HomeMy WebLinkAboutMINUTES - 12092003 - C37 CLAIM Ott
BOARD OF SUPERVISORS OF CONTRA COSTA COUNT'
BOARD ACTION: December 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), given
-a tPursuant to Government Code Section 913 and
`? ,t 915.4. Please note all"Warnings".
AMOUNT: Exceeds $10,000
CLAIMANT- Dan i e 1 Grundig '. ` e
ATTORNEY: Clifford,Drath, Murphy & Hagen DATE RECEIVED: November 3, 2003
ADDRESS: 1999 Harrison Street Ste 700 BY DELIVERY TO CLERK.ON:
Oakland CA 94612
BY MAIL POSTMARKED: October 31 2003
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWE TEN, Clerk
Dated: By: Deputy
RM
II. FROM: County Counsel TO: Clerk of the Board of rvisors
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:
/A JA
Dated: #(VMf2By: Deputy County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2)
{ } Claim was returned as untimely with notice to claimant(Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
(X) This Claim is rejected in full.
{ ) other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
DECEMBER 091 2003
Dated: JOHN SWEETEN, CLERK., By , Deputy Clerk
WARNING {Gov. code secti 913)
gg
Subject o certain exceptions, you have only six (f) months from the date this notice was personally served or deposited
in the m it to file a court action on this claim.. See Government Code Section 945.6. You may seek the advice of an
attorney 1of 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: DECKER 09, 2003 JOHN SWEETEN, CLERK By 0 Deputy Clerk
This warning does not apply to claims which are not
subject to the California Tort Claims Act-such as actions
. in inverse condemnation, actions for, specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation is essential to understand all the separate
limitations periods that may apply. The limitations period
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific,
statutes and cases applicable to your particular claim.
The County of Contra Costa does not waive any of its
rights under California Tort Claims Act nor does it waive
rights under the statutes of limitations applicable to
actions not subject to the California Tort Claims Act.
JOHN M.DItATH SAN DIEGO
JOHN R.CLIFFORD Drath, Clifford, Murphy& Hagen SUITE 1550
RICK J.MURPHY 600"CALIFORNIASTREET
GREGORY D.HAGEN A LIMITED LIABILITY PARTNERSHIP SAN DIEGO, 92 101
DAVID F.BEACH SUITE 700
SARAH F.BURKE TELEPHONE:(619)595-3060
LISA CROSS CRAMER 1999 HARRISON STREET TELEFAX:(619)595-3066
GRETCHEN W.LATIMER OAKLAND,CALIFORNIA 94612 ---
TAMMARA N.TUKLOFF
DOUGLAS R.LIVINGSTON TELEPHONE(510)287-4000 REC;tEIVED
ALLISON L.JONES TELEFAX(510)287-4050
LAURA SAGMEISTER FLYNN WRITER'S DIRECT E-MAIL: JDRATH@DRATHLAW.COM
MICHAEL A.WALKER
DAWN A.SILBERSTEIN NOV 0 3 2003
MOLLY E.HOOT
KENT P.TIERNEY October 31, 2003
CLERK BOARD OF SUPERVISORS
OF COUNSEL CONTRA COSTA CO.
RAY Z.BACERDO
Clerk of the Board of Supervisors
County
Contra Costa
651 Pine Street
Martinez, California 94553
Re: Claim of Daniel Grundig
Dear Clerk:
Our office represents Daniel Grundig in his claim against
the County of Contra Costa. Enclosed please find the County' s
claim form which has been properly filled out by our office.
Please file the original claim and return a copy marked
`received" to the undersigned in the enclosed envelope.
Thank you for your attention to this matter.
Very truly yours,
DRATH, CLIFFORD, MURPHY
& HAGEN, LLP
Brenda L. Quirk
SECRETARY TO JOHN M. DRATH
/blq
Enclosure
�;Iaim to: BOARD OF SWERVISM OF CONnA CMA CEKRM
INSMMORS M CLAMW
A. 'Claims relating to causes of action for death or for injury to person or to per-
sonal property or grouiamp-
a and which accrue on or before December 319 1987,
r19
must be presented not later than the 100th day after the accrual of the cause of
action. relating to causes of.action for.death or for injury to person
or to pemoml property or growing crops and s&i6h acerin an or after January 1,
1988, cwt be presented not later than six months after the accrial of the cause
of action,. Claims relating to any other Call3e of action (must be presented not
later Pun one year after the accrual of the Cause of action. (Govt. Code 5911.2.)
Be C =3t be filed with the Clerk of the Board of SupervLwm at its,office in
Room 106, County Administration Buildings 651 Pine Street, Mutinez, CA 94553.
C. If claim is against a district governed by the Board of Supervisors, rather than
6
the Counluy# the rave of the District should be filled in.
Do If the claim 13 against more than one public entity, separate claixs wst be
filed against each pub!"a entity,
E. Fraud. See penalty for fraudulent claims. Penal.Code Seas 72 at the end of this
f OM
RE: Clam! By Reserved for Clerk's filing stamp
.DANIEL GRUNDIG
RECEIVED
Against the County of Contra Costa
or NOV 0 3 2003
• District) - A
CLERK BOARD OF SUPERVISORS
(Fill7in name Y CONTRA COSTA CO.
The undersigned claimnt hereby makes claiq against thq .County or Costa or
the above-namd Di3triCt in the SUM Of *rUIJMC3%M at this tlrr@ad in support of
this claim represents-as follows: 01
1. When did the e or LqJury occur? (Give exact date and hour)
Jime A Q3 at_ ,1!22
2. Where did the e or LnJur"j o=ur? (Thalude city and county)
Lombardy Lane near intersection with Sleepy Hollow Lane, Orinda,, Contra Costa County, CA
VMMMMM� 00
3. How did daaage
or injwy occur? (Give fall details; use extra paper if
requires)
Vehicle in which claimant was riding struck a utility pole situated
19 inches from road surface,
4. What particular act or mission en the part of oounty or district officers,
swNwt3 or=Ployees caused.the.injury or-damar.?
Dangerous conditl'on"-(5f public"property, anc'liiding but not limited to placing
or permitting the placement of a utility pole too close to a public road
(Government Code sections 830 et seq.; 835 et seq.)
officers, servants Or eMP10Yft3 causing
are We names of county or district
th. e e or injury?
Unknown at this time.
6. what damage or injuries do you claim resulted? (,Give extent'of Wuries or
dama"B"'e-W claimed. Attach two estimates for auto damasee
See attached*
7., How was the claimed above oomputed? (Include the estimated amraimt of any
prospective injury or damages).
See attached.
MWW,,gm,W"WdWWMWW- -
8, NaM03 and addresses of. witnesses, doctors and hospi
Sf 1-P attagbed,,
9. List the expenditures you made an acwmt Of this accident or injury:
AMOWT
DATE ITEM
See attached.
Gove Code Sec. '910;2 provides:
"The claim ersm
1m must be signed by the claimant,
s= NMIMS TO: (AtLom )e 0 0 aName /7 NINE*
,.Z ._ some R
and Address of Attormay
L
John M. Drath
DRATHF 'CL=PD,r MURPHY
&
Dona Maria Way
HA(MN 0 -m
1999 Harrison-Street, Ste* 700 (Address)
QA.yland,..California 94612'
Telephone Woo 510/287-4000 Telephone No. I V I W a
MV r-1015 4.0 * * * '§ * * i if Iry I
NOTICE
Section 72 of the Penal Code provides:
"Every per3on wbo,, with intent to defraud, presents for allowence or ror
payment to any state board or officer, or to any county, city or diatrict board or
offioer, authorized to allow or pay the saw if .genuiney any false or fftudulent
claim, bill, amount, voucher, or writing, is punishable either by impriso6ment in
the county Jail'for a period of not more than oras-yearp by a fine of not exceeding
one thousand ($1,000). or by both such Imoisoriment and fine ie.or by iWisonment in
the state prison, by a fine of not exceeding ten th usandd dollars ($10,000, or by
both such imprisonment and Pine.
TOTAL P,02
ATTACHMENT A
Claim of Daniel Grundig
6. Compound, comminuted fracture of right femur; compound
fracture of the right humerus; multiple complex lacerations,
right pneumothorax; multiple rib fractures; closed head
injury; degloving injury of the right shoulder and upper
arm; degloving injury of the right groin and thigh. Medical
expenses to date approximate $600, 000 . Extent of lost
earnings and lost earning capacity unknown at this time.
7 . Medical expenses based on statements of expenses from Kaiser
Hospital/Permanente Medical Group submitted through
September 5, 2003 .
8 . Witnesses : See Contra Costa County IMPACT Team Report,
Orinda Police Department Case No. 03-15052
Hospitals : John Muir, Walnut Creek; Kaiser Hospital, Walnut
Creek
Doctors : Multiple physicians at both John Muir and Kaiser
9 . Kaiser charges to date: Approximately $600, 000, including
the expenses of John Muir Hospital;
Other expenses : See ATTACHMENT B and C
ATTACHMENT B
Daniel Grundig
Expenses Resulting from June 1, 2003 IVIVA
June 241 2003 to July 16,2003
Date Payee Item Amount Paid
6/24/03 Kaiser-Walnut Creek Discha Rx#516-64025 and Rx#516-6395 $30.00
Hair Cut at residence: $30.00,of
6/24/03 Hair 2000(no receipt) which$15.00 over hair cut in salon $15.00
6/26/03 Home Med-Equip Co. Overbed table rental- 1st month $27.221
Wheelchair Pick-up to and from
Kaiser, Surgery Dept.,Walnut
6/26/03 Bay Medic Transportation Creek, incl. Tip $187.00
6/26/03 Kaiser-Walnut Creek Surgery Dept. Registration Fee $10.00.
Wheelchair Pick-up to and from
Kaiser, Surgery Dept.,Walnut
7/1/03 Medic-Mobile, Inc. Creek $191.00
7/1/03 Kaiser-Walnut Creek Orthopedics Dept. Registration Fe $10.00
7/2/03 Moraga Nutrition Center Laxative, Bone Builder $37.83
Wheelchair Pick-up to and from
Kaiser, Surgery Dept.,Walnut
7/3/03 Ambul-Cab Service Creek $200.00,
California Dept. of Motor Temporary Handicapped Parking
7/3/03 Vehicles Placard application fee $6.00
7/3/03 Kaiser-Walnut Creek Surgery Dept. Registration Fee $10.00
Kaiser-Walnut Creek-Main Prescription co-payment for Rx
7/8/03 Pharmacy 511-2951334 $10.00
Orinda Optometric-Dr. Replacement glasses for those
7/15/03 Gaynor&Associates lost in 1 Jun 03 accident $227.00
75.45 hours of home care @
17.00/hour for Daniel Grundig
7/15/03 Ava's Referral Services from 6/29/2003 to 7/11/03 $1,282.65
Wheelchair Pick-up to and from
Kaiser, Surgery Dept.,Walnut
7/15/03 Medic-Mobile, Inc. Creek $190.00
7/15/03 Kaiser-Walnut Creek Surgery Dept. Registration Fee $10.00
County Connection Link Wheelchair Pick-up to and from
7/16/03 service(no receipt) Kaiser, Surgery Dept.,WC $6.00
T-shirt-replacement for T-shirt
which was too sweaty for clinic
Kaiser Volunteers Gift Shop- visit after ride with County
7/16/03 Walnut Creek Connection Link $16.24
Kaiser-Walnut Creek-Main Eucerin Plus for treatment of skin
7/16/03 Pharmacy graft donor sites $9.20
Kaiser-Walnut Creek-Main
7/16/03 Pharmacy Prescription Rx#511-2953696 $8.75
7/19/03 Longs Drugs-Orinda Corrector stool softener $5.67
7/16/03 Kaiser-Walnut Creek Orthopedics Dept. Registration Fe $10.00
7/24/03 Safeway, Moragaa Corrector stool softener $5.59
Total Expenses-6/24/03 to 7/24/2003 $2,505.151
ATTACHVINT C
Daniel Grundig
Expenses Resulting from June 1, 2003 MVA
July 13, 2003 to September 17, 2003
Date Payee Item Amount Paid
Wheelchair Pick-up to and from
7/13/2003 County Connection Link Kaiser, Surgery Dept., Walnut Creek $8.00
7/13/2003 Kaiser, Walnut Creek Registration Fee $10.00
7/13/2003 Safeway Correctol medication $5.99
7/19/2003 Longs Drugs-Orinda Urinal $5.67
7/21/2003 Longs Drugs-Orinda 2 Orthomed gel packs $7.12
7/28/2003 Ava's Referral Services 64.4 hours home care x $17.00/hr $1,094.80
Wheelchair Pick-up to and from
7/31/2003 County Connection Link Kaiser, Surgery Dept., Walnut Creek $10.00
7/31/2003 Kaiser, Walnut Creek Registration Fee $10.00
Wheelchair Pick-up to and from
8/7/2003 County Connection Link Kaiser, Surgery Dept., Walnut Creek $10.00
8/7/2003 Kaiser, Walnut Creek Registration Fee $10.00
8/12/2003 Kaiser-Walnut Creek Registration Fee $10.00
8/13/2003 Kaiser, Walnut Creek Registration Fee $10.00
8/14/2003 Ava's Referral Services 55 hours home care x $17.00/hr $935.00
8/21/2003 Kaiser, Sacramento Registration Fee $10-00
8/30/2003 Ava's Referral Services 46 hours home care x$17.00/hr $782.00
9/7/2003 Home Med Equip. Co Overbed table $27.12
9/16/2003 Kaiser, Walnut Creek Registration Fee $10.00
9/17/2003 Ava's Referral Services 7 hrs.@ 17. + 7.25 hrs.@ 15. $227.75
ITotal Expenses 7/13/2003-9/7/2003 $3,183.45
CLAIM ?(
10
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY t
BOARD ACTION: December 9 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), given
Pursuant to Government Code Section 913 and
yf 915.4. Please note all"Warnings".
AMOUNT:
$250,000
F ( 2. h A.,a
CLAIMANT: Leslie H. Spaiser A"
ATTORNEY: Donald A. Jelinek DATE RECEIVED: Noveber 5 2003
Jelinek & Associates
ADDRESS: 1942 University Ave, Ste 206 BY DELIVERY TO CLERK ON: November 5 2003
Berkeley CA 94704
BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SW EN, Cle k
November 5 2003 BDe
Dated: y: puty
II. FROM: County Counsel TO: Clerk of the Board o isors
This claim complies substantially with Sections 910 and.9,10.2.
{ ) 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:
J,_1.
Dated: By: Deputy County 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 full.
{ } Other.
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date.
DECEMBER 09, 2003
Dated: JOHN SWEETEN, CLERK, By Deputy Clerk
WARNING(Gov. code sec on 913) r
Subject to certain exceptions, you have only six(6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Govenunent Code Section 945.6. You may seek the advice of an
attorney of ybur 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: DECEMBER 09 2003 JOHN SWEETEN, CLERK By Deputy Clerk
W
i
This warning does .not apply to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and Legal
consultation is essential to understand all the separate
limitations periods that may apply. The limitations period
within which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific.
statutes and cases applicable to your particular claim.
The County of Contra Costa does not waive any of its
rights under California Tort Claims Act nor does it waive
rights under the statutes of limitations applicable to
actions not subject to the California Tort Claims Act,
4
-Ulaim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLADWU
A. Claims relating to causes of action for death or for injury to person or to per_
sora' 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. Claim relating to causes of action fordeath 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. Cla* 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 Clam mist be filed with the Clerk of the Board of Supervisors at its _office in
Room 106, County Administration Building, 651 Pine Street, Martinez, CA 945530
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 L�nn one public entity, separate claims must be
filed against each .0 uble-1
c entity*
E Fraudm See perialty for fraudulent claims, Penal.. Code Se 72 at the end of to is...
forts.
RE:. Claim By 'Reserved for Clerk's filing stamp
Leslie H . Spaiser
RECEIVE
D
Against the County of Contra Costa N 2003
or 3
ICLERK
BOARD OF SUPERVISORS
District) CONTRA COSTA CO.
-(Fill in na 0
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sum of $2 5 0 , 0 0 0- p 1 u s and in support of
this claim represents-as follOWS: u n d e t e r m 11 n e d a n d minimal) loss of earnings
-Mon
1. When did the damage or inJur%y occur? (Give enact date and how)
May 7 , 2003 , in the morning and thereafter
2. Where did the damage or injury occur? (Include city and county)
Contra Costa Health Services , Contra Costa Regional Medical
Center ,, Martinez , Contra Costa County
3. How did the age or injury occur? (Give full details; use extra paper if
required)
Complications arising from Colonoscopy
4. What particular act or omission on the part of county or district officers,
servants or .employees caused.the.injury or damage?
See Attachment A
was are We r1ames of county or district officers# servants or employees causing
the damage or injury?
Drs . Forman, Reif , Goldman and Raphael and others not yet known .
-WO
6 What ge or injuries do you claim resulted? (Give full extent of injuries or
damages claimed. Attach two estimates for auto ti mage
Perforation of colon and injuries as set forth in Attachment B
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective inJury or damage-0)
These are general damages for permanent injuries plus pain and suffering .
Claimant ' s earnings are minimal -, $500 per month . He has been in the
hospital f o r over 135 days.
8, Names and addresses of witnesses, doctors and hospitals.
See items 2 and 5 , above . All are located at 2500 Alhambra Avenue
in Martinez .
9* List the expenditures you made on account of this accident or injury:
DAM` ITE24 AMOUNT"
There are minimal out-of-pocket expenditures at this time :
A
Gov. Code Sec. -910:2 provides:
"The claim must be signed by the claimant.
SEND NOTICES TO: (Attorney) or-by some an his.behalf."
�ona��ame d Addresl of fttorney
A. Je ine
—-
J E L I N E K & ASSO'CIATES P, - VCIA �. rigr�ature)
1942 University Ave . , Suite 2 6 Attorney fe' r Claimant
Berkeley , CA 94704 1942 University Ave . , Suite 206
(Address)
Berkeley, CA 94704
510-841-4787
Telephone No. 510-841-4787 Telephone No* - - -
7 T V-1 I T I I it N
NOTICE
Sect-ion 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 genuinev any false or fraudulent
n
claim, bill, account, voucher, or' writing, is punishable either by imprisonment i
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 imprisomoent in
the state prison, by a fine of not exceeding ten thousand.dollars ($1OpOOO1 or by ,
both such imrprisonment and fineO
ATTACHMENT A
1. To prevent the perforation: given the size of the polyp, colonoscopy
perforation was preventable by submucosal saline injection prior to the polypectomy
to avoid the deep burn that occurred;
2. To prevent the complications of the perforation: earlier surgery was
needed, requiring an earlier recognition that Pt likely had a perforation. This required
analyzing available information:
a. After the colonoscopy, it was noted that there was a "level
of burn to the muscosa";
b. The paramedics and other medical personnel all were aware
of "quadrant pain" -- later that night, even after morphine and Flagyl, "pain 8/10 lower
abdomen";
C. At ER) it was noted that Pts "CBC was remarkable for a
white count of 18,000 with left shift with polys 79, bands 9";
d. Pts temperature had risen in a few hours from 98.1 to 101.6.
This was enough information to be alert that peronitis was likely setting
in and time was of the essence. Yet, even though Dr. Raphael had recommended a CT
(not done), the Surgeon in Charge, Dr. Goldman, ignored all these warnings (2a-d) and
instead relied on his physical examination, tainted by narcotics (he was aware of the
"taint," since he ordered "Hold narcotic pain med's for now so as not to mask sx's").
This narcotic-masked exam at 1:10 am, the early morning of the day of the surgery,
elicited from the drugged Pt that "Pt feels a lot better now." This resulted in no
further treatment or examination till morning
This inadequate physical examination, which if done right -- or calling for
through-the-night further exams after the narcotics wore off, led to the dangerous eight-
hour delay in surgery, which by morning led to immediate surgery after the faulty
morning x-ray was repeated and Pt was rushed into the operating room.
Had any number of warning signs been heeded -- or if Pt had simply been
given an early CT -- the cascade of events that followed could have been avoided.
(Claimant will need to see videos of the colonoscopy procedure, color photos and x-
rays.)
ATTACHMENT B
1. Aspiration pneumonia
2. ARDS
3. Acute renal failure on dialysis
3. Adrenal insufficiency
4. Heparin-induced thrombocytopenia
5. CVA with seizure
6. Hemothorax
7. Left pleural effusion
8. Critical care polyneuropathy
9. Other matters covered in hospital reports
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
. DECEMBER 09, 2003
BOARD ACTION.
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
i-IT.r
Board of Supervisors. (Paragraph IV below), given
ursuant
to Government Code Section 913 and
15.4. Please note all "Warnings".
e All,
AMOUNT: $300,000-00 DEC* 169 2003
L
PER LETTER DATED DECEMBER 15 2003
CLAIMANT: SABRINA DAWN PACHECO ATTACHED, SEMANSKY LAW FIRM DOES ;NO
LONGER REPRESENTS THE CLAIMANT,
ATTORNEY: MICHAEL PETER SEMANSKY DATE RECEIVED: NOVEMBER 07, 2003
ADDRESS: SEMANSKY LAW FIRM BY DELIVERY TO CLERK ON: NOVEMBER 17, 2003
535 .MAIN STREET, THIRD FLOOR
MARTINEZ, CA 94553 NOVEMBER 06, 2003
BY MAIL POSTMARKED.,
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWEED" Ns. rk
Dated: NOVEMBER 17, 2003 By: Deputy
II. FROM: County Counsel TO: Clerk of the Board of SupeMsors
This claim complies substantially with Sections 910 and.�,l 0.2.
( ) 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:
11
Dated:
By: Deputy County 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).
IF
IV. BOARD ORDER.- By unanimous vote of the Supervisors present:
This Claim is rejected in full,
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date,
Dated, DECEMBER 09, 2003 JOHN SWEETEN, CLERK, By Deputy Clerk
XX7AD"kTTkT1`_1 /tN"1--- ---I- A
CLAIM
• BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: DECEMBER 09, 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
r. t,Board of Supervisors. (Paragraph IV below), given
71
ursuant to Government Code Section 913 and
i {v {J j.yg<.. (may
15.4. Please note all"Warnings".
V
DEC. 169 200.5
t_ , ..
"T iN
AMOUNT: $300,000,00
S D
PER LETTER DATED DECEMBER iD3 R 2003
s
CLAIMANT: SABRINA DAWN PACHECO LN ATTACHED, SEMANSKY LAW FIRM DOES,.:NO
LONGER REPRESENTS THE CLAIMANT,
ATTORNEY: MICHAEL PETER SEMANSKY DATE RECEIVED: NOVEMBER 07, 2003
ADDRESS: SEMANSKY LAW FIRM BY DELIVERY TO CLERK ON: NOVEMBER 17, 2003
535 .MAIN STREET, THIRD FLOOR 0�
MARTINEZ, CA 94553 BY MAIL POSTMARKED: NOVEMBER 06, 2003
FROM: Clerk of the Board of Supervisors TO,-. County Counsel
Attached is a copy of the above-noted claim.
JOHN SWEER&-rk
Dated: NOV OBER 17, 2003 By: Deputy_
II, FROM: County Counsel TO: Clerk of the Board of Supervisors
This claim complies substantially with Sections 910 and.J,1 0.2.
( } 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.
0
Dated: By: Deputy County 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 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. DECEMBER 09, 2003
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: DECEMBER 09 2003 JOHN SWEETEN, CLERK By loft% Deouty Clerk
This warning does .not apply to claims which are not
subject to the California Tort Claims Act-such as actions
in inverse condemnation, actions for. specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation is essential to under'stand all the separate
limitations periods that may apply. The limitations period ''"
within which suit must be filed maybe shorter or longer
depending on the nature of the claim. Consult the specific.
statutes and cases applicable to your particular claim.
The County of Contra Costa does not waive any of its
rights under California Tort Claims Act nor does it waive
rights under the- statutes of limitations applicable to
actions not subject to the California Tort Claims Act.
ry
Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CL
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 10e 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.
(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 Martine4 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
SABRINA DAWN PACHECO
RECEIVED
Against the County of Contra Costa or N 0 V 0 7 2003
CLERK BOARD OF SUPERVISORS
District) GiAff.A COSTA CO.
(Fill in name)
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district
in the sum of$ 300 jo 000-00and in support of this claim represents as follows:
1. When did the damage or injury occur?(Give exact date and hour)
The injury occurred on July 26, 2003*
2. Where.did the damage or injury occur?(Include city and county)
Contra Costa County Jail in Martinez, California.
3. How did the damage or injury occur?(Give fall details;use extra paper if required)
Sabrina Dawn Pacheco was a prisoner/detainee in the Contra Costa County Jail located on
Ward Street in Martinez, California when she complained about the living conditions of
the jail and was forced to the ground by several Contra Costa County Sheriff Department's
officers. The officers treated her in a rude, angry and aggressive fashion. They
forcefully pried her hands and arms up behind her back and fractured her left arm,
4. What particular act or omission on the part of county or district officers, servants, or employees caused the
injury or damage?
Contra Costa County Sheriff Department's officers forcefully pried Sabrina Dawn
Pacheco's hands and arms up behind her back and fractured her left arm.
5. What are the names of county of district officers,, servants, or employees causing the damage or injury?
jury
Exact names are unknown at this time.
6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach
two estimates for auto damage.)
A fractured left arm. Exact medical bills for treatment are unknown at this time.
Sabrina Dawn Pacheco also sustained a wage loss in excess of $5,000.00 and it is
continuing.
7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or
damage.)
There is not an exact amount to date. Discovery in this matter is continuing.
8. Names and addresses of witnesses, doctors, and hospitals.
Discovery in this matter is continuing.
9. List the expenditures you made on account of this accident or injury.
DATE TME AMOUNT
Gov. Code Sec. 910.2 provides"The claim must be
signed by the claimant or by some person on his behalf
SEND NOTICES TO.--- (Attorney
Name and Address of Attorney
(Claimant's Signature)
1289 McDonald Drive
(Address)
Pinole, CA 94564
Telephone No. )Telephone No. .(510) 724-3456
NOTICE
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,account,
voucher,or writings 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(S 1,000),or by both such finpri'sonment 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.
SEMANSKY LAW FIRM HECEIVED-
ATTORNEYS AT LAW NOV 0 7 2003
535 Main Street,Third Floor
Martinez,California 94553 CLERK 80-AIRD OF SUAPERVISOM'?
(925) 372-8766is
�aV(.-I A fr-� STACO.
Fax (925)372-9436
Michael Peter Semansky Antioch(925)427-1411
Michael R. Shea Fairfield(707)429-4900
email: Semansky@sbcglobal.net
Kazuko Smith
Lisa Atkins
Legal Assistants
Nove-11,10er 6, Z.tl V-)
Clerk of the Board of Supervisors
County Administration Building
651 Pine Street, Room 106
Martinez,, CA 94553
Re: Sabrina Dawn Pacheco
Date of Loss: July 26, 2003
To Whom It May Concern:
Enclosed please find an original and one copy of the claim against the Co my of Contra
Costa in regards to the above-referenced matter. Please file the original and r u an endorsed-
filed copy to the undersigned, in the self-addressed stamped envelope provide
Thank you for your prompt attention to this matter.
Very truly yours,
SEMANSKY LAW FIRM
LISA ATKINS
Legal Assistant
/la
Enclosures
SEMANSKY LAW FIRM ej
ATTORNEYS AT LAW
535 Main Street,Third Floor DEC 1 6 4UUJ
Martinez,California 94553 CLERK BOARD F,
SUPERVISORS
C 0
(925)372-8766CONTRA COSTA CO.
Fax (925) 372-9436
Michael Peter Semansky Antioch(925)427-1411
Michael R. Shea Fairfield(707)429-4900
email: Semansky@sbcglobal.net
Kazuko Smith
Lisa Atkins
Legal Assistants
December 15, 2003
Clerk of the Board of Supervisors
County Administration Building
651 Pine Street, Room 106
Martinez, CA 94553
Re: Sabrina Dawn Pacheco
Date of Loss: July 26, 2003
To Whom It May Concern:
Please be advised that our office no longer represents Sabrina Dawn Pacheco for her
claims of personal injuries she sustained on July 26, 2003.
Thank you for your prompt attention to this matter.
Very truly yours,
SEMANSKY LAW FIRM
Lisa Atkins
Legal Assistant
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APPLICATION TO FILE LATE CLAIM c3T
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION
Application to File Late Claim NOTICE TOAPPLICAN?45c__&I"7/3��- k 2
Against the County, Routing The copy of this document mailed to you is your
Endorsements, and Board Action.) notice of the action takeA' on your application by
(All Section References are to the Board of-Supervisors' (Paragraph III, below),
California Government Code.) given pursuant to Government Code Sections 911.8
and 915.4. Please note the"WARNING"below.
Claimant:
Mme ' `a v us
Attorney:
Address:
ji
0 X ►
X41V
Amount: By delivery io e n:
Date Received: o
C)(9�2 By mail,postmarked on:! 19
I. FR Clerk of the Board of Supervisors TO: County Co*uZsel
Attached is a copy of the above noted Application to File Late Claim.
DATED* � "` JOHN SWEETEN, Clerk,By.
TY
II. FROM: County Counsel T erk of the'.IBoard of Supervisors
( ) The Board should grant this Application to File Late Claim (Section 911.6)
The Board should deny th"S A plication to File Late Claim (Section 911.6).
DATED. 3im; B. MARCHESI, County Counsel,By. E
III* BOARD ORDER By unanimous vote of Supervisors present
(Check one only)
( ) This Application is granted(Section 911.6).
(X) This Application to File Late Claim is denied(Section 911.6).
I certify that this a true and correct copy of the Board's Order entered in its minutes for this date.
DECEMBER 09 200JOHN SWEETEN, y
Clerk,B :
DATE. DEPUTY
WARNING(Gov. Code §911.8)
If you wish to file a court action on this matter,you must first petition the appropriate court for an order
relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement).See
Government Code Section 946.6.Such petition must be filed with the court within six(6) months from the date
your apvl cation for leave to present a late claim was denied.
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.
IV, FROM: Clerk of the Board TO: (1) County Counsel (2)County Administrator
Attached are copies of the above Application. We notified the applicant of the Board's action on this
Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's
copy of this Claim in accordance with Section 29703.
DATED* DECEMBER 09
0 2003 JOHN SWEETEN,Clerk,By:
DEPUTY
V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors
Received copies of this Application and Board Order.
DATED;
County Counsel,By:
County Administrator,By.-
APPLICATION TO FILE LATE CLAIM
i
This warning does not apply to claims which are not
subject to the California Tort Claims Act such as actions
in inverse condemnation, actions for specific relief such
as mandamus or injunction, or Federal Civil Rights
claims. The above list is not exhaustive and legal
consultation is essential to understand all the separate
limitations periods that may apply. The limitations period
within-which suit must be filed may be shorter or longer
depending on the nature of the claim. Consult the specific
statutes and cases applicable to your particular claim.
The County of Contra Costa does not waive any of its
rights under California Tort Claims Act nor does it waive
rights under the statutes of limitations applicable to
actions not subject to the California Tort Claims Act.
November 3,2003
RE:Late claim of damages caused by road debris
Board Of Supervisors of Contra Costa County
Clerk of the Board of Supervisors
County Administration Buildin&Rm.106
651 Pine Street
Martinez,CA 94553
Dear Sir or Madam:
As per the attached letter of Ms. Melene Maxfield, Liability Claims Adjuster of the Municipal Risk
Management Authority of Contra Costa County,I am submitting the attached claim for damages that occurred
on Dougherty Road in San Ramon on March 20, 2003. She recommended that the claim be submitted to
Contra Costa County,Risk Management Division since the incident occurred on a county roadway.
The intent of my letter is also to explain the delay in this claim.My initial claim,as the attached documentation
indicates,was submitted to City of San Ramon within 30 days of the incident,on April 22,2003.1 was not able
receive a response before June 13,2003,by which time I had to travel out-of-state,to Columbus,,Ohio,, for a
work engagement.I was,therefore,unable to submit a subsequent claim to your office.
I hope that you can take the above circumstances into consideration and kindly accept my claim for processing
I look forward to your kind consideration of this matter. Please contact me, if you have any questions
regarding this claim.
Respectfully,
kP010
Tamer Chavusholu
Enclosures(6)
PO BOX 334s SAN KAMON9 CA 94583
925.336.1831
Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAD A.NT
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 rordeath or for injury to person 01&MTTrD
or to personal property or growing crops and which accrue on or after January I, 'Co c%-TY of
1988, must be presented not later than six months after the accrual of the cause SArA QAfo a
6T- action,, Claims relating to any other cause o action must be presented not Are?2,.206.
later than one year after the accrual of the cause of action. (Govto Code §911.2..)
B. Clams must be filed with the Clerk of the Board of Supervisors at its 'office in
Room 106, County Anistration Building, 651 Pine Street, Martinez, CA 9j4553•
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 Sea. .72 at the end of this
form.
RE: Claim By } Reserved for Clerk's filing stamp
AMM ChMUS110LOFr}
ORION
fS
{ .....,.,,,.., I
I
Against the County of Contra Costa -3 Zra
or
r
District}
(Fill in nam-Ammon
�
The undersigned claimant hereby makes claim aoAinst the County of Contra Costa or
the above-aimed District in the sum of $ and in support of
this claim represents -as follows
�'�rM�wM'�lii�r+iy�4�'���11�Mn.111wr+rMlll�i+ll1/IM'M�FA►�ii�s
L. When did the e or injury occur? (Give exact date and hour)
.. .j
01MUM 0 20ID V*TV4 EX14 o°I .o ?M
aM�i � MMi�sIllf�M+�iM���M�I+i+IM�i����"�+�11 ��+1U!_Ar�llt+►lM+��+!
2. Where did the e or injury occur? (Include city and county)
SoU4Tt%%0UvJD ot4 "Potytt-rn-*J V.DAD IF,'�MQJF ?�OLW(%M C.Arwiot�
3. How did the age or injury occur? (Give full details; use extra paper if
required)
LAIZC* S-To N a M br- CAQ ATTAC"AGtr V
�m/,00400 aw. won�M�1Mr�F
A. What particular act or omission on. the part of county or district officers,
servants or .employees caused. the. injury or �3g.e.
couvalj*
*P"s ump'sty
1 TIM A MAIOo AD�. (POUG&Wj)
t
r r ,,....+xw..r,�'
CONTRA COSTA COt,JN'-I*'Y
err+
SAL IAUSK MANAGEMENT INSURANCE AUTHORITY AA �
1911 SACT INGGUFL DRIVE * SUrM 200 * 'WALNUT CREEK,CA 94596-5332 �` e
(925)943-1100*FAX(925)946-4183
�rz Au
June 2, 2003
Mr. Tamer Chavusholu
P. 0. Box 334
San Ramon, CA 04583
RE: CLAIMANT: Tamer Chavusholu
CLAIM NO.: GL-003421
OUR PRINCIPAL: City of San Ramon
DATE OF INCIDENT: 3120/03
Dear Mr. Chavusholu:
The City of San Ramon is self insured and this agency administers its self-insured
program. The claim you filed with the City of San Ramon has been assigned to me for
investigation.
During my investigation, it was learned that the location of the incident occurred on a
county roadway. Therefore, liability, if any, appears to rest with Contra Costa County.
We have forwarded a copy of your claire to:
Contra Costa County
Risk Management Division
2530 Arnold [give, Suite140
Martinez, CA 94553
We recommend that you contact there for the disposition of this claim.
Should you have any questions, please contact me.
Sincerely,
Melene Maxfield
Liability Claims Adjuster
MIM:sep
cc: Toni Renault--City of San Ramon
Sharon Hymes-Offord -- County of Qontra Costa Risk [Management
San mon
rA C A t I F 0 R N I A
0#p()R A Ito 11 IN
CITY OF SAN RAMON 2222CAMiNo RAmoN
P.O.Box 5148
June 13,2003 SAN RAMON,CALIFORNIA 94583
PHONE: (925)973-2500
WEB SITE:www.sammon.ca.gov
Tamer Chavusholu
P, 0,Box 334
San Ramon, CA 94583
RE: City of San Ramon Claim No.2003-26
NOTICE QF`REJECTION OF CLAIM
Notice is hereby91*ven that the claim which you presented to the City of San Ramon
on or about April 22,2003 was rejected.
WARNING
Subject to certain exceptions you have only six(6)months from the date this notice
i
was personally delivered to deposited n the mail to rile,under California State law,
a court action on this claim, See Government Code Section 945.6. This warning
does not extend the Statute of Limitations involving any federal cause of action.
Macorlane, City Plerk
ty of San Ramon
2222 Camino Ramon
P.0.Box 5148
San Ramon, CA 94583
CITY COUNCIL:973-2530 ADMINISTRATIVE SERVICES:973-2523 PARKS&COMMUNITY SERVICES:973-3290 BUILDING&SAFETY SERVICES:973-2580
CITY MANAGER:973-2530 POLICE SERVICES:973-2700 AQUATIC CENTER:973-3240 ECONOMIC DEVELOPMENT SERVICES:973-2550
CITY ATTORNEY:973-2549 PUBLIC SERVICES:973-2800 COMMUNITY CENTER:973-3200 ENGINEERING SERVICES:973-2670
CL—AUM PRESENTED TO THE CITY OF SAAANN Rf"EIV E-D
San ROam
Na.,j J�i...
r...0*0 I
Please read the instructions before completing.
AM,-2.2 2003
1. Claimant Name: jtL\ML CiAk4d4r-ACLLL CITY CLLR K
Claimant Address: 2 V0V_C_9(2FL
lzeslo!n�!(P D Wo W %"
City.,State.,Zip: rAN p=AmcN- C& 5 0 Z,I Coq C i 14,15 e-
Day Phone: q15 33�_jb-,4 Evening Phone: 15- 6.3.5 2=
2. When did the damage or injury occur? Police Report
Date: f 0 V
Time of day-. -T v-4 A-1-4rt
I At which location did the damage or qury occur"
4. What happened and why do you think the City is responsible?
AS A LAi�uE L U,!,C_I
-T vt—e I AWD Jlt6cl> DiVirlAu, -L
f jV-FAtj,2_' JjILL t
mirrtf lk�WA- "To"t- C 111 S,ttv��;0) T t1l.%j :1 glaj;:� sQZ_-4 'T T E!
5. Name and position of responsible City Employee(s),if known: 010 N14--,T -DR.:;V VfT-_-)1ZA-& ct-4 tAA0
S-)% N Ast.-L aLOADS, o t!1:1%
ft�c
6. Witnesses:
tF TtkF>E- j��Ab_S
hi b1i TtffL�
-fA T
7. What damage or injury occurred?
-Lv OFF-f-RKMAL A-ffAL"ifZ7b "tCe'
V__9T L-1i :jityZ IiAO
y= �jjaj ?AV_T vVil T ti't �)tx 0A1_ 7,z�, %AAj
8. Claim Amount: $ (-CA t T --
C v-�ZV_43> T-CV_ T Vir, r4C_%,>1%5 "AT
-STAe-r M A f TEe Tof i rAL I DO-:kr-
9. How did you arrive at the amount claimed? Please attach documentation. X AL:k., 111*i ;�
tT
!�CAZ-4 i Cc_ is:,q ri;k U AlTACki
Q wid
r__rl U U F,Sf
10. 1 declare under penalty of perjury under the laws of the State of California that the
following information is true and correct,and that this declaration was executed
on 2OL;�,at Ami Californi
a.
Signaturof Cianwnt tatives Signature
,0 %pro&
If represented by an'insurance company or an attorney,please provide the' tion requested below.
Name and Capacity:
Complete Mailing Address:
Davtime Phone Number.
FOR CLAIMS RELATING TO INJURY TO PERSON OR PERSONAL PROPERTY,'THIS FORM MUST BE
FILED WITH THE CM OF SAN RAMON WITHIN SICK MONTHS FROM THE ACCRUAL OF THE
CAUSE OF ACTION.A CLAIM RELATING TO ANY R CAUSE OF AC SHALL BE PRESENTED
NO LA7TR THAN ONE YEAR AF 1rER ACCRUAL OF IHE CAUSE OF AC770N.
Y `
AdI
ATE OR OF SHIETS
0: f mr.PAIRS SHEET NO.
-R.-Dmo.
DATE
CAA
"Alm g 4I#I�f �A4Td�t No. bO aq
iWAAM!"Co. AV"TGR PHONE"M L T"/
FILE No.
PARTS MtS�. SUBLET
CUAIy. ESTIMATE OF REPAIR COST HOURS
HF--
OPINION".
. .........
L
The Undersigned agreed to complete the above repairs for$
Of the amount, the above named insured is to pay PARTS� �
Insurance deductible misc.s
depreciation SUBLET$
_j wofk byinsumn SAILES TAX $ f� �
TOTAL.S ,
At VANM CHARGES$
GRAND TOTAL.$
By
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e
4 . . _` ivermor
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*IWOICE* I
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TAMER CHASHOLU 38{X}NORTH 1 ST STREET • LIVERMORE, CA 94550
P.O. BOX 334 (925)447-1100
SART RAMON, CA. 94583 PAGE 1
H+J�+�E: 925-?35--6352 BUS: 925-904-0380
SE-RVXE ADVWR: 856 JOHN TAYLOR
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FINAL
0TOGINAL REVISED LA AMUNT 561.00
,,, ESTIMATE: $ ESTIMATE: $ PARTS AMOUNT 125.69
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DATE TIME PHONE# AUTHORIZEDI I I I AMOUNT a TOTAL OAS,OIL,LUBE 0.00,
SUBLET AMOUNT 0100
MISC.CHARGES. 0.00
TOTAL CHARGES 686.69
ADJUSTMENTS 0.00
rma sm a VW i ACK W A APPROVAL SALES TAX 1~0.3"7
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ALL PARTS ARE NEW UNLESS SPECIFIED OTHERWISE. BAR#AJ 180510 EPA#CAL000148315
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