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Home My WebLink AboutMINUTES - 06132006 - C.28 I CLAIN]. g BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: JUNE 13, 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 California Goverriment Codes. I RIM is your notice of the action taken NR VM on your claim by the Board of Supervisors. (Paragraph IV below), MAY 0 8 2006 given Pursuant to Government Code A.M.OUNT: $2,685.38 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAINIAN'l . STATE FARM INSURANCE COMPANIES FOR: TERRENCE D. FREEMAN ATTORNEY: BY: STACEY L. I VANDEGRAFT)AT.E RECEIVED: MAY 08, 2006 UNKNOWN I ADD.RF.SS: P.O. BOX 2371 I BY DELIVERY TO CLERK ON: MAY 08, 2006 BLOOMINGTON, IL 61702-2371 I BY MAIL POSTMARKED: MAY 03, 2006 I FROM: Clerk of the Board of Supervisors TO- County Counsel Attached is a.copy of the above-noted.claim. MAY 082006 j JOHN CULLEN 1W , Dated: By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of S pervisors I ( 1'Iais claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply FAILS substantially with Sections 910 and 910.2, and we are so notifying clainiant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning or claimant's right to apply for leave to present a late claim (Section 911.3). O Other. 5.—*—oc� Dated: 1 By: Deputy County Counsel 111. FROM.: Clerk of the Burd � TO: County Counsel (1) County Administrator-(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 117 OARD ORDER: By unaninIious vote of the Supervisors present: V This Clairna is rejected in full. O Other: I 1 certify that this is a true and correct copy of the Board's Order entered iii its minutes for this date. I Dated: 1-&,-7 e 3 �I� OHN CU.LLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6)months front the date this notice was personally served or deposited in the mail to file a courtaction on this claim.See Government Code Section 945.6.You play 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 inuuediat�ely. *For Additional Warrirrg See Reverse Side of This Notice. AFFIDAVIT OF MAILING I I declare under penalty of perjury that .1 ant now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today 1 deposited in the United Slates .I.'oslal Service in I\lartin,ez, California, hostage fully prepaid a certified copy of this Board Order and Nolice.Io C'lai m ant, .addressed to lire claimant as shown above. DatedVk777ei . c�iB'Dro 161-1N CUI_,LEN, C.LEKI<,- B y DCI)LIty Clerk I I , STATE FARM State Farm Insuriance Companies INSURANCE State Farm Insurance Subrogation Services May 2 , 2006 PO Box 2371 Bloomington, IL 61702-2371 Certified Mail-Return Receipt Requested CONTRA COSTA COUNTY BOARD OF SUPERVISORS TMM IVED COUNTY ADMIN. BLDG RM 106; 651 PINE ST. MARTINEZ, CA 94553 r�l£6±E{t30ARC f�E SUPERVISORs RE: Claim Number: 05-5252-082 uJId l C�iSTA CO. _ Our Insured: Terrence D Freeman Date of Loss : February 2 , 2006 Your Insured: CONTRA COSTA COUNTY Your Insured Driver: RICHARD SONGSTENG Your Claim Number: ALARM NUMBER 6003870 Your Policy Number: UNK. Loss Location: willow Pass Concord, CA Dear CLERK OF THE BOARD OF SUPERVISORS : It is our understanding that you are self insured. Our investigation indicates you are responsible for this claim. Therefore, we are seeking recovery from you. This letter is to notify you of our subrogation claim and request your cooperation in settling this matter. To assist you in your review, here is a breakdown of the amounts State Farm paid by Causelof Loss : 041/045 - Uninsured Motorist BI $ 042 - Uninsured MotoristlPD $ 300 series/400 - Comp/Collision $2 , 156 . 65 501 - Rental $278 . 73 600-050 - Med Pay/PIP $ Other $ Salvage Recovery $ Amount State Farm Paid $2 , 435 . 38 Insured Deductible $250 . 00 Total Claim Amount $2 , 685 . 38 State Farm is seeking 1000 of the total claim Amount Payable to State Farm: $2 , 685 . 38 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 i i Page 2 May 2 , 2006 Please remit payment of this claim and include our claim number on the payment . If you have any questions, please call 877-457-8276 and any member of Team #60 may assist you. Thank you for your cooperation. In order to assist you in evaluating and processing the subrogation claim we are asserting, we may provide nonpublic personal information about our customer. We are sharing this information to effect, administer, or enforce a transaction authorized by the consumer. However, you are neither authorized nor permitted to: (1) uselthe customer information we provided for any purpose other than to evaluate and process the subrogation claim, or (2) Idisclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, aceyL. andegraft Claim Processor (877) 457-8276, Team 60 State Farm Mutual Automobile Insurance Company Enclosure (s) i RBZ0006Z ( date : 05-02-06 page : 1 INSY..M uuT ........ ae::::.B :ckenserfe.r I STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMENTS BY COL C;l W. . -6... policy number — + .> G O 7 — 7 4 2 .2 0 SC: ..................................................................::.... .:......:. .................................................................................. named insured date of loss FRE FMAN TERRENC E D 02 -02 — OG COL 3 9 O C denotes consolidated payment E denotes EFT payment P denotes previous data Cot_: 390 indemnity: 2 , 162 . 6-5 dir rcov: 0 . 00 expense: 0 . 00 payment number payee amount status COL pay cd rsn reporting party 102407160) TERRENCE D. FRE 64 . 72 PAID 390 3 Named Insu 102229497J TERRENCE D. FRE 2 , 091 . 93 PAID 390 1 Named Insu 102229096) TERRENCE D. FRE 6 . 00 PAID 390 2 Named Insu COL 5 O 1 C denotes consolidated payment E denotes EFT payment P denotes previous data COL: 501 indemnity: 278 . 73 dir rcov: 0 . 00 expense: 0 . 00 payment number payee I amount status COL pay cd rsn reporting party E 102408876K HERTZ LOCAL EDIT 278 . 73 PAID 501 1 Named Insu I i 5 05 - 0?2, P -23 2�t�10 11 r5 CCC Ri$6tPif `3c'TiT 9M 335 1421 P:Oi ; .BOAJw OF S'[?FP.VIS'ORB OF COKM COSTA COUNTY INSTRUCT RNS TO L'1-aKA—N A. A claim ralai%gg'to a cause of action for death or for injury to:person or to personal.property or growing crops.shall.be.ptescntcd pot later thm six =montles af= fx.seem of the-ca lse of action. A claim relating.many other cause°.of:action_shalt be.prwensed not l0cs-thwor: year after the accrual ofd cause iif ectiob_ (Gov.Code§9l t.2.) B. Clairm-must be fllad with the Clerk of the�Boud of Supervisors at Wq oifie'~ in Room 146; CGUMp Arltnizi�aa.BWldin&65.1 inr Street,hiar4nv,-CA.94553. C. If claim is against a district governed by the Board of Supervisors, rafher than the County. the name of tiro District should be filled'ta. F. if the claim is against-mora than one publia-endty, separate claims nr.is't be filed against.each. Public entity. E Prated. Sce penalty for fraudWent.claims,regi Code Sec.72 at the cad'Of this form,. •11irrrseen rwrUrrtrssea■1MIIM■*so s�s�ssrtr�as��rri�rssarrar��rsrrrrrri�ru rtar. RE: claim B^. ( R=crvcd for Clerk's.filing.stamp -r(__Pf Aga:ns'the Co.mt r.of Coatra Costa Or —r1l ) � I� � 5252-0$2 DF Di ! strict) (Fill-in the name) 1 The widersigned cla'bnzat hereby maces claina.agaras#the Cot+a4ty of Contra Costa or the above-named district is the sum of�; to QS;3� sad i i sugpvrtof. %s claim represents:as faltnws i t. �--. : hea did the dawagc or injury occur? ('Give exact'tt to seal h ur).• _ zoo(P 2. 'Where did the 7e"a or Mn'ut3r o==,? (Include city and county) Jf - J 3. low did the damage or injury orc r7 (Give;full details;ute extra pVet if required) pi 4•. what' actorlaiissioaontbbPofeatnt} ordistrictoffcemmn or ea oyees .Partic ca the�injury or dsmsee7 Lae, S 'hst are the namss:cf cAttnty i7r disJlof`ece ,Servants,of extsplos'e�es causing the . dcuna�c or..in�ury? • _ y I 7 � I i l FEU-23-2W6 11245- COG R l5K h1Mt G7V_NT 9'25 335 1X21 P.03 6. teat damage or injuries do your}cleim resulted? ((3ivc &U c)=t of huu`fes or dame cs dunod: A,ttsch,iwxa.estimrates for d damage,) Ao P" I � 7. How was tht amount daimcd above compared? (fuclu& the c.;timated eronunt of any prospective'igjia-y ordsmage.} 4 S. N aMU ad*ents of witnesses,dactors,and hospitals; cJ. Listth~mpendiau"-you made-on account ofthis accidcaf or injury, _ DAM _ TI'S' A2rrfOi� -- ■/sisrrl..l..ra.artrrrtlLr•!r■ssssa.. rrrts.r!lr..7r1 }.Cs y.Code Sec.910.2 proti-idcs"Ue clam shalt be }sigaed.by the claimant or by so;na pctmon on•his a belaa,Cf." ' SENT)NO i I )mev? Nsmc mitt address of Afxomcy ) I f A 1A 10r } / (Cla' is sipature) 1 (Address} Telephone No. .�a..rr'�1lr!'a■■....a OEM..a...R■Rrl s'rslss.ss..asrt..slssrlraa.a...rrsslsslUlsraas.. :pUBLIC.RECORDSNOTICE- - Pfea:r.fxa advased-tbacttrsa-ctaimform,cram!ct�iui filed'wlth"i�ia County Birder thc.Ttait.Glaims.Act,is sutrfcLcln public disclosutb ander the-California Pi-oblic Reowds Azt- (Gov.-Cods,.99 6500'ct sae.)_.Fiuthermorr; any a�uarhmcnta,addcndumt,or supplements attached to-the claim Form,includiag-wedical rrca,n*are a>;o subject to public dc5ilasttrc. awas 7rlr.as.'.sa.srsa.s aso,na aslrrrY Mir-To s.a:/rrrr.ss■■....a.:%*%as■■s..a as s a WVwSomru s4ctrcn.73 q f&a Pend Ca*provides_ Eyler)P=Qn who;Anch•i t=t to defraud;pmegts for allowanca.or fur peyymeut to&iy,mm board or officer,of to eny county, city;,or dist i board or offiaer,'sueiotized.to show or pay the-same if genuine, nay false,or frautulcntclaim,bill;account.voucber,or w-r MI& Is punishable eith rby.=' P isanmanr in the Ccjuaty jail"for pcsiod of-not wore-tbaa one:year, by a fe.of Bat excecsiist can d'icucand ddlibri (Si,060.00).or by both-Sud' 431mmew,and fine,or by imprisoracnettt in thc state prison;by a fine of not a di:ss t= caysaad dollars ($11,t)W) -6r by bow suet l=: rUiy nem acid tine. TGTFL P.03 •_•�••- RB Z 0 0 0 3 2 date : 05-02-06 IMSYS�SIC 10 time : 01 : 01 PM ' '>r tetc8.1 er ............. ............ ........... ... rsd� ...e . ......171; ....... ........ .................................................................................... ...... ..................... . ............................................................................................I.................. .... STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY VEHICLE DAMAGE REPORT carizuriber date of loss ....... .................................. ...... ................................... ........ ......................................................................... .................................................................................. 02-02-06 ................. ................ . . ........... Estimate Vehicle Info Vehicle Owner: FREEMAN, TERRENCE Vehicle Description: 98 Jeep GrandCherokee 4D Ut 106" W GREEN Date: 3/14/2006 10:26 AM Estimate ID: 05-5252-08201 Estimate Version: 2 Supplement: 1(F) 3/28/2006 09:05:38 AM Profile ID: *PLEASANT HILL (PCP) STATE FARM INSURANCE COMPANIES 1475 66th st EMERYVILLE, CA 9460 (510) 985-7000 Fax: (707) 641-7370 Damage Assessed By: JOE BRAZ Appraised For: CLAIM PROCESSOR TEAM 1 (800) 440-6175 Supplemented By: JOE BRAZ Type of Loss: Collision Date of Loss: 2/2/2006 Deductible: 250.00 Claim Paid: N Claim Number: 05-5252-08201 Insured: TERRENCE FREEMAN Owner: TERRENCE FREEMAN Address: 811 DODD CT BAY POINT, CA 94565-67519 Telephone: Home Phone: (925) 458-4895 Mitchell Service: 916523 I Description: 1998 Jeep GrandCherokee Laredo Vehicle Production Date: 3/98 Body Style: 4D Ut 106" WB Drive Train: 4.OL Inj 6 Cyl 4WD VIN: 1J4GZ58S5WC285612 License: 4BNUO14 CA Mileage: 169,188 OEM/ALT: A Search Code: B1MM Color: GREEN Options: Alum/Alloy Wheels, Air Conditioning, Power Steering, Power Brakes, Power Windows, Power Door Locks, Automatic Transmission. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 600034 BDY REMOVE/INSTALL FRT BUMPER ASSY 1.8 # 2 601325 BDY REMOVE/INSTALL L PARK/SIGNAL LAMP ASSEMBLY Existing INC *# 3 600011 BDY REMOVE/INSTALL L PARK/MARKER LAMP INC # 4 605220 REF BLEND L FENDER OUTSIDE C 1.0 5 605707 BDY REMOVE/INSTALL L FENDER CLADDING 0.3 6 605712 BDY REMOVE/INSTALL L LWR FENDER MOULDING 0.3 7 618040 BDY REMOVE/REPLACE L FRT DOOR REPAIR PANEL 55295907 197.00 7.0 # 8 AUTO REF REFINISH L FRT DOOR OUTSIDE C 2.4 9 AUTO REF REFINISH L FRT ADD FOR JAMBS C 0.5 10 630106 BDY REMOVE/INSTALL L FRT DOOR POWER MIRROR 0.7 # 11 618115 BDY REMOVE/INSTALL L FRT DOOR CLADDING INC S1 12 618610 BDY REMOVE/REPLACE L FRT DOOR RETAINER NEW 7.25* INC 13 629937 BDY REMOVE/REPLACE L FRT DOOR ADHESIVE NAMEPLATE 55155621AB 55.20 0.1 14 600386 BDY REMOVE/INSTALL L FRT DOOR TRIM PANEL INC 15 600415 BDY REMOVE/REPLACE L FRT DOOR OUTSIDE HANDLE 55076093 46.45 INC # ESTIMATE RECALL NUMBER: 3/14/2006 10:26:30 05-5252-08201 UltraMate is a Trademark of Mitchell International Mitchell Data Version: FEB_06_A Copyright (C) 1994 - 2005 Mitchell International Page 1 of 4 UltraMate Version: 5.0.214 All Rights Reserved Date: 3/14/2006 10:26 AM Estimate ID: 05-5252-08201 Estimate Version: 2 Supplement: 1(F) 3/28/2006 09:05:38 AM Profile ID: *PLEASANT HILL (PCP) 16 620790 BDY REPAIR L REAR DOOR REPAIR PANEL Existing 0.5 *# 17 AUTO REF REFINISH L REAR DOOR OUTSIDE C 1.9 18 620885 BDY REMOVE/INSTALL L REAR DOOR CLADDING 0.4 S1 19 621120 BDY REMOVE/REPLACE L REAR DOOR RETAINER NEW 6.35 INC 20 600453 BDY REMOVE/INSTALL L REAR DOOR TRIM PANEL INC 21 621780 BDY REMOVE/INSTALL L REAR DOOR OUTSIDE HANDLE Existing 0.2 *# 22 601030 BDY REMOVE/INSTALL L REAR DOOR :FRONT GLASS RUN Existing 1.0 *# 23 622480 BDY REMOVE/INSTALL L REAR OTR DOOR BELT WEATHERSTRIP Existing 0.3 * 24 936012 ADDIL COST HAZARDOUS WASTE DISPOSAL 2.00* 25 AUTO REF ADDIL OPR CLEAR COAT 1.7 26 933003 BDY* ADDIL OPR TINT COLOR 0.0 * 27 AUTO BDY* ADDIL OPR COLOR SAND & BUFF 2.1 28 AUTO ADDIL COST PAINT/MATERIALS 225.00* 29 900500 BDY* REMOVE/REPLACE PAINT OVERSPRAY COVER New 6.50* INC * S1 30 900500 BDY* ADDIL LABOR OF PAINTED STRIPE Sublet 200.00* 0.0 * 31 900500 BDY* REMOVE/REPLACE CORROSION PROTECTION New 3.00* 0.2 * * - Judgement Item # Labor Note Applies C Included in Clear Coat Calc ESTIMATE RECALL NUMBER: 3/14/2006 10:26:30 05-5252-08201 UltraMate is a Trademark of Mitchell International Mitchell Data Version: FEB-06 A Copyright (C) 1994 - 2005 Mitchell International Page 2 of 4 UltraMate Version: 5.0.214 All Rights Reserved Date: 3/14/2006 10:26 AM Estimate ID: 05-5252-08201 Estimate Version: 2 Supplement: 1(F) 3/28/2006 09:05:38 AM Profile ID: *PLEASANT HILL (PCP) Add'l Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 14.9 72.00 0.00 200.00 1,272.80 Taxable Parts 321.75 Refinish 7.5 72.00 0.00 0.00 540.00 Sales Tax a 8.250% 26.54 I Non-Taxable Labor 1,812.80 Total Replacement Parts Amount 348.29 Labor Summary 22.4 1,812.80 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 225.00 Insurance Deductible 250.00- Sales Tax a 8.250% 18.56 Customer Responsibility 250.00- Non-Taxable Costs 2.00 Total Additional Costs 245.56 I. Total Labor: 1,812.80 II. Total Replacement Parts: 348.29 III. Total Additional Costs: 245.56 Gross Total: 2,406.65 IV. Total Adjustments: 250.00- Net Total: 2,156.65 Less Original Net Total: 2,091.93 Net Supplement Amount: 64.72 S1: JOE BRAZ 64.72 Point(s) of Impact 9 LEFT SIDE (P) ESTIMATE RECALL NUMBER: 3/14/2006 10:26:30 05-5252-08201 1 UltraMate is a Trademark of Mitchell International Mitchell Data Version: FEB_06_A Copyright (C) 1994 - 2005 Mitchell International Page 3 of 4 UltraMate Version: 5.0.214 i All Rights Reserved Date: 3/14/2006 10:26 AM Estimate ID: 05-5252-08201 Estimate Version: 2 Supplement: 1(F) 3/28/2006 09:05:38 AM Profile ID: *PLEASANT HILL (PCP) Inspection Site: SIMPLY SUPERIOR Inspection Date: 3/14/2006 Body Shop: SIMPLY SUPERIOR Address: 2110 MARKET STREET CONCORD, CA 94520 Telephone: (925) 680-6946 Fax phone: (925) 680-6961 State Lic. No: 94-2909061 For your protection California Law requires the following to appear: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. *************************************************************** This is an estimate. Repair facilities must inspect the vehicle to determine if any repair's not listed are required, and to contact State Farm before making such repairs. Repairer also is responsible for conducting any necessary inspectiion and safety checks prior to and after completing repairs. *************************************************************** ESTIMATE RECALL NUMBER: 3/14/2006 10:26:30 05-5252-08201 Ult�aMate is a Trademark of Mitchell International Mitchell Data Version: FEB_06_A Copyright (C) 1994 - 2005 Mitchell International Page 4 of 4 UltraMate Version: 5.0.214 All Rights Reserved HERTZ LOCAL EDITION Rental Agreement No: A33282900 Phone: 1-888-777-3700 . Invoice Date: 03/28/2006 Fax: 405-775-5413 Document: 609066624149 E-mail: CUSTOMERBILLING@HERTZ.COM LOCAL EDITION Renter: TERRENCE FREEMAN Direct All Inquiries To: ORIGINAL INVOICE Account No. : ********0023 HCC HERTZ LOCAL EDITION CDP No. : 1199509 PO BOX 268825 CDP Name: HLE STATE FARM INSIROH OKLAHOMA CITY, OK 73126-8825 TAX Id: 13-1938568 PROCESSOR TEAM STATE, FARM-ROHNERT PARK *VALLEJO ACC PO BOX 6401 ROHNERT PARK, CA 94927-6401 RENTAL REFERENCE RENTAL DETAILS Rental Agreement No: A33282900 Rate Plan: IN: HIDA OUT: HID Reservation ID: 037-12.10408 Rented On: 03/13/2006 10:21 LOC# 726601 CONCORD, CA Returned On: 03/26/2006 10:36 LOC# 726002 CONCORD, CA Car Description: N/L COROLLA 5PET687 VIN #: 2T1BR32E96C564141 CAR CLASS Charged: B MILEAGE In: 13,132 Rented: C Out: 11,144 Reserved: 99 Driven: 1,988 BILLING INFORMATION RENTAL CHARGES Claim No: 055252082 DAYS 14 @ 22.99 321.86 Policy No: SUBTOTAL 321.86 Date of Loss: 2006-02-02 Type of Loss: 0 TAX 8.25b 26.55 Repair Facility: SIMPLY SUPERIOR TOTAL CHARGES 348.41 USO Authorized Rate: Authorized Days: 14 Adjuster: PROCESSOR TEAM CUSTOMER PAID -69.68 Insured: AMOUNT DUE 278.73 USD MISCELLANEOUS INFORMATION PAYMENT DUE UPON RECEIPT THANK YOU FOR RENTING FROM HERTZ PLEASE INCLUDE RENTAL AGREEMENT NO. ON YOUR CHECK. REMIT TO: HERTZ LOCAL EDITION PO BOX 268825 OKLAHOMA CITY, OK 73126-8825 UNITED STATES AMOUNT DUE: 278.73 USD Phone: 1-888-777-3700 Fax: 405-775-6413 E-mail: CUSTOMERBILLING@HERTZ.COM Mar '13 06 03: 56p p. 1 State Farm Insurance Joline Banks Lic. #0824812 2751 Concord Blvd. Concord, CA 94519 Phone: (925)687-2410 Fax: (925)687-2466 Fm To:C LC. From `n(� Fax: �j y,t ao i-7(r Date: Phone: Pages: (including cover) Re: G1I� 06'Sa `✓-< C7$2 CC: ❑Urgent ❑For Review 0 Please Comment 0 Please Reply ❑Please Recycle -Comments: Mar 13 06 03: 56p p. 2 . ........... co LO cc ... ..::;:: _. . .. . . . ... ....... ... . ............... . ........:. ::.. .. ...:...: . . ........:. ........ ...:..... :.::, .... RQLI ARS::$: Fo ::....:.:..::. AMT.OFJ. ... .. CASH AMT.RAIU CHECK �.��. :�.:�..:,� : 1 II BALANCE .,...:.: DUE Mar .13 OG 03: 5Gp p. 3 Incident Report Contra Costa County FPD 2006-6003870 -000 I Basic Alarm Date and Time 12:21:38 Thursday,February 2,2006 Arrival Time 12:27:55 Controlled Date and Time Last Unit Cleared Date and Time 13:12:11 Thursday,February 2,2006 Response Time 0:06:17 Priority Response Yes Completed Yes Reviewed Yes Release to Public Yes Fire Department Station 06 Shift A i Incident Type 322-Vehicle accident with injuries Aid Given or Received N-None Action Taken 1 32-Provide basic life support(BLS) Action Taken 2 82-Notify other agencies. EMS Provided Yes Apparatus-Suppression 1 Personnel-Suppression Personnel 3 Property Use 963 -Street or road in commercial area Location Type Intersection Address On WILLOW PASS RD at AVILA RD City,State Zip CONCORD,CA 94520 District 06BSW Apparatus-Q106 Apparatus ID Q106I Response'rime 0:05:28 Apparatus Dispatch Date and Time 12:2227 Thursday,February 2,2006 En route to scene date and time 12:22:27 Thursday,February 2,2006 Apparatus Arrival Date and Time 12:27:55 Thursday,February 2,2006 Apparatus Clear Date and Time 13:0303 Thursday,February 2,2006 Apparatus priority response Yes Number of People 3 Apparatus Use 1 Apparatus Type 13-Quint Personnel I 45178-SONSTENG,RICHARD Position: CAPT Personnel 2 46699-FRANKENA,MICHAEL Position:FFP Personnel 3 60910-LIBERMAN,CHRIS Position:ENG Authority Reported By 45178-SONSTENG,RICHARD 15:56:12 Thursday,February 2,2006 Officer In Charge 45178-SONSTENG,RICHARD 15:5614 Thursday,February 2,2006 Reviewer 53781 -WEST,JO ANN Page. 1 Printed: 03/13/2006 08:36;38 C.L V0`5SD70'Ci`6 Mar ' 13 06 03: 56p p. 4 Incident Report Contra Costa County FPD 2006-6003870 -000 Narratives Both drivers were given the Fire District contact information and this incident report number for reference. Alarm number 6003870 has been assigned to this incident. End of Report Page: 3 Printed: 03/13/2006 08:36:38 vSSZ �� U�� Mar ' 13 06 03: 57p p. 5 Incident Report Contra Costa County FPD 2006-6003870 -000 Authority 16:46:48 Friday,February 3,2006 Narratives Narrative Name 3870 Narrative Type Incident Narrative Date 14:47:12 Thursday,February 2,2006 Author 45178-SONSTENG,RICHARD Author Rank CAPT Author Assignment 1 ' Narrative Text At 1221 hours on Thursday February 2,2006 we were dispatched to a vehicle accident with injuries.One unit was assigned to this incident.Three personnel responded.We arrived on scene at 1227 hours and cleared at 1312 hours.The incident occurred at On WILLOW PASS Rd at AVILA Rd,CONCORD in District 0613SW.The local station is 06.The general description of this property is street or road in commercial area.The primary task(s)performed at the scene by responding personnel was to provide basic life support(BLS).No mutual/automatic aid was given or received. During response to this incident,a chock block fell off of the driver's side of the quint and struck two vehicles. I did a preliminary investigation as to why it happened and it appeared that the retainer arm that locks the chock into place had failed allowing it to come out onto the roadway. Upon return to quarters the apparatus shop was notified and the Quint was taken in for repair. The shop stated that the problem was in fact a failure of the retainer arm to properly hold the chock into place. The problem was fixed at that time. The'involved persons,vehicles and damage are listed as follows: #1 Ms.Carrie Lee Frazier 4260 Westwood Ct Concord,CA (Ph)825-1007 (C) 787-4827 CDL#E0178802 DOB:3-1245 Vehicle Lic#4PYB653 2001 Saturn 4DR Damage to left front bumper,broken air grill with broken plastics and scratches. Allstate Insurance #2 Mr.Terrence Freeman 811 Dodd Ct Bay Point,Ca (Ph);458-4895 CDL'#N2192270 DOB:4-3-56 Vehicle Lic#4BNU014 1998 Jeep Grand Cheroke Damage to the paint and metal on driver door and rear door driver side. State Farm Insurance Page: 2 Printed: 03/13/2006 08:36:38 2- A , 1 � 1 1 i a u � ,�---.. � ,. ,� �, �� r 4� y � , , .,. 1 i« L s,�' .�: 1 -1• "'"'mow 4 t� � __. 1 �S ~ l' __ _ �_ r N, �� _«---- "' _ `� nit "-�' .. '�� a !� ; ,.I� .__ ,,�,,, I J 4-� � �� . 3 � � r A ,�`� ♦ � �r L_.�. } � �� t (� ` �' f£ f�� r n' � i , �' _ ;,,; .,:. ,� E J 1` CERTIFIED. 66 1931 A 01 Pirated in U.S A 02-10 2005 subrogation Services-Auto Bloomington ')TATE FARM INSURANCE COMPANIES ?0. Box 2371 III I I I lilt I 111 1111 11 111 3loomington, Illinois 61702-2371 700.5. 3110 0000 5364 0568 i EIVED MAY 0 .8 2Q06 i . C RKBOARDOFOUPERVISOR$ - CONTRA COSTA CO. J. - i j _ -77 j FIRST-CLASS MAIL a M --0 UN n CA 1 -n N �, o �o � 0 CI)CI) +1 O O O 0 CLAIM . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTIO JUNE , 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 California Government Codes. f� you is your notice of the action taken En on your claim by the Board of '1 Supervisors. (Paragraph IV below), MAY 0 9 2006 given Pursuant to.Government Code AMOUNT: $72.00 COUNTY COUNSEL- Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: TEOLA DEUBERRY i ATTORNEY: UNKNOWN I DATE RECEIVED: MAY 099 2006 ADDRESS: 6542 WALDO AVENUE BY DELIVERY TO CLERK ON: MAY 09, 2006 EL CERRITO, CAI94530 MAY 03, 2006 BY MAIL POSTMARKED: i FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claire. JOHN CULL.EN, - Dated: MAY 09, 2006 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of S per-visors ( Fhis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to compty 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. 'flhe 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: I Dated: 1p' 0(P By: 01 Deputy County Counsel I.I.I. FROM: Clerk of the Board I TO: County Counsel (1) County Administrator (2) O Claim was returned as unti'mely with notice to claimant (Section 911.3). 1V. ARD ORDER: By unanimous vote of the Supervisors present: (1�This Claim is rejected in full . O Other: 1. certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:✓_w"v/_-\/""e,/ CUL.LEN, CLERK, By Deputy Clerk WARNING ( ovGcode section 913) ` Subject to certain exceptions,you have only six(6)months from the date this notice was personally sewed 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 ui connection with this matter. U you want to consult an attorney,you sliould do so uiuiiediately. *.Cur Additiorial Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I 1 declare miller penalty of per jlu.iy that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United Stales .Postal Service in alarti►icz, California, postage fully prepaid a certified copy of this Board Order and Notice to Clai iumt, addressed to the claimant as shown above. Dated. wzge,1K 0?"6 .0.1-IN CUL.LEN, CLERK 13y_ ri Deputy Clerk l BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY SHARON HYMES-OFFORD INSTRUCTIONS TO CLAEVIANT MAY 2006 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-"""'u"" 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 Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 945 5' C. If claim is against a district governed by the Board of Supervisors, rather than the County, the -naive of the District should be filled 'in.l D. If the claim is against more than one 1public 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��a��t��a�e■ ■�to��al■■�sa�etee�a�rrt��o ¢vneeee..................... RE: Clain By: i Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or ) MAY 0 '9 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) CONTRA COSTA CO. The undersigned claimant hereby makes claire against the County of Contra Costa or the above-named district in the sum of S '72, O el and i support of this claim represents 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) 3. How did the damage or injury occur? (Give full details;use extra paper if required) fro 7-- �iGr� ✓� �.�s�T Zuc/,4,Q Ce /'�°T ' .v�CaVG'o� Avg. CvwTZA C V-/,4 /VD Z)1 A,noay.p g/ _D D 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or:damage? 5 What are the names of county or district officers, servants, or employees causing the damage or injury? i i 6. What dainage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) � g ales f 'a / dam / a-cYw. . 7. How was the amount clai mrabove computed? (Include the estimated amount of any prospective injury or damage.) , � �r� S/ Gofoies - S. Names and addresses of witnesses, doictors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■ a a a a as an 2 a Dan a.an a n aBe a a. 6 a.ane C a n a l n.a t a n n a a ME e e ass... USE..■.■■■■as noa an 2 a as a a l .G iv. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornev) Name and address of Attorney ) I - (Claimant's Signa e) (Address) iC ee.1-tl Co# - ) I Telephone No. )Telephone No. _,07d��10� ...a...aa.a■aaa■ta.magnum aanoun aa■.1......■......a....■■.............................. 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. l amMR a.s a■Is a■a a a a a.a am a a■a am 3 a a.■a i n n a a■a■■a■a a a..a a a..a.a...a...I t..a..asea mea■.semi i 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 w7iting, 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 iin the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and lfin e. I (04b n ;��ZS..' tl.� _a s�.�' k'; a �.��t�dfOLf�-.;H�,C717�� •' .' :.4� - ��(lel•l! U'��•�I �.,;., y.'�.P�ta4I:S.10i 4. t► d.;tl1 ''Concord;CA.SM1. VOA Pectt�o�1v1L:1Ul&ft'ea,CA.945 , ?.. 925 6YCr3d388 �N.,_ 925 680550.7''x.'F:l�i(92s),6d;7�143 G REOUE r P.O:IJO. - •r Nan�� = ars.. ...p�/, .. �. , ` : Sic��d...h'.:t''�.r�1'�7�r�. ,i� �t�•-,� ,i•1�'�.��'�;o - ,•7,,'S.s. t :r.,;�e.� ...' t,S ADDREs.. STALE : 'a�. '��`Lb'C...f�j-tuQf'EH}�l ''-r.; T'r.� '�'9 �, �,•};Y. k>�;•,rW,'�" ,M:A,PTd`� - '`' "" *¢ ,- T LiC.Pt-AFE !;J�'+s 1IEHIC'aE'I.D:NOr a'•' '� �'�" _ , MdL SERtific E Iflf _E�_--. 'i�dt6ro�t�GN a', ff{L5ft'^ I Y FINISH FUUSrI ' ,f•.. .;ar;x.. - ':tiF. - •jai-� :�';' ,.M`',u:!. .s. - :;4, .TOT.1L:'' ;:r: ;x, �'' •P:'. _ `+'[01•AL:-.",ti'F= t' %'TOT.eSt:' ��ffSEASCaP,1•FOFB�'�OV'V�;, !' - - - SAECIAE:'EQUIRI`�EdV'Y i1CCSOENY' '". -'.[]"'kBANDONED='' :C a_': `',FU�TI9RE.6 x a Q bSINGLBIINE YVINCHtNO, [}'„l1RF:EST' °'. OUT OF CiAS'r”" C7 ¢'JAl fNE WNCHING.: $ y 2r;yy...•; �:t1AREG�STEREt2' "D'gRcAKDOiNN LI -1NWNDF �" ZNATG4.8LOG?55'':.; ;LOCK OUT' 0 30 DAY HOLD ❑^'SCOTEFI sLodks NON1 R .9bVA�•' c��=SYART�`'�� .�' "'t_�' '•Y" �.. '� .rr� '>® 'r� r* aT€? Liv ORDEROF llECt�lGTi E C�49lED TO. ; 'A a; F,Rs;'xow�e. o.:e. P , � . - SUMHQi�TO ,,Q I STATE POLICE ,a ..TBEDMAM a LOC�.P r rdSECOND TOW17 ,WAEELUFTht: - .:vc',: ,!;•:.Y. ,,:r,. ..xu ' r,�STORAdt !TO.,VdtA1G CHSRGE`. f.;. _p 11CrE:t ARGE'' • �.11d2�Y:. —Al Tx,,.ti.; - :. _ `"- EtIT_i1!•1 FgRS01V; ��': [�?:CASM'a•'- 'CHECK:''a4;. EXP -SPECIAL' g`GREDISaG/iROk;C1.N1C' SA.�AME ;x:DATE' >.,:. ,#'� l:ABOR,GHAR(iE7 j 'r,C• .rte•''1 "^'Y '� :t;9t.;.,.;.wF!=•.: + ;ST0FIAGE; :yX.. OPE 5': 1 �1dR?iJRe DATE '` ° +f,;; ' ..< J �; •-. a.•..�� PP ,btu .5, .� ',-5<.'�' .a�."j'F' .t _ �v'•" `` �r:.r�M;- �ra� ;reu�'/'ies;r+-?Y• ;t'": - :i:'': .yt� ':5.. .��, y � -:$US:TOTAL•- 7 :AUT. RNIED St ATIfRC-' DATE ;~ r"•Y L£/fi SED _�;.f�. _• ATE~_.::' - ., ."i '.+tx:.n..k•.,...,.r�y.' �(y.,�ti. cr' i.a ,. {"� �nom,++ L.�a 1•' ... ��. r,: - ":� , � No��poPeible'�ai:loss pF:tlatnage.Io:vehtcle�.�y•:•.i.':°. . ,. �..- f, In cavo a�llro,then or-erty oMec cauSekeyond aur cpnl.rG.. - _ 4�.^S�_::. .f�'.'!Y'�_ �P' •'lie ,'�p��:.�y,� "Pi h�•:. :.;� a.r�'..: rA X"ae�',��.�•'�.�y.- �'Y._.2➢,: TM;Y'^'�.y�... - ,i-+;. .M f '��,_.,�.�.�....i,.n:...i..+... - - nib' -!. -., .NO REFUNDS ON.DEPOSI ..,�,• .QR SPECIAL.ORDERS, .A - >;� -- - - R -•-- .' ---, fVATIONALCUSTOMER SERVIC . .. _ ,PHONE 4.800 321-2446 7 R MUST PRESENT CO _ CUSTOMER OF INVOICE FOR ANY 'WARRA 1 ..a :r .-rpt' - - _ �e•+ 't• ft, — r_ •cj= g. .'T. J{L�L-`.1 T:l 1•r'••I.I x„3,.Qh--�i.-�tif••.• ^l. :. .�:�" ��•:o,,... .��bi'�;��Ca,. C, �� y4 •� e'er ct • &+4Z r'.�t .ii�. �:+:.,'.r.,'r'�"�4� - .. .. .y .._ .._ l� rat Jt` �diC�:•, ' - - . . 's3;Q411 rGik j; �_ r R rKP >� �_ zh'i.\ ��'�.`�n"'�hJ:'d��,S,r;�i�1'•�. :I, _ r vs►>,:t. ... r. �3 -A ri -ti--r r:;!.7 TIM PLUB-N EW lea' l-)l r, ;. ,.��" f'��:.4c �a:: _�� .. 17 .. . i ni�`Yi�.�A L't� ,ttf .'4' ;`.�^.9'e n tier`..p •�$ ;.1 _ ? :� 3S t"'1�� 4;- ��c•:-:Q r -�..,�,�iiY.. ti; .�:. _ ttttiwr�r r�.t d . .�� ''r• .It ....,_. Y�l. a .i•. �'idy'.'r. �'• •'�•,' �•+,, ........ •': ..`��"'„'�_�r.{: - tit` _ '`-irr '`:`'s'.�� .. ;.`� -�:... �^;7 �i J -. .-.".:)'':`.. .w. "•Rr4 '.�. ,R.Y 4:`' .lai-.._, .7 _.+.� 1`~ :��5.. __�,.l..i� . •t.` .'�"' �'a .�•,,•`'`.: :�:�' .,r;' ;:, . . v` iTII`�• {J:ab I?1=:�8•�:k 1?�.. r1�E014a rra6.ry �'s' V- r r � i � ?x;� t`"'�i_.t{ '��-� �Q�' `.�•�+Z�4''L"'iit1>�. (n:C:�'1. ,:r.r bl:`�'f.i'�,�\.;1®f1n - .. , - �I.' - '' _• 1 _ • {`S _ - .._�l�_�-r.,,_�v•c' ..:..� ..-....-.._.it _.... ,.,�...v_...�.--_ -• _— - _ —� •_^tlr. _._— - - ' i' _ _ _ JI,'1,LS.. �t.'1�`b lam'" .: .�.�..�r.'-sw.C_::•,•.,.,5:. cp T. V V�...:? .. `• �r L : 'l'_ _ '1: '4:; ,_;. ;� - - �ra':ti r•-�rv- ,ice S 'i _. fir'• .uL rr "1• .1 ACK►JOWLE,DGE NOTICE AND ORAL APPfiOVAI.OF ANY INCREASE IN-THE gRIGINAL ESTIAT MED PRICES J( STERNS: INET.1f1fh PROX.-UNLESS.OTHERWISE SPECIFIEDPAtt'UUE?-C' GE tSi.COMPUTEO BY A _: "+t'v �:- ;,r;:':.• f'PERIOpICRATE''OF'1:5UPERMONTHONUNFAID;BALANCE-WH"ISAN:ANUAL'PERCEmaE.RAT$ ;'; '.TF�iSAG OF IS;' IF NECESSARY TO INSTRUTEJ.LEdAL'ACTION'TO ENFORCE COLtECT10N OF THE AfJOUNT.pULa "•' ;' �AINDERTHlSIh^YOSC� BtvFR•A R CTO PAY' tl'NF^F4CeRY„j`fl$I J' •LQ;:, VVV AVII t4 .}'j ..11.4 ' 900? 1�} "\ tQ.' A-LIVnpOd � 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ' BOARD ACTION: JUNE 13, 2006 Claim Against the County, or District Governed by ) the Board ol'Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document. mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), MAY 10 2006 t given Pursuant to Government Code Section 913 and 915.4. Please (rote all AMOUNT $2,317.45 COUNTY COUNSEL "Warnings"'. MARTINEZ CALIF, CLA_INIAMI': BRYAN McALLISTER ATTORNEY: UNKNOWN DATE RECEIVED: MAY 109 2006 ADDRESS: 2405 PEARLITE WAY BY DELIVERY TO CLERK ON: MAY 10, 2006 ANTIOCH, CA 94531 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk Of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C Dated: MAY 10, 2006 By: Deputy .11. FROM: County Counsel TO: Clerk of the Board of Sup rvisors (v)1l'lris clairrl complies substatltially with Sectioiis 9l0 acid 910.2. ( ) I1 hls Clalm FAILS to comply substantially with Sections 9l0 and 910.2, and we are so notifying claimant. The .Board cannot act for 15 days (Section 910.8). O 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 91 1.3). ( ) Other: _—. -- Dated: Jam' /t7-062 By: nncQgQ�l _Deputy County Counsel 111. FROM: Clerk of the Board ; TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unaniniious 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:✓_u77e_/&_C_ 6JOfIN CU_LLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to ceilain exceptions,you have only six(6)mouths from the date this,uotice was personally setved or deposited in the mail to file a comi action on this claim.See Governmeut 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 au attorney,you should do so uumediately. *For Additional Wariung See Reverse Side of 11iis Notice. AFFIDAVI'l.' OF MAILING 1 declare under penalty of pen jury that I am now, and at all times herein meutioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this t3uard Order and Notice to (.'lahnanl, addressed to the claimant as shown above. Daled:VGaa'>t✓/ Fav-Oeo I0lJN C111_.LEN, ('LFRK 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 riot 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 Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the naive 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. ■■rrrrrrrrrrrrrrerrarrerrarrraaarrrrrrraerarerrrrramores rrrrerrerrrrrrrrrman errl RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or. R 4 District) MAY 1 U 2006 (Fill in the name) ) CLERK BOARD QF.S LJ!PEF!ViS0RS CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of a7,3/7 y,: ands in support of this claim represents 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) goAweP.h L-o l7 Crll:�l 1J1eJ-Cn/ /�j�// �•k�j r!/� J/ ,d 6 • --i./ 3. How did the damage or injury occur? (Give full details; use extra paper if required) Gr 4. )AThat particular actor omission on the part of county or district of cers, servants, or employees caused the injury or damage? IIIA 5 What are the names of county or district officers; servants, or employees causing the damage or injury? 11,4 6.' Miat damage or injuries do your .claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates f auto damage.) , aidodsom .�c._ 0o rtJ �:i ' BB o� ,�,�ID ciCc� J � �c J.:.cf .-rjoa,� 1 Ile ado .t� 'Jo / 7. How was the amount c aimed above coin uted? (Inc ude the estimated amount of any prospective injury or damage.) pc�� 8. Names and addresses of witnesses; doctors, and hospitals: caM.� (/Cr��!/SCQC� )6 67 OT �o � V.;Sj /;drjarp y 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT r ■ raaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaENE aaaaaaaaaaaaaaaaaaaaasown aaaaaaaaaMal .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) 1 Frame and address of Attorney ) (Claimant's Signature) "21- (Address) .—■■aTelephone No. ) Telephone No. o 12- -06 0..2— a a a a a 0 5 a a a a a a a a a 0 2 a 0 a a a a 0 a 0 a a a a a a 0 6 N a 3 0 9 a a 0 a 2 a musang a 0 0 a a 0 2 5 0 a a a 9 a a a 0 a a a 0 a a a a 5 a a a a a a I aaaaaaaaaaaaaaaa0aaaa0a0aaaaaaaaaaaaaaa0a2aaaaaaaaaaaaaaaaaaa9aaa0aaa0aaaa5aaaaaaI PUBLIC RECORDS NOTICE: PIease be advised that this claim form, or any claun 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. ■■aa05a00aaaanations aEmu a9aaaaaaaaaaaaaaaaaaMEN Now aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaOsumi 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. ACURA OF CONCORD SPG REPAIR ESTIMATE ESTIMATE # RO185262 ESTIMATE DATE: 04/21/2006 VEHICLE: TL VIN: 19UUA56882A006247 ADVISOR # 581 MARVIN G HIRSCHEL CUSTOMER # 39204 BRYAN N MCALLISTER ADDRESS : 2405 PEARLITE WAY (H) 925-522-0602 (B) 925-382-4035 (EXT) ANTIOCH, CA 94531 CUSTOMER QUOTE OPERATION: COMBINED LEFT SIDE CONTROL ARMS QTY PART NUMBER PART DESCRIPTION PART PRICE EXT PRICE 1 AC51460-S84-A01 ARM, L. FR. UPPER 184 . 60 184 . 60 1 AC51365-S84-A00 ARM, L. FR. LOWER 182 .28 182 .28 1 AC52390-S84-A01 ARM, RR. UPPER 68 . 92 68 . 92 1 AC52360-SOK-A02 ARM, RR. .CONTROL 72 . 59 72 . 59 LABOR $ : 621 . 00 PARTS $ : 508 . 39 GOG $ ; 0 . 00 MISC. $ : 0 . 00 TAX $ : 41 . 95 ------------------------ SUBTOTAL $ : 1171 .34 -----------------------------------7-------------------------------------------- OPERATION: AL4W Four Wheel Align. All LABOR $ : 156 . 00 PARTS $ : 0 . 00 GOG $ : 0 . 00 MISC. $ : 0 . 00 TAX $ : 0 . 00 ------------------------ SUBTOTAL $ : 156 . 00 i -------------------------------------------------------------------------------- TOTAL LABOR $ : 777 . 00 TOTAL PARTS $ : 508 . 39 TOTAL GOG $ : 0 . 00 TOTAL MISC. $ : 0 . 00 TOTAL TAX $ : 41 . 95 -------------------------------- ESTIMATE TOTAL $ : 1327 . 34 CUSTOMER SIGNATURE 13 : 02 : 53 CUSTOMER COPY. PAGE 1 OF 1 04-,/24/2006 Page: 1 Phone Fax PARTS FOR: Vin: 19UUA56882AO06247 TL 2002 4DR TYPE-S 5AT KA Section: -CHASSIS Page: WHEEL; (B 18 ) i 1 5 10 2 0-12 ou O® 6 3 SOK3-81800 A BLOCK ID: B 18 ILLUSTRATION: SOK31BI800A PARTS PICK LIST Item Ref Description Part QTY Unit Price / EXT PRICE 1 11 DISK (17X6 1/2JJ) 42700-SOK-J21 2 241.33 (n 482.66 Total: $482.66 sa eAe-�j, L x a.. 02- 9, Copyright ° 2006-American Honda Motor Co Inc. All Rights Reserved :Release: April 2006 Yahoo? Maps - Concord, CA Page 1 of Yahoo! MYahoo! Mail Make Yahoo! oy ur home a e LO Sign In New User?Sign UpCAL . concord airport could not be found. The city center was mapped instead, i Map for: Concord, CA SAIvIe. Driving Directions:To Here- From m I:lere,Q Ili,iltt<,Llr.�;ci-s r_t(�,i mail Rtah(�_-t_i4'ik.-j, tirix Map 1:1,31'tl�tir77.lr.ttc•t:}it)- �" ..._�.._....._..._.._..__. Atom ,.may► '~ fieri va:; Out _. Vine Hill y �A .. '_�� •. pynatcl tndusttrat WAYand : to 40 °a .r : ',Aryi ,.._•, . ., � ri. fir, ..i•i Pacheco'. .i01, �' �h.,:•`.�7 con , A 1.i3�.1�?' '`�'.,a,?t: '% CO ... r,:Q71C@I 24 o. 1.0 km �r�0 �.5 MI 02005 Yahoos Inc S Sec these business locations un this Ina AVIS /corn in a Rc-(,enter Re-('enter only 1:i 1,++,.//i-ngns.valioo.com/maps result?addr=concord+airport&csz=concord%2Cca&countr.,. 04/24/2006 i CLAIM • �0 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i BOARD ACTION: JUNE 13.: 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 ) California Government Codes. The copy of this document mailed to you is your notice of the action taken on your claim by the Board of MAY 12 2006Supervisors. (Paragraph IV below), I given Pursuant to Government Code AMOUNT: $1,699.28 COUNTY COUNSEL Section 9.13 and 915.4. Please note all MARTINEZ CALIF. "Warnings". I CLAIJVIANTl CALIFORNIA STATE AUTOMOBILE ASSOCIATION FOR: RACHEL M. ;OR ANTHONY LASCANO ATTORNEY: BY: TIFFANY PERRYMAN DACE RECEIVED: MAY 12, 2006 UNKNOWN i ADDRESS: P.O. BO 920 BY DELIVERY TO CLERK ON: MAY 12, 2006 SUISUN CITY CA 94585-0920 RECEIVED FROM PENNY BY MAIL POSTMARKED: RAILEY - RISK-14ANAGE- MENT FROM: Clerk of the Board of Supervisors TO: County Counsel i Attached is a copy of the above-noted claim. MAY 12, 2006 1 JOIiN CULLEN 1 Dated. By: Deputy od 11. FROM: County Counsel TO: Clerk of the Board of S pervisors i ( ) 'This claim complies substantially with Sections 910 and 910.2. i ( "'This Claim FAILS to corrrply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). i O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claire (Section 911.3). ( ) Other: i I I i Dated: �'l7'��P ! By: C&Q$iGt_ Deputy County Counsel I 111. FROM: Clerk of tine Board TO: County Counsel (1) County Administrator- (2) O Claim was returned as untimely with notice to claimant (Section 911.3). i IV. OARD OItDEK: By urranirnous vote of the Supervisors present: (v This Claim is rejected in hall. ( ) Other.. i I 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date: I Dated � o?•��OHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 9113) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited ill the mail to file a court action on this claim.See Govermnent 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 inuuediately. *.For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING i I declare under penalty of per juiy that I am now, and at all times herein mentioned, have been a citizen of the United Slates, over age 18; and that today I deposited in the United Slates Postal Service in 1llartiriez, Clifornia, postage fully prepaid a certified copy of this Board Order incl Notice to Claimant, addressed to the claimant as shown above. I Dated: �w'Y'v� _.aZ0&4,.I0FIN CULLEN, CLERK lay _ Deputy Clerk i i I I I i i i I r , i i . I i This warning does,not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be tiled may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. i j The County of Contra Costa does not waive any of its rights under- California Tort Claims Act nor does it waive frights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act i I i ( � I I 0/ CS- i I e-i ' I I ( I rennY Bailey MY I I 7�MAY Cf VEMOD wt... 2 2006 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. I I I I I I I OFFICE OF THE COUNTY COUNSEL I SILVANO B.MARCHE51 COUNTY OF CONTRA COSTA I �Q+._� ==�o� COUNTY COUNSEL Administration Building i4,= ;a SHARON L. ANDERSON 651 Pine Street, 9 Floor , Martinez, California 94553-1229 CHIEF ASSISTANT GREGORY C. HARVEY (925) 335-1800 �; l ',111\\1: og = � VALERIE J. RANCHE (925) 646-1078 (fax) '�:� p ASSISTANTS cov�'� NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM I •I I TO: Tiffany Perryman 1 Subrogation Specialist i i California State Automobile Association P.O. Box 920 1 Suisun City, CA 94585-09201 1 I RE: CLAIM OF RACHEL M. OR ANTHONY LASCANO I Please Take Notice as Follows: I I The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: I I [X] 1. The claim fails to state the name and post office address of the claimant. I [X] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. I [XI 3. The claim tails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. I [ ] 4. The claim fails to state the name(s) of the public employees) causing the injury, damage, or loss, if known. 1 I I [ ] 5. The claim tails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation. the estimated amount of any prospective injury. damage or loss so far as known. or the basis of computation of the amount claimed. i [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. I I I i I I i I I I I . . Tiffany Perryman Re: Claim of Rachel M. or Anthony Lascano Page Two I I I I I [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code., ti 910.4. Please be aware that you have' only a limited period of time in which to file an amended claim. See Gov. Code, 5 910.6. I [ ] 8. Other: I SILVANO B. MARCHESI COUNTY COUNSEL I I I By: Monika L. Cooper Deputy County Counsel I I I CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., $$�1012, 1013x, 2015.5; Evid. Code. §§ 641, 664) I I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine�Street, 9tli Floor, Martinez. CA 94553-1229. On —v f rr 4-d-V , I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Tiffany Perryman, California State Automobile Association, P.O. Boz 920, Suisun City, CA 94585, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I I declare under penalty of perjury under thellaws of the State of California and the United States of America that the above is true and correct. Executed on ! /9 2D-06,, at Martinez, California. I I Kathleen O'Connell I cc: Clerk of the Board of Supervisors (original) Risk Management I IXI'0R-RRISR-MCMC LAIN IS\]NSUFF\CSAA-Lase no.wpd I I Page 2 I I I I I I California State Automobile Association iInter-Insurance Bureau P.O.Box 920 Suisun 01Y,CA 94585-0420 I May 4, 2006 I RECEIVED M AY X 2 2006 Contra Costa County-Risk Management Division 2530 Arnold Dr. Suite 140 CLERK BOARD OF SUPERVISORS Martinez,CA 94533 CONTRA COSTA CO. I RE: Your Insured: H.D. Williamson Your Claim No.: Unknown . Our Insured: Rachel M Or Anthony Lascano 3 ;�� Our Claim No.: 20-500975-8 Date of Loss: 03/28/2006 I MAY I Dear Ms. Penny Bailey: I This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts,request payment directly to California State Automobile Association Inter-Insurance Bureau (CSAA-IIB): I In order to assist with and expedite the evaluation and processing of this subrogation demand,we enclose the relevant documentation in support of our claim. This information may contain personal or privileged information about our insured,and is being provided to you pursuant to California Insurance Code Section 791.13 and may not be used for any unauthorized purpose. 1 Based upon this information,we ask that you issue payment of$1699.28 Repair Bill 1 $1,175.28 Deductible 1 $250.00 Loss of Use $274.00 Tow/Storage $0.00 Miscellaneous $0.00 I -------------------------- TOTAL $1,699.28 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will trot constitute a full and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination,unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked,as"payment in full"or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction,as CSAA has not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CSAA's specific agreement to accept an amount less than that demanded in this letter. I Sincerely,r1mi roll, 1 I Subrogation Specialist 888-900-6520 extension 6236 I Enclosure I F266K(.Apr 2002) i , . I I I I I Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 Est.imatP. Version: 2. Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL, O Profile ID: CSAA DRN O N i T- Mike Rose Auto Body, Inc. ' N 2260 Via De Mercados Concord, CA 94520-4920 1(925) 689-1739 Fax:(925) 689-0991 Tax ID: 94-2621349 BAR N: 0969527 EPA N: CAR 000004317 V Damage Assessed By JOHN GLOYN Appraised For: Glinda Ruthruff m I Condition Code: Good I Type of boss: Collision Date of Loss: 3/28/2006 Arrival Date: Final to Owner: 4/13/2006 W Payer: Insurance V Claim Paid: . W Policy No: Claim Number: A20500975601 Deductible: 250.00 File Number: F Owner: RACHEL LASCANO Insured: RACIIEL LASCANO Claimant: Address: Tpl.ephone: Work Phonp:Home Phone: I Mitchell Service: 912494 Description 2002 Buick Century Custom Vehicle Production Date: / Body Style: 4D Sed Drive Train: 3.1L Inj 6 Cyl 4A FWD VIN: 2G4wS52J621289556 License: 4YFP139 CA Mileage: 63,645 OkN/ALT: A Search Code: C754827 I Color: BURG Options: Alum/Alloy Wheels,Air ConditiOning,POwer Steering,POwer Windows,POwer Door Locks,Tilt Steerinq Wheel,Cruise Control,Electric Defogger,Automatic Transmiss.ion,AM-FM Stereo/CDPlayer(Siingle) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS ESTIMATE RECALL NUMBER: 4/10/2006 08:48:49 A20500975801 U1traMate is a Trademark of Mitchell International Mitchell Data Version: MAR 06 V Copyright (C) 1.1994 - 2003 Mitchell. International. Page 1 of 6 UltraMate Version: 5.0.214 All Rights Reserved I I I I I I I I I I I I I I I . i i i i Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 Esti.mate Version: 2 Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL Profile ID: CSAA DRN RECHROMED,RECORED,REMANUFACTORED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE NON-ORIGINAL EQUIPMENT MANUFACTURER AFTF.RMARRRT NEW PARTS" Line Entry Labor Line Item Part Type/ Dollar Labor CEG Item Number Type Op Description Part Number Amount Units Unit S1 1 201484 BDY REMOVE/REPLACE R FRT DOOR POUTER MIRROR ASSY 10316956 GM PART153.99 ` 0.3 #0.3T 2 AUTO REF REFINISH R FRT MIRROR COVER C 0.4 0.4 3 200735 BDY REMOVE/INSTALL R FRT DOOR TRIM PANEL 0.4 0.4 4 200815 P.DY REPAIR R REAR DOOR SHELL Existing 1.0. 5.2 5 AUTO REF REFINISH R REAR DOOR OUTSIDE C 2.2 2.2 6 202511 BDY REMOVE/INSTALL R REAR UPR REVEAL MOULDING 0.3 0.3 7 200823 BDY REMOVE/INSTALL R REAR OTR BELT MOULDING 0.3 0.3 8 200025 BDY REMOVE/INSTALL R REAR LWR DOOR MOULDING 0.3 0.3 9 202513 BDY REMOVE/INSTALL R REAR DOOR ADHESIVE MOULDING Existing 0.21 0.2 10 900500 BDY' ADD'L LABOR OP CLEAN AND RETAPE RT RR B.S.M. -Qual Repl Part 4.00 ' 0.31 T 11 200841 RDY REMOVE/TNSTALT. R REAR DOOR TRIM PANEL. INC 0.4 12 200e67 BDY REMOVE/INSTALL R REAR OTR DOOR HANDLE 0.7 p0.7 13 203860 REF REFINISH R QUARTER PANEL EDGE C 0.5 0.5 14 203064 REF REFINISH R QUARTER PANEL OUTSIDE C 2.1 2.5 15 203853 BDY REPAIR R SIDE BODY PANEL ASSEMBLY -S Existing 4.51#32.5 16 RT 1/4 AREA 17 201067 BDY REMOVE/INSTALL R REAR COMBINATION LAMP 0.3 0.3 18 201103 BDY REMOVE/TNSTALL REAR BUMPER ASSY 0.11 1.3 19 LOOSEN RT SIDE 20 900500 REF' ADD'L LABOR OP SUBSEQUENT VEHICLE RAGGING '•Qual Repl Part 0.21 T 21 900500 BDY• ADD'L LABOR OP ROPE RT SIDE bF B-GLASS -Qual Rept Part 3.00 1 0.3* T S1 22 900500 BDY1 ADD'1, LABOR OP PANEL RETAINERS 1}Qual Repl Part 19.60 1 0.01 T 23 AUTO REF ADD'L OPR CLEAR COAT 1.51 24 933003 REF ADD'I, OPR TINT COLOR 0.5- 2b AUTO ADD'L COST PAINT/MATERTALS 199.80 1 T 26 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 1.85 1 ` - Judgement Item .0 - Labor Note Applies C - Included in Clear Coat Calc i Reeycler Information Section: ESTIMATE RECALL NUMBER: 4/10/2006 08:48:49 A20500975801 UltraMate is a Trademark of Mitchell International Mitchell. Data Version: MAR 06 V Copyright (C) 1994 - 2003 Mitchell Internat.i.onal Page 2 of 6 UltraMate Version: 5.0.214 ,All Rights Reserved i i i i i i i i i i i i i i i Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 Estimate Version: 2 Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL Profile ID: CSAA DRN Prior Damage Remarks • FTNAL EST O.R. TO PAY Add'1 Labor Sublet I. Labor SubtoLals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 9.6 60.00 0.00 0.00 576.00 Taxable Parts 180.59 Bdy-S 0.0 60.00 0.00 01.00 0.00 Parts Adjustments 7.70- Refinish 7.4 60.00 0.00 0.00 444.00 Glass 0.0 60.00 0.00 0.00 0.00 Glass Adjustments @ 0.000 0.00 Mechanical 0.0 60.00 0.00 Oi.00 0.00 Sales Tax @ 6.250 14.26 Frame 0.0 60.00 0.00 0.00 0.00 @ 8.250 0.00 Taxable Labor Non-Taxable Parts Parts Adjustments 0.00 Labor Tax @ 0.000 0.0U Non-Taxable Labor Non-Taxable Labor1,020.00 Glass Adjustments @ 0.000 0.00 Labor Summary 17.0 1,020.00 Total Replacement Parts Amount 107.15 III. AddiLional CosLs IV. Adjustments Amount Taxable Costs 199.00 Insurance Deductible 250.00- Betterment 0.00 Sales Tax @ 8.250 16.48 Appearance Allowance 0.00 Related Prior Damage 0.00 Customer Responsibility 250.00- Non-Taxable Costs 1.85 Total Additional Costs i 210.13 I. Total Labor: 1,020.00 II. Total Replacement Parts: 187.15 III. Total Additional costs: 218.13 Gross Total: 1,425.28 IV. Total Adjustments: 250.00- Net Total: 1,175.28 ESTIMATE RECALL NUMBER: 4/10/2006 08:48:49 A20500975601 UltraMate is a Trademark of Mitchell International Mitchell Data Version: MAR 06 V Copyright (C) 1994 - 2003 Mitchell International Page 3 of. 6 UltraMate Version: 5.0.214 All Rights Reserved i I i I i I Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 Estimate Version: 2 Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL Profile ID: r-SAA DRN Less Original Net Total: 1,135.16 Net Supplement Amount: 40.12 S1: MARK GTT.LFJ4 40.32 Related Prior Damage Labor Subtotals Units Rate Tota ls RL-Body 0.0 60.00 o.0o RL-Refinish 0.0 60.00 0.00 1 RL 'Taxable. Labor 0.00 GST - E Tax @ 0.000 0.00 Labor Tax @ 0.000 0.00 Labor Tax 0.00 I RL-Nan-Taxable Labor 0.00 Related Prior Damage Labor Summary O.0 0.00 I Part Replacement Summary Amount RL-Taxable Parts 0.60 GST - E Tax @ 0.000 0.00 Sala.^, Tay. @ 0.250 000 Sales Tax @ 8.250 000 RL-Non-Taxable Parts 0.00 Related Prior Damage Parts Summary O.00 Related Prior-Total Labor: 0.00 Related Prior-Total Replacement Parts: 0I.00 Related Prior-Damage Total: 0I.00 Unrelated Prior Damage Labor Subtotals Units Rate Totals UN-Body 0.0 60.00 0.,00 UN-Refinish 0.0 60.00 0.100 ESTIMATE RECALL NUMBER: 4/10/2006 06:48:49 A20500975801 U1traMate is a Trademark of Mitchell International Mitchell Data Version: MAR 06 V Copyright (C) 11994 - 2003 Mitchell International Pagp 4 of 6 U1traMate Version: 5.0.214 All Rights Reserved I I I I I I I I I I I I I I I I I _ Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 Estimate Version: 2 Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL Profile ID: CSAA DRN UN-Taxable Labor 0.00 GST - R Tax @ 0.000 0.00 Labor Tax @ 0.000 0.00 Labor Tax (J 0.000 0.00 UN-Non-Taxable Labor 0.00 Unrelated Prior Damage Labor Summary 0.0 0.00 Part Replacement Summary AmounL UN-Taxable Parts 0.00 GST - E Tax @ 0.000 0.00 sales Tax @ 8.250 0.00 Sales Tax @ 8.250 0100 UN-Non-Taxable Parts 0.00 Unrelated Prior Damage Parts Summary 0.00 I ' Unrelated Prior-Total Labor: 0.00 Unrelated Prior-Total Replacement Parts: 01.00 Unrelated Prior-Damage Total: O.00' Total does not include overlap or labor adjustments . I THIS ESTTMATF. HAS BEEN PREPARED BASED ON THE USE OF C—SA PAATS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUF'AC'TURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Points) of Impact 4 Right Rear side (P) Insurance Cc: CSAA Address: 2055 MERIDIAN PARK BLVD. CONCORD, CA 94520-5767 Telephone: (510) 671-2708 ESTIMATE RECALL NUMBER: 9/10/2006 08:98:99 A20500975801 U1traMate is a Trademark of Mitchell International Mitchell Data Version: MAR 06_V copyright (C) 1994 - 2003 Mitchell International Page 5 of 6 U1traMate Version: 5.0.214 All Rights Reserved I I I I I I . I I Date: 4/21/2006 7:23:55 am Estimate ID: A20500975801 F.st.imate Version: 2 Supplement: 1 (F) 4/13/2006 10:36:56 AM FINAL Profile ID: CSAA DRN Fax Phone: (510) 689-7939 I BOdv Shop: Mike Rose-Via DeMercados-Conco inspection Site: None Address: 2260 Via De Mercados Address: Concord, CA 94520 Telephone: Inspection Date: (925) 689-1739 Fax Phone: (925) 689-0991 Slate Lir.. Nn: Company Code: Drop Off Date: 4/10/2006 Repair Dates: Promise Date: 4/13/2006 Start Date: 4/10/2006 Pick Up Date: Completion Date: 4/13/2006 Is Vehicle Driveable (Y/N)?: ASsisLed With RenLal (Y/N)?: THIS ESTIMATE HAS BEEN BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTTRS APPLICABLE TO THESE REPLACEMENT PARTS ARE,PROVTDF.D BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. This estimate has been re-calculated with a modified profile. I ESTIMATE RECALL NUMBER: 4/10/2006 08:48:49 A20500975601 U1traMate is a Trademark of Mitchell International Mitchell Data Version: MAR_O(;_V Copyright (C) 1994 - 2003 Mitchell International Page 6 of 6 UltraMate Version: 5.0.214 All Rights Reserved I I I I I I I I I A : •„�,��,�'� ....':e: /✓t� �� ::��t x:33: _ ^lS ..V.•'. ..wap!'”"'...s....... y4,r+'euww,•.. .. .. x W� .4r :. -. .. ,..: �_.. ...E ... .�.: .:,.. � ... .. :.. E'.. 2 K l 'E T 1 y'r • •y Ya II moll QIA v : ra Im�.. I I .. fy- sqF. � .�.. .. TY-�:fit::. '.�. •.:bnx: ..4:..:� �j.i��•�� • K" I r�x - fi y k 44 ,y S y- f .s x' R+ w t, , t..s:• x ,GJ I 471, ow- .,7, , S a d R �! t liv �+.� ► d 3 � r y T� ^ t PR-,. � ... it '1 N�. r AMIa r 1 � ' i qt y' r w fd" r �,. y i ti: d . .z �:.p L . t 'r �l • .. X, :.✓� �F d' a � �' i �'!i's".,,� '��.�, -� � �"�r« ''d}. � ,��fid, �S. ' .� Amy € of TR �. I j j 4 2"00 a �r i a r 4 w a � Il �" iW Q3 WIS c AN f ? x� .y -tt v .a •as ?'� y, h, z # x IN t "zoo AS 7 � m RIMS .......... 1 � s A a .r. � k a uM t y Y •4 a 41 �K jKK `.a.i+ - ane _ ,c= .•� �, _. 9 v y ' e b MI � ��fid`" s t � f ` �,'• .�' ,. TF zr# wm r- } ✓. vx. } $x w 1 3� APP 151 200 s _ . mac. 3 CLAIM p BOARD OF SUPERVISORS OF CONTRA COS'TA COUNTY goo j j BOARD ACTION: JUNE 13, 2006 Claim Against tine 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 California Government Codes. j ) you is your notice of the action taken on your claim by the Board of rs. (Paragraph 1 V below DAY TREATMENT CONTRACT NUMBER 24-13 VEX ), uannt to Government Code Section 3.and 915.4. Please.note all AMOUNT: UNKNOWN 'MAY 1 2 `20�orn' s". CLAI-MANT: LA CHEIM SCHOOL, INC. C UNTY COUNSEL VICTOR G. PRADA ARTMtE.Z•CAL-IF. ATTORNEY: WILLIAM J. PETZEL DATE RECEIVED: MAY 11, 2006 ADDRESS: 1970 BROADWAY,I SUITE 1200 BY DELIVERY TO CLERK ON:MAY 11, 2006 OAKLAND, CA 94612 HAND DELIVERED I BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors `['O: County.Counsel Attached is. a copy of the above-noted claim. MAY 11, 2006 JOHN C ULLEN, C k Dated: I By: Deputy 11 FROM[: County Counsel TO: Clerk of the Board of Supervisors i (.�Flris claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to conip'.ly substantially with Sections 9.10 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely tiled. 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: I I Dated: By: V-n Ce .0�� Deputy County Counsel I 111. FROM: Clerk of the Board I TO-. County Counsel (l) County Administrator (2) O Claim was returned as untimely with notice to clainiiant (Section 911.3). I - IV. ARD ORDER: By unanimous vote of the Supervisors present: ( I'his Claim is rejected in full. ( ) Otlner: I I 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:\&v7u/& J& iCULLEN, 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 sewed or deposited in die mail to file a count lection 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. Uyou want to consult an attor-ney,you shoidtido so inuruediately. *For Additional Warnurg See Reverse Side of This Notice. AFFIDAVIT OF MAILING I I.declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United Stales, over age 18; and that today 1 deposited in the United States .Postal Service in Mv-tinez, Californi.r, postage fully prepaid a certified copy of this Hoard Order and lNOtice to Claimant, addressed to the claimant as shown above. I I I.)atecl:✓w�v/ _o�.�0� .10[IN CUI.1-I3N, l'L.f:lZK lay _ _ Deputy Clerk I I I I I I I I I This warning does 14ot apple to claims which are not subject to the California Tort Claims Act such as actions din inverse condemnation, actions for specific belief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer defending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. j I The County of Contra Costa does not waive any, of its rights under California Tort Claims Act nor,does it waive rights under the statutes of limitations applicahie to actions not subject to the California Tort Claims Act I I I I I I I i I I I I i I I I I I I I j I I I i I I I I I I I I i I I I I I I I i I I - i 1 1 WILLIAM J. PETZEL (SBN 67129) Attorneys at Law 2 1970 Broadway, Suite 12001 RECEIVE® Oakland, CA 94612 3 Tel: (510) 452-1900 4 Fax: (510) 452-1980 MAY 1 2006 Attorney for CLERK BOARD OF ,Up,ERV�SORS 5 LA CHEIM, INC. Formerly CO/VrRAcoSrACo. LA CHEIM RESIDENTIAL TREATMENT 6 CENTERS, INC. 7 j LA CHEIM, INC., 8 vs. i 9 CLAIM FOR MONEY COUNTY OF CONTRA COSTA, 10 CALIFORNIA, 11 I 12 TO THE BOARD OF!SUPERVISORS OF CONTRA COSTA COUNTY: 13 You are hereby notified that La Cheim, Inc.(Formerly La Cheim Residential 14 Treatment Centers, Inc.), whose post office address is 5261 Claremont Avenue, Oakland, 15 California, 94618, claims damages from the County of Contra Costa, California. 16 This claim is based on the County of Contra Costa's decision to withhold monies i 17 owed to La Cheim, Inc. for Day Treatment contract number 24-133-51. 18 Contra Costa County unilaterally and without justification withheld sums that were to 19 be paid in November 2005 and December 2005, as well as January and February, 2006. I 20 The name of the public employee causing the withholding of the monies from La 21 Cheim, Inc., as known to date, is Jana Drazich. 22 This is an unlimited civil case. 23 All notices or other ciommunications with regard to thi claim should be sent to 24 William J. Petzel at 1970 Broadway, Suite 1200, Oakla C ' or ' 2. 25 Date: May �� , 2006 26 VICTOR GLERAD 27 CEO of LA CHEIM, INC. 28 C:IDoc:rn:ents and SetNngslOivnerWy UocumentslWetaeM.4 CHEMPLa Cheim, Incl Claim for Money.pld..wpd I CLAIM FOR MONEY I � r� '. CLAIM .02 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY � I BOARD ACTION: JUNE 13, 2006 i Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sectioii references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of DAY TREATMENT CONTRACT NUMBERI. 74 �� ervisors. (Paragraph IV below), {� r> . Pursuant to Government Code AMOUNT: UNKNOWN n.913 and 915.4. Please note all MAY 12 2006" rnings", CLAIMANT: LA CHEIM SCHOOL,1 INC. COUNTY COUNSEL VICTOR G. PRADA I MARTINEZ CALIF. ATTORNEY: WILLIAM J. PETZEL DATE RECEIVED: MAY 11, 2006 I ADDRESS: 1970 BROADWAY, SUITE 1200 BY DELIVERY TO CLERK ON:MAY 11, 2006 OAKLAND, CA 94612 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claire. MAY 11, 2006 JOHN CULLEN, CI Dated: By: Deputy Il_ FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantial Ily 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 1.5 days (Section 910.8). ( ) Claim is not timely filed. The Klerk should return claim ori 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: _ —i I Dated: By: Deputy County Counsel 1.11. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 91.1.3). .117 POARD ORDER: By unanimous vote of the Supervisors present: ( 'this Claim is rejected in full. O 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& 1-8, 0000_40HN CU.LLEN, 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 ur 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 attonrey,you should do so immediately. *For Additional Wanwrg See Reverse Side of Tlris Notice. AFFIDAVIT OF MAILING I declare under" penalty of per j1 . that 1 am now, and at all times herein mentioned, have been a citizen of the United Suites, over age 1.8; and that today I deposited in the United States Postal Service ill NI'l tiniez, California, postage filly prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. I Ua.tednei/,4e,, a2ov461-1.N C.UI,LEN, CLERK 13y _ Depu1Y Clerk I I i I WILLIAM J. PETZEL (SBN 67129) Attorneys at Law R n' 2 1970 Broadway, Suite 12001 Oakland, CA 94612 3 Tel: (510) 452-1900 MAY i 1 2006 Fax: (510) 452-1980 CLARK 4 I s ozR 'rsuP- Attorney for ONT h�Cis 4 co�IS�RS 5 LA CHEIM SCHOOL, INC. 6 I 7 LA CHEIM SCHOOL, INC., 1 8 j vs. CLAIM FOR MONEY 9 COUNTY OF CONTRA COSTA, 10 CALIFORNIA, I ! 12 TO THE BOARD OFA SUPERVISORS OF CONTRA COSTA COUNTY: 13 14 You are hereby notified that La Cheim School, Inc., whose post office address is I 5261 Claremont Avenue, Oakland, California, 94618, claims damages from the County of 15 Contra Costa, California. 1 16 This claim is based on the County of Contra Costa's decision to withhold monies 17 owed to La Cheim School, Inc. for Day Treatment contract Number 74-224-1. 18 1 Contra Costa County unilaterally and without justification withheld sums that were to 19 be paid in November and December 2005, as well as January and February 2006. 20 21 The name of the public employee causing the withholding of the monies from La Cheim, Inc., as known to date, is Jana Drazich. 22 This is an unlimited civil case. 23 1 All notices or other communications with regard to this claim should be sent to 24 1 / William J. Petzel at 1970 Broadway, Suite 1200, Oa Xan Califor 612. 25 26 Date: May 2006 27 VIG. PRADA CE of LA CHEIM, SCHOOL, INC. 28 C:IDoc•:anenls and Sellin,gslOwner'Iilfv Doc•unenls`'PelreAL.A CHELVILa Cheim SchoohClain:for jVfoney.p1d.5.5-4-06.wpd CLAIM FOR MONEY i BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY d, I. BOARD ACTION. JUNE 13, 2006 Claim Against the County, or DistrictlGoverned 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 California Government Codes. I D bis your notice of the action taken 11your claim by the Board of TBS CONTRACT NUMBER 74-083-10 MAY 12 2006 P'ervisors. (.Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AM.OUN'E UNKNOWN i MARTINEZ CALIF. "Waiizings". CLAI_ivIAN'I': LA CHEIM SCHOOL, INC. VICTOR G. PRADA A'T'TORNEY: WILLIAM J. PETZEL DATE RECEIVED: MAY 11, 2006 ADDRESS: 1970 BROADWAY,I SUITE 1200 BY DELIVERY TO CLERK ON:MAY 11, 2006 . OAKLAND, CA 94612 HAND DELIVERED BY MA-IL POSTMARKED: I PROM: Clerk of the Board of Supervisors ro: County Counsel Attached is a copy of the above-noted claim. MAY 11, 2006 3 011 CULLEN, e Dated: I By: Deputy It. FROM: County Counsel I TO: Clerk of the Board of Supezvisors (4".iFzis claim complies substantiially with Sections 9.10 and 910.2. ( ) 'Phis Claim FAILS to coinply substantially with Sections 9.10 and 910.2, and we are so notifying clainiant. The Board cannot act for 15 days (Section 910.8). ( j Claire is not timely riled. The; Clerk should return claim on ground that it was filed late and send warning of claimant's right Ito apply for leave to present a late claim (Section 911.3). Dated: By: f1-1 Deputy County Counsel III. FROM.: Clerk of the Board 'f0: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. B ARD ORDER: By unarurnous vote of the Supervisors present: (LK Claim is rejected in full. ( ) Otlier: I 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Datedl..4" q?*OAJO.HN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to cerlain exceptions,you Have only six(6)mouths from the date this notice was personally sewed 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 all attorney of your choice in counection with this matter-. U you want to consult an attorney,you should do so immedi,ltely. *Fur Additional Warming See Reverse Side of'I7ris Notice. AFFIDAVIT.' OF NiAI.L.ING 1. declare under penalty of perjury that I aur now, and at all times herein mentioned, have been a citizen of the United. Slates, over age 1.8; and that today I deposited in the United Slates Postal Service in 1 Iartiuez, Carliftwitia, postage hilly prepaid a certified copy of this Hoard Order and Notice to Claimant, addressed.lo t.lie clainiant as shown nbove. Dated: Al, a" i.10.1-IN CUI,I-.L.N, CLERK By _ Deputy Clerk I I i I WILLIAM J. PETZEL (SBN 67129) Attorneys at Law 2 1970 Broadway, Suite 12001 ° �II Oakland, CA 94612 ' J ® 3 Tel: (510) 452-1900 Fax: (510) 452-1980 MAY 1 1 2006 4 I CLEpi1C BO,q Attorney for CONT 4OOSTpERVISORS 5 LA CHEIM, INC. Formerly I ACO. LA CHEIM RESIDENTIAL TREATMENT 6 CENTERS, INC. 7 I LA CHEIM, INC., 8 vs. 9 CLAIM FOR MONEY COUNTY OF CONTRA COSTA, 10 CALIFORNIA, i I 11 I 12 TO THE BOARD OFI SUPERVISORS OF CONTRA COSTA COUNTY: i 13 You are hereby notified that La Cheim, Inc. (Formerly La Cheim Residential 14 Treatment Centers, Inc.), whose post office address is 5261 Claremont Avenue, Oakland, 15 California, 94618, claims damages from the County of Contra Costa, California. 16 This claim is based on the County of Contra Costa's decision to withhold monies I 17 owed to La Cheim, Inc. for TBS contract number 74-083-10. 18 Contra Costa County unilaterally and without justification withheld sums that were to 19 be paid in November and December, 2005, as well as January and February 2006. 20 The name of the pu lic employee causing the withholding of the monies from La 21 Cheim, Inc., as known to date, is Jana Drazich. 22 This is an unlimited civil case. 23 All notices or other communications with regard to this claim should be sent to 24 William J. Petzel at 1970 Biroadway, Suite 1200, Oaklan , California,_ 946 25 Date: May 1() , 2006 1 26 VICTOR GI,PER JYDA 27 i CEO of LA CH IM, 1C. 28 C:IDocuments and.Serting.vOwner'',Ali-L)oc:uaentvi.1'et-7el''iL.,I CHEIAPLa Cheim, hzclClain:for;tloney.pld.4..wpd I CLAIM FOR MONEY 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY e`02� BOARD ACTION: JUNE 13, 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 California Government. Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), MAY 12 2006 given Pursuant to Government Code AM.OL►N'f: $11251.97 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: DAVID GILLIAM i ATTORNEY: UNKNOWN DATE RECEIVED: MAY 12, 2006 ADDRESS: 2801 NORTH OLIVE AVENUE BY DELIVERY TO CLERK ON: MAY 121 2006 TURLOCK, CA 95382 i BY MAIL POSTMARKED: MAY 11, 2006 _ I FROM: Clerk of the Board of Supiervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Dated: MAY 12, 2006 By: Deputy H. FROM: County Counsel TO: Clerk of the Board of Su etvisors ( 445liS claim complies substantially with Sections 910 and 910.2. ( ) 7.his 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). O 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). O Other: --- _ - Uated: y ' �� By cimDeputy County Counsel TO: County Counsel (1) County Administrator (2) Ill. I.,ROM: Clerk of the Board I O Claim was returned as untimely with notice to claimant (Section 911.3). V ARD ORDER: B unannuous vote of the Supervisors resent: Y P P '.fhis Claim is rejected in flIl. ( ) Other: -- I — I certify that this is a true and correct copy of the Board's Order entered in its minutes for. this date. _DatedV_!_ _ .� �i�OIN CULLEN, CLERK, By Deputy Clerk WA-RNI NG (Gov. code section 913) Subject to cerlaiu exceptions,you have only six(6)months from the date this notice was personally sensed or deposited in the mail to file a corm action on this claim.See Government Code Section 945.6.You,nay seek the advice of an attorney of your choice in connection with this matter. If you wmrt to consult an attorney,you should do so immediately. *Fur Additional Warring See Reverse Side of 17ris Notice. AFFIDAVIT OF MAILING 1 declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today I deposited in the United Stales Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Ordermid Notice to C'I:limmit, addressed to file claimant as shown above. Dated\/U.We'.,1i� 07.� .KIAIN (1111I:N, CLEM 13y _ —_ epuly Clerk This Clo /f jkowvf _ ori e0 s i oi_2d /2 P /ze so% r � r Kik-or (jC 71� 0-0-a/ LmTell& !a ees Se� ��%/�cJeLc/�e�s is 4� �ec/ _ /6e dd Gs OCA _�i�i �_, e_` 7�/�/��ro%c_e C e G�ei'e /oU fec/ I Ale-11,'e _U es f S')/ der/AaG�lrr _moi/-0-0 C�/l �l'C��i > vaal(l- k CO//'ec STU 0/7 7o OZU/ S 7c7 /n' r e>afe�k Jcula_s /e asaaC /I 4" o��ii�2� se elAe fro- &✓UiC_/ec/ e Tie _ore_f ee �)er/ eajr)k— Qe7'C'�1 4/7 FG f v�L/1 C/)e%,1�_/_f r/J_e/��.f�0/)1(fj o 7�e _ �'f o 0Je e2D_7�Ii/J T�Azz - p/parec/iu61-f- U 12 2-e- 02aa 1 'Al r-§&A&Z L10 n- ad /'d /0660 awb / e /i r Zuil`G Ci r � r r � � Seelain _in_ .�s Ckl� �s �i�u m�Wec/ who r RECEIVED CLERK BOARD OF SUPERVISORS CONTRA`COST&CO. 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.) i 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. rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■■rrr■errrrrrrrrrrrrr.rrrrrrrr.rrrrr. RE: Claim By: Reserved for Clerk's filing stamp f)a vii 61yMm ) ) RECEIVED Against the County of Contra Costa or ) MAY 1.4 2006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) I ) CONTRA COSTA CO. i ) I The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ /a5/ 9Tor and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 0/7, or o6oul Aovemkr• ;5 2005 io OpfiI l2, 2006 2. Where did the dama e or injuryoccur? (Include city and county) Wesi COGn� De nilbnFocil�iy 5555 6ian4 Nwy. Bkhmonof, CR 941806 Corr�ro COSA eounff/ 3. How did the damage or injury occur? (Give full details; use extra paper if required) 5ee Q�locknel?� A 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? See 04oehmeld .8 5 What are the names of county or district officers, servants, or employees causing the ury: damage or inj g ? yead l�Sischen SOPel-11rser ,Jeff' U4eI-,f A/lc%I7 ..�u/oervrrer /�,6ruham; 00d SQpervlSer p/i�'/ iV,-Ihls Coin, 01611 Gl, W✓ efi I sue 0vdy, #e amount w,/l ie much yreofer as -Z wills eekpuni 111ve, compe /oy anr/e)(em�o�Gr�/.c/GmGye.r � fiy civ /�yh�s 6einJc vio%Jed,personal injw undo Paha 'suMerhii , and o 4orney)oe es. 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) See ��Iachtned C 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.)1-/7S f�e 2n01,,-PS0110f0010�ji7 u,p o//eolnmisso/f/PU/'chores OlGrin 70, perl&of As C/o%i`► Wen I hod A purchose my own kod, minus 370 for 11017- Food i le s fin f Were on die hills, 8. Names and addresses of witnesses,doctors, and hospitals: See 0�iochmed J 9. List the expenditures you made on account.of this accident or injury: DATE TIME I ' AMOUNT See 0�10chmenl if I 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) > 290/ P. �/ye we. (Address) L 2=(�09) X32- Telephone No. )Telephone No. J I I 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. 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. • J ' ha ve Gv_'ec _ser aus cllsea_s e_c_a//e-d-ce/izc-a!L_e— Gir�i _ �G� e , ea OGe anCe � �� V �oelu� S/ .!Z.!erlaus hc� r��'x_h_ h� _OU o�m�i_seas c�c% he_dIG � �:r in_�co e� �eG erg r_i ,�y �e_C / '�dia_D_��rfr�e CQ�fee �� r��OG✓_�Q C/J�_the-�c/ ase r_o_ _cessed i�f ose_o _er_v_srsTQw-eraa C/ �i � /.A2.0_D�5r�11QS_��Qec°i1D_7-4e- lip? rz�ilz�r� amviae ley-c/e-13LCD_es1eZz�eze-d me ��fd�n � e__ role Cclr_� _42��ecr/ h�e�e_ee./ir2Laz1 e Did A� fiee(�z� o e(f lb g—e Gj/-, dz�e' ---/-0� : r y �nedc, l se_:_� �e A// eg. ager d -r 617 a c2-qr ahe �vsp�� u��m " iii' 6��a�G•�c/ � r�y T ldomuka_/_'T/,-wne6I-eAe �f�Achm_enfA �_eaG��IaGLSD Ci� OL�LTLJC_ VU/ ey�e/e.% /2�eessG�� rel1 �Ume.�oc�s ea�p_/st1ilm eP ZO,,�I/ 111 PeW/ Ae 1;� _�D_ er JL l DQF #G/1 ea-UI-l-eal Aof 1 �7/J_'fU��)M lass 4—/- 9,aj 7 kl !Ad Ma 4 1 d,0 J--M—/- mllL�1— eOXL I" are OT 71' eS�P/_�L�J� D_oC-SKIU1_G�'C/L�T T/ 1�1/G7 AILV_e.Tx L'GUSeOJ� Ju��L1�'C�OQ/ ��01�U�D�Ce /ale TO %2�1�1 �X/QC' - - �CL�1 �U 0� I i T_h_e-Al lch _s LL(21-2&—�os�� c�ur�� Sh_�r-1- e-L-/-fi�e-al— r _�� co/. neec%r �/�/ D_eo_ti s _ >ICfi7-��d�7-0)�CZ_ Z61-0 Z' ww e P cv a_s_/�o c a �'e_c_ �ofh A- C�u��c�s_��r/�/_u�se �o i y� _ovy�/�i� o /ie �i �°f�e�?�nC / �� m e�.�oaG1/, �o_u �i' 1_Gl a en sa�2_�p�/.Cl�� e_/_'� a-sr_,_Co� c ��CI-,f- -seal—saoer-olh - ok - o�`_ C—k2. f c/_�k�e_L'or� 61--jal?c,rn " o%//Irame�ou�_ii�m� e!./fi h��.�o� ecs_ ��1 gas a�iif' _n_z _a_L as_e Ie(7u/c.r QieZ�iu s�h--.Ie-o-1-j-o- Z. �/��_ � eco _e_� Gee few a�/ C�ou/o%/�cire_/me �ef �i�e o_ Coy? -so-Z/- ImWe,0- � az es oil' Ae i& ofe ��ei?c�o� dos i� /G.� ene_ eoLc_u./_s' E,10�-d_Pv_ e�-�e�e _l9b�G Ci _ UI e/ �-e-�Aec P Ve% .aiJ-/��//�G/�P.��D/IG/e��_�(%✓L/'Iy /J�e _6G1/ oC/ 3 wP� s.� s�� i�/rre_�e�ues /Ud��i.� r ��ee a 6i'ea� s /ur�ch ar��/c_/r�e�_ urs �y cc/��e o_,6_o�ek %0- e 'e_. ince. �'�IQOs S.Ao�a ca/-�esG//I' ve !Le r_/'��el,le6ZzO �s /Pice_�ris,O arc/ sG/ods�JLII&-(CIt'or_60�C ..�/is , y Z s A su.�e y /-0-s-c-e_mhgn.-0_/I_G_11_01-9-C��r �?y.?��G 9�. �� /W �Dn)(2e r'e �esf I or XM?�e )cinesee fhi6l" ,�og/de �e �i_o zlpo� ''�c�//carne, or 1-a,?/eln 6 a_s PerG/Si1-2-C e lall'e/ was 2r l/ °o�r_e_c pec/on i e &112s _l10_GJ_COrJ_P_C_r, G._� G_�I� C�1i Oie �� /n0i7r /_ GAS CJ/G y,�1� Tor' e12� /I�vU _�r�o s and /Jl L�Q 14X[/_'C_kJ'e- Ioy -Lt a-, y Com�y aJ Be_s, �'��.5 /I_t`/ U/ aYn %JG_�1 u i' isILeres,Q�r�,��,��/'� _e_es l the,�h�� e�G�' ir�P� aril ��lese. 05eiu k�wi' 1� %/I_CUrePraTo�Z _O�Oryylole lPe Al/J��C�ed /eG��oC��e Q1�(� TO ed/n�_• '�M l,�aL— rrhe_ r�c_e�c�ec��n 7ro_ai o�- -on-d-012-0- /Mai e C�e_a_2o_ss�o;�d T�� x C14. _ oha//wmt -e_ _Uesl _�X17�� an C/ �z l'�r,�orli� o _ .pan ass —lla_/_nP.�J /�ir/r/POIcI me h� X�ra�om _ as C_f'�i li _njoye_f_aQj 6_c � e �eTe� _ ore; Z7 _Aj-d- er—ZCl ` e iSSU� o ru u _l7GM e KGIs' Gr P�j v/v2d/ 0C T�G Z 10u/d OJ6 01)Wd 1-ave cQ�9.1� le��n C/�r -o_r_sao-e her - all 070 /'0 ori rari�_i9brah n �_�' /_CGusec/ C�aF. �a c /� 7s /_�� OW e � inn��rr/1_n � YLoLe�ne �_G1n le,��`/ne/' &P/1/�Gr, Ci/7G/ �C�C'/�ii7 /n1'��-C/Ic� 1 suY '�erP'�Oscl2f� a_ S�V� e ��ei' h�/off_/ �U i_ ��ri 'G Q o-kL—w a a ea I/p, r_ d 'e�i_'a COW coae_i 1711.1 tree syls�� G� osteo �ros�.s, o2ori /v_Pr_�� le-cZ � / Zdaele- 16 ZZ7 6f Iv-i-/day,a exar_n/r, ri_� A shokJo. I�rB/'/./?l0/; GC/1�/1r/Je.�k�,�Qy die s T -5�55 CMV/-, u Noue� I,,'—Jn��e. -�rLu cJO.G_rIJ_e S_er_ eo,71` _el�';��' R hmmdd, Rdol i RD_,B_v_X Zl j _L6-1,_o �1 95329os L i i _x$38 I"ylum Loi—eve. VQJ1eV 6!/e1q, glM- i ro el- 1 7 ee elf � a� . I . i . I OLlo-, h/17C'/1 i 2/-05,A, ._7y -7 2 -l y_06 ' J50, y3 -5 - 05: 6. 2 3 -. 06 :3^l_5--0 - 5.53 g9 i 3-20- 06° I/6.91 - 2 -06 ,.9. - 6-06 : 99,1 2_7 _5a 3 S -/ . Zl—v_G: o, io �l- �1 0.6 9,5g _/- to - 04 : 31) fo00/ z2en j /2si 9 7 fece `o Coalls 1lemelgs Co1J , e &o vlo%% r I I I I i I i I i I I I I �� i i - i What is L'eliac visease : Wneat intolerance, L.eiiac visease ana seizures in t_.uiiurewrkuu... rabC ► vi z i r. . Tel: 1-800-387 4064 0r(515 r- 'home e-mail nevas products aboutspacial health reap us Celiac Disease and Wheat intolerance in Children and Adults Celiac disease is a digestive disease that damages the lining of the small intestine and creates malabsorption of nutrients (minerals and vitamins) from food. Celiac disease manifests itself as wheat intolerance and seizures in children and adults. This is caused by a protein called gluten, which is found in wheat, oats, barley, rye, barley, triticale,-spelt and kamut. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the small intestine. Specifically, tiny fingerlike protrusions, called villi, on tfie lining of the small intestine are lost. Nutrients from food are absorbed into the bloodstream through these villi. Without villi, a person becomes malnourished--regardless of the quantity of food eaten. Because the body's own immune system causes the damage,celiac disease is . considered an autoimmune disorder. However, it is also classified as a disease of malabsorption because nutrients are not absorbed. Celiac disease is also known as celiac sprue, nontropical sprue, and gluten-sensitive enteropathy. I Celiac Disease and Seizures in Children and Adults Celiac disease is a.genetic disease, meaning that it runs in families. Sometimes the disease is triggered--or becomes active for the first time--after surgery, pregnancy, childbirth, viral 'infection, or severe emotional stress. The symptoms of Celiac disease, including wheat intolerance and seizures in children and adults vary in severity. Read More... • What are the Symptoms of Celiac Disease? • What are the Complications of Celiac Disease? • Dermatitis Herpetiformis • How is Celiac. Disease Diagnosed? • Screening of Celiac Disease • Treatment of Celiac Disease • The Gluten Free Diet.' i http://www.elpeto.com/whatiscd.hItml 5/9/2006 for children:because,they•need'adequate nutrition to.develop properly. Children and Adults in Celiac Clinical Studies Some people with celiac disease may not have symptoms. The undamaged part' of their small intestine is able to absorb enough nutrients to prevent symptoms. However, they may suffer secondary diseases such as: • Arthritis • Osteoporosis • Dermatitis herpetiformis • Thyroid disease • Systemic lupus erythematosus • Type 1 diabetes • Liver disease • Collagen vascular disease • Rheumatoid arthritis • Sjogren's syndrome Children and adults in celiaciclinical studies demonstrate that the connection between celiac and these diseases may be genetic, but the pediatric/adult symptoms and diagnosis:of celiac disease maybe different among family members. Read More... • What are the Complications of Celiac Disease? • Dermatitis Herpetiformis • How is Celiac Diseasei Diagnosed? • Screening of Celiac Disease • Treatment of Celiac Disease • The Gluten Free Diet • What is Celiac Disease? s a Home E-mail News Products I Outlet Store I Special Recipes 1. Health.] About Us I Site Map (c) Copyright EI.Peto Products Ltd. 2005.All Rights Reserved. Original Design by: Everett Ranni. Updated &Maintained by: David Riesen, Search Engine Optimization by Nautalex http://www.elpeto.com/simpofcd.htlml 5/9/2006 i Symptoms of celiac Disease : Yeaiatnc/Aawt symptoms ana iiiagnosis of t enac iiiseas... rags I QL Y_ Tel: 1-800-387-4064 or(515 home e-mail ne-w,s pr MS, about Special. health rec►p us Pediatric/Adult Symptoms of Celiac Disease The pediatric/adult symptoms and diagnosis of celiac disease varies among individuals, as children and adults in celiac clinical studies have shown. Celiac disease affects people differently. Some people develop symptoms as children, others as adults. Symptoms may or may not occur in the digestive system. For example, one person might have diarrhea and abdominal pain, while another person has irritability.or depression. In fact, irritability is one of,the most, common symptoms in children. We distinguish between classical symptoms and .a more recent recognition of Celiac disease by secondary diseases due to undiagnosed CD. Classical symptoms in adults •. Recurring abdominal bloating and pain • Chronic diarrhea • Weight loss • Pale, foul-smelling stool • Unexplained anemia (low count of red blood cells) • Gas • Bone pain • Behavior changes • Muscle cramps • Fatigue • Pain in the joints • Tingling numbness inithe legs (from nerve damage) • Missed menstrual periods (often because of excessive weight loss) • Painful skin rash, called dermatitis herpetiformis Pale,sores,inside the 'mouth, called aphthus ulcers , Classical.symptoms':in children' • Delayed growth • Failure to thrive as infants • Seizures • Tooth discoloration or loss of enamel Earaches Anemia, delayed growth, and weight loss are signs of malnutrition--not getting enough nutrients. Malnutrition is a serious problem for anyone, but particularly littp://www.elpeto.com/simpofcd.html 5/9/2006 Complications of Celiac Visease : Nutnent maiabsorption ana 6ympioms of k-,eiiac uisea... rabe t vi z . Tel: 1-800:387-.4064"or 51. T,:F home e-mail nears products about special health recip us Complications of Celiaic Disease in Adults and Children i I There are complications associated with Celiac disease in adults and children. Damage to the small intestine and the resulting problems with nutrient malabsorption and symptoms of celiac disease put a person with celiac disease at risk for several diseases and health problems. • Lymphoma and adenocarcinoma are types of cancer that can develop in the intestine • Osteoporosis is a condition in which the bones become weak, brittle, and prone to breaking. Poor calcium absorption is a contributing factor to osteoporosis • Short stature results when childhood celiac disease prevents nutrient absorption during the years when nutrition is critical to a child's normal growth and development. Children who are diagnosed and treated before their growth stops m y have a catch-up period. Gluten Free Diet for Children/Adults Suffering from Nutrient Malabsorption and Symptoms of Celiac Disease A gluten free diet for children/adults suffering from nutrient malabsorption and symptoms of Celiac diseaselis recommended. Read More... • Dermatitis Herpetiformis • How is Celiac Disease Diagnosed? • Screening of Celiac Disease • Treatment of Celiac Disease • The Gluten Free Dietl • What is Celiac Disease? • What are the Symptoms of Celiac Disease? I i http://www.elpeto.com/compofcd;htmi 5/9/2006 i I San Jose.CA 95133 , X800)28g gppg Sacramento,CA 95834 1 (800)952-5691 - - • I 0'-f305860 1001 Acc to No. GILLIAN,DAVID STANISLAUS COU= PUBLIC MZ2057432 33, 04/20/1971 09/01/04 NG M SAFETY CENTER 09/02%04 17 :16 2 O'0 EAST HACKE TT P-P-tad: 09/10/04 00 06 HART #: 576671 MODESTO, CA 95358 a&-MpWbd: CATION: PSC I 114 COTTRELL,AKA sem: FINAL 209-525-56721 Reference Units PS UE TRANSGLUTAMINASE AB IgA TTG AB, IgA I >200 ! H Units NI -_•— NEGATIVE: <20 WEAK POSITIVE: 20-30 S TRQNG.-_P OSITI VZ_. .. Anti-endomysial an ibcdi_!es (EK0 are highly spepific and sensitive markers fpr celiac disea,se . Recently the ecific endomysial antigen has been identifie as the_pro ein crossli ing enzyme known as tissue transglutaminase ( G) Tissue transgluta ase is mea ured using FDA-approved ELISA. This -- method Pias- improve- specifics and sense -i-ty-compared-�o.•."thE immunofluorescent- ased .assay. 9n g Detection- -of--these .� bodses- s--an azd- n is osis of certain- lAxten sensitive enteropa fi.es such a celiac dis ase and dermatitis herpetiformis . GLUTEN <I0 .35 <0 . 3S SC CUSS 0 IGE SPECIFICkiN-VITROiA LLS GEN. INTERPRETIVE GUIDELINES < 0 .35 0 NEGATIVE 0 : 35 - 0 . 69 I 1 POSITIVE WITH INCREASING 0 . 70 - 3 . 49 2 LEVELS OF SPECIFIC IGE 3-59 - . '_ - AND-- GIE--SENS3-Ti-VI'TY -.._. .... -- .:._.._ ..... 17 . 5 - 4S . 9 I 4 i 50 . 0. - 95 . 9 5 - - - -- 1 i �-�° ERFORMING SITE ------ -------- N7t - ..Nie3�ola ..Ir�stiut ,-3-368-C)�` a-Hv :-; -Sam tan-Capp CA-" 92-6-7.5 ..... - R.A. Reitz, MD- , 800-6-2-4 57 SC - Quest Diagnostic , 3714 Nort • ga.te Boulevard, -Sacramento, CA 95834 Gerald-.E_....Si o --IIS-_�-ll_..LB �-452-5F3L_ LAST PAG: .OF REPORT • i � - �( �-. - HT1.;; 57432 GILLIAN,DAVID. Y%F.QUEST FOR MeblCAL CARL NAM "x�'/ CELL LOCATION BOOKING 0 i tj� 17L. BIRTH DATE. REASON (8E SPECIFIC) INMATE SIGNATURE DATE The Inmate Is responsible for knowing the=nG on the rmmm aiclle of this form:. do not writ>a,, i i t 4�I R1 �1 .Q is �ruc�� far�rx�>GQ pATE:. ..' TIME LM r y. a. .v ,l. _ •O tri •1 V f +.j , J_ �7 Y•7 .ice .��.. r-a 7� - `v •"f�'� :lam' id r 77 .: ':.' _..•.-. �'... -... - ' PULSE C//.0 .. •� . RESP. 22 4110� -30n yi%s'.r�Y�-1 :.�� i'2`.�" "f` � 'w.<.: !: -.'r�Ai.(i J; 'j Y.. .�� _•.r:^.,;.•• �,k,�. 1L i�1y r :��:' �.ti. :� :rte. ':i..r�•. - i Y•- 'Y. tAN'(ORDt , mos,Erc.j �:'� : j . PTHERX J i 31on3tur- f, / / Time Date OU OW UP CARE i -_---_--- - _-- �x _=i� � �_ ---- _ __ _ i . ------------ - ---- --1- ---- ------------ --------- • I - -_ _ - _ ------------- ------j--------------_�- --- -_��.--- ---- -- - __ -- --- - ----- - - -.. . . _ _ _ I_ _-_ _ - _ _ Contra Costa County Detention Fac lfies SPECIAL DIET ORDER MEDICAL ❑ RELIGIOUS This form constitutes an order to implement a special diet to inmates of the Contra Costa County Detention System: INMATE NAME: j;( i-! I r--N\ 1.�� 3t f� DOB: 4 C} Ct ISSUE DATE: d f -7 Ufa " OW wit WWW a'n MODULE: ��, c BKG.#: ,; '? :�r_f i EXPIRATION DATE:4i (:�j_�_. F m days unless renewed Type of Diet: 1. ❑ DIABETIC DIET: 3. ❑ LOW FAT DIET: 5. ❑ DENTAL SOFT DIET: Soft foods to be used instead of chewy or hard foods. Extra portions of liquids are to be 2. ❑ LOW SALT DIET: 4. OTHER: provided with each meal. 6. ❑ DENTAL LIQUID DIET: Total liquid diet. No solids. Extra portions of soups, juice or punch, milk and food supplement shakes to be served at each meal. 7. ❑ PREGNANCY DIET: Regular house menu to be followed. Milk to be added to dinner meal. A p.m. snack of one milk, Follow the approved alternate diet menu pattern as two slices of bread and 2 oz. of cheese is specified ran the Inmate Cycle Menu for Diets. 1-4. to be served after the dinner meal. 8. ❑ REUGIOUS: I have reviewed the Medical' /Religious_ needs of the above named inmate and find no reason to deny it. Medical Approval Chaplain Approval B.A.S. Review I DIRECTIONS: The diet specified will be approved by the signature of the Medical staff or Chaplain and then forwarded to BAS.for review and distribution. i Check the a0propriati type of diet. Any questions regarding the specifics of each diet should be directed to either the Medical staff or the Facility Chiaplain. Specific guidelines of these diets are in compliance within nutritional requirements of the County Oistician.Minimum Standards,Board of Corrections,proper medical practice and/or religious beliefs. Distribution:Original- IGtchen;Copy- Medlcal/Chaplain; Copy- Inmate;Copy- Inmate Booking DET 066:FRM Rev. 8/29/94 i j -- - i i --- -------- -- �- -1- ---- -- - _ i _ _ ___ ___...____ __._______�__ _�_ _____.__ �______�_____W_�___ ____ _____ _______ _ _ --_----- -- - ------------j---,_.....__ _---___.�._.__._ �__.-_.____ - _ _---- --...--- ----- -------I--- ___--_ -------__�:._.___�_�..��_�____---_ j ----------- -- ----------j----------�� __ _ �_ -------- -------- --- ----I------ -- ----�.-�-- _ _... ------ -------- - __ ---L_. - - -----------•--------- ------- - -._.. .._ . -- -- - -.. _. _.. -----I---- ---._ .._._. ____._. _�____._�__ .,_,�- --------- i -- --- --�- ---- -- ----I..------- - _ --------_ ________ ------ ------ ---------- ----------j- -- ------ ---------_._�� :i: _- ---j 1 CONTRA COSTA COUNTY DETENTION FACILITY INMATE REQUEST FOR INFORMATION MEDICAL REQUEST = ------ i i To: K,-fChe.n BtJ I CA From:QI iii C'?I I f I G , Bkg#-X()D 502 5L1$L1 - -- t t tooe> -- -- - ? Date:1�/ 21 / US Housing Assignment:'1g Kenn 2;� s ------';--�; Check One: Request Grievance ) Appeal ( ) Other - Request: 1 hir oc jr ordef gid. g Y ` n/1 f�` L t r +J My C2'IGI t�iSrGSP �2'(�TE�f1 I. t'�lt.pd in i,'If1�l1' iiir► _'1f)�!wef?�� ;A1f18cJ .3c. .rle eve. modi ►et'ood .5kfch 'i'1l'!t' let o fur: o CXr e,&t •>4'.^.fiS i,ri,:l?'- },7t (l 3i! tf,l '6it!I r,fir PIlle, A 1, :I �... •Y�, j 1 � ` r ?n:=r 's i� .r �. S..,l e % bee,,, t"GA e( Mu C,Q;?O,cj (.11 i%f (4.j r (Jedi`Y1�i;�� rlii' �l.%/C'�C ��L�.i :-v+if�2� �ts a� � c � T�'f'c . �..tjia l!:a\'_.:�1l:f. .�✓`''.<, i r , '+:�Fre'i.'�' ill v 1/ 1 - 1- Date Recd: it of Rec'd Bv: M tN1LLf- ' Routed To: ANSWER: ( ) APPROVED ( ) DENIED-(state reason) ' To Acc Vim^^ !� p. - \ ] t By: a e: / Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking _-- !j± DET 024:FRM 1/2/91 1 1, JF t( f I INTRA COSTA COUNTY -DETENTION FACILITY ( ) INMATE REQUEST FOR INFORMATION (�/) MEDICAL REQUEST j To: Ea-_111-4 Cjff'Ir))Gi 1zC From: )-yil .ii Ilium Bkg#QQL1502 WN i. (Doe) Date:J / 7 05 Housing Assignment: 78 Room 20 E Check One: ( ) Request Grievance ( ) Appeal ( ) Other Request:For -jy,.or AR on. t '/z !.,,ezk; .1 1;)l; 0)-h:::::kll,; ,. 'i'.e .)1�:1', � 11— f1�._�1.•l ? Jtf ;.' l.) :1i,lil.,_ ;'7 .r;..' !1"✓ i::f f :1� ,,;r i' L ' 1 ;Il^„�l1'i1 �li'il�rtll_V !;'a'��: '.A: �lJi :'( :t1= 11Li'� �t ii':c?4' �'r'!� .,:^,�1 i`fi•• '.'i:.i�.,t,i f);Y: �l�t�i t. li•�i i)r"li il:'i�iiiPlci �l'iifi, iit ii'i:Ji' 77?' , :�i ri• r,'l j ` Az i;^r)r{ iI;)il r illi!"i!1 Why 4i:f,:� i iil lcl; fl"A r7 j Q: e- 1,) n) I I i'iiilrl;7r .,j)r ?I�i',T _�'i� i:; 1•:Yl�:f•r •ril fi;1r��V y . Er ik:`(:Yl(•i1P.' i' Fl•"ui ;i('1 �,,v br :K r,ti'I. r:,(ii'_h T / 1rL)r'i ,=.i(}. a-it)d . I �. :ir:h.Ll I:,%ltrh I i,flil,7( "�.II�i"!'�i(Y It l]!1 �f�J S!ri.i)t't��i•I �?1'� ,r7 r:7�7'�%1 � .. . Date R Z o3' M 6,,046 � I Routed To: �l l Z- j i r ANSWER: ( ) APPROVED ( ) DENIED-(state rel on 4 (fiL ZEc. ►�S Sy �Y1 << 0 V_lfo tZ . (l 1 16 } J�;�A`art"+ Ak-.,,V`T _`� By: �;_�_. Date: Pink:Kept 13 Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1/2/91 . ... ... .,- ..y:n.,'�r'v iQ:�S`!•E4.,.��?Jr.•_:r.r.�, �i.a;w^ .. ,... ,. ., ,�"w:,-?i.,:Fa:,.r;:..::,". "Yniy::-.:+r.•}• :-.-!•'-.L.,�. ... CONTRA COSTA COUNTY DE ENTION FACILITY - r ( ) INMATE REQUEST FOR INFORMATION (,1)MEDICAL REQUEST 2J-7 From: Dwi rl &11 1 Qi -,,� Y ! Bkg# r. � r "> Dater_/� / (i5 Housi(DOB)ng Assignment: 20 Check One: ( ) Request Grievance ( )Appeal ( ) Other Request: t -,:,Ta� f,V �Tgi1 AQ hrC.k t0 mr Gnnar,l T INrr11' ►/!)1! ) l'r�r�)fi�i'11i T fi'zt 'tile ' �11•t:� ,'i ,':rl,P.'fyrai7l"; �1(:r(1(i� 1'' lri�rnti 1'ir:��li i i { ((�11_7. /l )) ( 1 Ir�:/.ttt!'�ITTI: ,16s h, h(", l"1Pi'!woe OOSPL?14 (fit%�IlTt% P �"r I' iu!lrk� lwf, (Called ri lUi=.;J1•^di lil4',I n TflaJ hliJir m :U�r�h—L(j�l � �'f �i i' J i� � .�i l: i .� 1. (a ►r ( r Ri - 'If `a Jt�(\i �l'1,%la�. � �1•YiL. r1 nK�2j -t�i_LL/l'11' '1'�i1 t iifn: Pi :a'.f (_Gf),%o TPP-4 (` it i, 1' i1ri �i,•�E'er r.A,-) i ` g a ,I r : 1_ knc,% y!iu ore s.e.t i{ r -F I�. UlrJ�,,Ald[AP llf',Iji� I—r_r + ht `-4N,,i t) ULd+ 011C N .'•i r)i I I... .. , AejV— Routed To: AN•WER: ( ) PPROVED . ( ) DENIED-(state reason) i Gt, `ll/ /e ��`l_.QS 14 y e Y1/1 �,kit S fie: /;?Iz ; Pink:Kept by Inmate Yell a ty t m White:To Booking DET 024:FRM 1/2/91 I i •I i I I CONTRA COSTA COUNTY DETENTION FACILITY I ( ) INMATE REQUEST FOR INFORMATION MEDICAL REQUEST I To: 1)) From: 't'Z;J %i Bkg# �:i. (DOB) Date: t / / i'i Housing Assignment: Check One: (,,-+Request ( ) Grievance ( ,) Appeal ( ) Other Request: i hilI I)'-:(1 :!I��C i i !%} i-:), d1 I :fil.''V� .'J1: ,�'/. li )..I r.') }I�/ �lrl L. 7-{11./'i/1 % %)%!.�/Ji/I'!? I /y IJ I/J /' r JI);- lily I);v �vL: - t ,:1 ti l:: 1 f)t-ii t�.)T'�:}:,;,.ir t Y,1, �1 i ;��' 1 i.. n !:J i4har (Jd it Y1�/'/Bili h /h Irv/ e 1 u! lw) 1 i`1;:J/! /i),. r !i'r"' 1 05 I Routed To: ANSWER: ( ) APPROVED ( ) DENIED-(state reason) i �'. n a e s ` 3 MedicalI By: Date: ! � / 1 •�. / _�-.. Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1/2/91 ; I '� ,C-'" 4xU�F�K:! _ `,.„++�., ,;' X;4i f-t.,;C•.:'"I,.i �., �o'rup' '"','.?t r:�rva32'. +:{?J•' 4• - r :v - •is T Ar: T' 1 CCI:NTRA. -CCI C� U�N DET`EI!�TTION FAZITY w. Y, •i. '+t ( .j;INA+tATE REQt1EST FOR IN .DRMATIQN MEDICAL R QUETb. ST`'. p� tt •:5' t :• � t '.i i'. ' . (We) Date : ::,' t Nousin Assign: a Y: , Check ane: Re uest' Grievance:' A :(.:) q ( ') (::) pReai ."f1� U�.CJt:,'�f, ,P• r: "i'ti{C .Ya �t' *`:� �-f-i` ,�}. iF.� �J ��G'';:?.t. 'lys' __... ... -t t• �v }° - :li`�'� ;k•�'i'r�• '.�t.'*t•,^-^(^Z';:�•i:-. .�1 t•f..i i�,^'.'#•t.f':''' .C,t:l�' •`f.L' �'}�'�';I)'.,C lt`Ii J.{:e'i..f.• .!n,-7,; ..f'�:`' ..r!' •L,J �r1'S.i.'' ,.lf•'' :7. �'",:.`':"%.:�,•; .L". �`,+i,d -°:i :I'+''f.,. -�i.• '`:�ti,eaf. c'` }t, -, f. is .rrTi.i,?Jl•� .�f kY#l..;ts's�T�� .r `t t%�'''•�itt'.j:f•..l..tr:'�Fi= e•t".,:Y�t. �~F"c'itt`1:;.:: .d». ':x':.r�•l:''!' .t. ..fa .=} •s...l nl:: �<r P. 11 C ±ti '.d'�, '4��;'-) tfF �>-�i,�l �tl:r' r•.. `.�-� .'k`; �.,:.'�'T'. }:a.k'9:,'G:it�'�}!•;;G..i...�«.i.l: -#...tt 'YE :-r�: .t.�: �i?:fl'`.,f t;t'. �;..i r.:�''`�I.t..:._:- `,:5't,' -_.}_...__. .. . _t .y:-' 1 ,SFr`,-�• :.�,,'_.Y....p•-• ii: .r� .3• f ♦.' "J: :r{:.ir`L'' t`iir.:l�� •�'�.>"?5. 'a 'Ti1:'r2A;. } - t'@.- :�:7:- a• '�. 'i` '.t-�:`�� J/!.. .:bri- +h'��7�/f��if•t.(.�}f'•/.rc ../rA.a'.�-",' 3 .ii,•ar,� I ;,,r .t'. •�•ft:�d• .Jj�;..!:' '.rs, ;<t:F �;i� .•P9 y fr eA 57 �' T, •.? {_ R t f` air ed, o, - Y t .1` �`ANS• I AP � `DENIM.( •f` on'� Esta e_`ceas �'; ..fit;. : J1 }: F,� , X 1,7 14 .Pihk:.Ke t'b inmate Yeliow;Re,l 'to:Inmate' White: fo Bookin +' bk`t 24:'FRM:•164 : `'' '`•. `:j.;' t: -'r t: 1 I . I "ONTRA COSTA COUNTY DETENTION;FACILITY (,A INMATE REQUEST FOR INFORMATION ( ) MEDICAL REQUEST To: From: Bkg# j=2_54n Date: / N O� Housi(DOB)ng Assignment: 18 Ronin %x )q Check One: (./j Request (-;)Grievance ( )Appeal ( .) Other Request: „ I I cr►. j_bLrtlf+;,, haje fe-0j) romf4je4e e II11 'Surhi; nes 00i beliP-ie rneed a SWlzirld;ef, IiibralbME krA 6a- 6 n idditwrl reinn,IiuniA4 Ile L4 iifae T dam iAed ' pW i e>rP b,dieh. T�is 04uep ONLY ,_,i t� CAS. �l uh f rill 4 11 Jilt SG 10J aV e. neeralk A e C, ni', CDJI SOPP �QI�Yt?JffiCIT-t dt Tr,� ��G��G 1�tOQrh�Oa PICC@ o !'X,P�A�. 1111(+ hifr. en lA10Phets Sf.�/ be- (._44r_he.c 46" I O /l/ . i Routed To: ANSWER: (ROVED . ( ) DENIED-(state reason) /I--/1-17.4 By: Date: Pink:L2T,F t by mate Yellow:Reply to Inmate White:To Booking DET 1/2/91 I I I I I . I i _ - - i_ _ - - - - -- - - �' xh� b�f __ _ __ -� 1� - - - '� --- - _ _ _ _ - - - - • - � -- - - -- -- -- - - -- � __ _ _ -- -- -- -- --- - - -- _ - -- - -�-- -- - - - _ _ _� - _ - i i CONTRA COSTA COUNTY I DETENTION FACILITY (.4 INMATE REQUEST FOR INFORMATION ( ) MEDICAL REQUEST To: From: . .Bkg# �' ,. / (DOB) r Date / i7i Housing Assignment: I l Oil Request , Other APPealCheck O ) Grievance Request: -L til '> i iri�'IG/Y! l w .:� � ^• >~11 vtl�l y ;ti,, *. . 1..,�;f -... iLr(ri .717. y'::r'I° ililll;?t`'' J_ r_;C.. Ti�.f:�;1`rii;t��• � :r.'1;� ��1:.„r!��:�IT%L i!1 ;):}�.-..! .':i: t.:�/-',r7 ."i i s . _ . .. - _ ::;i�::: i' :>�'•� .,ii%�,� r'1�� J �i rrJ.)�•'rl: .11 v'' i�i�. %JII T�1 il;)%" . .a.. . _. _>(lfti If' Y'1(I ii-I 'y:� i'):'1 fh/i iti ;. ��'s::a',.� i. i l.r7 i ,_af”) c::+itT _ �r;:"rt;'f f� ai!:� :'�///i 1;� :.�11��l li�t!l�%.r[1'E"� ''�: 'ii � �i+'1��'.r .'.+.)7`i .:r..• �y Date Rec'd: O4/ Z 3 / Redd Bye Routed To: ANSWER: ( ) APPROVED ( ) DENIED-(state reason) l fi -ru �G t S5 u. (rrl7) rart�l1 "? 5,fCjr>U XA By: L C�✓�---- y Date: /Z- / Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FRM 1/2/91 I i