The URL can be used to link to this page

Home My WebLink AboutMINUTES - 03142006 - C.11 a• CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY M BOARD ACTION: MARCH 14, 2006 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: $675.00 FEB 10 2006 CLAIMANT: I-LO HUANG COUNTY COUNSEL MARTINEZ CALIF. FEBRUARY 10/06 ATTORNEY: UNKNOWN DATE RECEIVED: ADDRESS: 135 BRANDYWINE WAY BY DELIVERY TO CLERK ON: FEBRUARY 10/06 WALNUT CREEK, CA 94598-3601 FEBRUARY 09/06 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWE E erk _Dated: FEBRUARY 10, 2006 By: Deputy Ili. FkOM: County Counsel TO: Clerk of the Board of Supervisors i ( t} 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: /0— t� 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). 1V. $OARD ORDER: By unanimous vote of the Supervisors present: (t� 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. 13ated:A-A>,eA / ce.#-eb JOHN C U L.L EN, 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 [n tl-ke 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 frilly prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. '.Dated: ] JOHN CUTL.LEN , CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. 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. ■/f////////////t///MENSER■■■■■■/t■f■■■■f f■f■f■sawn■■■f■■f■■■f RENEW ME■f f■■■f f■■1 RE: Claim By: Reserved for Clerk's filing stamp �— L dl.�G�� RECEIVED Against the County of Contra Costa or ) FEB 1. 0 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA Co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 6-"7,�; o o and in support of this claim represents as follows: 1. 'Vhen did the dmnage or injury occur? (Give exact date and hour) OA Dee-em beY3 i, zoos'-. /0 :30 ;n -Ika morn;liy 2. Where did the damage or injury occur? (Include city and county) /3�, 8rap C/Yw;h e E(Way> Wdlnat Cre.4k C/1 I4s`98 Contra Cos4a Cdz? 3. How did the damage or injury occur? (Give full details; use extra paper if required) A�ea-re- -re-k 4Ae- exdA,sedf 2X I r� L1 eytr w4 ek provid-e.s -/-41 dt6, fs of AL 1-J We d na-le occurred. I 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 7XiS hi euclyp4as Are s' oreountys?ropej. ?he lo&icY bafMIpavfo[- ks i-rPe fas heave itfejle yhr WeI dd not c:; 1 d®wn/reMoVe-- -lAe 4o_rmi�eto f&,sY4?c( R06a1yP16 free 7f-ank ' h'o,e be�re 4t Ya in y s-easoA_ Yidwfr. 5 What are the names of county or district officers, servants, or employees causing the damage or injury? J7;recf/yy n an e. j-,r'ow2v�; �i�e d 9e o eo� ld ��.e avoie,lQd :� Co un�r Pr,,-6/.'c ee.ldr�s ��,a.r��•n.� � �� SPo�Qd -��i e, feym �//�� fres ta�ron �,f' �-�1 r3 �u�al�+/�t�s free :.+ -t':•,r� ar dl ka� era� v'Y 'f4'j�Qd -�'/LiS -fYe..e he fef2 �/iQ YRli+y S2O�5l+iti S�AYtS. 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 7f,a f ct 1/,�y f re e 4r.- k (✓o-q hi9) boke Jo 4on a S'ecr sti� (' " � 'x 6 ,) o f ^Y backyard wooden feAee • Z-f a);// Cosfi g67� vo >L ye store -f ie broken -�'en�e, /ease ,,Qac o-#me%�e d ,Z esl;lh c, es, 7. How was the amount claimed above computed? (Include the estimated amount of any / prospective injury or damage.) �.3o•sd en t`i a��%�weY�fhQQ�%� uqs//� -�w •e s��mares Y�Ce i✓e�from i 19or R.g�LU 4'OCJ �e11 Cf�S W c4et; e ?C,-/l R (•� 1W) 8. Frames and addresses of witnesses, doctors and hospitals: �• Af- CA ck 9e ff ryes, .4 5'1,� ,r visor of 4 CC C�fr�'u d/;c. MI6 r�s �arljnaA z/-N.,1,2..b Y W-0y, �. xore"IkA,- o f it e crew (Tumr-.su;f 9�)c e. -tL remove 4¢4 f�+ , � ,lie -�re,,k. Marf::�ez, C4 *4," CM1/s 1v6 Jake 'tVvess oto C, Ve . 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT �s �e�Ar (��a6), hn rzs'f<esrof,�cn WdYk otr my hrokeA P-Pce 4AS ��en 5hlyf" e.d ■■amommomponammasoaaONE 00aMEmonsomanammomMMMmoMMMMMMMMMMMMEsommoomrmmasBEgoo ENE MEMO al Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attomev) ) Name and address of Attorney (Clappimant's Signature) Ya n d yalill ie (Address) CrezA to--A 94-t?9 - 3d�� Telephone No. )Telephone No. ��-�� <?¢7-�%ZZ ■ ■O ammommussommanomMason 0 monsoomNONE[ PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthennore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. 00■0aaaa0aa00aa0a0aaaaaa000aaaaaaaa9a0a5aaaa0aaaaaaaaaaa0aaa9aaa00a00aaa0aaaaa0aaa0aI NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisoiunent 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. S`i�-e.. o f -�'�-e. �'o��yo� �'-v,S`�a. �'a � �jcs� �.'o�7�Y�►1 S' read r,xldn,j -IXe bank of creok 4- be (ocatkJ 040,�lf 9 bot cklkj 'V-c0,:le4 jl�snc Z akoa-t 10 `PO/ -til tt-)'j S P-- 47� h y YQ r A bex�',OJ o,,, 5y""P 'y/f.4d 4),eekms f . -71 �,v e, vey;f i eafioh , Co ra ri 0410 V r-e e'ar i 5Ir- ems 40f , Selex, inc. dba 575 Boulder Ct. �� EDWOOD FENCES P.O. Box 5430 BO •000a000eooG BORPleasanton, CA 94566 Fences 0 Becks o Retaining Walls 0 Chain bink (925) 426-9620 Ornamental Iron o Vinyl Fax (925) 461-1486 LIC. 7 7176.3 FENCING CONTRACT www.borgfence.com �y� i DATE cid -Up JOB NAME�!1�Z- —{�\1 �� BILLING JOB LOCATION_ 5rr�, 1Q- lid _ JOB CITY ___ ,\h�i_ _{� _ ZIP CODES _ CROSS STREET�1. `' __tom] PHONE(H)� ,—��va-�___.—(W) —____ GENERAL EXISTING CONDITIONS FAX (Cell) _ n 1. TERRAIN LAT &SLOPE Ll DIFFICULT ,,_ 2. FENCE EXISTS? J NO -3-YES STYLE bz 3. CONDITION OF EXISTING FENCE?Flas��44.Q CAUSE OF DAMAGE?_1_I�o - 4. VEGETATION FIGO J YES 5. REPAIR EXISTING OF FENCE. 6. REMOVE EXISTING M LN. FT NCE. HAUL OFF PROPERTY BYq��Z°ONTRACTOR L1 OWNER 7. INSTALL NEW PRESSURE TREATED POSTS I 9�+A OF CONCRETE AT APPROX.yr— ON CENTER. Ll 4x4 L1 4X6 .. '6x6 8. INSTALL KICKBOARD d'NO J YES SIZE_ INSTALL BULKHEAD IJ YES 0 NO SIZE 9. INSTALL 2-NEW p1t`I):13 REDWOOD RAILS �d'CON COMMON J CON HEART 10. INSTALL - MEW '11'b REDWOOD FENCE BOARDS r ON COMMON J CON HEART 11. INSTALL / _- J NEW_- ---,* GATES GATE POST SIZE J 4x4 'U 4x6 J 6x6 12. FENCE TOP TO: -4J�UN LEVEL -Q CONTOUR ❑STEP,W_ JH THE SLOPE OF THE GROUND %S�b 13. SEAL,CONDITION AND PROTECT FENCE FOR AN ADDITIONAL ww— LN. FT. ONE SIDE OF FENCE LN. FT BOTH SIDES OF FENCE. (OPTIONAL) PLOT PLAN NOT TO SCALE ... ................. ...... B/B=BOARD ON BOARD F/S=FAN STYLE(louvered) P/F=PICTURE FRAME P/T=PRESSURE TREATED .... ............ ...._... .:. $ ll I 1 � ............... _ . _. $ 1 ....... .................................................... HOUSE � ................:.. 5r3&-- i........................... . VEGETATION $ .. ..... _.._...._................._.............................. ........ FRONT $ bOTOTAL ($500.00 MINIMUM CHARGE) ($1,000 MINIMUM CHARGE FOR IRON) Seal and Protect Fence _ (Optional)See#13 above t One Side F--J Yes L]No PAYMENT: _,lr \ 1 '� Both Sides Ll Yes L1 No Accepted by: X Customer's Signature Date Submitted by: L org Fence Associate Approximate Start Date:__ _. Contractor agrees to substantially commence the work on or about the approximate start or upon reasonable access to the job site being provided to con- tractor by customer but in no event later than 20 days; failure to do so, however,shall not be grounds for terminating the contract. Approximate Completion Date: CONTRACTOR SHALL SUBSTANTIALLY COMPLETE THE WORK ON OR ABOUT THE APPROXIMATE COMPLETION DATE. Owner or tenant has the right to require a performance and payment bond. Contract void unless accepted within 30 days. Please see reverse for additional waivers of responsibility. Geneirad Teirms and Conditions Professional's responsibilities: BF will complete installation in a workmanlike manner. BF will not start,conduct,alter,or finish installation except in accordance with applicable law. BF will either not start;or will immediately discontinue installation upon discovery of unforeseen physical or hazardous conditions at your service address. BF is not responsible for property lines,casements,covenants or other legal encumbrances that your service address may be subject to. Your Responsibilities: You agree to pay BF for installation according to the terms and conditions of this agreement. If your service address is subject to any easements,covenants or other legal encumbrances that could affect install ition,you agree to let BF know about them before installation. You agree to facilitate the location of underground utility lines. You agree that BF holds no liability for property lines,easements, landscaping,landscaping lighting,sprinklers,drains/water lines,driveway,walks,curbs,concrete,sewer,natural gas,cable lines or telephone lines. You agree to ensure that work areas are free of preexisting hazards, LE,unsafe physical conditions or environmental hazards and building/zoning code violations. You agree to allow BF access to work areas daring working hours. You agree to provide power to work areas. You agree not to allow unattended minors at your service address while BF is present. You agree to control pets and keep them away from work areas. You agree that if you,or anyone else,interferes with or delays installation,you will be subject to transportation/storage and labor charges at the cost of$50.00/hror S250.00 a day. You agree that a]I and any clean-up,moving of personal property or furniture or other work necessary to commence construction will be your responsibility. You agree to detach and attach anything on your fence.You agree that any claims against BF under this agreements should be made to BF within(15)calendar days of the date you first become aware of a problem. (BF will attempt resolution of any claim within 30 calendar days of receiving your notice) You agree that this contract is with you the homeowner only. We will not enter into additional contracts on the same address,nor collect money from neighbors. Some cities requit a ,.•mit on fences above 6'.Borg Fence is not responsible for height of fence if permit is required but not obtained. Cutomer Initial Access: Customer will provide access through own property or through adjacent property for Contractor's normal construction equipment,materials and employees to do the work at no cost to BF. BF will not be responsible for property damage or other material which is in the path of the access provided by customer,either above or below the ground,including but not limited to landscaping or irrigation,drain,sewer,telephone,gas,cable lines or electrical lines. In the event customer authorizes BF use of access through adjacent properties during construction,customer is required to obtain permission from the owners of the adjacent properties for such use. Customer agrees to indearmify BF and hold it harmless from all claims as well as all loss or liability resulting from use of adjacent properties by BF,provided,however,that nothing contained herein shall excuse BF from liability arising solely from the negligence or willful misconduct of Contractor,its agents,servants or subcontractors. Customer warrants that the job site will be in a condition for work on the start date. Any clean-up,moving of personal property or furniture or other work necessary to commence construction shall be charged to the customer. Changes and Change orders: BF,at your request,may arrange to perform additional work,subject to a change order,subject to additional charges payable by you to BF. Any changes to installation i.e.,a substitution of materials or an expansion of the scope of the work will require you and BF to first sign a written change order that will become part of this agreement. Following discovery of previously undisclosed/unidentified legal encumbrances on your premises,building/zoning code violations,or hidden/unforeseen hazards such as the presence of underground lines,rocks, roots,buried debris or any conditions differing from what you represented,BF may ask for a change order or discontinue installation without further obligation to you. If you decline a change order request,you may terminate this agreement and pay for all work performed and materials used/delivered up to the time of declining change order request. Securitv Interests/Liens: If you make all payments as required tinder this agreement,no security interest will be placed against your property by BF. If a security interest is placed on your property it creates-a lien,mortgage,or other cldim against your property to secure payment and may cause a loss of your property if you fail to pay as requested. If BF is forced to place a lien on your property,you agree to pity$400.00 in addition to your payment owed to reanove the lien for the cost of the lien. After paying on any completed phase of Installation and before making any further. payments,you may request from BF a signed,unconditional release from,or waiver of,any right to place any claim against your property applicable to the work then completed. Notice to owner: Under the Mechanics Lien Law,any contractor,subcontractor,laborer,material man or any other person who helps to improve your property and is not paid for his labor,services or material,has a right to enforce his claim against your property. Contractors are required by law to be licensed and regulated by the Contractors State License Board. Any questions concerning a contractor may be referred to the registrar of the board; CSLB PO Box 26000,Sacramento,CA. 95826 1-800-321-CSLB(2752) www.esib.ca.gov Insurance: General Liability and Workers'Compensation Insurance is available to you upon request. Warranty: BF warrants the workmanship of the installation of gates for one year from completion date,labor inclusive. BF warrants posts,found upon examination to be rotted,for 5 years(pressure treated posts only),labor exclusive. This warranty does not cover damage caused by abuse, misuse,neglect,or improper care/cleaning. BF will and does assign any manufacturer warranties to customer for any materials which are or become defective and customer agrees to look solely to the manufacturer for any claims that the materials are defective. Customer acknowledges that wood, by its nature will crack,discolor,expand and/or shrink over time and agrees that BF is not responsible for or obligated to correct these conditions. Cancellation: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE 'TO BF BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING. Special Order Cancellation such as Chain Link,ornamental iron,Vinyl,or special order wood is non refundable to us. If possible,BF will return merchandise with a restocking fee of up to 35%of purchase price that you will be responsible for. in the event the merchandise cannot be returned,you will be responsible for the entire purchase price. Special order item: /VA yes AlA no t Customer initial �` BF Initial BF=Borg Fence ti C y r� � m czo Tv I N to co � � a ,,j o �a io O W V N 5 cv O r Q� G. y N ®LLJ O LLO OCO <� tj LJ m o0 PROPOSAL. calif.caniractaes Ua..416971 .N�rrit?: Pci_goz2312: .•AddresS:1�,�_.,r=J t awd-ywi-�-G`�O Pleasatli Fill.CA 94523 (925)E32•E.633 City: 6VA1 NST t e�,CA AIG ... .°PJc j��25)E32 8fa3,. Project; .-- -... _� �rnce 1976 Phone: H;r��/��. FENCING. Date: /�.1D�� FAX Wehereb,-submitspecificati..ons.andestlmatoon— 4'-0`�_�!� :._ _Y Q -.cow.:_____.—_ _ I Construc6onwill consist of Poss V Sef in concrete :z• .feet Rails jr-0 lKickboard I Pencetboards/4K4 Retaining Eoards.' ' Trim�•�y Ga .. Hei h1. &r.c1 Other IFew.e removal:.Craig-Fencing . ilhatedalswillibe-'GONSTRUCTION HEART-R0UGH.REQW.00D: (All_redM,%ghitewoad?� Posts,kickboards and retaining boards;will be pressure treated. ALL WORK GUARANTEED FOR ONE YEAR �Il work rc basanpr�trK inwt:frr9srlike.r:r3!ner a_^rer�ne ta.s?siieartlp+s_rl_es.:?ny.alter=Uerci.tleviationrron�ecirca:ia-w i-.tickirnextr,: Gists will boco-TC ane�;rr zharre.mmt an'"fib(Ns Itie esGrl' •r1L aie..M eveen contuv;ent uponvmkes.ri;�[9ri31 a:Yrilr.,ylip�mW,.rcr 0,0175 bavo-dcur=rre..,Our woirkers'ere fully covered.by Workman's.Compensation.Insurance, N71 c: 1.Prop r?:rmner is:estmaivetcr propemelines. .4.It a 135��81i5 neC�d-0W GCI'v' :fill is;5 will hu;:�L1u:!1u.c=rFSt, 2Price does notln:ludo6alni,stain,rgrro•aior Irrerestwill.bed*oqe.1et5%per monnonmeU-0aaaffw-,. dirt spolts,vegetblci and plint matorials., 5,RcMr,-.rrrt sark q:nrlic^:?s ul irtsuraryCe9v8i19ols apOnr :e7.; 9.pears cr txsn3,ii rECul etl,wab:. :mer.restrat:bt;; v-rieeae call uneergrcuna S2rY1Ce Ater;it 1.6: 0 rN7z•'rac:Icr Jti;y rrarkir.7't4 rn wark is 6laney. Payments: 50%at tim st Serin vtateelivery_.Balance due 60op Corlpletlgn; AwhorizedSigrature. —.- - -.----.•--- RuSS Craig(owner) Note: This proposal may be ti lithdrawn if not.accApted%,ai' l ..5.days. Acceptance 611.Proposal The above prices:specifics' :. a nditiorw are salislaztcryand aire hereby accepted.. YouareaOhod2adto.doivorkas,specifeed..Paymentsvrillbe adeascullinedabove. Dated acoeptarzoe: • FENCEWITH.THE BEST=FORGET THE REST- visit our Wet:sile al cntgrcaC'.og'cam - • CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY e.1/ BOARD ACTION:MARCH 14/06 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 FEB 14 2006 915.4. Please note all "Warnings". COUNTY COUNSEL AMOUNT: TO BE DETERMINED MARTINEZ CALIF. CLAIMANT: EDDIE GARREIT ATTORNEY: WILLIAM L. BERG DATE RECEIVED: FEBRUARY 14/06 ADDRESS: 2440 SANTA CLARA AVENUE BY DELIVERY TO CLERK ON: FEBRUARY 14/06 ALAMEDA, CA 94501 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEEOPg Wk Dated: FEBRUARY 14, 2006 By: Deputy II. 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: 17 it V) Dated: c�. Z--006 By: Deputy County Counsel / ;J V - 111. FROM: Clerk of the Board TO: County Counsel (1) County Adi` inistrator(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�l' -Zv .I O H N C U L L E NCLERK, By , Deputy Clerk WARNING (Gov. code sec ion 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 frilly prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated://," /S' o ..IOH N C U L L E N CLERK By Deputy Clerk Claim to: BOARD•SUPERVISORS OF ODNTRA COSTA WN* INSTRUCTIONS TO CLAI}MNT A. Claims relating to causes of action for death or for injury .to person or to per- sonal property or growing crops and uhich accrue on or before December 31, 1997, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for-death or for injury to person or to personal property or .growing crops and which accrue on or after January 1, 1988, must be presented not later than six montts after the accrual of the cause of action. Claims relating to any other cause of action mast be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Cla.i= 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 roust 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 s'C. p Eddie Garrett j RECE�� Against the County y of Contra Costa } F kE3 1 4 2006 Contra Costa County CLeRKBOAnl) Fire Protection District) CONTFp? OF PrAWSORS Fill in name ) TA CO. The undersigned claimant hereby mkes claim against the County of Contra Costa or the above-named District in the sum of $To be determined and in support of t'iis claim re resent s �s T isa case o1 e ,fi �° t1.e Sjlneri nr ('our u1rJ, nn- 1. When did the damage or injury occur? . (Give exact date and hour) August 19, 2005 at 7: 26 p.m. 2. Where did the damage or injury occuY°r; (Include city and county) 1591 Ellis Street, Concord, CA. 3. How did trle damage or injury occur? (Give fu-U details; use extra paper if required) See "Attachment To Claim, " attached. hereto. 4. What particular act or omission on the part of county or district officers, se--wants or-employees caused. the.in,jury or. damage? See "Attachment To Claim, ". .-attached ..her.eto.. . .See also __ Incident Report No. 2005-5026713-000 . Wnat are the names of cl&y or district officers, servants• employees causing the damage or injury? See Incident Report 2005-5026713-000 , attached hereto. 5. What daMage or injuries do you claim resulted? (Give full extent of injuries or dames claimed. Attach two estimates for auto damage. Funeral and burial expenses , loss of support and loss of Carla Garretts love, society and companionship. 7• How was the amunt claimed above computed? (Include the estimated amount of any prospective injury or damage.) To be determined. This case would lie in the Superior Court, Unlimited Jurisdiction. $. Names and addresses of Witnesses, doctors and 'hospitals. See Incident Report 2005-5026713-000 , attached hereto. 9. List the expenditures you made on account of this accident or injury: DATE I'DI AMOUNT To be determined and provided up n ret e Gov`. Co Sec. -9des: "The cl im mustby the claimant SEND NOTICES TO: (Attorne ) or s me ersoehalf." Name and Address of Attorney William L. Berg Cla t s Signature 2440 Santa Clara Avenue., 215 Brush Street Alameda, CA 945101 Address Alameda, CA 94501 Telephone No. 51 0 ) 5 2 3-3 2 0 0 Telephone No. ( 51 0 ) 522-2756 sa * � N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the sane 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. TOTRL P.s3 ATTACHMENT TO CLAIM AGAINST CONTRA COSTA COUNTY 3. On August 19, 2005, a fire broke out in a storage room on the second floor of the condominium complex located at 1591 Ellis Street in Concord, California. This fire spread to the hallway, and the second floor was filled with smoke. The fire was ultimately put out by firefighters and other employees from the Contra Costa County Fire Protection District and the Concord Fire Department. However, Carla Garrett, the occupant of Unit 206, died in her unit of smoke inhalation. 4. Claimant is informed and believes, and thereon alleges,that the responding firefighters and other employees of the Contra Costa County FPD negligently delayed in responding to the fire; negligently delayed in extinguishing it, and failed to extinguish it completely; negligently failed to thoroughly inspect and evacuate the building; negligently failed to fully clear the building of smoke in a timely manner; and negligently failed to perform appropriate search, rescue, and evacuation operations at the subject premises. These individuals also negligently failed to inspect the residential units on the property to determine if there were victims of the fire or smoke inhalation injured on the premises; and they negligently failed to locate, evacuate, and/or render aid to Carla Garrett. These individuals also negligently refused to permit the owner or manager of said premises to come onto the property and perform appropriate search, rescue, and evacuation at the premises; and they negligently informed the owner of the building, or his agent,that said building had been thoroughly inspected and evacuated, and that no further effort to inspect units or search for occupants was necessary. In reliance on these assurances received from the responding firefighters, said owner and/or his agent did not inspect the building or conduct a search for Carla Garrett. As a consequence of some or all of these negligent acts and omissions, Carla Garrett was not found, and died of smoke inhalation; and Claimant Eddie Garrett has suffered damages, including but not limited to, funeral and burial expenses,and the loss of his sister's support, love, society, and companionship. Incident Re*-, Contra(01 County FPD 2005-5026713 -000 Basic Alarm Date and Time 19:26:19 Friday, August 19, 2005 Arrival Time 19:30:18 I Controlled Date and Time. Last Unit Cleared Date and Time 22:10:16 Friday, August 19, 2005 Response'Time 0:03:59 Priority Response Yes Completed Yes Reviewed Yes Release to Public Yes Fire Department Station 06 Shift C Incident Type 1 1 1 -Building lire Aid Given or Received N - N1 one Action Taken I I 1 - Extinguish Apparatus- Suppression 13 Apparatus- EMS 2 Personnel - Suppression Personnel 27 Personnel - EMS Personnel 9 Property Loss $75,000.00 Contents Loss $5,000.00 Property Value $75,000.00 Contents Value 55,000.00 Detector Alerted occupants I Property Use 429-Multifamily dwellings Location Type Address Address 1591 ILLIS ST City, State Zip CONCORD, CA 94520 Apartment Number APT 203 District 06JCN Fire Structure Type 1 - Enclosed building Number of Residential 1 Number of Buildings involved 1 Number of Buildings Threatened 1 Area of Origin V 41 - Storage room,area,tank, or bin Heat Source 66 -Candle Item First Ignited 51 - Box,carton, bag, basket,barrel Type of Material 99 -Multiple types of material first ignited Cause of Ignition 2 - Unintentional Contribution To Ignition 1 12 - Heat source too close to combustibles. Human Factors None CStructure Status 2 -Occupied and operating Floor of Origin 1 i Stories Above Grade 2 Building Length 30 Page: I Printed: 10/27/2005 16:17:44 Incident Re* Contra o;County FPD 2005-5026713 -000 Structure Building Width 20 Total Square Feet 600 Fire Spread 3 - Confined to Moor of origin Stories with Minor Damage I Item Contributing To Spread 51 - Box, carton,bag, basket,barrel Type of Material Contributing To 67- Paper, including cellulose,waxed paper Detector Presence I Detector Type I - Smoke Detector Power 1 - Battery only Detector Operation 2- Detector operated Detector Effectiveness I -Alerted occupants, occupants responded AES Presence 2 Apparatus-E101 Apparatus ID E101 Apparatus Dispatch Date and Time 19:37:l 1 Friday,August 19, 2005 Apparatus Clear Date and Time 19:43:50 Friday, August 19,2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 1 1 -Engine Personnel 1 34250-AJLOUNY,MAD Position: CAPT Personnel 2 54484- BRADLEY,THOuMAS Position: FF Personnel 3 64359-CONNER,JASON Position: ENGP Apparatus- E105 Apparatus ID E105 Apparatus Dispatch Date and Time 19:40:53 Friday,August 19,2005 En route to scene date and time 19:41:20 Friday, August 19, 2005 Apparatus Clear Date and Time 19:45:57 Friday, August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 1 I - Engine Personnel 1 36658 -.GONZALEZ, BOB Position: CAPT Personnel 2 46908 - FENDER, KERRY Position: I:NGP Personnel 3 66824 - HESS,JASON Position: FF Apparatus-Q 101 Apparatus I D Q101 I Apparatus Dispatch Date and Time 19:43:50 Friday, August 19; 2005 En route to scene date and time 19:43:50 Friday, August 19, 2005 P.uzc: 2 Printed: 10/27/2005 16:17:44 1 Incident Re* �.C:ount; FPD 2005-5026713 -000 Apparatus-Q10.1 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 13 -.Quint Personnel 1 29793 - PRICE,CHARLES Position: ENG Personnel 2 35631 - BUCK,TERRY Position: CAPT Personnel 3 65452 - DIAZ, TIMOTHY Position: FF Apparatus-.E309W Apparatus ID E309W Apparatus Dispatch Date and Time 20:02:55 Friday,August 19,2005 En route to scene date and time 20:03:31 Friday, August 19,2005 Apparatus Clear Date and Time 20:29:45 Friday, August 19,2005 . Apparatus priority response Yes Apparatus Use 1 Apparatus Type 14-Tanker&pumper combination CApparatus-E107 Apparatus ID E107 Apparatus Dispatch Date and Time 19:53:56 Friday, August 19, 2005 En route to facility date and time 19:54:01 Friday, August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 2 Apparatus Type I 1 - Engine Personnel 1 32101 - PENALOZA, FRANKLIN Position: ENG Personnel 2 33221 - HASEY,TIMOTHY Position: CAPT Personnel 3 60913 - WALKER,JASON Position: ENG Apparatus-E106 Apparatus ID E106 Response Time 0:02:20 Apparatus Dispatch Date and Time 19:26:19 Friday,August 19, 2005 En route to scene date and time 19:27:58 Friday,August 19, 2005 Apparatus Arrival Date and Time 19:30:18 Friday,August 19,2005 Apparatus Clear Date and Time 22:06:53 Friday, August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 1 1 - Engine i Personnel 1 38276- BOBROSK.Y, SCOTT Position: ENG Page: 3 Printed: 10/27/2005 16:17:44 I i Incident Re# Contra(0 County I PD 2005-5026713 -000 Apparatus- E106 Personnel 2 44107 -MARSHALL, PETER Position: CAPT Personnel 3 51121 -QUESADA,MIKE Position: FFP Apparatus- E109 Apparatus ID E109 Response Time 0:05:41 Apparatus Dispatch Date and Time 19:26:19 Friday, August 19, 2005 En route to scene date and time. 19:27:52 Friday,August 19,2005 Apparatus Arrival Date-and Time 19:33:33 Friday,August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 11 - Engine. Personnel 1 39213 - RAHMER, DANIEL Position: CAPT Personnel 2 55192 - WELLS, VINCENT Position: ENGP Personnel 3 68126- IMPASTATO,VITO Position: FF Apparatus-E102 Apparatus ID E102 Response Time 0:04:03 Apparatus Dispatch Date and Time 19:34:34 Friday, August 19, 2005 En route to scene date and time 19:36:20 Friday, August 19,2005 Apparatus Arrival Date and Time 19:40:23 Friday, August 19,2005 En route to facility date and time 19:33:26 Friday,August 19,2005 Apparatus priority response Yes Number of People 6 Apparatus Use 2 Apparatus Type 11 - Engine Personnel 1 37275 -WALKER, RONNIE Position: CAPT Personnel 2 45175 - DESOTO, DONALD Position: ENGP Personnel 3 68132 -AVILA,JOAQUIN Position: FF Personnel 4 37275 - WALKER, RONNIE Position: CA13T i Personnel 5 45175 - DESOTO, DONALD Position: ENGP L Personnel 6 68132 -AV1LA,JOAQUIN Position: FF I Apparatus- BC1 Apparatus ID BCI Page: 4 Printed: 10/27/2005 16:17:44 I Incident Rev, Contra(0, County FPD 2005-5026713 -000 Apparatus-BC1 Response'Time 0:04:53 Apparatus Dispatch Date and Time 19:34:34 Friday, August 19,2005 En route to scene date and time 19:36:53 Friday,August 19, 2005 Apparatus Arrival Date and Time 19:41:46 Friday, AuLUsI 19, 2005 Apparatus Clear Date and Time 20:41:01 Friday, August 19, 2005 Apparatus priority response Yes Number of People Apparatus Use 1 Apparatus"Type 92-Chief officer car Personnel 1 31704- STICE, WILLIAM Position: BC Apparatus- BC2 Apparatus ID BC2 Response Time 0:16:15 Apparatus Dispatch Date and Time 19:26:19 Friday,August 19,2005 En route to scene date and time 19:28:17 Friday,August 19,2005 Apparatus Arrival Date and Time 19:44:32 Friday, August 19,2005 Apparatus Clear Date and Time 22:10:09 Friday, August 19,2005 Apparatus priority response Yes Number of People I Apparatus Use I Apparatus Type 92 -Chief officer car Personnel 1 37894-NIELAND, KEVIN Position: CAPT Apparatus-Q106 Apparatus ID Q106 Response Time 0:13:22 Apparatus Dispatch Date and Time 19:26:19 Friday,August 19, 2005 l.n route to scene date and time 19:31:12 Friday, August 19,2005 Apparatus Arrival Date and Time 19:44:34 Friday,August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 13 -Quint Personnel 1 44867 -JOHANSEN, DONALD Position: ENG Personnel 2 46945 -VERDERAME,JACK Position: CAPT Personnel 3 64362- LEIMPETER,CHRIS Position: FFP Apparatus- El 10 Apparatus ID El 10 Response Time 0:16:32 Apparatus Dispatch Date and Time 19:26:19 Friday,August 19, 2005 En route to scene date and time 19:28:05 Friday, August 19, 2005 iPage: 5 Printed: 10/27/2005 16:17:=14 Incident Re* Contra County FPD 2005-5026713 -000 Apparatus- El 10 Apparatus Arrival Date and Time 19:44:37 Friday,August 19, 2005 Apparatus Clear Date and Time 21:32:07 Friday, August 19,2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 1 1 -Engine Personnel 1 34540- REY, ROBERT Position: ENG Personnel 2 44093 - LAATSCH,JAMES Position: CAPT Personnel 3 48372 - HATHAWAY, PATRICK Position: FF Apparatus-Q112 t— Apparatus 11) QI 12 Response Time 0:11:13 Apparatus Dispatch Date and Time 19:34:34 Friday, August 19, 2005 En route to scene date and time 19:38:04 Friday, August 19,2005 Apparatus Arrival Date and Time 19:49:17 Friday,August 19,2005 Apparatus priority response Yes Apparatus Use l Apparatus Type 13 -Quint Apparatus-E108 Apparatus ID E108 Response Time 0:13:59 Apparatus Dispatch Date and Time 19:35:37 Friday,August 19,2005 En route to scene date and time 19:35:37 Friday, August 19,2005 Apparatus Arrival Date and Time 19:49:36 Friday,August 19, 2005 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 11 - Engine Personnel l 37891 - BOWLES,GARY Position: CAPT Personnel 2 46940-GMEINER,KENNETI I Position: FF Personnel 3 66065 - WANNAMAKER, SCOTT A Position: FFP Apparatus- BC8 Apparatus fD BC8 Response Time 0:10:40 Apparatus Dispatch Date and Time 19:34:34 Friday, August 19,2005 In route to scene date and time 19:45:39 Friday, August 19, 2005 Apparatus Arrival Date and Time 19:56:19 Friday,August 19, 2005 Apparatus Clear Date and Time 20:32:23 Friday, August 19, 2005 Apparatus priority response Yes jPage: 6 Printed: 10,'27112005 1(.?:)7:44 Incident Rel Contra County FPD 2005-5026713 -000 Apparatus- BCS Number of People 1 Apparatus Use I Apparatus Type 92 -Chief officer car Personnel 1 40125 - MCCULLAH, MARK Position: BC Authority Reported By 44107- MARSHALL, PETER 08:42:12 Saturday, August 20,2005 Officer In Charge 44107 - MARSHALL, PETER 08:42:13 Saturday, August 20,2005 Reviewer 53781 - WEST,JO ANN 15:21:06 Wednesday, August 24,2005 Narratives Narrative Name E102-Captain Walker Narrative Type Incident Narrative Date 22:20:06 Friday,August 19,2005 Author 37275 - WALKER, RONNIE Author Rank CAP`l- ALlthor Assignment I Narrative Text E 102 was dispatched on the second alarm to the structure fire at 1591 Ellis Street. E 102 on scene and we were told to report to the IC in air. E 102 with the 1C and we were assigned to provide lighting on the second floor for Division 2. We used equipment off of E 106 and Q 106 and the power from the apartment that had been laddered for entry to complete the mission. Once completed,we were assigned to two apartlllents at the end of the hall (#201 and 11202). We made contact with the residents and asked them to shelter in place until we could clear the hallway of smoke. Once it was clear,we escorted the residents outside. We were then told to report to the front of the building and were released from the scene. Narrative Name New Narrative Narrative Type incident Narrative Date 07:41:04 Saturdav,August 20,2005 Author 44107 - MARSHALL, PETER Author Rank CAPT Author Assignment I Narrative Text At 1926 hours on Friday August 19, 2005 we were dispatched to it building fire. Fifteen units were assigned to this incident. Thirty-six personnel responded. We arrived on scene at 1930 hours and cleared at 2210 hours. The incident occurred at 1591 ELLIS St. CONCORD in District 06JCN. The local station is 06. The;general description of this property is nulltifamily dwelling.The primary task(s) performed at the scene by responding personnel was extinguishment. No mutual/automatic aid was given or received. The involved structttre is described as an enclosed building. The building was occupied i and operating. "Storage room, area, tank, bill" best describes the primary use of the room or space where the fire originated. The fire occurred on the second floor. The fire was confined to the floor of origin. "Candle" best describes the heat source.that caused the Ii Page: 7 Printed: 10/27/2005 16:17:44 1 f Incident Relo Contra*r County PPD 2005-5026713 -000 Narratives ignition. The cause of ignition was unintentional. The material first ignited was"multiple types of material first ignited".The use, or purpose of the tllaterial that was first ignited was "box,carton,bag,basket,barrel". "Heat source too close to combustibles"contributed to the ignition of the fire. The material contributing most to (lame spread was"paper". Tile use,or purpose of the contibuting material was"box, carton,bag,basket,barrel". The building was equipped with smoke detectors. The detection system was battery operated. The detectors)operated properly. The detector(s) alerted tile.OCC upants and the occupants responded. The estimated property loss on this incident was S75,000. The estimated content loss was 55,000.The estimated property value was$75,000. The estimated content value was $5,000. E6 arrived on scene after reporting smoke seen from one block away. Upon arrival E6 COuld see moderate black smoke conning from one unit on the second floor. E6 established command arid assigned incoming units. E6 identified a burn victim trapped by the fire on the second floor balcony of her unit and the firefighters fi-om E-6 and Q-6 laddered the balcony and removed the person and turned her care over to an on scene AMR paramedic unit. Q6 captain went up the interior stairway to the second floor and reported to command that there was smoke and heat in the hall down to the floor. E6 called for a second alarm. E6 was assigned as division 2 and was assigned E9. Div. 2 performed fire attack,and evacuation on the second floor. E-6 passed command to B/C 2 and joined his crew that was looking for additional victims and fire in the unit where the ladder rescue was performed. Div. 2 crews extended a jumpline with an apartment pack and found the fire in a second floor hallway that originated in a storage room. The storage room was fully Involved with flanges spreading out into the hallway for about 20 feet. The fire was put out with about 50-100 gallons of water. E6 met up with Div. 2 and was assigned to them. Div. 2 crews searched the floor and forced entry on a few apartments on the second floor to check for persons trapped and found none. Div 2 cleared smoke with one blower and broke out 11,111 window. Div 2 also did overhaul and removed contents to the parking area on east side of the complex. Upon investigation by E6, it was clear that the fire started in the storage room and spread into the hallway. There were candles found in the storage room. The AMR paramedic unit that transported the burn victims told firefighters on scene prior to their departure that the victim stated that she was doing some work and burning candles in the storage room and that t11e fire was started by one of her candles. Burn victims name is Friedel Funke of unit 208 (?). She had burns on her arms, legs,and head. I Eng 10 was RIC, Div. 3 was Q12,Div 1 was E8 +� Batt. 1 was safety, Batt. 8 assisted I.C. I Their was a total of 2 patients transported. One was flown to Doctors Hosp. in San Pablo. I f Paue: 8 Printed: 10/27/2005 16:17:44 v y• Incident Re# a Contra County FPD 2005-5026713 -000 CNarratives The other was ground transport with unknown destination at time of this report.The ground transport was due to smoke inhalation. Concord PD provided info and assisted with evacuations,crowd and traffic control. PG&C: secured utilities. Reil Cross responded and assisted several tenants that were not able to.rcturn to their homes. Board-up crew secured the building and units. Alarm number 5026713 has been assigned to this incident. Narrative Name 1 128 Narrative Type Other Narrative Date 13:06:49 Monday, August 22, 2005 Author 65175 -CHAMPION, RANDALL Author Rank I F Author Assignment 8 Narrative Text On 8/22/05 at 0740 hours, I received a voice mail from Capri. Marshall regarding this incident. Based upon the information he provided and the information in this report, I have assigned this incident case#05-42142 for follow up purposes only. I will attempt to locate and interview the occupant. Capt. Marshall was not able to speak with her at the time of the fire because she had been transported by ambulance to the hospital due to her burns. Based upon Capt. Marshall's investigation,there does not appear to be a need for an FIU investigation to occur. (S/l Davis was informed of this incident and concurs with my assessment). End of Report i I I Page: 9 Printed: 10/27/2005 16:17:44 CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �. BOARD ACTION: MARCH 14/06 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: $75,000.00 FEB 14 2006 CLAIMANT: WEST WILLIAMS COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: BRIAN L. LARSEN DATE RECEIVED: FEBRUARY 14/06 ADDRESS: LAW OFFICES OF BRIAN L. LARSEN BY DELIVERY TO CLERK ON: FEBRUARY 14/06 530.JACKSON STREET, 2nd FLOOR SAN FRANCISCO, CA 94133 FEBRUARY 13/06 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. FEBRUARY 14 2006 _. JOHN 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. ( ) 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: nCounty 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. PDARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in fiill. ( ) 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 /2 a? JOHN c_ U H,.EN, CLERK, By , Deputy Clerk WARNING (Gov. code sectio 913) Subject to certain exceptions, you have only six (6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional 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 frilly prepaid``a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:A6Y46 �tS'a?io�JOHN CULLEN f, CLERK By Deputy Clerk FEB-07-2006 11:51 CCC RISK MANAGMENT 925 335 1421 P.02 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later -char, one ye- after the accrual of the cause of action. (Gov. 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 govemed 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. ■s as a an Now ass a anus s■No s mum a am.us a ON as a Ed us Rosso pigs s s NIS a among ORE nos amps mango a to a l RE: Claim By: Reserved for Clerk's filing stamp RECEVED Against the County of Contra Costa or ) FEB 1 4 2006 BOARD OF C�©tiT��J �o✓TA c a u.�-T V .tX/tr�iFF�l�rDlStriCt) (Fill in the name) ) CLERK CONTRA COSTA CO SUPERVISORS. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ FS, 0 a a and in support of this claimrepresents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 901 Cou4r /H a,b r C c i-r i 0s rt"t Uuo7 y 3. How did the damage or injury occur? (Give fulldetails; use extra pa er if required) T 2 ComLcclunls Butts C,aud0 d t ems. 6o1L eaf wao Gf� riv�a C4U6g0 OU bAD, hcxO Ct t. V-ck -tD &wChsar-- i n m a LL . do 4- C�((!✓i u�- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 6AIh dW d 5 What are the names of county or district.officers,servants, or employees causing the damage or injury? COOCA �S A � BL0 FEB-07-2006 11:51 CCC RISK MANAGMENT 925 335 1421 P.03 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) I-°�'" bl-ad2 ()&uv 40.CLWz .t. �Dwj Ku,t*,j (wi Lcdct LJNQ,d., VU C.0 i dCCLRrecA 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) &Yt@./ (L.W trN V tJ k- / (!, a��.t-h c V1J f7 A amour-1- ( \)(-rwL4L @ CU0 tivuCil i e�•l' <S�.c.l s �IQG n5 8. Names and addresses of witnesses, doctors, and hospitals: SFG If - Ivoi ?o ULA fvte DQ. Mu(Wk -21N2 Miajio�, Sfi/a.rs.¢.r Sl:, CA q 14/to 6'F, CA 4y/i0 9. List the expenditures you made on account of this accident or injury: DATE TWE AMOUNT Or rA/i.r 7-1,"45— won arraswassasa asaaw aaarw a as asaa Manxman saawssawwwarrsaaaaww■'■■wwsaaaaar wa no sisessaaal ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his )behalf." SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) ( iau BRIAN LARSEN, ES®. ) tcs Signature) 530 JACKSON ST, 2ND FLOOR ) SAN FRANCISCO, CA 94133 ) (Address) Telephone N4_g1y)341-1qLh0 ) Telephone No.rv_/Ir ■■aaasaawasaaswsasrarsaawrrrs■■asaaaasaswaawoman a■awassaasasarwassaarwwasasssaaaasaal PUBLIC RECORDS NOTICE: Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■■aawwaawrassraa■.Mmanna a■waasaarrrraassarraaasaaansa.saassssaswaa■■awwawnow owns swung NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), 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. TOTAL P.03 r i i ..r CD . O . kr, N . �`t �. •� Cp ere f'- ce) G �= vto W . N d z� 7 o� COca 0Y i 1y d 0 A '' o C Qn 4 w.© 3�c, CLAIM of / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY l BOARD ACTION: MARCH 14, 2006 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 D � AMOUNT; IN EXCESS OF $25,000.00, SUPERIOR dav COURT TO HAVE JURISDICTION FEB 15 2006 all "Warnings". CLAIMANT: JOEL CORRAL COUNTY COUMSElINE - ATTORNEY: UNKNOWN DA�CEIVED:b FEBRUARY 15/06 ADDRESS: P.O. BOX•1832 BY DELIVERY TO CLERK ON:FEBRUARY 15/06 MARTINEZ, CA 94553 HARD DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE k Dated: FEBRUARY 15, 2006 By: Deputy H. FIROM: County Counsel, TO: Clerk of the Board of Supe isors (4'rhis 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: Belxtty County Counsel / U v 6- 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. ogOARD 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 (late. Dated & �d J O H N' C UL L E N r, 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 snail 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 wider 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; y,jwer e(, o2-VA JOHN CULLEN CLERK By Deputy Clerk Joel Corral P.O. Box 1832 Martinez California 94553 tel: (925) 518-3449 Tuesday, February 14, 2006 Clerk of the Board BoardBoard of Supervisors, Contra Costa County 651 Pine Street Martinez, California r Lb 1 5 2006 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. CLAIM FOR DAMAGES Claim against: Harlan Grossman, Superior Court Judge, and County of Contra Costa Claimant's Name: Joel Corral Claimant's Address: P.O. Box 1832 Martinez California 94553 Address to which notices are same to be sent: Date and Time of Incident: September 29, 2005 Location of Incident: Superior Court, Walnut Creek, California. Description of Incident: I was convicted of misdemeanor battery with serious bodily injury,Penal Code section 242. 1 was sentenced by Contra Costa Superior Court Judge Harlan Grossman on September 29, 2005 to 3 years probation with a four month jail term. My attorney immediately filed a notice of appeal in open court. Under Penal Code section 1272, 1 had an absolute right to release on bail or O.R. pending appeal. My attorney informed Judge Grossman of the requirements of section 1272. Judge Grossman said he didn't have time to consider any bail motion and remanded me to custody. I spent approximately 36 hours in jail before being released on bail. I was strip searched in jail. I suffered emotional distress and mental anguish and lost my freedom. Torts Committed: Harlan Grossman: False imprisonment, violation of civil rights under California and United States Constitutions. County of Contra Costa: Respondeat superior liability, denial of civil rights under California and United States Constitutions. Damages Incurred: Emotional distress, mental anguish, denial of civil rights, loss of freedom. Officials, employees, and agents causing damages: Harlan Grossman, Superior Court Judge. Itemization of claim: Specials presently unknown Generals In excess of $25,000, Superior court to have jurisdiction Attorney's fees tly unknown Total In excess of $25,000, Superior court to have jurisdiction Signed by or on behalf of claimant: Joel Corral, Claimant Dated: Tuesday, February 14, 2006 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:MARCH 149 2006 Clain 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 EB 1 6 2006 915.4. Please note all "Warnings". F AMOUNT: $44,490.15 COUNTY COUNSEL MARTINEZ CALIF. CLAIMANT: CRISTETA ONTIVEROS ATTORNEY: UNKNOWN DATE RECEIVED: FEBRUARY 16/06 ADDRESS: 1370 RAE ANNE DRIVE BY DELIVERY TO CLERK ON: FEBRUARY 16/06 CONCORD, CA 94520 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE N k Dated: FEBRUARY 16, 2006 By: Deputy II. VROM: 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: Dated: f' .(Mw Z�6 G By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel ( ) 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 corred copy of the Board's Order entered in its minutes for this date. Date;d/'�8,d'a/J .10H.N CU LLEN ', CLERK, By�O � , 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 shorn above. Dated: 6,�4WJ0HN CCi LLE\ (, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one yea.- after earafter the accrual of the cause of action. - (Gov. 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. Enos"mammon 0onsomommomom0aaas2 MEN SEE to01 RE: Claim By: Reserved for Clerk's filing stanip Cris�ctu nnbvens ) ) RECEIVED Against the County of Contra Costa or. ) I tt3 1 6 2006 District) CLERK.BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 4M- V5 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) SatoVdDv z ji-1J.zo1) (5 6WfYDJ 12:it) pm 2. Where did the damage or injury occur? (Include city and county) �5 �oan�- ign�vav� Rimmund Calif 3. How did the damage or injury occur? (Give full details; use extra paper if required) SeippM on tahhAm in pavyIn9 loto WAice;rservants vvras al arcG 4. What particular act or omission on the art of county or district , ror'emoeePPl 5 caused the injury or damage? NU_ mainkrlamt �h Q �� Iii- ares at- Deanfi�un o 5 What are the names of county or district officers, servants, or employees causing the damage or injury? C ` 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) (�yokh lt�t MK-Ie 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Total o- hosPIWI dDOW, 10) AbWohc� S. Names and addresses of witnesses, doctors, and hospitals: mad account of this accident or injury: 9. List the expenditures you e on a � 3 DATE TIME AMOUNT S e� Vuvvlyl� �Q ge ■.........■a aaa MEMO as aaa aaaaaaaaaaaaaaaaaaaaaaaaa■sa■t■aaaaaaaaaaaaaaaa aaa a as aaataaMI ) .Gov. Code Sec. 910.2 provides "The claim shall 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. Cq2�)� 0 C7 01 � MEMO ENE WERNMENE1 PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendurns, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■............■aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa■•aaaaaaaaaaaaaaaaaaaaawas aaaaaI NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), 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. Witness: Sandra Torres 408-393-4497 17695 Peak Ave Morgan Hill, Ca Doctors: Dr Joseph Matan 510-724-4300 Dr William Lyon 2160 Appian Way Suite 104 Pinole, Ca Hospital: Doctors Medical Center 510-970-5000 2600 Vale Road San Pablo, Ca Bill & Date of Service Amount Amount Paid (if any) Ambulance 12/17/05 $1,102.29 paid $1,102.29 Hospital 12/17/05-12/19/05 $40,454.90 partially paid $1,650.00 Dr Matan 12/17/05-1/19/06 (est) $1,500.00 waiting for bill $0.00 Annesthesia 12/18/05 $675.00 unpaid $0.00 Imaging 12/17/05-12/18/05 $101.00 unpaid $0.00 X Rays 12/17/05 $319.00 unpaid $0.00 Lab 12/17/05-12/19/05 $46.00 unpaid $0.00 Brookside Clinic 12/29/05 $40.00 unpaid $40.00 Brookside Clinic 1/19/06 $40.00 waiting for bill $0.00 Brookside Clinic 2/2/06 $40.00 paid $40.00 Brookside Clinic (XRAYS) 2/2/06 $52.00 paid $52.00 Brookside Clinic 2/16/06 $40.00 paid $40.00 Rite Aid Pharnacy 12/22/05 $18.99 paid $18.99 Rite Aid Pharnacy 12/26/05 $18.99 paid $18.99 Rite Aid Pharnacy 12/31/05 $18.99 paid $18.99 Rite Aid Pharnacy 1/04/06 $22.99 paid $22.99 TOTAL $44,490.15 JAN 23 2006.12:34 FR DMC SP PT FIN SVCS 5109705747 TO 919259495004 P.02i06 DRS OF SAN PABLO/PINOLE Summary Statement of Account Patient Account # : 004400810 Date: January 23 , 2006 Patient Last Name : ONTIVEROS Permanent Address : 1.370 RAE ANNE DR Patient First Name : CRISTETA Permanent City: CONCORD Permanent State: CA Admit Date : 2005/12/17 Zip Code: 94520-0000 Discharge Date : 2005/12/19 Physician Name: ENGLISH GREGG G Primary Insurance : PRIVATE PAY Secondary Insurance : None Total Charges : 40, 454 . 90 Discounts: 30, 341 . 18- Insurance Payments: --- Patient Payments : 1, 650 . 00- Total Amount Due: 8, 463 . 72 ---- ------------------------ --------------------------------- --- ---------------- Detach and include your payment method: ( ) Check ( ) American Express ( ) Visa ( ) Master Card ( ) Discover Credit Card # : Expiration Date: Signature : Mail to: DRS OF SAN PABLO/PINOLE 2000 VALE RD. SAN PABLO, CA, 94806-0000 01/23/2006 MON 11:52 LTX/RX NO 81681 Q 002 JAN 23 2006. 12:34 FP. DMC SP PT FIN SVCS 5109705747 TO 919259495004 P.03/06 A 1 O o g o 0 0 0 0 0 0 0 0 0 O G q O o 0 o a O o 0 e n n m e d r q o m 000m m (� no0mn .4 .000 .� gmloamgmnmmmhA .HmrOm n O m 01 m m O m h b W m O m m m N rl A 4 m O O b N IA �• H t m N .4 m 06 b Ip A • A n M p m e m m .-1 M • mgmrvpOm10MrOMaA • A1h m 91 M n Q m O O 1 .Y in \ O o O O O O o o p o o p o O O O O O O O O O O o O n ry m o g n q O N m o A O O O m W ry ry 0 0 m n H b o q m W 1p m m m g m m h A .4 VI r 0 10 v \ A e oc� riolnmma� o mrlor: � wr .ir: uilnlao0% ln -401ari .v0 Inom to • n m .i w 0 m a O a ry m W w W p N .d m m b b A •r A .11 n g m O M m .4 • M .• Q \ H A m N A len m 1• n K N m H W M • ry W m Ifl n A A N A M o � m e h rl w H • ry m A m -4 W w • .� A A A H A w H A w H A w A A A .-1 w .1 .4 w Q ra M Ip m m n m H m at h .4 °j In N ^ p� i N P E: tga IQ.1 y I�fl 1 Zib Nj +� F p►y q g �i 1� a� �sU` u � v�� pp� � • f®pQ � � g e r4 W pQ 10 IO n �1yy ('1 n m h O yi m N O a O e n N A e m M • n A q o n m A M m /n N N m N 0 0 0 b • • O N b b m r � F h 111 CCC A A h h h h n h o N Ifl m to a M M A rl nk. t�o•1 fry. b m b p 0. N N N ea N W m m m m n In m h r 1� 11 nHp n[A. mw tMmi mAA hAp Mm mryry.4 NeO m mryry.4 hwa0 m.l .m� 1A• mA .i n F Hm0 m mh hN nM n mn p M ~ nAnHnyy n i .1n HI . n rK[�dryfnAh rynnryry A . 1 O O O o 0 0 o e o o e o o O v O O v o 0 0 o e o O n ry 111 O 0 h p o m O OOmmn Hoo m n .•1 b O O A m m b 10 mm mn mmmn A A N by In A v n n 0 m g m m e W h a ry r m r A n m m m O q M A q p M m W N O m 10 111 A .4 O m 0 0 b g M m H • m N A m m b m A • M M m g e N N A t M r V qAn mOmlpMneM.e .� f M • n .o m1� •o .iwA A M A n nmwM .� A -1 b m w q a � A 1 A m (•� O p 00 0 0 0 e 00 0 0 0 0 0 0 0 - . 0 . 0 0 - ry ry N o O r g O m 0 0 o m ep ry " a e O q 1. ./ •p O O N m m a b m A m ry g m m h w .•I In r O b • 1 • • • • • mm 11�� n n m h w n m m Ip O m M A m g n m m N 4 l0 m W rl O m A A O m 0 0 1P n N • A .• m N A m W 10 10 .4 • A M M m g O m N A .r A • M \ V m g n m o m e /1 h O f'1 IY A ♦ RI • n 10 N N a ri .� w �1 ►1 A .1 w O .Qi VI O -1 A A -1 A O H S � r ry e m • • e • o S it m Ln w W a pnn pq IE pq pq ,L7� p, A m A A i K O w i •V [4 m S Np■f Iv � pyo � � m f! 14\0 •�$ N {Y W h U N � � pAi � AA S M •�HHiI 00 O • �1 1p at A m �1 of �•�sJ,• (FJ r N o o m N o O Comm " r1 VFX M O O A .4 A w • n ry A .4 N o m O A m m O • v m 1fl m O g m H �• m 111 m 0 w • " O N W Ip a ♦ n p M 1i i h h n n n n O m m vl W b .11 M M A M n 1•4 l<f .O �[�• q N N n1 N of N m m m m n /.1 m h l+ 1+ n q /a N N K o �o F o n t� A A .1 1.1 ry 1'1 A M 0 v b r O o .1 rl O o O O f0 O O o • N In l• 0 0 , W O b m le l• n M A 00 m 0 .4 w m m n g m m 4 n • O w �7 1111yyyy A o 9 0 0 0 0 0 e o e 0 0 o A 0 0 a o 0 0 N b n o p m el n r A m m h b f, {R{ 2, O O Q O O O O O o p 0 0 o o 111 m N m m M M n M N m m ry M n lYi v d A A !� 1'! n A A I.1 n ry n n Iv m n n h h n w H A A (4 ry b g m m 1+1 M M M M A PI M A M O O ry n M 1•I n M n M n M A M A • 1 ♦ • •. • • '� • � N N m N N m N N m N M g r m m m mm W m ow oft w . m r h m m � h m n m m p 0 t, 0 m O H A .l Ary A A A A .l ..ry4 w .1 A M f��{ .� H /�� A A ry Ary w nl x.{t w .{ e.A�1 .1 .1 A A pl A .n4 .4 A H A .4 .4 N -1 N .rvi ry w M .1 A OI m W H g m r m al 01 OI r .mi w M ehi M H .ht H A A A 1 A1 A N q nq A H f�A�4 A eeM�4 A A .4 ti N M n N H n H H n M A H H n N A ry •'1 A N .n'1 n H N .4 N � .4 H •4 sn.1 .n1 w 01/23/2006 MON 11:52 [TX/RX NO 81681 0003 JAN 23 2006. 12:34 FR DhJC SP PT FIN SVCS 5109705747 TO 919259495004 P.04i06 pppgll ro Q o v o o v o v a o o e o o e o v o 0 4 o v o 0 0 M N • In h 1I o Yt m e C! M It A a In In o 0 b M M M w W IC wI • .� h h n • h r h W n • R m V o A R I• of W m le b b b R N R ry N R N H � H A R m rl M O m H N Nn N n O O •/ m \ O o p o 0 0 0 0 0 0 0 0 o e 0 o e 0 o e 0 a g O o 0 0 0 0 0 o p o e W O OI M R ♦ O v o p O o O v O Ifl of O O m In O a M b w w In In p o lc M M M N In o i ro i .i O o n 0 0 0 0 0 0 P P h . n h r m 1� n M . o H ro lD W m m 1p b w b n 4 m a • O o e b h IA h O OI H an O o A .i d N 1a b N R N ro ro eq N11.1 A .1 ro m H M O O N ^ R O .1 III 0 \ r R n .r H A M H A MRA H H A H N A w .1 A H R A H .i 1'1 N n s1 N W o R N H M no M r� •7 .� W n h � � � pppj, RO m l0 � �r pM p pM�I � � T [0aJ1 0� � � M� •[i. � H 1mp��.� �q^�$J (F�y W CI W � pp�, ppi, +E 1iHA0 l�9 � � OMy QW�� OipL G Q � Rf � IO FG m QO 51 � M 4 M O bp' � � YI W 00 �45 rEpUN6i1 ryp W FY RI Ir r. W r • m V O O O O d • O g O 4 q b m Of a s O O o 0 0 aa g O o q O a in o O M N W a.1 CeE'aC� �ei'a �1 �4 �aCiCeCa � aahim 14 Rj .m-i .hi .m•{ .wi w H r4 .mi H A � n H H N � e H� M n e H� h n ry H M n ry H N n H f�I h n Vv rNi .RI .� w H .N7 .Ni .N1 .i .NI .1 ri •q N .i A .� .i A H .-i A H .-1 .7 .1 .i A r1 .1 .1 It 0 0 0 O O g O 0 e 0 o e O d e 0 o d O o 0 0 0 0 0 14 n R � lfl Y1 m a N In a Cl M `a Ol a In N a o b M M M vI In R M . .� h r • r r h m h • R m V v A N �c m m t0 v l0 a b R O O �tl 0 0 0 e r YI III 9 a ./ W O 4 wl .1 H A O H a ry o e O o o .O o O O o o O C O O O o e O o 0 0 o e o 0 o O o o O o o O 0 .7 r M R ♦ O o o e p O e O o In N 1n o 1f1 m d T PI N a! w N SII 0 O b PI M M m Y1 4 �p � �n n V .� O O o e O o O O c r r V h r r W r V N aC • O .� N IO Cp m m �D m .F71 o O� be Nro S o o V o e O o h in n O OI A V1 O O H .� M a � N NNNRN +� H -4 ArotiAM � A O \ o U loo N n .1 H rl n H .i .• H .1 A N .i .• H 'i A til .-i A rl M .i N . .1 o � • n In o O\ •p • q • �apy ♦ • • • • • r m .# m A oAu .aQi H � 5 �y 0 -0 to 641 • am sq O O Q O O Q V O 0 0 0 0 O b w 0 0 0 0 0 0 0 4 0 0 0 0 a o M rl m aD N m In P t ri t ri h P• r h r n h r 1 r� O M Aw N [01 1®1 tlF k KA `I la N vi �a {moi �1 �e �1 �! Ct K eri vhi m aai 0 40 r b b O .Hi .H1 Y~t O•i O m o0i m IOfI r b b 1f1 0 N O m o oml ryh 4l n H mm 00 a a � ..+t11 A ,CO IU4 N n • . • r A w+i n M . • r V • vOi M M M M M n M M MM O 00 N m N N N n N m m N n N N m W N m of N N H N m N In N M b m m M m •7 Ih•1 m r m 01 W a rO W r W r m q CI m OI Oo a m 01 m QI r m m a w RI r a p 01 a •I O g W A W .1 A H H .• .� H A H .1 A A 14 A R N N R mm !� mm C! A H A ..��11 .-1 .4 A .1 .• H .1 .1 H w� W d A H A W cel A .� .i M ..'I .1 A r+ A m H 01 a m •i m a .1 A OI H a A 01 A a .4 m w Q/ O Q O a .•1 Q/ A A .J -4 ,4 A W .j n N .+ R .a rRry1 1 A1�� [• W R .I .i 1AY N R R A ry R rf I'I N sq1 rl w .roj .7 w H d .� a w .N. ti w n .N1 01/23/2006 MON 11:52 [TX/RX NO 81681 004 JAN 23 2006. 12:34 FR DMC SP PT FIN SVCS 5109705747 TO 919259495004 P.05i06 g n q T . w H U1 1n n H W m H O H h m b m b H n w 0 0. 1! 1: n Ifl n q e b . .. H n m m.r H ry H 0 b ry b g n ry r H n m b w b N • � N H N a w ry ♦ m er ry .'1 at�+ nl O q ♦ ♦ b 0 C1 .� O of b N m r H d A N C w A A O Q n H O O O � q n n O e .+ t` •I m ry °� N e . � b • H H n m m H N H d b n b g ry n r. n n m b q b n � H N rt M a � . n h N ♦ m a n n en .� .1 o w ♦ ♦ b o N ti o N b h m r H O .1 rf n q .1 n .A O ot o M M a 0 0 r m aaa .+ � aH � ANH .fn .1dHH �nnln H .+ n .+ Hn HH .� .In ! H d Q s Yw N y t4W�t V�1 b IL .4 �C M 1pp LLJJ SMy p►�� 77 a w A p� � M � � pp p � 10 H � � � �♦ V � W CCC FF-WJ1J � K N M rMi H CI U iW aw 96 to ta to N b � Ia0 � p O Q H q m m m m q 0p 9-11 W m m W m . 00 . m W m m g m n m o W o OM H '010 A 0 {Hl H .�O H .-1 d M .4 .4 eA d H H n .q ryH . req 0" M e1 .9 '7 Mi .Nq "4 " O H O O e Q p 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o e 0 0 0 0 0 0 0 g r q q ♦ H H N N ry � m m d o H P w b M b .•f N 1n o o H r wf N n q j H O b n b g n n r W- n m b q �Y n r n rl ry H • 4n q . ♦ b 0 YI N O N b 1A ap n In O .1 r T .i n o h n ry n H n H G q b a � � Arm g n a q . .� .-I n n n •'1 m 1! O N b a H H n m ap H A N H o b n b w N w in ry .D b g b n . ■1 n r1 w r 4 :gyp 4 N . m wl M n w1 H .� p w ♦ r m o N .i o N b n m r n o N M P g H r•l N q �y p N n ry h H n m H .1 �o H H M +1 .� .•1 h .1 + e H V in N u) D W N A N r h N W o n ii �q : . . . . • • 0 . a pWWp� uu W n m bed W � in to i t i A L7 O F W dl W q Gl age a pi G• q 01 b II O m b pC] � q O K d pU FNY u1 0 01 � W m m � w m m o00 m m p o ti ti � o P .bpi .1 e0{ 4 N o N P n m m ubi a h r O �j b d +n in P ./ N H .� O H n m ♦ N O ♦ N Ne� b �f pC M ry n n M w n q M . n N m y W1 'i n Eb m m ap m m g q q e 0 a ry tWd tGJ1 P1 m PI H w� w q q w O II tY u �p �p v m a0 � O � (0 m m ap m m m ti m m p W m q ab W m W ap m m q1 m m O W m m Op m m .+ Yq m Q W 1 H m m W W m O Wt m m1 .�wo mH m .a O 73 w H H H ./ n H .� . H w H H .� . H .. H H .� H H H .+ .1 m n d n N G0 ! H a .� H .� .� n .1 H .i w .1 �1 ..ii .. H r/ .� In q q q q q W q q q y M e� n n n n N n ^ n M n n n n n ry n n n ry n n ry n n ry O 01/23/2006 IRON 11:52 [TX/RX NO 81681 005 JAN 23 2006. 12:35 FR DMC SP PT FIN SVCS 5109705747 TO 919259495004 P.06i06 o, a n N P al O p h 11 P1 1? T t . r a m O W M try O � .i O PI O•M N W YI N b M rl n H N .1 n IY � m M rl r0 >i m Q Q/ r A lilt W t 10 l b g t O ey n 0 1 O f\ N WA � p( � R P, 00 M .I W Iryy'71 lk R '1 � 8 C11 � � i• � ! 1� � � � '�• E7 m M 51 • 3 .a O If1 v o g 0 0 0 .y q t x 0 0 0 o a p p a n m r. a o o n .r In n el r O a` a m O la ul Ie ona� r ui � u� .: en .al� .i �e iln �cv eo 0� y1 w o w n r In q OI A •1 v p wl O W .1 blah IP Zr o frn M h n tV N N N Q Q \ O O mu (V O p M O \ b �g O O m m r O � N a a * TOTAL PAGE-06 ** 01/23/2006 MON 11:52 [TX/RX NO 81681 2006 Co co !«J W Tia❑ - F�. to W U) c�z, CL ..Cr Z coM LU �- 0 � mT a< 0 d oCC ® ¢ o LU F- 1<1 - ¢O z0 W w IL W CC � > cn o 0 z W ® w W.... `�+�•ra`,w, <ui F Bank of-America I Account Activity I Transaction Image Screen https:Honlinewest2.bank-ofamerica.com/cci-bin/ias/bit9biHfnYovx... -. - Online BankingBankofkmerica Higher Standards Search • Locations • Mail Help Sign Off Accounts Bill Pay&e-Bills Transfer Funds Investments Customer Service Accounts Overview Account Activity " Account Summary Find a Transaction Open an Account Check Image - Front and Back Posting Date: 12/20/2005 Check#: 1076 Amount: $1,650.00 Reference: CHECK Account: DDA-1222 Nickname: JOINT .. .... JACOUEUNE ONTIVEROS , 1 ;/ 1076 FRANCISCO A COR'i1�Z 2304 WILLOW A�E(82S) 11*', � �a''"f��✓ 11-3Fru10 u► ANTIOCK Cb 945Qq ' 2140 *ate ,• J $ Pius h � 1 BankAmerica ...... i cea:uaAaAm ce1s.13.nluq � '! _ 9 •-,�` f toms hD�i � � r 1000 3 581: 10 762 7 to0 7it,612 2 2u' X00000 15 5000,1' � E 09�( tfFk1CR,Wt3ft f�210=14 :7 D I w C7 s -4 C3 i L- J.7S9 r O Oz m -�-1 >0 M n To print this page for reference purposes please use the print button on your browser or click "File" and "Print". More information about images and image availability. Inquire on This Transaction ;Return to Account Activity Lower your risk of identity theft Because you can control the information you choose to release, you are the single best person to protect your information. Online Banking offers 1 of 2 1/12/06 6:38 AM .- NVOIC, C1P 5,311 www.amr-inc.com American Medical Response - AMERICAN AL RESPONSE WEST P.O. Box 3429 Modesto, CA 95353 Rip;: :::`;; ;;;;;; ; ;;;,;;;;;`; 401-55313372-00 ACQT ;. 002969349 .. ..... .......... PATIENT.NAME: : CRI STI NA ONTI VORS ET ;OF>SEFEV;EGE;€> 12/17/2 0 0 5 2 4 ; 1 2 2 i ACCOUNT NUMBER: 00 9693 9 A.M.RtVlotlN...::D.u..E..::::::::::. 1 , 102 . 29 DiiSATE ;>., 0 / 3/ 00 CRI STI NA ONTI VORS REMIT PAYMENT TO: 1370 RAE ANNE DR CONCORD CA 94520-4311 AMERICAN MEDICAL RESPONSE FILE 73329 . PO BOX 60000 SAN FRANCISCO, CA 94160-3329 LEASE CHARGE MY: ❑VISA ❑MASTERCARD CCOUNT ❑❑❑��❑❑❑❑.F1❑[11-1❑❑ EXPIRATION DATE F1❑❑❑ IGNATURE PLEASE ENTER AMOUNT PAID: S PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT .. - PATIENT•:NAME..; :.. :;. ..::';.::..:;: '.; ;: ACCOUNT:NO.. ..._.. ., :.•.. ..;._..TRIPt;NO.:. :' INVO.IG� DAI;E.-. CRISTINA ONTIVORS 002969349-0001 401-55313372-00 01/03/2006 ....:. , ... ...:.,:; .: f.. 1 ]ATE-OF SERVICE SERVICE..FROM •' '• "•.: :SERVICE::TO''`?:'�'::��'' :`>;+: •`�'':=:..�.::'�'= 12/17/2005 MEN' S DETENTION FACILITY DOCTORS MED CENTER . .....c.z.. .... ....., ..: .... :. ... :.. ... :.::. ..::.::.:. IIP RTANT MESSAGES Please advise us of any medical insurance that may cover this service . If you do not have insurance, please remit payment in full . Please contact our Customer Service Department at (800) 913-9106 if you have any questions . Thank you. CODE .:.: ;<; s ;:,>;.;:::-n DESCRIPTION :::::, .,..,,,: ..,. .:: .. .: : UNITS . UNIT CHARGE:;; :;.:x: ^:: :: TOTAL�CHARGE: -- .....r .. ._.... .. ... A0427 ALS1 EMERGENCY 1 1 , 061 . 61 1 ,061 . 61 A0425 ALS MILEAGE 2 20 . 34 40 . 68 CALL RCVD: 12: 38 :: 'TOT AL'CHARG.E..S":DUE:::=; 1 ,102 . 29 ,DIAGNOSIS• 71887 71907 E8849 SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to: American Medical Response, P.O. Box 3429, Modesto, CA 95353 Phone Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 Bank of America I Account Activity I Transaction Image Screen https://onlinewest3.bankofamerica.com/cgi-bin/ias/QJi I NyOgAOQ_... 's''` Online Banking BankofAmerica �V igherStandards Search • Locations • Mail Help Sign Off Accounts Bill Pay&e-Bills Transfer Funds Investments Customer Service Accounts Overview Account Activity Account Summary Find a Transaction Open an Account Check Image - Front and Back Posting Date: 01/13/2006 Check#: 1085 Amount: $1,102.29 Reference: CHECK Account: DDA-1222 Nickname: JOINT JACQUELINE ONTIVEROS ' 1085 FRANCISCO A CORTEZ `` f 2304 W111DW AYE(925)70"l U9 I 1/1 3IOLp I1-3511VO U ANTIOCH,CA 9450;1 � Oka of- ' BankofAmerica _ Cicstarnes� free ' _ j Qgtdiruu Aaaociau 9anttng � 993 1: 12 1000 3 581: 108 5- 2 740 714, 1 2 2 211' 010000 L LO 2 2 961' .n:r.u.�--�--^.- ,r- °'•-• ,..c_.4.s! e.<,-,.. .,-�t�!r'!!!':1-0�. "3Y 699 OF OC(uf.fU{ 5Fc LACK EMD 1r1T41��y1 O/y 073329 OF -31 OF i?"t>t.1�IGA12733126-=3 i To print this page for reference purposes please use the print button on your browser or click "File"and "Print'. More information about images and image availability. ilInquire on This Transaction l 1 Return to Account Activity i Lower your risk of identity theft Because you can control the information you choose to release, you are the single best person to protect your information. Online Banking offers I of 2 1/23/06 12:06 PM SAN PABLO ANES MEDICAL CORP 1:.;.. •,..:.�..;. .:,: ::`p .- ,_ :>;:::•::<.-:.:.�:..:.;::::= PAT E": WILLIAM NELSON M.D. CRISTETA ONTIVEROS PO BOX 7793 r: ?r ACC�IJNT';NUMBER-;...-, "-:STi4TEMENTrDATE =: SAN FRANCISCO, CA 94120-7793 3NWONT50594 01/16/06 ADDRESS SERVICE REQUESTED 675. 00 FOR ONLINE PAYMENTS VISIT AnesPavBft com 925-9511371/800-6976006 MAKE CHECK PAYABLE TO: SAN PABLO ANES MEDICAL CORP CRISTETA ONTIVEROS WILLIAM NELSON M.D. 1370 RAE ANNE DR PO BOX 7793 CONCORD, CA 94520-4311 SAN FRANCISCO, CA 94120-7793 II�I��rlr�Irl�Irr�I�Illrrr�I�rIr�Ilrrrrll�r�IIIF��lllr�r�l�rll II�I�rrI��I��II��I�III��rI�r�II��IIFlrrr�llrlrlr��ll�rllr�l DETACHE HERE AND RETURN TOP PORTION WITH PAYMENT ..:.....:....:. ....: :.::!..,�...e::.: .:._ ..:,,,,:,...:,.i:�.: .;.... :,".k.•'. - �er4.� .: - .:•:,�,tv:r:.;�::.:'t!::[. _•1��;•. _ - >_ ,C.P.T.IR.V.S._,.,..:......,•�>.. :..:.:..:�.,.:;'„_.,...: - - :•i. .:i=>�;s='i4MOl]NT�'r:.: �:. ;' '� � DESCRIPTION. ;�; '.�r Services by: SAN PABLO ANES MEDICAL CORP at DOCTORS MEDICAL 12/18/05 27814-PI Anesthesia Services 675. 00 We would like to file this claim with your insurance company. If you have insurance, please complete this form and return it to our office . If you do not , please remit payment in full . ,.STATEMENT..DATE.. ..:...:::.....:s:.. .::, . ...,...,:..:..:..PATIENT NAME'.'.:.::.:; :: 711 ... :..:....:...,::;..:. :.:.. ACCOUNTNUMBER`:.,: ,::'n; @w 01/16/06 CRISTETA ONTIVEROS 3NWONT50594 675, 00 t:• .'�;�.,� ,k�.:, - IeR:S NUMBS 4• '••< TELEPHONE.:,.�y> ;;�'�.-::+..,:'. ;f: �',;� :� :+=�� '4,:�:��.';i..Pa.men4sreceivedafter..;atiade;date;j�r.;s 925-9511371/800-6976006 26-0020015 ;:will's ear:6ri our nensta4ement:',,+ HRS: 9: 00 am to STATEMENT-PLEASE DETACH AND RETAIN- 4 : 00 ETAIN_4 = 00 Pm FOR YOUR INSURANCE RECORDS ..,;,C .:s_x.is"!'..,8r:. .,..;:.- 1`.1. ..-:.,. ,.• :?:;' :';`� — .,t. ,.7' <?L_: v - ,._.:..........,.:.....,,.� ........ ..... ..:...:. ......... .:...: TE YOU WILL RECEIVE A STATEMENT EACH . ....}. . ...�;..�.. .-,3,.. _.,,. . +,__,..� ., -.. _.....: ...,: .-:;._ .,r t.y:"� s. ,t,: -- -;s.• MONTH IF YOU ACCOUNT HAS AN OUT- Y!”, UT- b h.�'.............�Y,.' ..,.,,.,�. ..i.:�... ..t:T.., .. ..... a....„..:,•d'-„-..�.x-::�. r.:'-` �"i:..�:y'.;�::..��.yAy%.:Y:,r.•=>'�Se',i:';.':..t°�4 "(,�yf.<I.TS.4X. .!)Y:s,}x.,. ,Y,. o.;F it�i,.aY r ..J. ,...}ham <Fir`: •Z'i,r'.; y{Y.:v,:.,: `\;. ..v. 1:-•'h'4 �•�.� .. 1P'.":'li:^A. •tot: 1='sem �.'Y-i. !:4j1,.•�a•. _ ..1i:4�. ..,......<. - �- STANDING BALANCE.THIS STATEMENT IS FOR l.v d•,, t '"� :.._L:, ...,r,(;........�...,j.s...C:.L,. ..y:n:,. �`�.. ya�L:``:11.N^. v ...•, .-.:.',�+t:.`J.r•.�i•.:..,,.A;,Y:_s...-,. .\.:s-. -1 ,' :;.;T.:F :;•f:., - .•:!'ir :.rl.. a-:R'. �' • +:l•'r� ..};ti_. s-..,. :j: �7: ".. :i:::,1.)�.t,y�1F+i,':r�es.:: 1,;:^::',.,..:•'-"i'��-:�":•••'�-• "4:•':u,.�:.� •h' `•:��;� _- .:, Y+:6•.: .T PROFESSIONAL SERVICES RENDERED AND � .�:'::'... .. r:'I•'.. ,:.�4�::.'�' ....t�/:: - 'i,l. .'r, ,:�r;�': �,Ss<„ i''" ,.,�,.., ''.k� •,:a,.�:x n;;,;;hl.,�:1 fh. ,�.. : - ',, ��'_"' SHOULD NOT BE CONFUSED WITH ANY - '','.i,1,ej..iV„ ^ :. p �y�,,_ {•..ri,. t.I,s., ��c. :tl ai.-- i',,.nr..! .•i4, .s-.�' �'ti� � '�¢i: �': � ' "=a;�, ..�:c•.i :�i. �s;r, :...::;a>:i. •:;:•-".::,:,.• .: ,.:.-!�......:»p-:::.::1. aux, - - :>.>.,.,. •',M1,y...�:r..>:,:,,.-:..�.,...,:�:.:.:,._.:... ;.�... :�;;�•� �`::��- ,u...::..,,.`.+1'rra..e..._�,.?t.'.:.:v.. RC2 . L. . .,.•_>,-......., .:,...-:.. ..... .. ..- . ..:.;^'�J,;:`:-;::':::.., :,� :'':` ��':�:.;::''' -�� CHARGES MADE BY THE HOSPITAL FOR 1:,�.'r:+J:,E,.s:z-.'S--„`iA,�.'_..:-."f.a...+-.u,P.,::�.t':'•%:,.:..{..-u!.!`=•.".-d.':,.sre*.,�oLd.:.:<.=....;F.. ...._•.s...-:.: :..n:e.`: _N ..�Y'+'�• f...... .. '��•;:,•ctr. J . ::;lo::•<'•'b� :ruY : SUPPLIES AND EQUIPMENT.NEGOTIATING a , r „k-.. _ :I•,:::..:a.::,.:.�::.:'- - ;:.^fir:.::`v :3 �.'�•_ ..,,. :ix::= :.%�-`` �;� .{ 1; S M NT OF N •:�:� ..�' - ETTLE E N INSURANCE CLAIM IS tvv .sv ,.ls,., r1 ..r ,..K.. �:i:,n,. [.r:;'^'�:'n :xir;- :'.''�jY:':, ••,ncq:;, ?'.i:.i'w: , .,;,,. ,� .�,;,.�..G:.,.:1....,..:,Y..-.b.�:- �Y•:•:'•:.lJ ..',S:•-- - !.V% a}..-.,s �''F`:�:::.iv e7:.:'1,'>, . - a. '-�P;::+.-_: -..: •. ...•:::. .• '•;5..�.��,',:vv.. :r ,r±. .,• . ;t.�;':.: - �p� ;�'�i`�y: "=�v>::` k YOUR RESPONSIBILITY.PLEASE REFER TO YOUR + . t. ... .....:.....1, ,. -. ,. .. ,.. .�.,, `::• ^'t'� •:a�-•'."�°. ACCOUNT NUMBER IN ALL CORRESPONDENCE. TT N• nr, ..:,......::>;.,.,,..<,...:..,.:.r-us..:..,. ..,•: :: ��<�' PAYMENT RECEIVED AFTER STATEMENT DATE ��* I..c ,r.Nt.. .-ti;'I "i-+i,'T::i FRz' '.i:.. ":,5:i, .•`„�+ - .:f..�:•:�� .:e. ..tx,: a':.+.'- ;1+`n��;S`. zz..3�ii+•r :moi_ ,t;�t��;r:1';t.....:'�� c:. •-:..rte << ..:' .•_.r....- ...�..,.��..,,;Sri ...:�. .... ..: �� -:7'+ : .......Ft..•. •...:,.. :,,i ..a. ..a...,...:... ... ..... .. :' ;t::' "f':: "s;+�=:'ii! WILL SHOW ON YOUR NEXT STATEMENT. • ,..,..,,,,r..-....,..,,,..-.. :-�,..._..,.:,� ::. r..,C....,- _.,,r w.-.."..:.: _.,:..�:.-.., ::S'.:: `_1C'fE'>:� :�:ai. F.a: :.Y; '. ., .,-•-.,., - .: .• -....: .... a _.-,a.::�:�•,t.::.r...,':{�.iZ`.f'•[if',:;4�� :;';7'.,;,i;:i;::_:'" .la, :�:�d's'r ?',:;.: .i, '1, !i�:3.. :.Cn..':r _.'i±�:' P•:,�i:fj:'�:.Sro� iN�}.,_, T•,,,.:.::::.:!:+'•„' ({•'r�s�..s:�ili: - �G..,yy '.5,. �.F.. L, �i:;.:y _ .:ja��.T-` A:Z < y :s PATIENT STATEMENT AOCOUNT.;NUMBER': ':':.:...-...:.i•:r';,.:`cDQTEOFSTATEMENT: �=;:?;'. =:.•::. ,... _::. ... . . �::. .::.,:.. - 00149-1123425 01/17/06 G 13 AS ER RCARD•OFl:VISA.FILL OUT BELOIIV,;.`.."..,, .`. PATIENT'S:PHONE.NUMEtER"'�;,;': !;_' -;; PATIENT'S:D.O.Bi:::.;. '. "' CARD HOLDER CREDIT CARD TYPE 925/765-6191 10/27/46 EMPLOYER':-,';: :::'::-;..:�.PRIMARY;INSURANCE:!:>.:;.:;�,•::::.,':.:. : ...:.: CARD NUMBER EXP.DATE SELF PAY ADMISSION.DATE SECONDARY:INSURANCE•; SIGNATURE AMOUNT PAID tugammmmm $ 101.00 PHONE (925) 296-7156 MAKE CHECK PAYABLE TO: 001 OMW: BAY IMAGING CONSULTANTS MED GROUP 111Lrrll1Llllur111111nllnL11111Ir11Lnllllnlllrlulr�ll PO BOX 31455 ONTIVEROS , CRISTETA WALNUT CREEK CA 94598 1370 Rae Anne Dr Il�l��lrrlrirlrlrirrlrrlrllrrlllrrrlllr�ll�rrlllrrllrrrrlrlrl Concord, CA 94520-4311 DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT USING THE RETURN ENVELOPE ENCLOSED. ❑PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANGES ABOVE. DATE :.. :, * :: DESCRIP.,TION:OF:SERVICES. :",:.. ":.;:...... "':.':.:.,..:. DIAGNOSIS:•;;;.: AMOUNT::;.. ..:, 12/18/05 I 3600 26 ANKLE (2 VIEWS) V54.89 12/17/05 I 73610 26 ANKLE (3 OR MORE VIEWS) 824.6 35.00 12/17/05 I 73590 26 TIBIA/FIBULA (2 VIEWS) 729.5 34.00 PENDING I SU NCE PAYMENT: .00 Fo questions, to update your insurance information, or for No ice of Privacy Practices, phone us at (925) 96-7156, fax us at (925) 296-7174 or email us at billing@bmm- .net. Pleas • in Jude your account number in the email or on ihe check. PATIENT.'i::::::::'::..'...,. '. "".::: i.•;;''. ;;r: AGCOUNT::NUMBER ;'r:: _ � GN I 1VEItOS CR15 U1�9-11"[3' £� 101.00 LOCATION OF SERVICESERVICE'•.. : . :STATEMENT DATE-: DOCTORS MEDICAL CENTER - SAN PABLO 000 VALE ROAD TAO, E 1/17/06 :-,.:,..:..,..:;::�..:...•..:....,.�:-....-.-.,: ..::':.MESSAGE.....•,:;,...:.r:..:.,,..`...,,:...:.:'-:..::.:..:•.:::. -.::r..`'..-.'`:tiF:::::.�:-,:;:::�..:,:•`.`REFERRING'Pt1YSICIAN'.:":-.:::�,:::.:...:..:-:�: AHWAH, I INCOMPLETE INS INFO. PLEASE SEND BAY IMAGING CONSULTANTS MED GROUP COPY OF YOUR INS CARD FRONT AND BACK PO BOX 31455 OR REMIT BALANCE. WALNUT CREEK CA 94598 IRS#94-2965646 PHONE 925/296-7156 PHONE HOURS:8:00 am.to 4:00 pm. PLACE OF SERVICE I=INPATIENT HOSPITAL O=OUTPATIENT HOSPITAL F=OFFICE E=EMERGENCY ROOM 1. If you wish our assistance in filing a claim for your health insurance benefits,please complete this form and return it to our office.Failure to return the form automatically makes you responsible for payment in full. 2. If you need another claim filed for a second insurance company,please make a photocopy of this statement,then complete one form for each insurance carrier.Return all forms to our office. 3. Be sure to sign the appropriate authorization(s)below for each form submitted. Insurance Company: AUTHORIZATION:I HEREBY AUTHORIZE THE PROVIDER SHOWN ON THIS FORM TO RELEASE TO MY INSURANCE COMPANY ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. Claim Office Address: X Policy No.: Group No.: AUTHORIZATION:I HEREBY AUTHORIZE AND DIRECT MY INSURANCE COMPANY CARRIER TO PAY DIRECTLY TO THE PROVIDER SHOWN ON THIS FORM ANY BENEFITS DUE ME UNDER MY Name of Insured: Soc.Sec.No.: INSURANCE PLAN.1 AGREE TO PAY THE BALANCE OF EXPENSES NOT PAID UNDER THIS PLAN. Employer Relation of of Insured: Patient to Insured: X +....�`Y::i;s`^fir•---'as'. �, c; _r's'''H ity`},,,...;,-c_w"': Y :3a`:�'.'�.:,.y..::r •,._±: _ _ ...7A&z Ni _= _ �•__.:w- PATIENT NAME ACCT.# CA EMER PHYS*DMC SAN PABLO CMP CRISTETA ONTIVEROS E38 182870 PO BOX 582663 STE D-38 IF PAYING BY MASTERCARD OR VISA,FILL OUT BELOW. CHECK CARD USING FOR PAYMENT MODESTO, CA 95358-0046 VISA MASTERCARD VISA CARD NUMBER 3-DIGIT ON BACK AMOUNT ADDRESS SERVICE REQUESTED SIGNATURE EXP DATE IF SERVICES WERE RENDERED AT THE HOSPITAL, STATEMENT DATE PAY THIS AMOUNT I PAST DUE DATE THIS BILL IS SEPARATE FROM YOUR HOSPITAL BILL. 01/17/06 319.00 02/04/06 F;a•=:a�[�'�.:_'-- --- — � �,=...4::r Vii:_-.'v.^'- - :s:��s¢;'7� ='-a',- _ _ ,��{ F _ 0 ;1. v..]S•.�Y-.__. 3'a.•3A,.ins -it ._ -_ __3_nl( .....� - _-_ .w^, 15750 CRISTETA ONTIVEROS MAKECHrr 1370 RAE ANNE DR PAYABLE PAYABLE TO ��a CA EMER PHYS*DMC SAN PABLO CMP CONCORD, CA 94520 ?'`• PO BOX 582663 MODESTO, CA 95358-0046 QPlease O if address or insurance information has changed. Make changes on reverse side. -f�'�At� �_�_ Id►0 PLEASE MAKE COPY OF ENTIRE PAGE IF NEEDED FOR INSURANCE THERE IS A$10.00 SERVICE CHARGE FOR ALL RETURNED CHECKS. BILLING OFFICE HOURS: 8 AM-5 PM Phone ► 800 664-7660 Tax ID-#o- 942494000 Para Espanol ► 1-800-952-8351 Attending Physician ► AHWAH, IAN, M.D. Referring Doctor ► AHWAH, IAN, M.D. Account Number ► E38 182870 Service Provider ► CEP DMC SAN PABLO CAMPU Patient Name ► CRISTETA ONTIVEROS Statement Date ► 01/17/06 (DATE POS DIAGNOSIS DESCRIPTION OF SERVICES AMOUNT 12/1770-5 -'2-3 8248 99284 LEVEL 4 EMERGENCY, PHYS 291.00 12/17/05 23 8248 73600/26 X—RAY INTERP ANKLE 28.00 i i PAYMENr OF THIS ACCOUN IS YOUR RESPONSIBILITY. IF YOU HAVE INSURANCE, PLEASE CONTACT THIS OFFICE . THANK YOU EL PAG A ESTA CUENTA ES SU SI UD. TIENE SEGURO MEDICO, POR FAVOR LLAME EMPLOYER PRIMARY INJURY DATE ADMISSION DATE DISCHARGE DATE BALANCE DUE INSURANCE ** SELF PAY/NO INSUR 12/17/05 319.00 POS (Place of Service Codes) 1 - Inpatient Hospital 2 - Outpatient Hospital 3 - Doctor's Office 4 - Emergency Room JOf„iN COMPRGN0, N-D- , INC. ( BH) [::]VISA EIMASTER CARD BOX 70094554 PI�FJOLE:;.; CA $ AMT. CARD NO. EXPIRATION DATE SIGNATURE PATIENT NUMBER 0 13PC-05-07025 STA�EMEtVT OF CLINICAL LABORATORY & PATIENT NAME 0 � S CRI-�TE7�A ONTIVERO-� ETHOLOGISTS PROFESSIONAL FEES REFERRING M.D. 0 JOSEPH A. MATAN, N.D. ONTIVEROS18 OR • - • • • e E CF2I:STETA ONTIVEROS • • - • - • - • • - - • • - • A _ 1370 RAE ANNE DR. - • • - . • • - . • - - [� CONCORD, CA- 94520 ON. • - PERMANENT MEDICAL • - • AMOUNT OF PLEASE RETURN TOP PORTION WITH YOUR PAYMENT. PAYMENT is DESCRIPTION CHARGES/PAYMENTS CHEM 7 13- 00 CBC/PLT/AUTO DIFF 11 . 00 PROTHROM TIME 12.00 HENoGRAM/PLT 1.0 . 00 STATEMENT SENT TO YOU t IF YOU HAVE MEDICAL INSURANCE, COMPLETE THE BACK OF THIS FORM AND ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD. IF NOT, PLEASE REMIT PAYMENT. THANK YOU '- C.RI STETA ON T'-" � ��TT�ATE TOTAL DUE L tx 46 .00 OLOpGY BILLING OFFICE .,., BROOK SIDE HOSPITAL TELEPHONE NO. 510-662-5200 ---- ' :.:._..:iii:'.._. ...-'.;i........ o - 77—0- BROOKSIDE COMMUNITY HEALTH CENTER 2023 VALE ROAD, SUITE 107 SAN PABLO, CA 94806 TELEPHONE (51 O) 215-9092 OC-OFFICE CALL INS-INSURANCE PE-PHYSICAL EXAMINATION . HC-HOUSE CALL OB-OBSTETRICAL CARE EKG-ELECTROCARDIOGRAM HOSP-HOSPITAL CARE PAP-PAPANICOLAOU TEST XR-X-RAY L-LABORATORY OS-OFFICE SURGERY M-MEDICATION I-INJECTION HS-HOSPITAL SURGERY NC-NO CHARGE 417 _ �.r'. 1� Vn : - PROFESSIONAL_ "f F ..-LA CE 3740 BROOKSIDE COMMUNITY HEALTH CENTER 2023 VALE ROAD,SUITE 107 SAN PABLO,.CA 94806 TELEPHONE (51 O) 215-9092 OC-OFFICE CALL INS-INSURANCE PE-PHYSICAL EXAMINATION HC-HOUSE CALL OB-OBSTETRICAL CARE EKG-ELECTROCARDIOGRAM HOSP-HOSPITAL CARE PAP-PAPANICOLAOU TEST XR-X-RAY L-LABORATORY OS-OFFICE SURGERY M-MEDICATION I-INJECTION HS-HOSPITAL SURGERY NC-NO CHARGE NEXT ------------ 70803 ... ......... _ -I BROOKSIDE COMMUNITY ALTH CENTER 2023 VALE ROAD, SUITE 107 SAN PABLO, CA 94ab6 TELEPHONE (510) 215-9092 OC-OFFICE CALL INS-INSURANCE PE-PHYSICAL EXAMINATION HC-HOUSE CALL OB-OBSTETRICAL CARE EKG-ELECTROCARDIOGRAM HOSP-HOSPITAL CARE PAP-PAPANICOLAOU TEST XR-X-RAY L-LABORATORY OS-OFFICE SURGERY M-MEDICATION I-INJECTION HS-HOSPITAL SURGERY NC-NO CHARGE AFP 70787 RITE AID PHAIWACY#5913 (925)680-2845 n6dico si LUCKY CENTER Store DEA:BT5236458 graves: 1905 MONUMENT BOULEVARD RPH:KJH g 3 ra iem es: CONCORD CA 94520 para un Rs 05913 0269476 Date Filled: 12/22/2005 ima diana, mortal). ONTIVEROS,CRISTETA as de dano Date ofBirth: 10/27/1946 (925)765-6191 for en el 1370 RAE ANNE DR as de una CONCORD CA 94520 iitad para HYDROCODONE/APAP 5/500 TAB DAW:0 to no NDC:00406-0357-05 QTY:30 DAYS SUPPLY:4 JOSEPH MATAN MD DOCTORS MEDICAL,CENTER Antes de PINOLE CA 94564 nas isa (por REFILL 2 TILI1[ES UNTIL 0.6/18/2006 Isar este cialmente CASH )r ejemplo, . ...... .. .. ... .. oldgica, aria muy da biliar), ;a), s de la :I Iia ,puede ar alerta imentar el :no, el Ia 9ico 0 dimiento, administrar s efectos me y la . PAY: de con on su MEDICATION WARNINGS su iCOS EeGo:w13m54:4 IJiLCOHCC EEN:GA::FEIEGIi1JG[CTk :; ..::.... VFrnGOS : :.EMUUp ;ial riesgo : >..:...ucaa;,wrAn:nR:uam : .. .:.. : TOMANDOMS.DE LO�OUE SE RECONIIENDA �� .:P1f.EDE:CAL35iiff:E5YAEN&UEN�TA;:CONSLL'LE�; :den PUEDE.CAUSAR,PROBLEMAS RESPIRATORIOS.. COti:SLf:61Ep1¢O:CQtifO:TRA.Tkfi:El ................................. ... .::.:.. :ESTR[Iy1MFENF(f;MIEnITRASTOMA;ESTn;�<.:::::::::: uno a ...... Na::::>:<:: «<::<:>::::>;' ..... .. nar este ore fbiaoTay not inchwrAIM... l!! g; camentos ....'..:.:.....:...�'::..:_:::: ".:::::::::::::::: DROGAS PUEDEN:AFECfA...LA ACq NDE:EsrA .:..:.,,.,:..:::::::::.,..,:::::::::::::.::::: . R...:::::..S . .,. e em I = MEDICINA 1 p , azi da E u MEDT C CINA:COEN Nil EACETAMINOPHEN. :: :: : ......:i"i:"::i`::.: tal, TOMANDO M S ACETAMINOP HEN Ol1E.::: .. .. ..:.,...,:::.::....:::...; .....:::.::::::: butmina, RECOMENDADO PUEDECAUSAR:PROBLEMAS: Y:?i:":.:'::':::;: SERI08 DEL. ... 0 ::::.. . ..: ::::::;:: ...:: ....:.: r:::.::;:;< ::<:<:+s<c;:;:;:;:;::::�.s:: ..:.......::::.:......::...:.;.::....::....................:..... ............. .... ., TQTyIA T.A P CTG CON ......... .. ::s::>:>:::;..s:;::::. ncETan�maar+gN..slN:cox+suLrA.aecy:t;k,'. .Q:CTOR LEA:70DQS,l AS;E'......ASCO. ..::.' .... .....: .:.,...... ...........::: RITE AID PHARMACY#5913 (925)680-2845 16dico S1 LUCKY CENTER Store DEA:BT5236458 graves: 1905 MONUMENT BOULEVARD RPH:UJI ,detiempo CONCORD CA 94520 para un. Rx 05913 0269476 Date Filled: 12/26/2005 ima diana, mortal). a ONTIVEROS,CRISTETA is de daho Date of Birth: 10/27/1946 (925)765-6191 lor en el 1370 RAE ANNE DR as de una CONCORD CA 94520 !Itad para HYDROCODONE/APAP 5/500 TAB DAW:0 to no NDC:00406-0357-05 QTY:30 DAYS SUPPLY:4 JOSEPH MATAN MD DOCTORS:NIEDICAL,CENTER Antes de PlNbLE;CA 94564 nas isa (por REFILL ITIMES UNTIL 06/18/2006 isar este oialmente )r ejemplo, 010' ?lca, aria Muy la bifiar), s de la lia . puede ar alerta imentar el :no, el ia Jico o dimiento, administrar 3 efectos :ion v la PAY 1te �cerca de con su MEDICATION WARNINGS 1cos PL!4DE tWusk(usc&NbLuicix PUEDE CAUSARV RTIG.OS aal riesgo EL;USOO'E AL90HOLM_...A PREC6 t0k0U0rjAAtrr* PALA"A MiQUO"" PgUdFk 940§ TOMANPO.MqDE.l OQUESEAECOMIENDA PUEW'.6AUIAR ,den PUEDE P.4USAR.PR(?BLEXIASiRESPIRATORIOS.'. E wrmpNlWREUTR 13:T.0. ......K4 9�T# . . .Ina de ........ nar este )re f?jftpay not indWdftlis. ..... 'T, 3amentos ...... MA meq}{MAL is DROGRAS PUEDEN AFECTARLA ACC19N DE ESTA ejemplo, .............. azida, jai, ESTMEDICACOMNACETAMINOPHM: MASAAINOH QU butinina, RECO FUEDF CAUSARPROBLEMAS ............................ SER163 DEL I.HOG.A DO I Plqii.cou j: RITE AID PHARMACY#5913 (925)680--2845 ddico si LUCKY CENTER Store DEA:BT5236458 es: 1905 MONUMENT BOULEVARD RPH:CHP iem graves: es: CONCORD CA 94520 para un Rx 05913 0269476 Date Filled: 12/31/2005 na diaria, mortal). ONTIVEROS,CRISTETA s de dano Date of Birth: 10/27/1946 (925)765-6191 )r en el 1370 RAE ANNE DR s de una CONCORD CA 94520 tad para HYDROCODONE/APAP 5/500 TAB DAW:0 no NDC:00406-0357-05 QTY:30 DAYS SUPPLY:4 JOSEPH MATAN MD DOCTORS:MEDICAL,C. ENTER - Antes de TINOLE CA.94564 las sa (por NO REFILLS LEFT. sar este :ialmente :CASH r ejemplo, )I6ica, ria?g muy a biliar), a), s de la a puede r alerta mentar el no, el a ico 0 limiento, .dministrar efectos i6n y la PAY to cerca de MEDICATION WARNINGS :on su cos PSI.....CkF1......MNOa:.ENGtIf AStM7dl15+G!RN.>':::PUEDE.GAUSAR VR7I.GOS:: !al riesgo £C:�35i};O.....GNOki EB!<iA PREGIItiIOWFF;Ak......;.:. ::::::::....:..........: 9 coNDuc vc:avra o iu.uswa Il�aim s:. .... .....................:::::::............,..:...:..,....::............::.::.... .........:....::...:...........:...........L .:...:. TOMANDo M S D.....UE.... . . . .DA::>:......i!FfEpECktISAR.E5Si3ENMpEN7Q:CONSUC'CE::::::: den PUEDE:CAUSARPROBLEMAS RESPIRATORIOS:. COt7:SL1:IM0.IcL3.696RAA�YJifi> esTrsaEI�MteN'Fcrhnr�90.0hA:tSTA; : :::::. no de taeolliaa:: »::;>:::;:: :I r este ::: : : : :;>:::>::»>:<: <»;.a::.. re%May not incladew41 wmaa : ::...; . as e.ga asecdel�ba oma&RrdEd TOMA.R LAS DROGASNO-RECETADAS.ALGUNAS .am entos DROOAS PLIEDEN APEC A LA ACCI 5NDE TA: e1 emp to MEOICINA zi da ESTA MEDT NACO ENEACETAINI TOMANDOM:SACETAMINOPHENOUE .:......::::.>;:c;<:: ;>:: �:�::;::o:r:;o-:::.:<: .::: ::..:.:.::.:.:.:.:.:..:::.:.>..:.,.s::::::::..:.. )utinina RECOMENDADO PUEDECAUSAPITROBLEMAS,:.;:;5:;:;:::::::::::::: :: > .... ...it :::.:::: :'::: :: ::: <i::i::: :: >: 5: ::: . .. ,. . :::..:: ..... .:::. ..X::':................... :..::: ..:.::::.:. .. ACETAMdVOFHEN;SIN:CQ?LSUL7J1}LCQN:EE;::>`:::;:::,: �...�.. .... ..;.:�.�:�;��:�::�:: ::�.�:..:�;.:� . .. . .:::. D.00TI....LEA:3?Cl4ClS:1 RITE AID PHARMACY 9 5913 (925)680-2845 LUCKY CENTER Store DEA:BT5236458 1905 MONUMENT BOULEVARD RPH:EW3 CONCORD CA 94520 Rx 05913 0270611 Date Filled:01/04/2006 ONTIVEROS,CRISTETA Date of Birth: 10/27/1946 (925)765-6191 1370 RAE ANNE DR CONCORD CA 94520 ACETAMINOPHEN/COD#3 TABLET DAW:0 NDC:00406-0484-10 QTY:40 DAYS SUPPLY:5 WILLIAM F LYON MD 2166 APPIAN WAY STE 104 PINOLE CA 94564 NO REFILLS LEFT CASH PAY: MEDICATION WARNINGS ?UECE&R41SAR:54MNGLfNGtA+AUNTAA5: 9N:<:NQ7VMA,QTRA PRO.DUCTOS.CON: ILGQNCG;TFJ:I.GA::VREC%417!G[OTf'IiL::�:::ACETAMINOPF{ENSINCONSULTAR CONEL�:. $GIBiUG7R:1lVCD:iI:AL :. .D03 LAS:Ei1GUETAS CON...... . YEWGHO.... ':.3 ::: �::;::::a:i::;:::<: :��: :i;CU1DdD0.: PUEDE:CAUSAfl vflt}GOS:; .. tE ...::..:..: .::. ..: :5.:...DICO:CaE0:1itA�7Af311;:::i::: :: ::: :::: es 7iF�pMtENf4:Td... : .......... . .... ...... .... :... Price may not indtxcli :aEpj9ioppEeuGseiraii614Fe9+ eecptdrs$idDiaa®piirESped :." FUI3DECAUSAR:P '.ENAS RESFIRATQFU:OS:::::;;TO.MAR LAS:DROGASNO=RECETADAS.ALGUNAS.: :::.OROGAS PUEDEN AFECrAR,LA ACCION DE ESTA MEDIC INA ...............c::M R COHOL CON;:;::k MEdgNA�' :::':::. :. .... ........... NO TO AL.. , EST , .. ..�.�:::::::::::.:::.:. �:.::.:.:.:.:::..::::.�::.� .....: :...:.:.::::..:.:::::::::..:::.::.:::O:....�: :�]i.......::::.:.:.:...................:.........::' E§TA:R!.EOI......CODR1);71E:.I4QETAT71XOt?H.ET/:>i::::..: : : .. ., ....: . 3S7kA1YU0.... AGETA101N.............. 33EtAd[EROAIXS:7lIEDECdUSAR;i?pt�81:'EIadS:::` :��:�..:,.�:`:��:� .. . .... .... $kRN3$:OEt;ttclilt ':::::;::::;; <:`:::>>`::;;>z :i: :..;;::..