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Home My WebLink AboutMINUTES - 05241994 - 1.16 - CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 6 MAY 24, 1994 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Dara.graph IV below), given pursuant to Government Code Amount: $1,000,000.00 ® X=lqctl 913 and 915.4. Please note all "Warnings". CLAIMANT: HARRIS, Maurice MAY 0 5 1994 ATTORNEY: Leslie A. DiMario � Caul�sF. !►9AATIAIEZ CALIF. Date received ADDRESS: 57 Post St. , .,Sixth •Floor BY DELIVERY TO CLERK ON 5, 1994 San Francisco, CA 94104 BY MAIL POSTMARKED: M 6y 41, 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. �-- pHIL BATCHELOR, Clerk DATED: S_ �_�� Bl : Deputy Q Qh eJ II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( v1 This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 9 �� BY: � Deputy County Counsel 0 U II1. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. r Dated:Y1� _ PHIL BATCHELOR, Clerk, By �e,.�Q�,L� 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: BY: PHIL BATCHELOR by �p,� ,Q Q J Deputy.Clerk CC: County Counsel County Administrator LAW OFFICES OF CARY JAY SILBERMAN CARY JAY SILBERMAN, SBN 154407 LESLIE A. DiMARIO, SBN 164134 57 Post Street, Sixth Floor San Francisco, California 94104 Telephone: (415) 249-3939 Attorneys for Claimant In the Matter of the Claim of MAURICE CLAIM FOR DAMAGES HARRIS (Gov.C. Sections 945.4, 912.4) vs. COUNTY OF CONTRA COSTA, RECEIVED Y'. et al. rs. IMAY - 51994 i CLERK BOARD OF SUPERVISORS CONTR COSTA CO. TO THE BOARD OF SUPERVISORS, COUNTY OF CONTRA COSTA: Claimant MAURICE HARRIS hereby makes claim against the COUNTY OF CONTRA COSTA, and its employees, in the sum of ONE MILLION DOLLARS ($1,000,000). At the relevant times herein, Claimant was a detainee of the COUNTY OF CONTRA COSTA, Martinez Juvenile Hall. On or about November 11, 1993, Claimant was injured when he slipped and fell in the shower of the Martinez Juvenile Hall, causing injury to his face and other parts of his anatomy, as well as severe emotional distress, financial hardship, and continuing lost earnings. DATED: May 4, 1994 LAW OFFICES OF CARY JAY SILBERMAN By LESLIE A. DiMARIO LAW OFFICES OF CARY JAY SILBERMAN CARY JAY SILBERMAN, SBN 154407 LESLIE A. DiMARIO, SBN 164134 57 Post Street, Sixth Floor San Francisco, California 94104 Telephone: (415) 249-3939 Attorneys for Claimant In the Matter of the Claim of MAURICE CLAIM FOR DAMAGES HARRIS (Gov.C. Sections 945.4, 912.4) vs. COUNTY OF CONTRA COSTA, et al. TO THE BOARD OF SUPERVISORS, COUNTY OF CONTRA COSTA: Claimant MAURICE HARRIS hereby makes claim against the COUNTY OF CONTRA COSTA, and its employees, in the sum of ONE MILLION DOLLARS ($1,000,000). At the relevant times herein, Claimant was a detainee of the COUNTY OF CONTRA COSTA, Martinez Juvenile Hall. On or about November 11, 1993, Claimant was injured when he slipped and fell in the shower of the Martinez Juvenile Hall, causing injury to his face and other parts of his anatomy, as well as severe emotional distress, financial hardship, and continuing lost earnings. DATED: May 4, 1994 LAW OFFICES OF CARY JAY SILBERMAN By L SLIE A. DiMARIO Law Offices of Cary J 57 Post Street, 6th Floor • San Francisco, CA 94104 (415) 249-3939 FAX (415) 249-0839 'I F- MELVIN M. BELLI, ESQ. RECEIVED Of Counsel May 4, 1994 - 51994 CLERK BOARD OF SUPERVISORS CONTRA COSTA Co. Clerk of the Board of Supervisors COUNTY OF CONTRA COSTA 651 Pine Street, Room 106 Martinez, California 94553 Re: Claim of Maurice Harris Dear Clerk: Enclosed please find the claim of Maurice Harris against the County of Contra Costa. Please acknowledge receipt by returning an endorsed copy in the envelope provided. Thank you for your assistance in this matter. Sincerely, LAW,,OFFICES OF CARY JAY SILBERMAN Carol Grey Secretary to CARY JAY SILBERMAN Enclosures 4 2 s ¢ n - �1�d N, ltt cn t� <r 6 o o �n cd o kM �V w+ a � w n 0 a s AME1vID)aD CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MAY 24, 1994 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknown Sion 913 and 915.4. Please note all "Warnings". CLAIMANT: HARRIS Bert ' MAY 0 5 X994 ATTORNEY: Jeffrey Champlin COUNTYCOUNSEL MARTINEZCAUF.Date received ADDRESS: 1822 — 21St St. BY DELIVERY TO CLERK ON May 5, 1994 Sacramento, CA 95814 BY MAIL POSTMARKED: May 3, 1994 I. FROM: Clerk of the Board of Supervisors "170: County Counsel Attached is a copy of the above-noted claim. L 7 PHIL BATCHELOR Clerk DATED: �YI a.�„� $ Qq L{- BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( l) 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: *6 / 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 2k� _ PHIL BATCHELOR, Clerk; By_ .L , CA-4 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: O _Iq Q!:� BY: PHIL BATCHELOR by �^ „ 00, � , Deputy Clerk CC: County Counsel County Administrator CLERK BOARD OF SUPERVISORS FIRST AMMENDED CONTRA COSTA CO. CLAIM AGAINST CONTRA COSTA COUNTY 1 . Claimant's name Bert Harris Birthdate 10-21-41 2 . Claimant' s address 21131 Sacramento St #16 , Vallejo„Ca 94590 3 . Address where notices are to be sent, if different from above: LAW OFFICE OF JEFFREY L, CHAMPLIN 1822 - 21st St. , Sacramento, Ca 95814 1 4 . Daytime telephope, numbpx (916)_ 454-0113 In excesso i. guris ct un7 5 . Amoub�mj':)ff cAAwy6r Court Date of accident 3-16-94 Merrithew Hospital - Family Practice Bldg. 6 . Place of accident 25,00_'-Alh-ambra-,,i Martinez , Ca 94553 7 . How did accident happen Claimant was leaving the Family Practice building at Merrithew Hospital and slipped and fell on c-=z construction debris on the -steps leading from the building. 8 . Describe injury or damage Injury to left leg and knee, ]eft Gide of neck, left lower back - , left shoulder and left elbow. 9 . Name of public employee(s ) causing injury or damage, if known: Unknown 10 . List expenses or other items of your Claim: Emergency Room treatment, Merithew Hosp. $ unknown Sims Chiropractic Office $ unknown TOTAL $ unknown Sig ed by or for claimant - (Use reverse side if additional space is required. ) Dated -�s � '- � .. C6w Oro nix L v► MOW PiLn00 tiN0 �to rt, ::5 �d r- rorty (D �J o N M > 11 a E to S) - ca n7 N• l=1 -. Ln fi H Ln i-j Sy Wort' 0 41 1-- ro 0 CA F' a . r CD ol ol m` Rte( tits M CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MAY 24, 1994 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1 ,000,000.00 Section 913 andTRQ 5., nobTall "Warnings". CLAIMANT: HELDRIS Matthew Lloyd 9' y MAY 0 3 1994 ATTORNEY: COUNTY COUNSEL Date received MARTINEZCAUF. ADDRESS: 3072 Valleywood Ct. BY DELIVERY TO CLERK ON May 2, 1994 San Jose, CA 95148 BY MAIL POSTMARKED: April 29, 1994 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: gq�l gep�tyLOR, Clerk 0 II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: j�OLI _2kt22:2.BY: K Deputy County Counsel r 0 () & , 7 III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (�) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: �$�q91� PHIL BATCHELOR, Clerk, By e�,d .Q Q ,� Deputy Clerk v 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: Lgel BY: PHIL BATCHELOR by , ��a,Qp a �J Deputy Clerk CC: County Counsel County Administrator Clair, .o: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Clai^.s relating to causes of action' for death or for .injury to....person .or to per- sonal property or growing crops and which accrue' for; ..injury or before December 31, 1987, must be presented notlater 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 §911.2x) 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 form. RE: Claim By ) Reserved for Clerk's filing stamp 1A 4 J ) ® ,r f RECEIVE® -t} 'a�1 SBSF: �C44 ss'�S/Y ) Against the County of Contra Costa ) MAY or ) CLERK BOARD OF SUPERVISORS District) CONTRA COSTA CO. Fill in name) ) The undersigned claimant hereby- makes claim against the County of Contra Costa or the above-named District in the sum of $ �®4 Dp 6. and in support of this claim represents as follows: 1. When did the damage or` injury occur? (Give exact date and hour) �A �R ..�?,_30 -------------------- 2. Where did the damage or injury occur? (Include city and county) 3. How did the dainage or injury occur? (Give full details; use extra paper if required) eAA- t de 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 1j44fAq&0#. Carsy(_,rr1 ea Ar LvvQ r PeIV-044 *41-1ce1 r-Akdo &PJRE55(0A) ,over) 7. wnat are the names of county or district officers, servants or employees causing the darage or injury? ----NA RK rS r7S----=Ucro ...� ��.�«tP fdIa&—zate----------- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. fJ Lid 6 L GO S 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) _____-___-__ 3. Names and addresses of witnesses, doctors and hospitals. � 60,0 r A Ce sro- C6dWry .1',+t t--t/_/A)Ah*rer Ae,-01 4c �? careD� /��r/,4 �Z/ �l --------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM;. �., AMOUNT COW _ 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 laim/annt's Signature rt (Address Telephone No. Telephone No. NOTICE Section 72 of the! Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or. officer, or to any.-county, city -or district board..or officer, authorized to allow or 'pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1;,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars {$10,000, or by both such imprisonment and fine. L b Sit, °01. �i 1 1 •-� fit., � dd r -i- LN e N� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MAY 24,1994 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1750.00 i o Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PETCO, Inc . MAY U 9994 ATTORNEY: COUNTY MAR7fNF?CASFL Date received ADDRESS: 950 Grantline Rd. BY DELIVERY TO CLERK ON April 29 , 1994 Tracy, CA 95376 BY MAIL POSTMARKED: Hand Delivered via : Risk Mgmt . I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pIL BATCHELOR, Clerk DATED: - _ Z nA.4 ' II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓f 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: Ak 19 q 9 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:. l9 9 �PHIL BATCHELOR, Clerk, By 0,2J J' Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 113; and that today I deposited in the -United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by (��.c� .� Deputy Clerk 3 CC: County Counsel County Administrator Ola to. 'BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Clair relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, .must. be presented not later than six months after the accrual of the cause of action. Claims relating to, any 'other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form RE: Claim By ) Reserved for Clerk's filing stamp 9� RECEIVED ': GP n� f `0tll,CA Against the County of Contra QostA or MZ 6 APR 2 91994 _ District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. vin; The undersigned claimant hereby makes cla against the. County of Co ra Costa or the above-named District in the sum of $ ° '� and in support of this claim represents as follows: 1.3Yhen did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) C,es`n� 1�.9z/ti�`t� � �h✓1�'U"S �� S�s�� f�'�-�11�6� Cl'�:�-� 3. How did the damage or injury occur? (Give full details; use extra paper if required) �N------ ------------ -------------- --N------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 1\ �. wnat are the names o1' county or district officers, servants or employees causing the damage or in jury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or \ damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) -------------------------- ------ S. Names and addresses of witnesses, doctors and hospitals. tK(C.A*cZ �So 6P-AAA14&eXIV v ab 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT r Q c(1 Gov. Code Sec. 910:2 provides: (Attorney "The claim must be signed by the claimant SEND NOTICES TOR:- t ) orbV s me person on his behalf." Name and Address of Attorney Claimant's Signature Address C414. Telephone No. Telephone No. 9 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 ($10,000, or by .both such imprisoru.)ent and =fine. :,APR-18-1994 07:03 FROM JAG'S DIESEL TO 1209E+323122 P.02 � : •' �STlMATE Jag's Cli - Inc. 03379 81 Trevarna Rd. Livermore, GA 94550 (510) 447-8556 FAX (510) 449.76 --/5 j UNIT: !( aLt$ MVR: Z S ? STREET' rr,, t� MILES: GITY: RiAL NO.: PARTS LABOR HOURS PFSCRIPTIONCo ey- ! i l I MISC.MAT. p U - '`uwk fAL fli►FtY�„ RATE TD ER lug" RE 463 2870 ' MR!. '31 ' 94 16: 08 FROM TIP-13560 STOCKTON CA. PAGE . 001 ' R AIR ORDER Ip GfCsR��e°4ss1 , MAKE YEAR UNIT NUMBER A MODEL NO. SERIAL NO. LESSEE; RENTALwl aRANCH IN SERVICE DATE BILL TO: LEASE ❑ -!:;�7,d o RECORDED ON APPROVED BY DATE MILEAGE HISTORY CARD SUBLET P.O. NUMBER R.Q. WR EN ROAD CALL RECEIVED WORK PERFORMEDMECHANIC TOTAL CLOCK HOURS OUT—IN 0 3 0 A s I o 00 AN I 5 5 6 3 0 t 18 1 n �1 Tiros wheels �3 Net:&Studs n4 wheel Seals �5 Landing Gear ` �6 Frame [] Cross Members ❑8 Roils �9 Spring and Shackles 10 U.Bolts 11 Light&W10mrsCl�� Wiring 13 Brakes&Drums 14 Reserve Tank &Release Valve t5 Broke Chambers 16 Doors 1'7 Haps to 'Regist. & License 19 King Pin a Glad Hand 21 5th Wheel Lfl Reefer Unit 23 Miscellaneous 24 Acrident 25 Warranty CITY. PART NUMBER DESCRIPTION NET AMOUNT Total Labor L 016Tees 4 Parts {f -a Total ` Outside ~� Charges or) Total Other L1 00 j __ Grand • UNIT NO. MAkE MObEL SERIAL Numm DATE Off YEAR I MILEAGE HOURS I ACCOMPANYING UNIT EST.COMP.DATE DFSCRIPT ON.OF REPAIR OPERATIONS HOURS MATEfiIALS QTY. PRICE ■■ L:...r m ��■ ■ON � ■■■■■■ ■■ �■ �■■■ ON IN no i■■■ ■■■■■ ON ■■�■ ■■ im �s�■ ■■ Im =ME ■■ 11 01 ■■ ■■■■■ ■■ i■■■ ■■■■■■■ ■■ Elm ■■No IMM IMME ■■■ ■■ Im AIM■■■ ■■ Elm �■■■■ M■ ME TOTAL ESTIMATED COST � i