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MINUTES - 04102007 - C.16
CLAIM l BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 10, 2007 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), given Pursuant to Government Code AMOUNT: $609.54 MAR 0 6 2007 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: NIGEL WENDEN COUNTY COUNSEL MARTINEZ CALIF. ALIFCALIF. ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 06, 2007 ADDRESS: 208 DOVE CREEK LANE BY DELIVERY TO CLERK ON:MARCH 06, 2007 DANVILLE, CA 94506 BY MAIL POSTMARKED: MAIL POSTMARKED MISSING FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MARCH 062007 JOHN CULLEN, , Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of S ervisors ( his claim complies substantially with Sections 910 and 910.2. . ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). 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 l.3). O Other: Dated: 3—&—o7 By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER! By unanimous vote of the Supervisors present: (1} 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. J Dated/�o JOHN CULLEN, CLERK, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. Ff you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that t. am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service.in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ,'�4!ZOW,7- JOHN CULLEN, CLERK By�� eputy Clerk �r 208 Dove Creek Lane Danville CA 94506 Tel: 925-980-0639 ctFR MAR � 6 �UO/ February 28, 2007 KB�ARO CO ARD Op RA C STA�� Clerk of the Board of Supervisors Room 106 County Administration Building 651 Pine Street Martinez CA 94553 Re: Pot Hole Tire Damage Dear Sirs, I had submitted a claim to several places in recent months for two blown tires as a result of an excessive pot hole(over 37"long) on Camino Tassajara and have finally identified which authority/county is responsible. The public work dept in Contra Costa have pointed me in your direction Please find included a completed claim form along with copies of the receipts to verify the amount being claimed I am claiming $609.54 for the cost of the two tires, both of which were as new as the car itself is new. There were other costs incurred in this incident but am willing to absorb those assuming the costs of the tire replacements are covered. Yours Sincerely, Nigel Wenden „ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal properly or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the -name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. ■■■■!EeEMERMESSE•on t■■ on t■owns C n ito%lUSttttttit1EG MIR ROME■atlt.tt�R■an tEsettL to MI RE: Claim By: Reserved for Clerk's filing stamp ) Against the County of Contra Costa or ) District) (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ (1-07 . .SU- and in support of this claim represents as follows: T 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) CO X_r” Cc&-759 CC)0�.51y I How did the damage or injury occur? (Give full details;use extra paper if required) Orr z'.*4 ;e R;7' ��c��E oiv Gd i„�c� 7�ss �%2R —z r»i s�✓v�r�s 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? z Srz ND Lis _ W'S G� y �c S'w /V 5 What are the names of county or district officers,servants, or employees causing the damage or injury? 6. What damage or injuries do your claim resulted? (Give fill extent of injuries or damages - -claimed. Attach-two estimates for auto damage.) j y/c� N�� 7i/G�S' ; ��11c'� C:c,/-�-i/Y�./� � Tvw.�G t- A�X'��1/•��c��� 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) i✓r/!/cx�' ,�}-��.9r.<-x-�J kn. Ti.2� e2E�c�c���.5, FX C44 bow ./S dV6-AD- 4et 8. Names and addresses of witnesses,doctors, and hospitals: (AA6-11/0,--- tAl,, =Wa:i+ � 9. List the expenditures you made,on account of this accident or injury: DATE TME AMOUNT U 121/ -77 Lei . ■■staaaa■saasaatatasaaaaaa"tmanna aaaaaaaaaataata■aataaaaa■aaaataaaatassaaameaaKansas at ) .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) 2-09 -burr Cir�L� (Address) Telephone No. }Telephone No. 72—.5- --'F4 37 ■'s on am an as R a 2.2 a a as a a a am SIR t a a ism R a a a a INS as a a[a a It an a a all on a a a ass a a a am an SEEK a■t a ass no t am at 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. ■Enna EXERNARNMEW new BREENa a IN mug Box s a■a s a s a a[s a a[s a a[[[f a s a t a s a s s a[s t a t a[MEN was a a s a t a s s 1 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. NO REFUNDS ON DEPOSITS OR SPECIAL.ORDERS NATIONAL CUSTOMER SERVICE PHONE#800 321-2446 » , .. »..:. »..... CUSTOMER MUST PRESENT COPY lik:.i? R.!!' ::it:ai i Y4fAVIL)IN OF INVOICE FOR ANY WARRANTY r: lfJ{,.� 1.:1.11'I!.1''l[.1 t'tf•-Ii`tl..tl`I ?FII`! ICI II Il.11�i7 CI-4 -.:}.....L,:}r {:} 4'::!t:::::!i .:}::Y::!....::' !l!JI!J .1.1'1v01.Cl.{;?fT J.--J.41I!'i'413 Pi:tl:IG-) .1. !::.1111:);1 .1.""t.':.I.•'4 1...1:` :r i. "'C` F...11Ail-I 111 Nov 2i, H% i i'.36 am Wt NOV 224 26K 5:33 PRI :i C):1.(J i t:) iS i"t:i.I:) 'fc) Pl.L4aL:.l... WI:%I%I Jt UJ 1;.1'111!::.11 ',%Q'!'1i; LUUbt 11Kt L..J.i::;: 0 ULIT: 19 6,.i r TD;: Hi"1c_:�_'�r,r' t 1 .1.V',: LHLVIVIIIIil+r:irwli~ Sism Peck Fa't'e 8 R f Description Parts Labor FET iota! 214 TiNiUNST i.00 iNlt iELI(N F225i45R11 PGLLI PklriAtl 213.00 0.018 M55 273.00 21.4 U J ILBBU I i.95 TIE 1'O0,I & 1s!•ILHivCt 6 VALVE SIEi'i 0.00 1:!.17a &a ilii 214 LbTiSF 1.111lu I m lint StftVlLt Futi%i n.i Yl.t �.i9Y1 19. 6 ** FKtt Kt-bHLHYt Lr4U **tKtt ILKt KUIHIIU1N5 **FKtt FLHI Kth'HiKS 2i4 tl'iVI i.06 ENV. DISPOSAL TAX httt FOR TIRES 19.00 i.75 0.00 1.13 214 LIST I 1.00 DISPOSAL !IRE DISPOSAL FEE 19.60 2.5EI 6.06 2.30 214 FSLF 1.60 MSL-FRONT 32 E7.H;9 a.it l7. g 6.00 214 FSLRi.06 psi EAR 32 . @;&3 0.F4 U.da 0.019 214 1 ORGUt i.06 1 GRGUt WA 0.00 0.00. 0.60 0000 214 LUtltl'Il t 1.06 1'lFE GR 1'sltiRRD COU•'UN F'KA& REVOCT10 0.6i -20.190 0.!90 -20.00 V1bH/I`AH TEK ARD LU 4 ********43821 Exp.Date - HUTH AmO!tflL i294.77 1.11 1,X"lal't,_4 .....» ...._ ....................... .....................»..............._.........-..................................... } 1» fxr :lzi.0 L•"J., t.J0, l!J:,!!Jt!J 7-.; W., 00 1 i.-ki7{:)Y';: t..!'1<X1t{ fry 'nLtI7'G(:)'G<t.l. y� I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF ANY INCREASE IN THE ORIGINAL ESTIMATED PRICE: X TERMS: (NET 10th PROX.,UNLESS OTHERWISE SPECIFIED) PAST DUE CHARGE IS COMPUTED BY A TERMS ACKNOWLEDGE, 6E& ED B "PERIODIC RATE"OF 1.5%PER MONTH ON UNPAID BALANCE WHICH IS AN ANNUAL PERCENTAGE RATE OF 18%.IF NECESSARY TO INSTITUTE LEGAL ACTION TO ENFORCE COLLECTION OF THE AMOUNT DUE UNDER THIS INVOICE,BUYER AGREES TO PAY ALL NECESSARY COSTS AND ATTORNEY'S FEES. X TIRES UFFI S RRAKFS SHl)CKS gTRIITS ALIGNMENT NO REFUNDS ON DEPOSITS OR SPECIAL ORDERS NATIONAL CUSTOMER SERVICE PHONE#800 321-2446 _._... _._.. „ ... . „. „... _. CUSTOMER MUST PRESENT COPY ...... .. „. ... ... ..... ._. ... ... ..... . OF INVOICE FOR ANY WARRANTY r.7.t!Jt:}'rJ 1..F11`IJ.I�IU PCh•il'11.!1'd ;:�I•di�i hCi••ii'ItJi'�I� t.:h•I 'a A4;:7t:5::}.....L.:}f t:} .1.1'IvC)1C.1i:?ff J.--.I.Af VJ 0 f c. I• i.xI:l(:);; .I. Ali�'ra? J..Lf CL1!1I i:Sl!!tl11':r I::.lii�?;; .1."-.L rCa a h'W t .L""c: L..lIA:�I••i in Nov 20, H96 6:56 aal }i ye •�r :1. iI 4l �. i.l 1. i. L:. x 1•: Gut kov 204 C-15b 3:4C Pm ) ,:)01 to I c7 I u-I:,:_I... WI::.1 R Y Nit.NiA::.IH LIE@1'i:: LUUbt lith I...I`•1 I...:I.C,N in, J UttL: t9 154:1•r J.'Dis Hf%'CECH4355 Sism Yii?Cfi Part 0 1111 Description Parts Labor tti Iota! 175 TIHICHNST 1.06 iiiCHELiN 24546i7 PR!iWf 214.17;? &08 6.6i7 273.00 17_3 LBI1Lt11Ail !.IO 1!Kt NOUNI h !kkNa & VALVE Stti'1 0.50 !J.a &a 1J.K i73 LbT1bP - 1.00-I!RE TIRE SERVICE POLICY 0.00 0.00 0.150 0.6@ Rs FREE Rt-iSALI LACING R*FRtt TIRE RUIHIlUiiS "FRtt FLAT REPAIRS i73 DfVT i.58 DiV. U1SNIISFIL THA htt F5R 11KtS 17.+917 1./J &03 1./0 173 1115PI 1.001/1S1•'ubHL 11Kt UiVUbHL Ftt 0.1917 C.317 to.I717 If—30 1!3 Pbir 1..W Pbi hK'UNI 33 19.56 11.17;7 �.t� Mo1'13 PbiR i.00 PSI REAR 35 0.00 6.a 0.f�6 0.00 V1SAMI:U1tRi.ARD Li.. 8 R1tRr*vr"143tlt1 tXp.Udte - Autilii Hmunu 10314.11 ::......................................................._............................................................................. t;s:4;; til..lilt!} .:}.1.i°4.. f r 0 t'.Jt!J i...i\I:)t7'r:: .1.':Y , c'5 t:!':Jr..:.. I ACKNOWLEDGE NOTICE AND ORAL APPROVAL OF ANY INCREASE IN THE ORIGINAL ESTIMATED PRICE: X 1i PERMS: (NET 10th PROX_UNLESS OTHERWISE SPECIFIED) PAST DUE CHARGE IS COMPUTED BY A TERMS ACKNOWLEDGED$RECEIVED BY/ 'PERIODIC RATE"OF 1.5%PER MONTH ON UNPAID BALANCE WHICH IS AN ANNUAL PERCENTAGE RATE OF 18%.IF NECESSARY TO INSTITUTE LEGAL ACTION TO ENFORCE COLLECTION OF THE AMOUNT DUE UNDER THIS INVOICE,BUYER AGREES TO PAY ALL NECESSARY COSTS AND ATTORNEY'S FEES. X rrQcc �niuG�► c RRdICFS SNntr_�� STRUTS ALIGNMENT u n � ua p a ` UJ C1 'CC 5 mo Cc rx \� y <Ci ` V 7 _ } 0 woo ZWya+ WQw . 4� j 1t cc �a U UJ 0-Q Q <n 11 U- L LU <=> O< � Yo � u J V n \3a tib �s �4 y t h ZLL1a` ZWW�m maW� n y T a6Qg 6E OT LOOZ`LZ 833 MM R sk Management ,. 000 0goal p � bra GES . '. DP�y� t dam ► c� � dear � ANY ppman Wrt'H im 7RANsMtSSfOiM[F Tm FAQ +CALL -- MSR a 5 INS �. Imtdhl lb The � b I*Ma�, mo or a ar r um Qfh* win d � or i .d' `tric�o ' '�`' g r i d 97N�w MR 003 wvlzl:B LO '1Z `a�j um CIJ La V cri O0 cr �+ V cc N C>co + � NN Q � ''' s slow 60 U p csa N Q O ,d '��CQ • CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 10, 2007 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 D Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $1,439.69 MAR 0 7 Section 913 and 915.4. Please note all 2007 "Warnings". CLAIMANT: DAVID C. LOETZ COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 07, 2007 ADDRESS: 24 BLACK OAK COURT BY DELIVERY TO CLERK ON:MARCH 07, 2007 DANVILLE, CA 94506 BY MAIL POSTMARKED: NO MAIL POSTMARKED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MARCH 07, 2007 JOHN CULLEN, er Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of S pervisors (,.)/This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: -7` D 07 By: rYl�'Q 8,�,c,, Deputy County Counsel III. FROM. : Clerk of the Board T0: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: (p�( 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. e Dated:AX, JOHN CULLEN, CLERK, By Deputy Clerk WARNNG G (Gov. code section 913) Subject to certain exceptions,you have only six(6) months froin the date this notice was personally served or deposited in the mail to file a court action on this claim.See Goveiminent Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this platter. tf you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1. am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez,,California,.postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the clainlana as shown above. Dated: �!/� % �1� JOHN CULLEN, CLERK By __Deputy Clerk w BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS'T'RUCTIONS TO CLAIlYIANT A claim relating to a cause of action for death or for mA to person or to personal property or growing crops shall be presented not later thans' months after the accrual of the cause of action. A claim relating to any other cause of ac n shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) 3. 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. 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. 3. If the claim is against more than one public entity, separate claims must be fled against each. public entity. E. Fraud, See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. an KM a f a C C a a t a t a a C ata U■ ■a s a t a a am a C a C C C a Q 9!L a I t a a l a a C C Kong a a a l a r a a k a an a a a a I a a%a a I RE: Claim By: Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or . ) MAR 0 7 CUU I District) CLERK BOARD OF SUPERVISOAS CONTRA COSTA CO. (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) io �\ .,a (-P ., r7 . v o -A ►n i 2. Where-did the damage or injury occur? (Include city and county) t o �jyt-(1rel �p �q dIJ14411 �► �E' j -011 ( 1�i�( 0440yon 3. How did the damage or injury occur? (Give full details;use extra paper if required vwU r , 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? PR 00G:( 5 What are the names of county or district officers,servants, or employees causing the damage or injury? 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages 'clai ned. -Attach two estimates for auto damae.) -Fu)v �eel ���e�e iD ©keD kk r 6Q �1 xe z OL na f o- %Ct 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names.and addresses of witnesses,doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE AMOUNT a so RMUNNERNARRM on man-ninon a it mana@ Maltz an auto 221mano 0 a Raman Ramon a R1 ) .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the cl ' by some person on his behalf." SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) ,O (Claimant's Signa e) (Address) lanv,, Ile- L-'a C?g50Lo ) Telephone No. )Telephone No, ■.0MRRag aaaRala■■aafata aaaRMaaRca[alae aatERtta aRMaaRaaR■■aMaE a■MERata■■as MORE masa aaa al 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. ■ ■0aaa5aaaIaaaaaaaaaaaam■ ■ ■m a it a a a a a a3aIaaaaaacamaaa90aa0RaaaamaaaIts 2aaa0a5aaataOOaOai 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. Seever &'Sons Tire Pros AM��t�� V(925) 3687 Unit#4, Old Santa Rita Road 1{ARtfitf 44 ti;E, Pleasanton, CA 94588 463-3443 Fax: (925)463-1094 1 INIVOTCE 011.__5191 S-10/11/1216 E--11/06/0t5: pFlge : 1. Said: DAVID LOETti Vehs V15 MW 645 24 BLACK OA; CT Lit: 5MRC414 DANVILLE, CA 94506 ifii1 !24109 H-925-639-3861E' , POI# Sism Mech Part-# PTY: Description'', Price: ; F.E.T. Total 1 0 3611676106204 1 1,@0 361@YHYHH 36116760625 RMW_WHEEL ° _ ' 5105.00 0.00 505.00 1 0 3611676063@- 1.ff0 3610Y€THH 16116760630 BMW:WHEEL SE QUO0. 0. 520.00 i 0 OSL 1. OSt tASHHN SLIP WHEELS TCS BE'CHRMD`= 325:00 0.00 325.00 ray .�.:� `zz 427, b k , ,. 4 O . M 'r 3 s fx R = F� 7 s t� �. I HEREBY AUTHORIZE the above repair work to be done along with necessary materials.You and ADDITIONAL !' your employees may operate above vehicle for purposes of testing,inspection or delivery at my risk.An: - express=mechanic's lien is acknowledged on above vehicle to secure the amount of repairs thereto.I . PHONE NO. DATE CALLED WORK AUTHORIZED UNDERSTAND THAT ALL CHARGES ARE DUE THE 10TH OF THE MONTH FOLLOWING TIME BY PURCHASE,DATE.IF PAYMENT IN FULL IS NOT MADE BY THEN, I HEREBY AGREE TO PAY SIMPLE INTEREST AT THE RATE OF 2%PER MONTH(24%PER ANNUM)ON THE DECLINING AUTHORIZED BY ADD AMOUNT NEW TOTAL UNPAID BALANCE UNTIL PAID"IN FULL. I ACKNOWLEDGE RECEIPT OF A COPY OF THIS AGREEMENT.' COLLECTION FEES WILL BE ADDED N THE EVENT OF NON-PAYMENT. PHONE NO. DATE CALLED WORK AUTHORIZED TIME BY AUTHORIZED BY ADD AMOUNT NEW TOTAL -1ANK Yt:] 1 Fled C3..t17 VG Lia THE _)PrOF?" ri TY` TO (= YOF SE.RYICE TO YOU. OUR STAFF ��11Gk�iOtNrdg � iefat�bra1pptrivllifh!irrcredsl lini�bltialih� tl flri�.lh 1 lel_, M CUSTOMER SIGNATURE SignzAture Subtotal 1350.: 00 Cash Check #4 i:JrYedi•t Ct.ard Charge ��i��:te , ..C.ax G, 8. 7512-1'% 1313„ 6 CD Its) 1.439. 69 �0, izto $0. 00 I' MICHELIN' BFGO®dricff P 1 r4Mj®® o®uw�oP ��'�CEST�/dE �t�°�S t®�� SISMSE SO MUCH IS RIDING D'WR TIRES' Tires UBOC Image Viewer Page 1 of 1 Account Serial# Reference Posting Date Amount 1430010022 3237 000025799226 11/08/2006 _ $1,439.69 Alarm Promotions Inc. UNION BANK OF CALIFORNIA 3237 ttd8/tYrp www.plxmpmmomm 3025IrMpp 5 M Lrwmnre,CA 9454S511 925-667-2200 S DATEAMOUNT Dive 7`Aid.sfR�`/o/�ti� 4,v�-CWYh,,e><y N.Ah 4.vd bQoQ'"— ---�" A aNc/ Sors 7,xe DER OF 000323711• ':1 2 100049 71: 1430010022,11 o'0000143969d' C, v _ NCSC ?L'�r:3s 0020499245 11/07/2006 1 =m <,; '--__--_—_'—_ Eanl: of the He_t >f2310U762�� a oc� : • 036 _9 ONozo -•r.i _N o 04 =3 5 0 9 https://ibb.uboc.com/UBOC/IBB/imagerequest.do?cmd=Reference&referenceNumber=0... 12/27/2006 collier canyon road danville, ca- Google Maps Page 1 of 1 Results 1-10 of about 1,033 for collier U : _ ; canyon road near Danville, CA Maps A. Ups Store The B. Crowell Canyon Ranch 9000 Crow Canyon Rd, Danville, CA 10970 Crow Canyon Rd, Castro Valley, CA (925)736-9881 (510)728-4361 C. Thomas Husnick D. Highway Department 1850 Mt Diablo Blvd#240,Walnut Creek, CA 4999 Gleason Dr, Pleasanton,CA (925)518-3330 (925)828-0466 E. Hampton Inn Livermore-East Bay, Ca F. 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C/ � Aa z [ O � V 10 ,0 am ° IL � kn U) ra 1 � o w Q w LL 0 cr fm 80 el, LU `n a • v W wl \ w CT 0 <Z-) _k � ,•� V 4, .i h 0ta ISM CLAIM elb 4 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 10, 2007 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 I l Supervisors. (Paragraph IV below), MAR O $ 2007 given Pursuant to Government Code AMOUNT: $495.99 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". CLAIMANT: DARREN CARROLL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: MARCH 08, 2007 ADDRESS: 1275 SHELL CIRCLE BY DELIVERY TO CLERK ON: MARCH 08, 2008 CLAYTON, CA 94517 BY MAIL POSTMARKED: MARCH 05, 2007 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, e Dated: MARCH 08, 2007 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors (vy"T'his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). V Other: Cam a//e S , 1717Xt /F0007, Dated: :925-07 By: Deputy County Counsel 111, FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911-3). IV. ARD 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. a, Dated � ?10 HN CULLEN, CLERK, By eputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) montlis from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. l'f you want to consult an attorney,you should do so immediately. *For Additiaial Waming See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.. Dated: JOHN CULLEN, CLERK By Deputy Clerk 03/02/'2007 14:24 CONTRA CUSTA COU."T'i' CLEPI,,, OF -1HE 4 96Z=(3 NO, 130 • HOARD OF SUPERVISORS OF CONTkA COSTA COUNTY INSTRUCTIONS TO CLA A, A claim relating to a cwzie of action for death at for i4jury to pason 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 shW1 bee presented not later dM one year after the acomal of the cause,of action. (GOV. Code § 911.2.3 B. Claims must be filed Neilh the Cleric oftho Board, of Supervisors at its office in Room 106, County Administration Building,651 Pine Stteet.kfarti:nez, CA 94553, C. If claim, is against a district governed by the Board of Sapervisors, rather than-tlie Co=t-yA- the name of tlie.District slic.)aid be died in., D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. FMU& See penalty for fraudulent claiaw,Penal Code Seo. 72 at the end of IES form sesugoods""640 104 goo a M0699006 2 age 0040406041 aga4bum eveseasso Agaves Iffebtason so as RE: Clahn By; Reserved for Clerk-'stling,st=p VZOIA REC Against the County of Contra Costa or -.0 VZ MAR 0 8 District) (Fill;n the name) CLARK CONTRA,4 cc �s TR S., - I�-�.wil A CC). 7 The undersigned claimant hereby mkes claim against the County of Contra Costa or the above-narned district in the sum of$ and in support of this claim represents ag folly ars: 1. Where did the dw,-.iage or injury occur? (Give exac.,date andhotri) 0 2. Wher did the damage or rury occur'? (Iiicludeeity and colmty) (� / � 1, A 3. How did the daniage or injLuy oomir'? (Give full details; usevxtm paper if required) at k /&1459 A 4� TAO I COW, or y caused the injury or damage'? —fit po+tO4 cau5d f le lo r� 5 What are the names of cotmty officm r district os, servants,or causing the datnage or*un:? 03-,'02/2007 14:24 CONTRA ;--01_-.TA C0LJr-1T`,' CLEW DF- THE 4 96725373 NO. 130 G0 Z1 6. What damage or ikiinies do y0ir claire resulted` (Give full extent of in cries or damages claimed. Attaab two estimates for autoidaniage.) aee( 6, e' I- & -4 % �r _ V d--r�t Oki 7. How was the amowit claimed abqwe computed? (Include the estimated amount o,,000-��r� sny prospective injury or damage.) �Wg P,� I Y iceft)v; de J 6:0 I& &de Wrw"r lex fit yre-WI o-C— a-, kev Vlte/lr 9. Names and a dress Wof witnesses,doctors, and hospitals: rl 5) �.q, I 9, List the expmldinaes you made on account of fbis accident or miusy: PAIME, /1111 T MI , ) Gov. Code Stc,910,2 provides"The claim shall be ) signed by the caiman,"or by some person on his )behalf, SEN. D hLO—TICES TCLLA=uij�yJ_.___1 Name and address of Attorney (Claimant's Signature) (Address) Telephone No, felephone No: _ L ,��) �fo? �l _ ri`� $ ��{ PUBLIC RE CORDS NOTICE: Mase be advised that this claim forni- ,, or hay claim filed with Lite County under tike 'Cort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. CON, §§ 6500 A Seq.) Furthermore, any aftacbmwits, addendums,or tuppiements attached to the claim Wra, inciuding medical records,are also subject to public disclosure. NOTICE: Section 72 cif the Penal Code provides. Every person who, with iniew.-to dafratid, presents for Allowarze or for payment to any state board or O."ficer, or to my Qourity, cite,,or district bo-,u,d or officer, slithorime, to allow or pay the same if genuine, any false or fraudulent claiin, bill, account voischer, or writing is punishable either by imprisonment in the County jail .for a period of not more than one y-.Rr, by a fine of not exceeding one thousand dollars or by lith such imprisonmeal and Fame, or by imprisollmem- in 1-iie state prison, by a fine of not exceeding ton thousand dollars 10,000);or by both such imorisonment alid fino, ' ,-� *sr�.y '.�'fir.». �`<`� Y t x� ��< a ,�,� �� �[ `p�aY•,�,,:�-cam'`t: � � � �� 'S, �Z.q, V4 :.:,: ^.3 c .e'-a •i'� .�, +s, ,"E'�` a a a.,,�- �y, �'' ..-,$r vim. '+' t'� nye` =7a ''^7'_51 --z ick ��q'5 +r• .�{ ,.�'A�r�.•r' `n Y ry` a SN e+P�-+ fin`•"_.. 'a ''fie x v 41 h.'may. i� -{� ��yn, „ it � ->: ftp �Y kF"�.• .'p` � ^TM ...Z � G's'�' � �� "e"E � " i�? 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I t( � ,a. s^t��4 `�l; � 3 c a+•'. i,< a':'r m rt`S'1 a'i�•.�+ �tLt ,,yy S"�'.y.�r� •�_-- �'�6, c 1 },� 4Y�4 tt!�t es'�•�r N 1 "�1�. 4 911 �" Y �•,"� d '1 4� I is '1 Sf +jfi k {r. v' S ! �L\ g V' f 1 �� {Y r �'.,a �La�n�� 4 �' f k � ti• ,��t H {s��t��t TTt``++kS G� ; 'ar' c a'i.l tft '`tt"� l,,rc°t� )tC`+' pd c ��3,, r `+•, P'.+a1 � ',n ;. � e- x•�' M, r> T ���. r tt .tF P i )7,6f � '' i C ���'�>f tt r� '�o'r., s t�,�i u• ..� tir r r �t i}`�i� �` t y'°-�` dJ i ar � t..l' `lk �s;',.�.`fi lr }i'�9.'k� ;,. £x } �kw7�t'tuta.••tt Y LfPq JAN �Y�:fYb�Fja G � t� f Y �j3f � � w �, Y t��n' •6 � �xt St �_, �•� o `�'f��" t `$e�.��a ..'�f #dYa',t� #--wrr �`` 1�L 4[1A�[Y� ,'�tt at. ;"tai y�yra'� ._.r'(� -1..� 1 tit tt� z��+"`' .. ?"4t,.kk ^T' #. .� a t 45 Sr '{• .., q �� ,s{ 3r'�� .C. r.a,. .✓Ai e � t<<,,.i ��f ,?� ''�1��[�'�ti, kk$ t'ft{ t.x fiPp tl t't 'J - c' e d r F � vp OU 1t•, .-'K' r�t� �a(�.t Y' lfAt kv 1].�AI i� 1P.� 1 µ {Q { — �I 4' w x ,xs � r � to IP i Y x, 3 i" AF Ax I � . F _ k k* 1 r r i �g A y .. E F f� hK 6 jp S ] 4 } } :wy44` E H� b. lb CDz •d F:'. cam► cu r .. ,e, ui _ U� d J sours pp L� © ° ppOf L�L1 � C,o cc Y U c W t s n A - 4{\ NrCD �+ OP i T r r .. uj o Op :)Cf)LU o o a Q ?� 3�- mp x ti a w �d � CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION:ARIL 1(), 2C)C)7— 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. II ) you is your notice of the action taken on your claim by the Board of MAR 0 9 2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL AMOUNT: $25,000.00 MARTINEZ CALF Section 913 and 915.4. Please note all "Warnings". CLAIMANT:LAWRENCE E. WATERS, JR. C.D.C.# F-55056 ATTORNEY:UNKNOWN DATE RECEIVED: MARCH 09, 2007 DUEL VOCATIONAL INSTITUTION ADDRESS: P.:O. BOX 600 G-DORM-BUNK#JCBY DELIVERY TO CLERK ON:MARCH 09, 2007 TRACY, CA 95378-0600 BY MAIL POSTMARKED: MARCH 08, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. MARCH 09, 2007 JOHN CULLEN, C k Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Su ervisors (r.-This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present.a late claim (Section 91. 1.3). ( ) Other: Dated: 07 By: /�_( ,� Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). (1V. ARD 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: T / -24AV OHN CULLEN, CLERK,.By Deputy Clerk WARN . G (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. Ef you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez, California, postage fully prepaid,a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. r Dated: .V/�/,/ JOHN CULLEN, CLERK By Deputy Clerk ^�1 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY ay INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or. growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one-year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. Nano■u■nanamoosso■u■sum no bosom memo nomonruonuwiaasr0amnownrasosaN■oaraaaasaI RE: Claim By: LVReA&& 9/�R5 -'TR.' Reserved for Clerk's filing stamp ) Against the County of Contra Costa or ) ` ) MAR Z7000ya (A/ �� District) 0 9 [uu/ (Fill in the name) ) CLFjgKB ' C NT, OF )co�►sor?s The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$_2_1:&Q L, and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) /a,- r-500PM 2. Where did the damage or injury occur? (Include city and county) S „ e�,b'Wir A 044,44410d 3. How did the damage or injury occur? (Give full details; use extra paper if required)/}� 0A1 i2-li4-06- +4 4bove eAA,m w4- 1�&/4 AfY6e.l1AT&Jes+eA,"+J4;L �.� � 01%_h�S�00a r yo,,,,cZ: oc.i+b56.:.��hq.�z1S/ eRrC� W" Arn/ ` k► r� esrQ.�' oa, P p of�Jl f��5 � S B"*F'Ao&t c�*rbia �v►ti, �. 4. What articular act or omission on the art o coup or strict officers, servants, or employeesi caused the injury or damage?-,7-+ a, ?,v Je . 1 - p�t e ked- �l�d,Sc,`rt'rA-P-14� d make- S; ,Fe i�.w• - e,-e, �AwraA-5 Lw 5i..rrJ' AIkeq WAS S�4F��o�, iASeA1i� /ViLtaie,611# �d 7"k+p To twee Elaspl$�r�stswff C'1e �- 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 4�'YAU_ide-A /N�a�ic��"UR iz S � Pee-/;a!A;e,�u,4 y vie-_5+ 94 d6414i✓�i�G'G��YOAJ, � /;Z `-f�0(o .4¢ �1MC` ` QP rA WIN- 6. t Who damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Alb /�jLa-0 oA^,A-q e S^)4- _,Aj � R 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ,V0,,je �Ce- Reyiwal midrea� 8. Names and addresses of witnesses, doctors, and hospitals: ,_ ED PRr�v �eR m �K L Lo 100- -sHA,) KD DA�-e,a ia-I�i-a R�9R�"1�lez Ndsp4A ED NuRS� �C.�IR/�'I�toonl�ccountU H&M Doe:— 19-� -olo �ts�o Allf�i�tl f1✓e�.. 9. List the expenditures you made of this accident or injury: ���t`�NNZLC�}o c>S DATE TWE AMOUNT a is now an Now sommom MENU a a a uses MENU a womommoss on am moves NUNN Kong of Novas Mae No an 0 MEN a woman a a 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: (Attornev) ) Name and address of Attorney ) W. d 5b (Claimant's Signature) P.O. m Auzuk. In (Address) ' Telephone No. )Telephone No. .✓ e� ■a00a0aaaa0aaaaaaa0aaaa0aaaaa0aa0aaaaaaaa0aa0piaaaaaaaaa0a0aaa0a0a0aa0aaaaa00a0aa0aa01 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. a a a a a a a a a a t a a a a a a 0 0 r a a a a a a\a a a a 0 a\W a a a 0 a a a a 0 0 a 0 a a\a a\a U a a 0 a t a in a 0 r a a a N a a a A a a a 0 a a a a a l 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. r :r _c_�v�u_���?�►�3f_C��fm_ ,�aan ����� � 19-a7 z_ dna j�'S l a 1-3.2 k w� S_e_�/t,,2A pA1Ws_W /.o lzys� r � PPP/Wpp- Ce!;P/ey y � 1 CONTRA COSTA COUNTY DETENTION FACILITY ; ❑ MARTINEZ 925-646-4707 ❑MARSH CREEK 925-646-5719 '`,.❑WEST COUNTY (RICHMOND) ❑ JUVENILE HALL 925-646-4-775 t MED REC. 925-646-1647 FAX 925-646-5699 510-2_62-4360 FAX 925-646-4254 FAX 925-646-4272 FAX 510-262-4399 CONFIDENTIAL HEALTH INFORMATION TRANSFER FORM ❑ NEEDS IMMEDIATE ATTENTION Date Summary Completed ,� j0 ❑ No medical treatment given prior to transfer ❑ Medical record not available at time of transfer. Please call for information. INMATE NAME: \l•_.._� ` ;; < . ` J a INMATE ID #: AKA: DOB: ALLERGIES: Medical/Mental Health Problems (including suicide attempts, dental needs, special diets, etc.): ID Medications: DOSE ROUTE FREQUENCY START DATET STOP DATE (including TB) r C: ?i�"\t^j +L ��Q a "z^ \ `41 2� Vu �'fa ro g -� Treatments:. • a Pregnant (Check one): TB: PPD Test: mm Date: Chest X-Ray: ❑ normal ❑ abnormal Date: ❑Yes ❑ No ❑ Unknown Active TB Disease: ❑ suspect ❑ known If suspect or known active TB disease, attach TB Patient Plan and provide the EDC: date Local Health Officer was notified of the pending transfer: Other Lab Data: Tests (circle as appropriate): Treated Date RPR/VDRL: Reactive Non reactive Yes No GC: Negative Positive Yes No Pending Appointments/Labs: Other screening test results and dates (including hepatitis).- Immunizations epatitis):Immunizations given/date: Attachments: ❑Yes ❑ No Additional Information.- COMPLETED nformation:COMPLETED BY: Signature/Title 4 SPECIAL TRANSPORT INSTRUCTIONS: a. + A Page 1 of 4 12/14/06 M076157254 WATERS,LAWRENCE E 3-B Contra Costa Regional Medical Center-Emergency Department CHILCOTT,MARISHA,MD 2500 Alhambra Avernie,P.-Tartine7,CA 94553 Patient Visit Information MR# M001320407 Impression back contusion Staff Your caregivers today were: Physician: CHILCOTr,MARISHA,MD Nurse: JSC Patient Instructions Reviewed Back Pain Sciatica, received 12/14/06 - 2100 Activity Restrictions or Additional Instructions ice three times a day, motrin 600 mg three times a day as needed for pain and vicodin two tablets three times.per day as needed for pain for the next 7 days, then resume usual dose of 1 tablet Medication Dose and Instructions Hydrocodone-Apap (Vicodin) 1 - 2 TAB, BY MOUTH , #30 Ibuprofen (Motrin) 600 MG, BY MOUTH EVERY 6 HOURS, #30 4t3 Page 2 of 4 12/14/06 M076157254 WATERS,LAWRENCE E Contra Costa R,edonal Medical Center-Emergency Department 2500 Alhambra Averne,ldartinez,CA 94553 CHILCOTf,MARISHA,MD Back Pain Back pain can occur from a muscle strain, muscle spasm, herniated (slipped) disk, pinched nerve, or strained ligament. If you are overweight, out of shape, or use bad body mechanics (improper lifting, reaching, bending, etc.), you are more likely to injure your back. Back pain usually heals on its own with time and rest. Healing can take from a few days to a month or so. Home Care • Try to do your normal daily activities, but don't do anything strenuous for several days. • Lie down and rest, as needed, in a comfortable position. You can lie on your side with a pillow between your legs or on your back with a pillow under your knees. • Apply heat and cold to your back. For the first 48 hours, apply an ice pack to the area for 20 minutes on, then 20 minutes off. After 48 hours, use a heating pad for 20 minutes on then off. • Take over-the-counter and prescription medications, as directed by your doctor. Prevention Here are some guidelines to help you prevent future back problems: • Stand and sit up straight. • Don't stay in one position for too long. • When sitting, keep your knees even with your hips and put a cushion behind your lower back. • Don't stretch your arms or trunk when reaching. Move closer to the object. • Don't bend at your waist. Lower yourself by bending your knees. • Don't twist at your waist. Turn your whole body. • Exercise regularly to keep back muscles strong and flexible. • Learn and practice proper lifting techniques. When to Cali the Doctor Call your doctor, or go the Emergency Department, if you have: • decreased feeling or weakness in one or both legs e symptoms that get worse • sudden increase in pain Go to the Emergency Department immediately if you lose bowel or bladder control. �+ (-I Page 3 of 4 12/14/06 M076157254 WATERS,LAWRENCE E Contra Costa Regional Medical Center-Emergency Depaiiment 3 B CHILCOTT,MARISHA,MD 2500 Alhambra ui Avernie,Martlezy CA 94553 Sciatica Sciatica is lower back pain that often extends down through the buttocks and back of the leg. It usually only affects one side of the body. , The sciatic nerve is the largest nerve in the body. There is oneEZ- on each side. The nerve begins at the base of the spine and runs down through the buttock and back of the thigh, then branches _,'9111' throughout the lower leg and foot. �� Sciatica is caused by irritation or inflammation of the sciaticK' ` nerve when it gets pinched or stretched. The most common Y, ' g ,a reasons are a herniated (slipped) disk or arthritis in the lower spine at the root of the nerve. M f ; Common symptoms of sciatica include pain in a buttock after a period of sitting or standing, a feeling that electricity is shooting ; r down the back of the leg, and sometimes also leg weakness, ` 9 numbness, burning, or tingling. Sciatic Nerves Treatment for sciatica focuses on relieving the symptoms until the sciatica goes away (in a few days to weeks). The condition tends to occur more than once. Home Care • Try to continue with your normal activities, but don't do anything strenuous for a few days. • Lie down and rest, as needed, in a comfortable position. You can lie on your side with a pillow between your legs or on your back with a pillow under your knees. • Apply heat or cold to your back. For the first 48 hours, apply an ice pack to the painful area for 20 minutes on, then 20 minutes off. After 48 hours, use a heating pad for 20 minutes on then off. • Take over-the-counter or prescription pain relievers, as directed by the doctor. Prevention Here are some guidelines to help you prevent future back problems: o Stand and sit up straight. • Don't stay in one position for too long. • When sitting, keep your knees even with your hips and put a cushion behind your lower back. • Don't stretch your arms or trunk when reaching. Move closer to the object. • Don't bend at your waist. Lower yourself by bending your knees. • Don't twist at your waist. Turn your whole body. • Exercise regularly to keep back muscles strong and flexible. • Learn and practice, proper lifting techniques. Page 4 of 4 When to Call the Doctor Call your doctor, or go the Emergency Department, if you have: • decreased feeling or weakness in one or both legs • symptoms that get worse • sudden increase in pain Go to the Emergency Department immediately if you lose bowel or bladder control. Page 1 of 1 12/14/06 M076157254 WATERS,LAWRENCE E 3-B Contra Costa Regional Medical Center-Kmey eitr-y Departnvent CHILCOTT,MARISHA,MD 2500 Alhambra Avenue,Martinez,CA 93553 Patient Visit Information MR# M001320407 Impression back contusion Staff Your caregivers today were: Physician: CHILCOTT,MARISHA,MD Nurse: 3SC Patient Instructions Reviewed Back Pain Sciatica received 12/14/06 - 2100 Activity Restrictions or Additional Instructions ice three times a day, motrin 600 mg three times a day as needed for pain and vicodin two tablets three times per day as needed for pain for the next 7 days, then resume usual dose of 1 tablet Medication Dose and Instructions Hydrocodone-Apap (Vicodin) 1 - 2 TAB, BY MOUTH , #30 Ibuprofen (Motrin) 600 MG, BY MOUTH EVERY 6 HOURS, #30 s RUN DATE: 12/14/06 Contra Costa EDM **LIVE** PAGE 1 RUN TIME: 2100 Patient Summary RUN USER: N.SCHJO Patient: WATERS,LAWRENCE E Age/Sex: 39/M Medical Record No: M001320407 ED Provider: CHILCOTT,MARISHA,MD ED Nurse: SCHNEIDER,JOHN,RN Chief Complaint: Medical Clearance Priority: 3 Severity: 3 Triage (Condensed View) 1704 RODRXGUHZ,AXX.KO,RJV Amb Code 2 Y PD Y Transfer? N HPI/Sx: S/P MECH. FALL. SLIPPED ON WET FLOOR AND LANDED ON LOWER BACK AND HIP. , C/O LOWER BACK PAIN RADIATING TO LEFT HIP AND LEFT LEG_ Onset THIS PM Pain 0710 10 Location LOWER BACK , LEFT HIP AND LEFT LEG. Domestic Violence? No Smoker N PMH: SEIZURE, DEGENERATIVE DISK DZ.\, GSW TO RIGHT LUNG Language English Triage Vital Signs Time B/P HR RR Temp 1Sourcej02 Sat% Source Pain 0-10 Glucose Result User 117041 -144/89 195 118 96.7 10 199 RA 10 JN.RAMA Vital Signs Time B/P 1 1-IR IRR ITemp Source 02 Sat% Source Pain 0-10 Cardiac Rhythm: User 120031132/76 93 18 97.6 O 97 IRA 18 1 IN.PITS Allergies & ADR's Coded Allergies last reviewed by RODRIGUEZ,AKIKO,RN on 12/14/06 at 1708 . No known allergies. DRUG ALLERGIES W/REACTIONS: F D/ENV. ALLERGIES W/REACTIONS: Home Med Verification 12/14/06 1711 Home Meds Verification RODRIGUEZ,AKXKO,RN reviewed and verified by: RODRIGUEZ,AKIKO,RN; Home med list updated in Meditech by: RODRIGUEZ,AKIKO,RN RXM Scripts & Home Meds Prescription Type Issued Provider Entered Hydrocodone-Apap (Vicodin) 1 - 2 TAB, #12 TAB PO Q4-6H Rx 11/23/04 PHEB 11/23/04 REF 0 Hydrocodone-Apap (Vicodin) 1 - 2 TAB, #10 TAB PO Q4-6H Rx 11/24/05 HERE 11/24/05, REF 0 Acetaminophen/Codeine #3 (Tylenol/Codeine #3) 1 - 2 Rx 12/07/05 PHEB 12/07/05 TAB, #15 TAB PO Q4-6H REF 0 Sulfamethoxozole-Trimethoprim (Septra Ds) 1 TAB 7 Days Rx 12/07/05 PHEB 12/07/05 PO BID REF 0 Home Medication Type Issued Provider Entered Hydrocodone-Apap (Vicodin) Home Med 12/14/06 1 - 2 TAB PO Q4-6H PRN PAIN Methadone Conc (Methadone Conc) Home Med 12/14/06 RUN DATE: 12/14/06 Contra Costa EDM **LIVE** PAGE 2 RUN TIME: 2100 Patient Summary RUN USER: N.SCHJO Patient: WATERS,LAWRENCE E Age/Sex: 39/M Medical Record No: M001320407 ED Provider: CHILCOTT,MARISHA,MD ID Nurse: SCHNEIDER,JOHN,RN Chief Complaint: Medical Clearance Priority: 3 Severity: 3 Home Medication _ Type Issued Provider Entered 20 MG PO DAILY Cyclobenzaprine (Flexeril) Home Med 12/14/06 1 TAB PO TID Carbamazepine (Tegretol) Home Med 12/14/06 0 CHEW TID Nurses Notes Entered by RODRIGUEZ,AKIKO,RN on 12/14/06 at 1748 PT TO X-RAY VIA GURNEY. Entered by RODRIGUEZ,AKIKO,RN on 12/14/06 at 1815 UNABLE TO SIT UP TO TAKE PO MEDS. NOTIFIED TO MD. F ered by RODRIGUEZ,AKIKO,RN on 12/14/06 at 1820 . .DICATED AS ORDERED. Entered by RODRIGUEZ,AKIKO,RN on 12/14/06 at 1905 CONT. C/O SEVERE BACK PAIN. MEDICATED AS ORDERED AGAIN. Entered by ODOM,ANDREW,RN on 12/14/06 at 1914 REPORTED TO SCHNEIDER RN. Entered by SCHNEIDER,JOHN,RN on 12/14/06 at 2052 PT UP TO WHEEL CHAIR, CLEARED FOR DISCHARGE. Entered by SCHNEIDER,JOHN,RN on 12/14/06 at 2058 REPORT CALLED TO WEST COUNTY DETENTION. Nursing Head-To-Toe Assessment 12/14/06 1712 Head 2 Toe Assessment RODRIGUEZ,AK1'KO,RN 'fro exam WNL's: Y - . exam WNL's: Y Resp exam WNL's: Y GI/GU/GYN exam WNL's: Y M/S exam WNL's: N C-Spine Prec X M/S Note: PT IN C-SPINE. WAITING ONO MD EVALUATION, Psych exam WNL's: Y Meds Administered in E.D. 12/14/06 1820 ED Med Administration Record RODRIGUEZ,AKIKO,RN Medication/IV Fluid, Dose/Rate MORPHINE 4 MG PHENERGAN 12.5 MG; Route Intramuscular; Site R Deltoid 12/14/06 1906 ED Med Administration Record RODRIGUEZ,AKIKO,RN Medication/IV Fluid, Dose/Rate DILAUDID 4 MG; Route Intramuscular; Site L Deltoid 12/14/06 2018 ED Med Administration Record SCHNEIDER,JOHN,RN Medication/IV Fluid, Dose/Rate DILUADID 4 MG; Route Intramuscular; Site R Deltoid RUN DATE: 12/14/06 Contra Costa EDM **LIVE** PAGE 3 RUN TIME: 2100 Patient Summary RUN USER: N.SCHJO Patient: WATERS,LAWRENCE E Age/Sex: 39/M Medical Record No: M001320407 ED Provider: CHILCOTT,MARISHA,MD ED Nurse: SCHNEIDER,JOHN,RN Chief Complaint: Medical Clearance Priority: 3 Severity: 3 Diagnostic Imaging Orders Ordered Procedure Name Ordering Provider Signature on File 12/14/06 1721 Spine Lumbar Ltd 2-3 Views Goldstein,David,MD No Departure Info Disposition: JAIL/PRISON Departure Date/Time: - Diagnosis: back contusion Comment: Condition: Ambulatory/Alert 1( *aP : 4 !- 'F`" Y N b . L k �� gyp.. � -111111111111111 :'1200 -"" 7"- - __"�'�'' CONTRA STAN EAL' SER1/ICES, �_ _ v " a te �DETE TION�FACILITIES j x fit, t 5I. - k x} ° t f t ,e a x �1mn— EMERGENCY DEPARTMENT CONSULTATION `t > � +.' z, ,^ a t� a� a t ,_..fit- 6 § .x , ✓4 / P `' .. , - X510 J" ^ k ❑ MDF West County ❑ Marsh Creek ❑ juvenile Hall k f Name 4` f '' DC B 1�IR# y .r p d, 3} rg.k1-1 n + -qi r ; 3110 yea - ` �` y `"'"`. e°'' � { 1. �. Aller es S S t '-4 ` r 1 _ MOdkule , { , t PernnentnrPast;History z 1Jr ✓ u �t r s t ... i 1 3v Y' r ,, �+,r. ?, 1 y�.� t r �. t t i ISAM Mme--?': " dam. 'o-E3 �.rm- ;1.- .+ „ t -., �. i l . tr c s,;,ter", '>kc. - ,F" tidit'�`.,.rW ..�a.3..:.-« ,§ 1''r :u, -k� ,+.' M i t i YS - I -11 GurrentIedications (Name and IDose)„ �' j, ;r+ ` �'� t:" R s fs �; �. $ Patient Complaint T} a d , - - ----4 ��'��� "r� ",�,�_'�_����"�_'�-' '��" '—, �� r. `' ' h - s s Y i T ✓ ,r y �t r .Fry L s F az a t < E``r-�" t r ,. 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X 4- .� }z sEr,-., ..- y,t',� 4 F•? t'c§ �k t ` _ '. r a k raj r �#- a' ! -a -:tris- '.�.`t 1 ' i a� "� 3 3 . $ �r r A c fl � �" s 4* �c� 4 is� �zRq.1; 1"+" '„, - a,..h. ,a�cr '`#- ",r"x, "'t v . _ 3Fn A�+r,.-.?`"c 8� s s' - `� �. ..'^d t 'lfl,.. - ",'?,, cw'xc .,,.�, ,.'��;r"°'S-uxr.t:,. t:3. t^'° <G-„-+`Sr. a ,�+ .v"" "-''u' Y' t- _ y _ aa�' Ays is K rrn a� .�-'�� `t 'S� '� 1y - a c -e'G ,r ..ar ..t - r+'s, +'rr as � �. ^ tee �z s.r �+,. Yrs'�F h �j "- ,. ' °.r �,r-++, 3 k.3 r"* " '"s 'x�4.-i "M ` ,r � + 4 .N10 r d - - - -d } - *3 T amri - ''4--� [ _x t F "1 I, _ 1S- x. a .:t� ,�, _ III I } 2 -.".S 1fi S '3.�. ZL \ l rK-1 1sm i - ,i 3. K w PPlan O :Phone Consultation Only �e..,' t ts, r" d z 3,a,. L z .rr ,`. zr x� 11 4 t t' y �, r s', ' i1. ..A, .a r. t Verbal Orders ` ,. : ,�..- 1. y ce J x 1 4 -� ! 3 b. Y a n 5 5 ifi -.5 .�4s' ,£ F°^ .6t" .x-•.-,.�.�,r r 4�t,-.5 r r R Lr�' w ,. .,r .v T t _ tz �ava d : v' T y* .a,.. ^" £ t �3 ❑'1""', t0 M9 DAM .N.odule a ' - C '_ric�- Y.. -' t -sem. zn `t _ : .t ' muz- e at, ya } r ' n� s'sa x n molls. 1 z. r „ S,, 5 'Sr w -. i as aG Y^ '� and- ;a`.;�• .-^.c r "�ams. a .mo- a.w 4111 TSend toEmergencyDepartment fors t 1�"a 's = c-S, +k <'�`'G- .YH "C, $ �s"`}�`� 'Pk F'- r..a.✓' _ y4 y2 4 f2 'T." iL. 6 y Date : �. Time l `Irlr�M Signature/Tit1e � � -" - " r- �" _ �i -=r � DISPOS77, ITION: O Adn�tted to Hospital - t, ;: ,+ ❑ Returned to jail , MDF Review by Tate ... t. 17 1 :_..L _- =0ngirial"Char��' - t M_ r� pi�U. Gn .. r CONTRA CSTA HEALTH SERVICES DETENTION FACILITIES"r EMERGENCY DEPARTMENT CONSULTATION ❑ MDF West County ❑ Marsh Creek ❑ Juvenile Hall Name:': ' C.:'.. ?t ' f i"_i-` DOB : �c,f 'tr t� MR# i Allergies: 5 Module: .] ( Pertinent Past History: r ti y Current Medications (Name and Dose) S Patient Complaint: 1 f i t J) i ,' .,.1 €U;, t; `, n„ s _ t Observations/Findings: BP s { P R i T 4 i' E 1 A Nursing Assessment: P Plan: ❑ PhoneConsultation Only Verbal Orders: ; ❑ Move to M Module i i , O' Send to Emergency'Department for i /:-- •, rev " AM �' T Date _ Time %PM "Signature/Title DISPOSITION ❑ Admitted to Hospital ❑ Returned to Jail 4: MDF Review by Date Original Chart Pink ED --- — --- — --- -- 4 <. .: cl U W o a a Z,- �� "CO LU c o0 O Q CL- ui ¢ o 40 qu a � . A ' 1 kP'.J ML ct:N g meq= `.� LIJ w O -N4 ° Q ®' C� 0)<o C OLL O Q cc~ m` Y CJ .�.r� �mxys �q �q. �w WH , CO I ZZ O LQ CL)2�