER 16, ZOO Claim Against the County, or District Governed by } 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 California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: $573.19 CLAIMANT: STATE FARMINSURANCE COMPANIES FOR MARIA E. SANCHEZ ATTORNEY: uNK-NowN DATE RECEIVED: NOVEMBER 20, 20013 ADDRESS: 6400 STATE EARA DRIVE BY DELIVERY TO CLERK ON: NOVEMBER 20, 2003 P.O. BOX 6403 Romm PARK, CA 94927-6403 BY MAIL POSTMARKED: NOVEMBER 19, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 20 2003 JOAN SWEET , 1 Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors { This claim complies substantially with Sections 910 and.%10.2. ( ) 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: € 5 Dated: By. .y' Deputy County Counsi ITT. 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. BOARDORDER: 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:, ""'',/ 0,04 SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six (6)months from the date this ndtice was personally served or deposite in the mail to le 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• Ao,e' G TN SWEETEN, CLERK By Deputy Clerk STAT! €AR M State Farm Insurance Companies IliSURAtiG£� Claim Central Subrogation 6400 State Farm drive 403 November 18, 2003 P.O. Box FCohnert Park, CA 94927-640 Penny Bailey ++CC ��, ��� Beard Of Supervisors Of Centra Costa COVG 651 Pine #106 Martinez, CA 94553 NOV 2 0 2003 CLERK BOARD OF SUPEW RS CONTRACOSTACO. RE: Claim Number: 05-4939-818 Date of Lass : July 22, 2003 Our Insured: Maria E Sanchez Dear Ms . Bailey: State Farm Mutual Automobile Insurance Company, on behalf of Subrogee, Maria E Sanchez hereby makes a claim for $573 . 19 and makes the following statements in support of claim: 1 . Notices concerning this claim should be sent to: State Farm Insurance Companies PO Box. 6403 Rohnert Park, CA 94927-6403 2 . The date of the accident occurring on July 22, 2003 at Concord, at 4 : 10 pm. 3 . The circumstances giving rise to this claim are as follows : Our insured pulled from parking space & was struck by Matthew Slattengren driving a Chevy #1096788, 4 . The injuries reported consisted of the following: n/a S . Our total claim is as follows : Company' s Net Payment $323 . 19 Insured' s Deductible Int $250 . 00 Total Property Damage $573 . 19 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 Board of Supervisors Of Contra Costa CO Page 2 November 18, 2003 NOTICE : This form is to provide notice of our claim for damages in accordance with the statute. If this form is not acceptable for compliance with the statute, please rush the necessary form to my attention for proper filing. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provide for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. State Farm Mutual Automobile Insurance Company Dated: November 18, 2003 By: Mo\'k�k Kew pR� 4 (&- Employee Name Employee Title — G t-f ell-- X-1 EMployeV Phone Number Sincerely, Marla Kuznar Claim Processor (800) 440-6177 x7 State Farm Mutual Automobile Insurance Company mk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY A. Claims relating to causes of action for death or for injury to perm or to personal property or g vMug crops and which accrue on or before December 31, ISM, test be presented not later than the 100* day atter the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrae on or after January 2, 2986,must be presented not later than sic months atter the. accrual of the cause of action. Claims relating to any other cause of action most be presented not later than one year after the accrual of the cause of action. {Govt-Cade';§911.2.) B. Claims mast be filed with the Clerk of the Board of Supt isors at its o#'tte in boom 106, County Administration Building,651 Plot 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. I£. I+`MSu See penalty for fraudulent claims, Penal Code Sec.72 at the end of this farm. * w * w * *'a * at ,e r * • * �► a a *.: r * * r : * IN RE:Claim by `( —` — � ) Reserved for Cleric's Filing Stamp arM P4 �Vt,'✓3 9Y,?,)-7 6Y63 Against the County of Contra Costa 05-4 7" rV or District} NOV 2 p 2003 Pili in Name)} RK Bt?At�'t?CiF Stip Ct3NTF{q FINISR The undersigned claimant hereby makes claim against the County of Contra ak�o named District in the sum of S Q and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give esact Mt*and Hmr) ---------------------------- ------------ 2. Where did tate damage or injury occur? (hwhwe cky end caumy) __i�ju _C �4------------------------------- 3. How did the damage or in u • occ r? GtYo stat deter;u-a�e tr� . r Ei uh*d) g .� ry < p � � 4. What particular acct or omission on the part of county or district a ray servants, or e loyees caused the I Pk. _ Injury or damage? / ;r• /_ � �'.r j� v t' c • i (Over) j i S. What are the names of county or district officers,servant,or employees causing the damage or injury? 'ghat damages or injuries do you claim resulted? (Gbe etn extent of taaries Ydamages daim xt Attach two alt matas for 0044"M*94.) ---------------------------_------------___--__-_--__-----------------_---__-__-__--_ s. How was the above claimed amount computed? (1whWe the esieanned auaoant or airy pr o*peetWt eulury or dt"Ca.) -----------------------.r_ --_____--_____-____----- ._-______-_ S. Names and addresses of w€tnessesi dectoM and hospitals. - ----------------------------------------------------------- 9. .List the expenditures you made on account of this accident or injury: bACE i _ AMOUNT -57-50 Gov.Code Sec.910.2 provides: "The claim must be signed by the claimant SEND N0710ES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney (Llai ant's Signature) ' L�-o (Address) f Telephone No. Telephone No. NOTICE Section 72 of the Penal Cade 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 dollars(S1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars(S10,000}, or by both such imprisoument and flue. ITATi'AIM RB Z 0 0 0 3 H date: 11--23-03 page: 1 tNAYAA%Gid STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMENTS ,........ ! ' policy number G302 - 483 --0 !5C=- named insured date of lass 0AN'+CHIE;Z , '14-1-LAZ1:> Q '7 -22 --03 C denotes consolidated payment E denotes EFT payment P denotes previous data payment number payee total amount issued status E 102725208K VORNHAGEN BODY AND PAINT 323 . 19 10-30-03 PAID f All &; ----------------- ------------------- --------------------- --------------------- x fix' A x r r i i f va»" door �+ > i :p. R ,d 8 5 i �h� y x` i c� s: .rxra rx.w RB Z p p p 3 2 date: 11-18-03 ,N. .•w°� time: 12 : 33 PM STA'T'E FARM MUTUAL AUTOMOBILE INSURANCE COMPANY VEHICLE DAMAGE REPORT date of loss 07-22-03 Estimate Vehicle Info 'Ar Vehicle Owner: SANCHEZ, PHILIP Vehicle Description: 97 NISS SENTRA XE 4D SED bn5 7iir -ir �r -Ar tk -jr A -je -Ar -Ar lk lk -Ilk lk air 'Ar �r �r jk -r A- -A- -A- -k -k �r -Ar -Mr tk jk- -Ar ilk lk lk IC tk A- r VV 10/27/2003 AT 03 :30 PM TOB NUMBER: 4471 25297 VORNHAGEN BODY AND PAINT, INC LICENSE #:AF 167121 FEDERAL ID # : 680466225 600 HARVEST PARK DR. BRENTWOOD, CA 94513 (925) 516-1969 FAX: (925) 516-9166 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: KEVIN CORDUA 10/27/2003 03 :26 PM ADJUSTER: CLAIM REP TEAM 6 INSURED: PHILIP SANCHEZ CLAIM #05-4939-81801 OWNER: PHILIP SANCHEZ POLICY # ADDRESS : 261 HAZEL CT DEDUCTIBLE: $250. 00 BRENTWOOD, CA 94513-1901 DATE OF LOSS: 07/22/20103 AT 04 :10 PM EVENING: (925) 513-9216 TYPE OF LOSS : COLLISION POINT OF IMPACT: 6 . REAR INSPECT VORNHAGEN BODY AND PAINT, INC BUSINESS: (925) 516-1969 LOCATION: 600 HARVEST PARK DR. BRENTWOOD, CA 94513 INSURANCE STATE FARM INSURANCE COMPANIES COMPANY: DAYS TO REPAIR 1997 NIBS SENTRA XE 4-1 . 6L-FI 4D SED BN5 VIN: 1N4AB41D6VC727551 LIC: 3VKL183 CA PROD DATE: 10/1996 ODOMETER: 87661 AIR CONDITIONING REAR DEFOGGER TILT WHEEL INTERMITTENT WIPERS DUAL MIRRORS CLEAR COAT PAINT POWER STEERING POWER BRAKES AM RADIO FM RADIO STEREO CASSETTE DRIVER AIR BAG PASSENGER AIR BAG CLOTH SEATS BUCKET SEATS AUTOMATIC TRANSMISSION ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAIN ----------------------_--_----___-_--------_--_-_---------------------------_---- 1## NO CORE AVALIBLE STOCKTON 1 2# PLATING 1 3 REAR BUMPER 4 O/H REAR BUMPER 1 . 5 5 REPL BUMPER COVER 1 154 . 87 INCL. 2 . 5 6 ADD FOR CLEAR COAT 1 . 0 7# S01 HAZARDOUS WASTE 1 3 . 00 T SUBTOTALS ==> 157 . 87 1 . 5 3 .5 1 10/27/2003 AT 03 :30 PM JOB NUMBER: 4471 25297 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1997 NIBS SENTRA XE 4-1 . 6L-FI 4D SED BN'5 PARTS 154 . 87 BODY LABOR 1 . 5 HRS @$ 60 . 00/HR 90 . 00 PAINT LABOR 3 . 5 HRS @$ 60 . 00/HR 210 . 00 PAINT SUPPLIES 3 . 5 HRS @$ 27 . 00/HR 94 .50 SUBLET/MISC. 3 . 00 ----------------------------------------------------- SUBTOTAL $ 552 . 37 SALES TAX $ 252 . 37 @ 8 .2500% 20 . 82 ---------------------------------------------------- GRAND TOTAL $ 573 . 19 ADJUSTMENTS : DEDUCTIBLE 250 . 00 ---------------------------------------------------- CUSTOMER PAY $ 250 . 00 INSURANCE PAY $ 323 . 19 THIS IS JUST AN ESTIMATE OF REPAIRS, IF ON FUTHER INSPECTION, ADDITIONAL PARTS OR REPAIRS ARE NEEDED, YOU WILL BE CONTACTED FOR AUTHORIZATION. WE ARE NOT RESPONSIBLE FOR LOSS OR DAMAGE TO YOUR VEHICLE FROM FIRE, THEFT, ACCIDENTS, OR CAUSE BEYOND OUR CONTROL. NOR ARE WE RESPONSIBLE FOR ANY DAMAGE TO CAR ALARMS AND STEREOS ! WE WARRANT OUR WORKMANSHIP, INCLUDING REFINISHING, FOR ONE YEAR. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLVD=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: ##=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. 2 10/27/2003 AT 03 : 30 PM JOB NUMBER: 4471 25297 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1997 NISS SENTRA XE 4-1 . 6L-FI 4D SED BN5 ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARF3735 DATABASE DATE 9/2003 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PAR'T'S ARE DESCRIBED AS LKQ, QUAL, RELY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORFD PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN {#) ITEMS INDICATE MANUAL ENTRIES. PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 3 10/27/2003 AT 03 :30 PM JOB NUMBER: 4471 25297 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1997 NISS SENTRA XE 4-1. GL-FI 4D SED BNS PARTS 0 . 00 ---------------------------------- --_------_--__---_-- SUBTOTAL $ 0 . 00 ESTIMATE 573 . 19 KEVIN CORDUA SUPPLEMENT S1 0 . 00 KEVIN CORDUA CUSTOMER PAY $ 250 . 00 JOB TOTAL $ 573 . 19 INSURANCE PAY $ 323 . 19 THIS IS JUST AN ESTIMATE OF REPAIRS, IF ON FUTHER INSPECTION, ADDITIONAL PARTS OR REPAIRS ARE NEEDED, YOU WILL BE CONTACTED FOR AUTHORIZATION. WE ARE NOT RESPONSIBLE FOR LOSS OR DAMAGE TO YOUR VEHICLE FROM FIRE, THEFT, ACCIDENTS, OR CAUSE BEYOND OUR CONTROL. NOR ARE WE RESPONSIBLE FOR ANY DAMAGE TO CAR ALARMS AND STEREOS ! WE WARRANT OUR WORKMANSHIP, INCLUDING REFINISHING, FOR ONE YEAR. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: ##MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARF3735 DATABASE DATE 9/2003 AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER.. ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS . USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON, RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED FROM NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN (##) ITEMS INDICATE MANUAL ENTRIES . PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 4 10/27/2003 AT 03 :30 PM JOB NUMBER: 4471 25297 SUPPLEMENT OF RECORD 1 WITH SUMMARY 1997 NISS SENTRA XE 441 . 6L-FI 4D SED BN5 ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 5 .'. 4v. State Farm Automobile lnsuran z �y �s P.V�r. Box 6403 Rohnert Park, CA 94927-6403 _ ���� 100 �� 5 947 6�7 � FIRST CLASS MAIL � Nov 2 0 zoo 3 srAco�� 11/06/2003 THU 09:38 rai ruraaaYouv State Farm Insurance Companies PO Box 6403 Rohnert Park, CA 94927 IT FACSIMILE COVER SHEET "IN To: Contra Costa County Risk Management From: Richard Smith Attn: Penny Salley Electronic Auto Subrogation North Coast Regional Office Your Claim Number: Our Claim Number. 054952-783 Telephone Number. Telephone Number: 80040-6177 ext 7 Fax Number 925-336-1421 Fax Number: 800-440-6176 Your Insured: Our Insured: Jay Williams Total Pages Transmitted(including cover sheet): NOTICE: PRIVATE AND CONFIDENTIAL The Information contained in this facimile message contains private and confidential material and/or trade secrets material Intended for the sole use of the individual named above.If you are not the Intended recipient listed above,you are hereby notified that any disclosure,duplication,or distribution of this Information or the taking of any action in reliance on the contents of this transmission,without the express written consent of State Form Insurance Companies,Is STRICTLY PROHIBITED.If you have recieved this transmission In error,please notify us Immediately by telephone so that we can arrange for the return of this material at no cost to you. In order to assist you In evaluating and processing the subrogation claim we are asserting,we may provide nonpublic personal information about our customer.We are sharing this information to effect,administer,or enforce a transaction authorized by the consumer.However,you are neither authorized nor permitted to:(1)Use the customer Information we provide for any purpose other than to evaluate and process the subrogation claim,or(2)disclose or share the customer Information we provide for any Purpose Other than to evaluate and process the subrogation claim. Message: copy of subrogation docs;per your request. 11/06/2003 THU 09.38 YAb /UlDooliouu COPY Claim Central Subrogation 6400 State Farm Drive September 24, 2003 RohnerrtxPark, CA 94927-6403 Penny Bailey Contra Costa County Risk Management 2530 Arnold Dr Ste 140 Martinez, CA 94553 —" `�� RE: Claim Number: 05-4952-783 Date of Lassa August 28, 2003 Our Insured: Jay B Williams Dear Ms. Bailey: State Farm Mutual Automobile Insurance Company, on behalf of Subrogee, Jay B Williams hereby makes a claim for $7779.19 and makes the following statements in support of claim: 1. Notices concerning this claim should be sent to:j State Farm Insurance Companies PO Box 6403 Rohnert Park, CA 94527-6403 2. The date of the accident occurring on August 28,; 2003 at S Lucille Ln, at 1.30 PM. 3. The circumstances giving rise to this claim are as fellows: our insured was driving on S. Lucille and your vehicle backed out of a driveway into the lane of traffic. 4. The injuries reported consisted of the following: 5. Our total claim is as follows. Company's Net Payment $7447.97 insured's Deductible Int $ Total Property Damage $7779.19 ROME OFFICES: BLOOMINGTON, ILLINOIS 61710 11/06/2003 THU 09:38 FAX 7075884bUU ................ ........................ COPY Contra Costa County Risk Management Page 2 September 24, 2003 NOTICE: This form is to provide notice of our claim for damages in accordance with the statute. If this form is not acceptable for compliance with the statute, please rush the necessary form to my attention for proper filing. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: ( 1) use the customer information we provide for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information-we provide for any purpose other than to evaluate and process the subrogation claim. State Farm Mutual Automobile insurance Company Dated: September 24, 2003 By: K=loyee -Name Emgloye-e—Title Emnloyee Phgng__Number Cannipg Palmer C gia Process-or 48 00) 440-6177 x 2 State Far=-n:L]Aaj A :toMobij0 _jnSUrSjrXC Comnan CP M TKQ gstimates re no longer r=gjrgd by- thg industry. The esatwaev' a estimator., 11/06/ 003 '!'HU UU:JV rA.t rUrants4ovv Claim to. BOA"OFSUIPERVISOPS Of COVMA COSTA COUNTY MMMCTIONG ro 0AMMI A. Claims relatlap to erases of action for death or for Injury to perum or to personal property or growing ertvps and which swive on or before limber 31, 1987,onrt be presented not later the the 100*day*nor.the accrual of the ease of actiom Cidtsa Miadnt to cin-so of Acdaa for death or for Wary to person or to persoast property or growing crops and which secret ou or afiesr Jsmeaerf 1,IN*.must be preseate:d sot later than sis a safe after the a ws ual af.tM emu at attics,. Claims relating to any other=use of action man be Pris"W soe later than one year rftdr tea aecreal of theeAMae of&Ciba. (Gowt,Codes t1.2.) 8. Claims man be filed w#th the Clerk of Nat Boiled of SuperWxors at its office to Room 106, County Admin Hull ag.652 Pine Streak Maniacs,CA 9+155 G It CW=is splurt a ditto governed by tha'Board of 56pervisoM rather than the County, the name of the District sboul d be filled ins ` D. V the efstim Is ASsiaat snore than sac public a adty,separate claims num be Med against cacti public entity. i IL See penalty for fraudulent claims, Penal Code Sec.72 at the end of this form. #!iNa # * ###'i 11r • # # #####ii #1t # /1.#+M# #1! #9t f! # #1t#�♦ N # i9tbi it At IN RZ-CWmi by SVo.4-,t..Vv�r m et5 SG.b t v, [c.Far) Reserved for Cm's 1+M*z Scam _ } Against the orsnty of Contra Costa MINERS k,,,. r M 95-X4952-79s VF Dirtrirt� (lilt is Mame) " The undersigned claimant hereby Noakes claim against the County of Contra Costa>or the a ove nstne District in the sum of S"-111 sand in support of this clads represents as follows .- 1. When did the damage or Injury arcc+nrt {Gk-.e,E.x*1W&+tea HMw) .__ ...........__•.s_.....----*----- Z taifiere did tln d sntude or Injury occur! c bs*A&cay ow co nm r) ---------------- 3. How did the damage or injury ocavr:t (Gave m dtuft as,ettea paper trr.'eb*a) (3t,.r- a°rlSce rw 4cLt1 s rr v .1 tet r, S. F..tce+'IIIc. cx rt° _�`' rcz.1� 0 t 4L What pardtal9ar u s or uoaission on the part of county or dbisict oMccr,% ser,rants,or enupioyeas caused tho lojury ordan►apa? v 611 C'. Q., t�Cl C.k t 6 frt'�G7 0 u r•- 1 a'1 ��Lt i• t' Ct 5 +�'r�r^, (Over) 1.1/40!LUta,1 lYaU tlx7:«7a x t►ts r v r duuY�vv s. what aayt the at�tee�eaa ar eaolaaty+ar a�trfct olpaxes,serrrattts.�`emplayeaes tan�la�ag ttae daasageor ia:�ttryx ------------------------------ ---- -- -----------r+..r.. r.r..r--------- a.----------- a. What damps or Injuries do yaa e:laina mwdt+nd? a Ceht trtt tsrwr+a OtWwies Or da'aag s sk r L Aback cwo ambaft tar Mli+.dayrare.) , JV0 I"LA WIA ......rr..,....r....._ ._.. -.r... 7.r_Be was ffic abo.^e *0 MOM taft t sem+•otic alt aartlare ot.i►y�r��=g er+txmrra,) . 6v Off` ,�t- ------------------- � ndaa J h fte Psi — `3' �.' ...s .u.a•rr.wi.....+wo.rrs.wo..w...w.r.••..----......-....r.w•arw..ate.!',..+.'"• ..�....+. tee L•.i..L� I 8. (dames and addeeaeeae of wle doctarsl/and ii halal a M.. .. ....r.x-...r.... .a............. ............................... ............. 9. .Ust the you made an a topent of ibis accident or injury: e 11rail S 'Proper-�Y '04L P-4 OLq 41 A4 1-7 ' a:510-� F2+t)+n -i/t/►(y`}C� V�tjrd er(j�`�,�a�''}Jj1 Ityy ASOASOd . CS q � # #R+ , iY tM�fY i N f a It a at a*a a • a' a a I! Gov.Code Set.120.2 provides: "Tbt claim most be sixasd by the claimant SEND N071CyS M. (Artorna y) or by saint person on bis behalf." Name and Address of Attorney e ( Situartum) s (Address) , Telephone Wo. Tadcpi%►Dc Ale. 'd tris 'y4 7 4tl f ff #rfi * # f i #aYM * ff feFRi Ri �'f >kf lt • NR/� # ii ii il� fRtill ffMfl �►ifi'f NOTICE Section 72 of the genal Cade provides: "Every person wbo,with intent to de timid.preYeats for allowance or for payment to any stare board or aiticicr,or to any county,dtv or district board or officer.atetborised to allow or pap the same if gennlaea,any fain or fira ndale nt claim,blit,account.voutbeer.or wriihM Is punishable eitbe r by imprisonment in Me county,lsii for a period of not mares tkan awns year.by at 1100 of not exeeedlag one thousand dollars(51,000),or by bath sack Impriscomeaat and tine,or by Imprisonment in the slab t prtwo,by a tine of not exceeding ten thousand dollars(S1$,0M). or by both .Tele haptisinmesit and new. ....................................................................................................... . ............................................................................................................ ............................................................... rte AT 1�1 UNMEO STATES POSTAL SEFNICE First-Class Mail PoWage&Fees Paid USPS Sender: Please print your name, address, and Z! State Farm Automobile Insurance Co- RO. Box 6403 Rohneft Park,CA 94927-6403 -It's 11/Ufiit2UU3 'ltii! us�:9u rnm evr.r��x� � SENDER, • t"rt3migot8 i"tW3 1,2.aW 3.AIW Wmptete at lWn 4 ii<PJMMCtSd COiiV"13 1W. Me • p*ti yout ilii ms wW addrou on the tj8" C So#W W8 Can return the card to YOU. ■ ,Atter this wd to the back of the m20000e+. X f t or OA the fit nt if sp=e PWMKB- O. Is dWvwy addma W&Wt Imrn ke t 1? (3 Yes 1. Aftide Addre aad 20: 1f enter de Rveq address t*lc N: *+ IVED BY AD. SER CELLA ION DESK* OCT 13 2003 I . ' savice Type a C1►etMed Mal 0 ExPts"MWI C3 W� , 13 Return Ric wr��� r . • A�ST3a.� . 0 insumd Meal 0 pr y.O.O. s d. ReatOcted 0811VOI?FJ Fear} Yes . AatiCl81'la TMW p4py ht m wfyko Wit} c ni `mo Ps+iForm 3$11..luiy 1999 DT" tic R�ROCCO ad25�s-0o�t x 11i�6/20U3 '1'Mu uv:,%v rise► avruou�u�v Enterprix Rental Agreement 00173513 -- 2344 (000 2474 SAN RAMON VALLEY BLVD ascription Rote Amount r■IMONS SAN RAMON CA 54583-1602 14 DAYS i 41.99 587.315 14 DAYS DW V 14.99 209.8 SALES TAX% 8.25 46.5 MISC EXP 15. 901 To: 07MKii.W6lifMMSfI.C.iW�1tJ7i9 irrrrww STATE FARM-ROHNERT PARK SVC IST ATTIC TEAM 4•CLAIM REP* 6408 STATE FARM DRIVE ROHNERT PARK CA 94925 cc Date Qat Data in 9/02/03 9/15/03 � "enter Herne Phone ( � JAY WILLIAMS 825-878-9698 Address Office Phone 17 FETAR PL 1i 8S-!932-385 R8 City State zip � 1 SAN RAMON CA 94582-0057 Drlver License State Expires K0929472 CA 12/29/04 Von 12/29/42 Add lonaltMfver TOTAL CHARGES 831.2 Nasms ESS AMOUNT RECEIVED 331.2 SPOUSE 2ge !!river License state expires AMOURT ME........ ..... 1 500.00 Color Lfeense No. Claim #/Policy #/P.O. N WHITE 4YYJ423 054952783 filing inqutrfes Call Feel Tax 10 # Model Unit # Insured 36-3041733 03 XTER XK4607 WILLIAMS* JAY* filing information Date of Loss Type of Loss 8/28/03 INSURED Type I car SYMMfr shop Thank You For Choosing Enterprise FiiRDF15Q SYfAMONS $0D � �' e VISIT tis ATOUR WES SITE WWW.EN7ERPtRISE.Cold sY st st ■ • ils rs • a a • ■ • a 4 ft A ss e ■ to • ■ ! a R as + Pleuo Return This Portion with Remittance AMOUNT ME....... . .... . �► Soo.00 Remit tea: ENTEI ISE RENT A CAR Paid by. ATTN: ACCTS RECEIVABLE STATE PARVA-ROHNERT PARK SVC IST PO BOX 5686 ATTN. TEAM 4*CLAIM REP* CONCORII CA 94524-0668 $4#13 ST TE FARM CA DRIVE ; r :rN limn l Agroamont pronoun#t +x+861 OV 16 STP?351 067'513 5f10.OD 2344 1ltt�titrU�;i tttu u :4u rnn rvM„�,,: ;.;,, III I� I I Ili i���I I! � iil'A I ��i.'9o. .:i.;,`�':�'.'y_::.^r:,._ x. ::. :�.;•. Pb*'� gr _,x 11/ua/zuva Yn� vv.-*,j ann .. _ _. _... G"t�- � 1: - 7 ioll, f� k ':llJva..•4kl tt fil 11/Ut1/2UU3 Tflu u`u.4o raa iuiaootovv pu�r�at�\1t�t 1ryL3. ... ■ratY raKq RBZ0O03H date: 1.1.-06-03 page: 1 .01 111 07 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMEENTS policy number named insured date of loss 08 --25 --03 C denotes tonsotidated payment E denotes EFT payment P denotes previous data payment number payee total amount issued status E 102706518K ENTERPRISE RENT-A-CAR 500.O0 09-23-03 .PAIL) E 102706254K SYMMONS BODY & FENDER, I 6, 947 . 97 09-22-03 PAID s l ltrr rhfM RB 2 0 0 0 3 2 date: 11-06-03 time: 09 :33 AM STATE FARM MUTUAL ATJTOM0131LE INSURANCE COMPANY VEIN CLE DAMAGE REPORT { <.. date of lase ..-K `A` :, 08-28-03 719r -,TVIk -JL' Ift -Jk 'Jk -A6- -A.- I Ar 4vtkj -AtIk jktk7*e -Ar -r -At dktkik -Ar -Ar -.�k -Ar tk -ire Estimate Vehicle Info �r Vehicle Owner: WILLIAMS, JAY tAr Vehicle Description: C!1 Ward Pickup F150 4D PkupCrw GREEN/GO � 7*r tk -.k -Ar -*r -A* %k 'Ac tk 40 -+k Ik '1k 'AC -Mr lk- lk 4C -A- -Ar Kik are 30-A- yk 40 Yr - r -or tk tk -.AC -j+k lr Me tk lr -.& -Ar Date: 913/03 01:19 AM Estimate ID: 05-4952-78301 Estimate Version. 1 Supplement: 1(P) 9/19/03 06:02:37 AM FINAL Profile ID: STATE FARM SYMMONS BODY & FENDER INC. 509 SAN RAMON VALLEY BLVD. DANVILLE, CA 94526 (925) 820-3317 Fax. (925) 820.8897 Tax ID. 94-2536583 BAR#: AE070127-053102 EPA #:77-0294 Damage Assessed By: CINDY SYMMONS Supplemented By: VINCE PITA Type of Loss: Collision Date of Loss: 8/28/03 Deductible: WAIVED File Number: FINAL Claim Number: 05-41152-78301 Insured: JAY WILLIAMS Address: 17 PETAR PL. SAN RAMON, CA 94583 Telephone: Work Phone: (925) 829-9040 Home Phone: (925) 828-9696 Mitchell service: 912623 Description: 2001 Ford Pickup F150 Lariat Vehicle Production Date: 11/00 Body Style: 40 PkupCrw Drive Train: 5.41. In} 8 Cyl4WD VIN: 1FTRWOBL91KF82142 Mileage: 57,491 OEM/ALT: 0 Search Code: 8316836 Color: GREEN/GOLD Options: Air Conditioning, Power Steering, Power Brakes, Power Windows, Power Door Locks, Power Seats, Tilt Steering Wheel, Cruise Control, Electric Defogger, AM-FM Stereo Cassette, Automatic Transmission, Deep Tinted Glass, AM-FM Stereo/CDPLayer(Single), Fog Lights, 4-Door, Oriver-Front Air Bag, Driver-Side Air Beg. ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROM£D, RECORED, REMANUFACTUREED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 203024 8DY OVERHAUL FRT BUMPER ASSY 1.7 2 203025 8DY REMOVE/REPLACE FRT BUMPER FACE BAR XL3Z 17757 AA 310.00 IRC 3 REMAN BUMPER N/A 4 203510 SOY REMOVE/REPLACE FRT BUMPER VALANCE PANEL XL32176268A 172.53 INC # 5 203511 BOY REMOVE/REPLACE FRT BUMPER PAD XL3Z 17K833 SAQ 121-27 INC S1 6 203054 BOY REMOVE/REPLACE R FRT BUMPER FILLER TO BUMPER XL32 17AS61 AA 11.32 INC 7 203056 BOY REMOVE/REPLACE R FRT BUMPER BRACKET XL3Z 17752;AA 11.95 INC 8 203058 BOY REMOVE/REPLACE R FRT BUMPER PLATE XL3Z 178984 AA 12.32 INC ESTIMATE RECALL NUMBER: 9/2/03 08:49:32 05-4952-78301 UltraMate is a Trademark of Mitchell International Mitchell Data Version: SEP-03 A Copyright (C) 1994 - 2002 Mitchell International Page 1 of 5 UttraMate Version: 4.8.012 ALL Rights Reserved Date: 9/3103 01:19 AM Estimate ID: 05µ4952-78301 Estimate Version: 1 Supplement: 1{P) 9/19/03 06:02:37 AM FINAL Profile ID: STATE FARM 9 203060 BOY REMOVE/REPLACE R FRT BUMPER STUD PLATE F65Z 170886 AA 11.36 INC 10 203064 8DY REMOVE/REPLACE R FRT BUMPER TOW HOOK F85Z 17008 CA 42.82 0.2 # S1 11 203523 BOY REMOVE/REPLACE GRILLE 3L3ZB2008A 287.28 * INC # $1 12 201315 BOY REMOVE/REPLACE GRILLE OPENING REINFORCEMENT F85Z IIA284 8A 142.80 0.5 # 13 AUTO BOY CHECK/ADJUST HEADLAMPS 0.4 14 205062 BOY REMOVE/REPLACE R H/LAMP ASSEMBLY 3L3Z 13008 CA 160.00 INC # 15 204.308 BOY REMOVE/REPLACE R PARK/SIGNAL LAMP ASSEMBLY F75Z 13200 AG 47.05 INC # 16 203558 BOY REMOVE/REPLACE R FOG LAMP LENS & HOUSING 1L3Z152OOAA. 130.33 INC # 17 200064 BDY REMOVE/REPLACE NOW PANEL F65Z 16612 AL 372.87 1.1 18 AUTO REF REFINISH KOM OUTSIDE C 3.0 19 AUTO REF REFINISH HOCM UNDERSIDE C 1.5 20 204310 BOY REMOVE/REPLACE KOM DEFLECTOR 1L3Z16C90OAA 62.84 0.2 S1 21 200075 REF REFINISH RADIATOR SUPPORT 0.5 w. 22 SPOT RT SIDE S1 23 200082 ROY REPAIR COOLING RADIATOR SUPPORT Existing 2.0 *# 24 201228 80Y REMOVE/REPLACE R INSTALL FENDER STRIPE 0.2 25 201229 BDY REMOVE/REPLACE L INSTALL FENDER STRIPE 0.2 26 201230 BDY REMOVEMPLACE R INSTALL FRONT DOOR STRIPE 0.3 S1 27 203069 BDY REMOVE/REPLACE R UPR STRIPE TAPE SET YL3Z1620001CAG 79.88 * S1 28 203070 BDY REMOVE/REPLACE L UPR STRIPE TAPE SET YL3Z1620000CAG 88.03 * 29 201234 BOY REMOVE/REPLACE R INSTALL FENDER STRIPE 0.1 30 201235 BOY REMOVE/REPLACE L INSTALL FENDER STRIPE 0.1 31 201236 BDY REMOVE/REPLACE R INSTALL FRONT DOOR STRIPE 0.2 32 900500 BDY* ADD'L LABOR OP PAINT OVERSPRAY COVER New 5.00 * 0.0` * 33 900500 BDY* ADD'L LABOR OP FLEX / ADHESION PROMOTER New 4.00 * 0.0 S1 34 203073 8DY REMOVE/REPLACE L LWR STRIPE TAPE SET YLW 6200010AE 59.82 35 200157 REF BLEND L FENDER OUTSIDE C 0.9 S1 36 200160 REF REFINISH R INNER PANEL 0.3 37 SPOT PAINT S1 38 200166 8DY REMOVE/REPLACE R FENDER PANEL 21.32 16005 AA 30D.30 * 2.9 # 39 AUTO REF REFINISH R FENDER OUTSIDE C 1.8 40 AUTO REF REFINISH R FENDER EDGE C 0.5 S1 41 202141 8DY REPAIR R INR FENDER REINFORCEMENT Existing 2.0 *# S1 42 200647 BDY REMOVE/REPLACE R FENDER ADHESIVE NAMEPLATE F85Z 16720 CA 19.23 * 0.1 S1 43 200648 BDY REMOVE/REPLACE L FENDER ADHESIVE NAMEPLATE F85Z 16720 CA 19.23 * 0.2 91 44 200663 BDY REMOVE/REPLACE R FENDER WHEEL OPENING MLDG 20Z16038BAPTM 27.55 * 0.3 45 AUTO REF REFINISH R FENDER WHEEL OPENING MLDG C 1.0 S1 46 200704 FRM REPAIR FRAME AS$EMBLY -F Existing 4.0 S1 47 202785 GLS REMOVE/REPLACE W/SHIELD GLASS Sublet 313.07 * INC *# S1 48 900500 BDY* ADO'L LABOR OP SERVICE FEE FOR SUBLET Sublet 54.07 * 0.0 S1 49 900500 BOS* ACCESS/INSPECT DATE IN 9/2/03 Existing 0.0 50 DATE COMPLETED 9/18/03 51 AUTHORIZATION RECEIVED 52 FINAL ESTIMATED 51 53 205537 BOY REMOVE/INSTALL R RUNNING BOARD ASSY 0.6 S1 54 205538 BOY REMOVE/INSTALL L RUNNING BOARD ASSY 0.6 55 202502 BOY REPAIR R FRT DOOR REPAIR PANEL Existing 0.5 *# 56 AUTO REF REFINISH R FRT DOOR OUTSIDE C 2.6 57 201724 REF REFINISH R FRT MIRROR COVER C 0.4 58 205037 BDY REMOVE/INSTALL R FRT OTR BELT MLDG 0.3 59 201955 BOY REMOVE/INSTALL R FRF DOOR. POWER MIRROR 0.7 # ESTIMATE RECALL NUMBER: 9/2/03 08:49:32 05-4952-78301 UltraMate is a Trademark of Mitchell International Mitchell Data Version: SEP 03_A Copyright (C) 1994 - 2002 Mitchell International Page 2 of 5 UltraMate Version: 4.8.012 All Rights Reserved Date: 9/3/03 01:19 AM Estimate ID: 05-4952-78301 Estimate Version: 1 Supplement: UP) 9/19/03 06:02.37 AM FINAL Profile I0: STATE FARM S1 60 204032 BOY REMOVE/REPLACE R FRT DOOR ADHESIVE MOULDING YL3Z162087aAAN 50.62 * 0.2 S1 61 204+823 BOY REMOVE/REPLACE R FRT DOOR REAR GARNISH MLOG 10Z 7820982 AA 51.65 0.2 62 200809 BOY REMOVE/INSTALL R FRT DOOR TRIM PANEL INC 63 201274 BOY REMOVE/INSTALL R FRT OTR DOOR HANDLE 0.2 # S1 64 200872 GLS REMOVE/REPLACE R FRT DOOR MOVEABLE GLASS Sublet 227.69 * 1.0 * 65 200874 8DY REMOVE/INSTALL R FRT DOOR GLASS RUN Existing 0.4 *# 66 936012 ADDIL COST HAZARDOUS WASTE DISPOSAL 2.00 * 67 AUTO REF ADO'L OPR TWO TONE 1•g 68 AUTO REF ADDIL OPR CLEAR COAT 3.3 69 933003 BOY* ADDIL OPR TINT COLOR 0.5 70 933005 BOY ADDIL OPR RESTORE CORROSIO14 PROTECTION 2.00 * 0.1 S1 71 933006 FRN AOD'L CPR FRAME/RACK SET UP 1.5 72 933017 BDY$ ADDIL OPR COLOR SAND & BUFF 2.5 " sl 73 933030 FRM ADDIL CPR PULL FOR SHAY 3.0 74 RT FRAME RAIL S1 75 933036 FRM ADDIL OPR SHEETMETAL PULL 1.0 76 RAD SUPP 77 AUTO ADDIL COST PAINT/MATERIALS 492.80 * - Judgement Item # - Labor Note Applies C Included in Two Tone / Clear Coat Cale ESTIMATE RECALL NUMBER: 9/2/03 08:49:32. 05-4952-78301 UitraMate is a Trademark of Mitchell International MitcheLL Data Version: SEP-03 A Copyright (C) 1994 - 2002 Mitchell International Page 3 of 5 UltraMate Version: 4.8.012 ALL Rights Reserved Date: 413103 01.19 AM Estimate ID: 05-4952-78301 Estimate Version: I Supplement: 1(P) 9119103 06:02.37 AM FINAL Profile 11): STATE FARM Add{t Labor Sublet 1. Labor Subtotals Units Rate Amount Amount Totals 11. Part Replacement Summary Amount Body 19.5 b3.00 2.00 54.07 1,284.57 Taxable Parts 2,602.05 Refinish 17.6 63.00 0.00 0.00 1,108.80 Sales Tax 8 8.250% 214.67 Glass 1.0 63.00 0.00 0.00 63.00 Frame 9.5 63.00 0.00 0.00 598.50 Non-Taxable Parts 540.76 Non-Taxable Labor 3,054.87 Total Replacement Parts Amount 3,357.48 Labor summary 47.6 3,054.87 111. Additional Casts Amount IV. Adjustments Amount Taxable Costs 494.80 Insurance Deductible WAIVED Sates Tax a@ 8.250% 40.82 Customer Responsibility 0.00 Total Additional Casts 535.62 I. Total Labor: 3,054.87 11. Total Replacement Parts: 3,357.48 III. Total Additional Costs: 535.62 Gross Total: 6,947.97 IV, Total Adjustments 0.00 Net Total: 6,947.97 Less Original Net Total: 4,150.32 Net Supplement Amount: 2,797.65 51: VINCE PITA 2,797.65 Point(s) of Impact 1 RIGHT FRONT CORNER (P) } Insurance Co: STATE FARM Inspection site: SYMMONS BODY B. FENDER, INC Body Shop. SYMMONS BODY FENDER Address: 509 SAN RAMON VALLEY BLVD DANVILLE, CA 94526-4011 Telephone: ((92) 5) -820- ESTIMATE RECALL NUMBER: 117103 08:44:32 05-4952-78301 UltraMate is a Trademark of Mitchell International Mitchell Data Version: SEP-03-A Copyright (C) 1944 - 2002 Mitchell Internationat Page 4 of 5 UttraMate Version: 4.8.012 Ait Rights Reserved Date: 9(3103 01:19 AM Estimate ID: 05-4952-78301 Estimate Version: 1 Supplement: 1(P) 9119103 06:02:37 AM FINAL Profile ID: STATE. FARM I herey authorize Symmons Body & Fender Inc. to make the above repairs. Body Shop will not be responsible for loss or damage to vehicle or articles left in vehicle in case of Fire, Theft or Accident. X COPY OF ESTIMATE TO OWNER Cycle Time Information Start Date: 9/2/03 Completion Date: 9/18/03 WARNING: Accidental air beg deployment is possible. Personal injury may result. Avoid area near steering wheel and instrument panel even if air bags have deployed. Dual-stage air bag modules may be present that could contain an undeployed stage. When disposing of a deployed dual-stage air bag, always treat it as a "live" module. See appropriate MITCHELL(R) AIR BAG SERVICE & REPAIR MANUAL, or OEM information. ESTIMATE RECALL NUMBER: 9/2103 08:49:32 05-4952-78301 UttraMate is a Trademark of Mitchell International Mitchell Data Version: SEP_03_A Copyright (C) 1994 - 2002 Mitchell International Page 5 of 5 UltraMate Version: 4.8.012 ALL Rights Reserved _. ......... ......... 1.11.1 ..... ........... ......... ......... ......... .._...... ......... .. ......... ......... ......... ...... _.. . ................................................................................... $TAT* FARM Stave Farm Insurance Companies db INSURANCE a Claim Central Subrogation 6400 State Farm Drive September 24 , 2003 P.O. Box 6403 Rohnert Park, CA 94927-6403 Penny Bailey Contra Costa County Risk Management 2530 Arnold Dr Ste 140 Martinez, CA 94553 RE: Claim Number: 05-4952-783 Date of Loss: August 28, 2003 Our Insured: Jay B Williams Dear Ms. Bailey: State Farm Mutual Automobile Insurance Company, on behalf of Subrogee, Jay B Williams hereby makes a claim for $7',779. 19 and makes the following statements in support of claim: ' 1 . Notices concerning this claim should be sent to: State Farm Insurance Companies PO Box 6403 Rohnert Park, CA 94927-6403 2 . The date of the accident occurring on August 28 , 2003 at S Lucille Ln, at 1 :30 PM. 3 . The circumstances giving rise to this claim are as follows : Our insured was driving on S . Lucille and your vehicle backed out of a driveway into the lane of traffic. 4 . The injuries reported consisted of the following': 5 . Our total claim is as follows : Company' s Net Payment $7447 . 97 Insured' s Deductible Int $ Total Property Damage $7779 . 19 �0,0 3 NOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 Contra Costa County Risk Management Page 2 September 24, 2003 NOTICE : This form is to provide notice of our claim for damages in accordance with the statute. If this form is not acceptable for compliance with the statute, please rush the necessary form to my attention for proper filing. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) use the customer information we provide for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. State Farm Mutual Automobile Insurance Company Dated: September 24, 2003 By: Employee Name Employee Title Employee Phone Number Sincerely, Channing Palmer Claim Processor (800) 440-6177 x 7 State Farm Mutual Automobile Insurance Compal CP PS : Two estimates are no longer reauired by the industry. The estimate was reviewed bya State Farm estimator. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRITCTIt1N5 TO CLAIMANT 1 . A. 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 before December 31, 1987, must be presented not later than the 100 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 �9�+e. f-,\r m O'S 5i b r cje e.€od Reserved for Clerk's Filing Stamp F30X L141) 3 3 Against the County of Contra Costar e5-4300-737 ra or District} (Fill in Mame) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sura of SI and in support of this claim represents as follows: 1. When did the damage or injury occur? (civt exacttkta attd Boar) 30 --------.l.---- - ------------------ ---------------- 2. Where did the damage or injury occur' (Include City and County) bf __ ___. _ . __ .__ }-- _ r �__ ct I 3. How did the damage or injury occur? (cave W deta h;use extra paper if requIrei) ---------------------------- -- ----------._-----------------_-___-__, -_--__.__---_--_ t 4. What particular actor omission on the part of county or district officers, servants, or employees caused the f Injury or damage? {{ }} r) tCi D (Over) " 414 ; ---7 5. What are the names of county or district officers,servants,or employees causing the damage or injury? - What damages or injuries do you claim resulted? (Give IIT extant or uoud-or damages claimed. Attach two esdmat"for antadama;a) ---------------:�-..---------_--3------------_--_--_--__-------_-- ----------------- 7. How was the above claimed amount co puted? (Include dice estlmated amount of any prospective Wury or damage.) ©W c .._. -------------------------------- ------ ------------------.1 - ---- S. Names and addresses of witnesses;doctors,and hospitals. P-<. '10 r"'4 rr, t—d 2 by -- -' f i t C.t •. ' 'cz Yt'y'�? ,,i ' ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: ' tt AMOU1�"r . q,ra. -Pr y a-�JD3 /2e»-�Od / rr under- P0),Ly) 50 0 . OC) * � x ,� � ,� x * xx * * * * * * « xx•x * � * �'_ � * * ,� � xx � xx ,► x � xxx * � x ,� x * * � * * * x * * Coy Code Sec. 910.2 provides: "Tile claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney a ( Signature) (Address) r Par, )---7- 6qO3 Telephone No. Telephone No. & YY1 62 * xx * * x * xxxx � xxx * xaxxxxxxr� x * * xx * xxxx * xxxxaxx * max * * ax * xxxx 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 gall for a period of not more than one year,by a fine of not exceeding one thousand dollars ($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(510,000), or by both such Imprisonment and fine. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: DECEMBER ''16,2033 Claim Against the County, or District Governed by ) 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 California Government Codes, _ } notice of the action taken on your claim by the t Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and ' 915.4. Please note all "Warnings". AMOUNT. UNKNOWN ; CLAIMANT: CALVIN MAPF AND LESCHELLE HAMILTON ATTORNEY: STEVEN JAMES CHOI DATE RECEIVED: NOVEMBER 13, 2003 ADDRESS: LAW OFFICE OF STEVEN JAMES CHOI BY DELIVERY TO CLERK ON: NOVEMBER 13, 2003 1999 HARRISON STREET SUITE #2020 NOVEMBER 10, 2003 OA I AND, CA 94612 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE k .Dated: NOVEMBER 13 2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. { ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { ) Other: Dated: r . ' By: Deputy County Counsel III. FROM: Clerk ofthe 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: (vK 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: 1,LAawAt-je Z,_OZ43 JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING(Gov. code sectio 913) Subject�p certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mfil 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 Beard Order and Notice to Claimant, addressed to the claimant as shown above. Dated: r- JOHN SWEETEN, CLERK By Deputy Clerk OAKLAND MAIN OFFICE I 1' 1549 HARRISON STREET,SUITE 2020 PERSONAL INJURY ATTORNEYS OAKLAND,CALIFORNIA 44612 TEL 510.444.HURT FAX 510.444.4432 1 lnfoastevenchol.com November 10, 2003 Clerk of the Board Supervisors Contra Costa County Risk Management 651 Pine Street, 6th Floor - Rm 106 Martinez, CA 94553 Re: Cour Clients): Calvin Mapp and Leschelle Hamilton Your Insured: Contra Costa County / Allen Andrew Ruyters Date of Accident: October 14, 2003 Dear Clerk of the Board Supervisors: Our office represents Calvin Mapp and Leschelle Hamilton with respect to the above injury claim. We are making a claim for monetary damages and legal action may be taken in the event if this matter is not resolved. Please advise in writing if this notice of claim has been sent to the wrong person or is insufficient in any respect. If you and/or your insured is a Public Entity, please construe this letter as a valid notice of claim tolling the statute of limitations, or notify our office in writing within 10 days that it is insufficient or directed to the wrong person, entity or address. Please communicate with the undersigned and acknowledge our representation in writing. Adjuster and Claim Number: Please advise us of the adjuster and claim number of this case. Please forward all documents needing execution. Medical Authorization: We will provide you with full medical bills and records when our client completes treatment. if you still wish to obtain the medical records yourself, please send us authorization within 15 days. Claim Form: Please find enclosed the completed claim form. We have also enclosed a copy for you to return stamped and dated by the Contra Costa County. Our client's signed Authorization pursuant to Section 2695.2 of the California Insurance Code is attached. Thank you for your courtesy and cooperation. Very truly yours, Steve a Steve Ta Law Office of Steven James Choi www.stevenchoi.com f MftorLzadon I. Authorization to pbtAfn Records: The undersigned hereby authorizes the Law Offices of Steven James Choi and the following medical office and/or insurance company: , to inspect and make copies of the following records. police reports; medical records, employment records, which relate to my accident dated: October 14, 2003. This authorization is limited to records that relate to the above referenced accident! A photocopy of this general authorization shall be considered as valid as the original. This general authorization shall expire when all claims arising from the above accident are resolved. Patient's Rights 1. 1 understand I may refuse to sign this authorization. 2, 1 have the right to revoke this authorization at any time. The revocation will be effective immediately, but will not apply to information already disclosed. 3. 1 have the right to receive a copy of this authorization. 4. 1 may inspect or obtain a copy of the health information beingdisclosed. It. Authorization To Handle Insurance Claim: Pursuant to Section 2695.2 of the California Insurance Code, I hereby authorize the Law Office of Steven James Choi to handle my insurance claim arising out of the accident dated: October 14, 2003. This authorization is valid for one year from the date set forth below unless otherwise revoked or renewed in writing by the undersigned. All prior authorizations are hereby revoked. A photocopy of this authorization shall be construed as effective and valid as the original. Bated: / Z,�2 aloin l+�app Authorization 1. Authorization to Obtain Records: The undersigned hereby authorizes the Law Offices of Steven James Choi and the following medical office and/or insurance company: to inspect and make copies of the following records. police reports, medical records, employment records, which relate to my accident dated: October 14J. 2003. This authorization is limited to records that relate to the above-referenced accident! A photocopy of this general authorization shall be considered as valid as the original. This general authorization shall expire when all claims arising from the above accident are resolved. Patient's Rights 1. 1 understand 1 may refuse to sign this authorization. 2. 1 have the right to revoke this authorization at any time. The revocation will be effective immediately, but will not apply to information already disclosed. 3. 1 have the right to receive a copy of this authorization. 4. 1 may inspect or obtain a copy of the health information being disclosed. 11. Authorization To Handle Insurance Claim. Pursuant to Section 2695.2 of the California Insurance Code, I hereby authorize the Law Office of Steven James Choi to handle my insurance claim arising out of the accident dated: October 14, 2003. This authorization is valid for one year from the date set forth below unless otherwise revoked or renewed in writing by the undersigned. All prior authorizations are hereby revoked. A photocopy of this authorization shall be construed as effective and vol` the original. Dated: Leschetle Hamilton Claim to. BOARD OF SUPERVISORS OF CON'T'RA COSTA COUNTY A. Claims relating to causes of action for death or for Inajury to person or to personal property or growing craps and which accrue on or befare December 31, 1987, mad be presented not later than the 100* day after the accrual of the cause of action. Claps relating to causes of action for death or for injury to person or to personal property or growing craps and which accrue on or after January 1, 1988,must be presented not latter than six months after the accrual of the cause of action. Claims relating to any outer cause of action must be presented not later than one year after the accrual of the cause of actlom (Govt. Code§911.2.) B. Claims must be tiled with the Clerk of the Board of Supervisors at its office in Roam 106, County Administration Building,681 Pine Street,Martinez,CA 94553.1 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. 9 the claim is against more than one public entity,separate claims must be filed against each public entity. E. I+'raud. See penalty for fraudulent claims, Penal Code Sex.72 at the end of this form. RE: Claim.by ) Reserved for Clerk's piling Stamp Calvin Mapp and ) I Leschelle Hamilton } N0V I `�i 2003 Against the County of Contra Costa IK 800D 0F or District) (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of unknown and in support of this claim represents as follows: at this time 1. When did the damage or injury occur.? (Give exact flute and Hour) October 14, 2003 .at.. 8:35 AM ----------------------------------------------------------------------- - -_---------- 2. Where did the damage or injury occur" (inaude City and county) S/B I-680 -- Pleasant Hill, CA ---- -------------------------------------------------------------------------------- 3. How did the damage or injury occur? (Give Nn detaor,use extra paper ifrequired) Claimants were stepped in traffic for one minute. Defendant rearended claimants and pushed claimant ' s vehicle .into another vehicle. .No damage on 3rd vehicle so he left the scene. 4. What particular acct or omission on the part of county or district officers, servants, or employees caused the injury or damage? County employee/driver (Allan Andrew Ruyters) caused injury and damage by traveling at an unsafe speed for prevailing conditions (stopped traffic ahead) . See enclosed police report. (Over) S. What are the nam of county or district officers,servants,or employees causing the damage or irsjM? Allan Andrew -- --- ............................................................... a What damages or injuries do you claim resulted? (Gam to atew of inimies or dwwqu ds ma & An*&two ove naus 1w "=Xse-) All medical bills for injuries .sustained in auto accident. Calvin Mapp - soft tissue: neck, back, both leg's, dizziness Leschelle Hamilton - soft tissue: neck, back, both arms, eyes Both claimants: property damage, wage loss, and pain & suffering 7. How was the above claimed amount computed? (hidud+e the estlmated rmownt of any prosp&dtye b4ury or day o.) Will provide medical bills once treatment is completed. ..........i---------------------------------------------------------------- ---------- S. __.___ .8. Names and addresses of witnesses,doctors,and hospitals. Kaiser Permanente: 280 W. MacArthur Blvd. , Oakkcind`'- CA 94611 Luu Chiropractic: 2920 Sonoma Blvd. , Ste. C, Vallejo, CA 94590 ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: VAU rMM AMOU To Be Determined. 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 Steven James Choi Law Office of Steven James Choi (Claimants ` Legal Representative) 1999 Harrison Street Suite #2020 11999 .arrison Sts; ate, x#2020 Oakland, CA 94612 (Address) Oakland, CA 94612 Telephone No. 510-444-4878 Telephone No. 510-444-4878 �c ,� � � * * gas * * �e * ,� � � ,� * � ,� �r * * � * �r � * * � * � rr � * * ,x * � ,� * �r � � * � �re � xr * � �•* � NOTICE Section 72 of the Penal Code provides: "Every person who,with intent to defraud,presents for allowance or for payment to any state boaird 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 claims,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 tine of not exceeding one thousand dollars($1,000), or by both such imprisonment and fine,or by imprisonment in the state prison,by a firm of not exceeding ten thousand dollars($20,000), or by both such imprisonment and fine. i E TZ «, �! # w� .� ''• � �R"� MI6 ''e�M + ISS.• �r i ISI y ` " ■ s. �� sr � s I r jR MAT #�� �� ". *+ IMS �t . ` Fall r a • ... a 3 + 11.34 l _ { IR»�..i����+1111._ � ' a � _ * ..; a.J ■ r�ti� tl� �I� --------------- jar i. . STATE OF C400MA TRAFFIC COLLISION CODING � CLAP 655 a 8Lf 042 - Pw•za Gwm or Cwt ofa DAY yam limp" f 1 UPFI 110. Fl{IM!!pt 0 A, VT 1 0%35 J t�3zo PROPERTY --,Tm NO DAMAGE DESCAWTIMOFQ#M"Z SEATING POSITION SAFETY EQUIPMENT EJECTED FROM VE141CLE A8R ffi L-AIR W4 DEPLOYED MI C BiGYCt b fts'mil1 A=�W�XPRULE M-AR SAG NOT DEPLOYED 0-NOT EJECTED B-UNKNOVW N-OTHER DRIVER 1-FULLY EJECTED C-LAP BELT USED P-NOT REQUIRED V-NO 2-PARTIALLY EJECTED D-LAP BELT NOT USED W-YES 3-UNKNOWN 1 2 3 1`DRIVER E-SHOULDER HARNESS USED 13 2 TO B-PASSENGERS F-SHOULDER HARNESS NOT USED CHILDRESTRAINT PASSENGER 3-STATION WAGON REAR G-LAPMOULDER HHARAESS USED YF-ISL mD X-NO B-REAR OCG.TRK.OR VAN H-LAPXHOULM HARNESS NOT USED R-Ii VEHICLE NOT USED Y-YES 7 9-POSITION UNKNOWN J-PASSIVE RESTRAINT OSED S-IN VEHICLE USE UNMOWN 0-OTHER K-PASSIVE RESTRAINT NOT USED T-INVEHICLE USE U-NONE IN VEHICLE ITEMS MAPJ(ED BELOW FOLLOWED BY AN SHOULD BE EXPLAINED IN T14E NARILATIVE. PROAARY COLIJ*100 FACTOR TRAFFIC COMM D AfN'ES � Z 3 TYPE OF VEHICLE MOVEMENT PRMODING UST MM OF P ATPAUL f Z $ tL vc secs*m%Aur ctm A +� �.� yEa A CONTROLS FUHCTIINIHK3 A PASSENGER CAR t STATION WAGON STOPPED__ S.'ss / 8 CONTROLS NOT R*=IONING• B PASSENGER CAR VVI TRAILER $ mmmimNm OTHER IMPROPER DRIVING^. C CONTROLS OBSCURED C MOTORCYCLE 1 SCOOTER C RAN OFF ROAD NO CO#ITROLS P M14T I FACTCYR` 13 PICKUP OR P TRUCK [} C OTHER THAN DRIVI R' TYLE O€ E PICKUP I PANEL TRUCKYW`TRAILER 1 MAKING LEFT TURN UNKNOWN` AHEAD-ON F TRUCK OR TRUCK TRACTOR IF MAKIHG 1)iLm— E FELL ASLEEP• L3 SIDE SNAPS IG TRUCK I TRUCK TRACTOR WI TRLR. 0 BAC040 C REAR END Im SCHOOL BUS Hf SLOVA41 STOPPING WEATHER i TO I IY BROADSIDE L OTHER BUS I PASSING OTHER VEHICLE CLEAR E HIT OBJECT EHdERQEIiGY VEHICLE J CHIANG LANES B CLOUDY F OVERTURNED K HIGHWAY CONST.EQUIPMENT IK P R C RAINING G VEHICLE i PEDESTRIAN L BICYCLE L KWTERING TRAFFIC D SNOWING H 0THEE` M OTHER VEHICLE M OTHER UNSAFE TURNING FOG I VISIBILITY FT. N PEDESTRIAN N XING wTO OPPOSMLG LANE F OTHER`. MOTOR VENLCLE INVOLVED WITH 1 10 MOPED O PARKED A NON-COLLISION P MERGNG LIG 147 NO 0 P DESTFLIAN 0 TRAVELLING;NRONGWAY A DAYLIGHT C OTHER MOTOR VEHICLE 1 OTHER ASSOCIATED€ACTOR(B) R OTHER DUSK-DAWN Q MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2ITEMS) C DARK-STREET LIGHTS E PARKED MOTOR VEHICLE A vo°rcM*voo"7m YF8 DARK»NO STREET LIGHTS F TRAIN E DARK-STREET LIGHTS NOT BICYCLE o steno"11°C""0* FUNCTIONING* 1i ANMAAt: IVCs -DRUG ROADWAY SURFACEC vc*ECIM MUT " 'L Z 3 �aRIETY PHYSICALL DRY H Fvmv OBJECT: � {AMRK 1 TO 2ITE MS} is WET A HAD NOT BEEN ORIIOw Ic SNOWY-ICY J OTHER OBJECT: E VISION OBSCUREMENT: S HOD-UNDER INFE UEHCE SLIPPERY JWWY,2LY,ETC.) F 94ATTENTIOW: C HBD-NOT UNDER INFLUENCE` ROADWAY CONDITHOWS) 10 STOP LL GO TRAFFIC D HILI-IWAIRMENT UNK6 OWW (MARK f TO 2ITEMS) MED-9-fam -H-ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE* HOLE DEEP RUT' A NO PEDESTRLIWS INVOLVED I PREVIOUS CGR.LIBKNN F IMPAIi:HAENT-PHYSICAL` LOOSE MATERIAL ON ROADWAY` 8 CROSSING IN CROSSWALK J UNFAMU#*WITH ROAD 10-IMPAIRMENT NOT K NOM C OBSTRUCT"ON ROADWAY* AT INTERSECTION LK DEFECTIVE VER.EOUIP.: CITED H NOT APPLICABLE CONSTRUCTION-REPAIR ZONE C CROSSINGIN CROSSWALK-NOTy PY I FATIGAIED I.REDUCEL.1 ROADWAY WIDTH AT INTERSECTION HMO PEC}AL#'FORMI mm F FLOODED* D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOGS MATERIA. OTHER*. IN ROAD-INCLUDES SHOULDEROTHER': vure H NO UNUSUAL CONDITIONS IF NOT IN ROAD N NONE APPARENT 1 10 APP/ROACHING/LEAVING SCHOOL BUB RUNAVM4Y VEHICLE SKETCH sit -z-g MISCELLANEOUS t 1 1 t W t Soup WHIl7t LAW --'�-� CRlA I , I I ' —:....19'C CNr CLsrIrR I ZI } PD/sO 51%0,w ww kAa 'r.w...wc# : OTHER HER ' i OSP N 1300 P P ll�l IT ►I1 fill .� .no • +.�c rt !. gain ONI t . , sOilk �SSMIF,777; mk�Wwfw;,;, . ,EBA update 0 Fatal W and run update �� IMAM M • s • i 2AWA Yet ■ R if•�r..s .R a• oe:"r+ a �,I+11Ma/J" t ,1. 'AM11�r...� f..� . s+ �.ar l�s'A' r :�f►.. .A+ae ati.�1Ir,, 1".. tt►f.�-�i?d ,wi 1 seg. * a :1► aI p _ _ WA; p... i# Fils. L..✓A/a. FRIG-�A►.'.,�" .�, s3'w '� j �� r" IV /ri�.;a�. ,r�� a.. .e'>��.�.� ,,.. �a.. .t 31 '"s t► fti7Z FM RAPT t �;, .ii' F it. a ti+ t i .J.►, :s r} A,Ti 1,lWA; ri IFLUZ y.A f# .��is�r.� F 1 ,st. "t >5.. : ,y ,� �` a! i� :a� r.a•. x'.11'.. � ai,:�, .�_ �., �'�$ a+►aa .#- 1'�i� ,fr[` r lit�,.�i►_ i�� ,i{,._1 � r �' ►r �t�.ri� +►wr!a " "/.,a74«�f !1 �,t# � AW a+•-_ 4 A�1 ., . ::• 1e :� ?,r1�iN i# }.�► ��114.� ir1 tJ,�+ il•:4 7�!,�e` s. ;il:r.:��-�;� xr� t�l:.al�l.r k. _ f� .�:' a..��..i� _�r1 �_*,,�+��I,irt ��.��,.� 1.� ak. ;#; #'�' _ Al/.t '...a,1#,1� ?'': "" .AxRi♦ .. R/` .P�aF <!! '�; _7,If V r;._r t #� X S 1 u Ya099� _�.w'igivb:X 5Y"�L. Y ,�y Y :N M.: b Pi • Ati - ..fit , x - P A°•� �i• 6� �ft4 M-R .4 �i s! y1�.,vA 418 9`�^ � "✓ #,4 '".. =71 `! r 77 ri it G 0 x ,a r- m c > 3 lt > A d o (1 "s 'O m � m N M M w �wrrrrr� ru ru Er M C C3 rrrrrw+ MfMU1M �►. w r ®rwr�r ru w C3 1 llz:z, M zr K o sf- n S s..p s> :3 s c5 y+a: f r » ri 'Us POSTAGE-' CLAIM B ARD Qf SUPER3LI ORS OF CONTRA COSTA CQUNTY BOARD ACTION:DECEMBER I � 200; Claim Against the County, or District Governed by } the Beard 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 California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), gives Pursuant to Government Code Section 913 and 915.4. Please note all"'Warnings". i y- 4 Y AMOUNT. $430.18 CLAIMANT. ALAN CONE ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 10, 2003 ADDRESS: 193 CRAWFORD 'DRIVE BY DELIVERY TO CLERK.ON: NOVEMBER 17, 2003 BRENTWOOD, CA 94513 BY MAIL POSTMARKED: NOVEMBER 07, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 17, 2003 JOHN SWEETEN I Dated: - By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors R This claim complies substantially with Sections 910 and 9110.2. ( } This Claim FAILS to comply substantially with Sections 914 and 910.2, and we are so notifying claimant. The Board cannot act for IS days(Section 910.8). { } Claim is not timely filed. The Clerk should return claim on ground that it was filedlate and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). { } Other: ( } By- ( "` Deputy County Counse Dated: III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV./BOARD ORDER: By unanimous vote of the Supervisors present: { This Claim is rejected in full. { ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this Mate. DatedAMS& JOHN SWEETEN,CLERK.,By , Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions, you have only six(6)months from the date this ndtice 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: !' JOHN SWEETEN, CLERK By Deputy Clerk _ _ __ Claim to: BOARD OF SUPERVISORS OF CMITRA META CO N'I'Y INSTRUCTIONS TO CLAII]gAN T' 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 groaning crops and arhich 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 lei, Canty Administration, St�t.ytine , . C. If claim is against a district governed by the Board of Supervisors, rather than the County, the time 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 RECEIVED } } NOV 10 2003 Against the County of-Contra, Costa ) cOaERVISor oo aRs �Eaari0saCONTrRg C ca, District) (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 th;G_ t 1IaiM represents -as foLows! 1. When olid the damage or injury occur? (Give exact date and hour) 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) " �� ry �� .. { ..:r t s ;x z /%:' Y y "Mj�>� �3j' 'Z /f�1 ,.�d �k � /r�yY"f `' � //���/^i'`?/' ,Wt".F" 7��N .u:.'t/:..•�d�- _;y'`...' /��'r�,l"�.c''x'U� r'r ���f$ I .. r. 4. What particular act or omission on the part of county or district officers, servants or .employees caused. the.injury or damage? . >• � "'�''� ��,�.�� '� .,� Gam' �-- ............................11 .......................................................... ......................................................................................I.I.,.................I'll...................... ...................... ........................................................................................... j. wnat are the names of county or district officers, servants or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or : damages claimed. Attach two estimates for auto damage. ? (Include the estimated amount of any 7. How was the amount claimed above computed prospeetive --injurT.1cril ................................ -—------- --- B. 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. '9104-2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorneyy-. or by some-pjMlin on his.-behalf." Name and Address of Attorney (Claimant's S 7 Qgnatu�re (Address5 ,2 Telephone No. Telephone No. Ir-W 1 9 79 -9 9 T 7-2 it W W W W N 0 T I C E Section 72 of the Penal Code provides: 3 "Every person who,, with intent to defraud, presents for al payment to any state board or officer, or to any countyp city oftrPMArTlor officer, authorized to allow or pay the same if .genuine, any false or fraudulent claim, bill, account, vouchert or writing, is punishable either by imprisoriment in the county jailfora period of not more than one-year, by a fine of not exceeding one thousand ($19000), or by both such imprisonment and fine-,,-,or by imprisOment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000t or by both such imprisonment and fine. ................................... ........... ........................................ !1► r Off # f erzxaralufachired �4 �.i''crxcC�� # 1 � • d 1 SOLD [ CONE, ALLEN PHONE9 (92!5) 516-7731 INV# 131309 f A« NADO OOOOCC M16 50 CP 00 - # # « # 4 017 09/09/03 x 3 t 022, 12154- s # RIN PART it +•?�+�,�'� �''xiK�, �e�.y'�� f A�= 0 O` , STER CARD VER A Expokss SUBTOTAL 238-92, TAX 19.71� # a 'c • $rte w dad t # INVOICE TOTAL 258.63" ! k 4TE !M BUSINESS PAIGE bVb�l YOM ORDER WAS FILLED BY TOM HICKEY ! # R # # BRENTWOOD OO TIRE COMPANY Dace 9115/12003 Invoice# 3494 7985 BRENTWOOD BLVD. PCS# BRENTWOOD,CA 94513 Bal'# AC216099 Phone (925)516-0700 Fax (925)516-7338 EPA# CAL000260038 Company Home (925)516-7731 Vehicle 01 Ford Taurus Customer ALLEN CONE Cell VIN# Address 193 CRAWFORD DR Work License Tag# BRENTWOOD, CA 94513 Ext Engine Mileage 0 Tracts AUTO Part Number Part Description Qty Item Price FET Gare Ext.Price TIRE-NON-INV P215t60R16 CONTINENTAL TOURING 1 $85.00 $0.00 $0.40 $85.00 VALVE STANDARD VALVE STEM 1 $1.40 $0.00 $0.00 $1.00 TIRE-TAX CALIFORNIA STATE TIRE TAX FEE 1 $1.00 $0.00 $0.00 $1.00 Type ID Labor Description Emp 10 Labor Costs BAL-PA COMPUTER SPIN BALANCE JD $10.00 TIRE'S COME WITH LIFETIME ROTATIONS,BALANCING AND TIRE REPAIRS FOR THE LIFE OF HE TIRE I IUP TO 2t32NDS)RECOMENNED ROTATIONS EVERY 5,000 MI(Tire warranty is void Parts Total $87.00 with out rotation and alignment documentation) Parts and Labor are warranted for 12000 miles or 12 months,whichever comes first.This warranty is Labor Total $10.00 limited to the work mentioned on this form only and is not transferable.Vehicle must be returned to Hazard Waste $0.00 r store,at customers expenses,to honor warranty,warranty Is void in case of misuse andtor neglect. Sublet $0.00 Not responsible for missing hub caps after installation I The Parts and Accessories sold and installed by Brentwood Tire Company and the Service connected Subtotal $97.00 with the installation and adjustments of the Parts and Accessories sold and installed by this Repair Shop,are Guaranteed to be free from defects in material and workmanship under normal service and .10 $7 Tax use until such Parts and Accessories have been driven,used,or operated for a distance of 12000 Work Sales Tax Total $1$7.10 mites or a period of 12 months,from date of Service,whichever first occurs,unless otherwise stated under the Part or service lister!above. Total Payments $104.40 Payment Method VISA Amount Due $0.00 Estimate Revisions $0.00 $0.00 $0.00 $0.00 $0.00 $0.04 Signature- page z of ` ,� The Trod Shed Tire Pres 50 Bliss Ave. 1;'�'Customer CODY�� Pittsburg,CA 94565 Phone:925.432.3422 Fax:925.432.3778 Invoice #114322 BAR#AG 118987 EPA#CAL 00037111 Thursday,October 23,2003 Alan Cane 2409 Aldefwood Dr Printed at 1:07:06 PM on Antioch CA 94509 Thursday,October 23,2003 Workorder#138437 01 FORD TAURUS 28933 4SCD622 925-753-1898 2 4 Cash CATALOG_._ DESCRIPTION QT PARTS_ LABOR Co-deDISC FET T0TAL - ZZBRI 26 POINT BRAKE INSPECTION 1 .00 $0.00 10 NO NOISES,THINKS ITS TIME. PRB REAR BRAKE SERVICE PACKAGE 1 .00 $0.00 ZZBRRA BRAKE LABOR REAR AUTO DRM 1 94.25 443 $84.82 10 ZZBRTD RESURFACE BRAKE DRUMS 2 12.50 -2:50 $22.50 10 DF1 HAZ MATERIAL.DISPOSAL FEE 1 2.75 -.28 $2.47 10 CLEAN BRAKLEEN-ENVIRON SAFE 1 3.00 -.30 $2.70 DOTS DOT 3&DOT 4 BRAKE FLUID 1 4.95 -.50 $4.45 59+9X RELINED BRAKE SHOES 599X 1 49.95 -5.00 $44.95 ZZAL4W FOUR yVNE LALJdNM '#`fPA§§4N0ER) 1 74.95 -7.50 $6T,45! 11 PALW 1 WARRANTY:90 DAYS OR 4,000 MILES 1 .00 $0.00' IF NEEDS ALIGN,PLEASE DO...NIT A BIG POTHOLE,WANTS TO MAKE SURE ALL IS OK. Alan Cone(330-2251 cell)OK`d an addl $260.00 with Gary N.Scott on 10/23/2003, 8:45 AM NRO ROTATE OFTENI ITS FREE/ 1 .00 $0.00 Visa Us at Our Web Site www.tmdshed.com .corn VISA MIC$234.12 Parts $57.90 Taxable $57.90 Labor $196.95 Non-Taxable $196.95 Freight $0.00 Tax $4.78 Other $0.00 Discount ($25.51) FET $o. f* M $234.12 BATE Parts and labor warranties 100%for 90 days or 4000 mileAWhkhever comes fkst,this warranty limited to the work on this form only.Vehida must be returned to our shop,any Tke Pme or American Carfare Centers,at customers expense,to honor warranty.I herby authorize the repair work to be done Wong wide the necessary materials.You and your errrployeos may operate vewie for purpoass of testing,inspection ordeth*ry at my risk.An express Machainc's tion is aad=wfedgad on vehidee to secure the amourd of mpaks thereto.You wig not be trek}ftsponolbta for We or damage to vehicle or arficW fa#in vehicla in case of tire,thait,accident or any other cause beyond your control.Because of the extent of the teardown and inspection,the vehicle may not perform as well as before, Page 1 of 1 ... � � � � � 2 ■ . _ } + Soo . .f , \ - � y J � � 2a \ 6 m ® \ 2 / t ¥ $ : /k E � (m « fk Mf 0 ! : »< § EQ LO » 2 / a . : 7 3 ƒ cm : CLAIM BOARD OF SUPEMSOI&S OF CONTRA COSTA COUNTY BOARD ACTION: DCR lir, 200: Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section referenC" are to } The copy of this document mailed to you is your California Government Codes. notice of the action taken on your claim by the } Board of Supervisors. (Paragraph IV below), givei Pursuant to Government Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: IN EXCESS OF $25 ,000.00 CLAIMANT: THE HARTFORD ATTORNEY: .DAMES C. HAZEN, Esq . DATE RECEIVED: NOV. 17, 2003 ADDRESS: GRAY & PROUTY I NRELIVERY TO CLERK ON: NOV. 17, 2003 2150 RIVER PLAZA DRIVE, SUITE SACRAMENTO, CA 95$33 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE E i k' Dated: NOVEMBER 17,2003 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 914 and 10.2. ( } 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 9117.8). { } Claim is not timely filed. The Clerk should return claim on ground that it was fled late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( } Other: Dated: By: r r Deputy Count Counse III, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IV BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in foil. ( } Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated SIN SWEETEN, CLERK,By , Deputy Clerk WARNING(Gov. code section 913 Subject to certain exceptions, you have only six(6) months from the date this ndtice 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 s' SWEETEN, CLERK By Deputy Clerk _... ... _..... ..... .... . ............................................................. Bill K.Gray Sherry M.Dixon LAW OFFICES OF Other Offices John P.Welch,Inc. Lee E.Herschler James B.James Malcolm 0.Schick GRAY & PROUTY SANTA ANA Melinda Schaffner,Inc. C.Kempton Letts (714) 558-3751 FAX(714)973-4736 Marilee B.Hazen Kelly J. Hamilton A PROFESSIONAL CORPORATION SAN FRANCISCO Stephen M. Berger Roger A.Cartozian (650) 246-1440 FAX(650) 246-1441 Gehring C. Prouty 11947- 19981 2150 RIVER PLAZA DRIVE, SUITE 150 GROVER BEACH John R. Banks, Inc. G.Bruce Sutherland SACRAMENTO, CA 95833-4222 (805) 786-4050 FAX(805) 786-0131 Joseph A. Hernandez Lisa Sarett Marshall RIVERSIDE Christopher Cooley Thomas E.Mullen (916) 649-9961 FAX (916) 649-9965 (909) 276-8750 FAX(909)276-0392 Diane L.Cray David J. Gittelman E-Mail gp005@grayandprouty.com SAN DIEGO-CIVIL Christopher Herritt Alien Van Camp (619)718-9790 FAX(619) 718-9797 Daniel R.Brown Richard A. Lynn SAN DIEGO Terry Wheaton Dawn C.Nelms (619) 521-2660 FAX(619)521-2655 Jennifer A. Haber Amos Galam LOS ANGELES Frank M.Jodzio Joanne Marecek (323) 525-3170 FAX(323)525-3180 David J. Mitchell Julie N. Micheisen FRESNO Diana C.Guzman Kathleen L.Wilson (559)243-4390 FAX(559) 243-4399 Khanh Le Kwan Gary D.Gemberling SANTA BARBARA James D.Gabriel Shruti S.Shah (805) 565-2050 FAX (805) 565-2069 Ian Fyvie Karen 1.Rose REDDING Brandi G. Stelter Janice N.Hunter (530) 246-9061 FAX(530) 246-0781 David J. Demshki Bernie L.Williamson POMONA Lynne A.Pearson (909) 623-9966 FAX(909)623-9936 Jill S.Grathwohl Of Counsel SALINAS Kathe R.Moore James C.Hazen (831) 751-9365 FAX(831) 751-7978 November 13, 2003 CLAIM AGAINST PUBLIC ENTITY j, County of Contra Costa Noll Board of Supervisors c{ y ��Q3 651 Pine Street, Room 106 � �rR Martinez, California 94553 Attention: Office of the Clerk RE: Our Client: The Hartford and Fidelity National Financial Date of Injury: 5/22/43 Our File No.: C30318 Claim No.: YCJ c 01 130 Claimant: The Hartford/Fidelity National Financial Gentlepersons: The fallowing Notice of Claim and injury is given pursuant to the requirements of California Government Code Section 905, et seq. and Section 910, et seq. Pursuant to said statute, the following information is provided: 1 . The name and address of Claimant is: The Hartford Post Office Box 515016 Sacramento, California 95851-5016 _. ......... ........._111.1.. 1111. . ....... .. ......... ........ ........ .............. .......__1111. RE: The Hartford Claim No. YCJ c 01 130 November 13, 2003 CLAIM AGAINST A PUBLIC ENTITY and the Claimant is represented by counsel, whose names and address is: Name of Counsel: Gray & Prouty Name of Attorney: James C. Hazen, Esq. Address: 2150 River Plaza Drive, Suite 150 City/State/Zip: Sacramento, California 95833 2. The accident occurred on May 22, 2003, at or near a driveway entrance at the edge of the street at 1005 Fitzuren Avenue, in the City of Antioch, County of Contra Costa, State of California. The claimant, The Hartford, is a workers' compensation carrier who is required to indemnify employee, Peggy Banke, for injuries she received while acting through the course and scope of employment with Fidelity National Financial. The Hartford was obligated to pay out medical expenses and disability indemnity payments to Peggy Banke as a result of Peggy Banke tripping and falling at the driveway entrance at 1005 Fitzuren Avenue, Antioch. Thus, this is a subrogation claim. 3. The name and address of any particular public employee who may be involved are: Unknown employees and/or personnel that investigated this incident and were present on the date of the incident. 4. Nature and extent of injuries: fracture of left wrist. 5. Property damage: None. 6. Jurisdiction for this claim lies in: Contra Costa County Superior Court. 7. Amount of Claim: In excess of $25,000.00. 8. Expenses or Other Items of Claim: The cost of medical incurred in this matter is unknown at this time. Peggy Banke continues to be treated by Dr. Anthony Schilling at Diablo Orthopedic Specialists, Inc., as well as other medical personnel. On or about May 22, 2003, employee Peggy Banke, was on her way to visit a client at 1005 Fitzuren Avenue, Antioch, California. As Ms. Banke walked toward the driveway entrance to the property, she tripped on a raised ledge of concrete and began to fall forward. She placed her hands out in front of her to break her fall, however in the process of falling, she broke her left wrist. Pursuant to a policy of insurance, claimant, The Hartford, was obligated to pay medical expenses and disability indemnity to Ms. Peggy Banke. RE: The Hartford Claim No. YCJ c 01 130 November 13, 2003 CLAIM AGAINST A PUBLIC ENTITY Liability in this matter resides with the persons and agencies to whom this claim is presented due to their lack of supervision, their failure to follow policies set forth by the County of Contra Costa, failure to follow accepted safety rules and regulations, failure to make reasonable inspections of the premises where the accident occurred, failure to exercise reasonable care for the circumstances, failure to warn others of the dangerous condition on the subject premises identified above, failure to properly maintain the premises, and failure to properly repair the premises. Moreover, the County of Contra Costa, its employees and/or agents, negligently maintained, cleaned, inspected, and failed to warn Ms. Peggy Banke of the dangerous condition. This trip and fall accident was the kind of accident that normally occurs only in the presence of negligence. Furthermore, Ms. Peggy Banke did not, in any manner, contribute to the accident giving rise to this claim against a public entity. As a result of the negligence of the Contra Costa County and its employees and/or agents, Ms. Peggy Banke suffered injuries and damages, on whose behalf The Hartford was obligated to insure and pay benefits. Pursuant to Labor Code Sections 3852 and 3862, The Hartford is therefore subrogated to the rights of Peggy Banke for the injuries and damages incurred herein. We respectfully request that a copy of this Notice be sent to your insurance carrier, or appropriate provider, with the request that the carrier or provider contact us regarding this claim so we may submit substantiating medical records, bills, and other information. Thank you for your cooperation in this matter. Very truly yours, GRAY & PROUTY S �J MES C. HAZEN _ ...............................................................1.111111.111111.............. ..............................-, CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:,DECEMBER 16, 2003 Claim Against the County, or District Governed by ) 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 California Goveniment Codes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Goveniment Code Section 913 and 915.4. Please note all"Warnings". AMOUNT: UNKNOWN A3 CLAIMANT: CITIZENS TO REDUCE TRAFFIC". ATTORNEY: STUART M. SMAN DATE RECEIVED: NOVEMBER 19, 2003 ADDRESS: LAW OFFICES OF STUART M. FLASHMAN BY DELIVERY TO CLERK ON: NOVEMBER 19, 2003 5626 OCEAN VIEW DRIVE OAKLAND, CA 94618-1533 BY MAIL POSTMARKED: FAXED TO US BY LAW OFFICES OF STUART M. FLASBMA_N FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, JOHN SWEETEN C1 NOVEMBER 19, 2003 Dated. By: Deputy_ II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and.%'10.2. 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 Deputy County Course 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: M11 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: a4v%602L/_1_6_,!?Mf JOHN SWEETEN, CLERK, By Deputy Clerk WARNING(Gov. code sec ion 913) Subject to certain exceptions,you have only six (6)months from the date this ndtice was personally served or deposited in the mail to Ale 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 J.' HN SWEETEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL Is'KAL SILVANO B.MARCHESI COUNTY OF CONTRA COSTA .�,'- C3 , COUNTY COUNSEL Administration Building +,° 'a `•" SHARON L. ANDERSON 651 Pine Street,91"Floor Martinez, California 94553-1229 f �/ „ CHIEF ASSISTANT a � (925) 335-1800 ` q GREGORY C. HARVEY � VALERIE. RANCHE (925) 646-1078 (fax) ', '� AssisTAHTs b - NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Stuart M. Flashman, Esq. 5626 Ocean View Drive Oakland, CA 94618-1533 RE: CLAIM OF: CITIZENS TO REDUCE TRAFFIC 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: [ ] L 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. [ ] 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. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Page 1 Stuart M. Flashman, Esq. Re: Claim of Citizens To Reduce Traffic Page Two [X] 7. You are required to submit your claim on the proper form,which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SILVANO B. MARCHESI COUNT COUNSEL By --' Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 10]3a,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 Nan-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: at Martinez,California. ' k �/1 cc: Cleric of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 Wednesday, November 19,20031:31 PM Wit Flashman(610)662-5373 p,01 Law Offices of Stuai`t M.Flashman 5626 Ocean View Drive 1/08dan,C9468Es1 ) ( 1 � ZQp3 e-mail salflashgaol.cont UX P t}EI�,IVERY U FAX AND MAIL November 19, 2003 Mr. John Sweeten, Clerk to the Board of Supervisors Centra Costa County Coun Administration Building 651 Pine Street Martinez, CA 94553 RE: Itiz ns to Reduce Trafftc v Contra Costa,Countv et Dear Mr. Sweeten, PLEASE TAKE NOTICE that the Citizens to Reduce Traffic intends to commence legal action against Contra Costa County, the Contra Costa County Board of Supervisors, the Mount Diablo Young Man's Christian Association and Goes 1-40 under provisions of the California Environmental Quality Act, Public Resources Codae§21000 et seq., challenging the County's approval of the Alamo YMCA Project the associated approval of the environmental review for that project. This notice is provided pursuant to Public Resources Code section 21167.5. Most sincerely, 't,''� Stuart M. Flashman Attorney for Citizens to Reduce Traffic cc: County Counsel CLAIM B ARD OF SUPERVISORS OF CONTRA S C • OTA COUNTY BOA-RD ACTION: DEC. 10, 2003 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (.Paragraph IV below), give: Y Pursuant to Government Code Section 913 and 915.4.Please note all"Warnings". AMOUNT: UNKNOWN L CLAIMANT: KRISTINA PIAZZA Y ; ATTORNEY: UNKNOWN DATE RECEIVED: NOV. 20, 2003 ADDRESS: 4238 GOLDEN OAK COURT BY DELIVERY TO CLERK ON: NOV. 20, 2003 DANVILL , CA 94506 BY MAIL POSTMARKED: NOV. 19, 2003 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, NOVEMBER 2O 2003 JOHN SWE E , k Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors l This claim complies substantially with Sections 914 and,%.10.2. ( } This Claim FAILS to comply substantially with Sections 914 and 914.2, 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: if Date ,. ' - B Deputy Count Counse ==='L III. FROM: Clerk ofthe Board TO: County Counsel (1) County Administrator(2) ( } Claim was returned as untimely with notice to claimant(Section 911.3). IVARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full, { } tither: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date, Dated:A&ggg&;�* SWEETEN, CLERK., By ,Deputy Clerk WARNING(Gov. code se ion 913) Subject to certain exceptions, you have only six(6) months from the date this ndtice 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 Jai «'. SWEETEN, CLERK.By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCI`IONS 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. Cade 5911-2.) B. Claims must be filed With the Clerk of the Beard of Supervisors at its .office in Room 106, County Administration Building, 651 Fine 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 forst. RE: Claim By } Reserved for Clerk's filing stamp Against the Co&ty of Contra Costa } Nov 0 20 or 03 District) x° rR � 'r�s Fill M name ) ° The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in thesumof $ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact nate and hour) 44 2. Where did the damage or injury occur? (Include city and county) _Dn YA V, I I — h 4,h ut — 3. How did the damage or injury occur? (Give full. details; use extra paper if required �. Kt 4. What particular act or asion on the part of county or distric officers, # es'vts or-employees mused. the injury or damage": . . 0 Pav� Uj wnat are the names of county or district officers, servants or employees causing the damage or injury? ab, Wei-i2xIL13 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. x 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 made on account of this accident or injury: DATE. ITEM AMOUNT Gov. Code Sec. 910:2 Provides: "The claim must signed by the claimant SEND NQTICES T{?T (Attorne ) orb a -his,be-half game and Address of Attorney MC1Za'nVs s ture Address Telephone Telephone No. N O T I C E Kristina Piazza 4238 C,oldeu Oak Ct �mmvihe,CA 94506Section 72 of the Pena?. 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 imprisoriment in the county jail for a period of not more than one-year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine,*- or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($lp,p00, or by both such imprisonment and fine. u� mmL -P- tail center7719 Craw Canyon Road Danville,CA 945Q6 Phone(925)648-,25£3 FAX(925)648'167Gambardella -771 1 Cruw Canyon Road ® 'Danvi lo, CA 94506 • Phone (926) 648-2260 $ Fax (926) 648-4167 h 4 > ,awsw4b, � $i3 5 u.o ccs cc o CLAIM BOARD OF SUPERVISORS OF CQNTRA COSTA COUNTY BOARD'ACTION. DEC. 16t 2003 Claim Against the County,or District Governed by ) 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 California Government Codes. ) notice of the,action taken on your claim by the ... Board of Supervisors. (Paragraph IV below), give: Pursuant to Government Code Section 913 and # 915.4. Please note all"Warnings". AMOUNT: $100,000.00 GAZE CF AMRESS PER I DOM)DEC. 06, X03' LAMOS>W. STURGIS .J-40508 CLAIMANT: LAMOS WAYNE STURGIS SAN QU W IN STATE PRISON SAN QWMIIN, Gk 94974 R ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 21, 2003 ADDRESS: MAIN DETENTION FACILITY BY DELIVERY TO CLERK:ON: NOVEMBER 21, 2003 901 'COURT STREET, MARTINEZ, CA 94553 BY MAIL POSTMARKED: NOVEMBER 20, 20103 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 21 200 JOHN S WE , E , rk Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Sup6rvisors 4 This claim complies substantially with Sections 914 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: B y Deputy e y 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 ODDER: 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: fir'' KJHN SWEETEN, CLERK., By , Deputy Clerk WARNING(Gov, code section 913 Subject to certain exceptions, you have only six (6) months from the date this ndtice was personally served or deposites 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. Dated4 ,0 JOHN SWEETEN, CLERK By Deputy Clerk k i { .. ...... ..... ... _..._......_. ...... ..._.�.... .4-1..'/..t.2:?t`...c.� Z.4U4 1 ` f .. ............... -_... ____....... 1-� ..f� I''. .... LL.Sr!_t..'�...-4 ... I t _ ... ii RECE ' DEC 0 9 2003 a CLERK BOARD OF SUPE:,V'.`-'-as _.. ...-- ----___.. ... . ,ra .......... ............ ...._- {..i- ------- ----------------- __ _.. ..... - ..... .............................. .. .�.._.._.. ----------------- -----.. .,..._._._-- .__. _..-------------- ------------- _----- _ ._....... i S .-____..._. ..-._.____.._. .--_-..___._... .. . _... .._----------...__._..-------------- ---------- .. ----- __.......__ ... ..,... 1 1 '3 __._... _ -------- __ __---- ------------- __----------- -------- . ---_----._._- .-------- 1 ------------ ---- —f�.._ — — —... _—----------... _---- f � 1 sf -_---------- _ -- -----.... .............. __....__ — L+....... _ ----..._ --- -.—--------- __.._ ...._.._-----------------—-- . -- —._«__.— ..--- .. _._..._ _ ..-. ...._ � M j �' ...CO 4:14cm ' "u UJ IN � LAWI fs �a Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSIRUCTLONS TO CLAIIV€ANT A. 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 before December 31, 1987,must be presented not later than the 100 `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, mint be presented not later than six months after the accrual of the cause of action. Claims relating to any ether cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't 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 REC Against the County of Contra Costa or ) NO 2 12003 CtICRKBpA�?L7OF District) ot7n�rRAp � vlspq (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of S and in support of this claim represents as follows: 1. When slid the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. Hove disc the damage or injury occur? (Give full details,use extra paper ifrequired)