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HomeMy WebLinkAboutMINUTES - 04011997 - C29-C33 C.29 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA Adopted this Order on April 1, 1997 by the following vote: AYES: Supervisors Rogers, Uilkema, Gerber, DeSaulnier NOES: None ABSENT: Supervisor Canciamilla ABSTAIN: None ----------------------------------------------------------------- ----------------------------------------------------------------- SUBJECT: Board Proceedings during the Month of March. 1997 IT IS BY THE BOARD ORDERED that the reading of the minutes of the proceedings of this Board for the month of March, 1997 is WAIVED, and said minutes are APPROVED as written. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: April 1. 1997 PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator By ' eputy C.30 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY CALIFORNIA Adopted this Order on April 1. 1997 by the following vote: AYES: Supervisors Rogers, Uilkma, Gerber, DeSaulnier NOES: None ABSENT: Supervisor Canciamilla ABSTAIN: None ----------------------------------------------------------------- ----------------------------------------------------------------- SUBJECT: Affidavits of Publication of Ordinances This Board having heretofore adopted Ordinances Nos. 97-4 , 97-7 . 97-8 Affidavits of Publication of each of said Ordinances having been filed with the Clerk during the month of March, 1997 ; and it appearing from said affidavits that said Ordinances were duly and regularly published for the time and in the manner required by law; NOW THEREFORE, IT IS BY THE BOARD ORDERED that said Ordinances are declared duly published. 1 hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: April 1, 1997 PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator By Deputy 0 , 31 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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: $10,000.00 Section 913 and 915.4. Please note ai $tVfIRI CLAIMANT: Joyce Anderson FEB 2 1 1997 ATTORNEY: Michael R. Lauer COUNTY COUNSEL Lauer & Associates Date received MARTINEZCALIF. ADDRESS: 166 Santa Clara Ave. BY DELIVERY TO CLERK ON February 20, 1997 Oakland, CA 94610 BY MAIL POSTMARKED: February 21, 1997 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 21. 1997 `qIL 6epuyLOR, Clerk 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: `may I/ BY: / fes //. Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full, ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR O 11997 PHIL BATCHELOR, Clerk, B�j �'e '`e �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 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 3 1997 BY: PHIL BATCHELOR by L7/a\-�,-O� _Deputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SJPERVI.SORS OF CONTRA COSTA GMM INSTRUCTIONS TO CLAIMANT A. Clam 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, 1997, 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 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 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 � * fF iii lF lff Mlt It * * M ! * * +4 fFNMItlt lk � lkft lF ltk • IF 1R +41kf it lE � lE 1k * RE: Claim By ) Reserved for Clerk's filing[CLERKBOARD Astaatm\p/e .Tcyn( Anderson } EIVCDAgainst the County of Contra Costa 2 0 or OF SUPERVISORS El Sobrante District) A COSTA Co. (Fill in name } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 10, 000 and in support of t.his claim represents as follows: 1. When did the damage or injury occur? "(Give exact date and hour) Tuesday, November 5, 1996, Approximately 6 : 00 P.M. 2. Where did the damage or injury occur? (Include city and county) On San Pablo Dam Road near Milton way in El Sobrante, Contra Costa County 3. How did the damage or injury occur? (Give full details; use extra paper if required) I was walkin g at a .normal pace. Fallen leaves were everywhere, so I was paying attention as I walked. The toe of my left shoe caught the edge of a raised part of the sidewalk that was covered by dead and fallen leaves. I_was thrown off balance and landPd nn the f} of my (See 4. What particular act or omission on the part of county or district officers, Attachment) servants or employees caused the injury or damage? The sidewalk where I fell needed repair and had not been properly maintained. 5_ vrnat are the names of counL_v or district officers, servants or employees causing the ca .ae or injury? Contra Costa County 6. {that damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Sustained damage to my face. Profuse bleeding. The emergency room discharge report lists my diagnosis as a broken nose and cheekbone. (Cgntinup(j on nttarhmonr ) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Medical and related expenses, lost wages, pain and suffering. 6. Names and addresses of witnesses, doctors and hospitals. See Attachment 9. List the expenditures you made on account of this accident or injury: DATE My. Al UNT �11 j5tlb6',' , ';j3pctor ' Hospital Emergency Room (co-pay). $20 . 00 >11jr6j96 Ar an Cohn, Internal Medicine $82.00 (cdntinued o t ac ment) TOTAL:44k'ria *I* *. * * * -* *.* * * * *. * * * * * * * *61Bar 17* * * * * { { Gov. Code Sec. 91 Fsbehalf." es: °The claim t y the claimant SEND NOTICES T0: (Attorney) same Name and Address of Attorney Michael R. Lauer ' - LAUER & ASSOCIATES MICR EZt. NEY FOR JOYCE 166 Santa Clara Avenue 4340 Jana Vista Road ANDERSON Oakland CA 94610 Address. E1 Sobrante CA 94803 Telephone No. 510-658-2500 Telephone No. 510-222-0936 * * * * * * * * * * IF * * * N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill; account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both s*-,ch i^~risonrru^- and fine. Page 1 of 1 ATTACHMENT to claim aganst the County of Contra Costa by Joyce Anderson 3. (continued from page 1) face, mainly. I had been walking with my hands in my pockets because the weather was chilly. 6. (continued from page 2) My glasses were destroyed. I sustained much damage around my left eye. To this date, I still have a welt on my left cheek. I was unable to eat on the left side of my mouth for a month. I could not accept work as a substitute teacher for three days, and I had to take time out for medical appointments. 8. (continued from page 2) Dr. Arlan Cohn, 2435 Webster Street, Berkeley CA 94705 Dr. John Carrigg, Orinda CA, 510-254-6710 Dr. Stephen Chase, 296 Arlington Avenue, Kensington CA 94707 Doctors and nurses at Doctors Hospital, 2151 Appian Way, Pinole, CA 94564-2578 9. (continued from page 2) 11/12/96 Sorenson Optical, exam and replace glasses $ 80.00 11/18/96 Dr. John Carrig, Ear nose and throat, checkup $ 81.00 11/26/96 Dr. Stephen Chase, dental work $ 65.00 11/6/96-11/8/96 Lost wages at $86.09 per day $258.27 12/18/96 Post office $ 20.75 12/18/96 Photos of place of injury $ 11.85 c.\oFFICE\WPWIN\WPDocs�cLIENTS�ANDExs-ncLAIN&a .AND 2/18/973:21 Pm ATTACHMENT TO CLAIM FORM _T O DATE FEE PAYMENT ADJUST- MENT ggLANCE BALANCE PREVIOUS NAME y This is your RECEIPT for this amount_? 1 This is a STATEMENT of your account to date ) Rxt Rx2 FEE MATERIALS )FRAME ( )LENSES(v2) SORENSON & SORENSON OPTICAL SWBIF/TRIF/PROG./INV. 3010 COLBY STREET,STE. 112 O OVERSIZE BERKELEY,CALIFORNIA 94705 ( )HIGHPOWER (510)848-4733 TINT/COATING ( )TINT PHOTOCHROMIC ( )GROOVE ( )POLISH )FACET ( )SCRATCH RESISTANT ( )ANTI-REFLECTIVE ( )UV COATING )PRISM ( )SUNGLASSES PL ( ICLSOLUTIONS/SUPPLIES )OTHER EYEGLASSES SERVICE ( )PRESCRIPTION SERVICE ( )FRAME REPAIR PLEASE RETAIN FOR YOUR RECORDS4299 )FRAME ADJUSTMENT ( )SAFETY RX )OTHER C c; 01 /02/4 s A C =: O lJ i! T H I S T O F.: `r #+ OF , Steven S� Chase, 0:.D.3 , MS. JOYCE A,•lDL.RSOIN _--...-, Ff i_7._0glon Rven,ne _..- . __ . - _---__-_.__ .. _ ____ ___-_.___�'�c,.Gf .1�. 1�+ .� T.��_[� �r�_-__'__3J Kensincton.. CA 94707 E! _ORRANTE, CA. 94SO3 I __.,ccat_tn'- -ln: 395- -- +�� Date Patient Descriotion Th Surf F'r Esti 7 Haic M -------------------------- --------------------------------------------------- - --- � I 02/0?/75 JOYCE Prophylaxisophylaxi= Adult 1 :Kl,_ ,W 03/06/95 JOYCE Payment - Thank You 1 -`i' %_'5 __ 09115/95 JOYCE - Prophylaxis, Adult ._ ? _ 62 .06' .fit,' 09/15/95 JOYCE X-Ray , Single Filirt i - t_• 24 .s' ;_;3/ 17/95 JOYCE Payment - Thank You 1 -y.0 :'f_1 Payment '- Thank _Y L.t 1 -43.01% - - --'02/27/96 JOYC_. — - Prophylaxis Adult — � WWI-) 02/27/96 2[2/27/96 JOYCE X-Ray. Rite w_,-,g-4 Films 1 m.! :2/27/96 JOYCE Examination-,, Periodic 1 12 !1 + (-'q/.,,14/96 iOYCE Payment - Thank You 7. — — IISlot i 34 96 JOYCE Office Visit Peg , Hours 7 r 1._ vi�.! 1Sa� JOY G3 FEr%merit _ Ti1.K_n.:. 'l r��i ' T-59.O%,.: 09/26/96 JOYCE Prophylaxis. Adult --- 2 65.00 09/03/96 JOYCE Payment - Thank You l 60 30 j; jjZ25Z16 , JOYCE, Prophylaxis Adult \- - - - -- -- - �` - �� b S`< 12/09/90 JOYCE Payment - Mark ;!,_tb�.6n - ' Cur rent : -_.-0.00 Total Patient Responsibilityz 00.00 0yer iii; vf.yip/ Estimated Insurance Portion. : 4a_- _ _. Over 602 0 .00 Estimated Patient Portion . . : E3,0_5 Over P;_i: an c. =71 DOCTORS HOSPITAL OF PINOLE J E N E 1 P .O.BOX 31001-0121 PASADENA CA 911100121 800 332-9038 fo ANDERSON JOYCE V L 12/23/96 4340 JANA VISTA C ` EL SOBRANTE CA 94803 Re : ANDERSON JOYCE V Account Number: 3559184 Current Balance : 20 . 00 Admit Date : 11/05/96 Discharge Date : 11/0 Your insurance company has now paid its portion of your account . The current balance above is your responsibility. Please remit payment today or contact our business office if you have any questions . We are pleased that you chose our facility and hope the services you received were found satisfactory. Sincerely, MISS GROVES 9 : 00 - 4 : 30 209 578-2517 FUS/114-CMAXB �{���� � � r �1��� - _ - ^ \ . z . ! \ - � f - �} m 7 } . � § § o }t| A Mm f M � m \ § k M £` M» ru on 2 g ) cr } CL Ui } ® I! o \ (4 ` . , . , 2 . , , : . , , . / , Customer Copy 7, T- DOCTORS HOSPITAL 2151 Appian Way EMERGENCY DEPARTMENT Pinole, CA 94564-2578 DISCHARGE INSTRUCTIONS PLEASE NOTE: The examination and treatment that you have received in the Emergency Department has been given on an emergency basis only, and is not intended to be a substitute for complete medical care. It is important that you be checked again as instructed. If you notice any worsening of your symptoms, promptly call your referral doctor or return to the hospital. Results of studies such as x-rays, EKG's, and blood tests will be reviewed by a second physician- You or your doctor will be gotified if any additional fi ings are noted. YOUR DIAGNOSIS ISr PRINTED INSTRUCTIONS PROVIDED: ❑inIcated below o Abdominal Pain Burns Crutches Gastritis/Heartburn Hives N prains Urinary Trac-Infections Allergy Cast/Splint Fainting Gastroenteritis Hypertension aryngl Is Strep Throat Vaccines Asthma Conjunctivitis/Sty Febrile Seizure Headache Infections Pneumonia Sty V.D. Back pain Corneal Abrasion Fracture Head Injury Kidney Stone Rib Fracture Threatened Abortion Viral Syndrome Trauma-Chest/Abdominal Wounds-Abrasions [I DOMESTIC VIOLENCE INFORMATION Wounds-Lacs/Puncture E] CHILD SEAT BELT REGULATIONS INITIALS Wounds-eye/foot RN/LVN INITIALS ❑ Drug/Food interaction sheet received and understood. MD INITIALS ❑ The medication that you have received will make you drowsy. DO NOT DRIVE A CAR, RIDE A MOTOR OR BICYCLE,or perform any activity that requires alertness. -� ADDITIONAL INSTRUCTIONS: t 'Zz :J LEA CALL, as soon as possible, FOR AN APPOINTMENT WITH - •y• �- �Z • IN / DAYS. YOUR EMERGENCY HYSICIAN HAS BEEN: F. BEATY R. BOECHE P HAVEZ R. ER - C. WOLF D. LANTZ I ha•a received no ,nd - '"an the inst ions Cull' ed above. X !y/ at' nt or R resentative Staff Date I auth rize dispensing medications in NON childproof packages ---------------------------------------------------------------------------------------------------------------- DOCTORS HOSPITAL-PINOLE WORK/SCHOOL NOTIFICATION FORM Patient Name: was seen in the Emergency Department on He/she should be able to return to work/school on with the following restrictions: X M.D. --------------------------------------------------------------------------------------------------------------- EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Dose Disp. Sig 1.tlcoholPhysician Signature z M.D. 2. cause drowsiness Forrest Beaty Renee Boeche Robert Royer Cynthia Wolfe Patricio Chavez A24751 20A5864 G58656 G57378 G485574 3. 11 Spanish Instructions AB5295729 BB2135893 BF0653382 AW1120358 AC1790270 Doctors Hospital ; ! '-;u 53 E 5 ER 2151 Appian Way a :-0 E 2 : b . ! 'f Pinole, CA 94564-2578 EMERGENCY DEPARTMENT DISCHARGE INSTRUCTIONS 7230-3 i t j ? j i -f F 609112/961 J22570 o fir. lie. ARLAN CORN, M.D. x492329589 INTERNAL MEDICINE -R a94 1556298 2435 WEBSTER STREET • BERKELEY, CA 94705 95 ��$(v�� PHONE (510) 548.1933 FAX (510) 548-1957 "�`/L' n! PRIVATE ',7j MEDICARE tv1EDl-CAt, PPO ❑ ABMGTF{ER' -'- -r'1S�zl C, PATIENT'S LAST NAME _ FIRST / INITIAL M Fj DATE OF BIRTH AV'S a '1y v � x'7a,1612 r DESCRIPTION OF SERVICE CPLD fEE r DESCRIPTIOOF S RVICE I CRL4 FE£ r DESCRIPTION Of SERVICE I CPT-4 FEE 1, OFFICE SERVICES 3. INJECTIONS 6, CONVALESCENT&HOME SERVICES NEW PATIENT Ceftriaxone 250 mg I J0696 94772 Convalescent Admit 99301 _ T Oilice Visa 992021 Cholera 0.5 IN 90725 Convalescent Admit 99302 Otfica Visit 99203 Cyanocebaiamin 1000 mcg 90782 Convalescent Admit 99303 A, Othce Visit 99204 Dexamethasone 8 mg/J1100 90782 Convalescent Visit 99311 I Office V+ait v 99205 _ .Hepatitis 8 Vaccine ice t GOCIC 90731 Convalescent Visit 99312 fESTABLISHED PATIENT Gamma Globulin 3cc IM I J147C 90741 Convalescent Visit 99313 i Office Vise 99211 influenza 0.5 mi t G000a 90724 House Call 99351 Oflice Visa 99212 Pneumoco0cal 0.5 ml/G0009 90732 House Calf 99352 Cffice Visit 99213 PoVio,Inactivated 0.5 ml 90713 House Call 99353 ' Oflice Visit 99274 Rubella 0.5 ml 90706 7, HOSPITAL SERVICES _-i ._.,......-.._ .. Olbca Visn 99215 Testosterone 200 mg fM 90782 ADMIT Date: 99221 k --.. �. CONSULTATIONS Dip.lTet.Tox. 0.5 ml I J3180 90718 ADMIT Date: 99222 ' { 1 Off e Consult. -Y9%;2 2 u _{.Typhoid O 5Y.MI ml _,-� 90903 ,^_ ,_ ADM Daates'�--....-..-. 99223 Office Consult 99242 90714 _ Office Consult 99243 Injection Procedures 00124 # Q$ ea, 99231 ry'. Case Mana ement 99361 _ 2. OFFICE PROCEDURES 4. LABORATORY PROCEDURES # ©$ ea. 99232 Audiometry 92551 YS Glucoscan - 82948 VISIT Dates:_... 8.P. Monitor,24 Hour 93784 YB i Occult Blood 82270 # ®$ ea. 99233 Electrocardiogram 93000 YB Specimen Handling 99000 'DISCHARGE Date: 99238 EGG Rhythm Strip 93040 YB T.B. Test(PPD) 86580 CONSULT Date: 99253 Holter Monitor, 24 hour 93224 YB Throat Culture 87061 CONSULT Date: 99254 Incision&Drainage 10060* Urinalysis 81002 CRITICAL CARE Infiltration &Aspiration 20610" 1st Hour Date: 99291 Laryngoscopy. indirect 31505 YB VISIT Dates: Otoscopy 69210 YB # 9$ ea. 99292 Proctnslgmoitloscopy 45300 Y8 Emergency Room Visit 99281 I Spirometry 94010 YB 5. MISCELLANEOUS Emergency Room Visit 99282 I Spirometry with Inhaler 94060 YB Medical Report 99080 Emergency Room Visit 99283 _-� �_. Medical Testimony 99075 Emergency Room Visit 99284 Supplies v 99070 Emergency Room Visit 99265 t Medical Copies DIAGNOSIS1CO.9 CM -� -- ._: Abdominal Pain . 789.0 -7 Diabetes Mellitus . 250.0 -. Hypopotassamia . 276.8 G Pneumonia .... . . ., - . 482.4 Anemia 1 285.9 iC Dizziness/Vertigo .. .... . . 386.11 Hypotestosteronemia 257.2 ❑ Prostatic Carcinoma „',.. 185. Arrhythmia 427.50 C Duodenal Ulcer 532.90 G Hypothyroidism ..._ .... 244.9 0 Raynau8s Syndrome ;•1.. 443.0 ASCVD 429.2 ❑ Edema 782.3 Impacted Cerumen ... $80.4 ❑ Rectal Bleeding . .I. ,+�,... 569.3 Asthma 493.90 ❑ Rbrocystw Breast Dis. 610.1 7. Irritable Colon ... ..... 564.1 ❑ Rheumatoid Arthritis ...:4. 714.0 Benign Prost. Hypertrophy 601.1 0 Gastritis .. ..._..... ._ 535.5 i i Laryngitis ,. .. ..... . 46420 �] Rhmiti5 .......... . ... :.. 477.9 Bronchitis .... . ... . ... . 466.0 D Gastroenteritis ... .... 558.9 G Lumbar Ligament Sprain .. . . 847.2 ❑ Septicemia ...... .....}:.. 038.9 '7 Bursitis ....._ 727.3 ❑ Geller .._ ...__ ..__ 240.9 f1 Menopausal Syndrome 6272 ❑ Sciatica ... ... . . .. .. ... 722.10 Carcinoma, Breast 174.8 C Gout .. . .. . ... 274.9 C Mitrat Valve Prolapse ... . 746.89 ❑ Semite Dementia .. ...> . . 290.9 �,Cellulltis 682.9 ❑ Headache 784.0 I Myocardial Infarction 410.9 E: Sinusitis x... 473.9 S�4ervical Sprain 847,0 ❑ Hearing toss, Sensory .. 389.11 !� Obesity ... _. 2789 ❑ Syncope ... ... 780.2 -, _ Chest Pain, Atypical ... . 786.52 Hemorrhoids .... .. 455.6 'i 1 OBCeoarthlIhS ... 715.9 ❑ Tendinitis .....,s... 727.00 Cholelithiasis . . . 574.20 G Hepatitis, Viral .. 070.9 Osteoporosis 733.00 ❑ Thrombophlebitis 451.9 Chronic Fatigue Syndrome 780.7 ^ Hernia, Herat ... 553.3 Otitis Externa .. . .. ... 380.10 [; UTI .... ....... ......2... 599.0 Congestive Heart Failure 428.0 7 Hernia, Inguinal 550.90 f Otitis Media .. 361.00 C Vaginitis ... . ... .....`;... 615.10 ConjunctiWeis . . . .. ,, 372.30 CI Herpes Simplex 054.9 Parkinson's Disease 332.0 0 Viremia 790.8 COPD 491.2 [: Herpes Zoster 063.9 1 , Peripheral Vascular Dis. ... 4439 D ""' Coronary Disease 414.9 S'. HypercholeMerolemia 272.0 1 Pharyngitis .... _ 487.1 ❑ -- CVA 434,0 Hyperiipidemia 272.4 Depression 300.4 L; Hypertension 401.1 PHYSICIAN'S SIGN ATE Dermatitis .. . .. . . . 692.9 Hyperthyroidism 242.90 LABORATORY. GI X-RAYS. (] CHEST OLD BALANCE .- ECHO Ct HEMA i':3 HOLTER ❑ SPIRO TODAY'S PEES • PRESCRIPTIONS: PHARMACY: ' PAID TODAY ;�'Or NEXT APPOINTMENT IN: DAYS _WEEKS MONTHS NEW BALANCE C OV C OX EXAM ❑ RE-EXAM O EKG C PAP C PROCTO ❑ SPIRO THIS STATEMENT SHOULD BE MAILED TO INSURANCE COMPANY ALONG WITH THE COMPLETED INSURANCE CLAIM •; -18-97 TIIE 02 :48 PM HN W. OARRIcc. M. L. 516 -54 6713 P. 02 0-,/18/97 bill History Hardcopy for Joyce Anderson (7471 ) Fuge 1 Al ' Transactio115 in Date Carder Date Posting Code Ref Pat Dr Charge Payment Opon 11/11/96 18 Registration flat Add Joyce 3 0. 00 11/16/96„ 19,Fee Picket FT`i44cc JaYce 3 11/18/96 00 Patient Pay F4'•-14422 Joyce 3 —� 5. 00 11/19/96 20 Ins Claim 54314422 NAMM 12/1.6/96 13 WriteOff Clip 54314422 NAMOJ tb. 69) 12/1G./96 01 Insure Paymt 54314422 NAMM 69. 31 Charges Adj Chg Net Chgs ay.'-.men-;s Adj. Pay Net Pay Balance 81. 00 6. 69 74. 31 74. 31 0. 00 74. 31 0. 00 Account Balance 0-•30 Day 31-60 pay 61-90 Day 91-leo Day Over 120 0. 00 0. 00 0.00 0. 00 0. 00 0. 00 . � ¥ t \il � r §i> \ $ \ 0> / r - � 0 _§§ E / ; ° > 2 w M � « & D7 \ \ i } \ CD A coco CL CL ( $ 0 I CIOD % f } 2 ^ § \ � . c CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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: $480.50 Section 913 and 915.4. Please note all iRril[VT ID CLAIMANT: Marian Asan FEB 2 4 1997 ATTORNEY: COUNTY COUNSEL Date received MARTINEZCALIF. ADDRESS: 780 Oak Grove Rd. , #Clll BY DELIVERY TO CLERK ON February 24, 1997 Concord, CA 94518 BY MAIL POSTMARKED: February 21, 1997 1. FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. DATED: February 25, 1997 1p11 BeATCVELOR, Clerk Ipu Y. �ate_ 11. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: d BY: (;41�L- Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 11997 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. APR 0 3 1997 Dated: BY: PHIL BATCHELOR ��P off—Deputy Clerk T CC: County Counsel County Administrator Clair ta; BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLADIANr A. Ciai=s relating to causes of action for death or for injury to person or to per_ conal property or growing crops and Ihich 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 tAtich accrue at 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 titan Ow year after the aocrual of the cause of. action. (Govt. Code 5911.2.) B. Claimrmt be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 551 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 0M. 1F ! !r fF f IF !E f 1t 1F fF iF M M ■ M if 1F Ik Ir ! 1t !F 1t IF iF ft ft 4F ft !f 1F RE: Claim By ) Reserved for Cler s M4QiAti ASAN ) F13 Z 4 M c4w7leA eos:.4 cues y7`Y _ ) Against the County of Contra Costa CLERK BOARD OF SUPERVISORS or ) CONTRA COSTA CO. lh tvo f3/Pl` iS /45�?H.S%'�P '7 T1te /Vat{I / !!! District) Fill in vane ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 480 . 50 and in support of this claim represents as follows: 4 � Al.�ue aeu7 1. When did the damage or injury occur? (Give exact date and hour) 0/.125,87 u e roh, 00 �M 2. Where did the damage or injury occur? (Include city and county) Gonevl-d /Sled. (�ti &t PleaJaut 3• Flow did the damage or injury occur? (Give furl details; use extra paper if required) 14 etu car ow fwseeoetf /.3Iv�; GCttu.«+�+i° � laurx«, Co1fa /31w/, raw-��ue< f/ w«udJ" dfsa..+o:«d �flv�. •7 4/o, rc (�' h.,dfe ess7�o Ae wad'. '7,4,-re �3� iiYS nRee 6eec r/a.urt-Pe..l. 7 'here wu-e Aa;fe caar 71ae «fv. e �u�ilc•.�«.(ci7` {r«,ft 6 oe 7 <o,�.r). 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? rhe fr.lc u; ,�..a�,�. /'Thal // A,le .0 pt Xip/ 4e-1 7'a ge ,44ere /�riR • 'T/ cr�nl rosep� �etp. /}u a {er? �v�, l;,ur<n.</ %alce� /t p1`. cr e 7H / ua:c%r/ C RrJu cl <«« y �,.> cuef,, t ,Z / Ac /x C/ ca c'1..z ?e u•..c.Pi� lQs<re Pee f �. Wnat are the names of county or district officers, servants or employees causing the da7sae or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 3 hl,-rs ded7.o j�� u.- Tir<ar°k rnr �e r c� /y �wr 74;ut 7. How was the amount claimed above computed? (Include the estimated amount of any Q prospective injury or damage.) i P1' ,7 ji01 Ire p bt !+!ff C.*-7` uie au hn�7ucc ) t uke #ri e .lc;,e y �S �2 7i• /JN / f Cf�i ea C o- lat.E �[.ri/.ni!'r cud� uxl�rturle B. Names and addresses of witnesses, doctors and hospitals. 1 �L. O.Ar 49' x'1 "/T. llaq et �lr nce .gut Cunc�,/-� } eA - f,ho.oe 9. List,.the�ex,-penditures poU made on aow mt of this accident or injury: DATE AMWNT / /l Ld 9f43.4-, f.. ct6C� 3i9S ■ 1tMRfE * ■ k * .* iF ■ iF *'RiF * IF -1E *.i4lk # if it R ! ■ 1F ititM ■ � iF4R • [ * Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SUM NOTICES T0: (Attorney) or some person on his behalf." Name and Address of Attorney <K-• Claimant"s Signature) -790 C�exk Cary e_ Exec. Gf// Address. COAIC�.2A l c.4 Telephone No. Telephone No.{s/o 9�'- 8g / +� • � � � � * � � * tf it � � t � "{F�"�E"iF'"iF'iF�'i'�F'iF IF R if N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill; account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both s i-fir sa r . a*:d fine. :iC u TIRES 4+.27 1 B16�TIRE59 140 A CONCORD AVE L,CTNCURU. CA 94520 ra #i=:F;D!i5=04053 Phone: f ��10 i 67E,- 12G1� N E/ADDRESSACCOUNT NO. H-PHONE REFERENCE 0. 27031130—CP c5flN,MAR i G P.O.NO. W PHONE DATE/TIME Tea GAK GROVE R0. t1 RESALE N VIN N0. WO-ES NP ;1NCGRP.CE• 4452 YEAHIMAKE/MUDEL LICENSE NO. TAG NO. NEXT INSP.DATE BAR NO. � '- - 1z� -L�r�fiL7.• - 11. 2 R ALL PARTS NEW UNLESS '14UMIStU DAILITIME MILEAGE WRITTEN BY , Y N OTHERWISE SPECIFIED 572 ESTIMATE AMOUNT DATE TIME EMPLOYEE PHONE CUSTOMER REASON FOR REVISED ESTIMATE ORIGINAL REVISED 1 1 acknowledge 2 REVISED notice and oral approval of an increase In the original estimate price. J X PARTS & OTHERS LABOR :D: 11 u P40W E t :: � •lit N ` Cr',U(M FOR MqR ., AL:i�t;l_ti' SarGELTEG �: C^. �-j^• -�"' F'. Pay r N[ �— VEHICLE GRANT BIG TIRES, THE PURPOSE TO OPERATE THE VEHICLE O O I GRANDESCRIBED BIG0FOfl THEISSIO TO OOERATE INSPECTING, LF RF PARTS INCLUDES REMOVAL OF WHEELS AND DRUMS FOR THE PURPOSE OF INSPECTING THE BRAKES,SERVICING,OR DELIVERY.I RELEASE LABOR 7 -. _. BIG 0 TIRES FROM RESPONSIBILITY FOR LOSS OR DAMAGE TO VEHICLE OR CONTENTS THEREIN, IN CASE OF FIRE,THEFT OR LR RR OTHER - OTHER CAUSE BEYOND BIG O TIRE'S CONTROL I AUTHORIZE THE SUBLET REPAIR AND SERVICE WORK LISTED ON THIS INVOICE TO BE PERFORMED FOR THE AMOUNT SHOWN. $PAfl SUBTOTAL l?� TAX SIGNATURE'. (/ TOTAL ''�i o•'t'(: CASH AMOUNT CHECK AMOUNT CHECK N0. C.C.AMOUNT C.C.TYPE C.C.APPROVAL TYPE ON ACCOUNT THANK Q YOU! Bt6 0 Tit=ES #27 BIG�TIRES1 44o P LCN!:_IRD AVE SDN .DRU . CA 94`21,- L'A #CABOT pq raEi ', none: i 51 :I ; t r'aCle K i NAME/ADDRESS ACCOUNT NO. H-PHONE REFERENCE NO. RSAN'MAFtj P.O NO. W-PHONE DATE/TIME 780 OAK GROVE 9O. j1C± ) /qf'- X qT CONCORMA. 9451E RESALE N0. VIN N0. WO-ES NO. EI DEL LICENSE NO. TAG N0. NEXT INSP.DATE BAR N0. ,., r10PJv r r�I_Cr_,�:L �3 �!fG24s,; i,KS5. 72d SAVE PARTSALL PARTS NEW UNLESS PROMISED DATE/TIME MILEAGE WRITTEN BY Y N OTHERWISE SPECIFIED e,/3uq BT ESTIMATE AMOUNT DATE TIME EMPLOYEE PHONE CUSTOMER OR REVISED ORIGINAL REVISED 1 REVISED 2 1 acknowledge notice and oral approval of an Increase in the original estimate once. X PARTS & OTHERS LABOR 2^J ,I `iiLLS � Fjp..i vl'rtit. �'HT top, ' Pt HTP 71 I � I VEHICLE I GRANT BIG 0 TIRES,PERMISSION TO OPERATE THE VEHICLE LF RF PARTS HEREIN DESCRIBED FOR THE PURPOSE OF TESTING,INSPECTING, _ INCLUDES REMOVAL OF WHEELS AND DRUMS FOR THE PURPOSE LABOR OF INSPECTING THE BRAKES,SERVICING,OR DELIVERY,I RELEASE BIG 0 TIRES FROM RESPONSIBILITY FOR LOSS OR DAMAGE TO OTHER VEHICLE OR CONTENTS THEREIN,IN CASE OF FIRE, THEFT OR LR Rfl OTHER CAUSE BEYOND BIG O TIRES CONTROL.I AUTHORIZE THE SUBLET REPAIR AND SERVICE WORK LISTED ON THIS INVOICE TO BE PERFORMED FOR THE AMOUNT SHOWN. $PARE SUBTOTAL 1 � TAX SIGNATf-, L TOTAL 7ASMOUNTCHECK AMOUNT CHECK NO. C.C.AMOUNT C.C.TYPE C.C.APPROVAL TYPE ON ACCOUNT THANK YOU! • � TrrC %.Crle '.� //P/p/R eeo YIK !41 /</Y.� /lRceu j' ex e"i'd,.fl' J sl e� uUf 4,t ye prcutS�wAu«e fb vT � (j2i,ee<y //o?ve-euluu r C eur A7' <z IA,*4 AZ e cal/e9 744e<.c ez< j cZdJhe.l A" ./ Ae r•�f/` � �fn.1" a.lr easu<re�. T/ie <&r.k of wao 4H. 40 {-'� Z. w�d6/S c<.IW' --o rur<.y �wec:A,c- dFwheee" // .%1 aIt< u.c.<r« < c%t../u.<e Nw/i<�u"y ,Xa fe%/ /A�i�1ir w�See.J1 �Yj 9�crdr<c-e. d fico// Gz <yesl eaa/ �u,..T.l 7�e1 .•cw.< re circ�ck /17� yry e,:c%%d (�Tjr.e //n"C 744e, 2. "ee/i �j9A[//Cu✓lLreC /., rf./O� a '�lru<lC 'At llr/ 6uly 714, ,xe�<y'uwr+.c* yK7`, Z-7' .7 /�<e o•e We.y/<Y cI� e cre<,/.t -.�.7�<ore�`t�azc 07'/," o(fV/u,.••.<y:+et /ec.✓// ac.-=.+sti f(ft�Ru.�[S / / «r/' eda.l/r✓e. `�cT� tt \ 9 % « 0 ,\* � . � • & + V � \ � � CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 Go Amount: yQgg Amount: $1,825.00 Section 913 and 915.4. Please note all g v f ) CLAIMANT: Richard Cohn FEB 2 4 1997 ATTORNEY: COUNTY COUNSEL MARTINEZ CALIF. Date received February 21, 1997 ADDRESS: 1909 Parkside Dr. BY DELIVERY TO CLERK ON Walnut Creek, CA 94596-3549 February 20, 1997 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 24, 1997 IVIL BeAT%E.LOR, Clerl�� oL7-- 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). ?�Id Other, 6 Dated: / � BYDeputy 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 (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 1 1997 v PHIL BATCHELOR, Clerk, By��ii ate°— 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 adviai 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. APR 0 3 1997 Dated: BY: PHIL BATCHELOR b� c_c4A--`Deputy Clerk CC: County Counsel County Administrator Clair_ to: BOAM OF SUPEMSORS OF CONTRA COSTA 03Wn INSPR MONS TO CAIKWr A. Claiss relating to causes of action for death or for injury to Pe'sm or to Per- sonal property or growing crops and sdrich 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.4eath or for injury to Person - or to personal property or gr Ang at and slhich aomve an Or after JM=rq 1, 19880 must be presented not later than six mouths after the accrual of the cause of action. Claims relating to ay 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 mast be filed sd[th the Cleric of the Board of Supervisors at its office in Boom 106, County Administration Buildings 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 ene public entity, separate claimust be filed against each public entity. E. Fraud. See penalty for fraudulent claims, penal_Code Sec. 72 at the end of this t �taeerta� � �l �reaeeaa * +tste �e �ta +l� :r ,� a +lt � �r +� �rert +� � aattr ,� aa �t FE: Claim By ) Reserved for Clerk's filing stamp RICHARD COHN 1909 PARKSIDE DR. WALNUT CREEK CA ) RECEIVED Against the County of Contra Costa ) FEB 21 P07 or ) r I _ CLERK BOARD O,� District) CONTRA a, (Fillin rame nue undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the s= of $ �l �+ ZS - and in support of this claim represents as follows: 1. When did the damage or injury occur? -(Give exact date and hour) f}y L AsT /V/a: r-rT cg/- 4 r'c 3%s' /95 `I` 2. Where did the damage ar injury occur? (IMIUde city and county) k:�Si n b Pf_ i ✓L , 14eA LAly T Cr2 eic' C11 3. How did the damage or injury occur? (Give full details, use extra Paper if sr�2 mom) o ni PAS l<51,oa D��✓t`, cut /e /f /�i4s /vim T rR� a�� C1; 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage AN �i M �,J / Iti. � C C-AA h p (?Oc WT X' rvAS N©'7-1 ,=i,i=n y ri/G m94lY T ye,,4 < -TH/�r a-7—ePM OAPIV 4'vr4s ©.P2 S7 ,41 rhF' c ; y � F4OW w_c . Aye N M A."�,1�✓ / �.f ° a- �Q Li e,2�L,y 5 !� -rALCC'O TCS f<� � / 0>7 S ; ` q� f+SNfa ,C t1f ;r e �Y2Arfi/ (ate iM /V,JA cit j. 44nat are :.ne names of county or district officers, servants or employees causing the 6=age or injury? -4- 6. 'What damage or injuries do you claim resulted? (Give 611 extent of injuries or damages claimed, Attach two estima for auto damage. -;rev 7. How Uas tbe 2M"OMt claimed above computed? (Include the estimated ammmt of any prospective injury or damage.) 6. Names and addresses of witnesses, doctors and hospitals. -4 4 , 9. List the expenditures you made on accotmt, of this accident or injury: DATE ITEM. J L Goi. code sec. 910;2 provides: "The claim must be signed by the claimant SM NOTICES TO: (Attorney) or by veve person on his behalf." Name and Address of Attorney (Claimant's Signature) RICHARD COHN (Address) fwu� UN. WALNUT CREEK CA 94596-3549 Telephone No. 'Telepbo5be No. IF* 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 countyt 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 Jan 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 snob i. rison3eat and fine. • j- l"3- Q�-- pGZac`tic.a� 6E' 'iJnJol�L1c=. � ksiaPeD�. lJcAJvtL, f (1L �c, �, g`Is�l� Sys 44,, 'ryc::)a cel/�i 5 py.-t ��c( �.-�-� a C aXj s� ' --F�✓l 1 �-�' �PN'lNl� U'(/�� �q� Q..CIi! rC7N � C./CJJ( IBC/p�� 2 y 2ee Jr,�e •,7`/ �/G�/� ac ru.0 9� p a� a�� c��f�r7� eL yz lktwjl -e- !� j k R las'n�c,l i o� A� 1 GJh /'• OL Owe j i t 'r Ji r M a0 00 6.S�4Y'a a r C. 51 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 Mount: $25,000.00 Section 913 and 915.4. Please note all "W;R 'r0?1IIdJE]) CLAIMANT: Maxine Farias FEB 19 1997 ATTORNEY: c/o Peter C. Pappas COUNTY COUNSEL Date received . MARTINEZ CALIF. ADDRESS: 2400 Sycamore Dr. , Ste. 40 BY DELIVERY TO CLERK ON February 18, 1997 Antioch, CA 94509 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. DATED: February 18, 1997 JAIL 6epuCyLOR, Clerk�'j< 11. FROM: County Counsel TO: Clerk of the Board of Supervisors k) This claim complies substantially with Sections 910 and 910.2. " V. ( ) 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: -416-k Dated: )_`) L�� BY: _ aiaya LAW Deputy County Counsel Ill. 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. qq Dated: APR O 1 1997 PHIL BATCHELOR, Clerk, By\/ ,_o_,WZ— , 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 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. q Dated: APR 0 3 1997 BY: PHIL BATCHELOR J/L ��jt o c+puty Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISO"' OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # RE: Claim By ) Reserved for Clerk's filing stamp MAXINE FARIAS ) RECEIVED ) Against the County of Contra Costa ) �. � 8 or ) Contra Costa County Water District) BOARDO SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 25 , 000 and in support of this claim represents as follows: --------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) August 29, 1996 at 9 : 15 a.m. ----------------------------------------------—-----------—------------------ 2. Where did the damage or injury occur? (Include city and county) Highway 4 Brentwood, sidewalk in front of Peter Piper Dounut Shop -----------------—----=--------------------------------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) There was a large gap or hole in the cement directly - above the water meter. The hole was approximately three to four inches deep and isx to eight inches long. ---------------------------------- ------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? They failed to properly fix the hole or gap until after the injuries were sustained. (over) i 5. What are the names of county or district officers, servants or employees causing the damage or injury? Unknown -----------------—-------------^-----------—---------—------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or, damages claimed. Attach two estimates for auto damage. Injuries to my foot leg, body and nervous system. -------------—_—..-----—----------------------—----—_----------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) medical costs and general damages for pain and suffering. -------------------------------------....__-__....__-_-- -_-------------------- 8. Names and addresses of witnesses, doctors and hospitals. Delta Memorial 3901 Lone Tree Way, Antioch, 94509. Louis A. Enrique, M.D. , 3701 Lone Tree Way, Antioch, 94509 . -------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 8/96 . Prescriptions 25. 00 estimated 8/96 Delta Memorial 300 . 00 estiamted 8/96 L. Enrique, M.D. 75 . 00 estimated _-_ Gov.-Code Sec. $ 17:x;provides: tiThe aim must be signed by the claimant SEND NOTICES TO: (Attorne ) or by s me person on his behalf." Name and Address of Attorney - MAXINE FARIAS - c/o Peter C. Pappas laimant' Sig uree) 2400 Sycamore Dr. , Ste 40 c/o Petbe Pappas Antioch, CA 94509 ddress Drive , gnit-P 40 Antioch, CA 94509 Telephone No. Telephone No. 510 754-0772 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 ($109000, or by both such imprisonment and fine. 1 PROOF OF SERVICE 2 I , KRISTEN SHELDON, declare that I am employed in the County of Contra Costa in the State of California . I am over the age of 3 eighteen years and not a party to the within cause. My business address is 2400 Sycamore Drive, Suite 40, Antioch, California 4 94509. 5 On February 18 ', 1997, I served the within: 6 CLAIM BY MAXINE FARIAS AGAINST THE COUNTY OF CONTRA COSTA AND CONTRA COSTA COUNTY WATER DISTRICT 7 on all interested parties in said cause, by delivering a true copy as follows: 8 (By Mail) I place a true copy thereof enclosed in a 9 sealed envelope with postage thereon fully prepaid. I deposited said envelope in the United States mail 10 at Antioch, California. 11 X (By Band) I place a true copy thereof enclosed in a sealed envelope. I caused such envelope to be 12 delivered by hand to the offices of the addressee. 13 (By Facsimile) I sent, a true copy thereof via telephone facsimile transmission to the following 14 number(s) 15 Each envelope (if applicable) was addressed as follows : 16 Board of Supervisors Clerk of the Board 17 Room 106 651 Pine Street 18 Martinez , CA 94553 19 I declare under penalty of perjury, pursuant to the laws of the State of California, that the foregoing is true and correct , 20 and that this declaration was executed on February 18, 1997' at Antioch, California . 21 22 KRI T SHELDON Secr ry to PETER C. PAPPAS 23 24 25 26 27 28 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 t �,pp4pt[av,m.� Amount: $1,385.00 Section 913 and 915.4. Please note alrnng u - V10 CLAIMANT: Robert Jones FEB 2 8 1997 ATTORNEY: COUNTY COUNSEL MARTINEZ CALIF. Date received ADDRESS: 3225 Broadmoor Lane BY DELIVERY TO CLERK ON February 28, 1997 Fairfield, CA 94533 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. BY: pp1HIIL ATCVIELOR, Clerk__9 Qdo� DATED: February 28, 1997 �epu y / 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�,Yl% / BY: Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 1 1997 PHIL BATCHELOR, Clerk, 61, 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 B 3 1" BY: PHIL BATCHELOR4y�j�-�e��'`T—>teputy Clerk CC: County Counsel County Administrator Cla:c to: BOAP.D OF SJPERVLSM OF CONTRA COSTA CMM INSfRUCUONS TO CLAD4ANi' A. Claiss relating to causes of action for death or for injury to person or to per_ conal property or growing crops and u hich accrue an or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claim relating to causes of action for death or for injury to person . or to peracnal property or growing crops and idrich 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 cne year after the aocrual of the cause of action. (Govt. Code 5911.2.) B. Claim must be filed xith the Clerk of the Board of Supervisors at its office in Room 106, Comity Administration Building, 551 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 Seo. 72 at the end of this r FE: Claim By } Clerkts stamp RECEIVED ) _ 3 Against the County of Contra Costa g L GGA } ?4 61/G A c XA S District) CLERK BOARD Of SUPERVISORS —��— CONTRA COSTA CO. (rill in TISM) The undersigned claimant hereby makes claim against the County of Contra Costa or, the above-named District in the simn of $ [ ?,j; a?c� and in support of this claim represents as follows; 1. When did the damage or injury occur? -(Give exact date and hour) oe- d % 2. Where did the damage or injury occur? (Include city and county) J4A. r'44#le Ty C� vTC✓., c'.�ST.4 c � T� - AOIIIA,. 3. Now did the damage or injury occur? (Give full details; use extra paper if required) <- '9X0 oe /A, TO /f D17Z > Dos Br jDab//c GUS QHS 1";I-?-S- - Z- 7- �c/h�?5 rev T 0 uf-" _ c ve,v fl Tem ih� Gpl/lS/acv Goer% ` •r T S e c l*4` T L au% i; e C., .e 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? D u9 .4 D i 7'c �- Nnat are :.tie names of counry or district officers, servants or employees causing *he ds- e or y? ..3a :rj�:r 5. "haat dam4e or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates far auto damage. u�,�z4 Ct34,Je /Agro /� 10 F2A.�+oe /j Jd•r ani cA2 7. How was the amount claimed above computed? (Inc3mde the estimated amount of any prospective injury or damage.) ,fS o'�y 8. Mimes and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on aommt of this saoident or injury: DATE ITEM` AMMNT All Gov. Code sec. 910:2 provides: "The claim must be signed by the claimant SEND NOITCES T0: (Attorney) or by some on his behalf." flame and Adaress of Attorney (-Clair 's Signature) +�Addres� Telephone No. I Telephone No., N O T I C E Section 72 of the Penal. Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill; account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by hoth su--h i*-;.r.sonT,,ent a=)d fine. 01/15/97 at 15 : 04 D.R. 13804-0005223 AA1069!9a Est : Not On File . tiT _ P ATJ VC ) 1BOL7Y , =NC _ FAX (707) 428-1521 1205 N. TEXAS ST. FAIRFIELD, CA 94533- (707) 428-0428 Owner: BOB JONES Day Phone : { ? 434-8513- Address : 3225 BROADMOOR Other Ph: ( ) - - FAIRFIELD CA 94533 Deductible : $ N/A Insurance Co . : Phone : Claim No. : Adj . ; 83 DATS MAXIMA 4D SED BLUE 6-2 .4L-FI Vin: JNlHU01SXDT077747 License : 1GND983 CA Prod Date : 12/82 Odometer: 0 Power steering Power windows Power locks Power antenna Power mirrors Tinted glass Body side moldings Air conditioning Rear defogger Tilt wheel Cruise control 4 wheel disc brakes Bucket seats Recline/lounge seats Alloy wheels Clear coat paint -- --- - --------------- ------------------------------- - ------ ------- --------- - --- PART NO. OP. DESCRIPTION OF DAMAGE QTY COST LABOR PAINT MISC -- ------- --------- ------- ------------------------------ - --—- ---- --------------- 1* SET UP & MEASURE 1 2 . 0 2* FRAME AND ENGINE CRADLE OPEN 1 3* FRONT CROSSMEMBER OPEN 1 4 FRONT BUMPER & LAMPS 5 R&I bumper assy 1 0 . 8 6** Repl A/M Valance panel 1 86 . 13 1 . 0 1 . 0 7 Add for Clear Coat 1 0 . 4 8 COOLING 9* R&I Radiator auto trans 1 1 . 2 M 10* Repl Support assy 1 251 . 02 4 . 0 1 . 0 11 GRILLE & LAMPS 12 R&I Grille from 7/82 1 0 . 3 13* R&I RT R&I headlamp assy one s 1 0 . 6 14* R&I LT R&I headlamp" assy one s 1 0 . 6 15 Repl Aim headlamps 1 0 . 5 16 WHEELS & FRONT SUSPENSION 17* FRONT SUSPENSION OPEN 1 18* WHEEL ALIGNMENT 1 X 49 . 95 19 ENGINE 20* MAIN ENGINE SPLASH SHIELD 1 41 . 08 0 . 5 21* Repl RT & LT CORNER FRAME BRACES 2 14 . 50 0 . 8 22* R&I ENGINE OPEN 1 Page : 1 01/15197 at 15 : 04 D.R. 13804-0005223 AA10695$ Est : Not On File . ,-T _ P _ s AUT CD BODY FAX (707) 428-1521 1205 N. TEXAS ST. FAIRFIELD, CA 94533- (707) 428-0428 - ------- ------ PART NO. OP . DESCRIPTION OF DAMAGE QTY COST LABOR PAINT MISC ------ ------ -------- - ----------------- --- - -- - - - - -------- - ---- ----- - - -- ---- -- ---- 23* CORROSION PROTECTION 1 0 . 4 T 9 . 00 24* UNDERSEAL 1 0 . 4 T 9 . 00 Hazardous Waste Removal Fee 1 X 2 . 00 -------- ------------------ - --------------------------- ------ ---- ---------------- Subtotals =__> 392 . 73 13 . 1 2 .4 69 . 95 Page : 2 01/1�-/_rl at 15 : 04 D .R. 13804-0005223 AA106O58 Est : Not On File . AUTO B O D Y S N C _ FAX (707) 428-1521 1205 N. TEXAS ST. FAIRFIELD, CA 94533- (707) 428-0428 Parts 392 . 73 Body Labor 11 . 9 units @ $48 . 00 571 . 20 Paint Labor 2 .4 units @ $48 . 00 115 . 20 Paint/Materials 2 .4 units @ $23 . 00 55 . 20 Mech. Labor 1 . 2 units @ $48 . 00 57 . 60 Sublet/Misc 69 . 95 -- ------------------ ----- ----- - --------- ---- SUBTOTAL $ 1261 . 88 Tax on $ 465 . 93 at 7 . 2500°1 33 . 78 ---------------- - ------ ---- ----------------- GRAND TOTAL $ 1295 . 66 . . . . . .. ... ........... .... . ..... . . . .... . ..... INSURANCE PAYS $ 1295 . 66 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE . ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Non-asterisk(*) items are derived from the Guide AOF3607. Database Date 6/96 Double asterisk(**) items indicate part supplied by a supplier other than the original equipment manufacturer. CAPA items have been certified for fit and finish by the Certified Auto Parts Association. EZEst - A product of CCC Information Services Inc. Page : 3 Lafaye"s Body & Paint Works Date / —L phone e TOWING LAFAYRN, CALIF. NBmB �l - J��G/L K 3291 MT. DIABLO KVD. AaarBY: �? Z �C d�`9Yi7�liL�e,-,7,Z TdIII Is 204421 � � 7 i MAK[ YEAR LICENSE NO. OUAN. DESCRIPTION OR WORK DON[ VPARTIS LABOR HOURS A �' c — rYv i i -cry-L CD I HEREBY AUTHORIZE REPAIRWORK TO BE DON[ At DESCRIBED ABOVE WITH NECESSARY PARTS, TO B[ LISTED TOTAL LABO AT YOUR REGULAR PRICES. 1 AGREE TO PAY CASH ON DELIVERY Of CAR OR ON SATISFACTORY TERM: TO YOU AND UNTIL PAID IN FULL. IT SHALL CONSTITUTE A LIEN ON TNIf CAN. I FURTHER AOR[[ THAT YOU WILL NOT BE H[LD RSSPONSIBLE FOR CAR OR ARTICLU LEFT IN CAN IN CASE OF FIR[. THEFT, ACCIDENTS OR OTHER TOTAL PARTS GJ CAUSES BEYOND YOUR CONTROL. MY CAR MAY BE DRIVEN BY YOUR EMPLOYEE: RON ROAD TS:TS AT MY OWN RISK. EV SUBLET WORK AUTHORIZED BY -. TAX ON PARTS CHARGES AUTHORIZED BV - _ - 1 TOWING AND STORAGE R E. "o�-:zo BT- (/T'�./ TOTAL BUREAU OF AUTOMOTIVE REPAIR: CERTIFICATE ; 0328`�"./'��"�- .- �J�'7(� —` -' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 too Amount: $96,522.00 Section 913 and 915.4. Please note all# gs# CLAIMANT: Corazon F. Lacanlale MAR n 3 1997 ATTORNEY: John C. Ferry COUNTY COUNSEL MARTINEZ CALIF. Law Offices Date received February 28, 1997 ADDRESS: P.O. Box 23646 BY DELIVERY TO CLERK ON 200 Gregory Lane, Ste. B-2 February 27, 1997 Pleasant Hill, CA 94523-1810 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, p gg H DATED: March 3, 1997 BAIL DepuiylOR, Clerk r 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (V This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). Other: !4 iyloy .T�I.L Dated: ja J311 7 BY: aA&t,4­X Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 01 1997 PHIL BATCHELOR, Clerk, 8g�/� '"v iLaE�Gr _- , 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 3 1997 BY: PHIL BATCHELOR�y Deputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal 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. (Gov't Code 911.2 . ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. IL Lite V1Qild i5 .1Cjain:.C. .uurC Li::111 ...iC Yu.;l_: _- ..:ula t.p, sCY,,-,1.0 a aAi.lild8 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 �()clL�t-A ECLERK ECEIVED Against the County of Contra Costa) or ) FEB 81997 i I� rJlcll �C ln:ee(4'-d 6-,t. r District) (Fill in name) ) � ,'FM SpRS The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in sup ort of this claim represents as follows: .P"I V(!( _7.2 L,-� 914' 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) ��-!17?1A nla lY ��f,l �l t_/fes �S�LtC.ceY,3c%Yl _ 3. How did the damage ir injury occur? (Give full details; use extra paper if required) 4 . What particular act or omission on tbie part of county or district officers, servants or employees caused the injury or damage? (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? 'I Ji141C`� pC'`' `✓ 0 64 J 1'4;21./' t1, ))Lelle4 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. ) / c1lr 7 � lPr�r�� ( C fUr,1,:_u 71 e°5 �' a lit 1&14 da-4tt tit `; Id(r 7. flow was the amount blaimed above c puted? (Includ the est matedt Vit, amount of any prospective injury or damage. ) 8. Names and addresses of witnesses, doctors and hospitals. 9. List the ekpeiiditu�as you made ba au ;uuiiL ui i.i.:i5 auuideiit u injury. DATE TIME AMOUNT Gov. Code Sec. 910. 2 provides "The claim must be signed by the claimant or by some person on his SEND NOTICES TO: (Attorney) ) behalf. " Name tt and Address of Attorney ) JG�I✓1 �� ff� Claim 's Signature) C) F)C? (A dress) / 2�0 ("-7/v-c"-� G�z,x �cv�t C3 2- Telephone Telephone No. V/0 ) Telephone No. 5ff' 7,( 7 t' `21 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. "LG�Yv HI`II I-IL LL I':IV VU RV VI'IJ CALIFORNIA UNEMPLOYMENT INSURANCE APPEALS HOARD DECISION OF THE ADMINISTRATIVE LAW JUDGE OAKLAND OFFICE OF APPEALS ---------------------------------------- (510) 286-0695 DATE MAILED: tEEB 0 7 1997 CASE NO: OAK-04263 DATE APPEAL FILED: JANUARY 22, 1997 CLAIMANT: CORAZON F LACANLALE APPELLANT 609 TWINING CT ANTIOCH CA 94509-6530 DATE AND PLACE OF HEARING: FEBRUARY 7, 1995 PLEASANT HILL, CALIFORNIA SSR NO. : 553 -63-9723 LOIS-BYB: 096-12226 EMPLOYER: MT DIABLO MED CTR 2540 EAST ST CONCORD CA 94520 ACCOUNT NO. : NONE SHOWN PARTIES PRESENT: CLAIMANT EMPLOYER STATEMENT OF FACTS The claimant appealed from a Department determination which held her disqualified from benefits based on a finding that she had been discharged for misconduct connected with her most recent work. The claimant was most recently employed as a cook by the above- named employer for approximately ten years earning $14 . 50 per hour. She left this work on December 12, 1996, under the following circumstances. On the afternoon of December 12 , 1996, the claimant was repeatedly harassed and verbally insulted by a co-worker while ahs was performing her duties as a cook. This co-worker, Fermina Souza, for no apparent reason and on three separate occasions accused the claimant of being a thief and alleged that an eye infection was a punishment from God to the claimant. In response to this provocation the claimant, who was then chopping vegetables with a knife, said that she could kill Miss Souza and that she ohauld watch out when going to her car or words to that effect, The claimant thereafter voluntarily reported this incident to management. She was subsequently terminated for making this threat. hearing under oath and subject to cross-examination is generally entitled to greater weight than hearsay statements, whether or not such statements are in affidavit form. In Precedent Decision P-B-57 , however, the Board recogni,xed that sworn, direct testimony may be disbelieved where it appears unreliable, contradictory, or inherently improbable. In this case the employer's position is severely hampered by the fact that the employer did not bring Miss Souza to the hearing so that the undersigned Administrative Law Judge could have the benefits of her perception of what happened. The claimant's testimony is neither apparently unreliable or incredible and her recollection of events is deemed true and accurate. Under these circumstances it is found that the claimant used questionable judgment in responding to Miss Souza, but that there was no serious threat made or intended, but rather this was an occurrence largely brought on by Miss Souza' s obviously - inappropriate conduct. Under these circumstances the claimant's actions do not rise to the level of "misconduct" as that term is understood in Unemployment Insurance Law. Accordingly, the Department determination is incorrect and will be reversed on appeal. DECISION The Department determination is reversed. The claimant is not disqualified under Code Section 1256. benefits are payable provided the claimant is otherwise eligible. %, � LAN E. VAN W E Administrative Law Judge THIS DECISION IS FINAL UNLESS APPEALED WITHIN 20 CALENDAR DAYS. FOR APPEAL OR REOPENING RIGHTS, SEE ATTACHED NOTICE. ANY INQUIRIES REGARDING PAYMENT OF BENEFITS 'MUST BE DIRECTED TO THE LOCAL OFFICE OF THE EMPLOYMENT DEVELOPMENT DEPARTMENT AND NOT THE APPEALS OFFICE.. ALLOW 5 TO 7 WORKING DAYS FOR PAYMENT OF BEN FITS. IF PAYMENT IS NOT MADE WITHIN THAT TIME, CONTACT THE LOCAL OFFICE OF THE DEPARTMENT. THE DEPARTMENT IS A PARTY IN THIS MATTER AND MAY APPEAL THIS DECISION WITHIN 20 CALENDAR DAYS. pdm/ OAK-04263 3 $�s w � �_ � � � $��� � � � s a �, � �p � '�' "s 9— w � � � '' �' O - ��,, W � \t5 � A r � � � � � ,'� N ^' � ` �� ,- `- :� o � o � r � 1 I r ,. _ i I � , � M� t i r'"'i' PLEASANT HILL HRNG ROOMS (510 ) 602-7714 Feb 7 ,97 13 : 37 No .012 P .U3 - The claimant appeared and testified under oath that she did not mean the threat to be taken seriously and that it was only because of frustration and the harassment she was receiving that she made the aforementioned statement to Miss Souza. It is noted that the employer did not bring Miss Souza or subpena Miss Souza as a witness in this matter. REASONS FOR PgCISION Section 1256 of the California Unemployment Insurance Code provides that an individual is disqualified for benefits if he or she has been discharged for misconduct connected with his or her most recent work. Citing Maywood Glass Co. v. Steyart (1959) , 170 Cal . App. 2d 719, the California Unemployment Insurance Appeals Board in Precedent Decision P-B-3 defined "misconduct connected with the work" as a substantial breach by the claimant of an important duty or obligation owed the employer, wilful or wanton in character, and tending to injure the employer. On the other hand, mere inefficiency, unsatisfactory conduct, poor performance as the result of inability or incapacity, isolated instances of ordinary negligence or inadvertence, or good faith errors in judgment or discretion are not misconduct. The legislatively declared public policy of the state, in light of which section 1256 must be interpreted and applied, requires the extension of unemployment insurance benefits to persons "unemployed through no fault of their own" (Unemployment Insurance Code, Section 100) . Accordingly, fault is the basic element to be considered in interpreting and applying section 1256, and the test for misconduct is essentially volitional. (Rowe v. Hanson (1974) , 41 Cal, App. 3d 512) . The burden of showing a disqualification under Section 1256 of the code is on the employer or the Department. A claimant is not required to show that he or she is not disqualified under that section (Yresood v. California unemployment Insurance Appeals Hoard (1976) 57 Cal. App. 3d 29) . Every employee owes the employer an obligation of civility. Deliberate or repetitive conduct so disrespectful of an employer or supervisor as to amount to defiance is subversive of the employer's interests and is misconduct (Silva v, Nelson (1973) , 31 Cal. App, 3d 136) . A single instance of an offensive remark to an employer, however, attributable to hotheadedness rather than deliberation, is not misconduct. In Precedent Decisions P-H-218, P-H-293 and P-B-378 the Appeals Board followed the legal principle that testimony given at the OAK-04263 2 C . 31 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 G ,��,�� Mount: Unknown Section 913 and 915.4. Please note all • ings° CLAIMANT: Tanmii R. Mixon FEB 19 1997 COUNTY COUNSEL ATTORNEY: MARTINEZ CALIF. Date received ADDRESS: 1360 Springhill Dr. BY DELIVERY TO CLERK ON February 18, 1997 Pittsburg, CA 94565 February 14 1997 BY MAIL POSTMARKED: rY > I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 18, 1997 'p1l BePuIyLOR, Clerk II. FROM: County Counsel 70: 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: P/1/ If 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 ORDER: By unanimous vote of the Supervisors present This Claim is refected 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 1 1997 PHIL BATCHELOR, Clerk, By = 50-� . 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: AM 0 3 199BY: PHIL BATCHELOR by_ � Deputy Clerk CC: County Counsel County Administrator Clams to; gOAFD OF SfPfIiYISORS OF CONTRA COSTA COUN'T'Y INSMUMONS TO CLAMANT h. Claiss relating to causes of action for death or for injury to person or to per- zonal Property or ging craps and i6ioh accrue on or before December 31, 19$7 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to caws of action for death or for injury to petson • or tO Persarml Property or growing amps and vblch aoorw on or after JM=ry I. 19880 must be presented not later thaw SIX month9 after the aver al. of the oanse Of action. Claims relating to nay other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims must be filed %dth the Clerk of the Board of Supervisors at its offioe in Roos 106, County Administration Building, 651 Pine Street, Hartinez, C& 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. F. Fraud. See penalty for fraudulent claims, Penal. Code see. 72 at the end of this fes. BE: Claim By ) Reserved for Clerk's filing stamp RECEIVED Against the County of contra Costa , FED I e 1997 or CLERK BOAR OF SUPERVISO ,�, District) CONTRA COSTA CO. �7FJIJ in rame ) 7be vndersigned claimant hereby makes claims Inst the County of Contra Costa or the above-named District in the sum of and in support of this claim represents as follarmz 1. When did the damage.or injury occur? '(Give exact date and hour) � ClV\t1()l-f( (� (q � J�. �lair . rYz 2. there did the damage or injury occur? (Include city and county) ' �burl Ccsv'C�- /S Y� . 1 (��✓�C�r'G�.- I �- . � �a�'�Y'"w C'v-�-- �'6tl�`� . 3. flow did the damage or injury occur? (Give full details; use extra paper if I required) d r-74 o Ari: /1� 4. What particular act or omission an the part of county or district officers, servants or employees caused the injury or damage? One, ov--,moi z� , CUqD To-� hole, to' r�I /V� k [Ae wY10 yr l�,I a.vb1 b drnVt� a. WnaL are the rxwws of county or district officers, servants or employees causing the .:.3-zmage or injury? an-1 O SSvw1tnr-t� e- rerSPa� t J� ��r� nDrJ (rte � ' de. 6. khat damage or injuries do you claim r4 al.ted? (Give full extent of injuries or is C✓t . -41 et-3e C1.lM, 16t"r) VAgtSa ,,for auto�da�ge.prY -ir 7?lm ; }�. IYVtXFf1 - k�E'1t C �eS — Avrar,obt4e on yep c chte.(—. i 1t� 0t,xev� 7. How was the amount claimed above computed? (Dw3mde the estimated amount 'of any Gain oG/ea prosqecLive injury or ,amage.) I S. Names and addresses of witnesses, doctors and hospitals. {sou } ruL - 4'��ve - C�rriSy Yl - 10 �y tyt� lh @ �7G -ri I Co- F �rvtoli� 778 7 z� 9• List the expenditures you made on account of this accident or injury; DATE ITEM? AMFHRTT / -�Ia7 rnIsse "���"1±�- �&0 -f- � d ✓to ~IrG.ris C . w ea :447 W;T-q 5r e. } W" wt q Lnawe , w� we k (nw t. ovu- u��tcM call 3a. .Gov. Code Seo. 910:2 provides: "The claim must be signed by the claimant .,END NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney —l!-- �-- (Claimantls Signature 13�Ob W K-,r1,4 Gress. NephoNo. Telephone No, ne -* V I N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer,, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill; account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment In" the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by' both -ch i. risx re : 2nd fine. &r►vtri- L� ovi conk vzk Ave, J'u<, -� d\d� otti-c., ard- m ljVr- old. �pvstn I exp-e�j- ehC-el�) ovVL o -}fie mos}- �5 mwtds �. We- vow no �+ ull�.ak- vv,?, ha..d„ 4y-kvev) +kv-aw wa--s ave ex varnc�� lave Fb-�- lib le . The Car slaw mcA � +�ile, oroUrd OJ-- vjDivi!. Aa vo - know gni � dm so on +t- brd� . I�tle -F-I��� I�f sorn�eav� I�td qa..ren,dQd- u �j u s did c�ssis� cv�c� o� �a r� OA kwv\ b OtJ of t-e� L W6L-S asAlVne-, at- +-4 S�o f b� tWd P-' �✓v�- d ri�/c� �lov. w i4'k 4ke d�vcv� C, ONV(a CAr w tcc ' k 6.I so :Z a�Sk ��m r-vn 1 J cJs caw« �e re- -r- OU + Gp&ecs n o r- d.o AAA ". TIibe dri v7- �ai� Ine vUb�l� Ck-(f� otj�- L Jk-e l �e was doh . (n -I e mcar) VI �olt� s z �� w ly �"� e o� (�✓� Go'M?Ow�m tA/I"{- KV1�e , vm v i-e-L-co, kaA eked vlezX aY-\ a (VI�� , wig civ s ► , V,) 4-1 e v�- SP � ka-ol_ aid I� s also Iia o� kt o alc&klaS wi ff, II�✓lc��eV' d.Ur�v✓ S co�v"e -� ✓vtc� �GG� av� �C�V2 exPflXi2vD s �l� �� Ir�J ✓v�111�� in ✓tow �l lnn 'I ���S Sv✓� Of GIUl� oG'Wim? Dve KK WW� is 4a �✓ o lov\�-ev-- `VV 7_�3-79 B��a�����'• CUSTOMER MUST PRESENT COPY OF INVOICE FOR ANY WARRANTY WO R K ORDER NAME/ADDRESS g INVUICL* -7 - ...�;a ^.t./4v- " 'Z- f h CAR V HOME PHONE r t C SSG✓ WORK PHONE O J CAR M BEL �. SAL SPEf2SON • - A • •I III , LIC NN Z. 7 MILE �,`•••` (C1, 0 B/W I grant Big 0 Tires permission to operate the vehkle herein described far the fucose of testing,irupecArlg,includes removal of wheels and drums kr the ramois of froma Nm7 the brakes, ❑ W/W servicing,or delivery.I release Mg 0 Tires from respousiblllty for loss or damage to wifecre or contents Above,in ease of fire,than or other cause Deymd Go 0 Tires control.I authorize ALL PARTS ARE NEW UNLESS INDICATED the repair and service work listed on this invoice to be performed for the amount shown below. BY CODE: R w REBUILD U USED AMOUNT SIGNATURE: REPLACED PARTS AUTHORIZED $ IxREQUESTED VES❑ NO❑ WORK REQUEST/SPECIAL INSTRUCTIONS/SYMPTOMSfl : Oil Y 1 TECHNICIAN'S COMMENTS: OTT DESCRIPTIONI ;I' . PARTS INSTALL MASTER CYLINDER L1 Pull LA O REBuu TIRES INSTALL DISC PADS O FRONT ❑REAR INSTALL CALIPER ❑NEW O REBUILT INSTALL WHEEL BEARINGS 00 LI 0 AI ❑m 0'10 REPACK WHEEL ❑FRONT p BEARING ❑REAR USED TIRES DOO BAY WARRMTYI INSTALL GREASE SEMS ❑REAR T WHEELS RESURFACE DRUM ROTOR OFRONT ❑REAR INSTALL RELINED 0 FRONT BRAKE SHOES 0 REAR INSTALL WHEEL ❑FRONT _ CYLINDER 0 REAR INSTALL BRAKE C DISC MOUNTS HARDWAA ❑DRUM \ BRAKELBABIfl-.� °M I COMPUTER BALANCE LF SPEC ACTS 1 ROTATION 'AF SPEC ACT_ ^ WHEEL ALIGNMENT TYPE r Z WHEEL IG THRUST❑A WHEEL❑ INSTALL REAR BRAKE ❑ . on ... _�-- MISCELLANEOUS LR SPEC ACT- ENVIRONMENTAL CHG. 'RR SPEC ACi Olt Cill oils._WT BY D INSTALL COIL SPRING C FRONT ❑REAR OIL FILTER RIDE HEIGHT RA_lR_ TUBES INSTALL 0 IDLES STEERING ARM 0 PITMAN SEAT COVER USED ❑ INSTARMALL BUSHINGSOL 0°UNER LUG NUTS TORQUED ❑ INSTALL El UPPER JOIll BALL ❑LOWER HUB CAPS ON TIGHT ❑ SPEC ACTUAL WINDSHIELD WASHED ❑ INSTALL STABILIZER LINKS TRADE-IN ALLOWANCE INSTALL TIE ROD C IT ENOS-INNER 0 A INSTALL TIE-ROD ❑IT ENDS OUTER ❑RT INSTALL Clf 0 L 0 R BOOTS C A 0 RID TE RAS' INet 70th Prox.) Past due charge is computed by a . •• • •. "PERI001 PATE" of 2% er month on unpaid balances which • ' is an ANNUAL PERCENTAGE RATE of 24%. If necessary to IrelPhone No Date&Time Called By Work Authorized legal action to enforce collection of the amount due under this • ,e•- invoice,buyer agrees to pay all necessary costs and attorney's Authorized By Add Amount New Total fees. I agreelflcauto pay storage of vehicle left more than 48 hours after Phone No Date&Time Caltad By Work Authorized noton that repairs are completed. You will not be held responsible for loss or damage to vehicle or articles left in case m orae y mourn rev Total of fire,theft, accident or any other cause beyond your control. XVEHICLE RECEIVED BY PLEASE SIGN % •• DAMAGE REPORT ROPER/TAYLOR 02/12/97 at 13 : 20 D.R. 26379-0003583 AB076560/94-2638040 Est : T. KSENZULAK AMERICAN AUTO BODY REPAIR AND PAINT ***CALL 510-432-9910*** 105 BLISS AVENUE PITTSBURG, CA 94565-4937 (510) 432-9936-FAX Owner: JANICE ROPER/TAYLOR Day Phone : (415) 296-3051- Address : 100 YELLOWOOD PL Other Ph: ( ) 432-1107- PITTSBURG CA 94565 Deductible : $ N/A Insurance Co . : Phone : Claim No. : Adj . : 84 DATS MAXIMA 4D SED 2/TONE 6-2 .4L-FI Vin: JNlHUOlSlET205553 License : Prod Date : 0/ 0 Odometer: 0 Automatic transmission Power steering Power brakes Power windows Power antenna Power mirrors Tinted glass Body side moldings Dual mirrors Air conditioning Rear defogger Tilt wheel Cruise control Rear window wiper 4 wheel disc brakes Bucket seats Recline/lounge seats Alloy wheels Clear coat paint Metallic paint -------- ---- PART NO . OP. DESCRIPTION OF DAMAGE QTY COST LABOR PAINT MISC - --- - -------- - -- ------- - ------------ ------------------------ -------------------- 1 FENDER & LAMPS 2* Repr RT Fender 1 2 . 0 1 . 0 3 Add for Clear Coat 1 0 .4 4* Repl RT Shield 1 55 . 08 0 . 5 5* COLOR TINT 1 0 . 5 X 6* HAZARDOUS WASTE DISPOSAL FEE 1 X 1 . 50 7* WHEELS TIRES SUSPENSION OPEN 1 ---------- -------------- ------------------ Subtotals =__> 55 . 08 3 . 0 1 .4 1 . 50 Page : 1 DAMAGE REPORT ROPER/TAYLOR 02/12/97 at 13 : 20 D.R. 26379-0003583 AB076560/94-2638040 Est : T. KSENZULAK AMERICAN AUTO BODY REPAIR AND PAINT ***CALL 510-432-9910*** 105 BLISS AVENUE PITTSBURG, CA 94565-4937 (510) 432-9936-FAX Parts 55 . 08 Body Labor 3 . 0 units @ $50 . 00 150 . 00 Paint Labor 1 .4 units @ $50 . 00 70 . 00 Paint/Materials 1 .4 units @ $23 . 00 32 . 20 Sublet/Misc 1 .50 -------------------------------------------- SUBTOTAL $ 308 . 78 Tax on $ 87 . 28 at 8 . 2500% 7 .20 -------------------------------------------- GRAND TOTAL $ 315 . 98 -------------------------------------------- INSURANCE PAYS $ 315 . 98 UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SUBCHAPTER 8, SECTION 2695 8.D.2C.,YOU ARE ADVISED THAT YOU HAVE THE RIGHT TO HAVE ANY REPAIR FACILITY OF YOUR CHOICE TO DO THE REPAIRS TO YOUR VEHICLE. HOWEVER, YOUR INSURANCE COMPANY CAN REASONABLY ADJUST ANY WRITTEN ESTIMATE PREPARED BY THE REPAIR SHOP OF YOUR CHOICE. IF YOU CHOOSE TO USE A REPAIR FACILITY SUGGESTED BY YOUR INSURANCE COMPANY, THEY WILL GUARANTHE THE DAMAGED VEHICLE TO BE RESTORED TO ITS PRE-LOSS CONDITION AT NO COST TO YOU OTHER THAN AS STATED IN THE POLICY (I.E. POLICY LIMITS OR DEDUCTIBLE) OR ALLOWABLE DEPRECIATION. VISIT OUR WEEPAGE @ HTTP://WWW.ECIS.COM/-CRASH FARMERS COD # 1084 AUTHORIZED SIGNATURE DATE Estimate based on MOTOR CRASH ESTIMATING GUIDE. Non-aeteriek(*) items are derived from the Guide AOF3607. Database Date 6/96 Double aeteriek(**) items indicate part supplied by a supplier other than the original equipment manufacturer. CAPA items have been certified for fit and finish by the Certified Auto Parts Association. EZEst - A product of CCC Information Services Inc. Page : 2 - S� f'3c.TU�tis u/eir-C TAK-M ovx TI+E FDLA-Duj j L)AY SAvi -x--1 q7 ,of f ARevIT�T THC- &Le-S werz VJu.ED e iTfe?- Wrin� niI h t crr Lkl TNS �I52L�' VY�orni,�lq t T Fl LTcJr�S ,av►o Jc..AVI 6-it�L j See TH76 vle.w Vr4�1 C-s k6LkJ lie -I1� , lir- l4, s h.w b area w h eves L had Ur }- sseo Dtri✓e� t1�h c a�S ro� L ori y ir�,� '�k a..f- �-rea. Wk{v-\ d,rivivi ('11roJ51� �}'11e sky\&JEev 6- -fie aLSD rn rnGm iS Y`Z dwh-{t- 6 e5-�lmp a,{� �.►'�e d� Gau�'Se t� her I�'►nn� �• Yi'ltxon LSD) �21�3-1� M 4 6 o� �v- `S . � 43 M C� N � e O..•6D N�� � . 3r CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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: $100,000.00 Section 913 and 915.4. Please note all •��, ac��2 CLAIMANT: Gary B. Moore FEB 2 4 1991 ATTORNEY: COUNTY COUNSEL Date received MARTINEZ CALIF. ADDRESS: 901 Court St. BY DELIVERY TO CLERK ON February 25, 1997 Martinez, CA 94553 BY MAIL POSTMARKED: County Inter—Office Transmittal Mail I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 25, 1997 `VIL RAATT%LOR, Clen)�,'���� 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (�) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: e2l�O/11 BY:— 4,y{ aK4 a Deputy County Counsel 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 (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR 0 1 1997 PHIL BATCHELOR, Clerk, B� a-dc 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 3 1997 BY: PHIL BATCHELOR b� uty Clerk CC: County Counsel County Administrator Claim to: BOA}?D OF SOPER9I.M OF CONTRA COSTA Comm 11iS MCTIONS Ta Q.t MI T- A. Claims relating to causes of action for death or for injury to person or to per. Donal property or Browing crops and titian accrue on or before December 319 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 Browing crops and which accrue an or after January 1, 19889 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 4911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1069 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. TX: Claim By Reserved for Clerk's filing stamp GGA RECEIVED Against the County of Contra Costa ) or ) FEB 2 51997 Co rc CvG C w N I�l District) CLERK BOARD OF SUPERVISORS! U1111 in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the abov+wnamed 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) -`1-1 q� APPR?X01ATfLY f:7c.`cy- HOV25 - • A .. !r4 77 n! f ITS ' YC .sl .J - L s rt..e« - C�-+M .\ -a� 3. IIow did the damage or injury occur? (Give ftU detail �al use extra _er i f n7c, ) 1 {�f g� ,(Slca,� � �� ct" t4� atic�. 151 V ive 4 11 a �.�'1 �'� 11 \`'�" `-r , 1 8 0,c� t a � e, T�Nw �y e1' ISoNh"�1 ....1.. �,J 1..•-,...e,W.....�� OF'�Cny fu __ t f✓ RW ' Tjfv C 55 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? t{— C+w -1 P s1.1'CCK C1SICA .er �, w�4� uuJ1 n •Y �^ �-Poxt, ctw� E oeeclUV'C- (over) It g. 'What are the names of county or district officers, servants or employees causing the damage or injur. wllsl, 6��e1h,�c DoJ�s0 .� by h'1a LA 6. Veit damage or injuries do you claim resulted? (G6e full extent of injuries or damagesclaimed. Attach two estimates for auto damn e. �oV`�Heaa11W`Or.f koc,�;.-"1� G�SC %V.,9V 7. Now was the amount claimed above computed? (Include the estimated amount of any prospective irj�o�r damage.) OMO �Iv \ I6+ J 4./ t�s Ot..1 S� rcSS tai -vp �.� o� 5C 8. Some and addresses of witnesses, doctors and hospitals. hug , `p a�A Cr 9. List the expenditures you made on account of this accident or injury: DATE rMWJ AMSJNT aa • aaaaaaaaaaataaaaaaaaaaaaaaaasaaaaaaaaaa Gov. Code Sec. 910.2 provides: "The claim mast be signed by the claimant SENA NOTICES T0: (Attorney) or by some Person on his behalf." Name and Address of Attorney - JO � � a Lureco71aimant � (Address) I 1 Til�„hn±► N�: To�.enhone No. �3 - i a isii f a i f a a f f • a - `i sia a s 5 0 T I C 2 Section 72 of the Panal Code providesr wVery person who, with intent to defraud, presents for allowanoe or for payment to any state board or offioer, or to any county, city or district board or cffioar, authorized to allow cr pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or ~citing, is punishable either by imprisonment in the cotatty jail for a period of not more than one year, by a fine of not exceeding at thousand (=1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exoeeding ten thousand dollars (=10,000, or by both such imprisonment and fine. I .� %jj ry ifs OY'0 Vt GA r" v� V (4.. Mo WaS ow "��.4 MVaa_ ty c .. 1 ,5Ltc' 1 jaGs ` i cCi . urnt .j0v - N1s G,�,� fi- 3 " ci 1 u N S w c r be-r.j_.be,cays4 ?.Nc. � YdV �11rL1 \Snip \\JC \ v tQV o f of C t�owe \four Baur beL. avtov) �Gw� �?o Qer work ko \z" 7— wa-s�- t�.t LC i '4 PN\L�w` uk 7vk �C^t VO �4< �V1F1 ", .tA "�'v.� � Yq- :.��,. rn� tlQY T -1-0rAy��V e�< w�� r� o . c rit�G-� r.4y �ro� hoc \+S t� R 1 `�'�•..0 Zd} i of �w o��+c�-- , . � tGhli�.t "cro..� s~t �Cte,vSc.. .�• ex-ev< isc� . M� ..t`t.� a'i� . -- s avi. 0.•i ovNe� Ya �r45C 1 \n< u+,. L �. 3.. V s a.p,., 4, r!a .,r t i C? Co �t 1,4S , S ��\p Y t v tC c..4 y�v,�.l. t o C C x.14 CA � Sp/y � tr V. malfOcJ J"Ztt-s L34) va `tf V.S. ci -) - I t a ys. C-t. 'Slo sG� ctsSls {a�t, --I}. {_. QrcQtr \ SSd\ �t �' ciSSl5—STlao�� awdt` t\S � rtcti�6,,4NCi, - Kv�aS ou�' ��1tu�v`�e. . ,, � 40v� �G\~\�-v\6r o«.� C.•Moa\ \5 KIaC. 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M4 p N dQ cr y�yX� 0 g{ •••i p r z scr— s f", r o 33 r s o w S- P c O L -P C G 6 < t O Co S ry p r � 3 r CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 toy�,7, Amount: $413.06 Section 913 and 915.4. Please note all rnings"�MR . CLAIMANT: Enid E. Paulk FEB 7 1 1997 COUNTY COUNSE ATTORNEY: MART NUCALIFL Date received February 20, 1997 ADDRESS: 118 Warwick Dr. , #45 BY DELIVERY TO CLERK ON Benicia, CA 94510 BY MAIL POSTMARKED: February 19, 1997 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. February 21 1 IVIL BATCHELOR. Clerk�f( ' e�t G OLv DATED: y 997 BY: Deputy / / II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: T� 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 (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: APR O1 1997 PHIL BATCHELOR, Clerk, By a4r� 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 3 1997 BY: PHIL BATCHELOi�by Deputy Clerk CC. County Counsel County Administrator ^ter P.01,K Clair- to: WVZ OF SIPEMSM ()F tJ0hT" OOSCA OOUNn Ir..SMCTIO++S TO a AD AW A. Clai=s relating to causes of action for death or for injury to Person or to Aer- sonal property 4or growing crops and sdricb Worm on or before Deceaober 37, 1987, mat be presented not later ttn�a the 100th day after the accrual of the cause of aotioct. Claitas relating to causes of action fbr.death or for injury to peraun i09 to m» property or growing =Ws and � �SCCrW oa or after 1, presented not later than nix =oaths after the a=Wl or the oWnse of action. Claims relating to nay other cause of action must be presented not hater than one year after the accruarl of the cause or.action. (Govt. Code 5M 2.) B. Claims must be filed nth the Cleric of tate Bowd of Supervisom at Its office in It om 106r County Administration badiW. 657. Pias .Street, Marti=, 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, Penni.. Code Seo. T2 at the end of this IW. Claim By Reserved for Cierk*s filing stamp EAJ/jD E. PAElLAC, � i ftci:EiVED Against M County of Ccntna costa iDistrict) CLELiF SUPERYtStt1+E CONTRA COSTA CO. Dille undersigned claimant hereby ,flakes claim against the Couarty Of Contra COSta or the above-n=qd District in the sum of .0( _ BSrd i2) a`�pCYI'v Of this claim represents as follows: 7. Wtezt did the damage or injury ?^CUr? .(Gi.ve 7t44awd hour) -'AN(AAM &S1 199 '7 , 7: tSp P�' i"k'=; did the dmage or Injury owur? (Inclule city and county) (o$o FREEWA4 AND bIArMOAlb IVCAxA ' EAST awmb I AJ&HT tA)UE 3. How did the damage or injury ocour? (Give full details; use extra paper if required) sEe Ai-rAeseib 4. What particular or omission on the part; of county or district officers, servants or employees caused the injury or damage? rAIL(AltE To coMPLETCLY R.EPaIR ROAD WHEQE THIS A07` ttLK4-` Fb45 C,CWTIm(j4LLy C,aC[. keD t1v 7"E sf9AJE uxor/&v Pae 4r LEAST 4 YeArp, . 4cc.0+e0/AJIr 7v Tortu woos, CADVC0 b CaY STkEE7" /NAW.. TtW C.0UN7V 44.% H+R77 otT LEAST TEN CLAiM.S r.M TENS Por ffoLE' (ror+fiE LAST YEAR, FAILURE To COKk.EcT TttE rs1T Ar/WY "W .rL 9PUY . JAhJ-3e-195^ isa16 P.02/02 j. wnat arc the names of oountV or district Ofl'1CCrs, servants or =Wloyees causing t'w d3.--spe or :rjw-p? DEPT. of STREET rnA/NTENCE ph- WMAMEItPRL MAKES T4F DECIS10oV 7'O RfpAlA. STREt7S . 5. What damage or injuries do you Claim resulted? (Give full extent of injuries or damages � Attach two tes for 6�WNEwSlT P 14O�E�ESTXVV T/R S AA)b bAMAd-1NFr. AL1 MJ ME/JT. 7. Bow was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ACTUAL AMOUNT PAID TD REA411R GAR , 5 F S. :Names and addresses of vi , don and hospitals. ?OIiN WOOD , Q" of CWC-0 vW/NT. 6 PT 51() -(o7l " 30SO - NE toaFutMED -MIS SAME POTOOLE MAS SEfN ReftkeO AT LEAST /F DOZEN 77MES /N THE LAST ygAR, . s"e. POT HOLE U04S REPAIRED -rWO WEEKS BEftK9, AND HE REPAIREZ IT MakitO oh) t/ZS/g7 .4ND 1/2."? 8y PILuAw RTIEAST g IF ASPIIA(.T EA0+ 70t. 9. List the expenditures you made on socon t of this accident or injury: DATE nEm AHJON'f 1/51/q-7 TIRES W14EEL 406NMENIT 4'}13. 0(0 Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SM NOTICES TO: (Atto..-ne ) or by some Person on his behalf." and Address of Attorney / (Claimant's igmture //S WARWIc bk y5 Address. BEA)1C/A .fes 94510 1qWTelephone No. Telephone No. 707- 7 ��✓ � • IF +E # +v # 1t it # R it 1t s /F � ! /F NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officex, 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, voxher, or writing, is punishable either by imprisonment in the County Sail for a period of not more than one year, by a fine of not exceeding . we 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 i=,r:so-use :;, and fine. TOTAL P.02 Enid E. Paulk 118 Warwick Drive, #45, Benicia, CA 94510 Tel/Fax (707) 746-7852 DETAILS OF ITEM #3: How did the damage or injury occur? Driving east on Concord Avenue in the right lane, the car fell into a pot hole so deep that the front and rear wheel rims hit the pavement. Both the front and rear tires were damaged and the car came out of alignment. Because of the heavy traffic, the pot hole could not be seen until I was right on top of it. I saw the pot hole just before I hit it and all I could do is slow slightly because there were cars to my left and the curb to my right. After turning right at the corner of Diamond, I saw several stopped cars that were changing tires. I also stopped to check my tires but I couldn't see anything because it was dark. I proceeded home cautiously and noticed the car was out of alignment. The next morning I could see that the tires had bulges on the side and the rubber was split. r V3 P IUV I.._EF-.` ,I% -T I F2 F.; a E�ntn 2316 SONOMA BOULEVARD PROMMIND VALLEJO, CA 94598 AFOE443: (707) 643-3745 4: PAGE 1 *Q ENID PAULK 1/31/1997 ti 118 WAFWICK OR 45 CUSTOMER REF No - BDENICIA, CA 94510 - C,ALESSMIAN - JOHN LIPSEY W/O N - 718978 (CUSTOMER CODE - ENIPAU I hI V C3 X fZIE Ot *69445 j MAKE MILEAGE LICENSE NO. PHONE 93 FORD ESCORT 42332 3MBZ606 (707) 746-7852 111757013RAIN MICHELIN 175/76813 BW RAIN, 4 79.95 319.80 ZZAL4 ALIGNMENT 4 WHEEL 1 _ 69.E ,,.. 69.00 ZZTBG TIRE DISPOSAL CHARGE 4 0.25 1.00 { I� TIRES IN GOOD COND. i EXCEPT FOR DAMAGE CAU6ED BY BLOW! ALIGNMENT OUT, CAUSED BY BLOW! i • I ! i { 7O'IAl.. PARTS: 328.88 TOTAL r 69.' 10 (PAID^ BY CHECK 4DRIVER'S LICENSE , l µ SALES TAX .•. 23.26 413 0f:, THANK YOU FOR YOUR I+USINESS qLD PART❑ -- $AVL ❑ i)ISCAR! L - BI'LAW,LOU MAY b1000 L P14011 . ,PEa-PHM ANY NEEDED REPA AS DR ADJUSTMEN'S IHA- THE SMGG Sr,-. - r.. ,; ,(:Ai_`°,ARE NEOESSAAv ALL PARTS NEW,UNL,SS OTHF RW B I -'[ : PARTS AND_.0.ROR V A'RAN:=1rn '1 T;' l,x¢pei6.MILE$OR�DAYS WH,CHEVER - ::OVP,*1,,6, ' 1 11 1 1 - _SFORMDNIY VFIIGLF MOST r MERE T.%EU ..:A , ,n.-.OR WA„AANry AATERIAL5 YOU ANI . .)i1FE t,.. �,Il ENI, VEHICLE FCA PURPOSE.AR4 ADf51LONAt4- PWSTAX EMPLOYEE__ 11 IALONG WTI THE Nx CES-- 1 Y FHn a OF -..,. ..-._� — - YEiT,Nq- INSflf IUI OP WFR ,'+ AN EXPRESS MECHANIC° {IFN IS DE$f AIPtIUN—, ACILNOWL rOGED ON viBEI;. S-'.i ill'IJW )I REPAIRS ThEREY) YOUWitt NOT RE HEAL) HES,.N'.IHI F I'n, :.yA,F r,I VEHICLE OR ARelULFS -EFT IN ---------.-----__ _� _ _ .._ VEHI:Af N -ASE J I-1H(. IIfFI p: w Al.l ,'THFP CAUSE BEYONC •'OUR AUL'tCUEI[FC)HfX CON JO( TAG MUST BE PRESENTED OR C REU,r OR WARRANTY WORN. -------- --- BECA'.196 OE 'NF EX I' A ), I V r­'r-TION 'HE VEHIOLE 1.'.Al NOT `I.B,-E, TIME­_-� SAT E__,_PHONY PEAFOSIN AS Wf:1 F$ »RLtaf --- I A(FIF C NOT,Ct AND ORAL APPROVAL Or AN' INCREASE TN THE ' YIGfNAL � FST SATED 1(;E X_ _.-- DATE X -- ._ --DATE--. �._.. name Rddress ---------------------- ----------- --- ---- E: Iephone ------------- - Vehicle (VIN#) 97 70WE_5CORT_-_-_-_-_-_---_--_-_--- _- _ -- License 7076b ------------------------------ - --- . Mileage 4233? =cn:iiciar J-CCRxT��7 r . iie and Date Ii MT6 71- ,T73I797---------------------------- --- Specifications Ford 91+96 Escort Left Front qe rrorrt ---------------- r------. --------------'—'-� r Actual 4 Before I Specified Range I / Actual + ce:.. Decificc Harge 1------------1-------+-----------------1 /------------4------- . .__- _-- -------i ► -0.2° 4 -0.20 1 -0.60 1.00 1 Camber 1 -0.3° 1 - i'.6'' 1.0, ► 0.50 4 0.50 1 0.5" 2.0' 1 Caster ► 0.7" J0 2.0, I ► 0.050 4 -0.04" 1 -0.03" 0.13" 1 Toe / 0.05" 4 u" 0.13' ..... 4 ..... I ..... ..... I SPI ► ..... .. ..... 1 ..... 4 ..... I I Included Angle / ..... 4 1 ..... 4 ..... 1 -9.Wo -5.CK)" I Turning Angle Diff. ► ..... 1 _ _1 . L_ _ -...__ ------------------- Front 1 Actual 4 Before I Specified Range 1 Cross Camber 1 0.10 4 0.0° ..... ..... Cress Caster / -0.20 4 -0.20 Total Toe ► 0.10" 1 0.03" ! U,05° 25' Set Back 0 0.140 4 -0.030 i year Left Rear __:- __. _ .---------------------, Nc_uai - ;-- Before i— Specifieo Range uai :,ecttted Range -- /--- ------/-___... ..-.---- ---- -----1 / -0.30 4 -0.30 I 1.50 0.50 I Camber 1 X1.3: ► 1.50 0.5" 1 1 0.08" 4 0.08" 1 -0.03" 0.is I Toe 1 0.07 1 `---------1-----------1----------------' L---------------._. --------------------------' Rear k Actual 4 Before I Specified Range 0-------------4------------+------------------- Total Toe ► 0.16" 4 -0.031, 1 -0.05" 0.25" I Thrust Angle / 0.010 4 0.20° 1 -0.4000.40'- 1 _ _1 _1 Zoo; n Y l'ir'O iRR) (n O C o S 7riC '0 H P P I CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 1V below), given pursuant ,OD,vgr ntCde� Mount: $1,598.65 Section 913 and 915.4. Please note CLAIMANT: State Farm Insurance Companies FEB 2 1 1997 Claim Number: *05-6745-166 ATTORNEY: Insured : Kenneth Austin COUNTY COUNSEL Date received MARTINEZ CALIF. ADDRESS: North Coast Office BY DELIVERY TO CLERK ON February 21, 1997 6400 State Farm Dr. Rohnert Park, CA 94926-0001 BY MAIL POSTMARKED: Hand Delivered via: Risk Mgmt. 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. q , DATED: February 21, 1997 JYILATCELDRClerk' ,T : �epuiy c N-- /i a`� " 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: _� Lm 11 BY: /iJ//J �� 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. y Dated: APR 01 1997 PHIL BATCHELOR, Clerk, by—J�/��`�° Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. ; For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 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. r/ Dated: APR 0 3 1997 BY: PHIL BATCHELOR by'/y—� Utputy Clerk CC: County Counsel County Administrator Ron Han. I`I- R 91. 1997 STATF FA 0.M State Farm Insurance Companies INSUYgN CF North Coast Office February 14, 1997 6400 State Farm Drive Rohnert Park,California 94926-0001 Contra Costa City Building Maintenance Attn: Julie Aunock, Risk Management 651 Pine Street. 6th Floor Martinez, CA 94553 ****IMPORTANT**** PLEASE WRITE OUR CLAIM NUMBER* ON YOUR REPLY OR PAYMENT THANK YOU RE: Claim Number: *05-6745-166 Date of Loss: January 23 , 1997 Our Insured: Kenneth Austin Dear Ms Aunock: State Farm Mutual Automobile Insurance Company on behalf of Subrogee, Kenneth Austin hereby makes claim for $1598 . 65 and makes the following statements in support of claim: 1. Notices concerning this claim should be sent to: State Farm Insurance Companies 6400 State Farm Drive Rohnert Park, CA 94926-0001 2 . The date of accident occurring on January 23 , 1997 at Clayton Rd and Denikinger Ct, Concord, CA 3 . The circumstances giving rise to this claim are as follows: Your vehicle, driven by Jay Wintes, rear-ended our insured vehicle which was stopped at a signal light. 4 . The injuries reported consisted of none. 5 . Our total claim is as follows: RECEIVED � Company's Net Payment $1348 . 65 rff!B� 2 Insured's Deductible Interest $ 250. 00 Total Property Damage $1598. 65 1 1997 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. HOMEOFFICES: BLOOMINGTON, ILLINOIS 61710-0001 STATF IA0.M State Farm Insurance Companies Attn: Julie Aunock, Risk Management NSU 0.AN CF Page 2 February 14, 1997 North Coast Office 6400 State Farm Drive NOTICE: Rohnert Park,California 94926-0001 This form is to provide notice of our claim for damages in accordance with the day statute. If this form is not acceptable for compliance with the statute, please rush the necessary form to my attention for proper filing. Statp-Parm Mu*u"tomobile, Insurance Dated: FEB 14199]# By: 1Q�A l pofkc Employee Name c FEB 1 9 1997 L�M-Y� J lye ,t Employee Title 14 71'A Employee Phone umN ber Enc: Supporting Documents cc: Foster 2727 09 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 CLAIM NO 05-6745-166 POLICY NO 1537-002-05B LOSS DATE 01/23/97 DRAFT NO 1 02 561074 J DATE 02/05/97 PAYEE I.W.H. RESTORATION PAINT & BODY SHO & •KENNETH AUSTIN AMOUNT $******396 . 34 CONCORDHCAAR94520 COVERAGE TIN 05-6801230'32 COLLISION (LOMV) 400.3 8396.34 REMARKS SUPPLEMENTAL REPAIRS CREATED BY Tessie Bernal «« •�� STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY 1 OZ 561074 J NORTH COAST OFFICE BANK OF AMERICA NT 8 SA 11.35/1210 . ROHNERT PARK, CA CUSTOMER SERVICE AMERICAS 1233 DATE 02/05/97 N1° S Trivalley 02-116 CONCORD, CA COVERAGE .COLLISION (LOMV) CLAIM NO 05-6745-166 POLICY NO 1537-002-05B CLAIM UNIT 103 400-3 8396.34 LOSS DATE 01/23/97 INSURED AUSTIN, KENNETH wwzzxzwwzxzzzzzwwwwzwzwzzzzzxwwwietzzztt,wzzzzzzekstz+z*EXACTLY THREE HUNDRED NINETY-SIX AND 34/100 DOLLARS4p� F3 Pay to the t iatr'•" ' Order of: I.W.H. 1,tESTOR2;T102t"$AINT & BODY SHO & KENNETH AUSTIN 2180 A&S'� MARKET ST TIN 05-680123032 CONCORD to 94520 Aurx JLUX APPROVED BY CLAIM NO 05-6745-166 POLICY NO 1537-002-05B LOSS DATE 01/23/97 DRAFT NO 1 02 224280 J DATE 01/24/97 PAYEE r i KENNETH AUSTINw AMOUNT $******952 . 31 1 - 03ORATTg$ 5000NCODC942347 . `'. COVERAGE TIN 05-680123032 jdNa „; s��ST COLLISION (L400V) 8952.31 REMARKS WILLE S.. CREATED BY Emory Jenkins -1 STATE FARM MUTUAL AUTgMOBILE INSURANCE COMPANY 1 OZ 2242$0 J NORTH COAST OFFICE BANK OF AMERICA NT & $A 11-35/1210 RONNERT PARK, CA CUSTOMER SERVICE AMERICAS 7233 DATE 01/24/97 Danville 02-221 CONCORD, CA COVERAGE COLLISION (LOMV) CLAIM NO 05-6745-166 POLICY NO 1537-002-05B CLAIM UNIT 103 400.1 8952.31 LOSS DATE 01/23/97 INSURED AUSTIN, KENNETH _ ....:..w..ww+..w+.wwwwwww+wwwwwwwwwwwzzxxwwzwwwwwwwwwxxxwEXAC7LY NINE HUNDRED FIFTY-TWO AND 31/100 DOLLARS aYtk Ati`ltil'Atj `�' s'.' Pav to the Order of. I W H RESTORATIONS & KENNETH AUSTIN 2180 MARKET STREET TIN 05-680123032 CONCORD CA 94520-2347 AUTH EJFFFiK ,./ APPRO ED BY O e. w '• a R y.pp d, 01 10, 37 at 13:27 Q14 W Q1.1 C7; i t7) 'T E f-IF•Civi T i�,t E3 W FA C4P.tED ,clonparIi"+ t g-141 L-IKIY :� 0000 HVIGH3OR, STATE FARM :'-"a THERE. 115A VOWN R C:OUN RY DRIVF RAKIVILL.(_, CA 14526 {:i 1 O i 600-4000 FAX : (510) 800--4044 Af-PRAISAI.. REPORT iniured : KENNETH AUSTIN Claim #: M-6745-16GW iaimant : policy #: Claim Rep: JE:NKINS Repair Facility : I. W. H. RESTORATION PAINT & BODY SHOP Agreed By: on 00/00/00 00 int of Impact : 1. 6 REAR Type of Loss: COLLISION 2. 0 Vehicle Driveable? LKQ Parts Included? No Quality Parts Included? Yes Place of Inspection : I + ( 1 1 11 DRIVE IN Hppraiser' s Estimate 1598. 65 Agreed Price ? No Deductible -50. 00 betterments 0. 00 Prior/Unrelated Damage l 0. 00 Allowances 0. 00 Towing/Storage 0. 00 Total Loss ? No i smourary Repairs 0. 00 M LOSS Y 1348. 65 IVIGNTS: ;0 17NCE THE BUMPER WAcj Ru-MOVED Tt;E:; SIR BOD,' PAWFL. -;140W l) DOMHGi, . WIF>l:: Dttem WMA naPr i sa : C lot e -� 1 . � , _ r.c,� t, :•.a . 01 ,24117 Ie'r pec ion Date : WI /24 . , We Z1050011 00/00, 00 e+ e a. GRIFSTIH It ' File 410159 - 141959, 91� � to FRP1 I PJE5LJFR11UAf�EZ C�CJ 01 VA fj PA A U ^� LIKE A 600D N[[GH0OR, STATn FARM 11 THERE. 115A TOWN & COUNTRY 0R [ VE DANV {LLE, CA 94W, (518) 855-4000 FAY : 1510> 835-4044 SUPPLEMENT OF RECORD ' 0ten By : M. WISE N1/30/97 01 :27 p. m. ilaim Rep: EMORY JENKlNS # (510) 847-25Nm-2531 Insured : KENNETH AUSTIN Claim 405-6745~16601 Policy # nddress : 4405 SPOONWOOD CT CONCORD, CA Date of Loss : 1/F3/97 Day : (510) - - Type of Loss : COLLISION Other: (510) - - Point Of Impact : 6 REAR m Inspect DRIVE IN - ication ; Drive-In Repair I. W. H. RESTORATION PAINT & BODY SHOP (510) 827-3779- *cility : 2180 A&n MARKET ST CONCORD, CA 94520 License #69-0123032 )5 M8ZD PROTEGE LX 4D SED 4-1. 5L-Fl / [N: JM1BA141860143540 Lie. #: 3JQU457 Prod. Date : 0/�� Mileage : a2��N8 ^ " �e : 1 /0ket seats Cloth seats Recline/ lounge seats ower steering Tilt wheel Power brakes unkod glass Rear defogger Power windows >' ( ormittpnt wipers Power locks Cruise control ' iver airhay Passenger airhag Power mirrors ­ciai mouldings Dual mirrors - - --- - -- - - &A9T / OP0ESC!, [Pr}O� OF UAMAC[ /)|' g] i7 LAAOS POINT M{S[ ' NEAR 8UNPER O/H 9par Bowver 1 0, 80 ?� Q 0110 Pep! GEC Pumper cover Uody noiur l 0. 00 In- ! 2. 2 TIj;. 0m + Add for Edging i 0. 00 @. 0 Q. 5 j 3*pl Energv *hsorhec | 12�. 4N Io.-1 N, 0 ` Rep , ReLnf boom [ nr | 0. * WEAR �AMPS > Rep | LT Tail lawn assv i 10" 20 0. 3 *10 /* Refin FLE) 1 0, 0111 0. 21 0. W / ��J. m1� : 0 RWAe 8DD/ & F!. 00R ; / * 31 Repr Panel below lid i 0, 00 ° 5� FLOOR SETUP 1 0^ 00 |�-0 0. V! ^ ^ ^ ^ �� � � � a-TF=1-1" E:.-;: h' F='t Ft.lyI IIV:=;i.-1F: `-1 t*3 t:-:.F t..;FAlYfi- �cltq Y Claim # : 03-6-t45-166O! 95 MAZD PROTEGE LX 4D SED 4- 1 . L- F=1 PAR"f -- JrJ, OP. DESCRIPTION OF DAMAGE QTY COST I.-ABOR PRINT 011t;C — - ---- ---------------------------------------------------- t3* S1 Repr CORROSION PROTECTION 1 0. 00 k_3 0. 0 "T S__00 14 SI R&I Rear panel trim 1 0. 00 T0. 0 15* S1 R&l W/STRIP 1 0. 00 0. 3 0. 0 16* S1 CLEAR COAT 1 0. 00 0. 0 1. 5 LABOR RATE CHANGES - S1 $22. 00 to $ 3. 00 — Paint/Materials --------------------- Subtotals ==_) 637. 45 6. 2 5. 7 137. 00 Pal s ?tr. 97 at L3 .�7 141'9": ;�_ - f-3- -fa-FF- F=..(-1R"1 I (Vf-7;L,I X)r141 E" Claim # : 05-n 74` -166k11 95 (•i(.IZD PROTEGE LX 40 cEb 4- 1 . SL_-F T Parts 637. 45 Body Labor 6. 2 units @ $52. 00 322. 40 Paint Labor- 5. 7 units @ $52. 00 296. 40 Paint/Materials 5. 7 units @ $23. 00 131. 10 Sublet/Mise 137. 00 SIJBTOTAL -- $ -1524. 35 Tax on f 900. 55 at 8. 2500%• 74. 30 TOTAL COST OF REPAIRS $ 1598. 65 ADJLISTMENTS: Deductible -250. 00 TOTAL. ADJUSTMENTS $ 250. 00 NET COST OF REPAIRS $ 1348. 63 'Ih1ATE REVIB EO BY SHOP ESTIMATE REVIEWED BY ESTIMATOR -1, SUPPLEMENTS REQUIRE PRIOR APPROVAL BY A STATE FARM REPRESENTATIVE. ------- Sztiaatz based on Mf1TGR (.RASH ESTIMATi'raG GI110E. Non aztzrisk!rl items are derived f^ot the Guide IRNSwLr. Database Date 1Li?6 Jcuble asterisk(t4) iters indicate part supplied by a supplier ather than the original equ_ptent tanufactirer. CPA items have been certified for fit abd finish by the Certified Ado Darts association. EL'Est - A oroduct of C.'X infortation Service> Inc. c ;TF-7.1._t , F= F-'1 F!IVI I. 111 iww;1...i fZ i-4 fJ l E- Claim # : 05 -6745-1f £601 95 MAZI% PROTEGE: 1..X 4D SED 4--1 . `.`,i.- FI SUPPLEMENT SUMMARY ------ PART OP. DESCRIPTION OF DAMAGE OTY COST LABOR PAINT MISC ----------------------•------------ ------- DELETED ITEMS ----I----- * Refin CLEAR COAT 1 0. 00 0. 0 -0. 6 -------- ADDED ITEMS --------- * S1 Repr Panel below lid 1 0. 00 2. a 1. 5 * S1 FLOOR SETUP 1 0. 00 1. 0 0. 0 * 91 Repr CORROSION PROTECTION 1 0. 00 0. 3 0. 0 T 5_. 00_ S1 R&I Rear, panel trim 1 0. 00 0. 3 0. 0 * S1 R&I W/STRIP 1 0. 00 0. 3 0. 0 * S1 CLEAR COAT 1 0. 00 0. 0 1. 5 LABOR RATE CHANGES S1 822. 00 to 823. 00 Paint/Materials ------------------------- --------------------------- Subtotals ___> 0. 00 3. 9 2. 4 5. 00 Par, �, ,i Fi -T tea-i F. I- t--it I f (-I i'A t f -1 tyl F.F'-1]f i I T- Claim 4 . 05 -61745--I�t7.01 95 Hi)ZI) PROILGE LX 40 --)Ef) 4- 1 5L--FI Parts 0. 00 Body Labor 3. 9 units 1? $521. 00 202. 80 Paint Labor 2. 4 units @ $52. 00 124. 80 Paint/Materials 2. 4 units @ $23. 00 58. 50 Sublet/Mise 5. 00 -------------------------------------------------- SUBTOTAL $ 391. 10 Tax on $ 63. 50 at 8. 2500% 5. 24 ------------------------------------- TOTAL SUPPLEMENT AMOUNT- .1 96-7 4 Juc t i b I e 250, 00 ,% ' (Ainal Estimate 1202. 31 B. GRIFFITH TOTAL ADJUSTMENTS $ vnj)lerflent No. 1 396. 34 M. WISE NET COST OF REPAIRS $ 1348. 65 r. .Al—o -l"Otal $ 1 -S 48. 65 ii ;*TE REVIEWED BY 90 (�-- C ) ESTIMATE REVIEWED BY ESTIMATOR 1/( 1CPLEMENTS REWIRE PR BY A STATE FARM REPRESENTATIVE. haied en MOTOR "RASH ESTN*TllL-'4(3 GUiDL NorraAeri;kk*! items are derived f,nm the usiwe 7RI45414. latao83a pat. lj,j4 Double Asterisk(**i items indicate part supplied Uy a suoplier other than the originai equipment sanlifact&er. CAN items have been certified for fit and finish by the Certifi?d Auto Part; As-,ocJsto)P. EZEst A oradoct of rtf lnf5rvitij,i Services Inc. kilo # 101 �" 14101, L #=1 7 F F- } t-?IVI 1: Q'AtiiL..► 7 :Gam4nr tilt 11V!II-1' W•1 } ) 1 Claim Ni 05--6745 -Il;O.bl_ L 95 MAZD PROTEGE LX 4D WD 4--1. 5L- F_l QUALITY REPLACEMENT PARTS SUPPLIERS 0 % pEC Bumper cover body color Part No. : MA3239508R - £ 17. 00 SYUCKTON BUMPER SERVICE (209) 943-1101 S30 SOUTH ELDORADO, STOCKTON, CA 95aO3 STOCKTON BUMPER SERVICE: (916) 37a-3300 1045 TRIANGLE COURT SUITE B, W. 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J Q v � 1— Q' um •� _ o N s M , • M1 • e nJ ri rq a 1 V Q 1.1.1 U $ oma CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 Gov V[[ Amount: $1,000,000.00+ Section 913 and 915.4. Please note all "Wa gs". CLAIMANT: Melissa Sweet, Linda Lee Dodson, Sharleen Cosentini, FEB 19 1997 David Palutsyn, and Gerldine Fenik COUNTYCOUNSEL ATTORNEY: MARTINEZ CALIF. Date received February 18, 1997 ADDRESS: Heirs of Elaine Palutsyn BY DELIVERY TO CLERK ON c/o Melissa Sweet 860 Tradewind Lane BY MAIL POSTMARKED: Hand Delivered via: Co. Administrator Rodeo, CA 94572 1. FROM: Clerk of the Board of Supervisors 70: County Counsel Attached is a copy of the above-noted claim. p ii DATED: February 18, 1997 BgIL BATCJELDR, Cierk�9��_ _ d/ epuH. FROM: County Counsel TO: Clerk of the Board of Supervisors f`� (x) This claim complies substantially with Sections 910 and 910.2. Ad 4 ( ) 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: //.r Dated: ���� // BY: v Deputy County Counsel III. FROM: Clerk of the Board T0: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. APR 01 1997 q rD Dated: PHIL BATCHELOR, Clerk, By\/ Veputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: APR 0 3 1997 BY: PHIL BATCHELOR DY Deputy Clerk CC: County Counsel County Administrator RECEIVED TO: Contra Costa County Administrator's Office 1M 1 8W7 651 Pine St., 8th Floor �d• Martinez, CA 94553 CLERK BOARD OF SIIPFRVISn w�. CONTRA Cr:°'A rr CLAIM AGAINST PUBLIC ENTITY In the Matter of the Claim of FOR ELDER ABUSE AND THE WRONGFUL DEATH OF ELAINE MELISSA SWEET, LINDA LEE DODSON, PALUTSYN SHARLEEN COSENTINI, DAVID PALUTSYN, GERALDINE FENIK, Claimants, vs. CONTRA COSTA COUNTY / MELISSA SWEET, LINDA LEE DODSON, SHARLEEN CONSENTINI, DAVID PALUTSYN and GERALDINE FENIK, the heirs of ELAINE PALUTSYN, deceased, hereby present this claim to the County of Contra Costa, pursuant to California Government Code §910. CLAIMANTS' 860 Tradewind Lane ADDRESS: Rodeo, CA 94572 SEND NOTICES Heirs of Elaine Palutsyn TO: c/o Melissa Sweet 860 Tradewind Lane Rodeo, CA 94572 DATE AND CIRCUMSTANCES: During the past three (3) years until the death of ELAINE PALUTSYN, mother of claimants, on August 19, 1996. During said period of time, ELAINE PALUTSYN was a patient at the Richmond Health Clinic, in the City of Richmond, and at Merrithew Memorial Hospital, in Martinez, both of which are Contra Costa County facilities. At said time and places, various employees and agents of the Richmond Health Clinic and Merrithew Memorial Hospi- tal, including independent physiciansand other medical practitioners whose names are presently unknown to claimants, so negligently and carelessly and otherwise conducted themselves as to cause ELAINE PALUTSYN, a 78-year old woman in 1996, to suffer elder abuse and to also suffer severe and disabling personal injuries, finally resulting in her death in August of 1996. Claim Against Contra Costa County Page 2 February 14, 1997 DESCRIPTION OF INJURY/DAMAGE: Elder abuse, negligence, and carelessness in the care of ELAINE PALUTSYN, resulting in her death. The heirs of ELAINE PALUTSYN have lost her society, protection, comfort and support, all to their damage. PARTIES CAUSING INJURY: The Richmond Health Clinic and its staff, including independent physicians; Merrithew Memorial Hospital and its staff, including independent physicians. DAMAGES: Medical damages in the sum of$500,000.00; General damages in the sum of$1,000,000.00 Wrongful death damages in the sum of$1,000,000.00 DATED: February 14, 1997 MELISSA SWEET Heir of ELAINE PALUTSYN, Deceased 2 PROOF OFr-uE1;VICE BY MAIL�O�a �GP�Q15.fr I am a Citizen of the United 5tate5 and employed in the City and County of Alameda, California. I am over the age of eighteen years and not a party to the above-entitled action; my business address is 1970 Broadway, Suite 715, Oakland, California 94612. 1 am readily familiar with my firm'5 practicer for collection and processing of correspondence for maiiing.Under that practice, in the ordinary course of business, mail would be deposited with the U. 5. Postal Service on that same day with postage thereon fully prepaid. I am aware that on motion of the party Served, Service i5 presumed invalid if postal cancellation date or postage meter date is more than one day after the date of deposit for mailing in affidavit. On February 14, 1997 1 served the within CLAIM on the, parties in said action by placing a true copy thereof enclosed in a realed envelope with port- age thereon fully prepaid, at my buoincoo address for collection and deposit that same day in the United States Postal Service following ordinary business practices,addressed as follows: CONTRA COSTA COUNTY ADMINISTRATOR'S OFFICE 651 PINE ST., 8TH FL. MARTINEZ, CA 94555 1 declare under penalty of perjury under the laws of the State of California that the foregoing it true and correct. Executed at Oakland,California on February 14, 1997 a _ Batiya Ja obs . | \ « � \ \ \ ƒ \ o k / ƒ \ \ } � 7 \ / / . » \ ( \ 7 / � $ $ � \ \ . � CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 �comcat.Ca Amount: Unknown Section 913 and 915.4. Please notearm��ngs"v CLAIMANT: Travelers Indemnity FEB 2 n 1997 ATTORNEY: COUNTY COUNSEL MARTINEZ CALIF. Date received ADDRESS: P.O. Box 8112 BY DELIVERY TO CLERK ON February 19, 1997 Walnut Creek, CA 94596 BY MAIL POSTMARKED: February 18, 1997 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 20, 1997 IdIL ATCHELOR, Clerk: �eputy 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: -4�221f7 BY: //z/6L' _/41' Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (X) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. \ Q Dated: APR Q 11997 PHIL BATCHELOR, Clerk, By�T�7� aO�V , 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 claimantasshown above. Dated: APR Q 3 1997 BY: PHIL BATCHELOR -_7)eputy Clerk CC: County Counsel County Administrator The Tmvdm hommttY ComWny The AehuCaaulty"Sturty Cornpmy u.veo.d7YavekrsCrouP Alan Posin The Travelers Manager P.O.Box 8112 Claim Department Walnut Creek,CA 94596-8112 Walnut Creek Office 02/17/1997 Clerk Of The Board Of Supervisors 651 Pine Street Room 106 Martinez,CA 94553 R L CEIVED -A f 9� Clerk Of The Board Of Supervisors CLERK BOAR 651 SUPERVISORS 651 Pine Street Room 106 CONTRA COSTA CO. Martinez,CA 94553 Employer: Metrahealth Employee: Kay Koller Date of Loss: 10/23/1996 SSN: 544-36-5258 File Number: 158-CB-D5S8168J Arm Clerk Of The Board Of Supervisors: We are the Workers'Compensation carrier for Metrahealth and have paid compensation benefits to Kay Koller. Our investigation reveals that you are responsible for the reimbursement to us for all benefits paid under the Workers'Compensation law. Enclosed is a completed claim form. To date,we have paid$9,144.66 in Workers Compensation benefits. Please tum this letter over to your liability insurance carrier so that they may be advised of our Workers' Compensation lien. If you do not have insurance,please call me to discuss repayment arrangements. Thank you for your assistance and cooperation. Should you have any questions or wish to discuss this case,please feel free to contact me. Sincerely, Tammy mY L i, Claim Rep tative (510)940 Workers'Compensation Unit C22525WONT Clajc to: BOAM OF IMPERVIMM OF CWM COSTA CIM 7( IhSiRUCTIONS TO CLAI)= A. Cl.aiss relating to causes of action for death or for Injury to person or to per- sonal property Or growing ..ccrops -and �%&ich.�awcc�.r�uee{onnoo�rybefore ..D�le=ber' 3/1* 1�9�87, must be presented not later than he iWMh day after the 7�� of � Cause of action. Claims relating to carries of action forAkath or for injury to PW.Sft - or to personal property or grating crops and sdaich sloortie on or after January 1. 1988, must be presented not later tdmaa six moutbs after the axe of the cause of action. Claims relating to any, other cause of action mast be presented not later than one year after the accrual of the cause of.action. (Govt. Code $911.2.) B. Claims mast be filed eith the Clerk of the Board of Supervi=WJ at its office in Room 106, County Administration Building. 651 Pine Street, Mrtlberc. CA 9M- C. 553.C. If claim is-against a district governed by the Board of Supervisors, rather than the Countys the name of the District should be filled in. D. If the Claim is against more than ane public entityv separate claims must be filed against each public entity- E. Fraud. See penalty fear fraudulent claims, penal.Code Ser. 72 at the end of this �t �t1t i 1F /F /F aE It fF 1F aE � f ■ # aE � rt aE a � +IF wt 1E ,IE A a 1k f A wt fE iF � k � It +4 wt tE fF aE BE: Claim By j Reserved for Clerk's filing stamp T�cov�� e.e s ivaE,+r,y/mss/ RECEIVED Against the Caarty of Contra Costa ) FEB 1 91997 or District) CLERK BOARD OF SUPERVISORS ' -UF— - ) CONTRA COSTA CO. The umddeemigued claimant hereby makes claim against the County of Contra Costa or the above-mom District in the sum of Of CAI OA/40/^/GzRd In support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Oc z. 2aG : 5 o Arr1 2. Where did the damage or injury occur? (Include city and county) Coh kro- CoS1a Coon+� 3. Bow did the damage or injury oocur? (Give full detajja, use extra paper if required) PRase.vat:t 1�v Avco WWC.V 54AVdC k-4CWr oFf .�e,/,r✓grf AT 'ZIAM660-o vs CuQ✓E u t -r#od 'T CJAA10A/L 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? FAitoaa. T WJe^1)bE '"i Rot�G7'/ YC �fFR�IE� o.v l�ivay Reqs j. Nnat are the na'nes of county or district officers, servants or employees causing the damn-ge or injury? 5. Khat damage or injuries do you claim resulted? (Give Hall extent of injuries or damages claimed. Attach two estimates for auto damage. "AGTO FID /27 T"ibiA A)/ ;3*-vc vtAFT - -Xv&4, .Cy j d,AP"23EIp . OvRaT F�t.AG7'u!E of T-/� ✓E,tTtQ,CA T. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) dW aVl n!G $. Names and addresses of witnesses, doctors and hospitals. K'A/3E R, kmL mJ? 62"k )roqtl. Kc/1LC - W/7.✓ES,$f Dpi dEle 40ow MO/R WosP/ T�9L /+��3CAaiide /fir ! yt/aG16A MA+voLG9RE 7*,e L 9. List the expenditures you made on aoeouat of this accident or injury: DATE ITEM ANSI NT oAfavlwe. Ste a$ac,hecQ God. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES 70: (Attorney) or by some person on his behalf." Name and Address of Attorney laimant�s Si tore P. o QOx 2- (Address) l�Ju lnu f Gr e ek ro - RLtS96 Telephone No. Telephone No. S JO 41 6113 S � i 1t IE IE If 1F 1E �f IE � Ik /F IF E JE � If 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 sail 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 irerriso-u-,ent and fine. s QJ ^ ArO � 158 PAYMENT SUMMARY UNITED HEALTHCA DATE OF LOSS : 10/23/96 02/17/97 CB D568168 J KAY KOLLER 11 / 13 MLM SLS PG 1 ******* KIND/TYPE ISSUE AMOUNT KIND/TYPE ISSUE AMOUNT KIND/TYPE ISSUE AMOUNT CLM TT $7 ,75W64 SUP SIC $0 . 00 EXP O1 $0 . 00 TP $0100 SIM It,0 . 00 02 $0 . 00 PP $0 . 00 8IE $0 . 00 03 $OOO PT $0 . 00 TOTAL SI $0 . 00 O5 $0 . 00 FA $0 . 00 06 $O . O0 VR $0 . 00 SVP SDC $0 . 00 O7 $0 , 00 FU $01 00 SUM $0100 O8 WOO VC W0O SOE $0 . OO 09 $0 . 00 EL $0 . 00 TOTAL S8 $0 . 00 87 WOO LEGAL $0 , 00 89 $0 , 00 89 WOO ISSUE AMOUNT STAGED AMOUNT PENDING AMOUNT CLM $7 , 756 . 64 $O . O0 $0 . 00 MED $1 ,388 . 02 $320 . 12 $0 . 00 EXP $0 . 00 $78 . 48 $O . O0 SUP WOO $0 . O0 WOO �}@_-��a ■ - - . . - . }{ r a) 3 u . c- • ' r C . 31 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 1, 1997 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 $WTI` Amount: $500,000.00 Section 913 and 915.4. Please note all rnings". �` CLAIMANT: Gregory Leaf Williams FEB 7 4 1997 COUNTY COUNSEL ATTORNEY: J. Patrick Heron MARTINEZCALIF. Attorney At Law Date received ADDRESS: 1434 Lincoln Ave. BY DELIVERY TO CLERK ON February 24, 1997 San Rafael, CA 94901 BY MAIL POSTMARKED: February 21, 1997 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 25, 1997 Jy1L BeATCVELOR, C1erc����y Ca— Y. 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 qa late claim (Section 911.3). K) Other. 417 INA' Id J If Dated: / // ' + 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 11997 PHIL BATCHELOR, Clerk, ey�/�`®'�� . 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 3 1997 BY: PHIL BATCHELOR by 9 �lDeputy Clerk CC: County Counsel County Administrator �;laim tux SOM OF SOF€RPIM OF CONTRA COSTA COO M JJiSfRUCTIONS To M ADW;T A. Claim 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 319 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 #twirls 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.) S. Claims must be filed with the Clark of the Board of S ---is" at its office in Rose 1061, 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 and of this Tom. efe • eafesara ■ saseearriesesaseeaeeeeeasa • esea RE: Claim By Reserved for Clerk's filing stamp Grt�Cyp1� 1.�.✓tF LA9t�l•�R�s ) } Against t county o Contra Costa ) RECEIVED or ) �i otis,uv P<U tzar +t ter- ttt� d 100'1 Co � a �G:ilt District) —(FS11 in name? ) �i ERK gpARO OF STA CO,S4R5 She undersigned claimant hereby makes claim against the Cola, C TAco. the above-named District in the sum of $ 500, coo, and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact yydate and hour) �+�- tyG(5 �� 'fo V<✓q �r+c.i,ut�pt.� lhti h�1c.�Ha"t C3�.%t'�+ . 2. inhere did the damage or injury Wour? (Include city and county) CC\AO V�ZC,3 c� � Nwc�k6. CZ-+<t.Mkr<-�, Wc�2<.: 4•r M'uz,�{ I,v� Ov- . 3. Rote did the damage or,injury occur? (Give !pull details= use extra paper if required) �^t,w,,sl `(3w�tGR C�o-,.3«'tA1Li.�, 1,��•'�.1S2CwS pnl• a"t"N.N�14•>Mt-/./� 5., ?rwast+l 13,s�t�,.v,hs rrwvn- L-J�o.LL ZS AL:.;..2. �.� 2a.rvc„34 i.a ficnz. l'iv�tn�n,v�5� SZa�` �\ 7 I '— ri4t=_ . 4. that particular act or omission on the part of county or district officers, Servants or employees caused the injury or damage? y Mn2-twG"tI CJ�,_t.. •� Mc'�i<� tM1h2. lVt1-��n.9 �'�*�1ru.11Ni 11n.c l..{.z rM-.� w1til'r� /1+^�-c� l:,r�l<w✓YL v,. ax ✓tv� l'J- w�.Y7.MW2-Si w�-ctl sS n1 'r^1,c3S ✓r.✓c�. (over) Jp<�.a+���zS �l L�-E�^�-� �'q6 . U.,iLU A.v+-5 �lS c.tOSH (�. 'C(` ���'t • 5. 4What are the names of county or district offioerss, servants or employees causing the damage on injury? ' r7tCet��� MvNgtu6 2-� btu �2+ems Jt VI'th�f[E,+-S, �3r�r,,: ✓�'�'wviNi'�7s� �nli� L Ciw2 �Ly�� �a✓c�cr' ? i�nhnSlyL. ? r�,d D rzS 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claime� lttach tuo estimates for tauto damage. Sh-dth2e' 111Aih7e' ff}1ySi'W( /IV(/ i ti'GjZG rtr� J-1111.,E ! _ fi. Now Was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) .��.-clfL t'N�i[`ji�.yL C'fh"�S � foS�tvs75�,.�� iftr�')"' �}w f -Sit)T-4i2 it/d 4�Lv7c6frl /»d'�tl:aGS ���n4�'}.`ie�"(" j,+,rJ�.te. � ttv�}'¢F /i�✓ir/✓s� .���4'f/.3�rJb rY+✓c� �5�� � /^ / +A '" Pao B. Kemp ps and addresses of witnesses, doctors and bospitals. 9. List the expenditures you made on account of this accident or injury: DATE TPE.M AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NMCES TO: (Attorney) or bv some on his behalf." Name and Address of Attorney — �z < �C �=za J imam Signature to 13 �1Nc�ly �u2 1��3�� L1A10-1,) (Address) L-os -KS '4q`d3 Telephone No. Telephone No. e # # a # a # # # # # f e # # 0 0 a a a a 9 V I W 9 W a # # # V 0 T I C 2 Section T2 of the Penial Code provides: "'Every person %to, 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, +toucher, 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 (E1,000)« 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. ct ry 4 '. 1 s CAL TO: BOARD OF SUPERVISORS Contra FROM: Phil Batchelor, County Administrator : ' . Costa County �'"�'�^ ` DATE: April 1, 1997 �q'iiW '! SUBJECT: Final Settlement of Workers ' Compensation Claim - Kenneth E. Pond vs . Contra Costa County Fire Protection District WCAB Nos. OAK 135694; OAK 135695; WICK 0023850 & WICK 0026145 SPECIFIC REOUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Receive this report concerning subject final settlement and payment in the total amount of $70,000 from the Workers ' Compensation Trust Fund. REASONS FOR RECOMMENDATION/BACKGROUND: William R. Thomas, defense counsel for the County, has advised the County Administrator that within authorization an agreement has been reached settling the workers ' compensation claim of Kenneth E. Pond vs . Contra Costa County Fire Protection District. This Board' s November 19, 1996 closed session vote was : Supervisors DeSaulnier, Smith, Rogers, and Bishop, yes; Supervisor Torlakson, absent. This action is being taken so that terms of this final settlement and the earlier November 19 , 1996 closed session vote of this Board authorizing its negotiated settlement are known publicly. CONTINUED ON ATTACHMENT: _YES SIGNATURE:�" RECOMMENDATION OF COUNTY ADMINISTRATOR -RECOMMENDATION OF BO OMMITTEE \ _APPROVE _OTHER SIGNATURE(S). ACTION OF BOARD ON /99% APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS(ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. �y ATTESTED � /,i 1�7/ Contact: Tony Schleder - 335-1441 PHIL BATCHELOR,CLERK OF THE BOARD OF cc: CAO - Risk Management SUPERVISORS AND COUNTY ADMINISTRATOR Auditor-Controller Thomas, Salter & Lyding \ 9 (via Risk Management) BY v ��� DEPUTY C.33 TO: BOARD OF SUPERVISORS .;: Contra FROM: Phil Batchelor, County Administrator :r Costa _ { CountyDATE: April 1, 1997 9 •� SUBJECT: Final Settlement of Claim - John Burke vs . Contra Costa County Fire Protection District WCAB No. WICK 17091 & WICK 18193 SPECIFIC REOUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Receive this report concerning subject final settlement and payment from the Workers ' Compensation Trust Fund in the amount of $45,000 . REASONS FOR RECOMMENDATION/BACKGROUND: David V. Costa, defense counsel for the County, has advised the County Administrator that within authorization an agreement has been reached settling the workers ' compensation claim of John Burke vs . Contra Costa County Fire Protection District. This Board' s January 14, 1997 closed session vote was : Supervisors DeSaulnier, Rogers, Uilkema, Gerber, and Canciamilla, yes . This action is being taken so that terms of this final settlement and the earlier January 14, 1997 closed session vote of this Board authorizing its negotiated settlement are known publicly. CONTINUED ON ATTACHMENT: -YES SIGNATURE� L rl � RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOA COMMITTAJ APPROVE _OTHER SIGNATURE(S): ACTION OF BOARD ON _ APPROVED AS RECOMMENDED _ OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE _UNANIMOUS(ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTEDI `� �/p_),O� Contact: Tony Schleder - 335-1411 PHIL BATCHELOR,CLERK OF THE BOARD OF cc: CAO Risk Management SUPERVISORS AND COUNTY ADMINISTRATOR Auditor-Controller Mullen & Filippi (via Risk Management) BY� - - � � DEPUTY