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HomeMy WebLinkAboutMINUTES - 04042000 - C21-C24 CILAIM BOARD OF SUT'FEVISORS OF' C0NTI2A COSTA COUNns CALMORNLA BOARD AOOAPRIL, ; 2000 _ Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to 1 The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given )3(�;Maw pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: In Excess of $10,000-00 MAS Q 7 2090 G0LI 'r"cOUNSEL CLAIMANT: Michael Baird MARTNEZ CALIF. ATTORNEY: DATE RECEIVED: March 6, 2000 ADDRESS: 3312 Holly Grove Street BY DELIVERY TO CLERK ON: March 6, 2000 Thousand Oaks CA 91362 BY MAIL POSTMARKED. March 3, 2000 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 7, 2000 By: Deputy --- IL FROM County Counsel TO: Clerk of the Board of,,Supervisors { ) This claim complies substantially with Sections 910 and 910.2. ( This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.$). { ) 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-7, 00 By: Deputy County Counsel M. 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:621: -YPHIL BATCHELOR, Clerk, By �r�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 MAULING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR By Deputy Clerk CC: County Cnne�1 VICTOR J.WESTMAN DEPUTIES. COUNTY COUNSEL PHILLIPJANICE LL..AMENTAF NORA G.BARLOW B.REBECCA BYRNES SILVANO B.MARCHES[ /�vvim�y�,t^� *�J ANDREA W.CASSIDY CONTRA I.RA �` N:1 T MONIKA L.COOPER CH IEF ASSISTANT COUNTY COUNSEL VICKIE L.DAWES OFFICE OF THE 14- QUNSEL MARKES.ESTIS SHARON L.ANDERSON MICHAEL D.FARR CCkL&k7sf'Sf3MINkSTRAtC31�FIEIG LILLIAN T.FUJII ASSISTANT COUNTY COUNSELIs,STRE ; � DENNISC.GRAVES 1�wtJANET L.HOLMES MARTIf ,GAL[f° 3► N -1228 KEVINT.KERR GREGORY C.HARVEY BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. BEATR10E LIU MARY ANN MASON GAYLE MUGGLI PAUL R.MUNIZ OVALERIE J.RANCHE OFFICE MANAGER STEVEN P.RETTIG DAVID F.SCHMIDT PHONE(325)335-1800 BARBARA N.SUTLIFFE FAX(925)646-1078 NOTICE OF INSUFFICIENCY JACQUELINE Y.WOODS AND/OR NON-ACCEPTANCE OF CLAIM TO: Michael Baird 3312 Holly Grove Street Thousand Oaks, CA 91362 Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ D. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X ] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Page 1 [ 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. WESTMAN COUNTY COUNSEL By: ta Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P.§§ 1012, 1013a,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Tine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated. March 7,2000,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE,OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 e1 ,4-'ani 1 Michael Baird 2 3312 Holly Grove St. Thousand Oaks, CA 91362 3 (805) 4944367 � w 4 SO'SS1SORS VD 5 CI. S 60 RA CO C©. 6 7 Claim of MICHAEL BAIRD, ) 8 } } CLAIM FOR MONEY AND DAMAGES 9 vs. ) AGAINST PUBLIC ENTI'T'Y 10 COUNTY OF CONTRA COSTA } } 11 ) 12 13 14 15 TO THE COUNTY OF CONTRA COSTA AND ITS BOARD OF SUPERVISORS: 16 17 18 19 MICHAEL BAIRD hereby makes a claim against the COUNTY OF CONTRA COSTA 20 for amounts in excess of$103,000, and consequently does not state a specific sum. Claimant 21 makes the following statement in support of the claim. 22 23 24 1. Claimant's mailing address is 3312 Holly Grove Street, Thousand Oaks, 25 California 91362. 26 27 2. The date and place of the occurrences giving rise to this claim are: 28 The event causing claimants' injury occurred between an unknown date and present. The 29 events are ongoing and continue to take place. The events giving rise to this claim took place 30 within the county of Contra Costa. 1 3. The circumstances giving rise to this claim are as follows: 2 Events leading to, following, comprising and consisting of the placement of documents 3 containing derogatory information in claimant's personnel files in violation of County policy. 4 Specifically in violation of the Contra Costa County Sheriffs Office Policies&Procedures 5 Manual section 54, which states, in part, 'No memos, reports, or any written material which 6 contains derogatory information about an employee shall be placed in the employee's personnel 7 file unless the employee is provided a copy of the material. The employee shall have 30 days g from the date of receipt of the negative written information to deliver a written response". 9 10 Events leading to, following, comprising and consisting of the unauthorized removal of 11 documents from claimant's personnel file. Specifically, two (2)letters of promotion, numerous 12 letters of commendation, nominations for Reserve Officer of the year and numerous performance 13 evaluations. These documents were removed from claimant's personnel file in violation of 14 County Policy. Specifically in violation of the Contra Costa County Sheriffs Office Policies& 15 Procedures Manual section 54, which states, in part"Personnel files of employees are subject to 16 the following retention schedule. Transfer&Promotion Documents-None. Resolutions, 17 Memorandums, Certificates of Appreciation, etc-5 Years. Performance Evaluations-None". 18 19 Events leading to, following, comprising and consisting of the Contra Costa County Sheriff 20 Coroner's Office failure to return documents purged from claimant's personnel file in violation 21 of County Policy. Specifically in violation of the Contra Costa County Sheriff's Office Policies 22 &Procedures Manual section 5-4, which states, in part"As items are purged,they will be 23 forwarded to the individual employee". 24 25 26 27 28 29 30 I Events leading to, following, comprising and consisting of the keeping of an unauthorized 2 personnel file on the claimant. Specifically a personnel file kept by the Coordinator of Volunteer 3 Services located in the Field Operations Building. This personnel file was kept on the claimant 4 in violation of County Policy. Specifically in violation of the Contra Costa County Sheriff's 5 Office Policies&Procedures Manual section 5-4, which states,in part"Appendix l l of this 6 manual contains a list of all personnel files authorized and acknowledged by the Sheriff s Office, 7 as well as,their locations and persons authorized to access them". Appendix 11 states, in part 8 "Files containing Personnel actions, all memos to, from, and about the employee, injury reports, 9 commendations" are located in the Sheriff's Department Central Administration File(7th floor), 14 the Personnel Officer is listed as the Custodian of Records. The personnel file kept on the 11 claimant by the Coordinator of Volunteer Services contained background investigation material, 12 disciplinary actions, injury reports, commendations, and memos to, from, and about the claimant. 13 The personnel file kept by the Coordinator of Volunteer Services is not acknowledged in 14 Appendix 11 and is therefore not authorized. 15 16 17 4. Claimant's injuries, as far as known, as the date of presentation of this claim are: 18 Includes, but is not limited to damage, present and future, in the farm of breech of 19 contract, emotional distress, attorney's fees, costs and expenses caused to claimant by public entity's and it's employees' violation of claimant's rights. 20 21 22 5. The names of the public employees causing the claimant's injuries are 23 Warren E. Rupf, Sheriff-Coroner, Commander John Gackowski, Commander William Shinn, 24 Captain Wayne Beck, Lieutenant Mike Weymouth, Lieutenant George Lawrence, Sergeant Rick 25 Morgan, Sergeant Barry Whitcomb, Torn Young, Chief of Management Services, and unknown public employees. 26 27 28 29 30 1 6. Claimant's claim as of the date of this claim is in an amount that would plane it within 2 the jurisdiction of the Superior Court of the State of California. Claimant's claim includes, but is 3 not limited to damage, present and future, in the form of breech of contract, damage to economic 4 interests, emotional distress, attorney fees, costs and expenses. 5 6 7 8 9 10 11 12 13 14 15 BATED: 16 Michael Scott Baird 17 3312 Holly Grove St. Thousand Oaks, CA 91362 18 (805)494-4367 19 20 21 cc: CONTRA.COSTA COUNTY RISK MANAGEMENT 22 LAW OFFICES OF E'VANS &MALTER/Barry Evans, Esq. 23 24 25 26 27 28 29 30 0 l i ViN r r,f '-,.. � - rte• W CLAM BOARD OF SUPERVMS RS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACT10April 4, 2000 Claim Against the County, or District Caverned by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: M AR $100,000.00 UNSEL CLAIMANT: Shirley Bartolonei ` 'ZCAUF. ATTORNEY: c/o David. Timko, SB!N 124544 DATE RECEIVED: MARCH 3, 2000 ADDRESS: TIMKO & LASORSA BY DELIVERY TO CLERK ON: MARCH 3, 2000 2033 N. Main St. , Ste. 360 Walnut Creek CA 94596 MARCH 2 2000 BY MAIL POSTMARKED: , I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. . PHIL BATCHELOR, Clerk Dated: March 3, 2000 By: Deputy Qw-- ILFROn- County Counsel TO Clerk of the Board of S ervisors (,Vf"'This claim complies substantially with Sections 910 and 910.2. ( ) This claim PAILS 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: f ej ~ 6 er 1 t J Dated: By: ' .. Deputy County Counsel IY[. FttOM: 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:, �2VOPHIL BATCHELOR, Clerk, By C� " , 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 NIAEU NG 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: Lc 'O By: PHIL BATCHELOR ByQrr?"-, Deputy Clerk TIMKO & LASORSA ATTORNEYS AT LAw DAvm TIMxO 2033 N.MAIN STREET,SurrE 360 TELEPHONE:(925)933-3800 LINDA LASORSA WALNUT CREEK,CALIFORNIA 94596 FACSIMILE: (925)9474503 March 2, 2000 RECEIVED CERTIFIED MAIL MAR 0 3 2000 Clerk of the Board of Supervisors CLERK BOARD OF SUPERVISORS Contra Costa County ONTRA COSTA G0. 651 Pine Street, Roam 106 Martinez, CA 94553 Dear Clerk of the Board of Supervisors: Enclosed please find four claims we are making on behalf of our clients. We look forward to hearing your decision. Very truly yours, TIMKO&LASORSA A44 David Timko � r G I David Timko, SBN 124544 Linda LaSorsa, SBN 148550 2 TIMKO & LASORSA 2033 N. Main Street, Suite 360 =OF 3 Walnut Creek, CA 94596 Telephone: (925) 933-3800 4 Facsimile: (925) 947-4503 5 Attorneys for Claimant, SHIRLEY BARTOLOMEI 6rn 7 8 CLAIM AGAINST THE GOVERNMENTAL AGENCY 9 OF CONTRA COSTA COUNTY 10 11 12 CLAIMANT'S NAME: Shirley Bartolomei 13 CLAIMANT'S ADDRESS: 3709 Sundale Road, Lafayette, CA 94549 14 ADDRESS TO WHICH NOTICES ARE TO BE SENT: 15 Timko &LaSorsa 2033 N. Main St., Ste. 360 16 Walnut Creek, CA 94596 Telephone: (925) 933-3800 17 DATE OF ACCIDENT OR INCIDENT: Approximately 09/24/99 18 LO('ATION OF ACCIDENT OR INCIDENT: 3709 Sundale Road, Lafayette, CA 94549 19 HOW DID ACCIDENT OR INCIDENT OCCUR: Ms. Bartolomei adopted a puppy from the Contra 20 Costa Animal Shelter located in Martinez, California for her granddaughter. The puppy was not tested or isolated properly by the Animal Shelter workers and contracted rabies. Ms. Bartolomei and 21 her family and house guest were all exposed to rabies and forced to undergo a painful series of injections. 22 DESCRIBE INJURY OR DAMAGE: Ms. Bartolomei was exposed to rabies due to the puppy being 23 infected. She had to undergo rabies injections. 24 NAME OF PUBLIC EMPLOYEE(S) BELIEVED TO HAVE CAUSED INJURY OR DAMAGE: Contra Costa County Animal Shelter in Martinez, California 25 AMOUNT OF CLAIM: $100,000.00 26 ITEMIZATION OF CLAIM: Plaintiff has undergone medical care in the approximate amount of 27 $5,000.00 plus 28 &x olo Ft 1 I declare under penalty of perjury under the laws of the State of California that the foregoing is true 2 and correct. 3 Signed on behalf of client 4 DATED: March 1, 2000 TIMKO &LASORSA 5 Y 7 David Timko Attorney for Plaintiff 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 s IU W ;' R1 to i2+ 0 xr ". LO Q' N O' ® CD a = C totz o 0 > oo RD CD � l r cnCA ... > tip r' s , * Ul C m ay G ry IY a . f, r :,:i.. ;..'...,�...r• ....,ayy.;a;. +ra —9�s'io-..sr�+iraa . +z ..c�.sa� CIAINVI ` BOARID Off' SUPEM ORS OF CONTRA CO rA CO TNn, CALEDHNIA BOARD AC11011t APRIL 41 2000 Claim Against the County, or District Governed by ) the Beard of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given - pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $279025.10 ,�asL MARTINEZ CAUF CLAIMANT: Sharon Blackman, Guardia-► of Tenika Smith March 1 2000 ATTORNEY: Law Offices of Manny C. MartinePATE RECEIVED: 5 2049 Century Pa:�k East, Ste. 1100 March 1 2000 ADDRESS: Century City, CA 90067 BY DELIVERY TO CLERK ON: BY MAIL POSTMARKED: February 28, 2000 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk � 2000 B March 1 i Dated: y: Deputy �w H. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) Thi 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: - "� By: 72 '� Deputy County Counsel M. 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: 'Y, :;7 r oZ PHIL BATCHELOR, Clerk, By Lam- Deputy Clerk 1` 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 X1kHJNG 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: ,L �`" By: PHIL BATCHELOR By ► Deputy Clerk CC: County Counsel County Administrator VICTOR J.WESTMAN DEPUTIES. f' r COUNTY COUNSEL ANICELS.AMENDTAF . N08A G.BARLOW S.REBECCA BYRNES SIDY SILVANO B.MARCHES1 =4Ti�A COSTA C VI NTY ANDREA W CA OPER MONIKA L.COOPER CH IEF ASSISTANT COUNTY COUNSEL p� VICKIE L.DAWES OFFICE OF"�"HECO CQUNSEL MARKES.ESTIS SHARON L.ANDERSON MIGHA TFUJIIRR Y�kl?MINISTRATION131JI14!0; LILLIANTFUJfI ASSISTANT COUNTY COUNSEL =ir(kt STREETaLodR DENNIS C.GRAVES �yJANET L.HOLMES GREGORY C.HARVEY MART 'GA IF771229 BERNAKERR RD BERNARD L.KNAPp ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. BEATRICE LIU MARY ANN MASON GAYLE MUGGLI PAUL R.MUMZ VALERIE J.RANCHE OFFICE MANAGER STEVEN R RETTIG DAVID F.SCHMIDT DIANA J.SILVER PHONE{925}335-1$00 BARBARA N.SUTLIFF€ FAX{925}646-107$ JACQUELINEYWOODS NOTICE OF INSUFFICIENCY AND/O NQN-ACCEPTANCE OF CLAIM TO: Law Offices of Manny C. Martinez 2049 Century Park East, Ste 1100 Century City, CA 90067 RE: CLAIM OF: Sharon Blackman, Guardian of Tenika Smith Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] I. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ X] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date o.fpresentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Page 1 CX ] 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. WESTMAN COUNTY COUNSEL By Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a,2415.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 3,2000,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 2f 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 grooving crops and which accrue on or before December 31, 1987, must be presented not later than the 100'b 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 crust be filed with the Clem 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 SHARON BLACKMAN GUARDIAN OF TENIKA SMITH ) } RECEIVED. DURHAM TRANSPORTATION } Against the County of Contra Costa MAR• 01 2000 or CLERK BOARD OF SUPERVISORS ONTR COSTA CO. District} (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of$27,025. 1 Oand in support of this claim represents as follows.- 1. When did the damage or injury occur? (Give exact nate and Hour) NOVEMBER 2, 1999 4:30 P.M. 2. Where did the damage or injury occur? (Include city and County) SONOMA STREET RODEO, CA. COUNTY .OF CONTRA COSTA ------------------------------------------------------------------------------------- 3. How did the damage or injury occur? (Give fltll details;use extra paper if required) BUS HIT PARKED CAR AND MINOR CHILD WAS THROWN AROUND ON BUS AND WAS INJURED, WAS LEFT 40 MINUTES UNATTENDED: BUS DRIVER HAD NO DRIVERS LICENSE IN HIS POSSESSION, ----------------------------------------------- ------- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? THE BUS DRIVER HIT A CAR THAT WAS PARKED AND NOT MOVING. (Over) -auzg puE ;uauzuoszxdmi Bans gjoq Cq xo `( 000'01S) sxEljop puEsnoq; ua;2u1pa3axa jou,jo aug E Xq 'uosixd a;E;s aq;uz ;uamuosixdmI Cq xo'aui; puE luauxuosixdtax qans q;oq Cq xo '( 000`1$) sxEjjop puEsnogj auo 2uzpaaaxaIOU,jo aug E �q lawk auo uEq;axouT iou,jo popad E xo; 1p f,C4unoa aq; ui juauxuosudmi aCq xagjia ajgEgsiund sz'2ui;u.tt.To 'xaganoe';unoaaE 'Ipq 'zarela juajnpnExj xo Mit'i SuE 'auinua2 3i azun aq;,Clad xo molfe o; pazixoq;nE 'xa:)Ujo .zo pxEoq;au;sip xo Sip ',{junoa ,Gula o;xo'xaaO;o xo pxEoq a;E;s ,CuE o;;uaux,CEd xo,j xo aouE.ttojlE xoI s;uasaxd'pnEx3ap o;;ua;ui q;i,tt'oq,tt uosxad AWn :> :sapito.xd apoo jEuad aql jo ZL uoi;aas aDi toN M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M 5£T£—SfiZ—OT5 ol�auogtlajay 06ZO—£OZ—OT£ 'atraungdalal (ssaxpp,v) ZLSD,6 'Yo 'oH(1oH 'SS VSOcjjavw 90ZT (ax[T;ETT TS sjur TIEjz)) L9006 - )LSIO lanlNao nauxossaxp UluauTENI diNO 6poz zfffftMvw V. m ,,-jjEgaq szq uo uosxad autos Cq io (.Caux014d) :OZ saoaou axas meta p agj,Cq pau2is aq isnzu Eurup agL$9 :sapinoxd Z'0T6 -aaS apoO .,too M M M M M M M M M M M Ae M M M M M M M iM,M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M YIN Wall ax.va :,Cxnfui.To }uapixm siq;;o;unoaaE uo apEzu noS saxn;rpuadxa ag;;siZ 'g ------------------------------------------------------------------------------------- VO S'IONId'?Ia SKINKnO 1091 `(1-H )LZVHH SSHHHOaI Halmao gv3ia3W S -Ha LO9V6 'V3 -''C[NV- 'y3aau.Ls HZZT £OTT 'O'a HSIIdS 's a?I�T`T'IIM -slE;idsoq puE'sxo;aop'sassau;i,tt,jo sassaxppE puE saUMM g -------------------------------------------------------------------------------------- YIN ( aaeu[sp so X.MfUT aap32dsoad:Cua fo;unowe pa;suu�sa aT aPnVui) Lpa;nduzoa;una(uE pauTreja anoqu ag;sr,-A atoll •L •)Laos HaH a O SlaVd SnOIRVA NO SiIMIRE1 aVaaASS 'aaaRX S`aIS'T almnIOVRa 'NIVHdS id" SHORT (•aauunsp o;ns .jos saTsuipsa o.u;g3tsp+ •paunig3 saaeuitp so s3pnrui,To wwga mv anio) Lpa;jnsax ump nog op sazxnfui xo sa2gmp ju 9 ------------------------------------------------------------------------------------- 4 Cxnfui xo a2EUTEp aq;2uisnEa saafiojduxa xo's;uE txas'sxaaUjo;aix;sip xo 4unoa,jo sauTEu aq;axE ;EqM s d. �f x ;27 MANNY C. MARTINEZ A Professional Corporation Two Century Plaza (310) 203-0290 2049 Century Park East,Suite 1100 (310) 203-3303 Century City,California 90067 February 2E3, 2000 EI0 CLERK OF THE BOARD OF SUPERVISORS MAR 0 12000 ROOM 106 COUNTY ADMINISTRATION BUILDING 651 PINE STREET CLERK BOARD Cl,' LIPERViSORS COWRA COS`rA CO. MARTINEZ94553 AWN CLA��S Our Client Tenika Smith (Sharon Blacken Guardian Of) Tete Of Loss 11-02-99 Claim Number S103799GG Your Insured Durham Transportation, Inc. Tear: S i r Enclosed herein please find medical reports and statement of charges for medical services rendered to our above- mentioned client in connection with the above-referenced loss. For your convenience,we are also setting forth what we consider a fair settlement offer to bring this claim to a close. Further,our client may require future medical availability as these type of iri juries are noted for their recurrent symptomatolgy. Moreover,note must be made of our client's loss of earnings capacity relative to the limitation of the nature and duality of his physical activities resulting from this loss. Based upon the magnitude of this accident and the physical injuries sustained by our client,we are demanding the following sum as full and final settlement of all claims arising from this matter. Therefore,in light of the aforesaid,$ 27,025. 10 would be considered a fair and equitable sum to compensate this individual for this loss. We look forward to hearing from you within the next few days in order to conclude this claim. If you have any questions or if we can be of any further assistance,do not hesitate to contact our office. Sincerely, LAW OFFICES OF MANNY C. MARTTNE2 A PROFESSI+C NAL LAW CORPORATION anny .M ez,Esq. MCM/FC Encl.. DOCTORS MED CTR - PINOLE P.O. BOX 2517 SANTA ANA, CA 92707-0517 SMITH TENIKA K 004443834 Tar a.. .Rac«nax oae. $1119.51 11/06/99 de Ty" Paeor(TM INITIAL OUT 1411/02/99 BLACKMON SHARON Y 11/02/99 Pnwgp fNCMa7 bW Fn1npY C11p 1206 MARIPOSA ST. #743 70 RODEO CA 94572 F10m020775 - Page. 001/001 `uer�cripfion C i c:hargepayments 11/05/991 11/02/99 4903070 73070TC ELBOW,LIMITED 1 $170. 70 11/05/99 11/02/99 4903570 73564TC KNEE, 4 VW MIN 1 $357. 00 11/02/99 11/02/99 5305915 00099 MOTRIN 400MG + 1 $15. 30 11/05/99 11/02/99 6100522 99282 ER VISIT LVL II 1 $440.00 11/05/99 11/02/99 8114335 00099 IMBL KNEE $ 1 $136. 51 i 004443834 SMITH TENIKA K IRS#95372065917 THIS ACCOUNT IS DUE AND PAYABLE UPON RECEIPT. • " 1119.51 Detach ana r urn this po on your paymen i w MONTPIRA`ION DATEAR INTER BANK, NO. VISA [ MASTERCARD (Ma:uYl Amount to CHARGE E]AMEX DISCOVER ! cnRo NUMsea lau oiorrs a�sAs€� - cardholder's Name: Signature: Account Number: 004443834 Make Check Payable to: DOCTORS MED CTR - PINOLE Account Balance: $1119.51 Patient Name: SMITH TENIKA K Guarantor Name: BLACKMON SHARON Y Payment Amount $ Check here for change of address 0910121 004443834 0001119.51 3 If the address shokyn is incorrect,'please write in YOUI correct addre','s below Street Address City,State and ZIP Code Telephone Number DOCTORS MED CTR - PINOLE P.O.EOX 31001-0121 PASADENA CA 91110-0121 47 Aff CA EMER PHYS*DMC . .NOLE CAMPUS 7 , # BILLING OFFICE PHONE 1601 CUMMINS DR. , STE. D-43 94-3261481 1(800)664-7660 MODESTO CA 95358-6402 ACCOUNT NUMBER DATE OF STATEMENT UM 43-08-04443834 11/12/99 Address Service Requested PATIENT'SNA.l%IE —,--SMITH, TENIKA LOCATION OF SERVICE 05615-1 CEP * DMC PINOLE CAMPUS (209) 557-1264 TENIKA K SMITH PINOLE CA 94564 1206 MARIPOSA ST #743 RODEO CA 94572 DATE POS DIAGNOSIS DESCRIPTION OF SERVICES AwIOL'NT 11/02/99 23 ** 99283 LEVEL 3 EMERGENCY, PHYS CHA 135.00 *z 7295, E818 a EMPLOYER INJURY DATE ADMISSION DATE DISCHARGE DATE NONE 135.00 IF YOU HAVE INSURANCE, PLEASE COMPLETE THE BILLING INFORMATION AS REQUESTED ON THE REVERSE SIDE OF THIS STATEMENT. PAYMENT IS DUE UPON RECEIPT OF STATEMENT A FINANCE CHARGE OF 1.5 PERCENT MAY BE REFERRING DOCTOR BEATY, FORREST M.D. CHARGED EACH MONTH ON ACCOUNTS NOT PAID ATTENDING DOCTOR BEATY, FORRES T M.D. IN FULL.ANNUAL PERCENTAGE RATE I80 TENIKA K SMITH 1206 MARIPOSA ST NTIBER I STATEMENT DATE #743 43-08-04443834 11./12/99 RODEO CA 94572 PRIMARY POLICY N SECONDARY POLIC`s' 567974191 MAKE CHECK PAYABLE TO: SEE REVERSE SIDE FOR ANV EXPL.-L- ATION OF THIS BILL CA EMERGENCY PHYSICIANS ,.r. AN CA EMER PHYS*DMC PINOLE CAMPUS 1601 CUMMINS DR. , STE. D-43 r IN MODESTO CA 95358-6402 �` 135.00 ARE YOU CONFUSED BECK ISE YOU RECEIVED SEVERAL BILLS FP;--YOUR EMERGENCY ROOM VISIT? THE HOSPIT/ a BILL IS SEPARATE FROM THE EMER`• 4CY PHYSICIAN'S BILL ROUTINE COST r HOSPITAL'S EMERGENCY EEE PHYSICIAN'S FEE The routine cost for emergency services has a minimum of two fees, Each fee is billed separately by the provider of the services. The hospital's fees cover the cost of providing the nurses, technicians, equipment and supplies involved in the performance of your service. The physician's fee(s) are for medical care rendered in the emergency department. The emergency physician is an independent physician, not an employee of the hospital and therefore bills separately for his/her professional services. You may receive additional bilis from other physicians who provided services during your visit. PLACE OF SERVICE CODES (POS) 11 OFFICE 53 COMMUNITY MENTAL HEALTH CENTER 12 HOME 54 INTERMEDIATE CARE FACILITY/MENTALLY RETARDED 21 INPATIENT HOSPITAL 55 RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY 22 OUTPATIENT HOSPITAL 56 PSYCHIATRIC RESIDENTIAL TREATMENT CENTER 23 EMERGENCY ROOM.. HOSPITAL 61 COMPREHENSIVE INPATIENT REHABILITATION FACILITY 24 AMBULATORY SURGICAL CENTER 62 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY 25 BIRTHING CENTER 65 END STAGE RENAL TREATMENT FACILITY 26 MILITARY TREATMENT FACILITY 71 STATE OR LOCAL PUBLIC HEALTH CLINIC 31 SKILLED NURSING FACILITY 72 RURAL HEALTH CLINIC 32 NURSING FACILITY 81 INDEPENDENT LABORATORY 33 CUSTODIAL CARE FACILITY 99 OTHER UNLISTED FACILITY 34 HOSPICE 41 AMBULANCE- LAND 42 AMBULANCE o AIR OR WATER 51 INPATIENT PSYCHIATRIC FACILITY 52 PSYCHIATRIC FACILITY PARTIAL HOSPITALIZATION INSTRUCTIONS FOR FILING HEALTH INSURANCE CLAIMS 1. PLEASE COMPLETE A CLAIM FORM FROM YOUR MEDICAL INSURANCE PLAN WITH THE REQUIRED INFORMATION. 2. SIGN THE APPROPRIATE AUTHORIZATIONS BELOW. 3. ATTACH THIS COPY OF YOUR STATEMENT TO YOUR MEDICAL CLAIM FORM. 4. FORWARD THE FORMS TO YOUR INSURANCE COMPANY'S PROCESSING OFFICE. If you require another statement for a second insurance company,please photocopy both sides of this statement. NOTE: When filing secondary insurance, some carriers require a copy of the explanation of benefits (EOB)from the primary carrier. AUTHORIZATION AUTHORIZATION I hereby authorize the provider shown on the reverse side of this I hereby authorize and direct my insurance carrier to pay directly form to release to my insurance company any medical information to the provider shown on the reverse side of this form any benefits necessary to process this claim. due me under my insurance plan. I agree to pay the balance of expenses not paid under this plan. X X AUTHORIZED SIGNATURE AUTHORIZED SIGNATURE COMPLETE THE FOLLOWING INFORMATION QNIY IF REQUESTED ON THE FRONT OF THIS STATEMENT. Insurance Cornpan Employer of Insured Claim Office Address (Relation of Patient to Insured:) Policv Number RETURN INSURANCE INFORMATION TO OUR OFFICE Group Number IN THE ENCLOSED ENVELOPE. Name of Insured Social Securim Number CA EMER PHYS*DMC(_ _NOLE CAMPUS BILLING OFFICE PIigtiE 1601 CUMMINS DR. , STE. D-43 94-3251481 1(800)654-7660 MODESTO CA 95358-6402 ACCOUNT NUMBER D.A TE OF '"!:j' NT 43--08-04443834 11/12/99 Address Service Requested PATIEN-'fi S NAME SMITH, TENIKA LOCATION OF SERVICE 05615-1 CEP * DMC PINOLE CAMPUS (209) 557-1264 TENIKA K SMITH PINOLE CA 94564 1206 MARIPOSA ST #743 RODEO CA 94572 DATE POS DIAGNOSIS1 DESCRIPTION OF SER\e ICES AMOUNT 11/02/99 23 ** 99283 LEVEL 3 EMERGENCY, PHYS CHA 135.00 ** 7295, E818 i E 1iPL01`ER INJURY DATE ADMISSION DATE DISCHARGE DATE NONE 1.35.00 IF YOU HAVE INSURANCE, PLEASE COMPLETE THE BILLING INFORMATION AS REQUESTED ON THE REVERSE SIDE OF THIS STATEMENT. PAYMENT IS DUE UPON RECEIPT OF STATEMENT A FINANCE CHARGE OF 1.5 PERCENT MAY BE REFERRI\G DOCTOR BEATY, FORREST M.D. CHARGED EACH MONTH ON ACCOUNTS NOT PAIL) ATTE\DING DOCTOR BEATY, FORREST M.D. IN FULL ANNUAL PERCENTAGE RATE 18%. TENIKA K SMITH 1206 MARIPOSA ST A COUNN B R STATEMENT DATE #743 43-08-074443834 11/12/99 RODEO CA 94572 PRIMARY POLICY SECONDARY POLICY 5£7974191 MAKE CHECK PAYABLE TO: SEE REVERSE SIDE FOR A.'ti EXPLANATION OF THIS BILL CA EMERGENCY PHYSICIANS r�rr. .� CA EMER PHYS*DMC PINOLE CAMPUS 1601 CUMMINS DR. , STE. D-43 now Aff MODESTO CA 95358-6402 135.00 ARE YOU CONFUSED BECAJ ISE YOU RECEIVED SEVERAL BILLS FC=YOUR EMERGENCY ROOM VISIT? THE HOSPITi . BILL IS SEPARATE FROM THE EMER' JCY PHYSICIAN'S BILL ROUTINE COST IHOSPITAL'~ EMERGENCY FEE PHYSICIAN'S FEE The routine cost for emergency services has a minimum of two fees. Each fee is billed separately by the provider of the services. The hospital's fees cover the cost of providing the nurses,technicians, equipment and supplies involved in the performance of your service, The physician's fee(s) are for medical care rendered in the emergency department. The emergency physician is an independent physician, not an employee of the hospital and therefore bills separately for his/her professional services. You may receive additional bills from other physicians who provided services during your visit. PLACE OF SERVICE CODES (POS) 11 OFFICE 53 COMMUNITY MENTAL HEALTH CENTER 12 HOME 54 INTERMEDIATE CARE FACILITY/MENTALLY RETARDED 21 INPATIENT HOSPITAL 55 RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY 22 OUTPATIENT HOSPITAL 56 PSYCHIATRIC RESIDENTIAL TREATMENT CENTER 23 EMERGENCY ROOM., HOSPITAL 61 COMPREHENSIVE INPATIENT REHABILITATION FACILITY 24 AMBULATORY SURGICAL CENTER 62 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY 25 BIRTHING CENTER 65 END STAGE RENAL TREATMENT FACILITY 26 MILITARY TREATMENT FACILITY 71 STATE OR LOCAL PUBLIC HEALTH CLINIC 31 SKILLED NURSING FACILITY 72 RURAL HEALTH CLINIC 32 NURSING FACILITY 81 INDEPENDENT LABORATORY 33 CUSTODIAL CARE FACILITY 99 OTHER UNLISTED FACILITY 34 HOSPICE 41 AMBULANCE- LAND 42 AMBULANCE-AIR OR WATER 51 INPATIENT PSYCHIATRIC FACILITY 52 PSYCHIATRIC FACILITY PARTIAL HOSPITALIZATION INSTRUCTIONS FOR FILING HEALTH INSURANCE CLAIMS 1. PLEASE COMPLETE A CLAIM FORM FROM YOUR MEDICAL INSURANCE PLAN WITH THE REQUIRED INFORMATION. 2. SIGN THE APPROPRIATE AUTHORIZATIONS BELOW. 3. ATTACH THIS COPY OF YOUR STATEMENT TO YOUR MEDICAL CLAIM FORM. 4. FORWARD THE FORMS TO YOUR INSURANCE COMPANY'S PROCESSING OFFICE. If you require another statement for a second insurance company, please photocopy both sides of this statement. NOTE: When filing secondary insurance, some carriers require a copy of the explanation of benefits(EOB)from the primary carrier. AUTHORIZATION AUTHORIZATION I hereby authorize the provider shown on the reverses side of this i hereby authorize and direct my insurance carrier to pay directly form to release to my insurance company any medical information to the provider shown on the reverse side of this form any benefits necessary to process this claim. due me under my insurance pian. I agree to pay the balance of expenses not paid under this plan. X X AUTHORIZED SIGNATURE AUTHORIZED SIGNATURE COMPLETE THE FOLLOWING INFORMATION QNLY IF REQUESTED ON THE FRONT OF THIS STATEMENT. Insurance Company Employer of Insured Claim Office Address {Relation of Patient to Insured) Policv Number RETURN INSURANCE INFOIL'4IATION TO OUR OFFICE Group Number IN THE ENCLOSED ENVELOPE. Flame of Insured Social Security, Number t" t �i rL ysJ 911Q 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 an x-ray or EKG has been performed, it has been read on a preliminary basis only, and will be reviewed by a radiologist or internist within 24 hours.You will be notified if additional findings are noted. YOUR DIAGNOSIS IS: TRAUMA ADULT PEDES GYN-GU Laceration/Puncture Head Injury Viral URI Pneumonia/Bronchitis Fever Control Otitis Media Miscarriage,Spont. PID Sprain/Strain Concussion* Gastroenteritis COPD/Asthma Viral URI Otitis/Externa Miscarriage,Threaten Ovarian Cyst Burn/Abrasion Neck/Back Pain Ulcer/Gastritis Tension Headache Gastroenteritis Pneumonia/Bronchitis Irregular Vag.Bleed Curettage Contusion Corneal Abrasion* Esophagitis* Hypertension,New Pharyngitis,Viral* Asthma* Vaginitis* Menstrual Pain* Fracture Abscess* Seizure,Recurrent* Biliary Colic Pharyngitis,Strep* Poisoning,Pedes* Cystitis,Fem. Kidney Stone* Cast and Splint Care Cellulitis Abdominal Unknown No Complications Chicken Pox Febrile Seizure* Pyelonephritis* GC/Chlamydia Suture Removal- Animal Bite Alcohol W/D Synd. Migraine Headache Conjunctivitis* Allergic Reaction Scabies No Complications Chest Wali Pain Diabetes Chest Pain-Non Cardiac Croup* Sinusitis Dehydration Contact Dermatitis Atopic Dermatitis PRINTED INSTRUCTIONS PROVIDED AS INDICATED ABOVE other: PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW.--❑ or N/A ❑ ADDITIONAL INSTRUCTIONS: r For the health of your child follow up with your doctor to ensure that your child Is fully Immunized. ❑Call 970-5140 on for the results of your test: YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS BEEN: IF Y© MPTOMS ET W SE, OR YOU START HAVING ANY NEW PROBLEMS, RETURN TO THE EMERGENCY DEP T T IMME If y sy oms are n i better in hours/days,call your regular doctor or clinic,or return to the Emergency rim immediat r I have received and understand the inctions outlined above, atient or Representative Staff Date D/C Time For the health of your child follow up with yo doctor to make sure that your child Is full Immunized. HOSPITAL WORK/SCHOOL NOTIFICATION FORM 77�Ile.$ �'I1" was seen in the Emergency Department on 2 A-00 r H h ould be able to return to wo n Z//V'D7/J1; with the following restrictions: mo X M.D. EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mg. Disp• Sig. ❑ Do not drive while taking medication. ❑ Do not substitute. Physician Printed ❑ Spanish Instructions. Signature Name r DOCTORS MEDICAL CENTER � 4t+4 �8 _44 70 65 ER SM ! Tii, TENIKA K EMERGENCY DEPARTMENT ` ' �'`: 7 I't 7 000080142 DISCHARGE INSTRUCTIONS i`E A T" t X 0 bi ATT , r rri0 JERK " As M0 11 /12/99 012Y FORM#7015.107(REV.12/98)SEC.790 PATIENT COPY y f_ DOCTORS MEDICAL CENTER-PINOLE 2151 Appian Way, Pinole CA 94564 (510)741-2461 Discharge Instructions FORREST SEATY MD C ENIKA SMITH SPRAIN: ELBOW A SPRAIN is a tearing of the ligaments that hold a joint together.This may take up to six weeks to fully heal, depending on how severe it is. Moderate to severe shoulder sprains are treated with a sling or splint. Minor sprains can be treated without any special support. HOME CARE: 1) If a splint or sling was provided, leave it in place for the time advised by your doctor. If you are unsure how long to wear it, ask for advice. 2)Apply an ice pack over the injured area for 20 minutes every 2 hours for the first day. Continue this three to four times a day for the next few days. 3)You may take Tylenol or ibuprofen (Advil, Motrin)for pain, unless another pain medicine was prescribed. 4) Elbow joints become stiff if left in a sling or splint for too long. Range of motion exercises should be usually be started within the first ten days after injury. Consult your doctor on what type of exercises to do and how soon to start. FOLLOW UP with your doctor or as directed if pain does not begin to improve within the next THREE days. If a cast or splint was applied, it should be checked in 24 HOURS to be sure it has not become too tight from swelling. Look for the warning signs below. [NOTE: if X-rays were taken, they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care.] RETURN PROMPTLY if you develop any of the following: -- Pain or swelling increases Fingers become swollen, cold, blue, numb or tingly SPECIAL INSTRUCTIONS WEAR SLING FOR COMFORT. FOLLOW UP WITH DR.JENKINS AS NEEDED. I HAVE RECEIVED AND UNDERSTAND THE INSTRUCTIONS ABOVE. x x The exam and treatment that you received today has been provided on an emergency basis only. If your problem worsens or new symptoms appear,contact your doctor or return to this facility for further care. 11/2/1999(22:05) EMERGENCY DEPARTMENT Page 1 of 1 PLEASE DO NOT STAPLE W 'AREA a PRIVATE PAY PICA HEALTH INSURANCE CLAIM FORM PICAXy 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S 1.0.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#) (Medicaid#) (Sponsor's SSN) (VA File 0) (SSN or ID) (SSN) (tD) 2.P - 567974191 ATIENT'S NAME(Last Name,First Name.Middle initial) 3.PATIENT'S DBIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name.Middle initial) MM M )F 17 qMTTH TENT14A 5,PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7,INSURED'S ADDRESS(No.,Street) 12016 MARIPOSA ST sen spause� Child Other1206 MARIEDS6 ST CITY STATE 8.PATIENT STATUS CITY STATE Single Married Other F ( ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Employed Fuli-Time Part Time r y ( } ,j 94572 1 (510) 2453135 D Student D Student 09457a 510) ,4531 10 9,OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENTS CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a,INSUREDSDATDELOF BIRTH SEX �jYES 12 NO Q7 27 '1957 MF z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME p MM DD YYF l�YES NO d M t� -w c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z YES NO d.INSURANCE PLAN NAME OR PROGRAM NAME tOd.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? p, E]YES ! NO M yea,return to and complete stem 9 a-d. READ BACK OF FORM BEFORE COMPLETING b SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNATURE ON FILE 11-30 -99 SIGNATURE ON FILE SIGNED .-_. DATE _ -- SIGNED 14.DATE OF CURRENT. ILLNESS iFi.s9 symptam)OR 15.€F PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJURY(Accident)OR GIVE FIRST DATE MM i DD YY FROM MM OD YY TO MM DD YY PREGNANCY(LMP) ' 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.LD.NUMBER OF REFERRING PHYSICIAN 1s.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY FROM TO 19.RESERVED FOR LOCAL USE 20,OUTSIDE LAB? $CHARGES 11 YES []NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,23 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID AID RESUBMISSION ORIGINAL REF.NO. t. 1729. 5 PAIN IN LIMB 3. #r - . 23.PRIOR AUTHORIZATION NUMBER 2. LF-Al.13 ON 411 - - '- 24. A B C 1 D € F G H I J K Z FroDATE(S)OF SERVICE Place Type PROCEDURES,SERVICES,OR SUPPLIES DIAGNOSIS OR Famll DAYS EPSOTRESERVED FOR CS of of (Explain Unusual Circumstances) CODE $CHARGES UNITS Piany EMG COB LOCAL USE VY MM DD YY rvi CPTIHCPC MODIFIER t ! O Y, PHY CHARGE # W M i i i I 4 6 if s � � I . A 25.FEDERAL TAX I.D.NUMBER SSN EIN 26,PATIENTS ACCOUNT NO. 27.00CEPT ASSIGNMENT? 28.TOTAL CHARGE 29,AMOUNT PAID 30,BALANCE DUE or govt.claims,sea back) _ r YE5ER NO $ ln5ti S $ il-Arl 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,SUPPLIER'S BILLING Nom} S Z C INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office} i PHONE a ``�` � (I certify that the statements on the reverse ICEP * DMC P I HOLE CAMPUS CA EMER PHYS#DMC P I NOLE C AMP U ,this blif re m de a art there f.} l IIkku-s-T M. b. (2019) 557-1264 16031 CUMMINS DR. , STE. D-43 A24751 1 P INOL.E CA 94564 MODE'STO CA 95358-6402 SIGNEDPIN# GRP1t (APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 5168) PLEASE PRINT OR TYPE FORM WCP-150 (12-90) O A `iE@�-"jWB -0-D�- - --0 00 00?--00 000-0 00}1 FORM wcP.lscta FORM RR8.1soo 70 65 ER Doctors icaiCenter�ncy Sttt� TEi��A �e 000080,442 07/27/87. PHYSICAL EXAMINATION PE.limited b acid L7 SeeSID course for further PE d7 Y'• M 7* CCINST: cels n,see HR: RR: lT: / , .. 'a a Q WD,WN O no distress 6 6CS 15 0 non-toxic 0 age-appropriate behavior V, A N K I N S RD •�. AbnVOther: _; �,. 11 /02/99 8 1 Z T F ,r, EYES: Q lids,conjunctiva nl Q PERRL.,irises nl Q discs&fundi nl ,• :; AbnVOther: - . --. ENMT: .Q ext.ears.nose nl .O TM's canals nl Chearin ossl intact Cj nasal exam nl 0 lips,teeth,pms,palate nl Q propharynx nl AbnVOther. NECK Q neck-su le,- etric,no masses Cl thyroid nl ffno JVD Ci neck nontender J full ROM w/o pain AbnVOther:. ... - -. RESP: Q res iratoa effort ni ©clear to au`setiitatitiii' `ussion nI Q palpation of chest nl Q chestsymmeuy&ex ansion nl AbnVOther; "` •~ Cv: Q RRR;no murmur,gallop,nib ;Pulses: Q carotid n1 Q abd.aorta n1 0 femoral nl Q pedal nl Q no edema AbnVOther; GI: Q no tenderness•or mass Q liver&spleen nl Q no hernia nl Q rectal:no mass,HENS: Ci.+BS's 0 nondistended 0 no rebound/ ardin AbnVOther. GU: (male): Q scrotal contents nl Q p5nos nl 0 prostate ni 0 no CVA tenderness female: Q ekt. enitalia&vaginal n1 Cl urethra til 0 bladder nl Q cervix n1 Q uterus nl Q adnexa nl 0 no CVA tenderness AbnVOther: r.. MUSC: Norm a tiesk_-<)"jqRjM 2,L C3gLF0 L ba ni Q leis&hi s nl 0 ait&station nl Q di 'ts&nails nl AbnVOther: } SKIN: Q ins tion n1 Q palpation.rIl C']well hydrated Q Wound recheck:heating without infection AbnVOther: NEURO: Q CN it-XJI intact Q DTR's s mmetric Osensoryintact Ornotorstrengftril 0 strai t ks raises ne . AbnVOther: LYMPH: Normal modes: Q cervical Q other: AbnVOther: PSYCH: Q°ud entrinsi ht nl CI oriented x 3 Q memo nl Q mood nl U no delusions O.no hallucinations .0 no suicidal/homicidal ideations AbnVOther: t ". MEDICAL DECISION MAKING 12 lead EKG/3 lead EKG: C3 Review only O E.D.M.D.Interpretation: Rate: R hm: Cl ST Abnormal 0 No Chane 3 Chan Pulse Ox.: %on 0 Normal O Low ABG: pH p02 pCO2 HCO3 X-Ray: Q Review only O E.D.M.D.Inter: X-Ra : O Review on O E.D.M.D.Inter: . _ CBC: C]WNL .QAbnormal CHEM: UWNL NA _ _. ALB _. LDH PT ...INR _PTT +` WBC Cl Abnormalities: K SGOT _ CK DIG HGB %Segs GLU CL SGPT. MS TOX --- HCT %Band BUN 002 ALK PH. MS% BLOOD ETCH PLT %Lymphs CR CA _ Sillnibin Amyt OTHER: �. UA Stool guaiac: PoeltivelNegative Cl Control Pregnancy: . �.PosithreJNegative., : . -. = r UNSTABLE Critical care time: minutes TIME Time pt admitted to"Observation Status" Case discussed with: :. . Time pt.disch.from "Obs tion Status* Q Ot r du y M tV!I e t ube 4%d6 Cath f Blood Draw 1s .� o Dictation L] DlCtatinn Completer c C'Sheets; - Phystctan signaturo: Required P0.6F iii Gpmptete «T x�s Condititin,'C1 liff0roved :O Stable-. C1 Critical D Expired 'a a .Supervising Physaolan r.uaa ` D1SPtJ: ].Home 0 ADM 0 Transfer 0 AMA G LWOSS r PAINP signature- signsturat: .. t., D1S ADM SEffit RM' 7lME'~i' g ACM. ,D7' ,. ..CtACCEP7 NG MD S�,8TBYsO BLSALS ED/OC TIME 0 Dr. -ls the Supirvisfng lisp LD.PHYSIOAN 01 .WWW n De artrnent Record {)C#dt"S mo C lc8l enter 1j r4 r .Y 3 Pt.Name: 000084114?. Sex: M A e: D06: Priority: I II ffi N `f Mode: Ambu ated 0 EMS D WIC Ci Other PMD: A" #Ilia" 1f r) Triage 'me: Exam Rm.Time: LMP P AB - { !toil CC: t, . u Subj! I � _, i�.i= P -, o— . , w,. _. _. .. _. WT HTW7 VA CSD 08 PMH: serious illness ❑HTN ❑DM (VII)0 Choi 0 Anginar%II O CHF 0 CABG 171 PTCA❑A-fib/Arrythmia©CVAfM13'Seizures 0 Asthma/COPD LZO Appy.CJ Cholecyst.0 Ectopic 0 Abd.surg, Immunization:0 UTD 0 Not UTD 0 Immuni Info Given Tetanus: yrs. DV Screen d Yes o Police Notified? ❑Yes Social Services ❑Yes Allergies: A MEDS: one Language: Interpreter: SOC: Smoking,alcohol,drugs - Lives at:0 Home 0 Aione/Farn Signature: Ri+l FH: -0 CAD Eg DM CJ Asthma ED Seizures ®Nursing Home 0 CH ___... Neg. SeeFfl'I ,REVIEW OP.SY EMS, ieAbiusmals) �, Neg. S&HPI, 7-REVIEW OF;SYSTEMS_=,:(CitclaAbsigrria1s) CONST: fever-chills-wt.loss-weakness MUSC: new bone or joint pain-back problems ' EYES: acuity change INTEL: skin lesions-rash t1 ENMT: hearing loss-earache-nasal drainage-sore throatNEURO: syncope-focal weakness-HA-seizure-dizziness J RESP. SOB-cough-sputum-wheezing PSYCH: prior psych hx'-depression-anxiety CV: chest pain-palpitations-PND-orthopnea [HALLERGIC/IMMUNO.- ENDO: 1 ria- of dt sia. j Po Y P y .p GI: nausea'-vomiting-diarrhea-pain-melena-hematocheziaHEMEILYMPH: bruising-adenopathy GU: dysuria urgency-frequency-nocturia urticaria.hayfever,. ~ _. 0 All other Systems Negative 0 Complete History Unobtainable Due to: - Tme seen by Ar.: HPt:Elements-location,quality,severity,duration,timin 60B xt,mod` in factors assoc.sigixs&sytri toms.3 PFSH revtd#ed4,agree f r'yt �h d { PHYSI IAN ORDERS Time LAB i X-RAY 1 EKG Entry bme initial - T11me -'MEDS'tTREATMENTS'"` Time . -initial Ordered _ . Ordered Completed U CBC Q Met.Panel:(Basic/comp.) _,_... __.... 0 IV: _.._..__0 Saline Lock._ U Oardiac Enzymes U Blood Culture x _._ 0 Cardiac Monitor Q Pulse Oximetry PPT .U PTT ®Di oxin levet U 02 - -`"O Stool Guaiac O UA (dip/lab) .0 Urine C/S O dt::5cc11M :...... __ 0 PREGNANCY{serum 1 urine} ❑HHN 5rri AibuteralJ.i�:u Atrovent 0 Bki©d`Alcohol ®Urine Tox. 0 ASA!Tylenol s 0 Acctactteok :-`' 3 CXR Port 12V} D C-Spine Ll EKG ®OId Recocl.".- ,. .. X 4 � .. d 7a15s03A(4M) 5102661678 to?LLRRIJ B. SN't TH 80d P03 FEB 22 100 15:16 f I T E M I Z E D S T A T E M E N T CLAIM NO: ADJUSTER EMPLOYER: PiHENT: BIRTHDAY: INSURED TENIKA SMITH 509 BUS AC 07-27-87 1206 XARIPOSA STREET SBX:F I.D.# RODEO CA 94572 RELATIONSHIP: GROUP., OiTHBR INS1.1wCE: WORK INJURY*. NO INSUREDS ADDRESS: AUTO ACCIDENT: NO RELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE ZLLNESS/ACC DATE t 11-02-99 FIRST TREATMENT:11-15-99 DIAGNOSIS: 847.2 LUMBAR STRAIN TRAUMA TO (R) ARM TRAUMA TO (L) KNEE AND LEG PATIENT STATES THAT SHE WAS A PASSENGER. ON A BUS THAT WAS MAKING A (L) TURN AND HIT A CAR. HATE DESCRIPTION PROC CODE AMOUNT 02-09-00 EP COMP-DISCHARGE EXAM 99215 115.00 TO'T'AL 1370.00 r DALE:02-X22-00 Employer ID No Willard B. Smith, D.C. **N,/A'** 1103 12th Street Social Soc Xo Oakland, CA 94607 433-30-0#40 (415)836 -3836 Willard H. Smith, A.C. i ; 51026816?8 W?LLARD 3. SN.TH 8B4 P62 FEB 22 'Eo 15:16 I T E M I Z E D S T A T E M E K T CLAIM NO: ADJUSTER: EMPLOYER: PATIENT: BIRTHDAY: INSURED: TENIKA SMITH. 509 BUS AC 07-27-'87 1206 MARIPOSA STREET" SEX.F I.D•� ROMEO CA 94572 RELATIONSHIP: GROUP: OfiHER INSURANCE: WORK IN,7URY: NO INSUREDS ADDRESS: AUTO ACCIDENT: NO r RELEASE OF INFORMATIONtON FILE ASSIGNMENT OF BENEFITS: ON FILE ILLNESS/ACC DATE:11-02-99 FIRST TREATXENT:11-15-99 1 GNOSIS 847.2 LUMBAR STRAIN TRAUMAS TO (R) ARM TRAUMA TO (L) KNEE AND LEG PATIENT STATES THAT SHE WAS A PASSENGER ON A BUS THAT WAS MAKING A (L) TURN AND HIT A CAR. DATE DESCRIPTION PROC CODE AMOUNT 12-15-99 EP LIMITED 992.13 45.00 12-13-199 interseg. traction 97012 25.00 142-15-99 massage 97124 25.00 01-05-00 EP LIMITED 99212 45.00 01-05-00 interseg. traction 97012 25.00 01-05-00 massage 97124 25.00 PI-12-00 EP LIMITED 99212 45.00 01-12-00 into-sag. traction 97012 25.00 61-1.2-00 massage 97124 25.00 01-X19-00 EP LIMITED 99212 45.00 61-i9-00 interseg. traction 97012 25.00 01.-19-00 massage 97124 25.00 01-26-00 EP LIMITED 99212 45.00 01-26-00 interseg. traction 97012 73.00 01-26-00 massage 97124 25.00 02-02--°00 $P LIMITED 99212 45.00 .02-02-00 interseg. traction 97012 25.00 02-02-00 massage 97124 23.00 Continued. . . Willard B. Smith, D.C. 02-22-00 •1103 12th Street Oakland, CA 94607 Acct No 509 (415)836-3836 t 10 816'8 W i WD a. 5N I TH 804 K". PE3 22 '00 iSr v r ITEMI ZED STATEMENT CLAIM NO: ADJUSTER EMPLOYER: PATIENT: BIRTHDAY: INSURED; jTENTKA SMITH 509 BOTS AC 07-27-87 11206 MARIPOSA STREET SEX:F D.# RODEO CA 94572 RELATIONSHIP: GROUP: OTHER INSURANCE: WORK INJL"RY: NO INSUREDS ADDRESS: AUTO ACCIDENT: NO RELEASE OF INFORMATION.ON FILE ASSIGNMENT OF BENEFITS: ON FILE DESS/ACC DATE:11-02-99 FIRST TREATMENT:11-1559 .DIAGNOSIS: 847.2 LUMBAR STRAIN TRAUMA TO (R) ARM TRAUMA TO (L) KNBE AND LEG PATIENT STATES THAT SHE WAS A PASSENGER ON A BUS THAT WAS MAKING A (L) TURN AND HIT A CAR. DATE DESCRIPTION PROC CODE AMOUNT 11-15-99 NP CQMP.EXAM 99204 150.00 11-17-99 EP LIMITED 99212 45.00 11.-X17-99 hot or cold packs 97010 25.00 11-17-99 massage 97124 25.00 11-19-99 EP LIMITED 9921.2 45.00 11x19-99 interssgt. traction 97012 25.00 11-19-99 massage 97124 25.00 11;22-99 EP LIMITED 99212 45.00 11 22-99 hot or cold packs 97010 25.00 11. 22-99 massage 97124 25.C4 11!-2999 chiro.mani.tai(1-2 regions) 98940 35.00 11�;-f2�9}-99 �t�yyi�{s7s,age �(� 971}+24 25.00 12-03-99 EP LIMITED 99212 45.00 12x03-99 hot or cold pa aXs 97010 25.00 12703-99 massage 97124 25.00 12-08-99 EP LIMITED 99212 45.00 12?-08-99 interseg. traction 97412 25.04 12 08-99 massage 97124 25.00 Continued. . . Willard B. Snaith$ D.C. 62-22--00 11.03 12th Streat Oakland, CA 94607 Acct No 509 (415)936-3836 10)Log � ,�� 11}lisadaolios ght AC L—ft a Both 7lAM ac your paint war"? O Morning 9 Aitt. t 13 Evening What sadvid"of daily tiviag are fou sttl) having trouble beeattse of your / 7' 'pain? ))Dvlalkins S}DLit'dng 9)Cl Pushing/YuLtlag . `` 2)0 Sitting 6)aDtivtas 10)0 Wertz 3)gStaadine 7)DAdathing above your s.'to;tldars 4)G9rnding ;)QUsing Stairs ��� '} °�/ oodsy's Dow, patient Progress Report ?Went Nisi te, j Flow and yrnt fWatng today?12-latter D Worse e,7 The Sarre Dat;: Where Is your pain today? t 1):Nook D Right e,2 Left O Bath ITf>rC►IOaTalcetl ------ 2)Shoulders a light 13 Left fl Both r 3)Mid back f3 Right D Left Cl Both PAJN <)Low bark 13Right D Left D Both i)Cheat f3 Right D Left 13 Both IOG d)HIP 17 Right Cl Left D Both ') Thigh 13 Right Cl Left 0 Both $) Knee O Right Loft 0 Both 0 [3 9) Arm Q Right D Left Both t.0'II7II3Cf3t5: v l0) Log 13 Right a Left D Both 13 Right 0 Left Q Both 11), Fteadeches 13 Wsht G Left O Both Wbon is your pem worse? CS Moming Cl Aftmoon 0 Evessiog What sctivid:s of daily living an you still haviag trouble become of your Pain? 1)O Walking 5=iftias 9)e,3 peshing,Pi:lling 2)tl Sittins 013 Dzivins 10)Q Wok 3)DS=dfnt 7)0It arching above,you shoulders 4)C1Bettdfng S)OUsing Stairs Today's Datta � � Patient Progress Report ntittltName° , How ere you Haling y? Jde tar Cl Wo se Cl The"me Date. %%ere is your pain mday? l)Neck O Right C3 Left 13 Both CK98lCBZ1�y 2)mmulders O Right 0 Left D Both � 3)Mid bask O bight 13 Left t'] Both FWN 4)Lout beck C3 Right OLeft O Both TIt:n=t ))Cbcat O Right 12 Left D Both LOGti}Hip Cl Might 13 Left O Both 7)'thigh Q Right a Left O Both 9)Knee D Right D Left n Both �} a Right DLeft D Both Commas: 10)Les Arm a Right C3 Left D Both 11)Hedddohaa a Right t3 Left U Both D Right D Left 0 Both thI=is your pain worse? 13 Morning M Attaeaoon Q Evening Want eadvit at of daily living are you still having trouble because of your pi�thtfi ,.es,,,'tt.:_. �$U 41� ;EJ PvshintTulling 1)m Walking 10)O Work 6)a Driving 3)t3S3wuilteg 7)C1 Reading above your shoulders 4)Mantling S)Q Using Saha want aelivstise of daffy}hitt;ala you stili haviszg trouble beoamsc 5f�your (pain? 1)a%Wkiag S)GLiitict 9)Cf>2mh4wpuliins 2)D Si" d)t3 10)0 Wa t )MIStaudiag 7)ORtuieling above your shoulders 4)D3anding I)IOUTing States Todrry'a DW..e: S Patient Progress Report p' Pettiaztt Nartte '� ai�G' 0 Flow in you feeling toAll © better f3 Watse d The Same Date: Where is your pain today. f)flock 0 Right Q Left f3 Both B*rmadon TakAm By 2)shoulders e,3 Right 13 t,.eft a Both • • 3)Mid back Ci Right G Left a Both nMN i)Levu back D Right D Left D Both ` Chart O Might u Left Ce, troth 3) LOG d)Circ O Risht ❑Left 0 Both —,-4060 usl Ci,.... Ali;i� QED.{L Voll a VS-1 q 41H $1011 C3 uo'IC3 >tig l LT ;"a,.)4 1114$ ] rds'I CS tRgT3l Gi Xos4 N,I{ir R,r,fi.;N Today's Do :ghllf Patient Progress Report Ori 8atient Niers 14*w are you ftsslsag ay7 ettas a Wow C The Suns Dow: where is Your pain today? 1}Neck C1 r C7 Left 0 Both bforltsa�t�, y; 2)Shoitidem owl 0 Loft C3 130th r 3)NLG!sack a Right a Lei. C1 B�th p�,i�d 4)Law befit Ct Eight U Lef: ,Moth T>�nG #) t OW Ci Right d Loft Cl Both LOG 6} sip v Right Q Lett G Both Thigh 0 Right C Left a Both 7) S)Thigh 13 Right C2 Left a Both CY ight 0 Left is Both Conun : 0) Ate' , tight ❑Lett C1 Both 10)Lag p Right Q Left C Both i 1)Ncatiacttea Z3 fight Gt Left 0th • W Sea is your pain worse? iornittt C A£Iara000 vanirtg Wast•etiviiin of daily lives are ytsu still bavi:s iroobla;because of your pain! i)C'S iking S)C2Lif'dng 9Jss rv#ffiitt�r'Puliiag „ ��� ��I��j�" 21=i log 6)CllZriv:eg 10)0 work ` 'Y DStaodint 7,O1Cl'aching ateve your ahoaldtra Of 4;badiat B)Clttitrt Stairt Today's 13aw patient Progress Report Patient Name: How aro you iboliag t y? Bgttar C2 '+,txsc G"7th Same Date: Whore is yoar pain today? 1)Neck a t 0 L*ft (7 Both Infc�imati�m t Ukc .:Y: 2)Shftwere Sht 0Left D Both 3)Mid back 0 Right 0 Left 17 Bo KN 4)low back C]ftigEt C7 Loft tb 1t"dlTi1C11t: &Z.14 ASS d)Chen D Right 0Left 0 Sods a}ship 11 Right a Left Ci Both LOG ;)qipThi13�1 0 Leri 13 Both 8) Thigh 13 Right G Le!t ti Both ) 13 Right fl Left Q Both �l lts: 4Arta La fight 0 Lett R Both g a R.i 1 0 Loft Q Both 11)Audubta 0 R,ij;bt 0 Left 0 Both Wise;,is yo=*11 wom? Morn4 Cl Afternoon Atolllvcniag R'hat activido:of daily lt'GlttS aro you still bxvirq trcuble becatas of year PAW? :) Walkiaj :}C2Liitittt %4ru awPttui S Sitting 6)Ct Driving 10)Cl Work IM !ng hang above your sbouide» g )�tr8 Stairs Today's Date:*touyl Patient Progress Report Patient Name: Kow are you fa � enar Cl Worsts 13 Tlse Sema r Datc- whero is your pais today? 1)Neck Ci Rljbt a Lett a Both Info2'mdonTakpBy: 2)%widers 0 Right G Loft a Both 3)Mita back 0 Right D Left Q Both WN 4)Low back 8 Right 0 Left bth Trewmwt li)Chest Cl Right O Left Cl Both LOG d)Hip d Right 0 Ltft a Both 7)Thigh 0 Right to Left Ci both B)Lnot 0 Right 9 Left 13 both 4)Arm hl 0 Left 0 Bath �t]YTITriCt32S: , 10) L + d R& ❑ eft 0 Both air Right Omaft a Both 11)Headaches M!tight lettP',Both ` What;is your pain wem? PIA"At Attra�oa vaain$ Wbat activibts of daily liviz#ars you stili having trouble beuuw of your pant? a1k101 5)©Lwurrg Pri ing/Ptdlinq Sim" b)CD?ivipg 10)13 wank 3)Usem ding ?)a reaching above your shoulders dl,rVA"A;w& R)Mkinn Stam T 03, ZZ $3d zod T0t3 H3 x� 'z tI'M�!`l•1?f i SL9T89UT9 �'l k�extti 1b''t! W.,LL Httw J, 11 I ti 90; PU I FEB 22 `00 Today's t?a : �'� �•� '� Patient Progress Report Pti0ttt�lattlE: Haw ars you fkoling today? 0 B"r Cl %mc a The same Da w; Whore is your pain toJWa 1)Neck a Right 0 Lott Cl Both Il onrAtion AGA.VAI 2)Shoulders ,A°Mght t3 Left 0 Both 3)Mld heal, C Right 0 Loft 0 Barb. PAWN 4)Lour tock a Right O Lett nth TX 1C S) �bnat a Right a Left a Both LAG I) M!tight 12 Left 0 Both 7` Thigh a Right d Left 0 Both I a Right O Left 0 Both 1)�� 13 Right 0 Left a Both Ct�iTfiZlf IS: 'la} ght ..dant 0 Both t.t..,�.. ,.. 11)Meadacbes a Right 0 Lott 0 Bath when.is your pole worse? Cl Morning 0 AftMoon O Everting ;+ bat astivitisc of daily living at you,0 havial trouble because of gout pain? I)C1 Watkins I)OLiftial 9)Cl puawnippullins j 2)OSittisl 6)ODsivinl 1a)c 'Work 3}OSraading 7)011tow ting above your should= j)a8etdi�t; I)OU'ling Stain Todlv's Dow � � BOW PCQgre$$Report Where is your polo today? f) heck 0 Flight 13 Left 13 Seth TnfomAta0n Taken By: 2)shoulders .4MZht 13 left a 'Both Mid U4 C Right 0 Leh 0 Be h X (kN 4)Low book 0 Right a Left nth 7�E:.l$!1C'lll± C7 3ty�c�.;1ctest r't v.tgt,t rt 1 06 rt ruts C7 algal Ci Leri d xoom t;,,c,rual=tl5. 0)Asp -41-Mt a Left B Bath In)Leg a Right ..-Wtvft 13 both 11}lisadaches 13gi=ht 13 Left a Bath `A bw is your pain worso?Ar Morning W �jtw�b=&Uso , Evening ' at acttvitiet of daily living are you Stinheof your ;pad?„I�tfalkitsg 5)aLltting �i"'o Isuahitatrptttllol 2}aSittirg 6)a Driving la)a work JfC113tanditg 24a4eachiug above your%Moulders i9�diat S)Oulins Stairs Todd `s Dste: ills �� Patient Progross Report ratie�z Now are you isalias today? 13 Setter q Worse The Sante Date: �� } t Whose is your pain today's 1):week a Riot Q Left a Bata InformatiotlTaken Sy. J�`�.•�'t?�r'� .> 2} +s nldres «01Rt�ghi CI Lott a Both i j}Mid bank a Right 0 Loft 0 Bath PAN 4)Low back a Right 13 Left �,0 Both TTL`�21�1t 3}t3Xct G Right a Leh L7 Matic �. 5)ChHip 13 Right 13 Left 0 Both Thigh 0 Right M Left 0 Both i) ti)Thigh Knev C Right 13 Left 0 Both �•,,,�, 0Right a Left a ,Both t.zrrs11Cr115: i 9)Am ,J24ight a Le a Both la)Leg a Righta Both O Le 11)Headaches a night ft O both When is your pair+worse? _;L14ertYitg AlKl"te�tart JkSoociag VVbst acdvides of daty 11ving aro you still havins wmbte beaus of your Pilo? I • t 5)0 Lifting 9}.^sb1n;MWl1ag 2)a Sl as 03lhiving ID)0 Work I ftt �7481tkschlu above your shouldws I #Suirs now are you felling today? O Batter C3 Wom/A'Me SAWt Where it your,lain today! ✓ � t)Neck ®ILSht o Let. O 30th InforazdonTaken By,r -'�' - •' i •g)g --moi=ht O Left O Both 3)Mid Wit O RiYht O Left O BU b Low _ O let=ht O Left r,i?i' ih Treatment+ r� 3)Chest � 13 Cght G Left G Both LOG 6)mip 0 Right fl Left O Both T) Thigh 13 night D Lcft 17 Both ti} Knee O Right 13 Lett 13 Both )AAIMC Right 0 Left 0 1m+Both Conm: 9 L" .40,.t�ht C Left 13 Both 10)11)Htadechos O Right "49'rett C Both C3 a Lett 12 both Whet it your pain vmrse?y Mataittg Attcrnoon Evetat%g fWhat setivitiis of daily Living ane you VIA having troubio be"We of your pain? ;3' ikiag S)OLti'ting thr►o PttshingrPutiiag 2)0sittin$ 6)CDfiving 10)13 work .3}mitandlag 3>QAvmehiag sbeve yaws thouldert ding $)posit'Stain T t , n i .��(�� • t' P�f�PfltPrn r -- - _ 53ilIw3blX,3 b3m01 doba 011 as NO1SN31X3b3dAH '1',1►N'0105 US31 Molt WVX3 yova " t1 1F., t mol"aud"0.O NC3,lYi4#! V VWWWVbd MOIXg a -IVVIIlY"1 NOI A Nolswalxil XD3H 9 t1YIH WHX3 � DJ i X31:1j Sd30I9 —77X3'u3b Sd33A.L 1bb Iv -lu S3Il14W3 H3ddfl 53A3 w0aed } 'S$1 Inn 'S91 �_._._ 1H9Ib 1531 b313WOWwN,td 030NVH 1.331 SI IN3I1'dd ,{INtlN 1N9Ib SI 1Pl3; !b"d ',� - 1nJN Idd 11n0Idj I0 1d144ON 03b Ibdw I -NOI17724 031V1I 1830 HOOd VIYd 0009 L5t1 U 3HSIKON 113M :30WV3ded Hind -� 32f SSNd 00019 38n.Ldb38w31 NOUVN IWVX3 1'dOI SANd e fin j 's Fite: Patient Progress Report Patux+t Name i ZL How we you feeling today? © Behar C7 Worse 11 The Some Diac where is your pairs today? 1)Neck :EA�fht 13 Left 0 Both Infouria&n7alatn13YJ 2)�)� . '[titht 0 Left 0 Bath 3)Mid batik C2 Right 0 Left G th (� 4)Low balk 0 Right M Left .5-B th "jet O)tight Q Left 0 Both 'A, Lo(3 5)Cbest a Right O Left a Both flip a Right 0 Left a Both " 8)Thigh a Right 0 Loft a Both 9)Arm C night 0 Left q sorb .Gftht 0 Left 0 Both ti)Log edselnos 0 Right ..W.Uft O Both +►�'' a Right II Left O Both *boa It your pstn waren" 0 Morning 0 Aftcrnoon 0 Evening *hit eativities of dally living srs you atilt having trouble bmuto of your i)O WeGcing i)V LiBfttg 9)0 Pushtt gftifinr 2)0 Sitting Q O Driving lop worse 3)[]Sursditng 7)C Reaching above your simulders 4)ODending g)OUsibg Stairs jl Patient Progress Report Today'a Date: '�':' LEFT RIGH Illfff '.. .1•. i I t /{JI i 2i' • , • 4. �.. - �Y,I�YY.�pIiY '�YYYIr+iilfWqYl1• •liy •fes ..1 ''!.. i.A i� .,x .,+. DATh I I MOM 01*N ni3u 01 31$V 3ibG i 01 Wou3 r AltII8VSIG bili Vd 01 W06i !Alil I8ySI0 'Tdibl I: �SIS0�9Qud • N3HiObi 0333w OOR d :NOIS53udWI1S0 iW I x� 41ITP..'1Y X3?tau u'�"! X31"c ♦liVaVVhN y� Wi61mP9('CJ.1 fJt ml lk ill ... j .a WILLARD S. SMITH, D.C. llf,3-12th Street Oakland, California 836-3836 NAME DATE l^� ' ADDRESS C� r0 -- RES. PHO BUT. PHONE__ BIRTHDATE GE REFERRED SY _ SOCIAL SECURITY NO—4'�l 0 09 OCCUPATION EMPLOYED BY EMPLOYER'S ADDRESS LAST PHYSICIAN ADDRESS I�SURANLE CDMPANY POL CY NO. CH Er COMPLAINTS ' ti i f CCIOENT ON THE JOB OTHER i DATE OF INJURY�� '� RECURRENCE DRIVER _- - --___- PASSENG=R -.� GTNER REAR ENDED RIGHT SIDE LEFT SIDE FRONT OTHER i WHER Dig 1N RY OCCUR' HISTORY SOF INVURY HOW WERE YOU HAT? LG WER YOU CONS CIO ?� ,r WHERE WERE YOU TAKEN 4FTER INj1JRY OCCURREC? it �-- HAT WAS DONE FOR YOU THERE? A i PAT HISTORY: HAVE YOU HAD SIMILAR ACCIDENTS OR I 1ES BEFO E? WHAT WAS YOUR HEALTH STATUS PRIOR TO THIS INJURY? WERE YOU ABLE TO WORK PRIOR TO THIS INJURY?/ F NOT, EXPLAIN A YOU OFF FROM ! ", AS A RESULT OF THIS INJURY? IF YES, HOW LONG. ARE YOU TAKING ANY MEDICATION? IF YES, *AT KIND? i i OPERATION.,? BROKEN BONES? OTHER HEALTH PROBLEMS? HAVE YOU HAD X-RAYS TAKEN RECENTLY? IF YES, WHEN WHAT AREAS?496,� ARE YOU NOW PREGri(ANT?� 2F Y S, HOW MANY MONTHS? PATIENT'S SIGNATURE i at"41 .t _ `.. 2) �i C3 ititht Cl Let_ C3 Roth... Q) Arm a high, D Le 0 Both �=r/I ]tl)Leg Q'Right C3 Le. CI Both l� 11)Haadacltoa Right C3 Lett 0 Math C2 Hiiltt D Left C7 Both �' # � Wbem is Yew Pain wotxa? D Mattltnj C1 ltt9amooe D Evening j t• What setivitiet of daily living are you still having rrottble because of your Pain? 1)aW&Wns 1)C'3Lifting 9)0 PtubiaaPullatg 2)0 Si ti $ b)C l Driv q 10)0 Work 9)CIStandiag 7)QRaschiag about your sbould.•rs 4)ClBarcdirg !)CSL"Rirsg Stain +���+�' Today's Date: Patient Progress Report Patient Name. HDD aft you fccling today, 0 Be tar C3 Wom D no Scrag C• where is four?mitt Way! `t l+iynh s sw�w. _.ra r9 .t..aw T47�lsY'Rn.tlieat,'T1,lt:-.et fly J)laid".k 4M. Qum t'J llYVttttth t3A W Mirk C!EL,yht M Ltfr 1n l�C7Us �':•« Thfith $)lett �t1i�151 Q L.fi D tlr+lt of ,� 0 stia}tt 13 L+ft Q Anrh {a'A-)n2FC'l ts: Los t1E�La ..t.•,em MI.ter M %—I, 1 t)Lo C+citrs C It V-, a L, fl 13 DOSb O xi ht Q Loft 0 both When is ywr pain wo:sss". C3 Morning 0 Afternoon 13 Evealt<,g Whu scdtides of daily living,arc you stili havi»g itcubla boauusa of your Pain! t t D walking n CI r..ii;n,. 9)0 Pwh**,Pnilicg ON as CS.A.. �}to n..a.as:..,, +t}S.t t$y'{3{iltt� aj C}sr`.L,.a t7yua� ,� - .a.}tywiuMiuVi 1,•ii-{..k V ..W... .� .w W...... . x a2ir .{Q "A.t loam c) 41� 1 tape l) 10113 turd a tseq Today's;Dater Alt Patient Progress Report o Patient Nara �-----�— How We you feeiirg ay7,�.l f�ettar f3 Worsc 0 The Sine Date; Where is your jrie today? 1)Necx 0 Left v Both o h IrtformaticmTfticcn$y: a) C3 RlSbowdM jht a Loft � B th PAIN t1 Low beoic C ;hs cl€.eP: nth TMWWM )Chest Right C)Left 13 Both s LOG 5)kip 0 Right CLeft C7 Both 7}HipThia Right C3 Left d Bath )Knee C3 Right C3 Left C Both 8 8 n i;ht C3 Left a Both mss: 9)Arta tl)Log .ght 0Left C3 Both C Right (3 Left 13 Both ! 11)Headaches C3 i;ht f3 Lsft Q at't When is your pain worst'? stall; C3 AAa mmo vnair,; • � What activities of tinily tivitt art}tau still§suing aoubit because of your ` 1)C`I', king 3)C3Lifting 9} l' 4shltpaPuiliu; �� ttirig 6)DEhivins tO}tai Work � t75t+sndizt; TA44,achin;above yeas ahotstden tn3in; 8}tltJsiztg Stain t Today's Bate. '` Patient Progress Report Patient Name: Haw ett yon ilm:in8 t yt9ettei Cy Worse C!the Same D1lt0; Wheys is your pain today? ` 1)Nook 0 Right CLeft f3 Bath IIIfi7tx=tionT&enBy-.lj � 2)Shoulders ght 0 Left iC Bath 3)Mid back 12 Riot 0 Left C Ba PA JN d}Low hack C Right Cy Left Tlutment: 3}Chest ❑Right 0 Leat C3 grout LOG 8)Hip a Right 0 Ltft Ct Bat# 7)Thigh M Right 0 Left ❑ Both 8) Keret Cl Right 13 Leh 0 Bath F) Ates a&Sht C Left 13 Beth cd12T1Ynents: 0 Left 0 Bath 10)Leg Cl aiw 0 Left D Bath 11)Headachts 0 Right C3 Last 0 Bath When is your»worseIIMorning 0 Alteetoatt vetting Whet activities of daily 13'Gj am you atilt having turnable bookuse of yanr pain? 1)OWAndat S)QLifting hitt; ''ej'nittiuq 6)Cl Driving 10)13'Want 3}13 4tng 7p&' scbing shove your shoulders )r%Uslns Stairs Toaay's Bate; Patient Progress Report Pnti+sxtt!Vszrr+t: Haw am you feel's$wday? etstr 0 wane C The Sumo Dek- What is your pais today? 1)Weak C Ri;bt 1C Left t] Both Info3'IkL donTSlICtn,By: 1)Shoulders n Right 0 Left a Both 3`Mid}sack 0 Right C Left C3 oris PAINI)Law trick C3 R101 Cl Lett d oth Tragmmt $)Chest C2 Right Cl Lift C3 both LOG d)Hip 13 ttigat C Ler. a Both 7)Thigh C Right 13 Loft C Both 6)Knee Right C'3 Left C3 Bath 8))Ares 0 t C Left C3 Hath Corm tem: Leg .r�light I3 ett C3 Both 0 Right eft C3 Bat's 11}Headathesa Right Left Both t " When is your Pakworst? aznin; A eon tsning t� What aadr.ots;of daily living ars you still having trouble beaxuse of your Olin? alking 5)f3Lifting ushi-oullins D Sitting b)C t?riviog 10)Ca Worts 3)osubdittg 7)0Rcukiug4ove your shoulders l.�rlt3.wAi«o A)MIlaina Sts:ta z tr x i s C? e3j Zed To's Hl S tS 'S Q.Z iId n i m 8�.9I139c i3 CS IU)1.0s a Rightft C Both �40 11)Headaches a lxight 11153At Lef 0 Both +�J�Gr .:Wbm is your Dain worse? D Morning ❑Aftoromr 0 Evening Nb*-swivitlea of tally living ars dot:sill having troublt bo^mse of yw f sin? 1)O Wank,ng $)(3 i ifs s 4)C7�ucltasip+Pultttsg 3 3)0 519*0g 6,110 Driving 10)c V'AW c 3)r3stald"s 7)t3 Reaching above yotc shou;dsts 4)133ading 9)cueing$fairs f Today's Dttc Patient Progress Report Patient Name; How are you recitals today?r JI Darter 0 Worse C The Same Date. Wheoe is your pair today? 1)Nook D Right 0 Lett C Bo:ft Ido1'L1 4on.Taken .r,..� 7)9hoWders 0 Right C Left a Bo-,h 3)Mico hack a R.lght 0 Left c) 130th �}N A)Low back A ght C3 Lcf1 CI Both �I AttY1iW'Tlt ! 5)chest 0 Right 'C1 Loft C Both .(,,t 6)Hip O Right 0 Left 13 Both 7) Thigh a Right 0 Leh C1 Both $) ICree M R1yht a Loh C1 'Both 9) Atm IM Right C Left D Both Comments: Q Light C Left o Both a 10) lit esdaches 0 RigCT ht 17 Lef Both p Right Lift Q Both Wh=it your pains worse? 0 Maraing 13 Aftmoon C Eveaaog What actvitics of daily living as you stilt having trouble becenaa of your Dain? 1)OWalkiag 6)Q Lihing 9)a PuehinV?c:iiiag 2)13 Sitting 6)a Oriviag 10)D Work 3)03undbig 7)D Rcsteh-4 abovo your shoulders 4)C)Bcttding a)MUSing Stairs Todav's Date. '� ; Patient Progress Report Palie�tt Name' Haw are you tUallsg t y? t? 'Wbts+t 0 The Sure y Where is your ltafn today?+� 1)Neck M Right C Left f7 Both In"o 1 2)sbouldm a Right Ci Left © Both r 3)Mid back 13 Right 17 Lift 0» Both a Right Q N 4)Law btcls L,ait ts S)Chart a Right Q Lett C Botts LOG Hip Cl Flight 0 Left t3 Both b) ?)HipThi13 Plight 13 Left a Both Right M Left O Botts 8) Knee g Right 13 Left L7 Oath 4tdtnlz�ents. 10)Leg a Right 't7 Loft 0Oath 11)Haodaches C Right>C 3 Left H Both Right Q Left O Both When is your pain worse? Q t+loming CI Aftsnoon 13 Evening What aetivitms of daily IN"rg are you still having uvuhlt because of ytYtar RsCR�I CS .B �j P Pushift&Tuliing p t)L1 Walktog WICmY 10)Ci Work 2)O Sitting 6)0 driving 3)oswding 7)a Rantllicg above ycW Shoulders ;)�8,�#1ng S}C3t3arrng Staffs What a0vatW of daily living art YOU lti11 loving trouble because of yoz `Dale? ))13Walking 5)aLifting 9)E3Pusb:ng(Puling 2)t3 sitting 6)Ct Driving 10)C Wenn 3)l3Saadas 7)0 Reach"above your attou:den 4)122asding > autim stairs Taticat Date: �=' Patient Pro�ESs Itcport Patient Ntntt.g; Kew ire you tithes t 7 C 8Cl Worse O The Saantt Da#t' -- A Whore is your pain today? • 1)Neat t7 Right Cl Litt C7 EOtit b*rmafion Taken BY 2)moulders 0 Right 17 Left a Both 3)Mid back C Right 13 Left Q Both TWN a)Low bick D Plight C Left L9 Both 5)Cheat t7 Right u Left f3 Both LOG 6)Ps(i4 �Rtgtet G Left 0 Both �� -u"'•' i 'ydat"!q'.`e}:'► °' a" ,a cu t `{ a:. .L 9 '� f £ { hl !f?(��i1�> � �� ° Kv `ii..':''�r'r'r �".72 � � �y �,r �$�,,box °�_���,�,�`�� •�r � _� �, 'r; Ln 40 .. CO N ON 00 m to LU C&U. JL g 00 t .. _.v. 4 1 d� a/� 1d - ti: H z 8 04 a x w z z o o rn E-4 LO PL 0 E-4 H IL HHum W 4 W QJ ✓+ ti z a Z Z 134E 00 Ln E.4 uav �+ a " ', x ANJ CLAIM BOARD OF SUPLI2VISM QE CONTRA COSTA COUNTY 'Ai -QR LA BQA p A0011E April 4, 2000 Claim Against the County, or District Governed by the Board of Supervisors` Routing Endorsements, 1 NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (paragraph IV below), given pursuant to Government Code Section 913 and mow. 915.4. Please note all "Warnings". AMOUNT: $40,950-00 ;b CLAIMANT: Lawrence T. Brennan Cou—,w'°;_COUNSEL MARTINEZ CALIF. ATTORNEY: c/o Lawrence e. Weiss DATE RECEIVED: March 1, 2000 Attorney at :Law ADDRESS: 701A Fourth St. , #205 BY DELIVERY TO CLERK ON: March 1, 2000 Santa Rosa OA 9`404 BY MAIL POSTMARKED: Hand-Delivered L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 1, 2000 By: Deputy II. 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 5+10.8). ( ) 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: ` '% By: { f r ��' 4 ; `a ,_,,_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: {-A 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: PHIL BATCHELOR, Clerk, By 5L - , 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 MAE ING 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:Aa�1 ` y: PHIL BATCHELOR By v�., ' Deputy Clerk 'Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COITNTY INS'I'RUCIMNS TU CLQ MIAM A Claims relating to causes of action for death or for injury to person or to personal property or growing drops and which accrue on or before fiber 31, 1987,mug be presented not later than the 100e 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 lawny 1, 1988,must be presented not later than six months after the woual of the cause ofactaion. 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 Lode 911.2.) B. Claims must be filed with the Cleric 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 ea&Public entity. E. fes. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. ass#s��sss��s+��*:+s*�s��.#:ss+tss�asas:ss�s��►sr��rs:�e***�es�:�s�+r�:�s+��s�+���+�.�:::sss:s��:ss+�:s+�* RE: Claim By Reserved for Clerk's tiling stamp Lawrence T. Brennan j R ECEIM Against the County of Contra Costs or ) MAR 0 1 2000 (Animal Services department) CLSFiKBCfARgOFSUpE��1SOIS 13istrict) CONTRA,COSTA CO. (Fill in name) } 17.he undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of S 40, 950 and in support of this claim represents as follows: I. Wh►en did the damage or injury occur?(Curve exact date and hour) See attached sheet 2_ 'Where did the damage or injury ocau?(Include city and county) See attached sheet 3. How did the damage or injury occur?(Give full details;use extra paper if required) See attached sheet I i t i 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? i See attached sheet S. What arse the names of county or district officers,servants, or employees causing,the damage or injury? { See attached sheet 4. 'What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimer!. Attach two estimates for auto damage.) See attached sheet "7. How was the srnount claimed above computed?(Include the estimated amount of any prospective injury or damage.) See attached sheet i g. Names and addresses of witnesses, doctors, and hospitals. See attached sheet !9. List the expenditures you made on acuxwt of this accident or injurer. DAM 1 � See attached sheet ****+�r�*s*****+t*+�**********s#*******+�*+�s********#****a+r**+�*********s+►s��s**�r**s.�*�**:***�s�* Gov. Code Sec, 910.2 provides"This claim trust be signed by the claimant:or by some person on his behalf` law NQ=3 TO: (AUMU Name and Address of Attorney ) Laurence B. Feiss Attorney at Lau ) (Claixnad s Signature) 1701A Fourth St . #205 ) Santa Rosa , CA 95404 Lawrence . Brennan } 2053 Brook St. , Concord, CA 94520 (Address) ) ) 'Telephone No. (7 0 7) 576-1415 J Telephone No. (Q25) 6a2-2443 **>«**sus*+e,�*******•+�r�s�*«t+�*****�e*s:s*s******«*�r***s*****rs�*sus*yrs+�+�*�*r«****t:*s****s**+�**+r N071C E 1 Seaton 72 of tbs Pmatl Code p mvidea: Eay parr m who,with tow m trot aallowartoa or rhe prim=to any Am board Or*Mm.or to any ootw y,city,or dlstia board or ager,xodxdzed to am or pry lk mean if xm mae,any bUt or ftnA masa daim,WA*=Dun#, { vouch",or wrklot Is paaniahabk Ckber by imp bam neat in the=UW jail for a period of to amore than we year:by at Am of rasa one dwa ss ad(S1,M),or by both PAth irsapa waa ani and&w,at by izapd as eawt in ft ensure pdoon,by a fhw of rent J excea bW ton dwanod dollars(S 10,000).or by both xwh hvpnmx=M eases fam I a r ATTACHMENT TO CLAIM OF LAWRENCE T. BRENNAN AGAINST COUNTY OF CONTRA COSTA 1. The claimant, Lawrence T. ("Tim.") Brennan, owned a 7 year old female Akita dog named".Latus". On Sept. 11, 1999, the Contra Costa Department of Animal Services picked up the claimant's dog because the dog had bitten a child at the claimant's home on Sept. 9. Latus was taken to the shelter in Martinez . Lotus was originally only supposed to stay at the shelter for ten days(the quarantine period)until Sept. 21. However, Lotus was kept at the shelter without charges for 38 days. Both before and after the ten day quarantine period expired, the owner and his attorney, Lawrence Weiss, made repeated requests to Ted Brazier (Deputy Director, Dept. of Animal Services) for the dog to be either 1) charged or 2) released to the owner. The Animal Services Department did neither. Lotus died of"acute gastrosplenic torsion" on Oct. 17, 1999, while in the custody of the shelter. 2. At the Contra Costa County Shelter on 4849 Imhoff Place, Martinez, CA. where she was interned. 3. While in the custody of the county for 38 days, Latus was not properly exercised, watered, or fed. She was negligently or intentionally stressed by being imprisoned at the shelter for such a long period without any charges against her. Lotus was away from her owner and all of the people that she loved and knew. The owner was not allowed to take Lotus out of her kennel, even onto the shelter grounds in order to exercise her, despite his requests to do so. She died of"acute gastrosplenic torsion" as a result of said negligence. See attached Exhibit 1, Lotus' necropsy report. 4. Lotus' death was proximately caused by county officers and/or agents interning her at the shelter for so long without cause. The long term of confinement, and the lack of exercise and proper food/water stressed her so that she died. Ted Brazier was the deputy Director of Animal Services, was the person that attorney Lawrence Weiss talked to and was apparently the one who made the decision to keep her at the shelter and not return her to her owner as requested by said attorney. Lt. Abe Gomes, the lieutenant in charge of the feeding and caring for the animals, was the person who claimant talked to whenever he would go to the shelter. Lt. Gomes was hostile toward the claimant and to his dog. The exact names of the other officers are unknown at this time, but negligence lies with 1) whoever made the decisions to keep Lotus and not return her to her owner, despite the absence of any charges and despite repeated requests that she be released to her owner, and 2)the person in actual charge of feeding/watering/exercising Lotus, who performed these duties in a negligent or intentionally malicious fashion. 1 6. Lawrence T. Brennan claims the following as damages: (1) Property damage for loss of Lotus, his dog: $500. (2) cremation expenses for Lotus at My Pets Remembrance animal crematorium (3) claimant's half of the necropsy costs for Lotus which the county wants the claimant to pay: $200 (4) emotional pain and suffering sustained by the claimant: $40,000 7. (1) Market value of Lotus at time she was picked up from owner by shelter personnel (2) cremation expenses at My Pets Remembrance (copy of bill attached) (3)necropsy expenses (1/2 of which is requested of owner by county(see attached letter of demand by county.) (4) emotional pain and distress suffered by owner due to negligence or intentional torts by agents of county 8. (a) Dyanne Faris, the girlfriend of claimant, who saw the events surrounding the bite, and saw Lotus being taken away by animal control officers. 25013 Brook St., Concord, CA 94520. (b) Lawrence T. Brennan, the claimant, 2503 Brook St., Concord, CA 94520 (c) other officers at the Animal Services Department shelter, 4849.Imhoff Place, Martinez, CA 94553 (d) Hilda De Cock, pathologist at IDEXX Veterinary Services, who performed the necropsy, 2825 K.ovar Dr., W. Sacramento, CA 95605 See attached necropsy report. 9. EXPENDITURES DATE TIME AMOUNT (A) Lotus cremation 11-05-99 $ 250.00 2 , fl`1+1I Seir /itm mo mkYttaet 0.ROX0 111 Contra 1t,1ltC`c Anirnai Servk"Oitectaa,. rdnlCaP ar 91M34303 Costa L.✓/�-�i 1..1' S)�6-2�J95 n S1 Piccolo stw es ofwe kvola.Cast "Ou 94564.2632 10)374-3M February 3,2000 -rim Brennan { '1053 Brook Street lConcord,CA Dear Mr.Brennan: This is in regards to the billing matter relative to a necropsy performed on your deceased doer "Lvius°'at the rcgtjcst ofyotu"attorney? Mr. Lawrencc Wciss. Mr. Weiss and 1 discussed your request for a itecropsy examination after v0ur dog expired withe in the custody of Contra Costa County pending a court hearing pursuant to California Civil Code 334215. During this discussion. Mr. Weiss agreed. on your behalf to pay htlf of the fees ussocitrted with the necropsy. It was farther agreed upon that Contra Costa County would pay the entire amount if the final report was conclusive that the dogs" death was solely related to the care it received while in the custody of Contra Costa County Animal Services. 1 Our current records indicate that you have not reintburscil this department for your portion of the fres which were invoiced by Four Corners Veterinary Hospital in the total amount of$400.00. your half of the atlnount?wing S240,00. 1 contacted lliir. Weiss this week and he indicated he no longer represented yctu in this matter. but I that you had indicated that you diel not feel the fees were justified. r This is to remind you of our agreement and your original request for the necropsy to be jperformed, (See attachments) 1 have ioclude d a bill for the amount dine of$200.00. s If you have any further questions on this matter,plea!w C cl lice to contact rite at(925)646-2935. Sincerely. CTed tira,itr Deputy Director � et:. MiCii;u3k C;.Rutin.hpnttal�tnicts Ltin:ct�sr f Site 14-aJlt.AJminigmfive StLrvicez t}111wr Rtm Himcs,l,i,"Ibility Clailm Man gim kick h1uLq cnfiern File-Hrimn w. 1'i"" t-ites i 1 i . jj# 1 11 .1CREDM :. y-�r�'.r >'yj�� J+vV`'� ,lsI1�6,r"��VW'�10!` w ..ix'•' i /.�^�y,3yCti�• .� y�y.�.y�a ,H a-�. . .� �u� ", .,v :, �Y �11 i+rfJU'41N " ��,f y��.yw 1iYF'4,�,",'��Wq�M �1`}."•._ �'{'q M�iV w"�:1"..s.++W��{ :f.,y`YY' Yw"'��1if7�Yw � F. YV�I".it 'm ryNWyy«\�1�wA B X-41 „ 1 �''„' aar - w ",111411. +1 . •`.. �'fy g Wd p,w y<.r "`.'� a �V',,,�.y,'•: ^G'+g :•,�, w•..'+.1 wn k,'�' ..4 d, r vd i w 4 '* . „�► �. '�"^�rd'Ci�FiElNi��;��1 "I ��'� �` S�+a�IF�iF, i�1FtiF 4., �4.,'�+"��+ •'�� t - r •��,� µ +ti £K��'�„,�i{'�'-���* ,�ry3��h.._c_� d�'t��'t'i. �t fes, p•�”`��v""..�� �41r�� •� 'x . '+mh�u+ Y'4 4....',�v,%4' �-y �`'�"�'"�4 '�+�^„"q�"y4'i,�+t�Y' - t3'+�.Ky�y.r.w✓w�Mw S. Sh+i��.? ��'` r� +�' zT'Y - tJF� +Cir•. ct `'¢°!. t ,y... � „ ;� "�` 'W�� �' .,�`”' c w• � �'!w' 'k. .'iF`„ss°`��. ,`�Xi,''�' +,a1G'" «�s i �«"'� "� •* �..,,> .. iRDIN F14F,� '�''�#•a''^y''�.,,, 24- No t .ANo LS 7 281.0 1: 1 2 1 140 2 181: O 50 6 3 48 6 30�' .000000 2 5OOO►+r { i 3 I I i t i i i t t S i OCT°-26-1999 16:52 ANIMAL SVCS 646 2991 P.03 vww ww +rr wv•vVrw . w.• • wwv rr.+..r r .i.ws Jan 1 '92 4:212 i FDA CIS: VETERINMY HWITAL IWO( VETEPINARY SEPViCES 1126 MEADOW LANE West Region W�-444-4210 r"O�MD, CA 945`v-37 4 Oregon/Washin ton 12X. -4110 East/Central/ 0tarado 1-9,15-685-0512 ACCOUNT 0: 173 PATIENT= ,T. .LOTVS REQ #: 1835767 LAB I$-. P9426654 AGE: 7 SD: F COLLECTED: 10/19/JM SPECIES: CANINE RECEIVED: 10f2011".. 16:24 Imo' WITA RF.PORTED- 10,12,-1999 14:34 DOCToP: Y,UBICKA, T. TEST PPOCEDUl ES REGLLTS PEFEF'ENC;E RANGE UNITS NEWSY SOURCEMISTO?Y REMSTED Is fi FULL 3`EC'P Psy OF AN W144 (TOXICOLorl,Y 1� NECES$'Y). GM' WXRIPTION NEC101SY FIMINGS, AN AtJLT FES 14JTA IS NEOM-rED. THE SKU.L 4W CIPE O AND THE BRAIN PRIOR TO, SLSBtInION, TW ABDOMEN IS DISTeWD. WITHIN THE VENTM mIDLINE WE SEVERAL 9JnJQ"S PRESENT (NO SIGNS OF R,EC„`,EN '�l.�). THE ABDOMEN, IS C lea THE ST0A1XN FILLS uP 'SCS OF THE ABDOMINAL CAVITY, IS 4W)kULY DIS70CED, FIU-fD WITH GAS ANTS TWISTED OVER 117 DEGREES. THE STOMACH CONTAINS 2L OF A WOW GRA FLUID. THE VLE04 IS TWISTED TOGETFER WITH TME 5304ACN. DIFFUSELY CONWSTED, DW RED AND MEATY. TME I$ A SHW LINE CF DE?44MiTION IN THE CWDTA 00 PIMIKIL MOODW AT THE SITE OF TCP?SION. TW qT H WALL IS DIFFUSE DARK, SMA TO RED (CONGESTION AND EARLY .IS). THE TKV'ACIC: CAVITY IS DRY. TP*W. IS MODFRATF FIGHT V"IC LAR DILATATTON ASSOCCIAICD WITH A THIN VENTRICULAR WELL. A SMALL.. MOMT OF GASTRIC CONTENTS Hq5 LEAKED IN TW- WOYIMFL TPRc)tH. MICROSCOPIC DESCRIPTION NOT REQUESTO. DIAMIS ACUTE QASTROSPLENIC TORSION v COMMENTS THE DEATH OF THIS ANIMAL CAN BE VftAINED BY AN ACUTE GASTPVPLENIC TM..'SICN 0.0 180 DEGPEES WITH sECOWVty GASTRIC DILATATION AyD NEMIS. THERE 5EDi5 To BE No IMTCfiTICN FOR FURTHER TOxiCOLoGIC E~ MINATION. SWKES OF M ORGANS AW WEPT, FROZEN PQ FIXED IN. FO)MA.IN. PLEASE CONTACT T14E LAB WITHIN 49tRS IF YOU STILL WANT HISTOLOGIC OR TOXICOLOGIC FXAMINATION FnP ;W REQ, MTK) OGIST HD raE Ve CiX *, fw Dip loom- Am-icancollege of Meterinarg Pathologists (1-800-44d-A,= va319) pw:jeq BREt+NAN.T. .LCbTus t*t FINAL REWP.T t+-t BATON 003 * - indicates test proviousiq reparteo POLITE M: 1499 TOTAL. P.03 CLAIM , BOAR OF SUPE, SORS OF CO-NM CQSTA CC)UNno_CA,LJF_ )RNIA „ OMO AOO APRIL 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Beard Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph 1V below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $10,000,00.00 y . „ NEZ CALIF. CLAIMANT:Moorish Science Temple of America Rep. Mizraim Mohammed EI ATTORNEY:Rep. RECEIVED: March 8, 2000 ADDRESS: P. 0. Box 1011 BY DELIVERY TO CLERK ON: March 8, 2000 El Cerrito CA 94530 BY MAIL POSTMARKED: Hand-De iverpd 1. FRONL Clerk of the Board of Supervisors TO. County Counsel Attached is a copy of the above-noted claim. . PHIL BATCHELOR, Clerk Dated: Bch 9, 2000 By: Deputy 11. FRONL County Counsel TO: Clerk of the Board of"Supervisors ( This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 930.$). ( ) 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 By: / E-n� Deputy County Counsel 111. FRONL Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V BOARD ORDER: By unanimous vote of the Supervisors present: 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: ; JL) 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 f=ile 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 NL41LING 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 - 6 By: PHIL BATCHELOR By_ ' -° Deputy Clerk �•' / Apr- Ca'''m 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 100 'day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp MoofjE C A 5 i0: /3 ,� s-z 70 e7e3 ) RECEIVED Against the County of Contra Costa or ) MAR 0 8 2000 CLERK BOARD OF SUPERVISORS 1,C ?moi 0 District) CONTRACOS ACO. (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$( M�Uio)Jand in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) F 1 J /✓ LC P' Lr L Fief. Ux.drEK_ e.nw5+i v �'o�at_ ate . IAr-k 1 ��l���1 5 .31-15 .-4, 2. Where did the damage or injury occur? (Include city and county) e_ 0 L_Lk etj � S ► ' ' ` I- 1c �4 Y4-ty y4Q -,"- ak+)tA C o S 4 4 3. How did the damage or injury occur? (Give full details; use extra paper if required) i <'-O air p� -,` V�-S Ftev -- 4. What particular act or omission on the part of county or district officers servants, or employees caused the injury or damage? whir t,) --rtOviz+- rou O(A -t-M - -T %3 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) lip Y g-yz �s� /�v► ,. `` }r i2 f7 n�,J -- 1 i ` x r2-1 Wet'ttiA#-iO.O /to 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) G v # . M i "0 J ,2. A" J 2 t r l -2 !( rr 3 _- r, !r 8. Names and addresses of witnesses, doctors, and hospitals. vs Pe)t 1`� t.. S ' ? vez tom`- r-6 X HF)`,Q� art#-%(-) 9. List the expenditures you made on account of this accident or injury. DATE TMM AMOUNT t } Gov. Code Sec. 910.2 provides"The claim must be } signed by the claimant or by some person on his behalf" SEND NOTICES TO: (Attorney Name and Address of Attorney ) } (Claimant's Signature) (Address) Telephone No. )Telephone No.,5" D-3,v--q"i 61,v-S13-75-10 NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claire,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. CIArnM BOARD ACS APRIL 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the pard of Supervisors. (Paragraph IV below), given _.. pursuant to Government Code section 913 and KR 915.4. Please note all "Warnings". AMOUNT: $10,000,000-00 COUNTY GOUNSEL MARTINEZ CALIF. CLAIMANT: Moorish Science Temple of America/Mizraim Mohammed El ATTORNEY: DATE RECEIVED: March 8, 2000 ADDRESS: P. 0. Box 1011 BY DELIVERY TO CLERK ON: March 8, 2000 El Cerrito CA 94530 BY MAIL POSTMARKED: Hand-Delivered Y. FRONL• Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted claim. PHIL BATCHELOR, Clerk Dated: March 8, 2000 By: Deputy _gr(� II. FROnti County Counsel TO: Clerk of the Board of Supervisors (t}This claim complies substantially with Sections 910 and 910.2. { ) This claim PAILS to comply substantially with Sections 910 and 410.2, 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 411.3). { ) Other: Dated: I By: fag � Deputy County Counsel III. FRONL Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 411.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. { ) Other: I certify that this isa true and correct copy of the Board's Order entered in its minutes for this date. Dated: ;2-003 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. cede 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 445.6. 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 ANG 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. Bated: 6 By: PHIL BATCHELOR By� `� v,.A eputy Clerk rr— rnttnty rntinc-i / ., .,. AA._.:_:..__._.. v 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 fine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors,rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Renal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp } dASC5 . rJs 039s-/(,, S-2701/3 ) RECEIVED 6 -- 5`2- 3y5-94 } Against the County of Contra Costa or ) MAR 0 8 2000 District) CLERK BOARD OF SUPERVISORS (Fill in name) A-ft/4 S i'^-% m v P-s ) CONTRACOSTACO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district inthesumof$joMia,oQ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) / )9-rZ C 4 7 t 1 ,? &Off m . 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) / /r/d .,. cam-�. ��.. --n. ��u: .�--• ����,, ��.c.,�c� c-d-wt..� � ice. _. 4. Wf�at.particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ! t V S 44 Oct v g M 401'= 1 0 F COK3+ifLo/4_1'Oj_,14( ) 5. What are the names of county or district officers, servants, or employees causing the damage or injury? f SOU 7 130,4i . Or S () f,6gV 6. What damage or injuries do you claim resulted? (Give full extent of injuries o;/damages claimed. Attach two estimates for auto damage.) 3, 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) } 8. aures and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TME AMOUNI Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf" ENI)NOTICES T : Att me Name and Address of Attorney ) (Claimant's Signature) `` -'�' Balt t 0 i i (Address) Telephone No. }Telephone No. Sle 3,o —Y2_ ) NOTICE Section 72 of the Penal Code provides; Every person who, with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or 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. CI ALM BQMD A0Ql April 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. j notice of the action taken on your claim by the r ' ' Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and `' r 915.4. Please note all "Warnings". CC;U Y YY COUNSELAMOUNT: $10,000.000.00 MARTINEZ CALIF. CLAIMANT: Moorish Sience Temple of America ATTORNEY: Mizraim Mohammed El DATE RECEIVED: March 8, 2000 ADDRESS: P. 0. Box 1012 BY DELIVERY TO CLERIC ON: March 8, 2000 El Cerrito CA 94530 BY MAIL POSTMARKED: hand-Delivered I. FRONL• Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. . PHIL BATCHELOR, Clerk Dated: March 8, 2000 By: Deputy r IL FROM: County Counsel TO: Clerk of the Board of Supe isors ( ) 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: 7 Dated: �,/ - BY: `Deputy County Counsel III. FRONT: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IVf 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: f v2-WO 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 turning See Reverse Side of This Notice. AFFIDAVIT OF MATT INYG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By; PHIL BATCHELOR By V2, "�--Deputy Clerk r r'f""• ('nrterta. f`'n.mrrl r_..._._. VICTOR.I.WSSTMAN aEPLITIES: COUNTY COUNSEL PHILLIP JANICELL..AMENTAALTHOF� NORA G.BARLOW +{ j y � B.REBECCA BYANES SILVANO B.MARCHESI CONTRA J��T ANDREA W.CASSIVY 00 I T MONIKA L.COOPER CH IEF ASSISTANT COUNTY COUNSEL /� }y /�a//�#t VICKIE L.DAWES VFFI %e,'OFTHE CVU� (MSEL. MMARKE S.ICHAEL D.AIRR SHARON ANDERSONL_ ct� JIV, lA ISTRA9'1`E11R8}kbiN�'� ULLIANTFUJI1 ASSISTANT COUNTY COUNSEL � ?' DENNIS C.GRAVES JANET L,HOLMES MARTINEZ,CAL 1FOR,M 29 KEVINT.KERR GREGORY C.HARVEY r BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL ar EDWARD V LANE,JR. ' BEATRICE LIU MARY ANN MASON GAYLE MUGGLf PAUL R.MUNIz VALERIE J.RANCHE OFFICE MANAGER STEVEN P.RETTIG DAVID R SCHMIDT VER PHONE 925 335-1800 JACQUELIANA J.SNEY. t } JACOUELINEY.WOOOS FAX{925}646-1078 NOTICE OF INSUFFICIENCY AND/OR NONACCEPTANCE OF CLAIM TO: Moorish Science Temple of America Mizraim Mohammed El P.O. Box 1011 El Cerrito, CA 94530 Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of. Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ 11. The claim fails to state the name and post office address of the claimant. [ 12. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ X] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ 14. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. Page 1 [ J 6. The claim is not signed by the claimant or by some person on his or her behalf. [ ] 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. 'WESTMAN COUNTY COUNSEL By: � Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P.§§ 1012, 1013a,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 14,2000,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk.Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 Claim tcy: 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 I00t' 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. 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 _Moorl5k SQ1,tnCf_ e c me r t r c�... RECEIVED Against the County of Contra Costa or ) MAR 0 8 2000 cr�� } CLERK BOARD OF SUPERVISORS C M C�i• cQ District) CONTRA COSTA CO. (Fill in name) } �j 0C h) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of W k L4QJ and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) CCS — r � . __ / � f )L ' 00 &" 2. Where did the damage or injury occur? (Include city and county) C) P Co49 <�CIS414 fl F-t- 3. How did the damage or injury occur? (Give full details;use extra paper if required) V v Lo--� reP t t,(-/4 s -co x e- F-11�.s /1- C--I i,kt,t► C rr n t r c:�' X 7V3 5 l - What particular act or omission on the part of county or district officers, servants, or employees cased the injury or damage? 0 LJ f4'e 9 V.A f If AL OFFiPACr)E S 14o\-,U P )qUJ5- Tr�F-Oytmkn-k 1-14 A-+ f Ai (,S� 14 a-o-oc 3 44+v4i'tl k A jL tz 6 44 3 ! 5. What are the names of county or district officers, servants, or employees causing the damage or injury? TO F- c- 0 oA 10 OF �-r F-f- V i- � (:,K S 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto Odamage.) &I r— FAI AL ViC 91Prtf5 ,b... fg,-, s (e-u4-(QLJ IT-N A—A*Q 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ib M tttiok-,) -2- A-,,'z4tiold ;2 8. Names and addresses of witnesses, doctors, and hospitals. A-I'L S. 12 it 9. List the expenditures you made on account of this accident or injury. DATE TMM AMOUNT ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf SEND NOTICES TO: Ufto= Name and Address of Attorney (Claimant's Signature) a �" (Address) Telephone No. Telephone No.63 3,10-q 20 i NOME Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or 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, J CLAIM BOARD QEU, USMS QF CONTRA COSTA C'Q11Nn, +GALMOMIA _OAR AD CT10APRIL 4, 2000 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. notice of the action taken on your claim by the ` Board of Supervisors. (Paragraph IV below), given s pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". . ti t ' OUNSGL AMOUNT: 10 000 000 00 f�AnR- UiEZ CALIF, CLAIMANT: Moorish Science Temple of America Rep. Mizrairn Moharaned El ATTORNEY: DATE RECEIVED: March 8, 2000 ADDRESS: P. 0. Box 1011 BY .DELIVERY TO CLERK ON: March 8, 2000 El Cerrito CA 94530Hand-Delivered BY MAIL POSTMARKED: L FRONT: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk r 0 Dated: March 8, 2000 By: Deputy , ICI. FRONL• County Counsel TO: Clerk of the Board of pervisors ( 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: (.93`00 By: t'2 Deputy County Counsel IIT. FROn- 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: i 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. AF1 WAVIT OF NIAIIING 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: i -' By: PHIL BATCHELOR By - eputy Clerk C lim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSMCTION TO CLAB ANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100 'day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, 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 Fine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fr ud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp e: e, 516 ) RECEIVED Against the County of Contra Cost or ) t ) MAR 0 8 2000 CL Cr ►2 1*j District) CLERK BOARD 4P SUPERVISORS (Fill in name) 4-� 1�I� ff PE-4-F-4 S 1-1- ) CtINTRAG08TACt3. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ /014 iL)and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) I D — f I/— 1� 1 t r S- /0 2. Where did the damage or injury occur?(Include city and county) 3. How 1did �^the damage or injury occur?(Give full �details;use extra paper if required) TZ,) Is tom s 2-,04_C.:, r,+c �1-E / !< C4- Gj get,) 1 L 7 tip► � 2 'vr aKt ' r H " Wat particular act or omission on the part of county or district officers, servants, or employees cause Z injury or damage? U i t S (,U )41Zn) J G -Y n� 0y. 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) , e 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) �2. 8. blames and addresses of witnesses, doctors, and hospitals. It4 cLi #wfi-4-�zrsr A4cA4Y,4YL1,FX rtl 9. List the expenditures you made on account of this accident or injury. DATE TIl'v AMQUNT } Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf," SES NOTICES TQ: (Attorney. Name and Address of Attorney } } (Claimant's Signature) } (Address) } Telephone No. )Telephone No.('Sle2 31 NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or 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(S 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. CLAIM BOARD OF SUPERVISORS 011e CON-IRA COSIA CQUl i - CALW—QRNIA BOMU ACTT April 4, 2000 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Indorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". A R 0 3 301 AMOUNT: $500,000.00 tr a t>':'�E;Z CALIF, CLAIMANT: Kenneth J. Bunter ATTORNEY: DATE RECEIVED: March 3, 2000 ADDRESS: c/o Martinez Detention FacilitpY DELIVERS' TO CLERK ON: March 3, 2000 Module C, Room #28 March 2, 2000 901 Court St. BY MAIL POSTMARKED. Kar_tinez CA 94553 I. FROM: Cleric of the Beard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. . PHIL BATCHELOR, Clerk Dated: March 3, 2000 By: Deputy IL FROM: County Counsel TO: Clerk of the Board of upervisors (This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) tither: Bated: 3`— 3—c13 By: L k Deputy County Counsel M. 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: &OPHIL BATCHELOR, Clerk, By eputy 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 945.15. 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: , By PHIL BATCHELOR B QJ71v— eputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY � INSTRTJCTIONS TO CLA_ilvCAhT"t` A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100 'day after the accrual of the cause of action, Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Boom 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. fid. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp ofn.e�k, 77: Z A�ee } /2 X rte., o sJ ; } RECEIVE) Ar}; . Against the County of Contra Costa ar ) MAR 0 3 2000 tt �" 4 -!— is IN-r F:YN District) CLERK I OARD OF StJF'ERVISORS -- CONTRA COSTA C.0, (Fill in name) } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$506 and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) I '8.,,., �0100 1`? t 1 hers 2. Where did the damage or injury occur?(Include city and county) G..._�orf f�-! � �'• `�' '.. r"��' l•l. .* � ...3� .:� �. �. . "7':y`c..,f z%,.� f 3 Y � i:r' :� .+�. 3. How did the damage or injury occur?(Give full details; use extra paper if required) i.,.r t F' ..i:, .. y;; i .. ..!C. 4.: �Y' �3'�'Kt 1,.t� c:"ti. •�t,<:1 is S., '.'t.,.`s., w4.i =��. } t t '�1 Y?.L 'i. - .?y •- . `. ,.,f ^4' rr- 4 F;%, sr y!.Ytr t..?r.i .. <' 'i ° a7 I w 4Vv.,114 i4 e 4. .What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? _ E t e lF W o U-1^,,, 5. What are the names of county or district officers, servants, or employees causing the damage or injury? "A;4, µ y'�.L�L it ham::.."'F". y l:•'t i 14.. E,:E. ..:'C.. fti,,.'t r.t 4. 2 th .. >.i 1 epo,+ v'✓. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) A .•-E..(.,: •.. A3,..i 2�6 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage) G 8. Names and addresses of witnesses, � doctors and hospitalls. f'f'4�4Y 1F\k,-L., 0 ! Y;,r t ! ( ,�. Lit AA,, -UA,de'A l H w. p 4 tr i C 1,4 4 4 e- MU {C14A c,aov-Akt"$ ;k u Q A0Kd,t'-.*,rk tit/-L 101 INA 9. st the expt fttnditures you made on account of this accident or injury. DATE ****************************************************************************************** Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf" SEND NQTIC�'S� TO: (Attorney Name and Address of Attorney } (C aimant's Sig Lure) t�4Y qri°fir n� ��s_1 �a 1� } (Address) Telephone No. )Telephone No. NOTICE Section 72 of the Penal Code provides: � x Every person who,with intent to defraud,presents for allowance,w the payment to any state board or-officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or 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(S 10,000),or by both such imprisonment and fine. V � r r.rr � t 1 CLAIMi-j ,`` j j BOARD OF SUPERNISORS OF CONTRA_ COSTA CO TN`i`V, CALIFORNIA BARD ACTT 0I1k APRIL 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section references are to 1 The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given a s< c l 1 pursuant to Government Code Section 913 and 915.4. Please note all "Warnings AMOUNT. $77.60 S CLAIMANT: Clifford ChanCab#F° ATTORNEY: DATE RECEIVED: March 3, 2000 ADDRESS: 567 Sherree Drive BY DELIVERY TO CLERK ON: March 3, 2000 Martinez CA 94553-5919 BY MAIL POSTMARKED: Hand-Delivered I. FRONL Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. P111L BATCHELOR, Clerk Dated: March 3, 2000 By: Deputy Qba,2 II. FROM County Counsel TO: Clerk of the Board o Supervisors { 0,1This 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: � '�" By: ! -0� Deputy County Counsel M. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2) { ) Claim was returned as untimely with notice to claimant (Section 911.3). Its. 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: '-- 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. AF WAVIT OF NIAILING 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:t192 ,L `?tom By: PHIL BATCHELOR By r eputy Clerk i 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 100`x' 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 L r r=,1�&p edkJ RECEIVED 7MAR:O? 3 z000 Against the County of Contra Costa 7 0-M CLRD 0 SUPERVISORS or CONTRA COSTA CO. District (Fill in Name) The undersigned claimant hereby mares claim against the County of Contra Costa or the above named District in the sum of S O _ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact Date and Hour). ---__` +�`y t2.y_�` ---- --_-- ______________________________________ 2. Where did thedamageor-in occurs (Include City and County) 04 3. lbw Oid the damage or injury occur? (Give M details;use extra paper if required) N )l�tif 1 t /) AS R,4i y,,JV 1. V17� 4 y gi � �- ._. _... -------------- ----� ---- --- -- ----- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? t _ 78�-A4-E: Th� s D / ot�,2 s ,i31ly j AAA-iw( - )W Dei vC--rz.. C,.4V413 Lc 0' /eC"7`"y r<_ ,t' (Over) 7-0 MI V510 -.S . � mCN> UJ cn MLCY Coll r �v s. ! Y `tom M'(A ' �¢a d mrtimta� REV - - - - - !? ul 4A 5 - -J Lu 4 4 cnWcc " w 0 J El ld ClSam �,. wLU a 00 0 { L W y k z fn & -tat' r Z a LU cc w167 con cr a7 ev ppp p Z 3 G �x uj LU L� 2 i „ s rf f F'1,a"t'�..i%\��:.. i....!•'' w�.tom:....,.- 4H ,w',.... B AL,.r'3Ni...i,".:. WE I SAY , 1. 1 37(DrlJ i:;p�'•�. Y'L» w w ;.1 !"t.C,'..,, C,...s_. .m C:.�w_ r «#.f't.� ... .. '�,•$°` i_ .�. t.j i} th. 1 .: . l w_ .r ., i-1v ` #Ei�:"' w 7 l v4.t'. Hm,` _ s +.m Fakr S . ci `1 aI/e r,,LlcC--- 'wCt,-_. `:t? �.E +: ' G �# l 't G�! - "SQA a"-.0 cra , �eor0 Lt wSe , a k'^°t` SL.i iJ` FOR :AFI SERY 11 CE See reverse side for Warranty Information CLAIM BC1AR1) QF ��P ' ISM QE CQN. TR STA CQ11Nn* CALIFCIR 1A BOAR^ A0() APRIL 4, 2000 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Y ; pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $25,000.00 ASEL CLAIMANT: Caroline howler tk �;AUE. ATTORNEY:c/o David Tirako, SBM 1.24544 .DATE RECEIVED: March 3, 2000 TIMKO & LA SORSA ADDRESS: 2033 N. Main St., Ste. 360 BY DELIVERY TO CLERK ON: March 3, 2000 -_ Walnut Creek CA 94596 BY MAIL POSTMARKED: March 2, 2000 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 3, 2000 By: Deputy H. FROM: County Counsel TO: Clerk of the Board o Supervisors ( t,,<ibis 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), ( trOther: torr 15 0/7 t 6 L _ -- De Dated: 3 � �' By: �"- � _._Deputy County Counsel 111. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: { 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: ' ' HIL 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 trail to file a court action on this claire. 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:& �By: PHIL BATCHELOR By A& eputy Clerk I David Timko, SBN 124544 Linda LaSorsa SBN 148550 „ 2 TIMKO & LASORSA RE F1) 2033 N. Main Street, Suite 360 3 Walnut Creek, CA 94596 MAR 0 3 2000 Telephone: (925) 933-3800 4 Facsimile: (925) 947-4503 CLERKBO�,;, UP SUP VISORS CH O 5 Attorneys for Claimant, rd'18A COS 0. CAROLINE FOWLER 6 7 8 9 CLAIM AGAINST THE GOVERNMENTAL AGENCY OF CONTRA COSTA COUNTY 10 11 12 CLAIMANT`S NAME: Caroline Fowler 13 CLAIMANT'S ADDRESS: 3709 Sundale Road, Lafayette, CA 94549 14 ADDRESS TO WHICH NOTICES ARE TO BE SENT: 15 Timko& LaSorsa 2033 N. Main St., Ste. 360 16 7 Walnut Creek, CA 94596 17 Telephone: (925) 933-3800 18 DATE OF ACCIDENT OR INCIDENT: Approximately 09/24/99 19 LOCATION OF ACCIDENT OR INCIDENT: 3709 Sundale Road, Lafayette, CA 94549 HOW DID ACCIDENT OR INCIDENT OCCUR: Claimant's friend, Ms. Bartolomei, adopted a 20 puppy from the Contra Costa Animal Shelter located in Martinez, California for her granddaughter. The puppy was not tested or isolated properly by the Animal Shelter workers and contracted rabies. 21 Ms. Fowler was exposed to rabies and forced to undergo a painful series of injections. 22 DESCRIBE INJURY OR DAMAGE: Ms. Fowler was exposed to rabies due to the puppy being 23 infected. She had to undergo rabies injections. NAME OF PUBLIC EMPLOYEE(S)BELIEVED TO HAVE CAUSED INJURY OR DAMAGE: 24 Contra Costa County Animal Shelter in Martinez, California 25 AMOUNT OF CLAIM: $25,000.00 26 ITEMIZATION OF CLAIM: Plaintiff has undergone medical care in the approximate amount of $2,500.00 27 28 I I declare under penalty of perjury under the laws of the State of California that the foregoing is true 2 and correct. 3 Signed on behalf of client 4 DATED: March 1, 2000 TIMKO &LASORSA 5 By: 7 David Timko Attorney for Plaintiff 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 f, F';'"��'gc'��'�'`P".x r�`."3'�Yt;tt"�a-a,s1'w`o�;°' •"�,+D}�uslc,�nw�`x ���,�.q'L"{�"^�.y�5 `�'.y"`x'z's t!�' p,«r-:: .� �,••yam=sd»:.:.�.Y.t.$tos"lam.'+-_t ... .,, ni w nj LM tA r N D > c as O cu CD cD `c r w ® , o to 0 0 cn ro ;, o cn Ul cn cc 3� f 0 } t3 _ - -� -.4.��tiy:✓rti y hK�.+<,h�`"dtr'Wi6iif.,,.a.�r.'x ,. .. e' ":'`Y F'- � ., � ,�,_ - .. l CLAIM BO RT OF SUPERVISORS OFC NIRA COSTA COUNTY, CALIF RNIA BOAR® ACTttN1t APRIL 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given . � � {`' pursuant to Government Code Section 913 and , 915.4. Please note all "Warnings". AMOUNT: $209.53 T` 0 19 2241}JJJ CLAIMANT: Nathan Hendel MAR"tfA=Z CALIF. ATTORNEY: DATE RECEIVED: March 9, 2000 ADDRESS: 2642 Baldwin Ln. , Apt. C BY DELIVERY TO CLERK ON: March g, 2000 Walnut Creek CA 94596 BY MAIL POSTMARKED: March 8, 2000 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PML BATCJMLOR, Clerk Dated: March 9, 2000 By: Deputy IL FROM: County Counsel TO: Clerk of the Board of Siil5ervisors ( 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: f By: `2lz 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: • a C)G( 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. AFFII)AVIT OF NL41LING 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: a 0 By: PHIL BATCHELOR By Deputy Clerk ;tea �a 4s ` y f f r` f � ��> � /• r ale' 3a" OW f �'', , 4 k a�[f'ti � wy:vpy k' s6n Jose ( g ... f fi f xx m '3 w <rk.S ? K sit�r,�,r �> <„ µ { Y '� { frZ'A . q ah y rte. 70 X - %r� WN 14 f -r uA r s ra, WNW W.wwg ,� 6 yaks a 3 t �G # .rte ...s � Pw� :- ' {xX .cr ,,,.._ S3 3a.A� 1 5"' k .,� t �3 r 5 S ...% ?9e✓ r d ..2-.,:+{' i�,r-..ST�y vc.41` k✓ n :,c2P'q .�`9�', r ,a 'i> Esc T �k yy6 b,✓� �L^E;.' /'�'Fy;;� �,� aa< „a�., 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. (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 CIerk's Filing Stamp } MOF Against the County of Contra Costa RD or CLERK CONTR COs District) (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of S 261-S*3_ and in support of this claim represents as follows: 1. When did the damage or injury occur" (Give exact Date and Hour) __ * ec�#__ + ttvr►s� _ !t1, X--------4.t-Jv�----------------------------------- 2. Where did the damage or injury occur? (Include city and County) ------------------------- ------------------------- 3. _------- _ Lvvar---— --—- !lu _--&c� �ra-,�_ -,-,sr--_- 3. How did the damage or injury occur? (Give hilt details;use extra paper if'required) L-9- .,A R:'G'V.s.r3 ft R(�rJ '1`4nN t4 iA A ®aP P o T A0 t,e T�+IAT P v PJuT J R I`-D 'T-N Y AS'k NT fi4ly*#"C' It ✓}rJt ►�J t+ S. Y D res OTtzo k -r" jc ftw m. 3 v $;,tILr T1t� aJ h � iJai► t * s S kN� To 3t,.o,,,? Tt+t,�kFr�. !'tit11A 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage" "r)+e j°T R*.ff,'f C`G ovA-MV A4&-) Q Pv5 3 fieit K-iA v-= S}m a r-- �►3 it��5 (Over) County of Contra Costa Risk Management Department Nathan Hendel 2642 Baldwin Lane Apt. #C Walnut Creek, CA 94596 To Whom It May Concern: I am requesting a reimbursement of$209.53 for damage caused by hitting a deep pothole on the morning of Monday February 14, 2000 at 8:00 a.m. I believe it is the County's responsibility to reimburse me for the expenses I have paid. The damage was to the front right rim of my car. While severely denting the rim beyond repair the impact punctured the tire beyond repair as well. The new rim purchased from Volkswagen Dirito Brothers in Walnut Creek cost $139.64 and the maintenance to put the new rim on the car and realign the tires due to the force from hitting the pothole knocking the alignment off cost $69.89 at Wheel Works in Walnut Creek. The replacement of the tire was covered by Costco. The pothole is located on Concord Avenue between the Concord Ford Dealership and Buchanan Field Golf Course. The pothole was very deep and with no warning signs such as cones to slow traffic down and make drivers aware of the damaged road I was not able to see the pothole until I was right upon it. By then it was to late to swerve. The following day I went to the spot on Concord Avenue but discovered the pothole was filled in. I have attached pictures that show the size of the pothole and the approximate location. The time and effort I put into fixing the tire was tiresome and tedious and it would only be appropriate for the City of Concord to take responsible action and from now on fix the roads before they get to the dangerous and hazardous point that I experienced. Thank you for your prompt response to this matter. If you need additional information I can be reached at (925) 256-9290. Sincerely, Nafhan Hendel Enclosures r a f• x '`Sfi4i. �vC'rs�i K x a > tYtFf f ezv g k�'; z�I ,,a,> � >. •14f► afxr' '�3I"i3t w z. IAS ` C: �, :CA.W4�' > _ ,: b aE t q > t �w t 9tt� ` w =< ,-? J� TA GLS NDY M a tNhael Worist rrer,you h#vt;ti ctlo)oo 4tivhettrer fx not any work vela be Pfd an your vohicte:tt is important tti as tt►at vva provkita dtia ' '��-' � Y hrtarmatiort ao tltirt you�are at>la is fnakrilMarrrlyd doClrbrrr.Ttisraforr,ave lrava ItarnLred tfia parts surd sarvit:ae by tM ioI -' : krwrirlp cateporiaa> MOM . o �.. wo Ybu may ftard tftua IGxt»tfua fo: Thau an Thus an 000"Ipma _ opgonat Rama ' •Cvf%w rrrt nb ktrptr perterrrr�fstendtd purpap ,Compy wdh by ft vahkWa' • Address a awtamer or oonwnlenas etlffea rift,enhance Canpaw+ent doss not mat t deMpn (nprrdka oripi►ud mrnutadunr(t7EF q m m* i W�) +ply v+Ns by the rrt mora ar NladnaEr nolo.,et-) ' a nreelr� od �k dose to the end of ht U"M Ntt OW abon the •.pl area ow O m Wm++r,we can ony disoa►d$PWMcaftm or weak etc.) f91Y if'K*"no result,and omurot ooftm their daime of - ., ptrbs'mMrpa. QTY STOCK NUMB ER DESCRIPTION PARTS LAgORI R EXTENSION KSWAGM 69 89 I8U"A ; SAI RRA> Es _ � .` :� 'l��'aF�ril'a��w���•�•��•at'� �'af•�••�'�••�•���r�r�•'tr''te•���•�•a���-�'�•'�•.���'�•� a�at-�,�����•�t �c'���-�a��'3t•�� Wheal Torque Lb 1. F-4 .A . . ,. . , r- s'. Tty . ## Wheel Toi~q:ate yt ez ': 'tf4t.�."lF�lt'�t'�E•`K,�.'d"yr�"ts•'yg"Yr ,yf'.� i`r'9G�'#'iF^3#'•lE•'YG'ih'1F;(..?F`b^'}�'•�'�r.#-+F•R'•Ih$F'!F-tt.y"3f"tg' •t('.h"lr#'a�i '�.Y..�. , .�"k`•'i{•.�••D!#E 36-�'F'#�f• 0q.0au muffaft tMlrtl� MM m mM#0(lig mb an soch'�W SOW$0 m1mm,i1 w Wt t WAkdm Nf7 W I wl�ttwr�ila p Iee k"w�..By***Mott,t r*4"w ON Vo VaNdtt Itro n b ow " B x0 mart rtfrr lira ttIrWMNoa,rnd tlrt Ynpottanat of m4wquftlp thr top nnuot L ae nrNre that)tmaat fry ... Total Fame Libor �a9.� Tt�TAL�PART9ANi5LABOR - s I hertby*Ww1 a the MP&work to bs done done SALES TAX wdh ttsa nto--Y matertakr,Whtel Waft and Re -OOYeet may opwaM about vehfse for purposes 40e a r m^ tr � . `' eTOTAL of iasdnp,inspeobm a dadvtry at my Hsk.An *a � vehicle to somrt the am urtt of repdrs thtrata.n k1 ++ z it; ...'' _ +4 �hH s: .0 .t express ank;'t den 4 on above s d ,.. W-understood that WMd Works wdl rat btiroW rstnII aoknowWdpa that ft f mi"d Parts and aervim s vehit ion a lou a darm�t t vsht or widartkite FAR F$ 4"R TOTAL. Pfd on my vehkse en the iNrrrr that t k 1t n vehkdt In ave of&e,that or any other tease Wtyond Wh"Walt oxwN.ALL PARTS -q* trd,'f aprw m Pay On unoont Chown an AND MERCHANDISE ARE NEW UNLESS NOTED, N PERSON Q BY PIS'r3 ft s+volm OW 1 advsowbdpe takksp pomm&W '. x {R REMANUFACTURED,U-USED): r * ! of Agrveltldst �. u r - _ r13 �13HETUfMIFAf#TtJ1R0 ARi?s �•`. T'M���,�,,;;r;;:'61ALlYDtfy {:">:� ``Jr'v est>,es.�,, a�:}��^�tr f.,c}£�.asilLcrt•e-.sYn�A.< � ..4 U t t rloltatuwtorrt :ice. rs � t�� 8 NATU E �° x , all M 1840 North Dain Street r�h Ito Y • ` WALNUT CREEK, CALIFORNIA 94596-4195 j / r (925)934-8224 �lksvvagen1 LNUT CREEK PAR'T'S DEPARTMENT HOURS 7:30MTO 5:00PM OUR PARTS STAFF DALE. JOEL AND ROBERT ARE HERE TO HELP YOU WITH ALL YOUR PARTS NEEDS. PARTS HOT LIKE 925-9340$459 < ., 1002493 L'3iED dD ROBERT 02/14/00 107159 VWR 925-927-8004 ® RANDY,HENDEL HL 2642 BALDWIN LN#C r P T WALNUT.CREEK,CA 94596 T r T 1 0 1HO-601-025-R-091 ALUWHEEL 129.00; 129.00 129.00 w s � •NO RETURNS ON ELECTRICAL OR SPECIAL ORDER IYEMg SUBTOTAL t 29.Ot3 N •NO RETURNS WITHOUT'THIS Miti�E © •NO RETURNS AFTER 14 DAYS s •20%HANDLING CHARGE ON ALL RETURNS TAX 10.64 •SUBJECT To WARRANTY CONDITIONS ON REVERSE SIDE RECO NO REFUNDS BY �o0 FREIGHT 0.00 77 NS MAACfICE PAY THIS AMOUNT )38.64 17:05:07 CUSTOMER COPY 1 OF 1 AMU . s ,,.. c 7 CLAIM B.Q0 pAPRIL 4, 20 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Cade Section 913 and s ( 915.4. Please note all "Warnings". ^f AMOUNT: $539.36 L CALIF. CLAIMANT: Connie Joyce ATTORNEY; DATE RECEIVED: March 8, 2000 ADDRESS: 503 Camelback Road BY DELIVERY TO CLERK ON: Maw 8, 2QQO Pleasant Hill. CA 94553 Hand-Delivered BY MAIL POSTMARKED. L FRONL- Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 9, 2000 By; Deputy IL FROM: County Counsel TO: Clerk of the BoaM of Supervisors ( is 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: —, 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). 11V� 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: , '2 -' �Z_,R 00�3 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ;b&D By: PHIL BATCHELOR By ' -)—� eputy Clerk ,� . .��� �� �� . . - y \ . `U ' �� < ` >��^�� \ \ . y� � � \ > � �� � ` \ . \ - < \ w � » �, �� . . 3���� \ � ~ � � .�� . . ` �� , � . ` � � » & a� ` , : a ��. �\ � � � �%.y A � ��r��} � y \ y/ . � �. \ ? � z � ��� � . ��%\�y ^ � , � � + y .yy �. � \�� \ . > � �� \\ �^ � . w , � .y r � \ �� � �/» ` �2 ° ' ` \ f. \�°� ~ � � , � � \ \ \� � / x. � y\� � ,y y +� F r` N4. 4 F� } f � f f. 1 'f, � � ,, ;:, h �! .�. q., ��M Y t � ����'•••• '" w �" n. f :+. �� w . , +�`�� .a ^ ^Mo-`Cw.v ♦ w. ... .. •,• � �R4p +�.. _h.� .att.�L _ r' �� � � ��. f'i" ¢`f ��. l�, .;,�'., -04'f�; 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 100'h 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 EIVED Against the County of Contra Costa MAR A 8 7000 or ;S0 S � ' District Ar.,;:TAC (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above I named District in the sum of and in support of this claim represents as follows: 1. When did the damage or injury occur? (CAve exact Date and Hour) Z - -------------------------------------------------------- --------- ---------- 2. Where did the damage or injury occur?, (ind ---------- ude city and couitty) ------ --------------------------- ------------------------ -------------------)------- 3. How did the damage or injury occur? (Give fUR detath;use extra paper If required ------------------------------------------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? (Over) -aug pule}uauiuosladuij qa q}oq Sq.zo 1(0oo10l$) s tleilop pulesnoq}ua}2ulpaaaxa }ou;o auU le fiq'uosi id a}le}s aq}u j luamuosudutj.Sq xo 1auU pule }uamuoslzdwi Bans g}oq Sq jo 1(00011$) urijop pulesnoq}auo Sujpaaaxa jou jo aug le gg 1aleaS auo ueq} axouc jou jo poljad le ao;jjv f Slum aq} ul }uauiuoslxduq Sq xag}la ajglegsjund sl luI}lw xo ixaganon'}unoaale 1IIIq lium(a }uajnpnle.r3 jo asluj Sule lauinua2l lI amrs ag}Sled ao Mojlle o}pazuog}nv ljaagjo ao piuoq pulsjp ao ;baja 1S}unoa Sule o}xo IiaoUjo ao pjeoq a}le}s Sule o}}uatugvd xoj so ammmolje xo;s}uaswd 1pnleajap o}}ua}uj q}Im logm uosxad Sxana„ :sapinoxd apoj jleuad aq},}o ZL uol1334,S r, r o auo da ON auogdaja L (ssa-Cppy (aari}eu$r�s,1}irleuijlej�) Sauao}}v;o ssaxppd pule amm G1•jp#gaq sjq uo uostad autos Sq ao (Sauco}}v) -oi saxioK amas }uvw!uIa aq}Sq pau2ls aq}snw wjela aqj,, tsaprno id Z-016 `aaS aPOO •e09 ou suno � walla :S.zn[uj.co}uaplaa a sig},lo}unooale uo aputu nog sa.in}jpuadxa ag}}sjZ •6 ------------------------------------------------------------------------------------- -� �yJ, �/,,/ f. "f� ,�,,, '.v,,, 'spa}idsoq pule 1Sdo}a0p 1SaSSau}lu j0 sassa.cpple pule sau:le� •g �r (-aa p ao Sanjuq ampaadsoad:qua So;unouuu paluiun-aD apupui) j pa}ndcuoa}unou m pacumia anoge aql sum AdOH •t • �•aa�utsp o}ne so3 SOPS M—0#4 XPOR�-'PaUlUP sa3su[Bp ao sagtnjuxJo;ua�xa 1P�d ae��)-�,paxinsax nYileja riUg op Sartn[uj x0-SajL'u1Bp Xle�jtlt�--'� ,,.-� ��%��a' GSxnful�o a�letusp aq}�ujsnlea saagol�tu�a.zo 1s}ue�as 1scaa�o}ar,.z}sjp zo g}unoa,}o sautleu ag}axle}leq�. "S March 8,2000 Clerk Board of Supervisors Room 106 651 Pine Street Martinez,CA 94553 To Whom It May Concern: On Sunday,March 5,2000,1 was traveling on Concord Ave.between Diamond Blvd. and Contra Costa Blvd. at 10:30 p.m.In Concord,Contra Costa County. Just before the 680 overpass,my car was damaged when I drove into a pothole. Had I swerved to miss the hole,I would have broadsided the car traveling next to me.Both tires on the right side of my car went into the hole.The front tire blew out. I then drove my car to the 76 Station across the intersection,I called the Highway Patrol,in an effort to make a police report on the road hazard.After waiting 2.5 hours for them to arrive,I was told by the patrol men that if they filed a police report on the hazard it would put a point on my driving record.Obviously I declined having one made because this hazard was not of my making.The Officers who arrived on the scene were Officers Hanna(Badge number 15079)and Montano(Badge number 15123).The Log number that was filed was Log 2427.The local office(for highway patrol)recognizes this as a call on the 19682 Graveyard shift.Their phone number is 925-646-4980. By hitting this pothole,my car sustained the following damage: Two damaged wheels One flat tire The car was out of alignment. My car is a 1992 Honda Accord BX,two door. I found that the only place that I could get wheels was through the dealer(Honda).Therefore I ordered two wheels from Honda at$165.00 each,plus tax.Please see invoice#164012. 1 have attached an estimate from Firestone,which does not include tax,for the rest of the repairs.As you can see from the estimate,he had a problem with his estimate program. After checking with Goodyear,I found them to be more reasonable.I had the work done at Goodyear,as you can see by the invoice#058130. I am requesting a total reimbursement of$539.36 for charges incurred for repair to my automobile.I have both wheels in my possession,if you would like to inspect them. My charge is Failure to Maintain County Roads in Contra Costa County. a Please sec attached photos of pothole and the damaged wheels.There are pictures of the pothole taken on Sunday night,and pictures of the pothole taken on Monday the 6`}',where it had been patched.Today is the 86,and the patch has worn out again,and the hole is as deep as it was three days ago. Your prompt attention is appreciated. Sincerely, r , Connie Joyce 503 Camelback Road Pleasant Mill,CA 94523 Phone 415-977-7908(work) 6� 6 i.. ++E ao Ilk Ilk G � S43 2 �,* . s Rulg �t % & k �5 die 3 k y S.L 1C11y �^ ssh�yy G M�v��rf�,�see��,y�,y�** AILIkily ROVI 0"{�iT #://���-0y, �Ty �+:7' � }}} ,'t ?..:« � ��NA4�� t TEkt'fF w,xA�A t `. #�C7WIYRC`� .' f � �. � �I c�yy ISA ufib� �tt�M AKA ft A111"11)], � - 04 to, o '0 00 ' ;C4 i E i1 1 � � r l '� �2 C c`d iW 4 P TVR 1T{`,t.11C)RIMAL, 1{1 ti 7 . >`st�tfdiBR Fe k%, ......-....... cf..., r=.2...x..4 _. JA RA 1 'C i a , GBFiM F.0,8,POINT" :.r CAH CONCORD CA t ' a i! s 'fO ;." .. ; 0.00 rA AmmunaptIve Ism .:Per THANK YOU F'OR YOUR **WE ARE OPEN WEEKDAYS 8AM TO 6PM*** ( ( ( ( ( (OPEN SATURDAYS 8AM TO 4PM) ) ) ) ) ) PARTS 330 .00 BUSINESS! WE GREATLY APPRECIATE YOUR BUSINESS* SUBLET >SMOE. .TIM. .BRENDAN. .BILL«< FREIGHT 0 .00 -------------THAN -YOU! -�------.. ------- SALES TAX 27 .23 ` C OtJJ�R'S SIGNATURE q TOTAL 357 .23 WARRANTY DISCLAIMER:The only warrantipplying to this part(s) are those which may be offered by the manufacturer.The selling dealer hereby expressly disclaims all warranties,either express or impTled, including any implied warranties of merchantability or fitness for a particular purpose,and neither assumes nor authorizes any other person assume for it any liability in connection with the sale if this part(s) and/or service. Buyer shall not be entitled to recover from the damages to property,damages for loss of use,loss of time, loss of profiny§iv"R aryY&y incidental damages. R" nownlL ' Replacement Fargo Limited d arr my (Effective for Replacement Parts purchased on or atter March 1, 1990.) Time and Mileage Limits Darts Warranty"has Isis Except for bahrides a nu fairs,automobile parts supplies,by the Honda The only v`wa:r'antios applying to this perils)are those which may be Automobile Division- of Amer can Honda and purchased from and install- offered by the manufacturer. The s¢iling dealer hereaby, expYess3y ad b;1 an authorized-Honda as t omob;le dealer are covered for 12 months disclainns all warranties either express or implied,including any implied or 12.000 miles from the date:installed, whichever conies first. Honda warranties of mercharntabiNy or ffness for a Particular purpose, and .arts distributed by Americas Honda and ournha-ed from,but not instal(- tie.aher assurnes iter authorizes any other person to assurne for it any ed by,an authorized Ronda automobile,denier are covered for 12 months from the date of purchase. Replacement baiterr'es are covered for 36 liab^ity in connection with lite sale of this parha)and/or service. Buyer months from the dates of purchase, Replacement mufflers have a limited shall net be entitled to recover from the selling dealer any consequential lifetime war raniy, damages, damages to property, damages for loss of use, loss of time, Warranty Coverage lass of profits,or income,or any other incidental damages. Honda Motor Go,, Inc,will repair or replace, at its option, any genuine To Our Service Customers: Honda Part that is detective iri materials or wuork Wattship ander normal Our usual charges for labors are not based on actual mechanic`s time, use but are simply our prices for particular jobs. Parts,oKcept`Cir batteries and mufflers,that were set(,'and installed by an You will be char ed no more than the estimated rice approved b' you. authorized Honda dealer wr.�be repaired or reclaced without charge far However,if we discover that different or additions repairs are indicated, parts or.rbor parts.except for ba t,eno4 purchased;from but not installed you will be contacted for your advance approval of a revised esti€mate, by an authorized Honda dealer wil.be repaired or replaced without charge for the parts,but labor charges will be your resporis bility. Song-Beverly Warranty Act Notice A defective replacerne;,t battery 1ii,15 be replaced tree-of-charge during the t. Customer Is hereby notified that the said property is riot insured or first 12 months ;f tie battery fails after the first 12 months, you will be protected to the amount of the actual cash value thereof, or otherwise, giver;credit toward the'purchase of a new battery, figured at 1t36 of the against loss occasioned by theft-fire or vandalism wh,e the property remains current>uqW€sled retail price for each rnomh remaining in'tie 36 month with the dealer.2.Customer states no riptides of personal property have period. No cash reirnbui serment will be made,Any service or installation been left in the vehicle and dealer's not responsible for inspection thereof.3. charge,viii be at your expertise except during the 12 month tree-of-charge The dealer is not responsible for unavailability of parts or delays fn paras replacement period, shipment beyond dealer's controi.4.Clue to the type of service requested All parts supplied under this warranty o0ll be genuine Honda parts,and all sonne repairs must be sublet,5.All charges for repairs including labor and parts eeplaced become the property of the Honda Automobile Divis3cn. materials furnished are due and payable simultaneously with the delivery of f'tas Warranty Does Not elver the within described vehicle or prier to delivery upon the expiration of three ,3)days after notice that the repairs have been completed.Notice shall be • Paris distributed or scald outsrde the U.S.,k'ue,,to Rico,and the t;.S_ deemed to have beeri given upon the deposit in the United States nall, Virgin islands, postage prepaid, of written notification to that effect addressed to this • customer at;he address given on the Authorization For Repairs,6, if ffe Parts fn5tatied in vehicles'ar racing or competition. vahicle described herein:is not called for within throe(3)days after such • Any;.,art for which applicable proof of purchase date,ir:stailation date, notice is given,a stelage charge of$25,00 per day will be made for each day and vehicle rmieago at time or installations not presented. thereafter.7.Said Dealer is authorized to deliver the vehicle described herein a Any parts that are considered normal maintenance items, which are or any of its content to any person presenting this retieipt.8.In addition to any replaced,cleaned or adjusted as nor.-nal Owner maintenance unless they and all Cher legal rernodles available.T authorize Said Dealer to have a lion are defective in material or fncfory workmanship. on the vehicle described hereon of all charges for repairs,including labor and parts,storage andlo's loving,and to enforce such lien.Said healer is hereby f parts replaced under the New Dar I...imited Warranty, expressly authorized resell said vehicle at public auction after giving a twenty • Deterioration of any pa„clue to normal use and exposure. (20)day lwitten notice by certified mail to the legal owner,registered owner, • Farts installed in,a ear in which the odometer has been aitered,or on and Department of Motor Vehicles of intent to do so.On the sale date;the which the actual mileage cannot be.determined, vehicio shalt be sold to the highest,rash bidder and the proceeds of sale must be used first to satlsfv the lien plus storage coats and costs incident to sale, • Tires,which are covered by the tiro manufacturcr's warranty, and the halzance shaft be forwarded to the legal Owner,or if none,to the To Obtain Warranty Service registered owner,or it the address is unknown,it shall be forwarded to the Department of Motor VeNcles,0.If any such charges remain unpaid for thirty The defective part,or the car it is instancein, mast be returned by the (30)days after such request for payment,Said Dealer may also refer Such purchaser to an authorized Honda autornobile doaler during norr_al service charges to its attorneys for collection and the customer will pay a reasonable trouts,You+mus°provide a rnceipt trial shows proof of purchase as well as the attorney's tee. installation data and the rnilesge at time of installation,if the installation was done by an autbor zed Elands automobiie dealer.If the car is not driveable STATEMENT CONCERNING AMENDMENTS TO THE because of a defect covared by this warranty,call the nearest authorizedSONG-BEVERLY WARRANTY ACT AS FOLLOWS: Honda automobile dealer for towing<assatzncs,You will not have to pay for "A buyer of this product in California has the right to have this towing if1he detect is covered by this warranty. product serviced or repaired during the warranty pealed.The war- o a armor get warm:v service,or you are dissatisfied with the service or a rainly period will be extended for the number of whole days that the III vvarrarnty decision,speak with one of the dealership's managers.Generally, product has been out of the buyer's hands for warranty repairs.If a Problems can be solved most effeciive!y this way, if you need further defect exists within the warranty period,the warranty will not expire assistance,ask your dealer for the number of the Honda Customer Relations until the defect has been fixed. The warranty period will also be ,office that serves your area, extended if the;warranty repairs have not been performed due to Disclaimer of Consequential delays caused by circumstances beyond the control of the buyer,or Damages and Limitation of if the warranty repairs did not remedy the detract and the buyer Implied Warranties notifies the manufacturer or seller of the failure of the repairs within 60 days after they were completed,it,after a reasonable number of Honda disclaims any responsibility for loss of time or use of parts Or vehicle ire attempts,the defect has not been fixed,the buyer may return this which the marts are installed,transportation or any other incidental or corse- product for a replacement or a refund subs eat, in either case, to quentrad darnagc,Any iinpifed warranties, lr fciuding the implied warranty of deduction of a reasonable charge for usage. This time extension n;erchan,abisity and fitness for a particular purpose,are limited to the duration, of this vint,en warranty. does not affect the protections or remedies the buyer has under Some,talcs da not allow limitation on how long an implied warrant{iasis,or other Taws," the exclusion or iir;nitation of incidental or consequential damages,so the California Health & safety Coote section 25249.6 - Propo- above limitations or c.xciirsions may not apply to you. eitiOn 65:Sorme of the rnweria's being removed and used during the This warranty gives you specific legal rights,and you nnay also have other servicingOt vehicles are known to thea State of California to cause cancer,birth rights�,vhich vary from state is stato. detects or other reproductive harm. Honda Automobile Division,a division of American Honda Motor Co.-Inc.(a.California Corporation),offers these werrantles on behalf of American Honda, '100 Fest Aiondra BOLJ}evard,Gardena,California 90248-2702, :.'.;' 1990 American Honda Molar CO... Inc.•All Righ#s Reserved OK-131426(BACK) BRUC"ES SUNVA'ILEY GOODYEAR. 625 CONTRA COSTA BLVD. � CONCORD, CA 94523 �« (92'3I)6Ss7--535.3, BAR reEi:# AH17 027 =EI.1E.FtAL TAX II)# 880293170 o3/06/0o 03/o7/00 10-24 4M 03:59 PM TERR: 5242 F`AGE: 01 NONS I C: 905242 BILL TO: C.ONNIE: JOYCE 03 CAM!ELBACK PLEASANT HILL, CA 94523 PHONE 1 . . . . . . . (925 )691 --4853 VEH Yir(ArZ/i~'1AKE. 92:' HONDA }=HONE 2, VEH I CL.E MODEL. ACCORD DATE. RE QUE;3'7 ED r-'r3/o6/o() VEHICLE- COLOR. rAi\i J+, TIME REQUE3tI'E'%1 LICENSE/STATE. 3I)YM,809 / CA RETUP N Fr AR'r . . NO ODOME.TR IN/OUT C 0839 / 60859 SALESMAN. . . . . . c 05, / 015 F`R I C3R INVOICE. 1035,7126 ACCOUNT t COB TC CUSTII TYPEISTATE AUTHORIZATION CREDIT CARD NO. 524200051 V 01 36537 0 CA 381474 HDC 43OBS14130075014 SLSM TECH PRODUCT CODE BC QTY DESCRIPTION PARTS LBRIEXCISE LINE TOTAL 005 478 040-265 R I REPAIR AUTO TIRE FLAT .00 .00 .00 0005 078 047-100 R 1 LOOSE WHEEL .00 .00 .00 005 078 040-101 R 3 CHANGE AUTO TIRE, DISMOUNT L MOUNT .00 GAO 8.00 005 078 041-oe3 R I NEW VALVE STEM 3.00 .00 3.00 005 078 044-263 R I WHEEL BALANCE - COMPUTER SPIN 1.95 S.00 4.95 +005 fl78 078-162 �c 1 COMP 4 WHEEL ALIGN tAUDTL REAR iHL CNGi .00 59.00 59.fl0 INSPECT TIRES. ADJUST AIR PRESSURE - INSPECT STEERING AND SUSPENSION COMPONENTS - hEASURE AND CORRECT ALIGNMENT ANG-ES ON FRONT AND REAR SHIM ADJUSTABLE WHEELS - PROVIDE PRINT OUT WITH MANUFACTURERS SPECIFICATIONS - (SHIMS AND LABOR EXTRA WHERE REQUIRED} 005 116-023-599-0 R 1 P195I60RI5 87T S1 EAG GT 11 BSLRPTL 80.52 .00 80.52 QTY. I NO. MDV9FXHR499 305 078 041"-263 R 1 NEW VALVE STEM 3.00 .00 3.00 005 078 044-263 R I WHEEL BALANCE - COMPUTER SPIN 1.95 8.1% 9.95 0105 001 093-001 R I TIRE DISPOSAL FEE .00 1.00 1.00 BRUCE'S SUNVALLEY GOODYEAR APPRECIATES YOUR BUSINESS - PLEASE COME AGAIN M-F 7:30-6 SAT 8-4 SUN 10-4 HAVE YOUR NEW GOODYEAR TIRES ROTATED EVERY 5,000 MILE FREE! PLEASE CALL AND MAKE AN APP NTMENT.THANK YOU. IF APPLICABLE. r I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF AN INCREASE IN THE ORIGINAL ESTIMATE PRICE. SIGNATURE PARTS TOTAL........ 90.42 t CHARGED AMOUNT 182.13 LABOR TOTAL........ 84.00 STATE TIRE FEE .25 SUB TOTAL.......... 174.42 -r�ti' ---- TAXABLE AMOUNT 90.42 SALES TAX.. 7.46 STOMER AUTHORIZ f TAL 3C IIq Cl I RwEK -T-+fib"F-, I_... 1.� iia I ; AUTHORIZED BY. CONNIE JOYCE AUTH RECD BY. ISMAIL BANNER REC'D.. IN PERSON AUTH PHONE.... 000-0000 AUTH DATE..... 03107100 AUTH TIME..... 01:00 PM REVISED TOTAL. 1714.67 ADD'L AMOUNT.. 157.17 REPAIRS DESC.. AS DESCRIBED ON RID F=- F:�E:'4''IES'.FR S F= S31 ILS I C3 F-< 31 t` f-P�+C3FR'r*c�t,%A.-r SAF=- -r_` F-R" 1 i'4 C�; 14 tom"TD tail F;+ R;*24 -7"'Y :f.:.' th-4 F�"(3 iF-I-f�'A-T" 3C C3� i f ROHM#GSMS-009 12199 r FORM#GBMS-009 12199 t FORM#GBMS-009 IPJ99 _. 3,b. _ ...0 L as Q,on Etc Cv , _._ �s Num WA: whVY" wGi ten tom 1 , ; eon >C.. NOW we Any h£. !"A it 111A zw A.. ,e: mr t, .,. _ CLAIM BOARD QESUP R'IrISORS OF CONTRA COSTA COLTNT'Y, CAi If AMIA BOARD AC7I01*rE APRTL 4, 2000 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the 3 - Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and M AR `4 � 915.4. Please note all "Warnings". AMOUNT: $16,483.20 COQ; —1y COUNSEL MARTINEZ CALIF* CLAIMANT: Shantell Pervoe, Guardian of Ashley Lunnie ATTORNEY: c/o Manny C. Martinez DATE RECEIVED: March 2, 2000 2049 Century Park East, Ste. 1100 ADDRESS: Century City CA 90067 BY DELIVERY TO CLERK. ON: March 2, 2000 BY MAIL POSTMARKED: February 29, 2000 I. FRONS Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 2, 2000 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. { t/This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.$). ( } 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: By: �- y. d � 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 7 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: ? Zr ice, PML BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: L -2 , ? \D By: PHIL BATCHELOR By eputy Clerk r CC: County Counsel County Administrator 4CTOR J.WrESTMAN DEPUTIES: Yet PHILLIP S.ALTHOFF COUNTY COUNSEL JANICEL.AMENTA NORA G.BARLOW B.REBECCA BYRNES SILVANO B.MARCHEtiSI �++��� pq �n �+ K{-g-�� ANDREA W.CASSIDY CONTRA COSTA OUN ► MONIKA L.COOPER CH IEF ASSISTANT COUNTY COUNSEL VtCKIE L.DAWES OFF'CIE OF THE QUO COUNSEL MARKES,ESTIS SHARON L.ANDERSON MICHAEL D.FARR G` 24E7INIu7RA71ofiT BE71LC51StC�:;- LILLIAN T.FUJI I ASSISTANT COUNTY COUNSEL PfN STREI�T,• #t LOOR DENNISC.GRAVES JANET L.HOLMES GREGORY C.HARVEY MAF IN R Cz,�tLC { t #{ k�t3^I2 9 BERNARD L.K BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. BEATRICE LIU MARY ANN MASON GAYLE MUGGLI PAUL R.MUNIZ VALERIE J.RANCHE OFFICE MANAGER STEVEN P.RETTIG DAVID F.SCHMIDT DIANA J.SILVER PHONE(925)335.1800 BARBARA N.SUTLIFFE FAX(925)646-1078 NOTICE OF INSUFFICIENCY JACQUELINE Y.WOODS AND/OR NQN-ACCEPTANCE OF CLAIM TO: Manny C. Martinez Law Office of Manny C. Martinez 2049 Century Park East, Ste. 1100 Century City, CA 90067 RE: CLAIM OF: Shantell Pervoe, Guardian of Ashley Lunnie Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ l l. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ]3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Page 1 [X ] 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. WESTMAN COUNTY COUNSEL B 1 Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 3,2000,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§914,910.2,920.4,910.8) Page 2 1 � MANNY C. MARTINEZ A Professional Corporation Two Century Plaza (310) 203-0290 2049 Century Park East,Suite 1100 (310) 203-33015 Century City,California 90067 February 29, 2000 '3 CLERK OF THE BOARD OF SUPERVISORS MAR 0 2 2000 ROOM 106 CLERK BOAR0 OF SUP ERViSORS COUNTY ADMINISTRATION BUILDING CONTRA COSTA Co. 651 PINE STREET MARTINEZ, CA. 94553 ATTN CLAIMS Our Client Ashley Lunnie (Shante.11 Pervoe Guardian Of) Date Of Loss : 11-02-99 Claim Number S103799GG Your Insured Durham. Transportation, Inc. Dear: S i r; Enclosed herein please find medical reports and statement of charges for medical services rendered to our above- mentioned client in connection with the above-referenced loss. For your convenience,we are also setting forth what we consider a fair settlement offer to bring this claim to a close. Further,our client may require future medical availability as these type of injuries are noted for their recurrent symptomatolgy. Moreover,note roust be matte of our client's loss of earnings capacity relative to the limitation of the nature and quality of his physical activities resulting from this loss. Based upon the magnitude of this accident and the physical injuries Sustained by our client,we are demanding the following sum as full and final settlement of all claims arising from this matter. Therefore,in light of the aforesaid,$ 16,483.20 would be considered a fair and equitable sum to compensate this individual for this loss. We look forward to hearing from you within the next few days in order to conclude this claim. If you have any questions or if we can be of any further assistance,do not hesitate to contact our office. Sincerely, LAW OFFICES OF MANNY C.MARTINEZ A OF'ESSIONAL LAW CORPORATION 1 , L Y Manny C.Martinez,E MCMJFC Encl.. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY J 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 100'' day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988,must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code§911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 94553. C. If Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity,separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim by ) Reserved for Clerk's Filing Stamp SHANTELL PERVOE GUARDIAN OF ) ASHLEY LL)NNIE pp� �tECE0VED DURHAM TRANSPORTATION Against the County of Contra Costa MAR 02 or CLERK Et,a r'_ 0Ai i r.. District (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of 516,483.20and in support of this claim represents as follows:- 1. When did the damage or injury occur? (Give exact Date and Hour) NOVEMBER 2, 1999 4:30 P.M. 2. Where did the damage or injury occur? (Include city and county) -+------------- ------------------- SONOMA STREET RODEO, CA. COUNTY OF CONTRA COSTA - _ 3. How did the damage or injury occur? (Give tVtII details;use extra paper if required) --------------- _____ .BUS HIT PARKED CAR AND MINOR CHILD WAS THROWN AROUND ON BUS AND WAS INJURED, WAS LEFT 40 MINUTES UNATTENDED— BUS DRIVER HAD NO DRIVERS LICENSE IN HIS POSSESSION. ------------------------------------------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? THE HUS DRIVER HIT A CAR THAT WAS PARKED AND NOT MOVING. (Over) •auU pun luamuosuduxr Bans gloq Sq xo '(000'01s) sxnllop punsnoq#ual 2ulp=xa lou,lo au0 n Sq luosud awls alp ui;uawuosixduxr Sg xo'auU pun luamuosudmi qms gloq Sq xo '(000%) sxnllop punsnogl auo 2mpaaaxa lou,lo auk n Sq 'xnaS auo ungl axom lou;o pouad n xol Irnf Slunoa agl ur luamuosudmr Sq xaglp algngsrund si luilu u xo 'xaganon'lunooan 'lpq 'mrela lualnpnnx;.xa asln;Sun 'aulnua .(i amus aql Snd xo ,i+olln of pazuoglnn'xaaU3o xo pxnoq laulsip xo Slr) Siunoa Sun of x0'xa3ujo xo pxnoq alms Sun of luauxSnd xol xo aaun.#Aolln xoI sluasaxd'pnnxlap of lualur glx,u'ogm uosxad Sxan�„ :saprnoxd apo0 luuaa agl,lo ZL uorlaaS aallom "opt auogdalas 06ZO—COZ-01£ "oh auogdalal 850G-66L—019 (ss;)Jppv) ZLSV6 'VO 0aa0d ',La2[HLS VSOdIMM PUT xnlnxx2iS�,jumuj% 4 L9006 ''fd'O 'xsl0 &anj a3 sauxollv,lo ssaxPPy Pun aarom 216 SH0IA M 11 «"3ingaq siq no uosxad autos Sq xo (Sauxo4v) :O,L SaDILON QKaS lunmrnla aql Sq pauSis aq isnuz mP✓(a aUll :sapieoxd Z"016 -JaS apP0 *xO9 t not � Wall aly(I :Sxnfur xo luappan sigl Io lunoaan no apnm nog saxnlrpuad"aql lsr'I '6 ___..___________________..________..____.._______._________..____----_______.,____.,____a__,. HalmaO `m3iciax samo0Q ' -3,a HZixs 'El (IHV I'IIM °slvlldsoq pun'sxolaop'sassau4!mjo sassaxppn pun samuM "g ------------------------------------------------------------------------------------- Y/M (•aSsu mp xo SAnftq anpaadso id,fus 3o iunouus paisuimo atp apupui) ypalndwoa lunocue pautrela aAogn aql s,O&eaoH •L ------------------------------------------------------------------------------------- )LHf 1KI H'IX1w V IHOIH 'X2 arKI HaNX IHSIH ')T.IitIrNI UR([r L1OHS ZHHJIa "NIVHSS RVEN I 'NIYUcTS W3I1 H23 (.42stusp0tng .xo3 salsutpsa om;ip-l;y paupsia saistusp so npn(tq 30;uaxxa in att9) Zpallnsax minla nog op sawn fur xo sa2nmxrp lnr(M '9 Z.Unfui xo agnuxnp aql Sursnna saaSoldura xo'slunnxas'sxaaUp lauisip xo Slunoa,lo saumu aql axn ingm, ', 5102681678 W I L LARD B. SM I TH �� 2 PO4 FEB 22 100 14:56 1 �• Tt>daty`a�atetPatient Progress Report � Paufrrn Nona ,�` . How are you foolirt0 today? 13 Better a W«sa Same jak: Where Js your pain today? 1)Neck 13$,fight 13 Left ,.■Oth Ire ornation,Taken Rv- ) Both Mid back a Loft a 3t i FWN 4)Lo back a Right fl Leftlith "j'reahmeTt 3) �+t 17!tight 13 Loft D Both 0 6) Hip G Right 0Left C3 Both ) Thigh 13 Right a Loft a Both 7 7)Knee A Right (3 Left 13 Bctn 9) ..04ftht 0 Left C3 Both C T1 encs: ...0llisin C Lott 12 Both 110)Loarla�iioa fl Right 13 Left a Both � fl C eat th WI=is your patio worse! hlornfagAftvMoon 96vaning Wbat activities of daily livrsg aro you atilt baving"tibia baaause of your !Pain" .41 S)13 Lifting 0)0?sshingtPulling s F)CIURTSrilng ving 10)Cl Work rng g above your shouklors4 sodtag Stairs i Totfay's 01tat Patient Progress Report Yatieln Natr�: I. How are you fbel" todtry't 0 Better 13 Wotxe a Same >i'itort is your pain today? ! �✓� 1)heck 13 Right Q Left Both lhfoJ12t18t14nTakenBy: 2)SSoulders iskt 13 LeftC3 C Both Mid Uck IMN 4)Low back a Riot fl Lift oth Tledtfl7.Mt S)Cbnt Ci ht C]Left a Both SLOG 6)Hip 0 Right D Left 17 Both i)Thigh 13 Right fl Left 0 Both $) Thigh t 13 Left a Both 2) A� �t C3 Lett fl Both Comments: 14) slat (:l Left 17 Both Leg 13 Right (l Loft a Both il)?ittpain cs Cl or G Both .r'�' Whist is your pairs worts? oming fteraaaa fl ening What sotivMHes of daily 1�you still having trouble boosuse of your pain? l as S)©Lifting 9)a PuAirv?utling +6)13Driv4 10)M Work 34) S 7 $teaohiag above your shouldort roll6diag 8 !:?Using 9tairs I Today's Dare: Patient Progress Report Ment Nam!i How are you IbcHog today? fl star 13 Worse l The Satuc 1�/00/0 When is your pain today? 1)Neck 0 Right a Left .8.1oth Infbimation Taken By: 2)Shouldersfight C7 Left G Both 3)irtid bask ®Might a Loft Cl Bp�h ' ,�c �MN 4)Low back 17 Right ❑Loft ..Xg"?t.th TTealbrI 3)Cheat 0!lista n Loft A Both LOG Yip 0 Right 17 Lace a Both ) l fl Right ? O Loft Cl Both 7)Thlgilt 0 Bight C1 Left O Both 4)Atrnthe 17 Lift 17 Both ti'. : iQ La „ Right 0 Loft 17 Both s ❑Right 13 Left a th C 11}Hoadaehes �t fl La€k .�Both One is your pail) wom? otning ja-K raooa aEveniag NW activities of .ly living are you still having;trouble bucsuse of your �potitt7 g 3)fl Lifting 4)0 rushingmul?ing 6)a iviag 10)fl Work 3 ins 7r n9-obovv your shoulders 4 Rg g}®Clsitts Stairs 5102681678 W i t LQM S. SM I T7-t P05 FEB 22 ,00 14:519 Today's Data, Patient Progress Report za E Patient NtRn c I J cry How Mit you fe*Way? aftr a VOW Aft 5ama Da Whwe 1s yo+a'gala today? i 1)Nock Ettght 0 Left 0 Both hlfo T'afio l Taken ` { 2)Shoulders 0 Right a Left 0 Both --•••••� .r•��•'� 3 Mid back a Righz a Loft 0 BBo=.A MN A)Low back 0 t;lglhz 0 Lett ,— th T3't "lit nt �}C2t t a Right 0 Left E3 Bath LO() M Right ❑Left 13 Both 6)Hip y) Thigh Cl Right O Lett Ci Bath ! S) Thigh Knee 0 t M Left �Bath 9) Atte lot 0 Left Cl Both t�"t��r merits: 0'/v ght 0 Left 0 Bath 10)Leg Cl Right 0 Left 0 Both )1)Headaches Cl ttd t C Loft 0 Both i Warn is your pain wotaat otriing m "a Whet activities d daily living areyou ll ha '""4 trouble because of y= - pain? $Zit 5 Loh'it 9)0 Pttsttittg/HUM-le 6)"rivfug 10)t3 Work 7 aching above your shatti&n 3)Clusia;Saul f To*'*nate. Patient Progress Report l Patieent Name: How we you fettling today? Botta, Ct Wow t=1 The Samee: Whoo is your pain today? , 1)V.40k a Right 0 Left 0 Both Infol ion TakmB : 2)Shoulders 0 Right Ct Left 0 Both 3)Mid back Q Right a Left aB 'h FAJN 4 Law bKk M Right 0 LeR oth Tre&nent 5)Chest 0 Right CI Loft 13 Both i LOG $}Htp Cl Riglht 0 Left 0 both nigh ?Right 13 Left C3 Both sdal a Right 0 Left 0 Both 8}Keen 9)AM Right 17 Left 0Both t<9: 0 Right 0 Left 0 Both s 1ll 10)Lag Wb ❑a 0 Left a Both ti)Haadsah0ea bt Left Both /'"'_ ' 0 I When is your pain wora*s4T"O*Morntng 13 Aireraoo5,„rr aysnitig What ahxivi�d. of daily living aro Stitt having,trouble because of your pain? =TAS Szfdag 9}t3 p'csbingtPulling 210swft 000fivistg 10)}0 Work { 7) ng above yeti shoulda t; it )DUSIAg t + I Today's Oath Patient Programs Report Patient Nwe: aft>w sits you foeifng toaay7 , i3ocmr Q Worse 0 The Same .1da/ 1 F Wham is your path today? -� 1)Nock a Right 0 Left Cl Bath Infomudmi'TalamenB 2)Shoulds" 0 Right a Loft0 Both i 3)Midbeck 0 xlght 0 Loft Q Bath kN 4)Law back 0 night 0 Left �irYdoth "T ix)terlt 5)+Chest Cl Right 0 Left 0 Both LOG ti}Hip 0 Right CJ Left a Both 7} Thigh b IRiybt n Left 0 Both 6} iLnse 0 Right 13 Left a both � a Right 0 Left 0 Both con awlts: 9)Asch 0 Right 0 Lott 0 Both 10}Leg CI blight 11 Left t7 Bo t 11}Fteadaahes 0 Right 0 Left h Whea is yehm pain worm? 0 Morning IeAftm. b.'ening 'ABI Sati.atter of dally living are yoII tt Xavirg tyle t:�ia s sof your pa:a7 I)CIVIDjas Ksfug 9)0 Pushittg,nuing S ; tag 10)0 Wolk "inWS 6 Naruxii., tt above ycnhl shsouldtt3 ' 3( C1Bppd stairs 3. 510261 lVe W E_E.ARD B. SM I TH _ 1 POG FEB 22 '00 15:00 Today's Data: Patient Progress Report Flowaro YOU fool #toa►i 7 ,j f`l#atter i7 worse Q rbr s„aa 'mac c Whare ieoat polo rods ? Y N .� �>x� a Right C3 Lett cth Ti'&rmation Tak�l1 By: 2y Shoulders 0 Right a Lett a Both 3)Mid book E3 Right 0 Left a { ,PAIN 4)Low back a Right a Left eth "i'ream7t m S)Ghost a might. 13 Left a Bath _LOG 6)ch a Might 0 Luft a Both 7} Thigh Right 13 Loft a Both CI Tt 8)Knee CI R.igt a Left a Both igbltt Cl Left a Both (:tYIZ'�'12C#1'CS; 0)Arm Cl Rigbt 0 Laft 13 Both 10)Let m t C Left a 11)headaches a Right a Loft oth Who is your pain worse? CLUomIDS ,rz" A.1`5,+ening : :What activities of daily livinf as you sMI bavtng ttoubto because of your pain? S)OLINag 9)13 pushingr'Pulling ti# 6}13DAviag 10)0 Work din 7 a Rs #:tg# 2"Ousitti s�above year ahatt3ders OM0Today`s nate., Patient Progress Report Patient Nstno; ! Haw are you feeling today°y,�Oettsr 13 Worse 0 The Sarno Date: f Wharc is y9w pain today? 1)Neck a Might a Left �h Iz3fo3:tt%doll Taken By: 2)shototden Cl Right 0 Loft 0 Both Mid back Cl Right a Loft a h PAN 4)Law took O Right Cf Left ottt Treabnoit: { 5)Chest a Bight 0 Left a Both r LOG 6}g{ip 13 Right C3 Left a Both a Right a loft L3 Both s) 13 OF Right Cl Lctt 12 Bods 9)A7Right a Left Cl Hoar C'QYYIXY2�Y>#13; 1 10) Leg 0 C3 Right a Left a Hath Right Left C7 B t 11)Headaches a 'fiC3 t a Loft oth i ! When a your prim wades? *you ng a Attroub) 13vf your What eativitles of drily t wing ora you still having tdtrssbl a of��o+rr pain? 1)C3Watking 5)CaLifting 9)a Fushins/pulling r 2}CiSitsfng 6}01'3rsving 10)a Work 3)OStandiug 7)C1Reaching above ycu sboWders t 4)C10mviing S)QUsing Stain i ! i Today's Data: Patient Progress Report � i z=nderti Norrie: ,�r� Hove are you feels g todalyy-�-WTW-w t3 Wane ❑The SatrtG /r�T a Whom is}roar pant todey4 1)Nook C)Riot a Leff oth Infotrna tion Uma : 2)shouldem 0 Right a Loft a Both 3)Mid back a Right 0 Laft a alt PAIN 4)Law bank a Right Q Left „,.i ih T�tr ��..� Chest a Right a Left a Both - i LOGa Flip Right Q Lett t3 Both 3} 6) Thigh night t3 Loft a Both s i g) La Right C1 Left a Both C3 Right a Left a Both Comeft: 1 10 t�R.ight 0 Left a Barth a Might a Loft Cl 1, i i1)3teatirCltoa 0Riot 13 Left nth i When is your paid Warne L7 Manias VISeraoon 5A4ja# What aetivitica of daily livingyou 0111 ars 111 b6ing trou$ls beoausa of your f pin? 1)aWsuing S)Uffiftin$ D)fl Puthiogmii1.ieg ! 21$ , # 63 Q Driving 10)Cl wont 3) 7)9fts&UV abort your shoulders 4)allending polus ng Stairs 5102681675 � W LL.ARD B. SM r TT i � P07 FEB 22 '00 15:03 bdtg halo Patient Progresa Report 4 xatn ,�• �"'�' Maw are yeti fe1709 todaty? Cl warts 0 The Satire Imo; l I' Virisere is your pain today? 1)Noak C3 3tlght Cl Left 0 Both Infon atioliTa cenVC 1)�= D Right C Lett ' Cl Both 3)Mid bank C!Right C Left C3 Both a) w b" C3 Right 13 Left ,24otb Tre&nel�t< t -•..--��— S)Chest 0 Right U Lash i3 Both L b)blip 13 Right Q Left a Both thigh t3 Right (3 Left 0 Both 7) Cl Right Cl Left Ca Both S)Knee! CB Right Loft C3 Both � a� g} Arm d 0 Right f�L*ft C3 Hath 10)Leg Cl night 17 Loft a Both /�� 11)Httadacbea f3 Right 13 Loft otic wit"is your pain wom? Cl M'orniag 0 Aftetaoon Cl Evening ;What eotiviiits of daily living ora you still having trouble because of your +gain? 1)C3 Walking 5)13 L!fdrg 9)0 P,-hiwn&g / 3)ositing 6)0 Driving 10)13 wotie o1}t3Snadiny 7)Ciltakhttng above your shoulders 4}ClBoadixg e)t1[7eittg Starts Today's Dat*n,#ctod*y? Patient Progress Report Patient NamION � Haw aro you Buser 0 Wo -no Same Date; �. What*is your psis today? f 1)D1eak Cl Right 0Left El Both inf$riulikIlTakeenBy: - i)shoulders f3 Right 0 Left 13 861111 3)Mid bank QRight 0 weft C B �riCi th _m r l 4)Low baek ®Right 17 Loft .�+^+L7'8oth lf-PAN C Might C3 Left Q Both I LOG 6)rKlp 0 Right O Left ❑ 86th 7)Thigb [l Right 13 Loft a Both B)Kase 13 Right U Loft C3 Roth { C3 Right Q Left 13 Both Comments- 9) M Right 0Left U Both 10) a Right 0 Left Q Both 11)Headacbta C3 Riga a LaCt a Both y Whm is your Olin woke?0 Morning U fsftentom 0 Bwning What xativitioa of daily living are you still having trouble btcause of your pairs? 1)Cl g 3)0 Uftiag 9)i3 l"ashiftepulling 1)CSitting 6)UDrivitig 10)0 wank 3)QSUoding 7)13 Reaching above your shoulders 4)t333ending S)C.U$Wg Stain i i I i Today's Orae: x Patient ProgressReport ! Pittiezx NAme: Iz i lYcw ora you faati S t6dey? p=&xtcr Vti C1 The Sana �; 1 Where is year pain today?,+' 1 i 12 1)Nak 0 Right: D Left Ci Both InfomitionT CC11$�: t 2)Shoulders f5 Right 13 Left 0 Both i 3)Mid b"k 13 Right 13 Left C Roth 4)Low back 17 litt}ht U Lett 0 'Both TTY.tt#ilY?.t1tr MN 5)Chest a pjsbt 0 Left 0 Both ( kBp a Right 13 Left 0 Both 7)Thigh G Might Ca Leif C3'.Both Le 0 Right 8)Kant 1Let fl Both f3 Right C Left E7 Both 9)Arm 17 Right Cl Left a Both ' 10)L45 C3 Right a Left 13 Roth 117 Ha»dads®: »Right Cl Left C7 Both !` when is your pain worse? Q Morning Cl Aotmoon '13 Evening What activities of daily living are you still having trouble because of your Pala? 1)13Watkq 3)CLirdog 9)E1 rushinImulling 5 2)Wbtiag S)C Orivios 18)13 w at 3)CStanding 7)0Rcscbing alsvvc your shoulders � '. 4)l3Beeding g)CUsingstain L . 'lbdsyt'i Name;Dani Patient Progress Report ? Patien How are you*ft today''? ., 1liew 0 Worm 13 no S.. Z<,, Wb*f* _Whetr is your pain today? 1)Neck 13 Right 13 Left Cl Barth 1nnationTh)=By. 2)shouldon 13 Right 13 Left Q Both ♦ a 3)!wdid baa$,,. 13 Right 13 Left 0 Both a P" 4)Low beck n Right C Left 13 Rath 13 Right 13 Left Cl Both T � LOG 5)Chat 13 Right 0 Left a Beth � 6)Hit` C Right C1 Left 0 Doth 7)Thigh 13 Right 0 Loft 13 'Both y S)Xao a Right 13 Left t3 Both ( ,'it9:i 9t)) M 0 Right Cl Left t3 Both LOSQ Right 13 Left in Both S n)Headaches 0 Right 0 Left C Both Wbeeo is ymr pain worse? Cl Morning Cl Altettswott 0 Evening { What activities of drily living auras you sti'li having trouble because of your pain? ])C3Waiking S}13Giitiag 9)a PusbintilPulling j 2)13$Wiaag 6)a cTiving 1 O)Q Work j 3)133tautdins 7)C1 Rca*ns above your sboWdert 4)ORanding 8)OUSing Stairs i Today's bite: Patient Progress Report I Patient Nam «w. .. How are you 4wing today? C3 eotm 0 Wa 13 The Signe Where is your pain today? • t 1)block M nightCl Loft 13 Both h&=ficu Takw By: 2)$houkters a Right C3 Left a Both � 3)Mid bade Ci Right 13 Left 1:3 Both 4)Lew book Cl Right C1 Left 0 Barth NN $)Cheat U Riot Cl Left Cl Both LOG $)Hip C1 Right ©Ltft Ci Moth Thigh 13 Right C Left i7 Bath 8)Xnee n Right 0 Left i3 Both �y � Azm a Right 13 Left 13 Botts 10)Leg a Right 13 Left 13 Both Both 1I lfeadxehem a Right ❑Left tai j 13 Right O Left a Froth � When is your pain wee?Cl Morning 13 Afternoon C 'Evening 'W%t Activities,of daily living aro you still having trouble bea:euss of you: paint I)OWalking 3)C3Lif ing 9)O PuslahwPullitng j 2)0 Sitting 6)o Ddvbg to)a WQ* 31CStanding 7)0 Raetchtng above your shoulders 4)CBarading a)Outing stairs 1 f i Today's gate. Patient Prog)mss Report Patiamt N=4 How am you feeling today? 0 Better 13 Worse 13 Tho So= When is Your pAia ttwday7 : « 1)]+teak 13 Right 13 Left 0 Both 1nfwnafi tnT iFBy: 2)9houltter, a Right 0 Left 0 Both 3)Mid book 0 Right 13 Left Q Both N 4)Law back Cl Right 1?Left l3 bath T} �; S)Crest C Riot C1 Lett f3 Both LOG 6)Hip 0 Right 0 Left Cl Both 7)Thigh Cl Right Cl Left C1 Both 8)Ifaco 13 Right 0 Left 17 Both 9)Bros G Right 0 Left C Both CZEMMM: 10)Lag C Right 0 Left 13 both l2 Headaches 3 Might 0 Left 13 Both ) C1 Right Q Lett C Both When Is your pain worse? C3 Morafng Ci Afternoon 0 Evening What activities of daily aving are you still having trouble tweeause of yow �* pain? i)CI Wteiking S)13 Lifting 9)C PuahinvMling 2)0 Sitting 6)0 Driving to)a Work 3)0Stnaxhag 7)ORetabing shame yout should" 47C)Barding 8)4Usitag 5saits � GOGT 00e EZ H3.S eed Zoe H.LIWS *E Q11:1"1=1If1 84giegeo s 520 &81678 W,LLARD B. SMITH - pol FEB 2 '00 14:48 WILLARD B, SMITH, D.C. 1103-12th Street Oakland, California 836-3836 NAME I A DATE _ ADORE P OD RES. PHONE 8U5, PHON 3IRTHDATEAGE REFERRED BY SOCIAL SECURITY NO, OCCUPATION EMPLOYED BY PIPLOYER'S ADDRESS LAST PHYSICIAN.. aUQ'�ESS 1NSU;ANnr COMP nrY I POLICY NO. 1 t ACCIDENT ON THE JOB OTHER DATE OF INJURY RECURRENCE - -_ _ DRIVER PASSENGEROTHER REAR ENDED FLIGHT SIDE LEFT SICE FRONT OTHE WhE DID INJ Y OCCUR? STORY Of IN' IRY than x,t.tti. '.yaw ttv^, v .1�>. .�� w 1/+ Wt lJt7 11AtG0 SCT t�HSA RE YOU TA . N A,FTFR TWORY OCCURR€ WHAT WAVDONE FOR YOU.THERE? 3t Tony. TIAVI. .cru M^* **HILAO.. Acr nvuTc nd fiw. € GC�LSR _ WHAT WAS YOUR HtAL I H :a I A I QS PRIOR TO TM I:! I Nclt;V T WERE YOU ABLE TO WORM PRIOR 10 THIS INJURY?�4, IF NOT, EXPLAIN ARE YOU OFF FROM `WORK, AS A RESULT OF THIS INJURY? IF YES, HOW LONG? ARE YOU TAKING ANY MEDICATION? IF YES, WHAT KIND? i OPERATION.,? BROKEN BONES? r OTHER HEALTH PROBLEMS? i crativ� Yvu +nv .s rvtr�•+1rs,/d f��Ceatw�cttc +�" tt•" wr..Y irrlr�t !'��`yd_ L!_. I1R,�J15`! r AWp' vattt aunr 61WI +rsnr+v t .+ �"{� 7v+ Z8. mow MANY MONT1114 ,. i t i i PHYSICAL LAAMINATIO14 ACE S -- HT. W7.� TEMPERATUPE a BLOOD PRESSURE � _ PULSE APPEARANCE: WELL NOURISHED ROBUST G0004944 FAIR POOR DEBILITATED FIC �tM ULt11I rik 7MPAiREt_ NORMAL iFULT PAINFUL PATIENT IS RIGHT KANDED PATIENT 15 LEFT HANDED 3 DYNAMOMETER TEST: RIGHT LRS. LEFT„ LBS. HEAL C-.SG EFiEST ! ABDOME�� i EYES!) ), V+ LUNGS UPPER EXTREMITIES f� ENT� .I,� t .� HEART ._. �.. TRICEPS REFLEX BICEPS REFLEX NECK EXAM MEAD A NICK EXTRt ION FLEXION LATE L FLBX1 FOICJrWMA R L ROTAT L compl E"m t - R TEST: Ft BACK EXAM LEWIN � L R L.1►SRGtlR R Kamp TEST: HYPEREXTENST.0 SOTO-HALT. . 'FEST: r r LRG LOwR IP TIST:-t� a LOWER EXTREMITIES PATELLAR REFLEX ACHILLES REFLEX DIAD STIC IMPRESSION: 12.,, RECOMMENDED TREATMENT: I NRu��ua�a: r TOTAL DISABILITY: FROM TO PARTIAL DISABILITY: FROM TO DATE ABLE TO RETURN.TO WORK: Y.arra ! '��s Whom Is your pain today? 1)Nock a R* 1--eft CI Beth Infim mifim Taken$y: 2)Shoulders i3 Might C3 Loft C3 Both 3)Mid bit G Right 13 Left C3 Both iPAJN 4)Low bark C Right C3 Left D Bath �B#; C7 night 13 Loft is Both 'LOG 6)�t C)Right 13 Leat 0 Bath 6)Hislglt a Right D Left C3 Both 7)Kaes. C3 RiCbL n Left C7 Both 9)Knee Arm D Rips 13 Left C1 Bath cummc= Right C Lift a Broth �,- it))Lag 0 Right 0 Left C3 Both i 11)Fludeaohhea C Right M Left 13 Both Whan it your palm arosef Ci Witting M Atttaaaoa 13 Evemittg ;What adivitlee of daily HY4 am you still having twubla boaaute of your pala7 1)0 walking 3)MLififng 9)0 PushitwFulling 2)13Sitting 6)CUrlviug 10)13 Work 3)rJBUrAng 7)®Resobing above your rlwuldem 4)0804d*4 a)Owing Stair. TodA ':Data- patient Progms Report Patient Name, /r How tut.you fbalinn today? C7 l9t ttcr G WOV4 wire Sante Date' Where is your pais today? ` 1)Neck a Right C3 Left —A-SSI t Informadon Takrn By: 2)Shoulders .2- fight C3 Left 13 Both 3)Mid bask 13 Right 13 Left 13 Bath � A rN 4)Law back tl Right Cl Left .Ci-wh TIatment: --- s)Chart C3 Right i]Left 0 Both OG b) Hip el Right 13 Left 0 SOO 7) Thigh 17 Rigbt C3 Left 0 Both B)Ksee a t 13 Left 13 Both ht C3 Left Cl Both 9)Arra 1�¢ri8t1iS: 10)Lag ght Cl Left f Both C2 Right ght C2 Left C3 Bath a 12ijht C3 Left .+L'i"f3rth I Who XAVQ-'Morning 4r-Afloraoan-ff"`Evening r, 0 'i C -�G�.•� what aodvida of daily l'iv'ing are you WE having hvubk bocaurac of your �. pain? g �) PwhingiP4liing ! 6)0 Driving IO)t3 Work 3 7Jp�eaching abovat your shoulders Stater rbaayt Dater � ' Patient Progress Report 1'atiw flame: } Blow are you fa hu today" a BMW 13 Wom A<Samc � i Wham is your pain today? _ter+ 1)Nock Cl Riot C!Left ,rg8ath ldbmadonTe CenBy. 2)Shouldersght (7 Left a Both 3)Mid hack O Right a Lett 0 gbh 1` N 4)Law buck 0 Right 0 Left oth i)Cbeet 13 Right o Left a Bath �OG 6)Kip C3 Right a Left ❑Both 7) Thigh 0 Right C3 Left C3 Both 9) Knee ,, r 4 L7 Left C] Bath 9j Arm 0, Right 0 Left 0 Both 1: t 16) Log "ght C2 Lett Q Bath 1 c ■Right C CLeft h7 Seth © Right aft .,E!"Bath �taa is a llroraiag #�SE�arnaon stns et setMtiae of daily living ata you it.11 having trouble because of your ala? s 9yQ l�ttyhiag/Pullirtg i iC 6) dnyl 16)D Work 3 ding 7 AlHWachini above your shoulders ►i S)MUsing Stain 5102 ,81678 41�ARD B. SM!1W 2 P10 FEB 22 '00 15:09 I T E M I 'Z E D S T A T E M E N T j MR. MAI+FNY MARTINEZ CLAIM NO: , ATTORNEY AT LAW ADJUSTER: 2049 CENTURY PARR E. STE, 1100 LOS ANGELES CA 90067 - EMPLOYER: i P TIENT: BIRTHDAY: INSURED: 1 .ASHLEY LUNNIE 508 BUS AC 04-0$-87 11324 MARIPOSA STREET SEX:F i RODEO CA 94573 RELATIONSHIP: GROUP: i 3t'ER INSURANCE. WORK INJURY. ISO INSUREDS ADDRESS: AUTO ACCIDENT: NO R LEASE OF INFORMATION:CSN FILE ASSIGNMENT OF BMFITS: ON FILE I -ESS/ACC DATE:71-02-99 FIRST TREATMENT:11-1539 AGNOSIS: 847.0 CERVICAL SPRAIN/STRAIN 847.2 LUMBAR STRAIN TRAUKATIC INJURY TO (R) SHOULDER TRAUMATIC INO-CRYT TO (R,) KNEE 845 SPRAIN (R) ANKLE j PATIENT STATES THAT SHE WAS A PASSENGER ON A BUS THAT WAS MAKING i A (L) TURN AND HIT A CAR. DATE DESCRIPTION PROC CODE AMOUNT 312-0699 chiro.xar:ni.tx(1-2 regions) 98940 35.00 42-06-99 massage 97124 25.00 ".2-0899 chiro.m+ani.tx(1-2 regions) 98940 35.00 2:2-08-99 massage 97124 25.00 2-•13-99 EP LIMITED 99212 45.00 2-13-99 interseg. traction 97412 25.00 2-13-99 message 97124 25.00 2-1599 EP LIMITED 99212 45.00 2-15-99 interseq. traction 9701.2 25.00 31.2-X15-99 massage 971.24 25.00 12-17-99 EP LIMITED 99212 43.00 1,2-17-99 interaseg. traction 97012 25.00 12-17-99 massage 97124 25.+00 61-07-00 interseg. traction 97012 25.00 d1-07-00 massage 97124 25.00 41-07-00 chiro.mani.tx(I-2 regions) 98940 35.00 of-26 -00 interseg. traction 97012 25.00 Q1-26-00 ralssage 97124 25.00 I� continued. . . i Willard B. Smith, D.C. 02-22-00 1103 12th Street Oakland, CA 94607 j Acoft No 508 (415)836-3835 i i i f 51026'9167'8 101 J.ARD H. SM I TH P09 FEB 22 '09- 15:07,, 1 i a I T E I+I I Z E D S T A T E M E N T MR. ANY MARTINEZ CLAIM NO. ATTORNEY AT LAW ADJUSTER: 20149 CENTURY PARK E. STE. 11.00 LOS ANGELES CA 90067 EMPLOYER: PATIENT: BIRTHDAY: 3 NStMED ASHLEY LUNNIE 508 BUS AC 04-08-87 1. 1324 MARIPOSA STREET SEX:F )t1RODEO CA 94572 RELATIONSHIP: GROUP: 1, OTHER INSURANCE: WORK INJURY: NO INSUREDS ADDRESS: AUTO ACCIDZXT: NO RIELEASE OF INFORMATION:ON FILE ASSIGNMENT OF BENEFITS: ON FILE 4LNESS/ACC DATE:11-02-99 FIRST TREATMENT;11-15--99 IAGROSIS: $47.0 CEIt'V'ICAL SPRAIN/STRAIN 847.2 LUMBAR STRAIN TRAUMATIC INJURY TO (R) SMOULDER TRAUMATIC IXaURY`Tl TO (R) KNEE 845 SPRAIN (R) ANKLE PATIENT STATES THAT SHE WAS A PASSENGER ON A BUS THAT WAS MAXTN"G A (L) TURN AND HIT A CAR. BATE DESCRIPTION PR'OC CODE AMOUNT 11-15-99 NP COMP IEXAM 99204 .150.04 11-17-99 hot or cold peke 97010 25.01 11-17-99 chiro.mani.tx(1-2 regions) 98940 35.00 it-17-99 massage 47124 25.00 1-19-99 EP LIMITEII 9921.2 45.00 1-19-99 intereag. traction 97012 25.00 1-19-99 massage 97124 25.00 1.-22-99 EP LIMITED 99212 45.00 1-22-99 ,inters eg. traction 97012 25.00 1-22-99 massage 97124 251.00 1 -24-99 EP LIMITED 9921.2 45.90 .11-24-99 intermog. traction 97012 25.00 1-24-99 massage 971.24 25.00 1-29-99 chiro.za ti.tx(I-3 regions) 98940 35.00 1-29-99 massage 97124 25.00 2-01.-99 EP LIMITED 9921.2 45.00 2r-01-99 hot or cold packs 97010 25.00 �2-01-99 massage 97124 25.00 Continued. . . Willard H. Smith, D.C. 02-22-00 1103 12th. Street Oakland, CA 94607 1 Acot NO $08 (41.5)83€-3836 a i f! 5102651678 WILLARD B. SMITH P11 FEB 22 100 15:11 I . ITEMIZED STA. TEMEXT MR. MANNY MARTINEZ CLAIM NO: j. ATTORNEY AT LAW ADJUSTER: 2049 CENTURY PARK E. STE. 1100 LOS ANGELES CA 900+ 7 EMPLOYER: i P�TIENT: BIRTHDAY: INSLMED ;ASHLEY LUNNIE 308 BUS AC 04-08-87 1; 1324 MARIPOSA STREET SEX:F I.D.# "RODEO CA 94572 RELATIONSHIP: GROUP: i O�H ER INSURANCE: WORK INJURY: NO INSURED$ ADDRESS: AUTO ACCIDENT. NO RPLEASE OF INFORMATION:ON FILE ASSIGNMENT OF SENEFXTS: CSN FILE l I LHSS/ACC DATE:11-02-99 FIRS` TREATMENT:11-15-99 61AGNOSZS: 847.0 CERVICAL CERRV' $TR ICCA�y,�yq�SPR&IN/STRAXN 847.6 LIAR AIN j TRAUMATIC INJURY TO (R) SHOULDER { TRAUMATIC INJURYT TO (R) KNEE 845 SPRAIN (9) ANKLE PATIENT STATES THAT SHE WAS A PASSENGER ON A BUS THAT WAS XAXING A (L.) TURN AND HIT A CAR. I'I DATE DESCRIPTION PROC CODE AMOUNT ( 1-26-00 chiro.mani .tx(1-2 regions) 98940 35.00 2-02-00 EP LIMITED 99222 45.00 2-02-00 interseg. traction 97012 25.00 2-02-00 massage 97124 23.00 2-04.00 EP LIMITED 99212 45.00 02-04-00 interseg. traction 9701.2 25.00 02-04-00 massage 97124 25.00 02-07-00 interseg. traction: 97012 25.00 02-07'-00 massage 97124 25.00 42-07-00 chira.mani.tx(1-2 regions) 98940 35.00 02-1.4•-00 EP COMP-DISCHARGE EXAM 99215 115.00 TOTAL 1640.40 i� i h i' I t I DATE:02-22-00 Employer ID No Willard B. Smith, D.C. **N/A** 1103 12th Street Social Sae No Oakland, CA 94607 433-30-0449 (415)836-3836 Willard B. Smith, D.C. i f i 1 I (, tOOCTC?8 'fit 01� m 1 s���taNTCsgptnp "a-= / r fy 2 16 1 ,AFPIAN W,A3' L- - F TNOLS CA 9*364. P#C1.t'AkNC. tcovo. ,ia�a asit:. 1cr�s� ti '`�''��r1 610-7Z4-5000 98-372066 11 1 9 LUNK13 ASHLEY A 11324 -MARI OSA ST #733 RODEO CA 14171, a#IKiNAtSi rssax taNa ii.•10.199 20 71 b0006297& 0 71�1 YO 14 MARIP08A 9T #733 4 RODEO CA 94572 D y i@ RSY.4b. 'A Gi Gh Al ti41�Gf J Mtla iL a+�tv.6ATa t9 a".WTI 0 17%GNAflCiaa N N6NC Q dFi/1A05a �9 t v IT Z7502 110294 1 440! Oa 20;7Z XXD1,CATIONSl3UP'PL 28 Z763,0 110299 1 t6j 3,0 t OSZO SHOULDSR,COMPLT 7030TC 110299 1 t 2941 $Q i 0320 HIP UNI 2 •VIEWS '73510TC ll4299 1 357�Oft ' 0001 TOTAL I 11071 10 IL aAYlA at F+l0Yi6lflhC 51 rrmpAyffiwa is IST,AMOUW MIT a CONTRA COSTA Y 1 O/P MSDI-CAL H HSP40S23FI Y �' � t k esu*�tc'a NAita at t,rifa 4o Ce�r.r a�N�lN6..id tp. St G41Wv N►u! as tNt7URANdf S;�P riG. I A LEY ol 673932475 67393A4179 s>1�5AnAa!tt AumcS�t7d�fld+Cttdte N#IC 5s;M►LpYSA NNS+[ at 1t+Nt4�"JR tt7C/Q17h r 9tR1�.dAQ`,Cb. .•,-��,t ..k, ",,;, 7G u7ieJ,QII�j CO. 77 i•4dSS� 76 9 A�, � , � „�.�, ' .•:•�``'. � �. sa A1TGWlNQlM�Yi.iD A � 5 a ...'s�.,tf ..S,5 �tlTFt�A pNty1,�A • A6�fA fKSRUM lJTd Fula zzl0?4n n Fmys to i 7291 CONTRA COSTA H920 11 mill Il- NIb 696 CENTER AVX STB; #100 UATT MARTINEZ CA 94553 (17-) S 410 --m Toptlalwc �„ �� s►AflENTtX1NTA0LNC 2151 APPIAN WAY �. P MOLE ;R CA 94864 . Pt.TO W f 71 T CXiV D 1*Co. I 10.10.1 10 L-P 0 11 � 610—?$ -30C 96-37j215N 2106201 LUKJIE ASHLEY 132NA F 3 7 14{40r4alE j1pul 1E ME ° '' N A MA ER RAT ti maol 611empo 40, #G 196? 5' B 106 Q 4, :4,, -,1,7 Z ol 000 12 M3 2 7 iL -77 b , 'k• ^'y '.' .�•.i�'Yy „' r '.'t 1,y,;Ir,1r �r:y 'f.h;iR'.. i;'+, ':y+' t3 KANTALLP {DQE 1324 MARIPOSA 3TRE19T +45 991 � p ]tpflEtl CA 64672 �'� " it Rev.cm 44 t?EE03PT*4 N iiJO Amu 4$EERY.DATE "0 WAY.UNA E 17 MUL CM001 4E NGMmoEQ CM ou d I LVL 11 010600 1 440 ' 00 ; Yi. , .+ a. Ra itS ,9 YP1r +y"'+ ♦Y,w Rr`x r wtr' .�, ,: :.y, r � •r ,+,;,,. •'y,rja, ;.>,.i,t, ,,. � r.5 r+" ,,vz. �,, •,;,t ,r;,y ;�+y,r i :� . 4 . . a # , Y, ';;r;rt_.,t�r(,' x 'v+'�'; r.'i'' ..t ir. .' .•.t,5 �',• '.a,., ,. . 9� , ti' •xr.tn',:,v.i}ry .i p,r. ;+y�•+,.,t. r.A.:r.:p,`.yh`y'�y;'Ra,,F,.. n. ::h' f RRtx ,l. •,gw r �, 1 �' ' e , , , „ 'R, ..\¢,1, „ .`..�n ..;'�Ylti i,.{i 1, .5�'"•;',•. . . „ ,,tr• '�{. ',`�' S`a, , ,y. ,,•�`•, . � , .. i /` +: i'�rti;wt ol.,ri,.,/r.ii✓t 1(�'' n,,,. 11r. y ,.,.` �, ' .. � , � ,.f ,G,. r n>.N.{' 'r�'''V�?•l��5. "�`„R,,v..:'r+tir'n 5:' S'".,�,1': .i,rt,, ,•'•;1„4.'i.�”' +:1`. ,f,4.:,. S•. + „ �, � ,R `_ .,?, e ,, •' .•v R �I�. 7,a"�`x,+• r ry'�'y ;c ...:"'R:•'r':A, .. J�', .'+. .} 1 � .. i i r , of t.,' r .l, .., ,..4 * ' •at..".. „ :' '`'•°• r �:r"':�' " .�''•. y }, r 'S'r. r r' • r i.}'. .t+ " . is , a:•+':t' e ., ti'.'' . ht,. f.•R ..`.}' , �.�� , •r . • , , ,. ; R >'.���}'•.. •1".rw• 'J�•n, ti j�' .r� .. .v{•• r., ''x±'7 tip f r. .y,,, '' i , l `w, .� '%:,a;,,'r ;yl:a,,";a',•. /.3,'',r,h��+, ,SS.,�,t:,r'v'`±,r',k ti.f,w#:. r " ,r '�t,S•..;tw Y't'�'� .,, ,. ,.,.. 't.. ",,, .}•t H ,. , . ,;�d lF. .;,t`f,+�.5 t� '°wSx�'`r;.�, yv;`o i`• �'' �'f��:. a '; :1` # f .., •''r,•, '}k }:r ''S4 .. 1 `�R.1• •'''',d'`ty":' ,..��wi'lrn�. �''• ., „.. ',• '�F`,4�'r r'r,,, .f'. ;i•`,'tr '+ � , .. 0001 TrAL 440 0o 0 PAYER $1 6S eaR ND. U PAtOA PAYM1;NA EE 13r.AMOUNT OUB & ET f • 96 IMEIJAEO'�(WMi IIP,IkI ED CEi1T, i+HC•is N0. i#am"NAMt Y3 PlEUA1VwCE onouP NC, 17I TANATMEMAUYtWUATUNt=0 olm 4E gimKoyERwuldi i�iPWYER=AM, ” R5 ., :5` ""ti r'7r`v,ir,•'�,ft,: l" .v ,f, r, ?i:a'y �:wa'+• ..•r. , },.. , ..(,,• y 7'° + .r w.`t ,4 M.•,.. 4 ., ,a•�,�r. , , . r �'..fw.•,iJ' ., "1c,`t " t,�y, sT PaEM Ot43.0. (r`51�1 .��#' b Vr4' R, {/Vy f TE*�1.;z Ca al L � TE 711 V 7 !TIEIiAAM3 �znit+l'hirs .Rt ! ;7251 CONTRA CO3TA N920 � 696 CENTER AVE STE OiC10 MARTINEZ CA 9 465 s 92 Nah•'160 MR 7 0XIMUL YR1jkT13M76M ft RtoftIR YINYYT•YYhs r,kiw..,.,+.r•••••�•••,•••.- 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 an x-ray or EKG has been performed, it has been read on a preliminary basis only, and will be reviewed by a radiologist or internist within 24 hours.You will be notified if additional findings are noted. YOUR DIAGNOSIS IS: TRAUMA ADULT PEDES GYN-GU I-aceration/Puncture Head Injury Viral URi Pneumonia/Bronchitis Fever Control Otitis Media. Miscarriage,Spont, PID Sprain/Strain Concussion* Gastroenteritis COPD/Asthma Viral URI Otltls/Extema Miscarriage,Threaten Ovarian Cyst Burn/Abrasion = Neck/Back Pain Ulcer/Gastritis Tension Headache Gastroenteritis Pneumonia/Bronchitis Irregular Vag.Bleed Curettage Contusion Corneal Abrasion* Esophagitis* Hypertension,New Pharyngitis,Viral* Asthma* Vaginitis* Menstrual Pain* Fracture Abscess* Seizure,Recurrent* HIM Colic Pharyngitis,Strep* Poisoning,Pedes* Cystitis,Fem. Kidney Stone* Cast and Splint Care Cellulitis Abdominal Unknown No Complications Chicken Pox Febrile Selzure* Pyelonephritis* GC/Chlamydia Suture Removal- Animal Bite Alcohol W/D Synd. Migraine Headache Conjunctivitis* Allergic Reaction Scabies No Complications Chest Wail Pain Diabetes Chest Pain-Non Cardiac Croup* Sinusitis Dehydration Contact Dermatitis Atopic Dermatitis PRINTED INSTRUCTIONS PROVIDED AS INDICATED ABOVE other: PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW.—(] or WA n ADDITIONAL INSTRUCTIONS: r For the health of your child follow up with your doctor to ensure that your child is fully immunized. 0 Call 970-5140 on for the results of your test: YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS BEEN: IF YOUR SYMPTOMS GET WORSE, OR YOU START HAVING ANY NEW PROBLEMS, RETURN TO THE EMERGENCY DEPARTMENT IMMEDIATELY. If your symptoms are not getting better in hours/days,call your regular doctor or clinic,or return to the Emergency Department immediately. r ve received and understand the instructions outlined above, nt ar ep ® Staff Dto D/C`rime For the health of your child follow up with your doctor to make sure that your child Is fully immunized. HOSPITAL WORK/SCHOOL NOTIFICATION FORM was seen in the Emergency Department on He/She should be able to return to work/school on with the following restrictions: t X M.D. j ..MB-17 100 01'43PM DM )CTQR$ )IND CTT - PINCLI n�NT7tcxxNa / ,61 APFIAN WAY a rio,TAx Nt}. 7 COV 0. a won, 1t GIC w 4R o t t �fi�t i7 r� � d & .r 4r 11*1 G Q (/✓�r c LJG tut n !!t167i tI Nt9i O FR7 MPA3Tam Is .T NRTyCAt Rtoti#D MQ f 37 as 7 L"103911 23 7 Z 1 ' JtNTBLL R P AV09 v s 133# M.ARiPOSA 3T #733 RQDRU CA 94572 b } ! t d ' my-co. u woom I RAIN IA WY,DAn If KAM.WM it TOTAL ii 13 m*=vfm ohm= 41 660 ER SI1' LVL II Z7502 110399 1 440 ' 00 A 27; WrlCATI,OXl/S FPLIRB' 27610 I104�99 1 J. 1.•r .r,wtl •f•'I�'J i �.V� Li .ar.y"... r. I E.`!4,f Jh•r. r i Y....W.•f w, JY°J�•'l�f'.♦ .V.'r ,l," i i. `.4•,. .L.. . .... 'Ara[..r•.'r.a ��' r„ r . f :(.' ....r v • { • r .. � ' r vri , 'yJ"+•r.•, • r :,�' • d ♦r . re � '•r p'�L ' Y 9 it'r r�''lJ` i{'E�: .rf 1Y ! . J: �. M.• . r,.dr,�.4.. :'.l.• '�Y yr�B+'.• ' r ',.�E•y �J� 'S;{.r;h'. :i�i5 .ft�'.�' .! Ja r .{r`,S Yi .n=i . r:d r. rl' f, r "t'I+. r ,r i (` JJ ..., � w ..., , •..r . r � v ...+•"t'v .r. h rJ i t,f 5 d.; E ,h. .d r, .. •ya" i . �• '1`�. p{'E: �r••.ti�. ,r��:.T l.r "U da ,i�: . '�4..•l ..K�' Y "� . ,�',ri+.,�, .r .. r .., „ � � r'Jr. '.'ti.�r,... r+.t,,.Y,',.. .....Jra `'• .«♦`*. .• ' .''`t� a .•�,.4, ''+• •Y• + '�•K?i' ► tQ1 iOTAO 4,6611 30 9 PAYER 61 Pf1WpRA NOr u WAR PA'WOO tb at.mom WI � 'ONTRA fa'�P.E.r.M�r:D.Y-CAL ;.� ,,.., , ,• .... :,.. t R$�4�,•�.��H.. ... _ }r:' , . _ • ' .' ", . , ■'{N14A4r<C!NANI N/.A�. i0CtRTr 1iN NiO.•CMJ N 011btdMMAW UlmLmNtzwwNm ,uvv;"$ 'ASFIt.8�' Oi 573,93 479 4738 ,. w ningw' ^^^•�• pn� ee auMVMtru'Einrn 7T PNM.b1A0 tJY �. . ty wrcarua.a�. •�annwa rr iS09 V1 9x 7 r Px ra ATTtIkCW�PNYL 0 9 5 6 uu f Y iT DT1+�1PiiF'L33 dA hlaEwxaSUBO MANUAL 00P9 91,55 FT3 ircla i�'1ft77 PPn 0 07991 CONTRA COSTA gn 9ZC 695 CRNT2 AVE 6TR #100 Q)° � T . MARTINEZ CA 94653 ' ...,,.....,. ...•...�.....wr..s.aw air WEY{a M�MNC1f0f. 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 an x-rayor EKG has been performed, it has been read on a preliminary basis only, and will be reviewed by a r'" radiologist or internist within 24 hours.You will be notified if additional findings are noted. YOUR DIAGNOSIS IS: TRAUMA ADULT PEDES GYN-GU Laceration/Puncture Head Injury Viral URI Pneumonia/Bronchitis Fever Control Otitis Media Miscarriage,Spots. PID Sprain/Strain Concussion* Gastroenteritis COPD/Asthma Viral URI Otilis/Extema Miscarriage,Threaten Ovarian Cyst Burn/Abraslon = Neck/Back Pain Ulcer/Gastritis Tension Headache Gastroenteritis Pneumonia/Bronchitis Irregular Vag.Bleed Curettage Contusion Corneal Abrasion* Esophagitis* Hypertension,New Pharyngitis,Viral* Asthma* Vaginitis* Menstrual Pain* Fracture Abscess* Seizure,Recurrent* Biliary Colic Pharyngitis,Strep* Poisoning,Pedes* Cystitis,Fem. Kidney Stone* Cast and Splint Care Cellulitis Abdominal Unknown No Complications Chicken Pox Febrile Seizure* Pyelonephritis* GC/Chlamydia Suture Removal- Animal Bfte Alcohol W/D Synd, Migraine Headache Conjunctivltis* Allergic Reaction Scabies No Complications Chest Wall Pain Diabetes Chest Paln-Non Cardiac Croup* Sinusitis Dehydration Contact Dermatitis Atopic Dermatitis PRINTED INSTRUCTIONS PROVIDED AS INDICATED ABOVE other: PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW.—_© or N/A ADDITIONAL INSTRUCTIONS: For the health of your child follow up with your doctor to ensure that your child is fully immunized. Call 970-514+0 on for the results of your test: YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS BEEN: IF YOUR SYMPTOMS GET WORSE, OR YOU START HAVING ANY NEW PROBLEMS, RETURN TO THE EMERGENCY DEPARTMENT IMMEDIATELY. If your symptoms are not getting better in hours/days,call your regular doctor or clinic,or return to the Emergency Department immediately. r ve received and understand the Instructions outlined above, (1;8nt or Asp9KeWtaivi Staff © te D/C Time For the health of your child follow up with your doctor to make sure that your child Is fully immunized — — - - - - - - - - - - - - - - - - - - - - - - - - _- - - - - _ __ _ _ --- ---- - HOSPITAL WORK/SCHOOL NOTIFICATION FORM 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. f . uj CTORS MEDICAL.CENTER-1PINOLE � ,! -� ' 2151 Appian Way, Pinole CA 94564 (510)741-2461 Discharge Instructions KEN KUMAMOTO MD MEDICATION: CHILDREN'S MOT.\IN Children's Motrin or Children's Advil(generic name-ibuprofen) is a liquid anti-inflammatory medicine. It comes as a suspension, drops and chewable tablets. It is useful in children over 6 months with pain, inflammation or for fever when Tylenol does not work. DIRECTIONS FOR USE: -- When possible give this medicine WITH FOOD or milk to reduce the chance of upset stomach. -- When using Children's Motrin TO CONTROL FEVER,you may alternate each dose with Tylenol (acetaminophen)every 3-4 hours. For example, give Motrin,wait three hours, give Tylenol,wait three hours, give Motrin, and so forth. — Unless told otherwise, the following dose table may be used. For each weight, a dose range is shown. For temperature below 102.5, use the lower dose;for temperature over 102.5 use the higher dose: DOSE WEIGHT DOSE DROPS SUSPENSION CHEWASLES ADULT (lbs) (mg) (dropperful) (Teaspoon) (tablet) (200mg tab) 18 50-75 1 - 1-1/2 1/2-3/4 x x 24 50-100 1 -2 1 -2 1 -2 x 36 75-150 1-1/2-3 3/4-1-1/2 2-3 : x 48 100-200 x 1 -2 2-4 0-1 60 125-275 x 1-1/4-2-3/4 2-4 0-1 70 150-300 x 1-1/2-3 S-6 1 80 175-350 x 1-3/4-3-1/2 ` `x ' 1 -2 j 95 200-400 x .4-.8 x ,. 1 -2 Props 50mg/1.25mi dropperful;ewenslon=100mg/ 5mi teaspoon;Chewable=50mg/tabletj [Give one dose every 6-8 hrs,not 1:6 exceed'4 doses In 24 hrs.] WHAT TO WATCH FOR: POSSIBLE SIDE EFFECTS: Nausea, upper abdominal pain, drowsiness—>contact your doctor if these symptoms persist or become severe. Contact your doctor or return to this facility promptly if your child develops: bleeding from the stomach(may appear as blood in vomit or stool(red or black color); rapid weight ' gain, leg swelling or easy bruising. ALLERGIC REACTION: Rash, itching, swelling,trouble breathing or swallowing.=>Contact your doctor or, return to this facility promptly. #, « IMPORTANT *** * MEDICAL CONDITIONS: Before starting this medicine, be sure your doctor knows If your child has any of the following conditions: -- Stomach ulcer(active or in the past), history of GI bleeding(vomiting blood or bloody stool) -- Allergic reaction to aspirin or other anti-inflammatory medicines — Asthma, nasal polyps or angioedema -- Liver or kidney disease; bleeding disorder DRUG INTERACTION: Before starting this medicine, be sure your doctor knows if your child is taking any of the following drugs: Prednlsone,Aspirin or other Anti-inflammatory drugs, Lanoxin(digoxin), Blood-thinners WARNINGS: -- Do not take with prednisone or other anti-inflammatory drugs since this increases the risk of getting a bleeding ulcer, 11/4/1999(00:53") EMERGENCY DEPARTMENT Page 1 of 3 Discharge Instructions(cont) ` KEN KU'MAMOTO MD 's MOTOR VEHICLE ACCIDENT; No SERIOUS INJURY You have been in a car accident; however,your exam today does not show any sign of serious Injury.Because of the strong forces that may be involved In a car accident, it is important that ybu watch for any new symptoms that might'by a sign of hidden injury. HOME CARE: 1)A car accident can be emotionally upsetting even if you were not injured.Take time for yourself to rest and adjust to what has happened. Talking to others about your experience can help reduce anxiety and fear. 2)You may feel sore and tight in your muscles the following day; however,severe pain should be reported. 3)You may take Tylenol or ibuprofen(Advil, Motrin)for pain, unless another pain medicine was prescribed. FOLLOW UP with your physician or this facility if you are not feeling back to normal within 48 hours. [NOTE: If X-rays were taken,they will be reviewed by a radiologist.You will be noted of any other findings that may affect your care.] RETURN PROMPTLY or contact your doctor If any of the following occur: -- Headache or visual problems — Neck,back or abdominal pain — Repeated vomiting, dizziness or fainting -- Excessive drowsiness,or unable to awaken as usual — Confusion or change in behavior or speech ti �/ 11999(00:53) EMERGENCY DEPARTMENT Page 2 of 3 ,. tt oCTORS MEDICAL CENTER-PINOLE 2151 Appian Way, Pinole CA 94564 (510)741-2461 Discharge Instructions FORREST BEATY MD ASHLEY LUNNIE CONTUSION: LOWER EXTREMITY You have a CONTUSION of your LOWER extremity(leg, knee, ankle,foot, or toes). This causes local pain, swelling and sometimes bruising.There are no broken bones. This injury may take from a few days to a few weeks to heal. HOME CARE: 1)Keep your LEG elevated to reduce pain and swelling. This is very important during the first 48 hours. If walking causes pain, stay off the injured leg until you can walk without pain. 2) if CRUTCHES have been advised, do not bear full weight on the injured leg until you can do so without pain.You may return to sports when you are able to hop and run on the injured leg without pain. 3)Make an ice pack(ice cubes in a plastic bag,wrapped in a towel)and apply for 20 minutes every one to two hours the first.day. Continue this three to four times a day until the swelling goes down. 4)You may take Tylenol or ibuprofen(Advil)for pain, unless another pain medicine was prescribed. FOLLOW UP with your doctor or this facility if you are not starting to improve within the next THREE days. (NOTE: if X-rays were taken, they will be reviewed by a radiologist.You will be notified of any new findings that may affect your care) RETURN PROMPTLY or contact your doctor if any of the following occur: — Pain or swelling increases — Toes become cold, blue, numb or tingly — Redness,warmth or drainage from the skin SPECIAL INSTRUCTIONS SEE DR.JENKINS FOR FOLLOW UP AS NEEDED. 1 HAVE RECEIVED AND UNDERSTAND THE INSTRUCTIONS ABOVE. x exam and treatment that you received today has been provided on an emergency basis only. if your problem worsens or now symptoms appear,contact your doctor or return to this facility for further care. 1) EMERGENCY DEPARTMENT Page 1 of 1 �t # # +' N" C✓ l Via:. ..■.,�., tl e� PB '133 8588335, � < t s� 50001 .210fEs 29 a 2105 0 A t°s 9O0d s N x r r � f s , n - LAW OFFICES OF MANNY C.MARTINEZ A Professional Corporation 2049 Century Park East.#1100 Century City,CA 90087 FlMST CLASS MAIL CLERK OF THE BOARD OF SUPERVISORS ;. ROOM 106 COUNTY ADMINISTRATION BUILDING 651 PINE STREET MARTINEZ, CA. 94553 ATTN: CLAIMS f. K .r..,y E ! _ r r a n vv� ss ., _, ., — 3�`"�'"`"� •+- CLAIM BOARD QE SUPERVISORS OF CON-IRA CQSTA CQ1JNIYs N SIA BOARD ACTICTfit APRIL 4 2000 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given p pursuant to Government Code Section 913 and 915.4. Please note all "Warnings", 3 203H AMOUNT: $25,000.00 COUNSEL CLAIMANT: Kayla Smith P �r qdEx CALIF ATTORNEY: c/o Timko & LaSorsa DATE RECEIVED: March 3, 2000 2033 N. Main St. , Ste. 360 ADDRESS: �7alnut Creek. CA 94596 BY DELIVERY TO CLERK ON: i~Ir�rCh 3, 2000 BY MAIL POSTMARKED: March 2, 2000 I. FROM: Clerk of the Beard of Supervisors 'I`O: County Counsel Attached is a copy of the above noted claim. PHIL BATCHELOR, Clerk March 3, 2000 Dated: By: Deputy It. FROM: County Counsel TO: Clerk of the Board of Supervisors ( l,, fiis 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: ,, M tr71 -5 Cil � 137 _GAG 011 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: i _ QO PHIL BATCHELOR, Clerk, Byt 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 MAIIdNG 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: Ey: PHIL BATCHELOR By � , Heputy Clerk 1 David Timko, SBN 124544 Linda LaSorsa, SBN 148550 2 TIMKO & LASORSA 2033 N. Main Street, Suite 360 3 Walnut Creek, CA 94596 _ Telephone: (925) 933-3800 R 4 Facsimile: (925) 947-4503 5 Attorneys for Claimant, MAR 0 3 2000 KAYLA SMITH, a minor 6 CLERK BOARD OF Slip. V;SORS CONTRA COSTA CO, 7 8 CLAIM AGAINST THE GOVERNMENTAL AGENCY 9 OF CONTRA COSTA COUNTY 10 11 12 CLAIMANT'S NAME: Kayla Smith 13 CLAIMANT'S ADDRESS: 3709 Sundale Road., Lafayette, CA 94549 14 ADDRESS TO WHICH NOTICES ARE TO BE SENT: 15 Timko & LaSorsa 2033 N. Main St., Ste. 360 16 Walnut Creek, CA 94596 17 Telephone: (925) 933-3800 18 DATE OF ACCIDENT OR INCIDENT: Approximately 09/24/99 19 LOCATION OF ACCIDENT OR INCIDENT: 3709 Sundale Road, Lafayette, CA 94549 HOW DID ACCIDENT OR INCIDENT OCCUR: Claimant's grandmother, Ms. Bartolomei, 20 adopted a puppy from the Contra Costa Animal Shelter located in Martinez, California for Kayla Smith. The puppy was not tested or isolated properly by the Animal Shelter workers and contracted 21 rabies. Miss Smith was exposed to rabies and forced to undergo a painful series of injections. 22 DESCRIBE INJURY OR DAMAGE: Ms. Smith was exposed to rabies due to the puppy being 23 infected. She had to undergo rabies injections. NAME OF PUBLIC EMPLOYEE(S)BELIEVED TO HAVE CAUSED INJURY OR DAMAGE: 24 Contra Costa County Animal Shelter in Martinez, California 25 AMOUNT OF CLAIM: $25,000.00 26 ITEMIZATION OF CLAIM: Plaintiff has undergone medical care in the approximate amount of $2,500.00 27 28 1 I declare under penalty of perjury under the laws of the State of California that the foregoing is true 2 and correct. 3 Signed on behalf of client 4 DATED: March 1, 2000 TIMKO & LASOR.SA 5 6 By: 7 David Timko 8 Attorney for Plaintiff 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 , ru w rU r Ln 02 W E h�7 Cj W 0 Ln p.� r+ C1 O t� COO CD CA Cl) .� CA to CD � W C" 777777 -. v Xr �'i.'�� � � � � ;: - •'roda'�^�MA•..� kr Y\.m,v:.Jf� ad'�X.++�..,,;sn+. .. ... : :....r � s -� - .. CLAIM IWO A0Q APRIL 4, 2WO Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and Z 915.4. Please note all "Warnings". AMOUNT: $25,000.00 3ti E:risten Smith CLAIMANT: »' FEZ t;AL t ATTORNEY: c/o David Timko, SBN :124544 DATE RECEIVED: March 3, 2000 TIMKO &'LA SORSA ADDRESS: 2033 N. Main St. , Ste. 360 BY DELIVERY TO CLERK ON: March 3, 2000 Walnut Creek CA 94596 BY MAIL POSTMARKED: March 2, 2000 L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk Dated: March 3, 2000 By: Deputy6,1 I[. FROM: County Counsel TO: Clerk of the Board 81f Supervisors {;y-,y'This claim complies substantially with Sections 330 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}. i { t,}-Other: i/ _,C - �" � Dated: -3 — By: � Deputy County Counsel M. 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 ORDEFL- By unanimous vote of the Supervisors present: {may 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. AL Dated: PHIL BATCHELOR, Clerk, By % , Deputy Clerk WARNING {Gov. code section 913} Subject to certain exceptions, you have only six {6} months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFFDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: s By: PHIL BATCHELOR By Deputy Clerk rr. 1"nttnty rnrrical e a._,�_:..._. 1 David Timko, SBN 124544 Linda LaSorsa, SBN 148550 2 TIMKO&LASORSA 2033 N. Main Street, Suite 360 RECEIVED 3 Walnut Creek, CA 94596 Telephone: (925) 933-3800 ��� � 4 Facsimile: (925) 947-4503 3 2000 5 Attorneys for Claimant, CLERK BOARD OF SUPERVISORS KRISTEN SMITHcoy='�.�cos�A co. KRISTEN 6 7 CLAIM AGAINST THE GOVERNMENTAL AGENCY 9 OF CONTRA COSTA COUNTY 10 11 12 CLAIMANT'S NAME: Kristen Smith 13 CLAIMANT'S ADDRESS: 3709 Sundale road,Lafayette, CA 94549 14 ADDRESS TO "WHICH NOTICES ARE TO BE SENT: 15 Timko &LaSorsa 2033 N. Main St., Ste. 360 16 Walnut Creek, CA 94596 Telephone: (925) 933-3800 17 DATE OF ACCIDENT OR INCIDENT: Approximately 09/24199 18 LOCATION OF ACCIDENT OR INCIDENT: 3709 Sundale Road, Lafayette, CA 94549 19 HOW DID ACCIDENT OR INCIDENT OCCUR: Claimant's mother, Ms. Bartolomei, adopted a 20 pupil from the Contra Costa Animal Shelter located in Martinez, California for Ms. Smith's daughter. The puppy was not tested or isolatedproperly by the Animal Shelter workers and 21 contracted rabies. Ms. Smith was exposed to rabies and forced to undergo a painful series of injections. 22 DESCRIBE INJURY OR DAMAGE: Ms. Smith was exposed to rabies due to the puppy being 23 infected. She had to undergo rabies injections. 24 NAME OF PUBLIC EMPLOYEE(S)BELIEVED TO HAVE CAUSED INJURY OR DAMAGE: Contra Costa County Animal Shelter in Martinez, California 25 AMOUNT OF CLAIM: $25,000.00 26 ITEMIZATION OF CLAIM: Plaintiff has undergone medical care in the approximate amount of 27 $2,500.00 28 I 1 declare under penalty of perjury under the laws of the State of California that the foregoing is true 2 and correct. 3 Signed on behalf of client 4 DATED: March 1, 2000 T1MK4 &LASORSA 5 By: 7 David Timkd Attorney for Plaintiff 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 d � .,x �,s.,, �=r.�tea. vel--�? �:• "' '��,�"ic..�.`».�, -�;zz��* �:'tz .� - ,1-4 ru W R7 yY Ln .. Om © -J Ws ,� C7 Z C4 0 5 C :I > yr CD W p • O U) C/) CD Ul G. CO) r-t ro CCA) 7� C) rx <> h S TO: BOARD OF SUPERVISORS ;� •L'" FROM: Phil Batchelor, County Administrator x C o nt i DATE: April 4, 2000 u0std SUBJECT: Final Settlement of Claim Janet Sellers vs. Contra Costa County uounly SPECIFIC REQUEST($)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Receive this report concerning the final settlement of Janet Sellers and authorize payment from the Workers` Compensation Trust fund in the amount of$23,000. BACKGROUNDIREASONS FOR RECOMMENDATION: Robert J. Cavallero, defense counsel for the County, has advised the County Administrator that within authorization an agreement has been reached settling the workers' compensation claim of Janet Sellers vs. Contra Costa County. This Board's March 14, 2000 closed session vote was: Supervisors Gerber, Gioia, Uilkema, Canciamilla and DeSaulnier, yes. This action is taken so that terms of this final settlement and the earlier March 14, 2000 closed session vote of this Board authorizing its negotiated settlement are known publicly. CONTINUED ON ATTACHMENT: YES SIGNATURE: l RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE ✓'APPROVE OTHER . SIGNATURES): ACTION OF BOARD APRIL 4, 2000 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN X AND ENTERED ON THE MINUTES OF THE BOARD UNANIMOUS (ABSENT NONE OF SUPERVISORS ON THE DATE SHOWN. AYES: NOES: ABSENT: ABSTAIN: ATTESTED APRIL 4, 2000 PHIL BATCHELOR,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact: Tony Schleder--335-1411 cc: CAO Risk Management Auditor-Controller BY DEPUTY TO: BOARD OF SUPERVISORS FROM: Phil Batchelor, County Administratoruu, i DATE: April 4, 2000 � ..._ - ` u0std SUBJECT: Final Settlement of Claim Thomas Mathers vs. Contra Costa County C u nty SPECIFIC REQUEST(S)OR RECOMMENDATIONS)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: Receive this report concerning the final settlement of Thomas Mathers and authorize payment from the Workers' Compensation Trust fund in the amount of$31,000. BACKGROUNDIREASONS FOR RECOMMENDATION: 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 Thomas Mathers vs. Contra Costa County. This Board's January 18, 2000 closed session vote was: Supervisors Gioia, Uilkema, and Gerber, yes; Canciamilla and DeSaulnier, absent. This action is taken so that terms of this final settlement and the earlier January 18, 2000 closed session vote of this Board authorizing its negotiated settlement are known publicly. CONTINUED ON ATTACHMENT: YES SIGNATURE: pyy�q L,,,4ECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE Ll APPROVE OTHER SIGNATURE(S): ACTION OF BOA#N APRIL 4, 2000 APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS I5 A TRUE AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD X UNANIMOUS (ABSENT NONE ) OF SUPERVISORS ON THE DATE SHOWN, AYES: NOES: ABSENT: ABSTAIN: ATTESTED APRIL 4, 2000 PHIL BATCHELOR,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact: Tony Schleder—335-1411 cc: CAO Risk Management Auditor-Controller BY ,DEPUTY