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HomeMy WebLinkAboutMINUTES - 04061993 - 1.15 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO.CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the ction taken on your claim by the Board of Supervisors Coo n u �O a Wk graph IV below), given pursuant to Government Code Amount: Undetermined1gy3 tion 913 and 915.4. Please note all "Warnings". MAR 4 N, CLAIMANT: BARNES, Tyrone i1/Iidf1111CL, VA 94553 ATTORNEY: Jeffrey Fettner, Esq. Robbins, Dangott & Scharl.ach Date received ADDRESS: Attorneys at Law BY DELIVERY TO CLERK ON March 9, 1993 1540 San Pablo Ave. Westlake Building, 11th Floor BY MAIL POSTMARKED: March 8, 1993 Oakland, CA 94612 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED March 17, 1993 Jy!L BAATCHELOR, Clerk P y II. FROM: County Counsel TO: Clerk of the Board of Sup ors (✓) 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: 4 Dated: Z3 f3 BY: - �- a Deputy County Counsel 11I. 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. BO7RhiS: By unanimous vote of the Supervisors present 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: ~r R O 6 1993 PHIL BATCHELOR, Clerk, 8y . Deputy Clerk WARNING (Gov. code sectio 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney ,of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 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: APR o 7 1401BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator ROBBINS, DANGOTT & SCHARLACH A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 1540 SAN PABLo AVENUE PAUL ROBBINS WESTLATCF. BUILDING. 11TH FLOOR �� � MORRIS A.DANGOTT OAKLAND. CALIFORNIA 94612 ALAN M. SCHARLACH - TELEPHONE (510) 451-7128 JEFFREY I.FETTNER FACSIMILE (510) 451-0334 mm - 9 1= CLERIC BOARD OF SUPERVISORS CONTRA COSTA CO. March 8, 1993 Clerk of the Board of Supervisor COUNTY OF CONTRA COSTA 651 Dine Street, Room 106 Martinez, California 94553 Re: Our Client/Claimant: Tyrone Barnes Date of Loss: September 16, 1992 Dear Gentleperson: Enclosed .herewith please find original and copy of the Notice of Claim regarding the above-captioned matter. Please file and return endorsed copy in the envelope provided. Thank you for your cooperation in this matter. Very truly yours, ROBBINS, DANGOTT & SCHARLACH By• Z .�-- JEF RE I. FETT R JIF:grl: 1, Enclosures. ,(As„ stated) RECEIVED MAR - 91993 1 GLER BOAR O COTRACOS-TA CO`SOBS 2 NOTICE OF CLAIM 3 TO: THE CITY OF CONTRA COSTA, A Municipal Corporation, its 4 OFFICERS, AGENTS, AND EMPLOYEES: 5 PLEASE TAKE NOTICE that TYRONE BARNES, claims against 6 the COUNTY OF CONTRA COSTA, A Municipal Corporation, its 7 OFFICERS, AGENTS, AND EMPLOYEES for personal injuries, medical expenses, property damage and general damages sustained by said 8 9 TYRONE BARNES, by reason of personal injuries received by him, a and in support thereof the claimant states: �+ 10 �4Z $ 1. The name and address of claimant: TYRONE BARNES, O WJ 11 F 7 li N 4009 Jenkins Way, Richmond, California 94806. 12 H0 oa<0UD� 2. The name and address of claimant's attorneys: OzWaou"a 13 tO,Z;Zo ROBBINS, DANGOTT & SCHARLACH, 1540 San Pablo Avenue, 11th Floor, z �o(n < la Aoa0jov 15 Oakland, California 94612 . All notices of denial or acceptance L �F W of this claim should be mailed to said attorneys. Z 3 16 PQ 3 . The claim of TYRONE BARNES is for negligence Pq 17 0against the COUNTY OF CONTRA COSTA, its OFFICERS, AGENTS and 18 EMPLOYEES, ins OFFICERS, AGENTS, a^'a EMPLOYEES, and others, as 19 hereinafter set forth below: 20 (a) That on or about September 16, 1992, approximately _ 21 1:30 a.m. , claimant, TYRONE BARNES, was traveling on Giant Road 22 (between Miner and John) , Richmond, Contra Costa County, State 23 of California, when he ran over a pothole in the road, which 24 broke the rear axle of claimant's vehcile, causing the rear tire 25 to come off. The vehicle skidded to a stop, thereby causing 26 1 injury and damage to claimant. That the COUNTY OF CONTRA COSTA, 2 its OFFICERS, AGENTS and EMPLOYEES, its OFFICERS, AGENTS, and 3 EMPLOYEES, and others, negligently, carelessly and recklessly, repaired and maintained said vehicle. 4 5 (b) The claimant has sustained injury to his knee, 6 neck, back and body in general. The extent of injuries 7 sustained by claimant are unknown at this time. 8 (c) The accident as aforesaid, and the injuries alleged 9 herein, were caused by the negligence and carelessness of the 9 COUNTY OF CONTRA COSTA, its OFFICERS, AGENTS and EMPLOYEES, who �+ 10 Z °0 11 failed to take the proper precautions in driving, maintaining U P 0 LL N 3 W= and controlling said vehicle. o�oa>�a 12 a�Q�mm F°oa°�;n (d) Claimant was forced to undergo medical treatment FaYaoUa 13 �Zwa� . 50zWZ5zo and pay for medical expenses as a result of the carelessness and zW0(n <" 14 ALLuO`a 15 negligence of the COUNTY OF CONTRA COSTA, its OFFICERS, AGENTS �0 a �F W and EMPLOYEES. The exact amount of the medical expenses 3 16 incurred are unknown at this time. Fq 17 0 (e) By reason of the foregoing, claimant has been �i 18 generally da aged in the amount of FT_FTY THOUSAND DOLLARS 19 ($50, 000. 00) , plus medical specials and property damage. 20 Dated: March 8, 1993 ROBBINS, DANGOTT & SCHARLACH 21 22 By: 23 JE R4J I. FETTNER, ESQ. 24 2 - 25 26 1 PROOF OF SERVICE BY MAIL 2 I, GWEN LYONS, declare as follows: 3 I am a citizen of the United States, over the age of 4 eighteen years and not a party to the within-entitled action. 5 My business address is 1540 San Pablo Blvd. , 11th Floor, 6 Oakland, California 94612 7 I served by mail the following document(s) : x. 8 NOTICE OF CLAIM U 9 by enclosing a true copy of the document(s) in an envelope, 0 10 addressed as follows: o° ;i N 11 Clerk of the Board of W= Supervisors N 12 COUNTY OF CONTRA COSTA P U<Jo]C 651 Dine Street, Room 106 � JN m Z a N ZWaouJ .a 13 Martinez, California 94553 5N�amZo Z ON) <LO 14 I then sealed said envelope and deposited it with LL<0 o 1<< J0 15 postage therein fully prepaid in the United States mail at U1 ` 'm Z 16 Oakland, California. PG 17 I declare under � penalty of perjury and under the O 18 laws of the State of California that the foregoing is true and 19 correct. 20 EXECUTED this 8th day of March 1993, at Oakland, 21 California. 22 23 24 WE LYONS 25 26 t N ,. . i t' A �• Q xA r1 » Q OW G U u� 4 u Fax { + QZ ta oto "Li 4 L4, NQdwaHa U m z° to A 6 3a L ROBBINS, DANCTOTT & SCHARIjACH A PROFESSIONAL CORPORATION ATTORNEYS AT LAW 1540 SAN FABLO AVENUE PAUL ROBBINS WESTLAKE BUILDING. 11TH FLOOR � _ (RECEIVED MORRIS A.DANGOTT OAKLAND. CALIFORNIA 94612 ALAN M. SCHARLACH - TELEPHONE (510) 451-7128 ��� ... JEFFREY I.FETTNER FACSIMILE (510) 451-0334 3 QM CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. April 30, 1993 Clerk of the Board of Supervisors County of Contra Costa 651 Dine Street, Room 106 Martinez, California 94553 RE: Former Client: Tyrone Barnes Date of Loss: 9/16/92 Dear Gentleperson: This is to inform you that as of March 9, 1993 , we no longer represent Mr. Tyrone Barnes for injuries he sustained in the above-dated accident. You may contact him directly at (510) 235-7270 or 236-3843 , regarding his claim. Thank you and if you have any questions, please give me call. Very truly yours, ROBBINS, DANGOTT & SCHARLACH By: FREY I. FETTNER JIF:db: l CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District,governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $200,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CONLEY, Peggy and HAMLIN, Frank S. ATTORNEY: Date received ADDRESS: 2306 Center Avenue BY DELIVERY TO CLERK ON March 3, 1993 Martinez, CA 94553 BY MAIL POSTMARKED: hand delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MM DATED: March 8, 1993 IV BATCHELOR, Clerk I1. 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: e,14 9' / s.3 BY: ZL=3a <r Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present 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: APR 0 6 1993 PHIL BATCHELOR, Clerk, eyj��X� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this mutter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR 0 7 1993 BY: PHIL BATCHELOR Deputy Clerk CC: County Counsel County Administrator PEGGY CONLEY, CLAIM FOR PERSONAL INJURIES FRANK S. HAMLIN, [GOVT CODE SECTION 910, ET SEQ V. CONTRA COSTA COUNTY, MERRITHEW � '1�' HOSPITAL, Anita Duckett, Director RECEIVED of Nursing, Linda Bates, House Supervisor, Donna Garro, Charge Nurse of "J" Ward, Psyche Murillo, WR - 310 RN, Cora Fajota, RN, Jody Hartong, RN, Cyril Hinds, Psyche CLE BOARD OF SUPERVIS ,�,c.- Technician, Michael Kowall, CONTRA COSTA CO. Psyche Technician, Barbara Harper, Ward' Clerk, and DOES 1-5 TO THE CONTRA COSTA COUNTY BOARD OF SUPERVISORS, 651 Pine Street, Martinez , CA 94553 , Attn: Jeanne B. : You are hereby notified that Peggy Conley and Frank S. Hamlin, whose address is 2306 Center Avenue, Martinez, CA 94553 , claim damages from the Contra Costa County Board of Supervisors in the amount, as of the date of presentation of this claim, of $200,000.00. 1 This claim is based on personal injuries sustained by claimants on or about September 9, 1992, in the vicinity of Merrithew Hospital "J" Ward, 2500 Alhambra Avenue, Martinez, CA 94553 , under the following circumstances. Peggy Conlev's son and Frank S. Hamlin's brother, Dana w7ade Hamlin, while, an in-patient at Merrithew Hospital "J" Ward, died by hanging himself by the neck with a bedsheet on September 9, 1992 at 1858 hours in the men's bathroom of Merrithew Hospital "J" Ward. Decedent Hamlin had been an in-patient since admission on 7/8/92 and was diagnosed as a schizophrenic with drug and alcohol problems. Decedent Hamlin had attempted suicide on at least three 1 i prior occasions, 5/24/91, 6/8/91, and 5/14/92. Decedent was last seen alive at 1750 hours having a telephone conversation with his mother Peggy Conley, wherein decedent asked his mother to deliver food to him, asked his mother whether she was in heaven or at home and stated that he couldn't handle it anymore. Decedent was found dead at 1825 hours by staff member Cyrl Hinds, who had gone in search of decedent when decedent failed to return a food tray. Claimants assert that decedent was suicidal at the time of the telephone conversation due to prescribed tranquilizers Stellazine 10 mg, 3x, and Benadry 50 mg and that decedent's death was caused by inadequate supervision by staff. The names of the public employees causing claimants' injuries under the described circumstances are as follows. The following staff members were on duty at the time of the death: Psyche Murillo, RN, Cora Fajota, RN, Jody Hartong, RN, Cyril Hinds, Psyche Technician, Michael Kowall, Psyche Technician, and Barbara Harper, Ward Clerk. The following persons were members of the staff on the date of the death: Anita Duckett, Director of Nursing, Linda Bates, House Supervisor, Donna Garro, Charge Nurse of "J" Ward. The injuries sustained by claimants, as far as known, as of the date of presentation of this claim, consist of emotional distress and loss of consortium. Jurisdiction over the claim would rest in superior court. All notices or other communications with regard to this claim 2 should be sent to claimants at 2306 Center Avenue, Martinez , CA 94553. Dated: PEGGY COkEf Dated: FRANK S. HAMLIN 3 _. CLAIM r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. } the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: - $13,368.67 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HAM, Dr. Young Chul ATTORNEY: Date received 1993 ADDRESS: 258 Donegal. Way BY DELIVERY TO CLERK ON March 5, Martinez, CA 94553 hand delivered BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. gg DATED: March 8, 1993 B�il Deputy OR, Cler 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: Dated: %`'1 -�-� ���� BY:- Deputy County Counsel III. FROM: Clerk of the Board 70: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORD R 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: APR 0 6 1993 PHIL BATCHELOR, Clerk, By . Deputy Clerk WARNING (Gov. code sec on 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that'today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR 0 7 1993 BY: PHIL BATCHELOR by Z Deputy Clerk CC: County Counsel County Administrator V, NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Doctor Young Chuil Ham 258 Donegal Way Martinez, CA 94553 RE: CLAIM OF: HAM,. Dr. Young Chul 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: [ ) 1. The claim fails to state the name and post office address of the claimant. [ ] 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [xx] 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. [ ) 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000) . If the claim totals less than ten thousand dollars ($10,000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000) , the claim fails ; to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6 . The claim is not signed by the claimant or by some person on his behalf. [ ] 7 . Other: VICTOR J WESTMAN, County Counsel By: Dep y County Coun el CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a, 2015.5; Evidence Code §S 641, 664) I declare that my business address is the County Counsel's Office of Contra Costa County, 651 Pine Street, Martinez, California 94553; 1 am a citizen of the United States, over 18 years of ,age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non- acceptance of Claim by placing it in an envelope addressed as shown above, sealed and postage fully prepaid thereon, and thereafter was, deposited this day in the U.S. Mail at Martinez, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 11, 1993 at Martinez, California. cc: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE SS 910, 910.2, 920.4, 910.8) I\ _ Claim to: BOARD OF SUPERVISORS OF CONTRA =A COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19870 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claim 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 orm. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * RE: Claim By ) Reserved for Clerk's filing stamp �r47 RECEIVED Against h ounty of Contia Costa ) - 5 M or (_,zLZP� �#1����'�- District) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ , and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and ty) 3. How did the damage or injury occur? (Give full details; use extra paper if required) TJ�� -- �"1— 714-7 7c, 00 L7107r 4: What particular act or omission on the part of county or district officers,; servants or employees caused the injury or damage? �3 �6 � � SI/41 r) 5. What 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. ------------------------------------------------------------------ 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. �� O-V\_a ky-r-VJ et-y ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT k 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 C4 Clai is Signature Address laYi" 71,E s Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, �with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if-genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. 9 , PAGE NO. •' �jq�'y3�I CONTRA COSTA COUNTY HEALTH SERVICES TY Bi F DATE OF BILL C T O �f i 2500 ALHAMBRA AVENUE 1 ' 7� MARTINEZ, CALIFORNIA 94553 R E S I L;L 06/22/92 . / for- ,7 (510) 313-6500 " ! �I PATIENT NAME II PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED o n r HAMo, YOUNG C 19102313. "s 46 11J13J91 11 /'25!91 12 $ $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG HAM VETERANS ADMIN HOSPITAL 040146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 66? AND ADDRESS MARTINEZ, CA 94553 jl {I 11 If PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF �I SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE On' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.CO.NO.2 INS.CO:NO.3 AMOUNT 121691 MCAL BILLING ADI�3UST W419 144.00- 144.00- 028KS 111391 12 IsEDICAL j 99200503 6192.00 6192. 00 R EIVE® TOTAL ROOM AND BOARD 61` 2.00 6192.00 '1'11391 1 INTER14ED HOSP E AM 30800411 42 .00 42. 00 - 51993 111691 1 INTERI;IED HOSP E AM 30800411 42.00 42.00 111791 1 INTERMED HO SP E; Ari 306004/ 1 42 .030 42. 00 CLERK BO DOFSUPERVI ORS 111.391 1 INTERMED HOSP E Ate 30800411 42.00) 42. 00 CON RACosTA 0� 111991 1 I:iVTERS�E4� HOSP E'�AM 30800411 42..00 42. 001 , 112091 1 INTERNE. HOSP Ek, Ail 30600.411 42.00 42. 00 11 C1 yi 1INTERRED HOSP E1 AM 30800411 ' 42,00, ►2.00 112291 1 INT ERM ED HOSP E, AM 30800411 42 ,00 42.00 712391 1 INTERMED HOSP E)(AM 30E00471 42 .00 42.00 112491 1 INTERNED DOSP EXAM 30800411 42 .043 42.00 112 591 1 INTERMED HOSP E XAivi 30800419 42.00 4`2. 00 * TOTAL. MEDICAL t6 i WARD ) 462.003 462. 00 1113 1 1 LEVER LACK 33a81 1 405734- '38 1 .'50 1..50 111391 1 ARMSOA'RD 9 40590-39U 1 .40 1.40 11'1391 1 BLOOD GAS KIT 40590,a3b 4.56 4„50 111391 1 NUTRI-FLO EXT S T 4059093? 3.60. 3.80 111391 1 CATH -SUMP SALEM116F 4059337.2 6.25, � 6.25 111391 1 HIrPARIN LOCK 33 9 40593.352 6.50 6.50 111391 1 IV SET EXT 4U593493 2. 203* 2. 20 311391 1 IV PRIMARY 2051«l 40593535 8. 40 8,.40 111391 2 iVSET-SECON 2CO3ti18 40593543 11 . 50 11. 503 111391 2 IV STRT --PK WIA1SX1 . 40593659 12.40 12.40 111399 1 CATH TRAY 16F W)BAG 40594947 28.35 28. 35 111391 1 URINARY DRAIN 3AIG 40598963 11 .30 11. 30 113391 1 CONDOM CATHI.STAN1DAR 40599144 4.50 4..50 111591 2 INFUSION PUMP 40550147 60.00 60.00 131691 1 INFUSION Pi)f11P 40550147 30.00 30.00 111691 2 LEVER LOCK 338811 40573436 3.00 3.00 I 111691 . 1 BUTTERFLIES 23GA 40591059 3. 25 1 . 25 {I - 4 6 PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY - t NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE PAY THIS AMOUNT 7 V1 Uldu AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTHI SERVICES • Make checks payable to County Auditor-Controller. 625 Court Street, Room 203 Martinez, California 94553 ►� • III II CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. TMBICOF DATE OF BILL -fit 2500 ALHAMBRA AVENUE 2 MARTINEZ, CALIFORNIA 94553 t= xt t n6/22192 (510) 313-6500 INP l� ♦n r PATIENT NAME Ij PATIENT NUMBER SEX I AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED HA Me YOUNG C 1910280 °i 46]11 /13/91 11125/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG }IAM VETERANS ADMIN HOSPITAL D40146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND NARTINEI, CA 94553 ADDRESS j PLEASEiI RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF �l SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.CO.NO.2 INS.CO.NO.3 AMOUNT 1'116'Y1 'I CATH NDL IV 16G71 40591273 3.0,() 3. 00 111691 1 IV PRIMARY 2C55�1�1 40593535 8. 40 8.40 111691 1 CANNULA 3386 40596264 1 . 25 1.25 111691 1 ExTEN SET 1194 11 j 40596272 6. 25 6. 25 111691 1 CATH ANG 22x1 47598161 3.00 3. 00 111691 1 T PAD DISI' 40598518 32.75 32.75 111691 1 THORACENTESIS TjkAY 4059.8591 60.32 60. 32 ' 6 b 111691 2 CONDOM CATH.-MED [UM 40599151 9.00 9. 00 111891 1 T-PUMPS 140550089 10.00 10.00 b 111691 1 INFUSION PUMP I 40550147 30.00 30. 00 111891 1 HEPARIN LOCK :3319 40593352. 6.50 6. 50 111691 .1 EXTEN SET 1194 �� 40596272 6. 25 6.25 b 111991 1 T-PUMPS 40550089 10.00- 10.00 111991INFUSION PUMP � 4055,010 �� 11'1991 2 ISOLATION GOWN j 40593329 5. 20. 5.20 z4�, 111991 1 HEPARIN LOCK 3399 4059,3352 6.50 6. 50 111991 1 URINARY DRAIN 81G 40598963 11 .30 111991 1 CONDOM CATH.,STA DAR 4t)5991 44. ' 4.50 4.50 SI, 6,1 112091 1 T-PUMPS 411550089 10.00 10.00 r3 6 112191 1 T-PI MPS 4175500:69 10.00 10. 00 112291 1 T-PUMPS 40550089 10.0_{7 10, 00 _J2 112391 1 T-PUMPS �� 40550069 10.00. 10.00 112491 1 T-PU,'I3PS 40 550089 10.00 10.00 l"' 3 112591 1 T-PUMPS 40550089 10.00 10. 00 11 � 91I WALKER 40510001 so-'00 80. 00 11 +�71 1 'BALKER WHEELS Pl 4051091'9 .64,.00 64.00 v *+� TOTAL CENTRAL SUPPLY ' (e(ED 111391 1 HEMA-HENGRM/PLT/ DIT 40615106 31 .00 31.00 111391 1 IMMU PROTHROM 71IME 40670481 16.00 16.00 111391 1 IMMU PTT PART 1HROM 40670499 22.50 22. 50 111391 1 CHEM ACETAMIXOPINEN* 40680019 82 .00 82.00 111391 1 CHER AMYLASE S8;RUi4 40680043 32 .00 32. 00 111391 1 CHEM BILI TOTAL! 40680076 18.50 18.50 I� PATIENT NUMBER PLEASE REFER TO PATIENT I ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY NUMBER ON ALL IN CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE PAY THIS AMOUNT y, U AND CORRESPONDENCE. ,I IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE �I AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. 625 Court street, Room 203 I Martinez, California 94553 \l II ,. _7 CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. TYPE bATEOFBILL i 2600 ALHAMBRA AVENUE 3 ` MARTINEZ, CALIFORNIA 94553 1 1 06122/92 (510) 313-6500 IPP PATIENT NAME PATIENT NUMBER SEX AGE I ADMISSION DATE I DISCHARGE DATE DAYS AMOUNT ENCLOSED HAM,r YOUNG C 1910280 i 45 11 /13/91 11 !25/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG HAM VETERANS ADMIN HOSPITAL 340146 55235495) NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND MARTINEZ, CA 94553 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.t INS.CO.NO.2 INS.CO.NO.3 AMOUNT 113391 1 CHEM CALCIUM SERUM 40680084 18.5.0 18. 50 111391 1 CHEM CHOLESTEROL 407680175 16.00 16.00 111391 1 CHEM CPQ{ TOTAL 40680191 27.00 27.00 111391 2 CHEF! ELECTRO PANEL 406830266 91 .00 91 .00 111391 1 CHEF" GLUC RANDOM 40680357 16.00 16.00 111391 1 CHEM LDH 406307431 22.50 22.50 111391 1 CHER MAGNESIUM 40630464 32.00 32.00 111391 1 CHEM PHOSPHATASE AL 406BG480 22.50 22.50 111399 1 CHEM PHOSPHPRUS 40680498 16.00 16.00 111391 1 CHEM PROTEIN TOT-SR 40660514 16.00 16.00 111391 1 CHEM UREA NITR-SRR 40630639 15..00 16.00 191391 1 CHEM URIC ACID 407680654 16.00 16.00 111391 1 EXAM NOT REG HRS 40690042 1 .00 ; 15.00 111491 1 HEMA-HENGRPI/PLT,/DI F 406151,06'!"' 31 .00 31. .00 111491 1 CERULOPLSAN SRM 96* 40.644057 7.1 b' °, 7.'16 MET '.TEST 3714 Pa0RTHGATE BLVD . SACRAMENTO CA 95634 111491 1 IMMU PROTHROM TIME '. 4U670481 16.00. 16..00 111491 1 IMMU PTT PART THROM, ,4 3670499 22.50 22.50 111491 1 CHEM ALBUN EN 46680027 ' 16.00 16.00 111491. 1 CHE14 AMMONIA 4068-0035 , 45.50 , 45.50 111491 1 CHEM AMYLASE SERU1°} 40,680043 ' 32.00 32. CC 111491 1 CHE14 ELECTRO PANEL 40680266 45.50 45.50 111591 1 HEMA-CELL CT&DIrF F 40615809 9 -.` 27.170 27..00 111593 1 MICRO GRAM STAIN 401627549 18.503 18. 50 111591 1 URIN COMP URINALYS.T 40658015 14.00 14.00 911591 1 3NVU PROTHROFI TIME 40670481 16.00 16.00 111591 1 1WAU PTT PART THROM 40670499 22.50 c22.�5,0 111591 1 CHEM ALaUMEN 40680027 16.00 16.00 111591 1 CHEM AMYLASE SERUM 40680043 32 .00 32.007 111591 1 CHEM CREATININ SERV 406302.17 16.00 16.00 111591 1 CIiEM GLUC RANDOM 40680357 .16.00 16.003 119591 1 CHER PROTEIN TOT-FL 4U680522 36.50 36.50 111591 1 CHESS UREA NITR-SRM 40680539 96.00 16.00 111691 1 HEMA-CELL CT&DIFF F 40615809 27.00 27.00 PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR FLEASE.PAY THIS AMOUNT 7 `f-I U e o AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. Ma Court Street, Room 203 Martinez, California 94553 r. CONTRA COSTA COUNTY HEALTH SERVICES , PAGE NO. TY BLL DATE OF BILL ; 2500 ALHAMBRA AVENUE Y MARTINEZ, CALIFORNIA 94553 R t=PT t 1 06/22IQ2 - (510) 313-6500 . � IP;P. PATIENT NAME PATIENT NUMBER SEX AGE r ADMISSION DATE I DISCHARGE DATE DAYS AMOUNT ENCLOSED HAM.- YOUNG C 1910280 M 46 11 /13/91 11/25/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG HAM VETERANS ADMIN HOSPITAL 040146 5523549511 NAME Z58 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND KARTINEZ, CA 94553 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICETOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.CO.NO.2 INS.CO.NO.3 AMOUNT 111691 2 MICRO-CULTURE BLOOD 40627309 110.00 110.00 111691 1 MICRO GRAM STAIN 40627549 18.50 18. 50 111691 1 CHEIM AMYLASE SERUM 40680043 32 .00 32. 00 111691 1 CHEM GLUC RANDOM 40680357 16.00 16.00 111691 1 CHEM LDH 40680431 22.50 22. 50 111691 1 CH€iii PROTEIN TOT-FL 40680522 36.50 36.. 50 111791 1 MICRO--CLT'-ANY OTHER 40627366 55 .00 55.00 1118391 1 MICRO-CLT-ANY OTHER 40627366 55.00 55.00 111899 1 COPPER SRM 98 40645145 10.20 10. 20 PIET WEST 3714 NORTHGATE BLVD SACRAMENTO CA 95834 111891 1 COPPER UA 96 40645 52 9, 9.61414 MET WEST 3714 NORTHGATE SLVD SACRAMENTO CA 95834 111891 1 PROTEIN--TOTAL UA 9.3 40647893 4.12 4. i2 MET WEST 3714 NORTHGATE bLVD SACRAMENTO CA 95834 111691 1 URINE PROTEIN 4UANT. 40659138 32.00 32..00 111891 1 CHEM CREATININ SERV 40580217 16.00 16.`00 111891 1 CHEW UREA NITR-SRM 405830 +39 16,00 16. 00 111891 1 CHEM PANEL OF 7 40680738 53.50 53,50 191991 1 MICRO-CLT-ANY OTHER 40627-366 - 55 .00 55,.00 1.12291 1 HEMA-HEMGRF/PLT/ iii F 4061 5106- 31.00 31 .00 112291 1 IMMU PROTHROM TIKE 40670481 16.00 16.00 112291 1 IMMU PTT PART THROM 40670499 2250 22.50 112291 1 CHEM CREATININ SERU 40650217 16:00 16.00 112291 1 CHEM ELECTRO PANEL 40680266 45.50 45. 50 112291 1 CHEM UREA NITt2-SRM 40680639 16.00 16.00 112291 1 CHEM PANEL OF 7 401680738 - 5.3.50 53.50 112491 1 COPPER SRM 98 40645145 10.20 10. 20 MET NEST 3714 NORTHGATE BLVD SACRAMENTO CA 95634 � PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY �i)y� p NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE PAY THIS AMOUNT UL 8 0 AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. 625 Court Street, Room 203 Martinez, California 94553 < ti ,•• CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO TYPE GF bATEOFBILL ✓f 2500 ALHAMBRA AVENUE `s BILL MARTINEZ, CALIFORNIA 94553 R F Q T i_t. Ob/22192 (510) 313-6500 INP. w n> r PATIENT NAME �I PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED v I HAMr YOUNG C 1910260 M 46 11 /13/91 11 !25191 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER, GUARANTOR YOUNG HAI VETERANS ADMIN HOSPITAL 040145 552.354950 NAME 256 DONEGAL WAY INSURANCE PROF . COMP 040146 662 AND 'MARTINEZo CA 94553 - ADDRESS i� PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF ( SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE, PATIENT SERVICEON HOSPITAL SERVICES CODE CHARGES INS.CO.NO.t INS.CO.NO.2, INS.CO.NO.'3 AMOUNT ** TOTAL CLINICAL LAS 1752. 24 1752.29 112091 1 CYTO 81) C FLUID i� 40730038 72,.50 72. 50 112091 1 CYTO CELL BUTTO61' 4073 0145 72.50 72. 50 112091 1 CYTO WRIGHT STN 40730986 20.00 20.00 * TOTAL PATHOLOGY 155.00 165. 00 I� 111491 1 ECG 41100017 77.00 77. 00 * TOTAL EKG 77.00 77. 00 112191 1 EEG-STANDARD { 41300344 ` 1 38.,00 136.00 * TOTAL EEG 138.00 138.00 111391 1 CHEST 2 VIEW 41410021 1240-00 124.00 111391 1 ABD (KUB) 41410200 84..50 84.50 111491 '1 ABDOMEN ULTRASOUND 41 447b 12 -,, 353.50 353.50 111591 1 CHEST 1 VIEW � 414/0010 81 .00 81 -00 111591 1 PORTABLE 41418062 34.50 39. 50 111791 1 CHEST ,2 VIEW 41410026 12440 ",1'2"4.00 111'791 1 CALL TECH � 41418.1,20 "v 63.,00 63.00 111991 1 CHEST 2 VIEW 4141006' 12,4.00 124.00 * TOTAL X-RAY ( 993.50 993. 50 111391 6 FOLIC ACID 1MG I� 41703406 12.`00- 12.00 111391 1 MULTIVITS 41703027 2 .002.00 111391 1 NAG SULF 2GIrl100CiiC 05 41711169 16.00 16. 00 111391 1 PNYTONADION INJ' 10M 41714171 8.75 8.75 111391 480 LACTULOS SYR1001r,115C 41716457 19.'20 19. 20 111391 2 THIAMINE 50MG 1jJAS 41719253 4.00 4.00 111491 2 POT CHLORIDE INJ 417003501 12.62 12. 62 111491 1 FOLIC ACID 1MG 41703405 2.00 2.00 111491 1 MULTIVITS 41703927 . 2 .00 2.00 111491 2 D5/LR 100OCC 41710047 15.00 15.00 11149.1 1 T6 SKIN TEST 41715715 2.00 2. 00 111491 1 THIAMINE INJ 100MG 41715921 3.00 3. 00 111491 2 THIAMINE 50MG 1IrAS 41719253 4.00 4.00 II PATIENT NUPLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY NUMBER ON ALL INQUIRIE MBER S it CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE,.PAY THIS AMOUNT 7 Y1 uldouAND CORRESPONDENCE. i IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. ' CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. Ma Court Street, Room 203 Martinez,California 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. TYPE OF oATEOFsiu 2500 ALHAMBRA AVENUE BILMARTINEZ, CALIFORNIA 94553 R F R T L 9_ 06122192 r (510) 313-6500 I tti r n r PATIENT NAME' �1 PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED HA flr YOUNG C 1910286 N 46 11/13191 11 25191 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER' GUARANTOR YOUNG HAM VETERANS ADMIN HOSPITAL X740146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND MARTINEZP CA 94553 ADDRESS PLEASE11 RETURN TOP PORTION WITH YOUR PAYMENT DATE OFDESCRIPTION OF Jl SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE QTY. HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.CO.NO.2 INS.CO.NO.3 AMOUNT 1114915 ZINC SULFATE 22 111491 2 'PIGGYBACK FEE �l 1iMG 41719366 2.53 2.55 4172151 5 40.00 40.00 111591 1 FUROSE#SIDE 100 1010, 41700295 3.68 3.68 111591 1 POT CHLORIDE IN-. 41700501 6.31 6. 31 111591 1 FOLIC ACID 1?4G 417034136 2.00 2. 00 111541 1 MULTIVITS 417U3927 2100 2.00 111591 1 05/LR 100OCC 4171 047 7.50 7.50 111591 2 THIAMINE 10MG T1 6 41719253 4.00 4.00 1115 .+1 1 PIGGYt3ACK FEE 41721515 20.00 20.00 111691 1 POT CHLORIDE IN 41700501 6.32 1 6. 31 111691 1 FOLIC ACID 1PIG 41703406 2.00 2.00 111691 1 MULTIVITS 4170139-27 . 2.+00, 2.00 1117x91 1 D5/L : 10(YaCC 41.710' 47 , > 7.50 7. 50 111691 2 THIAMINE SONG TB 4 17 f9 25 3 . 4.004.00 111691 31 C E F T R I A X 0 N I G M 055UC .41714584 120.0q 111691 4 'PIGGYBACK FEE 41721`515 80.,00 1'0. 00 1117511 2-POT CHLORIDE IN41- Oils-01 12.82=, 't2. 62- 11'1791 1 FOLIC ACID 1FIG 4"l7t73, 111791 1 MUtTIVITS 4171339'27 2.Ofl . .2'.do 111791 2-D5/LR 100OCC 4179 A,4,' 5.:10"0 111791 2 HEPARIN FLUSH (' OOU, 4171'48179 4.86 40`16 111791 2 THIAMINE 50NG T�8 41�71,9253 4 4'004"00 111791 1 C EFTRIAXON1 GN 1)50C 4'171.95184 4C#.013 . 40.00 111791 1-PIGGYBACK FEE 41721,5-x,5 20.00- 213.00- 111891 1 FOLIC ACID 1MG 41701404" 2-.0)Dt 2.00 111891 1 MULTIVITS 41703427, 2 .00" 2- 00 111891 2 AC ETA MINOPIli Eiji 31 5MG 41704 66 2.00 2.00 111891 05W I UUCC 41710062 N/ C 111891 3 HEPARIN FLUSH (• OOU 41714804 7.29 7.29 111891 2 THIAMINE 50MC Tj 8 41719253 4.00 4. 00 111891 1 CEFTRIAXON1GM D! 50C 41714584 40.00 40.00 111391 1 PIGGYB-AC1C FEE 1 41721515 20.00 20. 00 111891 RANITIDINE 50MG OOC 41722729 N/C 111991 1 FOLIC ACID 1MG 417173406 2.00 2.00 111991 1 MULTIVITS 41703927 2 .00 2.00 111991 20 SPIRONOLACTONE �)5MG 41713637 10.60 10. 60 ,r PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY - ` NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE PAY THIS AMOUNT 3 91 Ud BU AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. 625 Court Street, Room 203 ,, Martinez,California 94553 t\ CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. TYB�oF .DATE OF BILL f 2600 ALHAMBRA AVENUE ' MARTINEZ, CALIFORNIA 94553 tt a t a t 06122192 (510) 313-6500 INP PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED T A 4 ►v r HA Mo YOUNG C 1910260 ,"; 46 11 /13/91 11 /25/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG HAM VETERANS ADMIN HOSPITAL 040146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND IOARTINEZ/ CA 94553 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE OTY HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.00.NO.2 INS.00.NO.3 AMOUNT 111911 2 HEPARIN FLUSH (100U 41714809 4.86 4. 86 111991 20 SPECIAL ORDER MED 41719089 15.00 15. 00 SYPRINE 250 MG CAPS 111991 2 THIAMINE 50MG TAB 41719253 4.00 . 4. 00 111991 1 CEFTRIAXON16H D550C 41719584 40.00 40.00 111991 1 PIGGYBACK FEE 41721515 20.00 20,.00 112091 1 FOLIC ACID 1 MG 41 703406 2.00 2. 00 112091 1 MULTIVITS 41703927 2 .00 .2.00 112091 2 HEPARIN FLUSH (10OU 41714809 4.86 4. 86 112091 2 THIAMINE 5ONG TAB 41719253 4.00 4. 00 112091 1 C EFTRIAXON1 GM 05500 41719584 40.00 40. 00 112091 1 PIGGYBACK FEE 41721,515 201.00 20.00 112191 1 FOLIC ACID ING 41703406 2.00-, 2.00 112191 1 MULTIVITS 41703927 2.0 : .. 2.00 112191 3 HEPARIN FLUSH (100U 41714$09 7. 291;, 7.,29 112191 5 ZINC SULFATE. 220MG 4171.9386 _ 2.55, 2.55 112191 1 CEFTRIAXO,N1GM 05500 41719534 40.0`6 40.00 112191 1 PIGGYBACK FEE 41-721515. 20-.00 '20.00 112291 1 FOLIC .ACID 1 iv3G 4170 3406 2.00 . - 2.00 112.291 1 MULTIVITS 41703:,x,27 2._ 0_ 2.t!0 112291 3 HEPARIN FLUSH (1Ci0U 41,714t69 7. 29 '21;29 112291 1 CEFTRIAKON1GM D550C 41'719554 40.00 40-00 11 `229'1 1 PIGGYBACK FEE 411215"1.5 `213.00-' 20.00 112391 1 FOLIC ACID 1 PIG 41703406 2.00 2. 00 112391 1 MULTIVITS 4170:927 2100 2.00 112391 1 3 HEPARIN FLUSH (100U 41714809 7.29= 7. 29 112391 311 SPECIAL ORDER RED 41719089 22.50 22.50 5YPRINE 250 MG CAPS 112391 5 ZINC SULFATE 22,014G 41719386 2.55 2. 55 112391 1 CEFTRIAXON1GN 0550C 41719584 40.00 40.00 112391 1 PIGGYBACK FEE 41721515 20.00 20.00 112491 1 FOLIC ACID 1MG 417133406 2.0:0 2.00 112491 1 MULTIVITS 41703927 2.0D 2.00 112491 2 HEPARIN FLUSH (1000 41714809 4.86 4.86 112491 1-CEFTRIAXONlGM 1Y550C 4171958.4 40.00- 40.00- 112491 1-PIGGYbACK FEE 417215/5 20.00- 20.00- PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY - NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE PAY THIS AMOUNT t Y i UL�it3 AND'CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. Ma Court Street, Room 203 Martinez, California 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. ;;.. TYPEOFDATE OF BILL S 2500 ALHAMBRA AVENUE 8 MARTINEZ, CALIFORNIA 94553 R c AT t t 1 0 6/?9/9 2 (510) 313-6500 INP PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED �v a HA Ke YOUNG C 1910280 1 �, 46 11 /13/91 11 /25/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOUNG H0 VETERANS ADMIN HOSPITAL 040146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND YMARTINEZr CA 9455.3 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.1 INS.CO.NO.2 INS CO.NO.3 AMOUNT 112591 1 FOLIC ACID 1MG 41703406 2.00 2,.00 112591 1 FULTIVITS 41703927 2.00 2. 00 112391 10 SPIRONGLACTONE 25MG 41713637 5 .30 5. 30 112591 1 HEPARIN FLUSH (100U 41714309 2.43 2. 43 112591 30 DIPHENHYDR.APIINE 500 41772112 3.00 3. 017 112591 10 FOLIC ACID 1MG 41772260 0.90 0.90 112591 10 MULTIVIT CAPS 41772609 0.20 0. 20 112591 40 SPIRONOLACT CT '25FIG 41778259 10.40 10.40 112591 20 THIAMIN 50MG 41778879 1 .00 1.00 112591 960 LACTUL SYR 10GM,/15C 41785692 38.40 38. 40 112591 10 ZINC SULF 22J�16 CAP 41789108. 0.90 0. 90 * TOTAL PHARMACY '23.13 923.13 111391 1 ANAL BLD P02,PCOZ&P 418131171 . 80.00 $0. 00 111591 5 OXYGEN PER HOUR 41802162 30.00 30.00 111591 1 NASAL CANNULA 41.830100 8.130 5.00 111591 1 OXIMETER USE 4/ 881061 71 . 50 71.50 111591 1 ANAL BLD P02.PCO2&P 4181311-11 80.00 , 80.00 111691 1 OXYGEN PER DAY 41802190 125.50 12.5. 50 111591 3 PULSE OXIIVIETER CHEC 41,881-179 121 .50 121..50 111791 1 OXYGEN PER DAY 4180`2190 125.50 125050 111791 2 PULSE OXIMETER CHEC 41881w070 81 .00: £31.00 111891 2 INCENTIV SPIROMETRY 4'18815.15 29.00 29.00 111891 12 OXYGEN PER HOUR 418021;82 72..00,: 7 2.00 111891 3 PULSE OXIIETER CHEC 41881079 121 .50 121 . 50 111991 1 INCENTIV SPIRO�,IETRY 41 b01 515 ' 14.50 14. 50 111991 8 OXYGEN PER HOUR 41802162 48.00 48.00 111991 1 PULSE OXI DIETER CHEC 41881079 40.50 40.50 112091 12 OXYGEN PER HOUR 41802lb2 72.00 72.00 112091 3 PULSE OXIMETER CHEC 41881079 121 .50 121 .50 112191 8 OXYGEN PER TOUR 41802182 48.00 48.. 00 112191 3 PULSE OXIMETER CHEC 41881079 121 .50 121 .50 112291 3 PULSE OXIPrIETER CHEC 41881079 121 .50 121 .50 112391 8 OXYGEN PER DOUR 41802182 46.00 48. 00 112391 2 PULSE OXIKETER' CHEC 418811779 81 .00 81 .00 112491 3 PULSE OXIMETER CHEC 41881079 121 .50 121 .50 PATIENT NUMBERPLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY NUMBER ON ALL INOUI RIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR ..PLEASE PAY THIS AMOUNT T Y1 u e d(i AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. 625 Court Street, Room 203 Martinez, California 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE No. TYPE OF DATE OF BILL _�f .i ;2500 ALHAMBRA AVENUE � BILL ^" MARTINEZ, CALIFORNIA 94553 R r-6 1 L L 06/22192 (510) 313-6500 INP ~" y n 4 PATIENT NAME PATIENT NUMBER SEX AGE I ADMISSION DATE I DISCHARGE DATE DAYS AMOUNT ENCLOSED 8AM, YOUNG C 1910280 M 46 11 /13/91 11/25/91 12 $ INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER: GUARANTOR YOUNG HAI~? VETERANS ADMIN HOSPITAL 040146 552354950 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND MARTINEZ. CA 94553 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE- EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO,NO.1 INS.CO.NO.2 INS.CO.NO.3 AMOUNT 112591 2 PULSE OXIMETER CHEC 41681079 81 .00 81. 00 ** TOTAL. CARDIOPULMONARY OVARY 1864.50 1864. 50 112291 1 P.T. EVAL 30 SHIN 42010041 77.50 77. 50 112291 1 GAIT TRNG 15 MIN 42010421 29.00 29.00 ** TOTAL REHAa THERAPY 106.50 106. 50 111891 1 B SURFACE ANTIGEN 43670066 18.00 18. 00 111691 1 A IGM ANTI6ODY 43670082 17. 50 17. 50 111891 1 ANTI H8C-IGc4* 43670132 17.00 17. 00 111991 1 ACID FAST SSNEAR/CUL 43670363 37.50 37.50 ** TOTAL LAB-CLINICS PUBLIC HL 90.00 90.00 111391 1 TREATMENT ROOD 453U,000-'>. 50.00 50.00 111391 1 COMP ADMIT HX&PX-NE 453,01017 120.00 120. 00 ** TOTAL EMERGENCY ROOM VISITS 170.00 3�0nfl0 111391 1 IV PLACEPADULT-COMP 4,5-421435 24.01 24.00 ** TOTAL EMERGENCY ROOM PROCEIP 2440 24.00 i 2751 5624440-01-0002 13572.99 1371 6.9'9 144.00 PATIENT 44.00PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY �i NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED, OR PLEASE.PAY THIS AMOUNT 1 44 t 0-- 1 y l U tisy AND CORRESPONDENCE. IF-INSURANCE CARRIERS DO NOT PAY ANY PART OF THE • AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. 625 Court Street, Room 203 Martinez, California 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO: 10 75PI OF DATE OF BILL f .2500 ALHAMBRA AVENUE .. MARTINEZ, CALIFORNIA 94553 R fi A t t. Q6/22192 (510) 31=3-6500 mak,- INP. PATIENT NAME PATIENT NUMBER `DA s _ SEX AGE` ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED xs HAM. YOUNG C 1910280 Srd b 11 /13/91 111 /25191 INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER- GUARANTOR YOUNG HAS? VETERANS ADMIN HOSPITAL 040146 552354951 NAME 258 DONEGAL WAY INSURANCE PROF COMP 040146 662 AND MARTINEZ/ CA 94553 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE ON' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.t INS.CO.NO.2 INS.00.NO.3 AMOUNT SUMMARY OF CHARGES 6Y DEPARTMENT MEDICAL (d WARD) 462.00 462. 00 CENTRAL SUPPLY 759.07 759. 07 CLINI,AL LAS 1752.29 175?. 29 PATHOLOGY 165.00 .05.0j EKG 77.100 77.00 EEG 138.00 138.00 X-RAY 993. 50 993.50 PHARMACY 923.13 923.13 CARDIOPULMONARY 1864.50 1864. 50 REHAB THERAPY 106. 50 106. 50 LAB-CLINICS & PUBLIC HLT 90.00 90.00 EME?_kk CY ROOM VISITS 170.010 170-100 EA RGENCY Room PROCED 24.00 24 JO 12 DAYS HiiEOI C AL 61 516:00 6,192.00 6192 .00 SUBTOTAL CHARGES 13716.99 13716.99 TOTAL LIABILITY 13716.99, 1 '7'16._99 PAYMENTS & ADdS 144.00- 144.00- YOUR 44.00-YOUR INSURANCE HAS ShEN BILLS& �7,�vpa r 2751 5624440-01-0002 13572.9911-3716.99 144.00- PATIENT NUMBER PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY NUMBER ON ALL INQUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED,OR PLEASE PAY THIS AMOUNT 11+1}. 0Q- 'I yT u g!du AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE • AMOUNTS SHOWN UNDER ESTIMATED INSURANCE COVERAGE. CONTRA COSTA COUNTY HEALTH SERVICES • Make checks payable to County Auditor-Controller. Ma Court Street, Room 203 Martinez,California 94553 - 1 . 1 5 County Counsel CLAIM MAR 3 1993 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA -• Martiridz, CA 94553 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1,350.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: RARANG, Victor and Kathleen ATTORNEY: Date received ADDRESS: 101 Via Serena BY DELIVERY TO CLERK ON March 2, 1993 Alamo, CA 94507 BY MAIL POSTMARKED: hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. GATED A March 3, 1993 Jy!L BATCHELOR, Clerk P y II. FROM: County Counsel TO: Clerk of the Board of S rs ()() 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: 1943 BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD OR 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: APR 0 g 1g93 PHIL BATCHELOR, Clerk,, By Deputy Clerk WARNING (Gov. code sec 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnino see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR 0 7 1993 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator sR e Clair to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY n_ INSTRUCTIONS "In CLAIMPuNT 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 or property or growing crops and which accrue on or after January I,-' 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 Hoard of Supervisors at ita',offiee 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 fil ng stamp RECEIVE IN 4"h eggr) L L=C4 ) AAga�nst the County of Contra Cet' ) 2 199,3 ., or ) gOAFtDOFS 'EFtViS4A District) Ci.ERKCo* ACOSTA C4,_ ' - - Fill- in name ) -- --_ The undersigned claimant hereby makes claim against the County of Contra Costa or c-1c:b the above-named District in the sum of $ �I,,�35Q . � Q , ,ptr,a�4 and in support of. this claim represents as follows:1lost- . 1. When did the damage-or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) .._...� _.. tw___ 3• How did the damage or injury occur? (Give full details; use extra paper if required) ( ItcKu � ol- L?v! vert5 qnc�,. ., S ern d r r na (tu c1`irn� cvtcE�'t; tebr» rYttlr.� -�vjpicto nto our 4. What particular act or omission on the part of county or district officers, servants or employees caused the inj or damage? ��. �-- rlo��rt Centro j t amu. ,jncttn (-,tr4 Y}S, Ovul Qteaiect... 1.l)(Li v Ai%r J Yip' '� {'f PYIi%�-( :a. Cbver). f��1lttih`j mutt Z t� uJt pooc2nd. rvnr ttrnL leekcr.rd.5, �. wnat are the napes of county or district officers, servants or employees causing the dazrage or injury? j� Cc,Un 5. What damage or inJuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. (c`it' a P(a`+� " " (V oz ��S6 b �1/1n>jr � do&;�qty s el e- `��5� � �J A I l''1 11,;t 1 q - -- /-/3�,74 ?. ` yHou was the amount claimed above computed? (Include the estimated amount -dr any- prospective injury or damage.)' dance b f us w 3. Names and addresses of witnesses, doctors and hospitals. ---------------------ell'e re c . out O u 1"_' dry e L�qY , -- 9. List the expenditures you made on account of this accident or njury: DATE ITEM AMOUNT 13113 fc0kg � ic�o rK h�i,�r� �' 33 2-3 = Z-l�S: �f < <r _ n0 Lao rK 1w y Gov. Coo Sec. 910.2 provides: . .,. "Thpclm must be signed by the claimant SEND NOTICES_ peran on his behalfr . some Name and Address-of Cla' S gnature Address Telephone No. Telephone No. /5_/ NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the. county jail for a 'period of not more than one year, by a fine of not exceeding one thousand ($1,000).,' or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding tem thousand dollars ($10,000, or by both such imprisonment and fine. v d (510) 828-3100 * FAX 734-04174r EARL ADAMS TILE& PLASTER, INC. Q, S 3675 Old Santa Rita Rd., Pleasanton CA 94588 (707) 642-2141 (209)467-0170 #,I 5310-B Power Inn Rd.,Sacramento,CA 95820 (916) 383-7699 * FAX 383-0782 He Plaster Contractors License No.C53-268346 PROPO, SUB ITTED TO PHONE DATE STREET JOB NAMES /o �^ 's ®1 CITY, 74A E AND ZIP CODE- 1#_-.50JOB LOCATION In dQ JOB CODE IMAPBOOK CITY JOB PHONE 103 REPAIR CONTRACT; Describe Repair Below. , �-�- oral, tl PXemove 1,4%s lg�m c e- r WO e t_--5 XO-5: e- Ac i0l -5 1�9 12910�1 A/0 7L Re.,Ina I/e A -7 A elfil A/// 661 Ilse � J yr ��►G --ro Become- Xdvixo -7-// s k/ S loetl�le_xle To cancel this Contract, You the BUYER must notify the SELLER at the above address by certified mail or telegram no later than midnight of the third(3)business day following the date of this transaction. If cancelled within this period all deposits will be refunded with no penalty. All repairs are guaranteed for 30 days. Contractors are required by law to be licensed and regulated by the Contractor's State License Board. Any questio7nj contractor may be referred to the Registrar,Contractor's State License Board,9835 Goethe Road,Sacramento,CAAddress: P.O. Box 26000,Sacramento, CA 95826. WE PR7t//7 OSE he elb to f nish material an bor-complete in accordance with above specifications, th � � / dollars ($zo EACH SEPARATe PHASE OF WORK TO BE PAID FULL TTI E O REPAIR AII;material is guaranteed to be as specified. All work to be completed in a workman like manner according to standard practices. Any alteration or deviation from above specification involving extra costs will be executed only Submitted By: Date: upon written orders, and will become an extra charge over and above the . estimate. All agreements contingent upon strikes,accidents or delays beyond our controlrOWNER Owner to carry fire,tomado and other necessary insurance. Our are fully covered by Workman's Compensation Insurance. Accepted By: Date: TANCE PROPOSAL-The above prices,specifications and conditions factory and are hereby accepted. You are authorized to do the work ied. Payment will be made as outlined above. Buyer Date: ent litigation is required to enforce the terms of this contract, the g parry will entitled to attorney's fees. ACKNOWLEDGES 8 ACCEPTS ALL TERMS SET FORTH ON REVERSE THIS CONTRACT. Buyer Date: PROPOSAL MAY BE WITHDRAWN BY SELLER IF NOT ACCEPTED IN 30 DAYS When a swimming pool is drained, a natural hazard is temporarily created caused by the absence of water in the pool. As a result of this natural hazard it is possible that, despite any precautions taken by EARL ADAMS TILE-COPING & PLASTERING the following conditions might occur: (1) the pool might "float" due to hydrostatic pressure or surcharge conditions, (2) the pool shell may crack, (3)there may be checking in the plaster, (4) a person or thing could fall into the empty pool, injuring themselves and/or the pool, or(5) the pool light is cooled by water. If turned on while not immersed it will be damaged or blow up. Disconnect breaker or tape switch to prevent accidental turn on. The buyer agrees to save and hold EARL ADAMS TILE-COPING &PLASTERING harmless from any liability therefor. EARL ADAMS TILE & PLASTERING agrees to take all reasonable precautions for prevention of pool floatation. NOTICE to OWNER Under the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier or other person who helps to improve your property,but is not paid for his/her work or supplies, has a right to enforce a claim against your property. This means that after a court hearing, your property could be sold by a court officer and the proceeds of the sale used to satisfy the indebtedness. This can happen even if you have paid your contractor in full if the subcontractors, laborers or suppliers remain unpaid. To preserve their right to file a claim or lien against your property, certain claimants such as subcontractors or material suppliers are required to provide you with a document entitled "Preliminary Notice." Original (or prime) contractors and laborers for wages do not have to provide this notice. A Preliminary Notice is not a lien against your property. Its purpose is to notify you of persons who may have a right to file a lien against your property if they are not paid. (Generally. the maximum time allowed for filing a claim or lien against your property is ninety (90) days after completion of your project.) TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY, YOU MAY WISH TO TAKE 3 ONE OR MORE OF THE FOLLOWING STEPS: 1. Require that your contractor supply you with a payment and performance bond (not a license bond), which provides that the bonding company will either complete the project or pay damages up to the amount of the bond. This payment and performance bond as well as a copy of the construction contract should be filed with the county recorder for your further protection . 2. Require that payment be made directly to subcontractors and material suppliers through a joint control. Any joint control agreement should include the addendum approved by the Registrar of Contractors. 3. Issue joint checks for payment. made out to both your contractor and subcontractors or material suppliers involved in the project. This will help to ensure that all persons due payment are actually paid. 4. After making payment on any completed phase of the project, and before making any further payments, require your contractor to provide you with unconditional lien releases signed by each material supplier and subcontractor involved in that portion of the work for which payment was made. On projects involving improvements to a single family residence or a duplex owned by individuals, the persons signing these releases lose the right to file a claim against your property. In other types of construction this protection may still be important, but may not be as complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU MUST BE CERTAIN THAT All MATERIAL SUPPLIERS, SUBCONTRACTORS AND LABORERS HAVE SIGNED. • M uouniy uounsei CLAIM MAR 2 21993 ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Martinez, CA 94553 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section 913 and 915.4. Please note all "Warnings". CLAIMANT: SALAS, Elsa ATTORNEY: Stanley J. Bell. Law Offices of Stanley J. Bell Date received ADDRESS: Two Transamerica Center BY DELIVERY TO CLERK ON March 11, 1993 505 Sansome St. , 18th Floor San Francisco, CA 94111 BY MAIL POSTMARKED: March 10, 1993 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED March 17, 1993 JAIL BATCepuHELOR, Cler I1. FROM: County Counsel TO: Clerk of the Board o 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: Dated: Z� /��3 BY: Deputy County Counsel III. FRnM-- Clerk of the Board TO: County Counsel (1) County Administrator (2) (, Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (1�)DOThis 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: APR 0 6 1993 PHIL BATCHELOR, Clerk. B . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately, *For additional warnina 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: APR 0 7 '19 BY:PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator RECEIVED MAR 1 11993 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. 1 CLAIM FOR DAMAGES FOR PERSONAL INJURIES 2 TO: BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 3 651 Pine Street Martinez, California 94553 4 PLEASE TAKE NOTICE that the undersigned hereby serves 5 and makes demand upon you for the cause and amounts set forth 6 in the following claim: 7 Claimant ' s name and address: 8 ELSA SALAS 9 2035 Sherman Drive Pleasant Hill, California 94523 10 ,4 a _ Claimant ' s mailing address to which notices are to be 14 Z ° r 1 1 sent 0 0 a WF�w � o o�oomo 12 Stanley J. Bell, Esquire LAW .OFFICES OF STANLEY J. BELL -e � 13 A' Professional Corporation °W o z W° z Two-.:Transamerica.. Center_. ar-1 W a` o 0. 14 505+`-S ,__ansome Street, 18th` Floor zoZ � San Francisco, California 94111 Ne �zF 15 Amount of Claim: 16 Special damages and expenses proximately caused by the 17 occurrence described below and general damages are in excess of 18 the jurisdictional minimum of the Superior Court . 19 Date and Place of Occurrence giving rise to the Claim 20 asserted: 21 On or about the 12th day of October, 1992 on San Pablo 22 Dam Road, north of Bear Creek Road in the County of Contra 23 Costa, State of. California. . 24 Description of Occurrence`: 25 That-on or about. the aforementioned date and for some 26 1 time prior thereto, the above-named public entities, and each 2 of them, negligently and carelessly controlled, supervised, 3 designed, constructed, altered, repaired, owned, maintained, 4 operated and entrusted the aforementioned roadway so as to 5 proximately cause and permit said roadway to be in a dangerous, 6 defective and unsafe condition in that there was inadequate and 7 insufficient site distance along the curve of said roadway, in 8 that the enbankmert was not adequately cut away to provide an 9 adequate site distance; and further in that they failed to post 10 warning signs or any other proper control devices to warn aa" < 11 oncoming motorists of sharp and dangerous curves in said o, 0 :; W F F w a o 'pgo�m = 12 roadway; that in all respects the unsafe conditions as stated O �Sa�� 13 above constituted a trap for vehicles at said roadway and F OPP 0zW°o further in that they allowed it to be obstructive and confusing e:� Wao�a 14 � o6z" 15 to persons and vehicles using said roadway, thereby creating a reasonably foreseeable and substantial risk of injury to 16 persons using said roadway; that said public entities, and each 17 of them, were further negligent and careless in that they knew, 18 or in the exercise of ordinary care should have known, of the 19 dangerous condition of said roadway and the risk of injury 20 created by same, and failed to remedy said conditions, having a 21 reasonable opportunity to do so; that as a direct and proximate 22 result of the negligence and carelessness of said public 23 entities, and as a further direct and proximate result of the 24 dangerous and defective condition of public property, as 25 aforesaid, while claimant ' s husband, JORGE E. SALAS, was 26 -2- 1 driving on said roadway, a vehicle operated by Karen D. 2 Phillips was caused to cross the double line and directly into 3 the lane in which JORGE E. SALAS was traveling, causing her 4 vehicle to strike JORGE E. SALA' s vehicle head-on, thereby 5 causing him to sustain severe personal injuries and thereby 6 causing claimant to be deprived of the consortium, conjugal 7 society, comfort, affection, companionship, moral and emotional 8 support of her said husband. 9 DATED: March 1993 . 10 LAW OFFICES OF STANLEY J. BELL � x ^ aoao , 11 Wpq � Z.� n 12 By. od =off STANLEYT, BELL ��' $aWan Attorneys Claimant w� aIays 13 o z�-oW 3WOZWvio aaw °G�� a 14 zpo~z � � W da ��wF C!1< 15� e 16 17 18 19 20 21 22 23 24 25 26 -3- RE: Claim of ELSA SALAS ACTION NO. + PROOF OF SERVICE BY MAIL - C.C.P. Sections 1013a, 20 .1.5 . 5 I , the undersigned, hereby declare that I am a citizen of the United States, over the age of eighteen years, and not a party to the within action. I am employed by the LAW OFFICES OF STANLEY J. BELL. My business address is 505 Sansome Street, 18th Floor, San Francisco, California, 94111 . I served a true copy of the CLAIM FOR DAMAGES FOR PERSONAL INJURIES by mail, by placing the same in an envelope, sealing, fully prepaying postage thereon and depositing said envelope in the U.S. Mail at San Francisco, California on March 10, 1993 . BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 651 Pine Street Martinez, California 94553 I declare under penalty of perjury that the foregoing is true and correct . Executed in San Francisco, California, on March 10, 1993 . Donna L. Kotake �RViSC�R� C1fR�'soNtRAo�5 G� d p r r • `��..• .''r "° to LC) ' t3" Fr. � �O � 00 a © �, U wo � 0 dik Q. 04 U `fl .D t p N a � o W y w = � s 4 County Oaurlsal CLAIM MAR Z 12, 493 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIAE$ffif1E'z, A 94 553 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Undetermined Section 913 and 915.4. Please note all "Warnings". CLAIMANT: SALAS, Jorge E. ATTORNEY: Stanley Bel.1, Esq. Law Offices of Stanley J. Bell Date received ADDRESS: Two Transamerica Center BY DELIVERY TO CLERK ON March 11, 1993 505 Sansome St. , 18th Fl.00r San Francisco, CA 94111 BY MAIL POSTMARKED: March 10, 1993 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED:. march 17, 1993 gtIL BATCHELOR, Cler II. FROM: County Counsel TO: Clerk of the Board of toperVisors ( 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: IWO.'I'6k ZZ ��1�3 BYDeputy County Counsel 11I. 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 da XPR U 6 1993 Dated: PHIL BATCHELOR, Clerk. By . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina see reverse side of this notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez. California. postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claima�tPn shown 1993above. Dated: R BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 1 11993 ;4 CLERi'.BOARD OF SUPERVISORS CONTRA COSTA CO. CLAIM FOR DAMAGES FOR PERSONAL INJURIES 1 2 TO: BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 3 651 Pine Street Martinez, California 94553 4 PLEASE TAKE NOTICE that the undersigned hereby serves 5 and makes demand upon you for the cause and amounts set forth 6 in the following claim: 7 Claimant ' s name and address : 8 JORGE E. SALAS 9 2035 Sherman Drive Pleasant Hill, California 94523 10 Claimant ' s mailing address to which notices are to be �40W$ a 11 sent : Wzweo o� o u Q a 12 Stanley J. Bell, Esquire �►�o2f: - LAW OFFICES OF STANLEY J. BELL W- ,I � W 13 A Professional Corporation ow ozWOz Two .Transamerica Center.. e�lWao5°xy 14 505 Sansome Street, 18th Floor z "' H � w San Francisco, California 94111 � aoazw F ° " ~ 15 a � z C/1 0 < Amount of Claim: 16 Special damages and expenses proximately caused by the 17 occurrence described below and general damages are in excess of 18 the jurisdictional minimum of the Superior Court . 19 Date and Place of Occurrence giving rise to the Claim 20 asserted: 21 On or about the 12th day of October, 1992 on San Pablo 22 Dam Road, north of Bear Creek Road in the County of Contra 23 Costa, State of- California , 24 Description of .Occurrence: 25 That, on . or about the aforementioned date and for some 26 I time prior thereto, the above-named public entities, and each 2 of them, negligently and carelessly controlled, supervised, 3 designed, constructed, altered, repaired, owned, maintained, 4 operated and entrusted the aforementioned roadway so as to 5 proximately cause and permit said roadway to be in a dangerous, 6 defective and unsafe condition in that there was inadequate and 7 insufficient site distance along the curve of said roadway, in 8 that the enbankment was not adequately cut away to provide an 9 adequate site distance; and further in that they failed to post 10 warning signs or any other proper control devices to warn �1 a � oncoming motorists of sharp and dangerous curves in said a0W0o 11 PQ96wr2 '- roadway; that in all respects the unsafe conditions as stated O� aM 12 ao above constituted a trap for vehicles at said roadway and 13 °W0 UZ further in that they allowed it to be obstructive and confusing �aWao�w 14 � 0 6to persons and vehicles using said roadway, thereby creating a zF 15 reasonably foreseeable and substantial risk of injury to 16 persons using said roadway; that said public entities, and each 17 of them, were further negligent and careless in that they knew, 18 or in the exercise of ordinary care should have known, of the 19 dangerous condition of said roadway and the risk of injury 20 created by same, and failed to remedy said conditions, having a 21 reasonable opportunity to do so; that as a direct and proximate 22 result of the negligence and carelessness of said public 23 entities, and as a further direct and proximate result of the 24 dangerous and defective condition of public property, as 25 aforesaid, while claimant was driving on said roadway, a 26 I vehicle operated by Karen D. Phillips was caused to cross the 2 double line and directly into the lane in which claimant was 3 traveling, causing her vehicle to strike claimant ' s vehicle 4 head-on, thereby causing him to sustain severe personal 5 injuries . 6 DATED: March 1993 . 7 LAW O ICE OF ST L J. BELL 8 9 By: S J. ELL 10 At o s f Cla' ant a az o 0w0a 11 W � zweo . s _ 0� ou , 12 O W� aO2Ha — v vaWa 13 3 WoN " oz u x 14 �aWa0a zw �� CO 6 x w 15 a oz N� 16 17 18 19 20 21 22 23 24 25 26 RE: Claim of JORGE E. SALAS ACTION NO. PROOF OF SERVICE BY MAIL - C.C.P. Sections 1013a, 2015 . 5 I, the undersigned, hereby declare that I am a citizen of the United States, over the age of eighteen years, and not a party to the within action. I am employed by the LAW OFFICES OF STANLEY J. BELL. My business address is 505 Sansome Street, 18th Floor, San. Francisco, California, 94111 . I served a true copy of the CLAIM FOR DAMAGES FOR PERSONAL INJURIES by mail, by placing the , same in an envelope, sealing, fully prepaying postage thereon and depositing said envelope in the U.S. Mail at San Francisco, California on March 10, 1993 . BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 651 Pine Street Martinez, California 94553 I declare under penalty of perjury that the foregoing is true and correct . Executed in San Francisco, California, on March 10, 1993 . Donna L. Kotake of Vgeli�_� c., G ri P ct. N .n rr o o o N O a d = a W4 � tIl CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of _California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $105.00 County Co (Para n 913 and 915.4. Please note all "Warnings". CLAIMANT: SALAZAR, Ernest MAR 2 2 i 1�j ATTORNEY: Martinez, UA y4663 Date received ADDRESS: 7 Grandview Place BY DELIVERY TO CLERK ON March 9, 1993 Walnut Creek, CA 94595 BY MAIL POSTMARKED: March 8, 1993 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: March 17, 1993 gglL BATCHELOR, Cler epuII. FROM: County Counsel TO: Clerk of the Board of SvpeWisors ( 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: W"c,G 2-3 BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 6 1993 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warnina See reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times heroin mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the Nnited 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: APR 0 7 1993 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRDCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of 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 yea.Fafter .the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims mist be filed With the Clerk of the Board of Supervisors at its office in Room 1060 County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by 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 vublic: anti* . E. Fraud. See penalty for fraudulent claims, Penal Code See. 72 at the end of this orm. RE: Claim By ) Reserved for Clerk's filing stamp MO _92A) A-aA� j RECEIVED MM Against the County of Contra Costa ) .. 9993 or ) CLERK BOARD OF SUPERVISORS PJ)N District) I CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim agains the County of Contra Costa or the above-named District in the sum of /D,5 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. ere 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) r3A 09 e l7 Sp v '►"� 514 )er4-ff `DO-J YY1�-� N�-�JJ 'Iv CJr►Tcl2 'fUA, nve, r ,o�reM ' ,its p-e, A ,ay.-?' 179� 93— G3!' 2 YM•M- --M__MM -M-_M--MYM�--M-M_ 41 . What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 4,c Z�.v �i �/J �'�'i ®v� ,y� /,3 E yv co op.¢s/tnn (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? (v e P use- err F=F ------------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. A 00 A 40 , -5-,4V- poor. `/A J�4 C.,T' b- ---------------------------------------------------------- --------------------- 7. How was the amount claimed above co uted? (Include the estimated amount of any prospective injury or damage.) -------- ------------------------------------------------- f.9T_ +_ 8. Names and addresses of witnesses, doctors and hospitals. i Gash• �h O ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT t Gov. Code See. 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 "KID 1 Cld i s Signature) Avoo Address Telephone No. Telephone No. el— 3 ;Zd 3 �t NOTICE Section 72•of •the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. ` 5070 GLOUCESTER LANE . LIC.#638497 MARTINEZ, CA 94553 BUS: (510)937-8761 PGR: (510)867-3542 _ LIGN DOOR COMPANY "For All Your Door Needs" INVOICE DATE - �` "' >'Yl APPROX. DELIVERY BY SOLD TO C Y I r, Z, r-, r CAV,l e \.j C C. e. PHONE: HOME L t _ - U - WORK QUANTITY PRODUCT/ITEM/STYLE • • AMOUNT ITEM DUE a TO 8�17 a,EL. A PtAc9 JA -9 Le 6- moo . 7 A . 5 HARDWARE TYPE_ BRIGHT or ANTIQUE $ HINGE TYPE BRIGHT or ANTIQUE $ PREHANG YES NO JAMB SIZE SWING $ EXTERIOR TRIM YES NO STYLE $ INTERIOR TRIM YES NO STYLE $ WEATHER STRIP YES NO COLOR $ STAIN & FINISH YES NO COLOR $ INSTALLATION YES NO $ SUBTOTAL $ NOTE: ALL SALES FINAL WITH DEPOSIT. TAX $ NO REFUNDS,STYLE CHANGES ACCEPTED BY TOTAL $ ALLOWED PRIOR TO DOOR DATE CHK DEPOSIT $ PREPARATION ONLY. DATE CHK BALANCE DUE $ APPROVED BY CUSTOMER SIGNATURE S e � a a a a✓ a 4i a ` I ttt ✓✓ ry D p 7 coy a z� n� 4 t� A " : f , 15 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ,?Sehhe action taken on your claim by the Board of Supervisors J (Paragraph IV below), given pursuant to Government Code Amount: $147.79 Ciel% y V: Section 913 and 915.4. Please note all •Warnings". CLAIMANT: WALLER, Charles R. "'r� ��,�L�553 ATTORNEY: 001 Date received ADDRESS: 561 Bustos Place BY DELIVERY TO CLERK ON March 4, 1993 West Pittsburg, CA 94565-6711 BY MAIL POSTMARKED: hand.delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, ' C1March 8, 1993 ppHIL BATCHELOR DATED: E I1. FROM: County Counsel TO: Clerk of the Board of upervisors ( ►�) 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: AuGLc �, /9�3 BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present Y )( ) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 6 1993 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice ofan 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: APR 0 7 1993 BY: PHIL BATCHELOR by , Deputy Clerk CC: County Counsel County Administrator d ♦r Clair,: to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must .be, presented not later .than the 100th day after the accrual of the cause of. action. Claims relating to causes of.action for -death or for injury.to person or to personal property or growing crogs .and 'whieh accrue on or after January 19 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not _. ....later-„than .one,.year.after the accrual of .the cause of action. (Govt. ,Code §911.2.) B. Claims must'be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal, Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp -,I ) Against the County of Contra Costa } 4 or } District) c tcsoAsaOF$UPERv4:�CARI Fill--in name CONTRA COSTA CC) The undersigned claimantlhereby makes claim against the ��unt of Contra Costa or the above-named District 'in the sum of $ -d 1� d in support of this claim represents as follows: _........... 1. When did the damage or- injury occur? (Give exact date and hour) 2. Where did the damage'°or injury occur? (Include city and county) f o 3. How did the damage or injury occur? (Give full details; use extra paper if �/� required)--7A, '��� ` r'� lt.)r'��c�c��!--'a>..�s�' c r-��.���-�-'� � ' �x?A� _ y l�Ca�i ac)l.}�,� a r' �j.�'.' /,'� �,v -�=i� �'t�•rJ �70�� C..�i.lE'y' �C''��'S"S . ...,� f 7, O 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) 7. wnat are the naves of county or district officers, servants or employees c4ps,ing, the darsage or injury? ------L� ?��aJ----------------- ----------------------_-------------- 6. What damage or- injuries do you claim resulted? (Give full extent,�of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) r 1:�,1'-410 YM-------N-__-. $. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on'account of this accident or injury: /DATE ITEM AMOUNT Gov. Code Sec. 910:2 provides "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some 2erson on his..behalf.". Name and Address of Attorney Claimant's Signature kAddress Telephone No. Telephone No. --/,q NOTICE Section 72 of the Penal Code provides: - _- - - - "Every person who, with intent tol 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 punishatle ;e, ir `by 'imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and- ine�or",:by imprisonment in the state prison, by a fine of not exceeding ten thousai `dollars ($10,000, or by both such imprisonment and fine. eaA1�:3-_ . 4 4— i a O w o ¢ m • - v e vV" t r . Qwtm sZ U= y fi `� 41, I'] .yYS r'77 : LU vr6t� ' NS w cc it y"' ! N Ni Fr m ocn 911i, WUo O zQqc;a'FSw =FTmo Xr 'W C. p p. s w w F s U ,Z o zoo Z J x a owl cs, c7 0: w o .'w. �y,� m aZ¢� 'I'll u E <m z '.calm z ` c . Z w�QFOF C i r '.L �LL J,, LL TVA U o .. u.. 'W ,zoO.LL J Z, GZ00 F- 7 g ,a Z 2 .(n 1 a h ¢ �'p'' W.; MFW .�y w ,. 2 Z U ., w- U �� Cd Z LE p : W 3 0w a W - J '�!`'¢ ¢o w w w 'm o y y CC o a �..: :> °Q IL o 0 0 `�Q aj. p ¢'• ¢ .._ N LLw `' m` _j ❑ D LL'.m 21 w ww a LU L11 t< ,Q m z zrf rn LU lu m t N Z w Y z��zv a w > > m W z, �x O. o O o O o aq ( w zSwr« :Lu Iu CL s LU w W 2 ¢ U Z 2 0 F- Z 2 COL QUO ' • • f l �~ Z Qmw Q W= o�� �t >Q> �'' aoo >f K oho mNmr Ic (t RE ii B e EWE;. O LL� _ } '{� �. ,00 Z' CE 1661 LEI R cc w r❑ ❑ LL �_ ❑ w ¢ to ,W a h o O ❑ x w ❑ .❑ z O o[ Y°� V ❑-.J a LLti q .¢ Fs VIRE a ❑ y .LL ❑ I O ¢ p Q O a cc cc O w ww ❑ ❑ 3 � �eae: w a rJ a ❑ ¢ f �� x w w LLI w I" �a3 : d z w OME cc _J_a w J U U Ua Q m,❑ ❑ � ac o a z o ❑ I- M. Fn wy aj R cc LU a: 0,. i � a F' \J w ¢ z O ¢ x a I. Y ( 'H f Jt- a ml \ a+ F� '` N M LL ¢K ¢ Z�, Z O } ti 'x - �n w O z x a ¢ a F Fc o z J cs i I' w w,:'w ❑ v -' U D 2 -CS m a' `m W S 'fL S '.U' U k+ N fA 3 U rn LLI ¢ Q W 2 'J .w 0 U U: Z > FJ( N of C O Z W O 4nd w a a: w' z z x z a a m. aw a mi U v m cs i .x m a,ac w .J o o O €m z cc m a. a w = s' ¢. w > ¢ .LL LL w: ¢ ¢ yr=a si:� awoLL.F ¢ 'ap W iW N � �_ �I I sgW G U. m }i 3. O ¢ :U m LL J. ¢'; 2 J 2 :tnH WH`:»f fq.R K fq Q Q.OJ s I h f U ❑ �„ OU LLt _�3 _ a� 00 aPa �ia� LU HOP J ,�W j J aunty Gaullsal AMENDED 1. 16 flH CLAIM AR BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 11AatImGz, C!1 94553 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT APRIL 6, 1993 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HURTADO, Nathan ATTORNEY: Rory D. Jensen, Esq. O'Brien, Sullivan & Jensen Date received ADDRESS: 1299 Newell Hill Place, Suite 300 BY DELIVERY TO CLERK ON March 10, 1993 & March 12, 1993 Walnut Creek, CA 94596 BY MAIL POSTMARKED: hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, pp g DATED: March 17, 1993 Btll Deputy OR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Sperv' ors ( P/) 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: g BYDeputy 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 0 ER: 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: APR 0 6 1993 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning See reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR 0 7 1993 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator RECEIVED MAR L 1993 CLERK 80ARD OF SUPERVISORS CONTRA COSTA CO. NATHAN HURTADO V. CONTRA COSTA COUNTY BOARD OF SUPERVISORS AMENDMENT TO TORT CLAIM Claimant, NATHAN HURTADO, hereby amends the Tort Claim which he has served in the above-entitled matter to state that the "Cambridge Elementary School" is to also include the entities known as Cambridge Center and/or Cambridge School, where the names of such entities are to be incorporated in and made a part of the original Tort Claim form. Dated: March 12 , 1993 _ RORY D. NS on be if o NATH HURTADO (P suant o Gov Code §910 . 2) 1 RECEIVE® MAR 1 2 1993 CLAIM AGAINST CLERK BOARD OF SU1FER SORS 5 a CONTRA COSTA CO. y CONTRA COSTA COUNTY To: CONTRA COSTA COUNTY BOARD OF SUPERVISORS 651 PINE STREET MARTINEZ, CA. 94553 1 . NAME AND ADDRESS OF CLAIMANT: Nathan Hurtado 1760 Detroit Avenue #32 Concord, CA 94520 2 . ADDRESS TO WHICH NOTICES SHOULD BE SENT: O' Brien, Sullivan & Jensen 1299 Newell Hill Place, Suite 300 Walnut Creek, CA 94596 3 . DATE AND PLACE OF ACCIDENT: September 16, 1992, at approximately 12 : 00 noon. The accident occurred at the Cambridge Center, Cambridge School, and/or Cambridge Elementary School (hereinafter "CAMBRIDGE" ) , located at 1135 Lacey Avenue, Concord, California, 94520 . 4 . GENERAL DESCRIPTION OF THE ACCIDENT: Claimant, Nathan Hurtado, was injured during the recess period at CAMBRIDGE in Concord, California. Claimant ' s injury resulted from a negligent attempt to stop a fight at CAMBRIDGE with excessive force being used by the employees/counselors/teachers and the school psychologist at CAMBRIDGE, which negligent excessive force resulted in Claimant ' s head being pushed through a glass window. 4 - RECEIVED MAR 1 01993 ' 3; S_s P.n. CLAIM AGAINST CLERK BOARD OF SUPERVISORS -_ :.r... CONTRA COSTA CO. CONTRA COSTA COUNTY To: CONTRA COSTA COUNTY BOARD OF SUPERVISORS 651 PINE STREET MARTINEZ, CA. 94553 1 . NAME AND ADDRESS OF CLAIMANT: Nathan Hurtado 1760 Detroit° Avenue #32 Concord, CA 94520 2 . ADDRESS TO WHICH NOTICES SHOULD BE SENT: O'Brien, Sullivan & Jensen 1299 Newell Hill Place, Suite 300 Walnut Creek, CA 94596 3. DATE AND PLACE OF ACCIDENT: September 16, 1992, at approximately 12 : 00 noon. The accident occurred at the Cambridge Elementary School at 1135 Lacey Avenue, Concord, California, 94520. 4 . GENERAL DESCRIPTION OF THE ACCIDENT: Claimant, Nathan Hurtado, was injured during the recess period at the Cambridge Elementary School in Concord, California. Claimant' s injury resulted from a negligent attempt to stop a fight at the Cambridge Elementary School with excessive force being used by the employees/counselors/teachers and the school psychologist at the Cambridge Elementary School, which negligent excessive force resulted in Claimant ' s head being pushed through a glass window. The accident .was also the result of the negligent failure of Contra Costa County, its agents, employees, managers, and representatives to adequately and competently hire, interview, investigate, train, police, supervise and control the conduct of employees/counselors/teachers and the school psychologist at Cambridge Elementary School and/or to implement proper policies for the supervision, control and discipline of students, such as Claimant, at the Cambridge Elementary School. In addition, Claimant was denied proper medical care and was mistreated and mishandled and purposely harmed by the school psychologist and counselors/teachers/nurses/employees of the Cambridge Elementary School prior to, during and after the accident as described herein, thus justifying the award of punitive damages . Contra Costa County, its agents, employees, managers, and representatives were also negligent in creating and allowing a dangerous condition to exist and not correcting such dangerous condition at the Cambridge Elementary School, including, but not limited to, not replacing glass windows with shatter-proof glass, plexi-glass and/or a similar type of safety glass in the area where claimant was injured. Said area is a common area where children gather and play during recess and other times of the school day. 5 . GENERAL DESCRIPTION OF THE INJURY: As a result of said incident, Claimant suffered from a complex left facial flap and avulsion which required debridement and repair of complex left facial flap laceration and avulsion, which required over 100 stitches and will require plastic surgery in the future. Claimant has been permanently scarred and disfigured as a result of said incident. A copy of the "Plastic Surgery Procedure, Plastic Surgery Consultant" report prepared by Dr. Kim Fang is attached to this claim and made a part hereto, along with copies of photographs of Claimant' s injuries. A copy of the Offense Report relating to said incident is also attached and made a part of this Tort Claim. 6. THE NAME OF THE PUBLIC EMPLOYEE CAUSING THE INJURY: Jerry Zimmerman. The names of the other employees, agents, _ managers, and representatives of Contra Costa County are unknown to Claimant at this time. 7 . Dollar amount of the claim exceeds $10, 000 and is within the jurisdiction of the Superior Court. Dated: March 3, 1993 _ =�af YJENSEN of IV6HAN HU TADO (Pursuant to Gov. Co §910 .2) HURTADO, NATHAN / cc: K. Fang, MSD. M. Goldin, M.D. PLASTIC SURGERY PROCEDURE PLASTIC SURGERY CONSULTATION DATE OF CONSULTATION/PROCEDURE: 9-16-92 PREOPERATIVE DIAGNOSIS: Complex left facial flap and avulsion, status post glass injury. POSTOPERATIVE DIAGNOSIS: Complex left facial flap and avulsion, status post glass injury. PROCEDURE: Debridement and repair of complex left facial flap laceration and avulsion, 15 centimeters total. SURGEON: Kim Fang, M.D. ANESTHESIA: Local. COMPLICATIONS: None. INDICATIONS: The patient is a 15 year old Hispanic male who apparently was in a fight in school, when the school counselor pulled them apart and then was accidentally thrown against a glass window. The patient sustained a large complex flap laceration, avulsion injury to the left face and presented to Mt. Diablo Hospital Emergency Room. Plastic Surgery consultation was requested by Dr. Goldin. The patient is up to date with shots. He has no known allergies, otherwise healthy. EXAMINATION: The patient has a large gaping wound of the left PLASTIC SURGERY CONSULTATION/ PLASTIC SURGERY PROCEDURE 1 MT. DIABLO MEDICAL CENTER (510) 682-8200 HURTADO, NATHAN CONCORD, CA 94520 PATIENT IDENTIFICATION 76869(6/91) t • HURTADO, NATHAN face that is approximately 6 x 4 centimeters. Apparently he has a 4 and 1/2 x "3 centimeter flap laceration based on the left infra-orbital region with a very narrowing skin pedicle about 1.2 centimeter but only a subcutaneous pedicle with 8 millimeters in width. The distal tip of the flap is nonviable. Superiorly there is another flap which is 1/2 x 1. 2 centimeters with very narrow 5 millimeter pedicle. Laterally there is another flap that is based in the preauricular region.The whole flap has elevated the subcutaneous fat. The patient's bony surface appears intact. Motor and sensory are grossly intact, except for decreased sensation in the adjacent area of the lacerations. The parotid duct does not appear to be involved. There is clear saliva expressed from the Stensen's duct. There is no C-spine tenderness. Pupils equal, round, reactive to light and extraocular movements are intact. Skull facial bones, maxilla and mandible appear intact. Limited X-rays show no fractures or foreign bodies. DESCRIPTION OF PROCEDURE: The patient was anesthetized with 1/2 per cent Lidocaine 1:200, 000 Epinephrine. He was prepped and draped in the usual sterile manner. The wound was scrubbed with betadine and normal saline. There was good hemostasis. The distal flap was nonviable. It was sharp and debrided. Then using corner stitches of 5-0 Prolene the flap was tacked back into position. Then the dermal layer was closed with interrupted buried 5-0 Vicryl sutures. The skin was closed with combination of interrupted and running 6-0 Prolene sutures. At completion the wound was closed. The flap appeared slightly cyanotic, but at this time the flap is viable. The patient also has shoulder discomfort which is being evaluated by Dr. Goldin. His discharge from the Emergency Room will be per Dr. Goldin. The patient's mother has been instructed to elevate the head of the bed. He is to take Keflex 250 milligrams p.o. q. i.d. He was given one gram intravenous Ancef in the Emergency Room. He was to take Tylenol or Tylenol #3 as needed for pain. They will arrange for followup appointment in my office Friday morning or sooner if there are any signs of infection. I advised the PLASTIC SURGERY CONSULTATION/ PLASTIC SURGERY PROCEDURE 2 MT. DIABLO MEDICAL CENTER (510) 682-8200 HURTADO, NATHAN CONCORD, CA 94520 PATIENT IDENTIFICATION 7686916/91) HURTADO, NATHAN mother that the flap may not survive in which case, the patient may need further debridement and grafting. The mother has been advised to avoid contamination from pets or animals. c KIM FANG, M KF:gp D: 9-16-92 T: 9-16-92 PLASTIC SURGERY CONSULTATION/ PLASTIC SURGERY PROCEDURE 2 MT. DIABLO MEDICAL CENTER (510) 682-8200 CONCORD, CA 94520 HURTADO, NATHAN PATIENT IDENTIFICATION AM(6/91) REFERRED BY Mt. yiarDlo rK REMARKS STATEMENT KIM FANG, M.D., D.D.S., F.A.C.S. PLASTIC,RECONSTRUCTIVE&AESTHETIC SURGERY 877 YGNACIO VALLEY ROAD SUITE 101 WALNUT CREEK,CA 94596 (510)946-0405 S.S.#1551-90-6353 FED.ID#41.1588602 CHARGES OR Nathan Hurtado PAYMENTS MADE 1760 Detroit Ave. AFTER LAST DATE SHOWN WILL APPEAR Concord, CA 74520 ON YOUR NEXT - STATEMENT - , BALANCE FORWARD DATE FAMILY PROFESSIONAL CHARGE CREDIT ADJ. 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FACTORS LOCKED FORCED ENTRY RANSACKED SELECTIVE TAKE TAKE EASILY REMOVED ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown ( )Yes ( No ( )Unknown ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown LONE SUSPECT DAY SINGLE DWELLING UNIQUE FACTOR INVOLVED SPECIFY ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown MULTIPLE DWELLING OTHER: INVOLVEMENT CODES: A-Arrestee S-Suspect K-C/V V-Victim C-Complainant J-Subject W-Witness B-Business Victim O-Owner INVOLVMT LAST NAME FIRST MIDDLE NOME PHONE JBUS. P"ONE CODE _ 117)19 Z/m/r7 /rlA ADDRESS CITY STATE SOCIAL SECURITY NO. OLN/ID NO. STATE I DOB RACE I SEX HEIGHT WEIGHT HAIR EYES (o-.2d-S� G✓ /� AD DI NAL INFO. INVOLVMT I LAST NAME f FIRST MIDDLE HOM PHONE BUS. PHONE CODE �7Ug ,--;0w/ 8-6j'0 ADDRESS CITY STATE SOCIAL SECURITY NO. �- OLN ID NO. STATE DOB I RACfE SEX HEIGHT WEIGHT I HAIR EYES / _ z2 - F/ C✓ M ADDITIONAL INFO. INVOLVMT LAST NAMES �• FIRST MIDDLE N ME PHONE BUS. PHONE CODE �L DSC-GNC r`� A i�� ,'s ADDRESS CITY STATE SOCIAL SECURITY NO. �o �L i moi ao velo N/10 NO. STATE- 1008 RAC SEX HEIGHT HT WEIGHT JHAIR ]EYES -/�- 7 W ADDITIONAL INFO. IN VOLVM7 LAST AME - FIRST MI DLE "'OS/E PHONE �BUS. PHON- CODE A i T�So// ADDRESS _ - CITY STATE SOCIAL SECURITY NO. OLN 1D NO. STATE DOB RACE SEX I HEIGHT WEIGHT HAIR EYES ADDmO LINFO. silty ii'i (�Giii�i 1115'lCl1i" �', i G c,o�rect copy or the onaina, :n INVOLVMT LAST NAME FIRST MIDDLE ) Ij I Iff?"ITE O"pN€• JBUS. PHONE CODE ADDRESS CITY STATE SOCIAL SECURITY NO. DaW: n 13 OLN 1D NO. STATE DOB RACE SEX 'HEIGHT WEIGHT HAIR IF—YES ADDITIONAL INFO. VEHICLE INVOLVEMENT CODE: A-Arrestee S-Suspect R - Recovered N - 5`ki1a`=,Yaf`Scene V'-Victim X-Stolen 1 -Impounded -Released to Owner Z-Repossession VER.INVL L/C LIS VYR' VMA VMO VST VCO' .�•;ADDJ TI AL INFO.. 4 CODE VEH-INVL LIC LIS VYR VMA VMO VST VC ttll�� 1-iP1J-0r--- CODE O VIN _ REG. OWNER ADDRESS Z 4 �ggME AS V W Z J— O= UNIOUE FEATURES VALUE �-'W on S CP-97-t AUG 84 "rwaE CONCORD POLICE DEPARTMENT cR No. 2 DF OFFENSE REPORT 9- -: 74 + EVIDENCE ( )None ( )Photos ( )Trace Evidence ( )Standards CSI ( yes ( )No Name ( )Prints ( )Diagram ( )Impressions ( )Other Y NVOLVEMENT CODES: CATEGORY CODES: DISPO CODES: STOLEN I-W E-Evidence K-Safekeeping A-Automotive 8-Bicycle C-Camera P -Prop. Room y W S -Stolen F-Found E-Equipment/Tools H-Household Appliances M-Musical Instruments R -Ret.Owner $ 0 p R -Recovered L-Lost O-Office Equipment P -Personal Accessories R-Radio/Sound Devices O-Other: RECOVERED d u O-Safety of S -Sports Equipment T-TV V-Viewing Equipment Others Y-Other D-Dollars/Money K-Credit Cards $ USE ADDITIONAL LINES AFTER EACH ITEM FOR ANY ADDITIONAL DESCRIPTION/INFORMATION —Additional bicycle information must minimally include: Boys/Girls,Color(s),Wheel Size,No.of Speeds, Locked/Unlocked,City License No. I E CODE ARTICLE BRAND MODEL SERIAL 1 VALUE DISPO ODE CODE /� /w0 � ✓GZ/i L � 171 T srJ iT Q�mC c/�oc.- 2'>�oc��,�-• S.t�v� � �a � HiQ �o i 'Td Lift r'] L �. ,9�-r��Z .�r�r> �J �r �«1SS/�OGyn S C✓i.�/zi'o cL/ �� C .�J7 v) 77�c2 f REPO, GAFFICER I.D. It BEAT DATE AND TIME REPORT WRITTEN SUPERVISOR APPROVING TYPIST DATE AND TIME REPORT TYPED J / � CP-97-2 AUG G -PAGES c CR # 61y "el 1 REPORTING �OFFICER BEAT DATE AND TIME REPORT W/RITTE� SUPERVISOR APPROVING TYPIST DATE AND TIME REPORT TYPED J CP-100A SEP ! ` r sT. we`' ra +�s�+•-' w%'., -,a31, �F �'i z PAGE -oF ' 2 CONCORD POLICE DEPARTMENT QRIG SUPP OFFENSE REPORT CR CLASSIFICATION I DATE AND TIME REPORTED ROUTING '/' ( )Det.Bur, b4 Juv.Bur, o?yw?1o2 5/9 s+- /�G 9 /G- 1L /4.J 1 1 Traf.Bur, ( )Sp.Inves. OCCURRED: DATES TIMES LOCATION OCCURRED ( IOther/Agency: /2 r-. 1 1 //-3S 44C_f f LAKIr- BURGLARY& THEFT FROM AUTO-M.O. FACTORS LOCKED FORCED ENTRY RANSACKED SELECTIVE TAKE TAKE EASILY REMOVED ( )Yes 1 )No ( )Unknown ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown LONE SUSPECT DAY SINGLE DWELLING UNIQUE FACTOR INVOLVED SPECIFY ( )Yes ( )No ( )Unknown ( )Yes ( )No ( )Unknown MULTIPLE: DWELLING OTHER INVOLVEMENT CODES: A-Arrestee S-Suspect II C/V V-Victim C-Complainant J-Subject W-Witness B-Business Victim O-Owner INVOLVMT LAST NAME FIRST MIDDLE HOME PHONE IBUS. PHONE CODE K �Lo.e�.✓eE .q�.t�//E c. ��✓���— J p r ,✓ G&S- 30� n/�.✓� ADDRESS CITY STATE SOCIAL SECURITY NO. / 7Lo ' 32 .C.�lrleo.►4 �� a../4-1- e_4 CI NO. STATE - DOB RACE SEX HEIGHT WEIGHT HAIR EYES ADDITIONAL INFO. // d4"oS,f+a; Ze 7r►/ /�- tn5�..�0.� s �- ✓a�cE,O �Kl - /'4''e710a INVOLVMTJ LAST NAME FIRST MIDDLE HOME PHONE j8US*PHONE CODE 5 /'�GC� r/'/ /q TT1A^-1 A ^"j ADDRESS - CITY STATE SOCIAL SECURITY NO. OLN ID NO. STATE DOB RACE SEX HEIGHT WEIGHT HAIR JEYE5 22-d/ ADDITIONAL INFO. INVOLVMT LAST NAME '.FIRST MIDDLE I HOME PHONE JBUS, PHONE CODE ewe • ADDRESS - CITY STATE SOCIAL SECURITY NO. CI NO. STATEDOB RACE SEX HEIGHT WEIGHT HAIR EYES J J ADDITIONAL INFO. INVOLVMTJ LAST NAME FIRST MIDDLE HOME PHONE JBUS, PHONE CODE ADDRESS CITY STATE SOCIAL SECURITY NO. OLN ID NO. STATE DOB RACE SEX HEIGHT WEIGHT HAIR EYES J J J ADDrTIONAL INFO. INVOLVMT LAST NAME FIRST MIDDLE HOME PHONE BUS. PHONE CODE ADDRESS CITY STATE SOCIAL SECURITY NO. OLN ID NO, STATE DOB RACE SEX HEIGHT WEIGHT HAIR EYES J ADDITIONAL INFO. - VEHICLE INVOLVEMENT CODE: A-Arrestee S-Suspect R -Recovered N -Stored P-Parked at Scene V-Victim X-Stolen I -Impounded O-Released to Owner Z-Repossession VEH.INVL LIC LIS VYR VMA VMO VST VCO ADDITIONAL INFO. CODE VEH.INVL LIC LIS VYR VMA VMO VST VCO ADDITIONAL INFO. CODE Z 0 VIN 7t REG,OWNER ADDRESS SAME AS V W lL J= 0= UNIQUE FEATURES VALUE H W S T' CP-97-1 AUG 84 PAGL CONCORD POLICE DEPARTMENT Z cR No. OF OFFENSE REPORT EVIDENCE ( )None ( QPhotos ( )Trace Evidence ( )Standards CSI (74Yes 1 )No Name �^��� ( ►Prints ( )Diagram ( )Impressions ( )Other INVOLVEMENT CODES: CATEGORY CODES: DISPO CODES: STOLEN • z R E-Evidence K-Safekeeping A-Automotive B-Bicycle C-Camera P -Prop.Room W m S -Stolen F -Found E-Equipment/Tools H-Household Appliances M-Musical Instruments R -Ret.Owner $ L o R -Recovered L-Lost O-Office Equipment P -Personal Accessories R-Radio/Sound Devices O-Other: RECOVERED o z u O-Safety of S -Sports Equipment T-TV V-Viewing Equipment L Others Y -Other, D-Dollars/Money K-Credit Cards $ - USE ADDITIONAL LINES AFTER EACH ITEM FOR ANY ADDITIONAL DESCRIPTION/INFORMATION -Additional bl_'cycle information must minimally include: Boys/Girls,Color(s),Wheel Size,No.of Speeds, Locked/Unlocked,City License No. JL INVOLV CAT ARTICLE BRAND MODEL SERIAL If VALUE �T CODE CODE DODE CODE 2-14-92. /►3 3 8 /ales — �.-5 ra,o 7r, /�C 9.+�o.s r- i4 T✓N�/,'[.f U�/,� c✓,o s .PE cr,✓; /-s ez,e-4, 14 /fie r- /.JTu R El- �►S c�7�s➢��✓eCG �a r /J /�`�9✓r �_�"Ce le?x4 a�J eV 7a a'7 'lee'05 Z .SC.�fo v� D/9c.'�•.►G.t . /�- F[o�f.✓cE S7r7 rr',C 77#7•',7' '41v 92e 77^1/ .4 e/;j /.✓ F/yN 7�/E /,LJf1Tl5C ,�jun/TA.n/ (i✓r/ti✓ �- "'�u,Q,y� � 7-1g4 114' D.0 /^'/ro f'►+f Iii��l..J. J` � �/ 0.e a fIGSO ".e OtS 7-7/c ,P-r4.ts eW, 7-1k /. ' C,./, dS.-k✓naS eAc-,-/ tSC,--o,[E r7-4t5 r7+(e 'oe TiJL I.,- 7'Ar 7-0 Gr Ti<C 77.caC C'a��s Q A;,q ./.�, f t�.r h e✓ns.r�✓ . r>s�� �7'e�'7 1t`/� /C� D✓l1l.J �M 14r✓/}'-/ /�J/�1 �jL� �. 77-_' r"4-- J,7-7 [ [y `S'rycl G C 7-311c5 L.�.✓Q J- �,%J N G,t'/`>AN `Tt.�raG�S{'��a t�/T O // Tom'�rS L.�J�•/A'� [.�O c-.. �! f � �u?- w. -7,1,1 n s:: k %,J 7U 7-7 A-- C`r- we/lr /�.�n.T n/A nkc /Q�,�"✓i14 A L.v.Sn� `S✓, tea,✓, 7� •- REPO TING OFFICER I.D. ! BEAT DATE A D TIME REPORT WRITTEN SUPERVISOR APPROVING TYPIST DATE AND TIME REPORT TYPED J CP-97-2 AUG 94 PAGE 3 CR # ?.?- C,.Ssa .7*- ..✓mss nr� �C' ee .fes n4mr Tk` J ,nntlH��✓ s"y� i�J^7'n/7�en1�► 14ok7o r_e /-�.-+ f1 ,g.i✓.rr nif .Joo.� Alar i^^!hlnokj/< /C.[ /�� 5- Idler. RWP "T".4NG OFFICER BEAT DAQTE AND TIME REPORT WRITTEN SUPERVISOR APPROVING TYPIST DATE AND TIME REPORT TYPED J J ✓601.4 I .3 CP-100A SEP ad CONCORD POLICE DEPARTMENT PAGE 1 OF 1 CRIME SCENE INVESTIGATION BUREAU SUPPLEMENTAL REPORT CASE NUMBER CLASS ORIGINAL DATE TIME -OFFICER AT SCENE TECH OFFICER 92-21552 242 PC 09-16-92 1253 PRIMAVERA MINGES r' DATE RESPONDED TIME ARRIVED TIME COMPLETE - LOCATION 09-16-92 1447 1535 2540 EAST ST/1135 LACEY LN VEHICLE INVOLVEMENT CODE: A•Anptee S-:Strpsct :q-Reeov�red N Stored P-Puked V YCtim .;<X•SLolen {-]npp�rtiled ?j-gele�edtoOwrw Z-PAP an Inv License License Vehicle Vettide Make Vehicle Model Vehicle Style Vehicle Color Additional Information Code State Year EVIDENCE PHOTOGRAPHS LATENT CARDS NONE 10 NONE NARRATIVE' VICTIM: FLORENCE, NATHAN 07-11-80 I RESPONDED TO THE MT. DIABLO HOSPITAL EMERGENCY ROOM AT THE REQUEST OF OFFICER PRIMAVERA. HE REQUESTED PHOTOS OF VICTIM FLORENCE AND HIS INJURIES. UPON MY ARRIVAL, I LOCATED THE VICTIM IN A TREATMENT ROOM LOCATED IN THE EMERGENCY ROOM.. THE DOCTOR WAS SUTURING THE VICTIMS LEFT SIDE OF HIS FACE WHICH I COULD SEE HAD A VERY LARGE LACERATION ACROSS THE CHEEK AREA. I TOOK APPROXIMATELY 3 PHOTOS OF THE VICTIM'S INJURIES. I THEN RESPONDED TO THE CAMBRIDGE CENTER ON LACEY LN AT THE REQUEST OF .OFFICER FRYE. HE REQUESTED PHOTOS TAKEN WHERE THIS INCIDENT OCCURRED. I TOOK APPROXIMATELY 3 PHOTOS THE LOCATION WHERE THE INCIDENT OCCURRED. REPORTING OFFICER&I.D.J ::APPROVED BY R. MINGES #203