HomeMy WebLinkAboutMINUTES - 06082004 - C29 CLAIM ,►
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 08, 2004'
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 Cozies. _ _ _ _ _) notice of the action taken on your claim by the
Board of Supervisors. (Paragraph IV below), give
Pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
AMOUNT: $13,317.08
CLAIMANT: DELTA DIABLO SANITATION DISTRICT
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 05, 2004
ADDRESS: 2500 PITTSDURGRANTIOCH-HIGHWAY, BY DELIVERY TO C.LERi ON:MAY 05, 2004
ANTIOCH, CA 94509-137.8
BY MAIL POSTMARKED: HAND DELIVERED BY
COUNTY COUNSEL
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
MAY 05, 2004 JOHN,SWE lark
Dated: By: Deputy
II, FkOM: County Counsel, TO: Clerk of the Board of Supceirvisors
( ) This claim complies substantially with Sections 910 and 910.2.
( ffhis Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Beard 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: Deputy County Couns
,
III, FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant(Section 9113).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
( This Clain 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: -,�17 e-01- Z JOHN SWEETEN, CLERK`,, By , Deputy Cleric
WARNING (Gov. code secti n 913)
Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposite
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 deposite'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&"e, 2 JOHN SWEETEN, CLERK By Deputy Clerk
OFFICE OF THE COUNTY COUNSEL "u3 SILVANO B.MARCHESI
COUNTY OF CONTRA COSTA M COUNTY COUNSEL
Administration Building ,�%, �<� � ., ~� `�N�.
651 Pine Street, 91" door r, >" i `ti; SHARON L. ANDERSON
" c J CHIEF Ass1STANT
Martinez, California 94553-1229
GREGORY C. HARVEY
(925) 335-1800 ti
(925) 646-1078 (fax) � � _�' VALEREE J. RANCrE
D f��
AssisTANTs
1 ti>'}e� i
.wlt'.t
NOTICE OF INSUFFICIENCY
AND/OR
NON-ACCEPTANCE OF CLAIM
TO: DELTA DIABLO SANITATION DISTRICT
2500 Pittsburg-Antioch Highway
Antioch, CA 94509-1373
RE: CLAIM OF: DELTA DIABLO SANITATION DISTRICT
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.
[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.
[ ] 6. The claim is not signed by the claimant or by some person on his or her behalf.
{ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit
your claim on the enclosed form, including all the required information. Gov. Code, § 910.4.
Please be aware that you have only a limited period of time in which to file an amended claim.
See Gov. Code, § 910.6.
Page 1
Delta Diablo Sanitation District
Re: Government Tort Claim
Page Two
[
18. Other:
SILVANO B. MARCHER
COUNTY COUNSEL
C. . ..
Monika L. Cooper
Deputy County Counsel
CERTIFICATE OF SERVICE BY MAIL
(Code Civ.Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664)
1 am a resident of the State of California, over the age of eighteen years,and not a party to the within action. My
business address is Office of the County Counsel, 651 Pine Street,9th Floor,Martinez, CA 94553-1229. On May
12,2004, 1 served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the
document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez,
California addressed as set forth above. I am readily familiar with Office of County Counsel's practice of
collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S.
Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business.
I declare under penalty of perjury under the laws of the State of California and the United States of America that
the above is true and correct. Executed on May 12, 2004, at Martinez, California.
K thleXO'Connell
cc: Clerk of the Board of Supervisors(original)
Risk Management
Page 2
CLAIM
B ARD OF SUPERVI ORS OF CONTRA COSTA COUNTY
BOARD ACTION: JUNE 08, tl{}4
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 Codecs. } notice of the action taken on your claim by the
.Board of Supervisors. (Paragraph IV below), giv
Pursuant to Government Code Section 913 and
915.4. Please note all"Warnings".
AMOUNT: $13,317.08
CLAIMANT: DELTA DIABLO SANITATION DISTRICT
ATTORNEY: UNKNOWN DATE RECEIVED; MAY 051_ 2004
ADDRESS: 2500 PITTSBURG-ANTIOCH-HIGHWAY, BY DELIVERY TO C.C,ERK ON:MAY 05, 2004
ANTItJCH, CA 94509-1.373
BY MAIL POSTMARKED: HAND DELIVERED BY
CCJUNTY COUNSEL
FROM: Clerk of the Board of Supervisors TO; County Counsel
Attached is a copy of the above-noted claim.
MAY 05, 2004 JOHN SWE Jerk
Dated: By: Deputy
IT FROM: County Counsel.. TO: Clerk of the Beard of Su visors
( } This claim complies substantially with Sections 910 and 910.2.
4
{ ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we arc 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 Coun:
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: JOHN SWEETEN, CLERK, By , Deputy Clerk
WARNING(Gov. code section 913)
Subject to certain exceptions, you have only six(6)months from the date this notice was personally served or deposits
in the mail to file a court action on this claim, See Government Code Section 945.6. You may seep 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 '1 8; and that today I deposite4.in the United States Postal Service in Martinez, California, postage full;
prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: JOIN SWEETEN, CLERIC By Deputy Clerl
,�:�-t�t�v: D�1ta Diablo Sanitation District
OFFICE AND TREATMENT PLANT: 2500 PITTSBURG-ANTIOCH HIGHWAY,ANTIOCH,CA 94509-1373
TEL.: (925)756-1900 ADMIN.FAX: (925)756-1961 MAINT.FAX: (925)756-1963 OPER.FAX: (925)756-1962 TECH.SVCS.FAX: (925)756-1960
www.ddsd.org
RE
CL[CLERK BLIFM
u4
gL
i
,
April 14, 2004
Contra Costa County
Public Works Department
Attn: Dave Sanchez
Construction Inspector Supervisor
255 Glacier Drive
Martinez, CA 94553-4825
Subject: Delta Diablo Sanitation District (DDSD) Invoice No. 6953
Attached is the above invoice in the amount of$13,317.08 for reimbursement from Contra
Costa County (County). As we have indicated on our invoice, this was for repairs to our main
line due to damages caused by Delta Excavating while doing work for the County. We have
also enclosed a copy of the contractor's invoice for your reference.
Please expedite payment of this invoice as soon as possible. If you have questions regarding
this invoice, please feel free to give me a call at (925) 7561924.
Thanks for your assistance.
Sincerely,
Theresa Harris
Finance Supervisor
cc: Mike Dixon, Maintenance Manager
Tim Roa, Construction Inspector
Attachment
Recycled Paper
;. Delta Diablo Sanitation District
OFFICE AND TREATMENT PLANT: 2500 PITTSBURG-ANTIOCH HIGHWAY,ANTIOCH,CA 94509-1373
TEL.: (925)756-1900 ADMIN.FAX: (925)756-1961 MAINT.FAX: (925)756-1963 OPER.FAX: (925)756-1962 TECH.SVCS.FAX: (925)756-1960
www.ddsd.org
Invoice #6953
April 14, 2004
Contra Costa County
Public Works Department
Attn: Dave Sanchez
255 Glacier Drive
Martinez, CA 94553-4825
RE: REIMBURSEMENT FOR DELTA DIABLO SANITATION DISTRICT'S MAIN LINE
DAMAGE
Reimbursement for Delta Diablo Sanitation District's "main line" damaged by Delta
Excavating while doing a project for Contra Costa County at Shoal Road, Bay Point, CA. Repair work
was conducted by M&L Underground Construction, Inc. as per attached invoice (Invoice 04-140).
TOTAL DUE $13,317.08
PLEASE MAKE CHECK PAYABLE TO DELTA DIABLO SANITATION DISTRICT AND
REFERENCE THE ABOVE INVOICE NUMBER FOR PROPER CREDIT.
PAYMENT TERMS: NET 30 DAYS. UNPAID BALANCES SUBJECT TO
10% PENALTY, PLUS 1.5% PER MONTH SERVICE CHARGE.
Recycled Paper
. n 'ernr Construction, Inc.
P. 0.Bax 13247
Pittsburg, CA 94565'
(925)427-4007 Fax: (925)427-7143
CA.Lie#304571
�� �
r
04 ZO INVOICE # 04-140BXLL TO.- SO�
CC 001,.
Delta Diablo Sanitation District - j���G INVOICE DATE: 3/24/2004 i
2500 Pittsburg-Antioch Hwy.
Antioch, CA 94509 JOB NO.: 327-Shoat Rd#2
Attn: Tim Roa APPROVED BY: Tim Roa
DUE DATE: 4/23/2004
L
DESCRIMON QT RATE AMOUNT
T&M BILLING FOR: WORK ON 3/8-3/10 AND 3/17/04,AT SHOAL ROAD,IN BAY POINT,CA.
1[DESCRIPTION]:
Excavate,locate,and re-repair approx 15'of 10" Sevier Service Main,per D.D.S.D.spec.
[LABOR]:
Foreman. Poo , 27 59.50 1,606.50,
Driver. ACCIDUNf N t�. 27 46.00 1,242.00
Operator. ACCOUNT CC' IRI flt 353t 21 53.50 1,123.50
.Labor hours. REWEWlAPPRWAt By 56 42.80 2,396.80
MDSE RSC€IVED BY
[EQUIPMENT] #APPROVEF0A PAYNIS�tt '3�.O
Pick-up Truck wv/Tools, 54 19.50 1,053.00
10-wheel Dump Track. _ 11 42.75 470.25
5 Yard Dump Truck. 16 37.50 600.00
Backhoe. 30 38.50 1,155.00
Equipment Transport. 5 85.50 427.50
Air Compressor wv/Tools. 8 32.50 260.00,
Wacker/CompactorN-Plate. j 12 20.00 240.00
Pump&Hale. �� -+ �,,� ,/� 8 20.00 160.00
Flatbed Truck, f � 4 24.50 98.00
Saw Cut Machine. 4 26.75 107.00
Fuel&.Maintenance Charge. / 1 36097 360.97
Steel Plates. ' dl 7`" t' G , ': 1 36.00 36.00
Traffic Control. 1 150.00 150.00
Shoring. 1 100.00 100.00
Test Plugs. .t�-'rte �i 130.00 130.00
Job Materials. rr , 1 1,600.56 1,600.56
PAYMF W TERMS: NET 30 DAY.S,FROMDATE OFINYDICE. Torn $13,317.08
t)uv'tv13 p- e ovr-a.. C, - Caw {'��, ow-v rAAa o V a5 6
�- (q'ue +r> oma+' ma:tA ewc�t &.rev" 44: .. YeA..✓, We, vve- c'*A -e3,
GSW W1 ,. zoqwd 4tG we -PoAd c VOA
&f Or
All
♦R' r •� Y ��Jf� V �-
L CONSTRUCTION, INC. i ' �ti�l'1al Report
Cant�r"rs Lac No. 59399 ,�,�.f' �,�C{.�' Datec•
Phone: (925)42.7-4007 NIA
rN Fax:(9 51 421- 143
7LAIBBOR
Name / Jbb Name l . 1/"I r /�; �� su M w Th F sg Total R&O fWU4 t`rime over
Name coda iOUM T
or
A 4to MOAD OPeT
sr
ST
OT
OT
ST
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_Equt tnent urs and Labor
{' Tnwke-Mck-ups } NOTES
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attExcwAkor-170
220 •, r1 c d IAP
car= ti
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Loader-950 Id f
Loader_ 956 '} Aka <
vaer r 1�6 t?�i '(4- c'xt
Rex Compactor
Wrier Tru&-<4000 Gelto c WA `
CoftPwsorwAoOIs
WackerlCompadcr MATERIAL: TAG#
�-
qAz)qkOPI A 1;"kA IL
-aj
*F:orman: I A roved
PROTNE{9125 4.27-4007
FAX (OM 417-7143
f DAILY*/TIME &MATERIAL REPORT
. r STARIRDITR
✓ 'kk i
CUSTOMER JOB NAME/I`3'U1wER` � �"° rd
ate TOW �
NAME R Su M T Th F Se Hours', `` t NOTES
T ly,r'
c tSt T �}
T
T
T 4
r
eD Mjt4.J,
T
T
T �®x✓T 1�.� tom'�
F
T
T -Th •
ICK-UP W/TOOLS
RUCKS-10 WHEEL Dmk At 100
RUCKS-BOBTAIL P MP.
TJCHS-Simn-nUmp
RUCKS-B AT13ED TRUCK
ACKHOE
OADER
Zi
CAVATOR
DOZER
EX COMPACTOR
{1UIPMENT TRANSPORT
OMPRESSOR W/TOO IS �.
�7MPING JACK ; r
IBERPLATE
RASA PjjMI"S W/TOOLS
SER.W/TARGET
ONCRETE SAW
RESSURE WASI ER
RAF'FIC CONTROL
EEL.PLATES
3� f. (•Arc'.-'� - 9
Office of the County Counsel Contra Costa County
651 Pine Street, 9th Floor Phone: (925) 335-1800
Martinez, GA 94553 Fax: (925)646-1078
RECEIVED
Cate: May 4, 2004
To: Clerk of the Board of Supervisors mAY 0 5 2004
Attn: Emy Sharp, Deputy Clerk CLERK BOARD 0. t 09s
From: Silvano B. Marchesi, County Counsel
By: Monika L. Cooper, Deputy County Counsel r)')
Re: Government Tort Claim by Delta Diablo Sanitation District
The attached letter and documentation should be treated as a government tort
claim. Thank you for your assistance. Please call with any questions.
Attachment
CONFIDENTIAL ATTORNEY CLIENT DOCUMENT
CLAIM �r
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY /
BOARD ACTION: JUNE 08, 2004
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), givt
Pursuant to Government Cade Section 913 and
915.4. Please note all "Warnings".
AMOUNT: $5,000.00
CLAIMANT: ROSE DEMING
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 06, 2004
ADDRESS: 23 BUCHANAN LANE BY DELIVERY TO t.LERK ON:MAY 06, 2004
DANVILLE, CA 94526 .
BY MAIL POSTMARKED; MAY 05, 2004
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
MAY 06 2004 JOIN SWEET
,
Dated: By: Deputy
II. FROM; County Counsel.. TO: Clerk of the Board of Supervisors
( `This claim complies substantially with Sections 910 and 910.2.
4
{ ) This ClaimFAILS 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: 7) " ",� By: -;``r/ L " , - Deputy County Couns
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 ABOARD 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 Carder entered in its minutes for this date.
Dated: JOIN SWEETEN, CLEF, By , Deputy Clerk
WARNING(Gov. code section 13)
Subject to certain exceptions, you b,4ve only six(6)months from the date this notice was personally served or deposite
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seep 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: ,(, 04 JOIN SWEETEN, CLERK By Deputy Clerk
c
CLAIM
BO"D— OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION JUNE 08, 2004
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 you:
California Government Codes. } notice of the action taken on your claim by the
Board of Supervisors. (Paragraph IV below), gii
Pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
AMOUNT: $5,000.00
CLAIMANT: ROSE DEMIN0
ATTORNEY: UNKNOWN DATE RECEIVED: MAY 06, 2004
ADDRESS: 23 BUCHANAN ZANE BY DELIVERY TO CLERK ON:MAY 06, 2004
DANVII.LE, CA 94526
BY MAIL POSTMARKED: MAY 05, 2004
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
MAY 06,, 2004 JOHN SWEETX&L
Dated: By: Deputy
II, 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 914.2, 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 Coun
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: JOHN SWEETEN, CLERK, By , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposit
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 ofperjury 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 deposite ,in the United States Postal Service in Martinez, California,postage.full
prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: JOHN SWEETEN, CLERK By Deputy'
Clsits to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. Claims relating to causes of action for death or for injury to person or to per-
sonal property or growing crops and which accrue on or before December 31, 1987,
must be presented not later than the 100th day after the accrual of the cause of
action. Claims relating to causes of action for..death or for injury to person
or to personal property or growing craps 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 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, Penal. Code Sec. 72 at the end of this
form.
RE: Claim By ) Reserved for Clerk's filing stamp
Against the County of Contra Costa ) MAY 0 r
or }
<..l. � District)
Fill in name
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sure of $ and in support of
this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
Z00 2 c u ...... _..�.. ....—-----....__-___
2. Where did the damage or injury occur? (Include city and county)
v� <v��4' �� f`I� {,�r T��;A�7� .�? ✓��✓s„f z c�l�i�'�'rT�".4C->l� �t�.� �' '^'� \ �.r � .. �:. ''1 S
_...� -:.�.ray.f.v:.tnr�..,.....�....r���........r.o..�
3. How did the damage or injury occur? (Give full details; 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 ?
(over)
7. wnat are the names of county or district officers, servants or employees causing
the damage or injury?
_ J
5. ghat IaimedinjAttaehdtw�oesti.�ates fortauto (Give damagef'uil extent of injuries or
damages
Fes-- ��rr�.wr.rraYrMrrr a.o
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
•Y•. rraw.+.++1M+r�.a.ir.rsrwirir_+w_�+rr.sr
r r+r+.� rr•rrY+rwrrw+la.M_+er
8. Namesandaddresses of witnesses, doctors and 11OSpitals.
9. List the expenditures you made on account of this acccOdent or injury:
AM
DALE -
n'Telephone
9 provides:
t be signed by the claimant
X2 ;7L4
} NOTICES TU: EAttornev) son on his. behalf."
Name and Address of Attorney mant's igna,ture
dLJL"al , to
Telephone No.
W if
NOTICE
Section 72 of the Penal Code provides:
"Every person who, with intent to defraud, presents for allowance or for
payment to any state board or officer, or to any county, city or district board or
officer, authorized to allow or pa�iti the �isipuni.shable eitheany r by se i�risora�uent�in
claim, bill., account,. voucher, or writing, b a fine of not exceeding
the county jail- for a period of not more than one year, y
one thousand MtOOO)t or by�both tsuch imprisonment
o t and fine, {$lEl,tlt�(?or by �nmentor byira
the state prison, by a fine
both such imprisonment and fine.
To: Board of Supervisors of Contra Costa County 5-3-04
From: Rose Deming
Re: Claim form answers
3.) I, Rose Deming,am the mother of Tyler Deming,age 14. My son was on his bike using
the crosswalk at the intersection of Diablo Road and West Pintado. An Animal Control
truck hit him by making contact with the front bumper of the truck to the back tire of
the bike. This impact caused Tyler to fly into the air and land on his hip and back. The
driver, Mr. Parrott, stopped and asked if Tyler was o.k. Mr. Parrott waited there until
Tyler got the chain put back on his bike. The seat was badly scrapped up causing the cloth
to tear in many places. The back tire was bent and the bike was slightly torked. Mr.
Parrott did not give Tyler any information about himself, instead, he drove away. When
Tyler came home, he explained what happened and since he's only 14,he didn't ask for
information regarding the driver who hit him. Since Mr. Parrott left the scene of the
accident without notifying Tyler's parents or giving Tyler information,I believe this falls
in the category of a"hit and run". I believe in order to have a driver's license,adults must
know what to do in an accident situation. Mr. Parrott was clearly not paying attention and
could have easily killed a pedestrian. Tyler remembered that he was in an animal control
vehicle and with this information the Danville Police were able to identify him.
4.) Mr.Parrott,the animal control officer, hit a child on a bike while in a crosswalk and
then left without giving proper information.
6.) The damages are as follows:
$ 5.00 Police report
75.47 repair of bike
541.14 Identical bike replacement estimate
4.378.39 Medical allowance
$5,000.00 TOTAL
Tyler is an active teenager. He has excelled in team sports and has recreational interests.
He attends Los Cerros Middle School. Tyler has never needed extensive exams on his back
until this accident. He was sore for several months which limited his activities. The
medical findings are enclosed in this report. It broke my heart when the Dr. Sonu said
that Tyler has a back of a 40 year old when he's only 14. There was no know problems to
Tyler's back previous to this accident.
We bought a new bike seat($45.47)to replace the damaged one and paid to have the
wheels straightened ($15.00 x 2 = $30) totaling approximately $75.47. This figure is not
in the total amount of damages.
Medical Summary: $45 Co-pay for $10(2003)x 3 = $30 plus $15 for (2004)
$20 Over the counter pain medicine
7 Back brace
$92 sub-total
$4,286.39 Pain, suffering, loss of sleep, discomfort
#4,378.39 TOTAL
December 22, 2003
Northern California Spine Institute, Dr. Charles Sony
Tyler came to Dr. Sonu with obvious low back pain. He was wearing a lumbosacral corset
for support. He walked with a very stiff leg and obvious back pain. Tyler had tenderness
in the lower lumbar and range of motion was quite limited. Can forward bending he can
barely flex forward about 20 degrees. Recommended MRI
1.) Right low back pain for 4 months
2.)Cauda equina is grossly unremarkable
3.)hypoplasia of L3-4 disc
4.)posterior disc bulge at L4-5 disc
5.) loss of height of disc L5-S1
6.)posterior disc bulge
7.)superimposed broad-based, left poster lateral disc protrustion
8.) left neural foramina stenosis
9.)right neural foramina stenosis
December 22 2003 Dr.Gambhir
Alliance MRI - 1.) hypoplasia of L3-4 disc
2.) posterior disc bulge at L4-5 disc
3.) loss of height of disc L5-51 disc
4.) a superimposed broad-based, left poster lateral disc protrustion
5.) left neural foramina stenosis
6.) right neural foramina stenosis
December 29 2003 Dr. Sonu
Northern California Spine Institute
Follow up MRI scan
1.) left-sided contained disk herniation at L5-51 causing lateral recess and
foramina compression.
2.)recommended physical therapy for rehabilitation
3.) if pain persisted in 4 weeks,recommended for an epidural injection
January 26, 2004. Dr. Sonu
Northern California Spine Institute
Follow Up on disk herniation at L5-S1.
1.) leg pain gone
2.)Tyler is on his way to recovery.
Joseph M.Grant, M.D.
,lames D.Fontbine> M.D.
New therim CARK'OPM" Sp►lue X�tit to Devin .Rooth,M.D.
A Medlcal Corporadw Charles M.Scrnu,M. .
s
December 22,2003
TYLER J.DEMING
HISTORY OF PRESENT INJURY/ILLNESS; Mr. Deming is a 13-year-old boy seen
today for evaluation of the love back pain.
He indicates that the symptoms began about 4 months ago,without any precipitating event.
About 2 weeks ago he was hit while riding his bicycle in a crosswalk. A carr hit his rear tire and
basically knocked him to the ground. He landed on his left shoulder. His low back pain has
worsened since that time. He indicates that sitting, as well as bending,seem to aggravate his
condition. When he starts playing spurts he can barely move. Previous treatment has included
Tylenol and 4-Advil-at a time. He denies any bowel or bladder incontinence,no radiation of pain
into the extremities.
PRESENT MEDICATIONS: Advil.
ALLERGIES: None.
FAST MEDICAL HISTORY: Surgery for hypospadia and asthma.
TOBACCO: None.
ALCOHOL: None.
SOCIAL HISTORY: The patient is accompanied by his sister and his mother.
REVIEW OF SYSTEMS: Review of systems was discussed with the patient and is negative
for other cardiac,pulmonary,liver,kidney or hematologic
problems.
PHYSICAL EXAMINATION: Physical earn shows a healthy young boy with obvious
love back discomfort. He is wearing a lumbosacral corset
for support. He walks with a very stiff legged gait,with obvious back pain. He stands on his
heels and toes without difficulty. Romberg test is negative.
Back exam:shoves some lower lumbar tenderness,no evidence of any step-offs or spasm. Range
of motion is quite limited secondary to guarding. He has 0 degrees of extension. On forward
bending he can barely flex forward about 20 degrees,
67251 West Las P oaitas#2W•Plemanton,CA 94588•.(925)489.6274
6WI NoMs Canyon Road#1,30-San Ranier,CA 94583•(925)469.6274
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TYLER J.DEMING
'age 2
December 22,2003
Lower extremity exam shows nornud bink and tone. Light touch sensation is intact. Motor
strength testing shows 515 strength in the EHL,tibialis anterior, gastrocnemius,quadriceps,
hamstrings,hip flexors,extensors,abductors and adductors. Clonus is absent. Straight leg raise
is negative to 90 degrees. `seep tendon reflexes are absent at the knees and at the ankles. Clonus
is absent.
IMPRESSION: back pain.
PLAN: I discussed the findings with the patient. I have recommended that we obtain
an NEPA scan of the lumbar spine to better evaluate the capse of his symptoms; He
has severe back pain. 1 think it is unusual for a young 13-year-old young man to have such
severe back Rain and therefore have recommended•the MRI scan. I will see him back after the
stud been obtainers.
artAmtcri=
MD
Diploc a Board of Orthopedic Surgery
Fellow,American Academy of Or8mpedic Surgeons
CMS:drng
,..^— Joseph M.Grant, M.D.
James D. Fontaine,M.D.
Northern Cadifornin Spine �titate
Kevin C. nth,M.D.
AMedW tlaa Charles M.Sonu,M.D.
December 29,2003
TYLER J.DEMING
Mr. Deming returns for followup of his MRI scan.
PHYSICAL EXAMINATION: ,Physical examination demonstrates that he has had
improvement of his pain.
DIAGNOSTIC STUDIES: MRI was reviewed. This demonstrates that he has a small
left-sided contained disk herniation at L5-S1 causing some lateral
recess and foraminal compression.
PLAN: I discussed the findings with Tyler and his mother. He indicates that his pain
is improving. We will go ahead and send him to physical therapy for some
rehabilitation. I will see him in 4 weeks for a recheck. Ifhe continues to have pain,we will go
ahead and send him to lir. Fontaine for an epidural injection.
Sena,MD
Diplo Hoard of Orthopedic Surgery
Follow,Ama icon Academy of orthopedic Surgeons
CMS:rnar
5725 West Las Posbe#200•Pleasanton,CA 94588•(925)469-W74
5$11touts Cron Road#130•San Ramon,CA 94583•(925)469-6274
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12/23/2009 15,22 9252759022 PAGE 01
A .L L L A N S E MRI l rpt t 0
SAN RA.MON REGIONAL "Ifit ,rW"
CENTERmr G�:r.nAatlnrt of HsasRwim t�t,far,'nna
DEMI.NG,TYLER DECEMBER 22, 2003
261300 DR. CHARLES SONU
IRI OF THE LUMBAR SPINE WITHOUT CONTRAST
CLINICAL HISTORY- Right low back pain.for 4 months.
COIV PAWSON: alone.
TECHNIQUE:
Sagittal FSE T1
Sagittal FSE T2
Axial FSE T1
Axial FSE T2-7214&
FTN'DTNGS: Diere is no spondylolisthesis or evidence of spondylolysis. The vertebral body
heights are well maintaincd. There are no significant vertebral marrow signal.abnormalities. The
cones vledullar-i>is normal in position,located at Ll, The cauda equina is grossly unremarkable.
T12-11, through L4-5: There is no si&mfficant desiccation of the discs. There is what is likely
hypoplasia of thi;L34 disc. The rest of the discs are well maintained in stature, There is a mild
posterior disc bulge at L4-5. There is no evidence of focal disc protrusion,central canal stenosis
or significant compressive neural foraminal stenosis.
f.5-S1: There is mild loss of height of the disc. There is a posterior disc#sedge_ 'Dere is a
superimposed broad-based,lefi posterolateral disc protrusion. This results in:mild left neural
foraminal stenosis. There is nes significant impingement of the left Sl nerve root. There is very
mild right neural foraminal stenosis. There is no significant central canal ste-nosis.
)[M RESSION,
L Mild,broad-based,left posterolateral L5-S1 disc protrusion,resulting in mild left I,.5-S1
neural fora.rninal stenosis.
2. Very mild,right L"I neural foraminal stenosis.
Sangcets. mbhir, Mit
SGlss
D- 12/23/03 T: 12/23/03
6001 Norris Canyon Road, San Ramon, California 94583 a (925) 275-0634 • Fax (925) 275-9()22
Joseph M.Mani,M.D.
' James 0.Fontaine,M.D.
Northern C�lsll�for� Spine Institute ��C.Booth,M.D.
AM$dWI Charles M.Sonu,M.D.
January,26,2004
TYLER J.DEMING
Tyler return for followup of his disk herniation at L5-S1. He indicates that it has not hart since
the other day when he went snowboarding. Otherwise he feels like his leg pain is gone.
PH'Y'SICAL EXAMINATION: Physical exam shows he walks normally without a limp.
Neurologic examination is normal. Straight leg raise is.
negative to 90 degrees.
PLAN- I,discussed the findings with Tyler and.his mother. i think he is pretty much on
's way to recovery. I wi11 see him back on a p.r.a.basis.
Charlax� Sc�aa,11 D
Dip€omate,American Board of fhthopedic;surgery
Fellow,Amerifum Acacle my of Orthopedic Surgeons
CMS:mar
5725 West Las plias#200-Pleasar*m,CA 845m•W6}4W4274
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