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HomeMy WebLinkAboutMINUTES - 05222007 - C.15 CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 22, 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 Cod es. Rj�j� ) you is your notice of the action taken krRM on your claim by the Board of Supervisors. (Paragraph IV below), APR 17 2007D given Pursuant to Government Code AMOUNT: $500000.00 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings" CLAIMANT: LINDA A. WRIGHT f.. ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 17, 2007 ADDRESS: 4579 CUMMINGS ROAD BY DELIVERY TO CLERK ON: APRIL 17. 2007 EUREKA, CA 95503 BY MAIL POSTMARKED: APRIL 13, 2007 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL 17, 2007 JOHN CULLEN, 1, r Dated: By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Su rvisors ( 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 topresenta late claim (Section 911.3). ( , Other: / G �i m r!d . i'1 �vGI iL? i7� a/: 11CC- v Q S T Q- G U b ! -tel�` Ov/7-744Gn Gur r Dated: �{�/7 X07 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. OARD 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:/�itaZa2{04W.7 JOHN CULLEN, CLERK, By Deputy Clerk WARM (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 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. lfyou want to consult an attorney,you should do so immediately. *For Additional Waning See Reverse Side of This Notice. AFFIDAVIT OF MAILING t 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 f 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:, " °24w.;;,� JOHN CULLEN, CLERK By Deputy Clerk zz CITY OF RICHMOND CALIFORNIA 6 APRIL 2007 SU 1401 MARINA WAY SOUTH RICHMOND CA. 94804 RE:RICHMOND POLICE CONDUCT UPON FINDING MY SISTER ALICE J.WRIGHT DECEASED IN HER APARTMENT,22 FEB 2007. EXECUTOR:LINDA ANN WRIGHT 4579 CUMMINGS RD EUREKA CA 95503 (707)442-8143 I LINDA A. WRIGHT,CALLED MY MOTHER ON THE DATE 22 FEB 2007, AT APROXIMATELY 11:00 AM JOKING WITH HER ABOUT HAVING HER GRAND CHILDREN AT HER HOUSE, WHEN MY MOTHER TOLD ME THAT"THE POLICE HAD CAME BY",I ASKED HER FOR WHAT? SHE SAID THEY ASKED ME IF I KNEW ALICE WRIGHT! I ASKED WHAT DID THEY WANT? SHE SAID I DON'T KNOW! I ASKED MYSELF,WELL ALICE IS NOT A CRIMINAL SO WHAT DO THEY WANT? AND IT HIT ME THAT SHE MAY BE DEAD! I CALLED INFORMATION FROM MY HOME IN EUREKA CA. AND ASKED FOR THE PHONE NUMBERS OF THE RICHMOND POLICE AND THE SAN PABLO POLICE, I CALLED THE RICHMOND POLICE AND ASKED THE WOMAN ON THE PHONE"WHY THE POLICE WENT TO MY MOTHER'S HOME? AND INFORMED THE PERSON ON THE PHONE THAT MY MOTHER HAD A BAD HEART,AND THAT I WAS ALICE WRIGHT'S OLDER SISTER. I ASKED IS SHE DEAD,IS SHE DEAD? THE WOMAN TOLD ME SHE HAD NO INFORMATION AND THAT SHE WOULD HAVE THE OFFICER TO CONTACT ME! AT APPROXIMATELY 11: 33 AM, AN OFFICER CRUZ CALLED ME AT MY HOME IN EUREKA CA. AND SAID I AM SORRY TO HAVE TO TELL YOU THIS OVER THE PHONE BUT YOUR SISTER IS DECEASED!HE SAID SOMETHING LIKE I AM ALL DONE HERE, CAN YOU HAVE HER BODY MOVED? I SAID YES! HE GAVE ME A PHONE NUMBER TO HAVE THIS FUNERAL HOME TO MOVE HER BODY, WHILE HE WAS ON THE PHONE WITH ME HE SAID SOMEONE IS GOING INTO THE HOUSEI I CALLED MY MOTHER BACK AND SAID MOTHER ALICE IS NOT AMONGST THE LIVING! SHE SAID I HAVE TO GET DOWN THERE WITH MY BABY! I CALLED THE FUNERAL HOME, AND MADE ARRANGEMENTS TO HAVE HER BODY REMOVED. I CALLED NUMEROUS OTHER FAMILY MEMBERS AND CALLED MY BANKING INSTITUTION TO INSURE PROPER FUNDS WERE AVAILABLE. I HAD TO INSURE THAT MY HOME AND PETS WERE SECURE BEFORE THE FIVE HOUR DRIVE DOWN TO THE BAY AREA. I LEFT THE FOLLOWING MORNING 23 FEB 2007,DRIVING TO RICHMOND,UPON ARRIVING THERE I FOUND OUT THAT THE POLICE HAD NOT SECURED MY SISTER'S BODY,NOR HER PROPERTY,PEOPLE WERE ALLOWED TO GO INTO HER PROPERTY AND VIEW HER DEAD NUDE BODY AND REMOVE PROPERTY FROM HER PLACE. THERE WAS NO POLICE TAPE AROUND TO LIMIT ACCESS TO THE POTENTIAL CRIME SCENE,ALICE WAS ONLY 49 YEARS OF AGE,AND SHE WAS IN HER PLACE,WHERE HER RENT WAS PAID UP TO THE 28TH OF FEB 2007,A COMPUTER A GUN THAT WAS MISSING,CREDIT CARDS,AND MONEY,AS WELL AS OTHER PROPERTY.I FOUND OUT AFTER MY SISTER WAS CREAMATED THAT THERE WAS NO TRUE REPORT DONE OF MY SISTER'S DEATH,THE CORONER DIDN'T BOTHER TO MAKE A REPORT,NOR DID THEY EVEN EXAMINE HER BODY AND A"MEDICAL DOCTOR", SIGNED OFF ON HER DEATH AND WAS NOT EVEN ON THE PREMISES,NOR DID HE HAVE ACCESS TO HER BODY. THE LANDLORD PARADED PEOPLE INTO MY SISTERS HOUSE TO SEE HER DEAD NUDE BODYI AS THE SPOKESPERSON OF MY FAMILY I SEE THAT MY SISTER WAS TOTALLY DISCARDED AS TRASH,AND NO RESPECT,AS A TAXPAYING MEMBER OF THIS SOCIETY. I WAS LED TO BELIEVE THAT ALL INVESTIGATIONS WERE COMPLETE,ONLY TO FIND OUT THAT THERE WERE NO REPORTS,I CALLED INTERNAL AFFAIRS AND THEY WERE TO CONTACT ME AND SEND WHAT INFORMATION THEY HAD AND MY PHONE CALL HAS NOT BEEN ANSWERED, I SEE THAT THE REMEDY CAN NOT BE REALIZED BECAUSE MY SISTER IS GONE AND CREAMATED! WE WILL NEVER KNOW HOW OR WHEN SHE DIED, DUE TO INCOMPETENCE OR THEY DIDN'T CARE, FINANCIAL COMPENSATION IS IN ORDER PAGE I ALICE J.WRIGHT DECEASED PAGE 2 ALICE J. WRIGHT DECEASED 6 APRIL 2007 CITY OF RICHMOND CALIFORNIA RE:POLICE CONDUCT BECAUSE I BELIEVE THAT YOUR MUNICIPALITY NEEDS TIME TO RESPOND TO THIS NOTICE THIS WILL SERVE AS THAT NOTICE AND IF A DOLLAR AMOUNT IS NECESSARY AT THIS TIME I WILL STATE$500,000.00 FIVE HUNDRED THOUSAND DOLLARS,WHICH IS SUBJECT TO CHANGE DEPENDING ON FUTURE DAMAGES,AND ATTORNEY FEES. ALL FUTURE CONTACT WILL BE MADE TO ME AND,OR AN ATTORNEY WHICH WILL BE MADE AVAILABLE TO YOU AT A LATER DATE. CERELY � 4579 C S RD EUREKA CA 95503 (707)442 8143 Cc:contra costa coroner Cc:Richmond police department Cc:attorney Cc:contra costa county board of supervisors Cc:files Cc:Richmond city attorney J� . ; r r:. +: ,�i. +IxY+xl4'.:%+YSRixf al�f,,+'an.;u�+ +u "awl�l+S stn<'. ;.s'.�y�!`l,'anq.ax�xxZ:�lrnJHsn:n.xxgrs> rlmw rm•�YnCR.i,/,•>L7nn{r+x YFrxtzKr.xcir\� _� ,.. A �r, nom. COUNTY of CONTRA CUSTA L� MARTINEZ, CALIFORNIA i CERTIFICATE OF DEATH FxIf r3 Ll dIM f "' .is:.aY xlna lan. ;..a.l I nu usuuetF J... nuar.. ,7 fi.AN . . fWF1 HT r I F .. ------ i .r sY fF v1 �u L C/1a�6 4? F 1 r I� 1 . r A vfi0 0:1 4410 I `( I I ry I Never to le' nd 02/22/2007 1 Unknown FLfCx u -. '+..'' 1 n,aA :1 f1 I } k'2M5 Y NM\l+. J nOn /Mrr w1.• ' .'C N$ }, �W.i.,M'• 4r r. al., to y ......._.� p7 r Una versa t y ducat jon L17f 1 y ryn fl rcl ,l R u nmol•i r Cc r Cc 1 94601 _.J 45 CA _ .�� r _ _..- r:iJ 1 M1L irll'IY4 S -•. J 111dA h Ir t er. S) flrl^ln r Rd I:lre CA 51n1 • ,•:'.I nl 1/•v YIYt µ4M . i EQ '�N r .IN, l M 1• .... A x.i f..V _...... M1RIMq'4 t r 1 j� Nt'LJ 13. i ki lne•r ! r>xas <<'t t J OR Y( l I Re 5 of Li nda A Wr i ghr 4 LLS I cuiming s R7 nu rka CA r 3 ' .j E 1 •:. .n _... F.rr 1 Ji'MR IMF --.... .._ - _..__ X111 r.♦..SrµllnM.f _._.. n v I. r. bafmd � .,ruFwY. ....-. I (,T }•n i IIN r ��+yy i 3 r 1 -w s s r ... c- ln�.v C 1/ .' (l 1 VP..G j rui It r.�u(ar Funeia Srtcairn FI lf4 _ 1 IF.' Y it a cJ V F?• w ) SRI Fv?N Ohl cess it nce ` I' rlvf J1� 1 'rIl fl - Tru c ---------- Con ' '.:.. ( m t r o i*os T.,) I r 3 s -a ,f r a 4 ; 1 11 i ai ......1 1 t1 pike _-... Hi. J 2017 4n• p' .._.... ...__ _ . . .._.. .... 1 u .� Q ru n )lFerten nn .c I �el !- xlvn It .... ... ...._._ _..... ..... .]YR t i w �c^ 1 c�nr > twwm ' y' wl I1J al•. es Y nz'9 I " X•W: rt N � '•' I' �i a+Fwwc wx' •• ].! /, `.h.IH 4 rr •u vlr w(• 5 C/f1 tr.•;' If.: I Illi ..J..et TC✓YSC I §_r':Hent .'h.. J F, ; r ,row a F c:ea tt �3.rA se,�ncT *ohr Ca. o f �.� Ol /it/ JOo I)1t14/2007 - � 9 k 11s✓tn Ate nus Richmond, CA 94801 L: n. r , ' .. •....v_rµ..N a-s r.. �..•,- ..,' r i1.:.:r., ra.o+re.al•a-, ,'..•.yb. - r' t TAIf I A l r.,n !' I FaI,PUTN. CE.M1 ,79AC1 rGY r r crRr1F'It_I r , OF Va..REC,0RDS, 2 0 0 0 6 4 23 7 7 r.0 ttu COSTS !qh•fy+ t A; .. un; 1'; L,,r. " .JI.1 I I rr.l r I, 1 t7 s P'.•' Q II r N;%ij Inl n Il.nl tlu.r- ti ��tiQ'"°� �` Ooh>i HEALIH ",f. (rlNl'c.A'. I Ir •.UNIT II V..'i Ort lr :;Si *'; OFFICER ILI '.1 I1II 11 1 11 �h 1 1! _11 11 U1 ( 1 � C I)i l 1 1 t I 1 7 t l I I I � 1,A •� .......... .. `_._ .. .�'. Yt[4�!�'lhYlfbf� Ll�f><IYFIYIIffraiei�.+iiii4Ji4rw.ibW:L"r'S.'�a.,�^.�.[•••.• 22 FEB 2007 I MAE B. WRIGHT, GIVE MY DAUGHTER LINDA A. WRIGHT FULL AUTHORITY TO HANDLE ALL THINGS PERTAINING TO MY DAUGHTER ALICE J. WRIGHT(DECEASED),ON THIS DATE 22 FEBRUARY 2007. I AM OF SOUND MIND AND JUDGEMENT. SIGNED, -' MAE B. WRIGHT 1924 CHURCH LANE# 119 SAN PABLO CA 94806 (510)236-0104 A A. 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N y: ✓f 1 } V�VV! 1 � ,��t �d�y� 't� s � 'r 1 b• i'�t r't '� r l ,•l) i f� r l5, 1 r ✓r a �' ✓ r a !�� a �� � r }n Ft• �✓_t(. Y y, e�S fir+�' ": r � ,.t 1 'ark '� a r� d ,� �. ,. _l� �4hY '�, t ryStl t � 2 5 1 3 f e 3 ✓ y� _, r \\\\\\VVV \\t • I LO nilll (�y/1,� J 1� i l V e'1- uj 9 qY��,° /T o ` Lu y O 0 y 0 2 U) a2. z ®c Q m o u S999_?-6E6 EOOO 0220 zOU- \J Y � 4P1 &SUNNI" Li r � � 1 \ 1� N s � 2 �� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 22, 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 D 09%? on your claimby the Board of v Supervisors. (Paragraph IV below), APR 18 2007 given Pursuant to Government Code AMOUNT: $100,000.00 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MABTIREZ CALIF CLAIMANT: LEONARD POLK ATTORNEY: .CRAIG M. BOEGER DATE RECEIVED: APRIL 18, 2007 SCRANTON LAW FIRM ADDRESS: 2450 STANWELL DRIVE BY DELIVERY TO CLERK ON: APRIL 18, 2001 CONCORD, CA 94520 APRIL 16, 2007 BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO, County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Dated: APRIL 18, 2007 By: Deputy II. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( 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). O Other: Dated: 44 0-0�7 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). (I V. 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: � *49, !JJOHN CULLEN, CLERK, By Deputy Clerk WARNiN (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 covet 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 attontey,you should do so immediately. *For Additional Waming See Reverse Side ofTltis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i. ani 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 if) Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:A/AV � JOHN CULLEN, CLERK By Deputy Clerk Af BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAID7ANT 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.) 13. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Aduutiistration 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 .narne 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 ft audulent claims,Penal Code Sec. 72 at the end of this form. man[[anQUQ[[uat■■nn a KK as anann[Kaunas uQn[t[nnuntna anlKQKQt[atQ t[[agnant[[q[■Q[QQI RE: Clain By: Reserved for Clerk's filing stamp LEONARD POLK ) ) RECEIVE® Against the County of Contra Costa or ) DISCOVERY HOUSE, CONTRA COSTA COUNTY ) APR 1 8 2001 ATCOHOJT " Am-npTJrpROMAM District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRACOSTACO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$may onn nn and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) .11/01/0 6 2. Where did the damage or injury occur? (Include city and county) CONCORD CA 3. How did the damage or injury occur? (Give full details;use extra paper if required) BUS DRIVER HIT A SPEED BUMP AT ABOUT 50 MPH' 'CAUSING CLAIMANT TO FLY IN THE AIR AND STRIKE -HIS HEAD ON THE ROOF. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? DROVE OVER SPEED BUMP AT 50 MPH. CLAIMANT REPORTED INJURY TO JENNY JENNINGS. CLAIMANT WAS TOLD INCIDENT REPORT WAS PREPARED. 5 What are the names of county or district officers,servants, or employees causing the damage orinjury? JENNY JENNINGS, DRIVER OF THE DISCOVERY HOUSE VAN CLAIMANT . WAS IN AT THE TIME OF THE17IfjoRy, 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) CERVICAL, THORACIC AND LUMBAR SOFT TISSUE INJURIES. SPRAINS, STRAINTS, BROKEN GLASSES. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) $100,000.QQ 8. Names and addresses of witnesses, doctors, and hospitals: MERRITHEW MEMORIAL HOSPITAL, ALHAMBRA AVE. MARTINEZ CA. APPROX $2, 000. 00 ANTIOCH FAMILY CHIROPRACTIC, 3105 LONE TREE WAY, ANTIOCH CA. $596.00 9. List the expenditures you made on account of this accident or injury: DATE TIIv1E AMOUNT t 11 /08/06 - 11 /15/06 $596.00 a as eamamtama a saaene*amee ■ aaa¢el mametmlataemaa av¢maa¢mmvv emeame¢!aa¢eavemmea Manama a 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) 1 Name and address of Attorney ) Craig M. Boeger ) (EI ants Signature) SCRANTON.LAW FIRM 2450 Stanwell Drive ) SCRANTON LAW FIRM Concord, CA 94520 ) 2450 Stanwell Drive (Address) Concord, CA 94520 Telephone No. ,925) 602L2727 )Telephone No. (925) 602-2727 U's yam Magnums amim Kansas as Mamassets aaels¢umnaenemvea¢amva¢ma a¢aaua¢evam emam use vaev emelt 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. m was tUna■atmala■no"a omits■ ■Una ea[m amemaatemm mmaammeeva ma■le■eeaa¢teamaaeme mussels a■vat 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 exceednig 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. L — / k _ C:3 . a . .. . . � . . \ � v i � f . � . . � . . � - � . f & g - . cf� � . ■. % 5 S \ y.a �� . � / / � ■ - oo / \ \(POD r-z, Pƒ . � A % � \ i } \ \ e ± « \ % ƒ 6 @ > # � » & _ � zl� -5 � a ± 10 o r� / rp a D s ƒ> � . � �� CLAIM BOARD OFSUPE LSO RV RS OF CONTRA COSTA COUNTY c BOARD ACTION: MAY 22, 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 Uy the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $9,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PETE OTIS RISPER ATTORNEY: MSCIIELLE DAWSOid DATE RECEIVED: APRIL 19, 2007 ADDRESS: 800 FERRY STREET, BY DELIVERY TO CLERK ON: APRIL 19, 2007 MARTINEZ, CA 9455341629 BY MAIL POSTMARKED: APRIL 18, 2007 FROM: Clerk of theBoard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL 19, 2007 JOHN CULLEN, r Dated: By: Deputy II. FROM.: County Counsel TO: Clerk of the Board of Supervisors P (,,) this claim compliesss with Sections 910 and 910.2. 1 ( ) 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). (Maim is not timely filed. The Clerk �ilr� - t.ur4}-claim-on-ground-tbat-it-was-fled-late-and_ send warning of clafman 's right-te-apply-for-feave-to-present a-late-ciairn-(SecTi n-9+F.3-)- (;Other: G(Cc.c qq (5 Dv-) ( an o- G-E 0C o. Ic or, Cha< e 'lei mn � 1 Dated: �,z By: �3'7�A�,t Deputy County Counsel III. 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. OARD 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: ZOOFOHN CULLEN, CLERK, By Deputy Clerk WARNI.N (Gov. code section 913) Subject to certain exceptions,you have only six(6) ninths from the date this notice was personally served or deposited in the snail to file a covet action on this claim,See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection witln this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all.times.herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in N'tartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: �+ o2e� ` JOHN CULLEN, CLERK By �"� eputy Clerk OFFICE OF THE COUNTY COUNSEL 6E SILVANO B. MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building 651 Pine Street, 911 Floor A,: ='.* SHARON L. /ANDERSON Martinez, California 94553-1229 _ CHIEF ASSISTANT `s (925) 335-1800 i GREGORY C. HARVEY VALERIE J. RANCHE (925) 646-1078 (fax) AsslsrAws �y POsr� COTj NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM TO: Michelle Dawson 800 Ferry Street Martinez, CA 94553 RE: CLAIM OF: PETE OTIS RISPER Please Take Notice as Follows: In regards to the claim submitted on April 18, 2007, on behalf of Pete Otis Risper, portions of the claim'are timely and portions are untimely. The portions of the claim prior to October 18, 2006, presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because they were not presented within six months after the event or occurrence as provided by law. Because the portions of the claim prior to October 18, 2006 were not presented within the time allowed by Jaw, no action was taken on those portions of the claim. The claim was forwarded to the Board for action only on the timely portions of the claims. The only recourse at this time is to apply without delay to the County of Contra Costa governed by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. (See Gov. Code, §§ 911.4 to 912.2, inclusive, and 946.6.) Under some circumstances, leave to present a late claim will be granted. (See Gov. Code, § 911.6.) SILVANO B. MARCHESI COUNTY COUNSEL By t?V4X4L p� Monika L. Cooper Deputy County Counsel Page 1 CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My �bu ess address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On �3� 2CrU 1 served a true copy of this Notice of Untimeliness as to a Portion of the Claim by pl ing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Michelle Dawson, 800 Ferry Street, Martinez, CA 94553 as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S.Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the la s of the State of California and the United States of America that the above is true and correct. Executed on 2 3,3, D 7 at Martinez, California. Kathleen O'Connell cc: Pete Otis Risper Clerk of the Board of Supervisors (original) Risk Management Page 2 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT - Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100'' day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ****************************************************************************************** RE: Claim By Reserved for Clerk's filing stamp 0+1 ) Cin kut Corcrok4-i0r✓ � rYt. �J. ) RECEIVE® Against the County of Contra Costa or ) APR 1 9 7007 eaok4t -nl CoQ2ara- rt cw , M F District) (Fill in name) ) -`°G0NTR'%00STACO .ISOF The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ �1 j 00o °d and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 3 ^2z zdd7 P oma. 2. Where did the damage or injury occur? (Include city and county) lM a1,+;ti-uZ Cour*y TRit E- /L10a'Ol e_ CO, Co. Cbu k�(. cm, 0. ,�-- ) 3. How did the damage or injury occur? (Give full details; use extra paper if required) 0,1 3--z-97 C-Wocluh M.Ajo .�10�clb?_d Ay CanV/T_r,,V �P, L��✓Qs Ont61-eo( N01*1tib 0/x-1 'Ldwu GCLrtiof MJ ca , Fit der. /tlFnsl�V`9 /'.y &vwi j S:-J- c4, o0/ZYe- In?/;I .')coA S, .w,;;�7 CGi`+l��cyo� V U -- Wkqf- '�✓Fo( Wrt �a4.`fl . C/40 8�k � r—d C, V0 L dlY�E/L QarF (1o( eGa cai3��cs f.,/,ti,e,•���c.�_eG:�� ��.G,;o�, . �l �,�`yL � e.���a,u✓� `��-�-< <2�u,r�l ✓''�� M �ati�f- a.�o-(�� �-e GR��tifo(c�cc>,Gf rk/ /yr��4� . W�-� .� ' ca�t c Pea 3-zs�o ? J < 30 CC)L2, 90(�j10"L� - � � SO DC09, ( d ✓Ulm azVC-f 4,Lj cel( eta U-�c(s t cv'- 0.,�r c�(t S �� E�� j�racF�(l ,ti �%�s;f wy rW417 / f St�o�f LAIaff-�, d!�,1.1 sCA-�Zq.71,� �y Id Cq(( ��.� � �= c�aS plf r1� t�l��r�n�9 IZ�t, calvkVI,dva 1j lily oN aim �Nd ca((go( E , rUvrs�- Pcttrtc"q E-MOWI)IE A)W-SF Cc(w�jt a-lv�SFe•i? CtvCA SGle4{ U/a5 /v/-/ iln� q i�lz C ,1-,q L- y4ad(d( 011�/,CGraf G�U-grQ`�,�r���jf� 2c� �c(c, tc( was c�'o,•-F, c��o �h � !?�✓ �c� orl 3 -2S- a?. A4IOUIj 6grC41 4vd�lt41fo( 14 F rr,- a�-E 1,4v &VOS A-D t--j ��r t �r /J,�' CA) Q�d7 ggvc Coen-kC,r "Lin/I, qf"-(tlrtNCC Com- Vvf !'RoLs�, �-o S'��� �� Wol�o( �;�. �� -fn ��' ,6aSS� .1 alas c�i✓�@.. ,Nsflf�Ce7�; idcQ(Aj is q -2- 07 ..yM gates t ugCpa OJIVOI sfF- rY-A!.I rho -6f,- sOm', yCww jM q-S- 7 ? ,4A044C, SGM E.- 111109 gOfVgrbrJ ,M "M piA,'vf- YAW f 6 Q,44V/aaco,61 � . C-(A V q.,v/lm c,/v 2vd( r£i�S'E �d A O y ?h�� q{ V(J�-M� grFIVaAlC \ C41Vl{ k,`L 14VSL � S A U, U4PuY�/ )I C( fs 29-74/ri.1r'ytmi �lr�r�arrrCE CtOVd � �kd Vt+� 00A 8- W(�SAA4 SfghAkd. -rk,5"- gUyS 7-%,Wr- r%tf%� G LAVE 44 Caw aid ON4j in! S11 r, rf ki u Cays &,/-fi�F- -7 vn kr ter . tv �r cis f�,u+kcqSo whavE- tri Sp a{ ono jj CW c aJsL 7"/- c 0 A/fwJ 1'a/L- AoG -IS /V r-(- J,+fa g;pct, -fe my y°c/ R/`' a��( c� �e.. w�a-(--�.✓'�2 ✓I><Pfi�.w;gs �q�u�.✓� � ti���. ivf,ll �� �`°``'`'� � ���� q,vgtNga)SSfa�rolyt - a,-oC41vy ca els ���sa i✓�4✓rna��iC W t.p ev42. (A/[(( hl�ar , � Va&' . CcivSt 1rdo �av� R lr0i`Gf..- rev �1S -'�� ofNdz i4 tw 0 113 q. Gt f wvt 4. What particulair act or omission on the art of county or district off gers, servants, or employees caused the ^injuf_ry or damarge?I_ICOLAk �1 (01-p. 4(S4�D�o1vW �J2� /✓1 ��J�aN�ft 5/ct�)✓�q/ X 0 60GJ (J�alo i �U G�OCp (�I"F�,r �'l /2Y y Q!C�✓ D� AIOXIoY7'4 Q- 5. What are the names of county or district officers, servants, or empl yees causing the damage or injury? a/J +" Cor pQlq-�mw, OrM4�0. �� 6. What damage or injuries do you claim resulted? (Give full extent of injurieW damages claimed. Attach two estimates for auto damage) 9p f- SPC(� c� �6 rc�J C�0 �2Q vo oar i0� L-`a,5 NZ-.7-3 Q# �9� '� (b:40�ti 6V,- 'a3 � �/� {�,e 41 "47`, Cads rvv/'St'., �(� �� � a 00 C {�2 7. How was the amougt claimed above computed? (Include theS v estimated am unt of any prospective injury or damage.A3 COQ() go r Ott( 'ItiI - /VLO 9-� -T s'ai'/1��—�f/� (gwfV cal? JTV- r, (,?P-3,-3, t{,pop UDor lo qF n) q.Uo( 11 V_9a7�,L��oU ylam` CtPN�7'Tc 0( 13 2 Ck. 'pn//LL L-OCkC_d cJ(D ICU CO- C<-), &CIN4� 4 �c`L S YS1�c-&S ' 8. ) ames and addresses of witnesses, doctors, and hospitals. "�lwq{cL1 Qs��F ©�✓ 3"��0? � �C �ct�C�,l£�t��(� vtiv��� ��zT��co'ot, 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT ****************************************************************************************** Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney Name and Address of Attorney ) dVliC.tA,((F- oawSonl soor�t Q _' - ) (Claimant's Signature 90( (Address) Telephone N q�S�3 3 S S-000' )Telephone No. CLOVAIZL Qe ************ ***************************************************** *********************** NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand($1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. EA28B 3/22/2007 8:56:33 AM. CANTEEN CORPORATION MARTINEZ DETENTION FACILITY Pick LiSt Name: PETE RISPER Inv. Date: 03/22/2007 Invoice: 4592804 Id: 2007004314 Module: EA28B Serial #: ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- Qty Item Code # Price Amount ------------------------------------------------------------------------------- 1 FLOUR TORTILLA 1OCT 4110 $1.80 $1.80 1 SWISS ROLLS 4142 $2.55 $2.55 1 SALSITAS 3134 $0.80 $0.80 3 9 RAMEN BEEF 3OZ 4412 $0.92 $8.28 5 RAMEN SPICY SHRIMP 4414 $0.92 $4.60 6 RAMEN SPCY BEEF 3OZ 4417 $0.92 $5.52 20 2 CHEESE CURLS 3114 $1.40 $2.80 3 SPICY TORTILLA CHIP 3109 $1.45 $4.35 2 CHEDDAR CH PUFFS 3111 $1.35 $2.70 2 COFFEE 3OZ 2104 $3.80 $7.60 1 CHILI CORN CHIPS 3112 $1.40 $1.40 10 4 BEEF SALAMI 5OZ. 4135 $1.85 $7.40 1 MAYONNAISE SQUEEZE 4127 $2.15 $2.15 1 MICROWAVE POPCORN 136' $1.30 $1.30 2 RIPPLE POTATO CHIPS 3110 $1.55 2 BBQ POTATO CHIPS 5OZ 3116 $1.55 $3 .10 10 1 MUFFIN \ CHOCOLATE 4151 $1.25 $1.25 3 FRUIT PUNCH 6OZ 2107 $1.65 $4.95 2 LEMONADE 6OZ 2110 $1.65 $3.30 1 JAL CHEESE SQUEEZER 4111 $0.80 $0.80 3 CHEESE DIP 4OZ 4134 $1.60 $4.80 1 BABY OIL 4OZ 8118 $1.00 $1.00 11 2 SNICKERS 1105 $0.85 $1.70 2 THREE MUSKETEER 1112 $0.85 $1.70 2 SNICKERS W/ALMONDS 1127 $0.85 $1.70 1 RED VINE LICORICE 1125 $0.90 $0.90 2 M&M PEANUT 1102 $0.85 $1.70 3 BUTTERFINGER 1106 $0.85 $2.55 2 STARBURST FRUIT CHEW 1155 $0.85 $1.70 2 BABY RUTH 1 1133 $0.85 $1.70 1 WHOPPERS 2.75OZ 1139 $1.10 $1.10 2 100 GRAND BAR 1138 $0.85 $1.70 19 o Page 1 EA28B 4/5/2007 10:16:11 AM CANTEEN CORPOP.ATION MARTINEZ DETENTION FACILITY Pick List Name: PETE RISPER Inv. Date: 04/05/2007 Invoice: 4612903 Id: 2007004314 Module: EA28B Serial #: Qty Item Code # Price Amount 1 SWISS ROLLS 4142 $2.55 , $2.55 1 SALSITAS 3134 $0.80 $0.80 2 1 RAMEN BEEF 3OZ 4412 $0.92 $0.92 1 2 CHEDDAR CH PUFFS 3111 $1.35 $2.70 2 1 BBQ POTATO CHIPS 5OZ 3116 $1.55 $1.55 1 1 FRUIT PUNCH 6OZ 2107 $1.65 $1.65 1 BAG O HOT SAUCE 4138 $1.15 $1.15 2 1 IRISH SPRING 3 .2OZ 8203 $0.93 $0.93 1 COLGATE TOOTHPASTE 8213 $1.33 $1.33 1 M&M PEANUT 1102 $0.85 $0.85 3 ------------------------------------------------------------------------------- 11 Previous Balance: $15.78 Base Sale: $14.43 New Balance: $1.16 Debitek: $0.00 Tax: $0.19 Total: $14.62 ------------------------------------------------------------------------------- Signature: EASTER CARDS NOW AVAILABLE. Page 1 CODE - ITEM MAX PRICE CODE ITEM MAX PRICE zc --T.Sr' ''71517-hazor-LeSS tinaVe Crenrn 40Z L) S Diet Pepsi 20o.z 9 1.50Foam Roller Cushions Ij O Hawaiian Punch 20oz 9 1.50 E 9UW Panty Liners 22pk[] •2 2.95 D 7277 Mountain Dew 20oz 9 1.50 M Tampons Tampax 10pk[] 3 2.95, A 7= Mountain DeK2Doz Code Red 9 1.50 A Eyebrow Pencil, Black a "%:1 "1:95• Jarrito's Mandarin Soda 9 1.50 L Mascara, Black 0 1 3.30 TfUliarritos'sTamarind Soda 9 1.50 E Pink Frost Lipstick a 1 ...1.56 41 3b Ur, Pepper 20oz 9 . 1.5U Lipstick-Wine[J 1 1'56 613 Ball cap, o Clotrimazole I%Vaginal Cream(W Fem les)a 1 3.95 15 oz Plastic Bowl[J 1L.0U =I Massengil Douche hoz[J 3 2.44 M Insulated Coffee Mug 20oz[] 1 2.85 u Ivl amms a s i Golf Pencil 0 1 0.20 M Vitamin C 500mg 100tabs)0 1 3.85, S Coloring Pencils 12pk 0 1 2.10 E Antifungal Cream.5oz[1 2 2.35 C Sunglasses 0' 1 : 4.50 . D 77F Chapstick.15oz[] 2 1.46 E Address Book a 1 2.95 h Hydrocortisone Cream loz[1 2 1.85 L . 6127 Dictionary[] 1 8.95 C Ibuprofen(16tabs)0 1 1.85 L Writing Tablet 5x8 a 3 1.15 A Multiple Vitamins Pak[1 5 0.67 A Writing Tablet 8&1\2x11 [] 3 1.10 T 8150 Quinsana Medicated Foot Powder 3oz 0 1 3.33 N Drawing Tablet 9x12 0 2 3.20 I 787217 Nasal Decongestant(16Tabsy a``' 1 1.48 E Envelopes, 6&3\4 Plain 10pk[] 3 0.75 O Halls Mentholyptus(9Tabs)0 t 5 0:87 O 76TW Greeting Card,Birthday[j 5 1.65 N Tylenol Extra Strength(10Tabs)[] 2 1.48 U Greeting Card, (Love, &Miss You)[] 5 1,65 Artificial Tears ij 2 1.70 S6117. Basic Holiday Card[] 11n ;5'. 1.65 Contact Lens Solution[] 2 1.65 Envelope 9x12[] ;9 0.61 Acne Medication 1 fi oz[] 1,i 3.50 Maverick Poker Cards[] 2- "2.50 8143 Chlorophen for Allergy relief 1 tablet[] 9.1 ' Maverick Pinochle Cards[] 2. 2.50 Prilosec OTC 14 tablets[] 1. 12.00 Manila Envelope 1 0x1 5 0 9 0.70Loratadine(like Claritin)10 tablet[] V 3:20 673 File Foler,Legal[1 2 0.85 Ranitidine(same as Zantax)o , 1 5.95 Legal Document File Q 1 3.25 Stool Softener(Docusante Sodium 250 mg) '1 0.85' Envelope Plain I.10" 10pk[] 3 '0.95 Hemorroid Suppositories(Anusol)[] 1• 1.85 Manila Envelope 10x13[J 3 : U.SU Antacid I ablets (121 abs)(J 3 0.63.,11 . Work.Find Puzzle[] 1 1.25 anvas oes-_WM- Me ens ize Crossword Puzzles[] 1 1.25 C Canvas Shoes-White\Men's Size 8[] 110.50 Numbered Legal Pleading Paper lUpk[J ;.3 2.1U A. Canvas Shoes-White\Men's Size,9[J.,. 1, 1U:50(., 62 Laundry soap oz . N Canvas Shoes-White\Men's Size 10,[]„ 1 10.50' Irish Spring 3.2oz[] 3 0.93 V Canvas Shoes-White\Men's Size 17 O`. 1 10.50. Y Ivory Soap 4.5oz[] 3 0.82 A 7509 Canvas Shoes-White\Men's Size 12`(] 1 10.50 G Dove Soap 4.75oz[1 3 1.52 S` Canvas Shoes-White\Men's Size 13[] n,,_„1 10.50 I; Dial Antibacterial Soap 3.5oz[j 30.97 Canvas Shoes-White\Men's Size 14 0t'. 1 10.50 E' Extra Body Shamp6615oz[) 1 2.22 S Canvas Shoes-White\Men's Size 15[1 1 10.50 N, .= Balsam Conditioner 15ozi] 1 2.22 H Canvas Shoes-White Women's Size 5(] 1 8.50 E Balsam Protein Shampoo 14oz[] 1 1'.22 O Canvas Shoes-White Women's Size 6,[] I"" '8:50 Balsam Protein Conditioner 14oz[J 1 1.22' E = Canvas Shoes-White Women's Size Ti].,. ,;.1: 8,.50 Dandruff'Shampoo 4oz[j 1 " 0.82, S Canvas Shoes-White Women's Size,8[]. 1 8.50+ Styling Gel 16oz[] 1 2.41_ Canvas Shoes-White Women's Size 9 0 1 8.50, ' 1 W Sulfur 8 2oz[1 - .1 2.45" omen tirdering Velcro 31555 170rcTer f9lies Small er Pomade 4oz[] 1 1.70 7205 Velcro Shoe-MenT omen " f Hair Food 4oz[] 1 1:45' V Velcro Shoe-Men's'6'\Wmone'8'(j T .11.40 Skin Cream 4.5oz(Generic for Noxzema)[j 1 1.15 E Velcro Shoe-Men's'T\Women'g'[] 1 11.40 Lady Speed Stick 1.5oz[j 1 2.96 L Velcro Shoe-Men's'8'\Women'10'0 1 11.40 Mennen Speed Stick 2oz[] 1. 2.93 C Velcro Shoe-Men's'9'\Women'11'[] 1, 11.40 78797 Toothbrush,3"0 1 0.25 R Velcro Shoe-Men's'10'.\Women"12'[] 1 11.40 H Colgate Toothpaste 2.7oz.[] 2 1.33 O Velcro Shoe-Men's'11'\Women'13'[] 1 % 11.40 Y, Mouthwash hoz[]„ 1, 2.40 Velcro Shoe-Men's'12'\W6men'14'0, 1 11.40 G -aw Washcloth,Green 0 X 0.85 S Velcro Shoe-Men's'13'\Women'15'[] 1 11.40 ' Palm Comb[] 1' 1.52 H Velcro Shoe-Men's 14(1 1 12.25 E Comb 5"a 1 0.26 O Velcro Shoe-Men's 15[j 1.1 12.25 N Soap Dish, Box[] 1 0.90 E Velcro Shoe-Men's 16[] 1'., 12.25 E After Shave 4oz[j 1 1.25 S Velcro Shoe-Men's 17'[1 1 12.25 7-Gel Medicated Shampoo 4.4oz[J 11 6.65 INDIGENT HYGIENE...LESS THAN $2.00 BALANCE ONE MEDICINE O Body Lotion 11oz[] 1 1.00 oo rus Hair Brush(No Handle)[] 1 2.75 Toothpaste i Baby Oil 4oz a 1 1.00 Deodorant Antibacterial Soap 1.5oz 1 7877 Baby Powder 4oz[1 1 1.08 Comb 1, Cocoa Butter Lotion 11 oz[] 1 1.08 Golf Pencil 1 j Sott&Beautitul Relaxer Kit[J 1 7.65 Paper(6 Sheets) 1 3 Pony Tail Holders[] 2 0.45 uzuu Hyorocortisone I oz i� Petroleum Jelly 4oz[j 1 1.44 Ibuprofen 200mg 8pack 1 1 Z Shower Ca 1 0.40 Generic T lenol 500m 5 k 1 2 P[1 Y g' P "" �[ p Comb,Mini Pick[j 1 1.22 Antacid - 1 W W Pink Oil Moisturizer 8oz[1 1 4.10 Chlorpheniramine 4mg 24 pk(for atlergiesj1 ? 8115 Denture Adhesive 2.7 ozij 1 3.25 Miconazole(antifungal)2% 1 1 W U Denture Cleanser(30 tab)[] 1 3.75 Stool Softener(Docusante Sodium 250 mg) 1 O W Schick Razor(each)[j 3 0.46 020 Hemorroid Suppositories (Anusol) 1 Personna Razor(each)[J 3 U.bf Petroleum Jelly 40z 1 .'LL p 7fluiotrimazole 1%Vaginal cream(tor remales 1 \ t' t ontra t ossa l op'n- l omimssary Menu 'lvlaster e�enerait'1�opulahoil Canteen ,Total cost of ordered items will be deducted from your trust account. Sales tax will;be Added to"'ll items with an p. We reserve the right`to limit orders this oroeris suolecr to posrea commissary roves. t-iease terrain«om.piacing an order z4,nours priori to rransrer care,as rrns may oeiay nnarcasn;wnnarawais." U Tr yt-A U& 100 Grand Bar 1.5oz 1.t 9 - j r0185 a Pv : 4131 Blueberry Muffin 4oz 9 :1.15 . Baby Ruth 2.31 oz - (9;' ' 0.851, ( , 74142 Swiss Roll 12oz. 9 -2.55; 1151{ Breathsavers Roll i 9i 0.55- `S' .4151 ` Double Chocolate Chip Muffin 6oz' ' s %9 1,2_5 2. 1106` Butterfinger 2.31oz. 9 0.85 I a T� .,4144 F..rosted.Strawberry.Pop Tarts.3.6oz .. 9 1:00 ,1,119: Butterscoten Discs 9 1,10 R" "4145 ; Chocolate Donut Gems 3oz 9 `1.00 " r y :3107 ; Pork Cracklin's 2 5oz,; 9 :1.35 , 11-31r Coffee 1 5oz 9. 0 85' #1130' Granola Bar 1.Soz ;9". ,.,0 751 ^3108 . Pork Cracklin's Hot N Spicy 2oz - r 1:35 C ; 1126' Hot{Tamales 2.12oz t;_j, ?!9- `0.85 j C_ .3113 : Hot Fries 4oz JoSi 9 .:x1'40 " A ',111 Z Jolly Rancher Assorted 4oz ,r 19i. -1.20L i H: 13115' Hot Cheese Crunchies 4.5oz 97':;.1'.40 ' N '' 1118 Jolly Rancher Fire 40z 9` .-1.20 1 -31191 Chili Cheese Chips 1.1250z 9 - U.80 D "';1.107, Kit Kat Big Kat 1.94oz 9,;` k0.85i = P� 3114 Cheese Curls 4.5oz 9 .• 1:40 Y 1120, Lemon Drops 4 5oz ,, 9'r 0:90 S," "3112` Chili Corn Chips 5oz 9 -'1.40 ( 1129. Lifesaver Five Flavor 2.12oz 9 1,0:85 3109Spicy Tortilla Chips 4.75oz . 1102 M&M Peanuts 1.74oz 9.„ .0:85, { o_ 3103 Jalapeno Chips 1 5oz 9 _ 0.85 j t t 1,101: M&M Plain 1 69oz 9', ,0:85. 3110, Ripple Potato Chips 5oz.; 9 1^55 1104 Milky Way Dark Chocolate 1.76oz 9 ;0.851 ,3111. Cheddar Cheese,IPuffs, 9 1.35 7109 Nestle Crunch 1.55oz 9.. 6.85 r 3117 Guacachips 3.5oz 9 + 1.55 1136 Nut�ageous 1.8oz 9. : 0.85 3105` Doritos Nacho Chips 1.75oz 9 085 I . . 11.25. Red Licorice Vmes 4oz 9;`,:,0.90 -3127: Cool Ranch Dortitos 1.75 oz 9 -0.85 , ` .1114 Reese's Peanut Butter Cup.l.6oz 9'- 0.85 -3133'Jalapenitos 1.5 oz 9.` 0.80 ; ;• 1,137 Reese's Pieces 3.5oz 9 1.'10 3134.., Salsitas 1.5 oz 9--. -0.80 ,. 7:. ,rt - - . , 1123 Root Beer,Barrels 4.5oz 91 •1.20 3116 BBQ Chips 5oz 9 1.55 0.8 C 5 5111., Oatmeal es 14oz 1105 Snickers 2 07oz r 9_ 0.85 01 .5108,', Raspberry Shortbread C ,+ 9 2.55 � ook!es 10oz• 9 , X2.55 ' ° .1'127, Snickers w/'Almonds!'1 76oz' " $g r '0.85- ; O_ :5106' Chocolate Chip Cookies 14oz 9 . ' 2:55 1,121 Sour Fruit Ball Hard Candy 402' 9^ 1:15 K 51121Vanilla Wafers 12oz ;9 1.90 ' 7155 Starbursts*�wt Chew 2.7oz' 9_ 0:85 ; _I ';'5101` Grandma's'Chocol1.ate Chip Cookie 2.75oz 9, '0.80 1124 Sugarfree�Wild Fruit 2oz t 9 " 1;20r E '5102" Grandma's Peanut Butter Cookie 2.75oz 9_ 0:80 1,112 Three Musketeers 2 13oz 6 •-Vi85 S .5104` Grandma's Oatmeal Cookie 2.75oz 9 ' ..0;80 ` 1139 Whoppers(theatre size)2.75oz 9 1.105110; Oreo Cookies 1.8oz 4pk 9 '0.80 : 4107 O'Bnan's,Beef Stick_1-.125oz 9 0.90 5603- Cappuccino Cookies 3oz 9 1.00 4106 Beef Stick Hot_1oz - 9 1;00 5121 Lemon Creme Sandwich Cookies,5oz 9 '1;06- ''4156 Beef Jerky•1.9 oz (9. 2.55 :5123: Little Dabbles Oatmeal Cream 3.8 oz .' 9 0:85" r S 4110 Flour Tortilla's 10\ct 18oz- '9; 1:80 51241 Little Debbies Nutty Bar 3oz 9 0:85 G N 4104 Trail Mix 2oz 9_`_ 0.80 5105' Rice Krispy Treats • .9' '0.90 A '4134 Nacho Cheese Dip 46z{` 9 1`60 G! 4412' Ramen, Beef 3oz' t 9_, 0.92 nJ 4135. Beef Sausage hot&spicy 5 or.= 9 1:85 S ;44;13; Ramen,Chicken 3oz' 9..; 0.92 n' 4136 'Microwave F?opcorn,3.5oz 9 1.30 O :44;14. Raiment Spicy Shrimp 3oz' „9 0.92 S .4137 Pica Sauce'tOoz, 9 2:15' tl :44'15 Raiment Chili 3oz' 9 : 0.92 4112 Peanut Butter&'Jelly.Squeezer 2oz 9;i 1:00 R r 4416, Ramen,Spicy,Chick en.3oz.' 9- '0.92 4216 Strawberry:Preserves 126z t 9 2.30 S 44175 Raiment Spicy Beef 30z' 9 "'0.92 4108 Kosher Dilt'Pickle toz-' 9'- ' 1:05 4423 Beef Stew Pouch 7.5oe ,9 1.88 4161 Strawberry Fruit Snacks 2.25oz 9 1.35 7 41.46' Soy Sauce hoz plastic bottle 91.80 4324, Artificial Sweetner'1'O pk 9; ,,1.0:60 4421= Hot Chili with Beans 7.5oz' 9 , .2.10, _. 4138-,_ Bag O'Hot Sauce 8pk., 9; 1.15 4410, Spanish Rice w/Cjhedd&Jalapeno 2.2oz" 9 1'.00 41,14 ';Tu a Pouch 3oz 9 1'80 4411. Bag O'Rice 2oz' 9"• `1.00 t;j4149Hot Pepper Cheese 4oa 9 2.55 4101 . Chicken Breast 3oz 9 3.10 J4123 BBQCornnuts1.4oz :'9; 0,80 ;.4433: Oysters 3oz 9-' 2.651 4105 Gatddetto's Snackens 1.75oz 9 0.80 4409, Refried Beans w/Jalapeno&Green Chili 4oz':, 9' 1.20 '. ,4140 Ctieese-lt 1.56z 19 0.80LS 2119 Hot Chocolate 50z' 9 2.15 4111 Jalapeno Cheese Spread 1oz 9 0:80 D ' 2104 Freeze Dried Coffee 3oz 9 3.80 4141 Jalapeno Nacho Slices.7oz 9 '_0.70 R 2164 Decaf Coffee 3oz 9 - 3.40 4113 Club Crackers 5.25oz -,9 1.80 . I 2107 Fruit Drink Mir.6oz t.9 _ 1.65 1 4127 Mayonnaise 11.50z 9 2'15 N. 2109 Iced Tea Drink Mix 607 9 1.65 3135 Flavor Blasted Gold Fish 9 0.90 ' K 2108 Orange Drink Mix 6oz 9_', 1.65 4150 Mixed Spices(seasoned Salt)_ 9 2.55. S 2110'. Lemonade Drink Mix 6oz 9. 1.65 .-4117 Oaimeal Strawberry&Cream 5pk 9 2.15 2140; Cocoa Joe 5oz 9 3.80 Oatmeal Maple&Brown Sugar 5pk 9. 2.15 Cappuccino 5.12oz 9 1.70 oney un oz French Vanilla Coffee3oz 9. 1 3.80 4119 Cinnamon Roll 4 o 9 1_20 1 6120 1 Stamps(book often) 90 Bear Claw Danish 4 oz 9 1.15 Legal Stamped 5pk 5, 2.40 eU 9►Gp 9D0409;•�� ►99 `� ' 4fZa4 g4Lp6 4 �pF.R► CpN��E � � .a Cl) - r � t it mgr� �+ *��a�J o-�^ � J fM N m N ✓ O .vim' 'Q�iV'Ylr��.1'�"• W .n.:n o �2 / yNi V LL 1 0 0 CONTRA COSTA COUNT v. DETENTION FACILITY (X) INMATE REQUEST FOR INFORMATION �+ { )lbME/�DIC/A-L REQUEST To: 00A t—f4A1 �nrpC>PGr�ira,n) �o/ Yd / PJ Y- From: P45m, RiG014, e cooa> Date: t 5 L-6-:7—Housing Assignment: Check One: ( ) Request ( Grievance { ) Appeal ( ) Other ,y Request: gmlfsAi Crito `ti, "A . n+_INAt Af . Njm�, ')r A'�i j --/1A rG,aa39 d%ni4,� fsxf iG.dr aS A s/�tCEcra�- TAr ,Stdf Zklr! Af,Yi ,44JVC //!:init ,,r,.j �a�5a l�S��7/.'t:��2rz�tJAJ. AorSS rrn)SS. t✓S}�4. dA/M-fY'ac 1�(rJ !d�/"(y ty°a�Y�lisl� CA rlbRc4 jil s .4 f aa�LC� ��fll 6.J rarrr�vlAr✓� y u u OW fyf 00�46 aft.'er��s ' rn�. �N► SsclGwa t aa�C c.,,f��,rc tFr��,.a rt, rt, rA/F n-t i'gcic$-nod 4 �_�( 1.A r�im(,ctf�frt,T do,4 �11J*Ak r, z t'l�! tK" QS rtXW KtA#40 -1.1,Ad.-1vH 9111'APry J,�. 4C 11 d�iJ cCwrtl h, �Il-/!1V tt�i a-r qPA t46. % 2 �,"'-.�.:G.1 M'1) �1 d��i '-���.�,� ,f���iE���o�t`��n1/9`r�.�i`d�f1:y�,Q �e 2t��(rS ♦��� Date Rec'd: ! / Rec'd Bv: Routed To: ANSWER: ( )APPROVED ( ) DENIED-(state reason) By: Date: ! ! Pink:Kept by Inmate Yellow:Reply to Inmate White:To Booking DET 024:FAM 112(91 1�. y 9 Y y,ll CIOt C OS.TA CpUNTy DETEN=TION .�A 77 CILITy O INMATE RE t QUEST FOR INF pRMATtONo :) ( )MEDICAL^REO(jEST From; F & J,' Date; too- __.Bkg# .. Check One, { Housing Assignm t )Requests ` { " Request < t I lei ac � e. )€ .,d} c PPI+ �. �� ( ) Other �. E y " K Y i, A f�L~y�wi r, Y.Jj i 45 , i 0 t ' :do� r til I f PC III, N— --IE # APPROVED . )DENIED-(state re son), �. Pink:Kept by Inmate DET FAM 712197 Yeitow:Re Ply P y to inmate -- White:To Booking r ._ xr Qi1p r Vq \ r dD y l iso V J fJ VN .r o o E 14 � � 1 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: MAY 221 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 CLAIM AGAINST HOUSING AUTHORITY OF CONTRA on your claim.by the Board of COSTA COUNTYQ G� � Supervisors. (Paragraph IV below), jEY\4 tz' given Pursuant to Government Code tr, AMOUNT: $1,602M2 Section 913 and 915.4. Please note all APR 1 9 2007 "Warnings". CLAIMANT: NIKIA SMITH COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 19, 2007 ADDRESS: 2115 WASHINGTON WAY BY DELIVERY TO CLERK ON:APRIL 19, 2007 ANTIOCH, CA 94509 BY MAIL POSTMARKED: APRIL 18, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C Dated: APRIL 19, 2007 By: Deputy LI. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: "1 0-7 By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (]) 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: (v)� 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:,�ay a2 g, AWJOHN CULLEN, CLERK, By Deputy Clerk WARNI (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 ,)dvice of an attorney ofyour choice in connection wide this matter. If you want to consult an . - attorney,you should do so immediately. *For Additional Waming See Reverse Side oMiis 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 Q/ Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553, either by mail or in person. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity; separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp Nikia Smith RECEIVE® Against the County of Contra Costa or APR 1 9 2007 The Housing Authority of Contra Costa (District) CLERK BOARD OF SUPERVISORS (Fill in name) CONTRA COSTA CO. The undersigned claimant hereby mak s claim against the County of Contra Costa or the above-named District in the sum of 0.fl 32 and in support of this claim represents as follows: Nf(l. 1Q i aODR 1. nWhen did the damage or injury occur? (Give exact date and hour) t tf YVID(1+� fl6() �2,1GV�— 2. Where did the damage or injury occur? (Include city and county) n�11 ak1 �or(m �1ne af�C S ok Whl�ti O_OMVx on �v ��{ ( mper cnd 3. How did the damage or injury occur? (Give full details; use extra paper if required) VvAltd Vk Trom k1,z, i� w6lS 4,c(e 12e,50DnJd p Air ALJ Spot- i� CU14 160y 4. What particular act or omission on the part of county or district officers, servants or I employees caused the injury or damage? 1� 1nc� rncd&( �``���5 `C 4q) 6xA5 i ct5 noLo bec' Qe Po �Qcd SenG� is 11�Q(�' clmform H" OGri.. ttU>tiS Irl (Tw��^Oel 6-� C.oYtkrc� e o5-- 5. What are the names of county or district officers, servants or employees causing the damage or injury? Cay- cIc nq:c� 6. What damage—or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attached two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) -e,V r�4 M o(w, 4w2 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT C kA Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICE TO: (Attorney) or by some person on his behalf." Name and Address of Attorney LT)A aR.1 SmAj —� (Claimant's Signature) ally Qashtc c,IOn w6-cA (Address) ion o A&� ('A gySD� Telephone No. Telephone No.V�jJo) 1p 81--3 0 T 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 ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000) or by both such imprisonment and fine." Omform SMITH, NAKIA ESHON Aff�I' Z® # 1 EST RR H43320745 CAATE01 0726201 VEHICLE 0929817893076 VIN# 1G1AL55F267826315 TKCAP13 LIC CA 5UAN286 CLS B 06 CHEVY MILES OUT 19587 FUEL OUT 3/8 CDP 1685699 EXPLORER-SANTA CLARITA PC CLM# 0250796661.001 ESTIMATE OF CHARGES RENTED: 0312 912007 13:49 @ ANTIOCH HLE RETURN: 0410612007 01:00 @ ANTIOCH HLE THIS IS ONLY AN ESTIMATE. Taxable charges are denoted by a T,and additional details about some charges appear beneath the table. Hertz's estimates of Your total charges appear on the right of the table below. Hertz's estimates assume(1)You will rent and return the vehicle at the times and places indicated,(2)if a mileage charge applies,You will drive no more than the distance indicated and(3)You will not incur any charges that either are listed below opposite****or cannot be calculated until return. If any of these assumptions is incorrect,additional charges or charges at higher rates may apply. CHARGE RATE 1 AMOUNT CHARGE ESTIMATE TIME 1 MILEAGE CHGS:RATE PLAN- HLE EX [C] CLASS B 14 @$ 17.99/DAY WITH ALL MILES FREE $ 251.86 ADJUSTMENT PROMOTIONAL COUPON SUBTOTAL T$ 251.86 ADDITIONAL CHARGES APR 11 *0 13"08' FEES FOR ANY ADDITIONAL AUTHORIZED OPERATORS NOT INCLUDED T$ OPTIONAL SERVICES FUEL&SERVICE$0.219 IMI$5.4991GL 13 FrK CAPT$ TAXIFEES TAX 8.25 %ON EST.TAXABLE TTL$251.86 $ 20.78 ADJUSTMENTS ESTIMATED COMPANY CHARGE $ 194.74 ESTIMATED CUSTOMER CHARGE $ 77.9 ESTIMATED CUS FOMER BALANCE $ 77.90 TOTAL ESTIMATED CHARGE $ 272.64 CC AUTH WOULD BE $ 100.00 NOT A FINAL BILL- NOT VALID FOR REIMBURSEMENT s � e 4. ���� - ----= ------ ---- -- � -\- _cam- vil v Gu.).. --LURA v- G_ `I _ -- -J- -- - Usk - - - --CQO ------ 1 k\'� _ _ Ju;ti_. - -- _ z L's) r g� � ./� L RO: 0602356.00 Detailed Customer Invoice Page: 1 4/11/07 12:49PM Mike Rose's Auto Body of Antioch 1610 West 10th Street Antioch, CA. 94509 Phone(925)778-1330 Fax(925)754-5426 BAR#AD239198 EPA#CAL000293613 NAKIA SMITH Date of Loss: EXPLORER INS. 2115 WASHINGTON WAY ANTIOCH,CA 94509 Year: 98 Make: CHRYSLER Home: 510-689-8073 Model: TOWN&COUNTRY Phone: Work: 925-706-2696 EX00000 Type: Fax: Est.: DAVID#505 Style: Adjuster: Received: 3/29/07 Color: BRONZE Claim#: 0250796661 Del.Date: License: CA 81393555 Policy: Date Paid: 4/11/07 Mileage: 119,348 Betterment: 1 VIN: 1C4GP64L6WB665368 Deductible: 450.00 Ln. Description Parts Labor Units Refin Units Other 1 TEARDOWN 2 Repair FRONT BUMPER 3 Rem/Repl/Refinish RECOND Bumper cover 348.00 2.00 3.00 4 Refinish Add for Clear Coat 2.00 5 Rem/Repl License bracket 37.25 0.20 6 Repair FRONT LAMPS 8 Qual Repl Parts RT Fog lamp as 9 Repair aim lamps 0.30 10 TINT COLOR 0.50 11 Paint Materials 102.00 12 Clear Coat Paint Materials 40.80 13 REPLACE AIR SENSOR 35.17 0.20 14 REPLACE RT PARK/SIGNAL LAMP 71.25 15 REPLACE FOGLAMP BULBS 26.20 Totals 1517.8712.701 15.50 142.80 Total Category Rate Units Est. Suppl. Total BODY LABOR 75.00 2.70 187.50 15.00 202.50 PAINT LABOR 75.00 5.50 412.50 412.50 OEM PARTS 37.25 132.62 169.87 AIM PARTS 86.00 -86.00 PAINT MATERIALS 142.80 142.80 REMAN PART , 348.00 348.00 Subtotals 8.20 1,214.05 61.62 1,275.67 SALES TAX 50.66 3.85 54.51 Grand Total: 18.201 1,264.71 1 65.47 1,330.18 .Date Payment Received By Method Charge Type Amount 4/11/07 INS CK#81-8755 ROBIN T#1 Check 754.71 4/11/07 CASHIER'S CK#57-52990663 ROBIN T#1 Check 330.00 4/11/07 CASH ROBIN T#1 Cash 120.00 Total Payments: 1,204.71 Balance Due: 125.47 RO: 0602356.00 Detailed Customer Invoice Page: 2 4/11/07 12:49PM LIMITED WARRANTY THIS WARRANTY COVERS THE QUALITY OF WORKMANSHIP ONLY AND DOES NOT COVER PARTS, MATERIALS OR EQUIPMENT.MIKE'S AUTO BODY MAKES NO REPRESENTATION OR WARRANTY,EXPRESS OR IMPLIED,CONCERNING PARTS, MATERIALS OR EQUIPMENT.PARTS,MATERIAL AND EQUIPMENT MAY BE COVERED BY A MANUFACTURER'S WARRANTY.ALSO EXCLUDED FROM THIS WARRANTY IS NORMAL WEAR AND TEAR,RUST REPAIR,DAMAGE CAUSED BY RUST AND DAMAGE RESULTING FROM UNREASONABLE USE OR IMPROPER MAINTENANCE OF THE VEHICLE. PAINTING, STRIPES AND DECALS: THE SHOP PROVIDES A PAINT MANUFACTURER LIMITED LIFETIME WARRANTY FROM DATE OF REPAIR ON(1)PAINTING RELATED PRIMING AND PAINTING WORK PERFORMED BY OR AT THE SHOP AGAINST CRACKING,CHECKING, SEVERE LOSS OF GLOSS CAUSED BY CRACKING OR FADING,AND PEELING OF THE TOPCOAT OR ANY OF THE LAYERS OF FILM INCLUDED IN THE REFINISHING PROCESS;AND(2)EXCEPT FOR DEFECTS WHICH ARE CAUSED BY EXPOSURE TO EXTREME ENVIRONMENTAL CONDITIONS,THE APPLICATION AND ADHESION OF DECORATIVE STRIPES AND DECALS PERFORMED BY OR AT THE SHOP AGAINST LOSS OF ADHESION. SHOP WILL RE-PRIME,RE-PAINT,RE-STRIPE,OR RE-DECAL THE SPECIFIC SECTION OR SECTIONS OF THE WARRANTED VEHICLE(EXCLUDING RUST REPAIR),AT ITS SOLE OPTION,WHEN THE CLAIM IS MADE WITHIN THE WARRANTY PERIOD,EXCEPT FOR DEFECTS RESULTING FROM UNREASONABLE USE, MAINTENANCE, OR CARE OF VEHICLE OR EXPOSURE TO EXTREME ENVIRONMENTAL CONDITIONS. MECHANICAL REPAIRS AND PARTS: THE SHOP PROVIDES A ONE(1)YEAR LIMITED WARRANTY FROM DATE OF REPAIR ON ALL MECHANICAL REPAIRS AND NEW OEM PARTS INSTALLED BY OR AT THE SHOP(UNLESS THE MANUFACTURER'S WARRANTY FOR SUCH PART IS SHORTER IN DURATION, IN WHICH CASE THE SHOP'S WARRANTY FOR SUCH PART IS SHORTER IN DURATION,IN WHICH CASE THE SHOP'S WARRANTY HEREUNDER FOR SUCH PART SHALL BE LIMITED TO THE DURATION OF THE MANUFACTURER'S WARRANTY), SHOP WILL REPAIR ANY WARRANTED MECHANICAL ASSEMBLY OR COMPONENT,OR WILL REPAIR OR REPLACE ANY DEFECTIVE NEW OEM PART,AT ITS SOLE OPTION, WHEN A CLAIM IS MADE WITHIN THE WARRANTY PERIOD, EXCEPT FOR DEFECTS RESULTING FROM UNREASONABLE USE,MAINTENANCE,OR CARE OF VEHICLE. THE WRITTEN WARRANTY SHALL BE NULL AND VOID IF THE REPAIR IS ALTERED,ADJUSTED OR TAMPERED WITH BY ANY PERSON OTHER THAN THE SHOP. THIS WARRANTY IS NOT TRANSFERABLE.ANY CLAIMS MADE UNDER THIS WARRANTY;THE VEHICLE MUST BE BROUGHT BACK TO OUR FACILITY.CLAIMS MADE AFTER ONE YEAR;COPY OF ORGINIAL RECEIPT MUST BE REPRESENTED AT THE TIME THE CLAIM IS REPRESENTED.THIS DOCUMENT WHICH IS NON-TRANSFERABLE IS BETWEEN THE CUSTOMER NAMED ABOVE AND MIKE'S AUTO BODY, INC.THIS GUARANTEE SHALL NOT BE VARIED, SUPPLEMENTED,QUALIFIED OR INTERPRETED BY ANY PRIOR COURSE OF DEALING BETWEEN THE PARTIES OR BY ANY USAGE OF TRADE. THIS GUARANTEE WILL ONLY BE HONORED AT THE MIKE ROSE'S AUTO BODY, INC. WARRANTY AUTHORIZED BY: SS/MIKE ROSE - PRESIDENT POWER OF ATTORNEY:The undersigned hereinafter called"INSURED"for the consideration of repairs made to"INSURED'S" automobile,does hereby grant to said Mike's Auto Body, INSURED'S power of attorney to sign or endorse any checks and/or drafts made payable to INSURED,and any release thereto,as settlement for insured's claim for damages to the above described vehicle. SIGNATURE DATE SUPPLEMENTAL AUTHORIZATION: I acknowledge notice and verbal approval of an increase in the original estimated price. BY: DATED: RO: 0602356.00 Detailed Customer Invoice Page: 3 4/11/07 12:49PM ACKNOWLEDGEMENT OF FINAL BILL: I acknowledge that I have received the"FINAL INVOICE"along with a copy of the"FINAL ESTIMATE"completed by Mike's Auto Body,Inc. for the repairs completed on the vehicle stated on this form. X Dated: 04/06/2007 at 04 : 53 PM Job Number: 966 68555 MIKE ROSE'S AUTO BODY OF ANTIOCH, INC. - Federal ID # : 942621349 BAR# AD239198 EPA# CAL000293613 WHERE QUALITY COUNTS 1610 West 10th Street Antioch, CA 94509 (925) 778-1330 Fax: (925) 754-5426 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY Written By: DAVID RAYMOND Adjuster: Insured: NAKIA SMITH Claim # Owner: NAKIA SMITH Policy # Address: 2115 WASHINGTON WAY Deductible: ANTIOCH, CA 94509 Date of Loss: Cellular: (510) 689-8073 Type of Loss: Comprehensive Point of Impact: 12 . Front Inspect MIKE ROSE' S AUTO BODY OF ANTIOCH Business: ( 925) 778-1330 Location: WHERE QUALITY COUNTS 1610 West 10th Street Antioch, CA 94509 Insurance EXPLORER INSURANCE CO. Company: 3 Days to Repair 1998 CHRY TOWN & COUNTRY 4X2 LXI 6-3 . 8L-FI 4D VAN GREY Int : GREY VIN: 1C4GP64L6WB665368 Lic: 8D93555 CA Prod Date: 02/1998 Odometer: 80000 Condition: Good Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Theft Deterrent/Alarm Dual Air Condition Auto Level Rear Wiper Body Side Moldings Dual Mirrors Privacy Glass Luggage/Roof Rack California Emissions Fog Lamps Clear Coat Paint Metallic Paint Power Steering Power Brakes Power Windows Power Locks Power Driver Seat Power Passenger Seat Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek CD Player Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag Traction Control Leather Seats Bucket Seats Recline/Lounge Seats 7 Passenger Option Automatic Transmission Overdrive Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP . DESCRIPTION QTY EXT . PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2** Repl .RECOND Bumper cover 1 348 . 00 2 . 0 3 . 0 3 Add for Clear Coat 0 0 . 00 0 . 0 1 . 2 4 Repl License bracket 1 37 . 25 0 .2 0 . 0 5 FRONT LAMPS 1 04/,06/207 at 04 : 53 PM Job Number: 966 68555 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 1998 CHRY TOWN & COUNTRY 4X2 LXI 6-3 . 8L-FI 4D VAN GREY Int: GREY ---------------------------------- --------------------------------------------- NO. OP . DESCRIPTION QTY EXT . PRICE LABOR PAINT ------------------------------------------------------------------------------- 6** Repl Qual Repl Parts RT Fog lamp 1 86 . 00 Incl . 0 . 0 assy Town & Country 7# Rpr aim lamps 0 0 . 00 0 . 3 0 . 0 8# TINT COLOR 1 0 . 00 X 0 . 5 0 . 0 9# SO1 Repl ambient Air Sensor 1 30 . 80 0 . 2 0 . 0 10 SO1 Repl RT Park/turn lamp 1 71 . 25 Incl . 0 . 0 ------------------------------------------------------------------------------- Subtotals =_> 573 . 30 3 . 2 4 . 2 Parts 573 . 30 Body Labor 3 . 2 hrs @ $ 75 . 00/hr 240 . 00 Paint Labor 4 . 2 hrs @ $ 75 . 00/hr 315 . 00 Paint Supplies 4 . 2 hrs @ $ 34 . 00/hr 142 . 80 ---------------------------------------------------- SUBTOTAL $ 1271 . 10 Sales Tax $ 716 . 10 @ 8 . 2500% 59 . 08 ---------------------------------------------------- GRAND TOTAL $ 1330 . 18 ADJUSTMENTS : Deductible 0 . 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 1330 . 18 THIS IS A PRELIMINARY ESTIMATE AND ADDITIONAL CHARGES MAY BE REQUIRED FOR THE ACTUAL REPAIR. Gu 11K cc deg,-", 2 -1 04/-06/2607 at 04 : 53 PM Job Number: 966 68555 PRELIMINARY SUPPLEMENT 1 WITH SUMMARY 1998 CHRY TOWN & COUNTRY 4X2 LXI 6-3 . 8L-FI 4D VAN GREY Int :GREY -------------------------------------------------------------------------------- N0. OP . DESCRIPTION QTY EXT . PRICE LABOR PAINT ------------------------------------------------------------------------------- ------- ADDED ITEMS ------- 9# SO1 Repl ambient Air Sensor 1 30 . 80 0 .2 0 . 0 10 SO1 Repl RT Park/turn lamp 1 71 . 25 Incl . 0 . 0 ------------------------------------------------------------------------------- Subtotals =_> 102 . 05 0 . 2 0 . 0 Parts 102 . 05 Body Labor 0 . 2 hrs @ $ 75 . 00/hr 15 . 00 ---------------------------------------------------- SUBTOTAL $ 117 . 05 Sales Tax $ 102 . 05 @ 8 . 2500% 8 . 42 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 125 . 47 NET COST OF SUPPLEMENT $ 125 . 47 Estimate 1204 . 71 DAVID RAYMOND Supplement SOI 125 . 47 DAVID RAYMOND Job Total $ 1330 . 18 INSURANCE PAY $ 1330 . 18 THIS IS A PRELIMINARY ESTIMATE AND ADDITIONAL CHARGES MAY BE REQUIRED FOR THE ACTUAL REPAIR. 5 .r 1 LA R f l GO e"t �] UJ e tai ;zt co 0 tct tit u CLAiM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY . I BOARD ACTION: MAYA 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. j� you is your notice of the action taken D @39 on your claim.by the Board of APR 19 D61) Supervisors. (Paragraph IV below), 2007 given Pursuant to Government Code AMOUNT: $835.18 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF "Warnings'. CLAIMANT: STATE FARM INSURANCE COMPANIES FOR COURTNEY SMITH ATTORNE);LBY: GLENNA SUTTER DATE RECEIVED: APRIL 19;? 2007 NONE ADDRESS: P.O. BOX 2371 BY DELIVERY TO CLERK ON: APRIL 19, 2007 BLOOMINGTON. in 61702-2371 BY MAIL POSTMARKED: APRIL 11, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. APRIL 19, 2007 JOHN CULLEN, le Dated: By: Deputy 11. FROM.: County Counsel TO: Clerk of the Board of Su 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). ( ) 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: L7/' �' y� . 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). V. BOARD ORDER: By unanimous vote of the Supervisors present: . 44"�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:z6�� ot 4, djJOHN CULLEN, CLERK, By Deputy Clerk P WARNI.N (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1. 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: af4-C7,;z. JOHN CULLEN, CLERK By Deputy Clerk STATE EARM State Farm Insurance Companies INSY0.ANCE O State Farm Insurance Subrogation Services April 12, 2007 PO Box 2371 Bloomington, IL 61702-2371 Certified Mail-Return Receipt Requested Clerk Of-The Board Of Supervisors County Of Contra Costa, � � � 651 Pine St, Rm 106 f��®� Martinez, CA 94553 APR 1 9 2001 RE: Claim Number: 05-5350-964-BLM CLERK BOARD OOSUPERVISORS — Our Insured: Courtney Smith Date of Loss : December 2 , 2006 Your Insured: CONTRA COSTA COUNTY MEDICAL CENTER Your Insured Driver: PSO officer on duty Your Claim Number: Your Policy Number: Loss Location: Contra Costa County Hospital Martinez, CA Dear Clerk Of The Board: we have been informed you are the liability carrier for the party involved in this loss with our insured. Our investigation indicates your insured is 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. r To assist you in your review, here is a breakdown of the amounts State Farm paid by Cause of Loss : 041/045 - Uninsured Motorist BI $ 042 - Uninsured Motorist PD $ 300 series/400 - Comp/Collision $735 . 18 501 - Rental $ 600/050 - Med Pay/ PIP $ Other $ Salvage Recovery $ Amount State Farm Paid $735 . 18 Insured Deductible $100 . 00 Total Claim Amount $835 . 18 State Farm is seeking 1000 of the total claim Amount Payable to State Farm: $835 . 18 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 County Of Contra Costa, Page 2 April 12, 2007 Please remit payment of this claim, or contact us to discuss settlement . Include our claim number on the payment . Thank you for your cooperation. If you have any questions, please call 877-457-8276 and any member of Team 460 may assist you. 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) use the customer information we provided for any purpose other than to evaluate and process the subrogation claim, or (2) disclose or share the customer information we provide for any purpose other than to evaluate and process the subrogation claim. Sincerely, s `4 Glenna Sutter Claim Processor (877) 457-8276, Team 60 State Farm Mutual Automobile Insurance Company Enclosure (s) * + ' BOARD of STJPI VISORS OF COMTA COSTA Com INSMR LMONS T4 A. A daim rely to S.cane of action,for death or fox injury to person or to personal prop ox growing crops shall be presented not later than six months after the accrual of the carm of act%on. A claim relating to any other came of action shall ba,preseated not loots thetn one after the accrual ofthe cause of action. (Gov. Code§ 911.2.) B. Claims must be filed with the Clerk of the Board d 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, me name of the District should be filled in. j). If the claim is against more than, ane public entity,separate claims must be filed against h public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec.72 at the end of this farm. aaaass aasonkX&iaaanalK*almaa.■■9Ratiaa%RaaaaaMMRon X"rawas=aRaw Ktaa{a,■a a a as la I asal RFs: Claim By: Reserved.for Clak's filing stamp ,wee. r m cou fh eo ;20A _ ` ` } RECEIVED Against the Cou*of Contra Cosu or ) APR 1 9 2007 �-- ) CLERK BOARD OF SUPERVISORS (Pill in the name) ) CONTRA COSTA CO. The undersigned claimant hereby makes claim againsttbe Cocmty of Contra Costa,or the above-I&imcd district in the sum of$ 8-3-5.18 and in support of this clam((represents as fo am: 1, When did the damage or injury occur? (Give date and hoar) 6 7,30 In ?. Where slid the damage or injury occur? (Include clty and county) eonfr& easy 4- 3. Flow did the damage o;injury occur? (Give full detects;use extra paler if required) i4ospjt s;ee,"r, Ve/„cle t'u raur lasereds v�htele "en l�'• wa5 parked 'un oeca.pi a. 4. What'partiaalar act or omission on the part of co"or district officers, servants, or=p ogees caused the iajury or damage? Fay&re, fo ",v/ra t v ak de 5 What are the names of county or district offices,szrvants,or employees causing the damageorn"Jury? cl kt?aon Z 'd 96L 'ON iN3A39VNVA M8 000 Ad66:( 001 ,1 'N�r �--. 6. What damage or Wurrlas do your claim resulted? (Give fall extent of injuries or dau &gcs claimed. -Attaoh-two estizuVhts for auto damage.} - . . . . 7. Flow was the amount claimed above computed? (Include the estimated amount oJ any prospective injury or daft ap.) 4:5s�1 Out 4:f, 8. Names and addrepses ofWitresses,doctors and hospitals• - L>epu�� cher:{' u�tts with seeurit� o�1cer^. , 9. List the expenditures you made on account of this socident or iulury: / �i7ATB 7 Tm AMOMW DedAcd1I1c pat'cl b� ) rtstLrea' goo 00 ad appe.K Ka a KKKr KK■a■a aaaaKEwell aZaire aa■gnat aaa eased as Kaa on was asp use as aK a as an a KK K as Ral ) .Gov.Code Seo. 910.2 provides` nw claim sball be )signed by&e claimant or by some person on his )behalf" SENT)N-OTICES TO: tAttoxa� l � --, Name anis address of A#tomey } 5t" (C 's signature) 3 } (Address) 4,12,02 : 7 Telephone No. )'Telephone No, ��` 214- Neoax aaaaa aKavail aaaaKa.aKaaala tame aKaa Ka■KK RaaKaa.KKaKaaaa add K. aKaail PUBLIC RECORDS NOTICE: Please be advised that this claim fGiM or any claim Sled with ibe County,under the Tort Claims Act,is ff bject to public disclosure under the Califamia Public Records Act. (Gov. Code, 56 6500 et seq.) Furibersa any attachments,mWendums,or supplements attached to fire claim form,including medical records,are also s bject to public disolosum. a a dud■■■aKaKaaaa as KaKKaa as aaa aaaaKAN"We�vaaKKKu�Kab be Ka.aaKla..aa aaiaFM aa1■a as Egg ataKat Section 72 ofrhe Penal Code Provides: Ery person whoa 'Prat$uftUt t0 defraud,p=uts for allowance or for payment to auy state board or c Ticer,m to any county, city, or district board or offi.cw, andoriz.ed to allow or pay the same if gemuirre, an false or fraudulent claim,bill, acccnmt voueber, or writing,is punishuble either by imprisonment iu the County iaH for a period of not more ti m one year, by a fine of not exceeding one thousaud dollars ($1,000.00), or by I oth snub imprisonment and fine, or by imprisonment i a the Mate prison., by a fine of not exosedimg ten dxMW I dollars [$10,000),or by both such imprisonment and fine, 'd 96L 'ON iN3W39b'NVA }SId 3N Wd6Z:C t00Z •Z 'NVr n.n,... RBZ0006Z date: 04-10-07 page: 1 STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY AUTO PAYMENTS BY COL claim rhes policy number .. .. ........ 0948 - 152 - 05A :..:...................:::...................................:.................:. named insured date of loss SM=TH C OURTN E Y 1 2 — 0 2 — 0 6 C O L 4 0 0 C denotes consolidated payment E denotes EFT payment P denotes previous data COL: 400 indemnity: 735 . 18 dir rcov: 0 . 00 expense: 0 . 00 payment number payee amount status COL pay cd rsn reporting party E 102425703K TRI-VALLEY AUTO 735 . 18 PAID 400 1 Named Insu •••••••. RBZ00032 date : 04-10-07 °••� time : 01 : 41 PM z4ute Via: Gentes ` �eaxzr STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY VEHICLE DAMAGE REPORT c1a�m number date of loss .... ....................................... Ps 12-02-06 Estimate Vehicle Info Vehicle Owner: SMITH, COURTNEY Vehicle Description: 05 CHRY 300 4D SED BLACK �r -4k -cert+e -.r -A- -A- -Ar -Ar �+etk -Ar �+rtAr -jcyr -A- -A- r -4L- Jk- -jC --k- -zr -Ar �k -Ar -Ar �k -Ar �k -Ar �k -.k -A- -tom 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 TRI-VALLEY AUTO BODY INC. LICENSE # :AG173640 SERVING THE VALLEY SINCE 1980 3561 FIRST STREET LIVERMORE, CA 94550 (925) 443-8548 FAX: (925) 443-0110 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: J.R. ROMERO 12/29/2006 04 : 18 PM ADJUSTER: MIGUEL RODRIGUEZ INSURED: COURTNEY SMITH CLAIM #05-5350-96401 OWNER: COURTNEY SMITH POLICY # ADDRESS : 3616 RIO GRANDE DR DEDUCTIBLE: $100 . 00 ANTIOCH, CA 94509-5419 DATE OF LOSS : 12/02/2006 AT 07 : 30 PM EVENING: (925) 757-1982 TYPE OF LOSS : COLLISION OTHER: (925) 708-8958 POINT OF IMPACT: 6 . REAR INSPECT TRI-VALLEY AUTO BODY INC. BUSINESS : (925) 443-8548 LOCATION: 3561 FIRST STREET LIVERMORE, CA 94550 INSURANCE STATE FARM INSURANCE COMPANIES COMPANY: 2590 N FIRST ST DAYS TO REPAIR SAN JOSE, CA 95131 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: VIN: 2C3JA43R65H624895 LIC: 5KQT557 CA PROD DATE: 12/2004 ODOMETER: 33672 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS KEYLESS ENTRY BODY SIDE MOLDINGS DUAL MIRRORS CLEAR COAT PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER MIRRORS POWER TRUNK/TAILGATE AM RADIO FM RADIO STEREO SEARCH/SEEK CD PLAYER DRIVER AIR BAG PASSENGER AIR BAG 4 -WHEEL DISC BRAKES CLOTH SEATS BUCKET SEATS AUTOMATIC TRANSMISSION OVERDRIVE ------------------------- ------------------------------------------------------ NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ---------------------- ------ -------------- ------- ------------ ------------------ 1# Sol AUTHORIZATION TO PAY SECURED 1 - OWNER PROVIDED 2# SO1 WITH A COPY OF ESTIMATE/FINAL 1 BILL 3 REAR BUMPER N 4* SO1 REPL BUMPER COVER W/300 , SXT 1 300 . 00* 1 . 7 3 . 0 5 SO1 ADD FOR CLEAR COAT 1 . 2 6# FLEX ADD PER COVER 1 2 . 50 T 7# SUBL HAZ MAT DISPOSAL 1 2 . 00 X 1 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: ------------------------------------------------------------------- ------------ NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------- ------------------------------------ ------------------------------------------ ------------------------ ------------- SUBTOTALS =_> 304 . 50 1 . 7 4 . 2 LINE 4 RECON COVER WAS WRONG. REPLACED WITH OE PARTS 300 . 00 PARTS DISCOUNT $ 300 . 00 -5 . 01 -15 . 00 BODY LABOR 1 . 7 HRS @$ 65 . 00/HR 110 . 50 PAINT LABOR 4 . 2 HRS @$ 65 . 00/HR 273 . 00 PAINT SUPPLIES 4 . 2 HRS @$ 30 . 00/HR 126 . 00 SUBLET/MISC. 4 . 50 ---------------------------- ------------------------ SUBTOTAL $ 799 . 00 SALES TAX $ 413 . 50 @ 8 . 7500% 36 . 18 ---------------------------------------------------- GRAND TOTAL $ 835 . 18 ADJUSTMENTS : DEDUCTIBLE 100 . 00 ---------------------------------------------------- CUSTOMER PAY $ 100 . 00 INSURANCE PAY $ 735 . 18 2 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES : B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS : #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. 3 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR3NW05 DATABASE DATE 11/2006, CCC DATA DATE 11/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS . OPT OEM (OPTIONAL OEM) OR ALT OEM (ALTERNATIVE OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OEM VEHICLE DEALERSHIPS . OPT OEM OR ALT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. OPT OEM OR ALT OEM PARTS MAY INCLUDE BLEMISHED PARTS PROVIDED BY OEM' s THROUGH OEM VEHICLE DEALERSHIPS . ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS . USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS . LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES . NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES . SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES . PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 4 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------- -------------- ---------- ------- DELETED ITEMS------- 2** REPL RECOND BUMPER COVER W/300, SXT 1 -204 . 00 -1 . 7 -3 . 0 3 ADD FOR CLEAR COAT -1 . 2 ------- ADDED ITEMS ------- 1# SOl AUTHORIZATION TO PAY SECURED 1 - OWNER PROVIDED 2# SO1 WITH A COPY OF ESTIMATE/FINAL 1 BILL N 4* SO1 REPL BUMPER COVER W/300, SXT 1 300 . 00* 1 . 7 3 . 0 5 SO1 ADD FOR CLEAR COAT 1 . 2 --------------- --------------------------- ------------ --------------- ---------- SUBTOTALS =_> 96 . 00 0 . 0 0 . 0 LINE 4 RECON COVER WAS WRONG. REPLACED WITH OE PARTS 96 . 00 PARTS DISCOUNT $ 300 . 00 -5 . O0-, -15 . 00 BODY LABOR 1 . 7 HRS @$ 65 . 00/HR 110 . 50 PAINT LABOR 4 . 2 HRS @$ 65 . 00/HR 273 . 00 ADDITIONAL SUPPLEMENT LABOR -383 . 50 PAINT SUPPLIES 4 . 2 HRS @$ 30 . 00/HR 126 . 00 ADDITIONAL SUPPLEMENT MATERIALS/SUPPLIES -126 . 00 ---------------------------------------------------- SUBTOTAL $ 81 . 00 SALES TAX $ 81 . 00 @ 8 . 7500°1 7 . 09 ---------------------------------------------------- TOTAL SUPPLEMENT AMOUNT $ 88 . 09 NET COST OF SUPPLEMENT $ 88 . 09 ESTIMATE 747 . 09 J.R. ROMERO SUPPLEMENT SO1 88 . 09 J.R. ROMERO -------- CUSTOMER PAY $ 100 . 00 JOB TOTAL $ 835 . 18 INSURANCE PAY $ 735 . 18 5 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES : B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS : #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM. 6 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DR3NW05 DATABASE DATE 11/2006, CCC DATA DATE 11/2006, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS . OPT OEM (OPTIONAL OEM) OR ALT OEM (ALTERNATIVE OEM) PARTS ARE OEM PARTS THAT MAY BE PROVIDED BY OR THROUGH ALTERNATE SOURCES OTHER THAN THE OEM VEHICLE DEALERSHIPS . OPT OEM OR ALT OEM PARTS MAY REFLECT SOME SPECIFIC, SPECIAL, OR UNIQUE PRICING OR DISCOUNT. OPT OEM OR ALT OEM PARTS MAY INCLUDE BLEMISHED PARTS PROVIDED BY OEM' S THROUGH OEM VEHICLE DEALERSHIPS . ASTERISK (*) OR DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS . NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS . USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND BENCHMARK PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS . LABOR OPERATION TIMES LISTED ON THE LINE WITH THE NAGS INFORMATION ARE MOTOR SUGGESTED LABOR OPERATION TIMES . NAGS LABOR OPERATION TIMES ARE NOT INCLUDED. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES . SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES. PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 7 12/29/2006 AT 04 : 18 PM JOB NUMBER: 5636 13472 SUPPLEMENT OF RECORD 1 WITH SUMMARY 2005 CHRY 300 6-2 . 7L-FI 4D SED BLACK INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 8 # .�..- {a4p�,� 4 jai 4 �f R i j � „ ,�. :..�++..:MA-+Rs. ti. j 4 ,� t �[F i .. .. : . ,. .. � ar w�Y �_ "�� - ,a-•�- �,�` ,�""� �:,.,- K � .tt «�. �.r {PNS? , � ;1M+v Y.e� yy, r �^e R' ! 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BOX 2371 ?OCl6 2154 0004- -6345 7b � i s MAILED FROM ZIP CODE 6170 Bloomington, Illinois 61702-2371 FIRST—CLASS MAIL r GIERhrp�11FlA�t.. C40PN 166-1031 A-01• Printi y0,�, Subrogation Se STATE FARM IN 02 1A $ 05-30C 00 P.O. Box 2371 7806 2150 8004 6345 762 LL oo0as2sssa APR 11 2007 ^{ . MAILED FROM ZIPCODE 6170 s Bloomington, Illinois 61702-2371 ' art,, RREWC.LA8a A L F}« U r d�Y V 'fi 4 O , O � 4 F ? s APR 1 9 2001 • CIERKCONRRAO� Ala >_ CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY r BOARD ACTION: MAY 22, 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 R!PR on your claim by the Board of Supervisors. (Paragraph IV below), 2 0 2007 given Pursuant to Government Code AMOUNT: Section 913 and 915.4. Please note all $2,000.00 COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: DENNIS N. SMITH ATTORNEY:UNKNOWN DATE RECEIVED: APRIL 20, 2007 ADDRESS: 3906 PEACHWOOD DRIVE, BY DELIVERY TO CLERK ON: APRIL 20, 2007 CONCORD, CA 94519 BY MAIL POSTMARKED: APRIL 19, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Cl Dated: APRIL 20, 2007 By: Deputy 1,1. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( 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 wailhing of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: `�`�oZd� �� By: ���Deputy County Counsel III. 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). V. OARD ORDER: By unanimous vote of the Supervisors present: (v)� 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:/& dt� J OHN CULLEN, CLERK, By eputy Clerk WARNI.N (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 tile a covet action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. if you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that i am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: L"V l '29 "��� JOHN CULLEN, CLERK I B �Deputy Clerk ' r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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.) 3. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Adn.iinistration 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. 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. ■tat a a■aa an Rua a■a a a a t Mist a t at a no as a■aa■auuu■Run at L a t t a as IRRIEYl■a a to a a■es go 11 RE: Claim By: Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or. j APR 2 0 2001 District) CLERK BOARD OF SUPERVISM (Fill in the name) ) CONTRACOSTACO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ l.,rX6 and in support of this claim represents as follows: 1. When did the age or injury occur? (Give exact date and hour) //0 7 2. Where did the damn a or injur,y occur? (Include ci d county) Z,/2 e/o +ti'scR 0 C.4 3. How did the damage or injury ccut�rr? (Give full details;use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? �/ P /— vM /I o 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 claimed. Attach two estiin7tes for aup damage.) < 06 d#.-- ai^z p� 7r rz 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: B� vTNr/c Iste�T , N. Law t�'3�' /,0/ _� '`1FF 9. List the expenditures you made on account of this accident or injury: DATE TIME p AMOUNT ✓ r. 2 GG d' H9 f ti o 6 JTZ r� ®n (.cw�:y ��4 4Lt°✓ ■aa\asasaanaaaana sign calms a Kansas•a■s[s■naalna[nig[ala\+!!r!a•al![s\sn■++ala[+■aeleln si .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney_) 1 Name and address of Attorney ) /] (Claimant's Signature) } (Address) ) Give dab ���/r v Telephone No. )Telephone No. ?2- Z noanss[lasanInsRama la![aanaaa an l alualaal a a as Russ aaIngo ERR a■■■s llasln■MR a a ass aa■a s sn f PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the CoLmgl under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, s"5 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. l lata all nlla■■Dn t++■!lana Basil awls!la■■as■no\an%asnalaatSam■\!l■![q\aa■an noun aaalna[st 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 foie, 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. 02280 CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER DISCHARGE INSTRUCTIONS DOCTOR DISCHARGING: SMITHDENNIS 125 592-5915 AD O See printed list of medicines to take fter discharge. Note that this list also contains at n r 'l home medicines you should STOP taking. 7 /28 / 1947 `r11 L D F I N r , c 1 1. A M HOMEDOSE ROUTE FREQUENCY SP CIAL I TRUCTION NEXT DOSE DUE MEDI INE (food/drug interactions k t .. H 1 a k. P � , 4 f UP ! �I fifes r; G I DIET - l f, l O Check & record weight daily ACTIVITIES OK TO DRIVE DYES ONO PRECAUTIONS BATH/SHOWER O YES O NO EQUIPMENT COMPANY PHONE WOUND CARE INSTRUCTIONS SUPPLIES OTHER SPECIAL INSTRUCTIONS y� r 1 ',' ftQtY42-11 f you are a smoker, stop! elp is available at 1-800-NOBUTTS. Smoking can cause heart & lung disease. O HOME HEALTH O HOSPICE AGENCY PHONE PHYSICAL / OCCUPATIONAL THERAPY O PNEUMOVAX GIVEN O FLU VACCINE GIVEN (OCT-FEB) O PRINTED EDUCATION MATERIALS GIVEN TOXATIENT. SPECIFY: W.J DOCTOR / OTHER DAY / DATE TIME HEALTH CENTER LOCATION , CUI �.� (err" ;,1- ui �I ^�,t,.� t aoc ) U Q TO SPEAK WITH AN ADVICE NURSE, CALL 1-877-661-6230 EMERGENCIES, CALL 911 I UNDERSTAND THE ABOVE INSTRUCTIONS Signj"fid of pa ien[7patient' legjal 'representative If signed by other than patient indicate relationship,' r Z. Date Time Nurse's signature, Title Print Name Original: Medical Record DISCHARGE INSTRUCTIONS MR376-7 (10/30/06) Yellow; Patient/caregiver. . r ; n , al:rrNI MC^'1 925 682-51115 A0 f CONTRA COSTA r. HEALTH SERVICES % uILOFIR[ . CONSENT TO SERVICES AND CONDITIONS 7 /2P/ 1947 CrLA[ iti 1 X07 OF SERVICES AND OF ADMISSION �1 MEDICAL/SURGICAL TREATMENT CONSENT: The undersigned consents to the procedures that may be performed during this hospitalization or on an outpatient basis, including emergency treatment or services, which may include but are not limited to laboratory procedures, x-ray examinations, medical or surgical treat- ment or procedures, anesthesia, or hospital services rendered the patient under the general and special in- structions of the patient's physician or of any other member of the hospital or health center's medical staff, including physician residents and independent contract physicians. The undersigned further agrees to the pro- visions expressed on the reverse side of this form. TEACHING PROGRAM: The undersigned understands that Contra Costa Health Services, Contra Costa Regional Medical Center and Contra Costa Health Centers are teaching institutions and that residents, interns, and health care students, under the supervision of professional staff, may be involved in providing medical and/ or health care. CONSENT TO RELEASE MEDT-CAL ELIGIBILITY: The undersigned authorizes the Contra Costa County Employment and Human Services Department to release information concerning the status of the patient's Medi-Cal application; and to send information regarding the patient's Medi-Cal eligibility to the Contra Costa Health Services Department. The undersigned also-authorizes the above Agency to send Contra Costa Health Services a Letter of Authorization, to allow the Medi-Cal program to be billed for any medical services re- ceived at a county facility that may be covered by the Medi-Cal program. FINANCIAL AGREEMENT: The undersigned promises to reimburse the County of Contra Costa for any services not covered by Medicare, Medi-Cal, insurance, or any other health care compensation carrier, at the rates established by the Contra Costa County Board of Supervisors during the time this consent is in effect. This consent is valid and in effect for any hospital, outpatient, emergency or other medical care and/or ser- vices rendered to the patient at any time within 365 days from the date indicated below.The undersigned fur- ther agrees to use any damages or indemnity paid to or on behalf of the patient as a result of the injury or illness which necessitated this care to reimburse`flie county up to the amount billed, but not to exceed the rates set by the Board of Supervisors. —continued on reverse The undersigned certifies that he/she has read the foregoing, received a copy thereof, and received a copy of the "Patients' Rights", and is the patient, the patient's legal representative, or is duly au- thorized by the patient as the patient's general agent to execute the above and accept its terms. 12, LZ r^ DATE SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE 1 / WIT 0 GNAT R IF REPRESENTATIVE, STATE RELATIONSHIP If patient unable to si n,S TE REASON: Date By ADVANCE DIR CTIVE (E D, inpatient) ACKNOWLEDGMENT OF HIPAA NPP Do you have an Advance Directive? O Yes Cl?�No If yes,will you provide us a copy? O Yes ENO Place sticker here If"no",was an Advance Directive if signature not already obtained. pamphlet given to you? C Yes i-No — Date MR463-1 (11-06) Side 1 Original: Chart Copy 1: Patient Accounting Copy 2: Patient :1 CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS EMIT•; CfgNIS AMBULATORY CARE t+ 7 ? Q / 19 a 7 925 hat -- CONSULTATION FOLLOW-UP z 14 tdll ' F I ^i " ILA MC r C NOTE: This form is to be used for consultation follow-up (off-site and same-site) and for patient initiated Specialty Care. CONSULTANTS REPORT s Date of Visit: [❑ Self Referral] Clinic Type: 07 NIS 2 Send Reportto: ❑AHC/AMC ❑BHC ❑BPFHC C/AMC ❑MTZ ❑NRCH ❑PHC ❑RHC --- Chief Complaint: Allergies: Pain: ❑ Nom ❑ Yes: Intensity: FINDINGS / Nurse Signature [❑ Dictated (If so, please write diagnosi and plan below.)] Va - ; 6 :LAl -L LZAChart Check to PCP? _ ❑ Yes ❑ Nof1 Original:Consult Site Consullan a d sigp5 - Date Yellow: Requesting Site ; ' MR191A-0 (4-01) Pink: PCP AMBULATORY CARE CONSULT/I=TION FOLLOW-UP P. t, ., . „ c / . _ \\ � ��� �/ Iz # 0 CC \ U C <Z LLA a \ in � \! ® \ © 3 . } Q4 , « / 4 / o y � � • § ` . � . Q ++ 70 yam/ �H CA •Z � •N ' � cnU) �¢ovvt—c �o ® o "O d+4 =?4,U Q QZ LU Cl. 0 0 ul d. ¢ Cl) L N m a N V ( iii Qs �Y v ,r, y. 0 r o f CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 22, 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. 91L ale you is your notice of the action taken ( on your claim by the Board of / APR 2 0 2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL AMOUNT: $4,621.35 MARTINEZ CALIF. Section 913 and 915.4. Please note all ". CALIFORNIA STATE AUTOMOBILE ASS "Warnings . CLAIMANT: FOR: TAEJUNG/KEVIN KIM BY: KEVIN MATTHEWS ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 20, 2007 P.O. BOX 920 ADDRESS: SUISUN CITY, CA 94585-09203Y DELIVERY TO CLERK ON: APRIL 20, 2007 BY MAIL POSTMARKED: APRIL 19, 2007 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, .lerk Dated: APRIL 20, 2007 By: Deputy . II. FROM: County Counsel TO: Clerk of the Board of S ervisors ( , 4his 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 911.3). O Other: Dated: �' oZ5-D� By: r'Y1 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. ARD ORDER: By unanimous vote of the Supervisors present: (1,f 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: lZft 0:2'02 AN CULLEN, CLERK, By Deputy Clerk WARNIN Gov, code section 913) Subject to certain exceptions,you have only six(6) months trom the date this notice was personally served or deposited in the nnail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN JOHN CULLEN, CLERK By Deputy Clerk O California State Automobile Association Inter-Insurance Bureau P.O.Box 920 Suisun City,CA 94585-0910 April 18, 2007 RECEIVE® APR 2 0 2007 Contra Costa County Clerk Board of Supervisors/County Admin.Bldg.Rm. 106 651 Pine Street CLERK BOARD OF SUPERVISORS Martinez,Ca. 94553 CONTRACOSTACO. Re: Insured: Taejung/Kevin Kim Claim No.: 03-KC9987-6 Date of Loss: 01/25/2007 Dear Contra Costa County Clerk Board of Supervisors/County Admin.Bldg. Rm. 106: We are investigating this loss which occurred as follows: When we have concluded our insured's claim,we intend to recover damages for the loss from you. Attached are the itemized bills to substantiate our subrogation claim. As we have paid this claim,we have a right to recover from you. If you are not insured,please make your check or money order payable to the California State Automobile Association Inter-Insurance Bureau. Repair Bill $4,621.55 Deductible $0.00 Loss of Use $0.00 Tow/Storage $0.00 Miscellaneous $0.00 --- ---------------------- TOTAL $4,621.55 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 not 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. If you have insurance,please contact us immediately with your insurance information. A return envelope is enclosed for your convenience. cSiincerely, Jt,wt n 1l ryyl La,G we , Subrogation Specialist 888-900-6520 extension 6241 Fax 707-863-9052 F268K(Apr 2002) Fax: R r 17 2006 09:22am P001/003 -r •••, ++ �..• w+vrr�tcv v u� uPtiKAl:llu'1A C.:UU ' T 'TRU PWS'Tt]CTMAN'[' - 01 N A AA claim�pTafing#a a 093].5 Of B ATZ f07 dem OI MM t0 P=M Or t1DPe30rie1 — or ^ FWM mps'sbaU be yms=t-d not Idea t m sig=g&s after &e ar ud of rho m of o action. A clain t kdtLta to anp otbLer cense of mtian shell.be_presented n0i Inez tlEft gear _ afkf tb6 bzanml ofJ6 c girt q action. U ' (Gov.Cods§911a) m B. Claims mast be Zed. 4vi& flie CIE& of fie Board of Supe-visors of tis office in Roo 1061 j ' GOi1S Y Add, i ni�Binding,651 Pine S't ri%, Web!%CA 94553. W • w C 1f ciabn is agaipgt a dig gnvemed by the $onrd of Supervisorss rather tbmt the co= the • nvnza wJ•�L,.'h:..�!ra-L��_9! i_ res • . � DECEIVE® APR 2 0 2001 CLERK BOARD OF SUPER4ISORS CONTRACOSTACO. Fax: Apr 17 2006 09:22am P002/003 APmst60 Carmiy of Chatra Caste.m ) � UistdcQ . Tko mA=Pod ciatman'baeby ups claim ap mst for Cnunty of cagm cosh or the ab district im 60 stun of Z i S and ire.snp Sort offis cl=rets as totlum: f '-6+ DRwt A-e- 1 Wye did iha �. damap;0 az I f o=lr? (Gin exactds[e=a how) !4 : 2. Whore&d fie damage Drcy orcin? Una uda city and county) t3GiV {t9 _ 1 Cow-o2b� 6YJ-r+t A Gos-rtl 3. Sow dict.tie damage.or iaj>ary o==? (Give fun dotk=mchu pq=ifm;j*r4 Fax: Apr 17 2006 09:22am P003/003 'What d map or "Rpmes do your claim resulted? (Give fall effete d of injuries ordia mgt* ~tlaime&-Attach two astb m a[ca for auto denmpe-) - lir was tlo smomt clamed above Computed? (Emdude� es(mated 6=0mf a �y mar` ' ,) t,L SUeP60:1-lVJ&? #�DCUr►nP.nr�S �►jc(,UD--P-Z Names and addresses of wihmes,doetom,and hospitals: List the cV�a,Aiba=you made on awo=of this aoddmt or h3j - ' DAM TIME AMdt� 'asaaaassas as gas an as Ana akata a►a asasaa aaa Rt a t t as aR■an■s=a asaa ata as KKR a as a t=ansa asaa )-GCs'•Code See.914.2 provides"The Claim ShDB be jd by•f1C daunt crby so=Pusim on has b6da - `eme ane address of Attnmey ' ) (Ciaamaut's Si�sat�e, (AAdre") • w -717 e1ppJ el�1a. )T4cpbune No. $—`�bbSZ Ca }c(o 7, InIaft*[aeries an Nil R.aaaa asp,,,,a ago I&,,a...%&now% MaRmw ■saga, "til PUBLIC PYjCORDS NOTIMs lam k advised that ibis cWm farm,or mW daim Mcd with the Comity under the Tort claims A�is jeet to � ablk dwkwm tmdilia Ca1;-Eemk Public R=%* Ant (Gain. Code, s5 6500 at wq) Fmdtwn Mr. HilY Machmimbi addendnms, or sngplemeats axfldmed in the alernm farm,iaClndmg medical ,are aisn •echo dac disal , asRskr;aaaa as an a it a s sass a a Mas at as Alla■Elk&aa•ll aa�astlat=aaaaa a ata as■a==Eat as sma a WAR,vas sills • NOTIM- ecdm 72 of*9 Pmd Code pruvi& VeTy Persona wbi%wb kwstt to defaud,Press inr a awmmn or for pq=mt to wY 8taD baud or ,or mW away, may, ©r cH9diit boned or of=, em&wimd to sllaw Cr gay the smn ff M=ba, false or :ate claim,bbl,a=mp vouches,or vntn&b punishable either by bVdwmamt in&a Cmm* •amu for a %dod of ads mora tl= one year, by a&c of not Wil;one tfio =4 dnIn (51,0001.001•), or by smb nPdwnmmE aosl ar by imprimment m t]x subgrisg% by a fie of net a ag tiff th dollars 810,4tlD�Cr by bo$z such impaisemme�cad fie. , £ d HPON Alffiovffl NSTN 003 Wd91 :A ;AV $ 'NAW Date: 01/29/07 03:54 PM Estimate ID: 7175 E slim ate Version: 0 Committed Profile ID: CSAA Mike Rose's Auto Body, Inc. 2001 Fremont Street Concord,CA 94520-2626 (D25)686-1739 Fax: (925)686-1744 Tax ID: 94-2611349 BAR#: BAR#AA076624 EPA#: CAD 981159189 Damage Assessed By: COLIN KENDALL t` Condition Code., Good 0 Date of Loss: 01/25107 Arrival Date: 01126/07 N Payer. Insurance Deductible: WAIVED 0' Claim Paid: N N File Number. P CD Policy No: KC99876 Claim Number: A03KC9987801 N Insured: TAEJUNG KEVIN KIM V m Mitchell Service: 918120 D 7 Description: 2005 Honda Civic EX SE Vehicle Production Date: 5105 Body Style: 4D Sed Drive Train: 1.7L Inj 4 Cyl 4A FWD W VIN: 2HGES267X5H597484 License: 5MKH649 CA p l Mileage: 20,920 OEM'ALT: A Search Code: 0629544 Color. BLUE MET Options: ALUM/ALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION,AM-FM STE REO/CD PLA YER(S INGLE) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, REMANUFACTURED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE RON—ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS." Line Entry Labor Line Item PartType/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 800763 BDY REMOVE/REPLACE EXHAUST MUFFLER 18030-SSD-A00 17720 02 2 800815 BDY REMOVE/INSTALL R W/SHIELO PILLAR FINISH MLDG Existing 02' 3 900500 REF` REPAIR SUBSEQUENT VEHICLE BAGGING "Qual Repl Part 0.00' 02' 4 900500 BDY` ADD'L LABOR OP CORROSION PROTECTION(A PER PANEL) "Qtsal Repl Part 10.00' 05' 5 900500 REF* REMOVEIREPLACE FLEX AGENT "Qual Repl Part 7100' OA` 6 900500 BDY' REMOVEIREPLACE SOUND DEADENING MATERIAL —Qual Repl Part 15.00` 0.1' 7 900500 EiDY' REPAIR PULL 1 SQUARE REAR FRAME RAILS/QTRS Existing 310` 8 900500 BDY' REPAIR ROUGH PULL REAR BODY 8 FLOOR Existing 110' 9 800816 BDY REMOVEIINSTALL L W/SHIELD PILLAR FINISH MLDG Existing OT 10 801642 REF BLEND R REAR DOOR OUTSIDE C 02 11 801643 REF BLEND L REAR D 00 ROUTS IDE C O8 ESTIMATE RECALL NUMBER: 01/29/07 15:54:20 7175 UltraMate is aTrademark of Mitchell International Mitchell Data Version: NOV 06_V Copyright(C)1994-2003 Mitchell International Page 1 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 01/2910703:54 PM Estimate ID: 7175 Estimate Version: 0 Committed Profile ID: CSAA 12 801662 BOY REMOVE/INSTALL R REAR BELT MOULDING 03 13 801663 BOY REMOVE/INSTALL L REAR BELT MOULDING 03 14 801664 BDY REMOVE/INSTALL R REAR DOOR MOULDING 03 # 15 801665 BDY REMOVEANSTALL L REAR DOOR MOULDING 03 # 16 801718 ROY REMOVEANSTALL R REAR DOOR TRIM PANEL INC 17 801719 ROY REMOVEANSTALL L REAR DOOR TRIM PANEL INC 18 801774 BOY REMOVEANSTALL R REAR DOOR HANDLE 0.7 # 19 801775 ROY REMOVEANSTALL L REAR DOOR HANDLE 0.7 # 20 801921 BOY REMOVEANSTALL R ROOF SIDE MOULDING 03 21 801922 BOY REMOVEANSTALL L ROOF SIDE MOULDING 03 22 801923 ROY REMOVE/INSTALL R ROOF DRIP MOULDING OS 23 900500 REF' REFINISH/REPAIR R ROOF RAIL EDGE OVER DOORS Existing 08' 24 900500 REF' REFINISH/REPAIR L ROOF RAIL EDGE OVER DOORS Existing 08` 25 801924 ROY REMOVEANSTALL L ROOF DRIP MOULDING 06 26 803561 ROY REPAIR R QUARTER OUTER PANEL Existing 55`# 27 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 2.0 28 803562 BDY REPAIR L QUARTER OUTER PANEL Existing 651# 29 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 18 30 802083 REF REFINISH LUGGAGE LID OUTSIDE C 1B` 31 SPOT BASE BLEND WITHIN 32 802089 ROY REMOVEANSTALL LICENSE PLATE GARNISH 03 33 802090 BDY REMOVEANSTALL SPOILER 05 34 804500 ROY REPAIR LUGGAGE LID PANEL Existing t.0` 35 803534 ROY REMOVEANSTALL LUGGAGE LID LOCK CYLINDER Existing OX 36 802138 BDY REMOVE/REPLACE LUGGAGE LID EMBLEM 75701-S5A-WO 17.33 02 37 8012315 REF REFINISH FLOOR PAN ASSY 08' 38 SPOT REAR FLOOR 39 802318 BOY REPAIR REAR BODY PANEL Existing 4D'# 40 AUTO REF REFINISH REAR BODY PANEL C 1.1 41 802323 ROY REPAIR REAR BODY FLOOR PAN Existing 3.0`# 42 802995 BOY REPAIR R REAR BODY SIDE RAIL AS SY -S Existing 151# 43 804530 BOY REMOVEANSTALL R REAR BODY SIDE TRIM PANEL Existing OA'# 44 900500 BDY' REMOVEIREPLACE ROPE BACKGLASS MLDG "Qual Repl Part 4.00OA` 45 804531 BOY REMOVEANSTALL L REAR B OD Y SIDE TRIM PA NEL Existing OA`# 46 803013 BOY REMOVE/INSTALL REAR BODY TRIM PANEL Existing 02' 47 802382 ROY REMOVEIINSTALL R REAR COMBINATION LAMP 03 # 48 802383 ROY REMOVEIINSTALL L REAR COMBINATION LAMP 03 # 49 802398 ROY REMOVE/INSTALL R REAR INR COMBINATION LAMP 03 50 802399 BDY REMOVEANSTALL L REAR INR COMBINATION LAMP 03 51 AUTO ROY OVERHAUL REAR BUMPER COVER ASSY 12 52 804280 ROY REMOVE/REPLACE REAR BUMPER COVER Remanufactured 195.00' INC 53 AUTO REF REFINISH REAR BUMPER COVER C 23 54 804286 ROY REMOVEIREPLACE REAR BUMPER IIVPACT CUSHION 71570-S5D-A01 5658 INC 55 802443 _ROY REMOVEIREPLACE REAR BUMPER REINFORCEMENT BAR 71530-SSD-AOCZZ 11383 03 # 56 AUTO REF REFINISH REAR BUMPER REINFORCEMENT 1.0 57 803024 BDY REMOVEIREPLACE REAR BUMPER ADHESIVE NAMEPLATE 75722-S5A-000 1&70 0.1 58 803029 ROY REMOVE/REPLACE REAR BUMPER ADHESIVE NAMEPLATE 75723-SSA-A20 8.37 0.1 59 804669 BOY REMOVE/REPLACE REAR BUMPER ADHESIVE NAMEPLATE 75731-S5A-A30 25.13 0.1 60 AUTO REF ADD'L OPR CLEAR COAT 25' 61 933006 FRM ADD'L OPR FRAME/RACK SET UP 15` 62 AUTO ADD'LCOST PAINT 440.10` 63 AUTO ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00` ESTIMATE RECALL NUMBER: 01/29/17 15:54:20 7175 UltraMate is aTrademark of Mitchell International Mtchell Data Version: NOV 06_V Copyright SCJ 1994-2003 Mitchell International Page 2 of 4 M Ultraate Version: 5.0215 All Rights Reserved Date: 01/29/07 03:54 PM Estimate ID: 7175 Estimate Version: 0 Committed Profile ID: CSAA -Judgement Item #-Labor Note Applies C -Included in Clear Coat Calc Remarks PRELIM Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 37.1 62A0 0.00 0.00 2,30020 Taxable Parts 648.14 Refinish 16.3 62A0 0.00 0.00 tA10.60 Parts Adjustments 20.86- Frame 1.5 62A0 0.00 0.00 93.00 Sales Tax Ld, 8.250% 51.75 Non Taxable Labor 3A03.80 Total Replacement Parts Amount 679.03 Labor Summary 549 3A03.80 Ill. Additional Costs Amount IV. Adjustments Amount Taxable Costs 440.10 Insurance Deductible WAIVED Sales Tax 8250% 36.31 Customer Responsibility 0.00 Non Taxable Costs 3.00 Total Additional Costs 479.41 I. Total Labor: 3,403.80 ll. Total Replacement Parts: 679.03 01. Total Additional Costs: 479.41 Gross Total: 4,56224 IV. TotalAdjuslinents: 0.00 Net Total: 4,56224 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY BARRARTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, BATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Point(s)of Impact , 6 Rear Center(P) Insurance Co: AAA Address: 2055 MERIDIAN PARK BLVD. CONCORD,CA 94520-6767 Telephone: (510)6712708 Fax Phone (510)6897939 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS ESTIMATE RECALL NUMBER: 01!29/07 15:54:20 7175 UltraMate is aTrademark of Mitchell International Mitchell Data Version: NOV 06_V Copyright(C)1994-2003 Mitchell International Page 3 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 01a9/07 03:54 PM Estimate ID: 7175 E slim ate V ersion: 0 C om mitted Profile ID: CSAA SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Company Code: Drop Off Date: 01x'26)07 Time:02:00 Repair Dates: Promise Date: 02/16)07 StartDate: 0113D/07 Is Vehicle Driveable(YIN)?: N Assisted With Rental(YIN)?: N ESTIMATE RECALL NUMBER: 01!29/07 15:54:20 7175 UhraMlate is aTrademark of Mitchell International Mitchell Data Version: NOV O6_V Copyright(C)1994-2003 Mitchell International Page 4 of 4 UltraMate Version: 5.0215 All Rights Reserved px` ''.' .+ea gym, a8 r ` A,Mg,"f mw � t AM xe €a a8888888 MCA F Y �s xx P ? s A e� a x kgs �x'P: ��. '� �s,� �? k� s� s �+� ��5 Y" .[ 'k �„ � � t i a � � re � m £ gb F�= ® �� �{ ,._ ,n�.. � �+4 Fo#- ua�{, ��. �` "�`` � " r�' ' - �- �� =fin � ���m. s �.�.. m ��• �Y a+j @ S +e i�m�.. 3 Y s��� � �� �' n r$ x � r" �.�.m � ��.., '% _ r ��� y �i; d �_ � rt ,P w, � �S �A h o�� —$ Q � m ��m� b I¢�6� vl��n���. ['. & , �e ��,°` t �� a,�� »� u� .�.�. x as k 0g y 4M ffis- Pi. }P $Y'e-0 w 1 N Klwa ��r Urex ara � a i s _ 'P � l A 1° a";t a-" % �0 �°� x i M av `sysa rr' s 3 . kY r ON's..:. sz N xg a ,3 N vt 04 TJ FAX T RM r re if _� a ® a 0 { ."off ZI ly,all K MAP � w �F t a b � a ( n x a - sI� y n�Yf S rv� lzz � 41a 6c a i'kt '.m:.zP i, .§+ ;�"' �uva�..u.mxa.wss.�: 4�F � •�",� .»,xmc,,:m., ...€ # x.�,X. '�. e � � I ��, �a � ��i i , �w Ii�il is , . I �� � � ;�. Y Fk Ili I �+��� � ��If� ;, q I�� s � �` f. iu�� I a� i ���� i��§�� �:,� b �� r. >, < . it i � �� � � fit. .0 Ili ;re -; �E . ., — � ,� e ,sem,- �,,, x � ��, r s� y�.���-ate ,, f�°"P �.� �-7�"� � - dam '" vs_��° �. � z� '� �`k ��,vn'�� - � w ;� m � � °� � �� ���a ry m - gam�.�� �t„ ` ,"� �" ��"� '�" -�. _ �...� � E sem. � ��°� P � � �,�` ���, ,;. �4x��,;.���. �4: � ,�,p �-�� �,��a i a � #'o-•. � ��ea ,..8 � � � e ta '�.e � £ �� � ,.�",�,ah x s� x at m '�a s "�« " �" a'a''"�"' :�m — n� ism" �" °3,'� a ��. �" � �� a f" .' t Alf `.$ j 7L gip act K- 31" IiT b MAN IWTJ m . s qg OIn 7701 POP r �2 A 3 k �...k � e a#� �w� � r � ^ ✓u'� g, m hvcia3."aq' ^' � � g��a+° $ Ad Fl x. t'soga eT +re ;,Efl �. E AKIWO .—W 11 off-, °a.. att °a �� f & i' j fi" r• law Itl n� s� �r s.�^a P x„�-,.0� "��a�q i� ���������I�����"�� � v� 7tik"�"r�"`°x'�"a¢ q`'>!� •: i fr gg v�i j� € �'n°,,t;cu�s,k e�ti ",ae. st.. ,�ek '� � "�'u'�. ,a §t��� swwws�t Sem�` w''r. c '�,'$ �wa�`+� "°� •F ��`sa.�a.e �w n.-trail z s Ir x. ua3" e€ M a "s� zit x a= 4 k 4� 2 g�a 7 s -ANT@,Pr'x+ m act � r�,-j � e+ a•<. " 777,VON "' a . oil- ✓ .wua i°�'°`^ a �"�' r 4a:«4 "�`� ��` � �. �'-�' �,s s 'a na "� >,�'a. e r^ a sh. §a �„ ��� �� ��, .�,�&'gam� k,,.�a P a � ^ - �s�cemi•"Ea� �i° & ! "s�'3" .ms�fb"",N �, e g? °' S a �a��� a� ,. m F 3 .x �.�6� •.�� *s � as""if�,. �s`�''� �d � gra dt � jr r x fr. y a .""W4 a r d Y" "t" �`N t MV Tab ,- ' w A i P .m m 11 PROPIR m r � ys N. d g � C Kk '"s.i,.b," s f�,.tx yet, 'PINS � v�� *e �»-fia t^ wR"�` s�`e � 'c' � „'� u'�' �� s�� �ere'��*z .;'�. �FA � '� z '�,�,•r `t` r* � Q �# .e 'e�n'�S''i.��.i[?-arc+ , A�- g Z��was F�m+ t�� �d�,�.�i�� �g=rP'"" �.,��a �s ;Ry�ga•a � i �`a�",�-a= s �.,3.Yh RM-d1� ,� r� a b� "'t. �,a: ,�!�'�° �rR`�w'+°•»,'R+cs[�'"*� .a �.k� t � X x���&+wx*p=agF m �� `"'m e.,�y�®�.�0r a n .�4 � k Ex "F, .x-x-' ,g . dp d°�%z x ingg ` ,''F' ux IN` � � a� F-x ,FY * a ✓ x'x' x 4 `i' 'rr. Re'a .d' - ��`P">ro "" ®k �,,�C *.a°ra �`«xa�snIX,a��'f" �p°+`+'� � �- � �re'�"3 + � xr�*' `�": '�TMs"� � �, N �+ W^b`+�, ,�s.:xizt'�9',f ak�`��a r �e a a-e�.�P*'vit�' r. *:�- �' +"� h y� Xu�� �q.' R..^i`�+ie$ t�"�4 � ���i �S •ems �kS� x �_'. ., MINK"". OR r'Sc•'�'„' j�T=p t - w Ent�2�*Y'psi 4 k+= - � r' a a 'x R:. m �9�3 'fes X18' � � � i..F". Apr•. 4 a� � .rry a T v Z r w?o-��a•=^ ,k '.w Ef �r '� a � �k '° "� ��,�nakr5 k �� ����� am-c �� 4��A� J"�4�✓' i'S xa�-, s � a� �Xl, x- � esu," w ,f• �, ,k'�, ;,w ��`� as� s� � � _ Omi IX 66, �°? � s rT t're£gym. ,.� P�'�TX' .ff... &Rwn �"4��Xt9 y. ,� �•� �` +� �n f, M � t9t99ss r n roff; m' AA &qrw �e ry r n tk �Fa"ib0. �ryg° F � $ s hw 9*'e �-�'; ®a` 'R � � w���s ,�R*m�, �• p_;�" 5 'ti - �d m,��F� � � � 3 xI q a ` s z � PAY, d �«@ b °s MM-- 515 a - % a g}�J 'gym mX 3 A � r 2 a4ej.a � � t } t M ICm v , 16 T: � w w � n � x Ali a a / w � AW k #a w a C�G �,,x$ �, d �rE • Fffin T tea"^ e e 3 �,�. <d S a iXx4 e.� Z ,mss +� M� ��°aam � ad$ ate¢ "' � ,a 5� �� '•,�� k"# A��.'�K"�5°� �q; �ad ��� � �y spa r✓^ d � ��� �;, x � �� w� ;a�� # r :rt ----------------- ai3°p Date: 02/19/0712:16 PM Estimate ID: 7175 Estimate Version: 1 Supplement 1(F) 02/15407 09:12:40 AM FINAL Profile ID: CSAA Mike Rose's Auto Body, Inc. 2001 Fremont Street Concord,CA 94520-2626 (925)666-1739 Fax: (925)686-1744 Tax ID: 94-2621349 BAR#: BAR#AA075624 EPA#: CAD 981159189 Damage Assessed By: COLINKENDALL Supplemented 8y: COLIN KENDALL r• O 0 N Condition Code: Good Date of Loss: 01/25,07 Arrival Date: 01/26/07 N Final to Owner. 02/1547 CD Payer. Insurance Deductible: WAIVED Q Claim Paid: N N File Number. F t) Policy No: KC99876 Claim Number: A03KC9987801 r~ W Insured: TAEJUNG KEVIN KIM 0 W 7 Mitchell Service: 918120 W W Description: 2005 Honda Civic EX SE Vehicle Production Date: 5105 LWJ Body Style., 4D Sod Drive Train: 1.7L Inj 4 Cy)4A FWD VIN: 2HGES267X5H597484 License: 5MKH649 CA Mileage: 20,920 OEMiALT: A Search Code: C629544 Color. BLUE MET Options: ALUIWALLOY WHEELS,AIR CONDITIONING,POWER STEERING,POWER WINDOWS POWER DOOR LOCKS,TILT STEERING WHEEL,CRUISE CONTROL,ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION,AM-FM STEREO/CD PLA YER(SINGLE) "ALL CRASH PARTS ON THIS ESTIMATE ARE "NEW" ORIGINAL EQUIPMENT MANUFACTURER PARTS, UNLESS OTHERWISE SPECIFIED. PARTS DESCRIBED AS RECHROMED, RECORED, REMANUFACTURED OR, RECONDITIONED ARE CONSIDERED "REBUILT" PARTS. CRASH PARTS DESCRIBED AS "QUALITY REPLACEMENT PART" ARE -NON—ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET NEW PARTS." Line Entry Labor Line Item PartType/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 800763 BDY REMOVEAREPLACE EXHAUST MUFFLER 18030-SSD-A00 17720 0.7 2 800815 BDY REMOVEANSTALL R W/SHIELD PILLAR FINISH MI-DG Existing 02' 3 900500 REF' REPAIR SUBSEQUENT VEHICLE BAGGING "Qual Rep[Part 0.00 02' 4 900500 BDY' ADD'L LABOR OP CORROSION PROTECTION(.1 PER PANEL) "Qual Rep[Part 10.00' 0.5` 5 900500 REF' REMOVE/REPLACE FLEX AGENT "Qual Rep[Part 7.00' OA` 6 900500 BDY' REMOVEIREPLACE SOUND DEADENING MATERIAL "Qual Repl Part 15.00` 0.1' 7 900500 BDY' REPAIR PULL/SQUARE REAR FRAME RAILS/QTRS Existing 3A' 8 900500 BDY* REPAIR ROUGH PULL REAR BODY&FLOOR Existing 1A` ESTIMATE RECALL NUMBER: 0112947 15:54:20 7175 UltraMate is aTrademark of Mitchell International Mitchell Data Version: JAN 07 V Copyright(C)1994-2003 Mitchell International Page 1 of 4 UltraMate Version: 5.0115— All Rights Reserved Date: 02/19/0712:16 PM Estimate ID: 7175 Estimate Version: 1 Supplement 1(F) 02/1507 09:12:40 AM FINAL Profile ID: CSAA 9 800816 BDY REMOVE/INSTALL L W/SHIELD PILLAR FINISH MLDG Existing 02' 10 801642 REF BLEND R REAR DOOR OUTSIDE C 08 11 801643 REF BLEND L REAR DOOR OUTSIDE - C 08 12 801662 BDY REMOVEIINSTALL R REAR BELT MOULDING 0.3 13 801663 BDY REMOVE/INSTALL L REAR BELT MOULDING 02 14 801664 BDY REMOVE/INSTALL R REAR DOOR MOULDING 03 # 15 801665 BDY REMOVE/INSTALL L REAR DOOR MOULDING 03 # 16 801718 BDY REMOVE/INSTALL R REAR DOOR TRIM PANEL INC 17 801719 BDY REMOVEIINSTALL L REAR DOOR TRIM PANEL INC 18 801774 BDY REMOVEANSTALL R REAR DOOR HANDLE 0.7 # 19 801775 BDY REMOVEANSTALL L REAR D 00 R HANDLE 0.7 # 20 801921 BDY REMOVEANSTALL R ROOF SIDE MOULDING 03 21 801922 BDY REMOVEANSTALL L ROOF SIDE MOULDING 03 22 801923 BDY REMOVEANSTALL R ROOF DRIP MOULDING 05 23 900500 REF' REFINISH/REPAIR R ROOF RAIL EDGE OVER DOORS Existing OS' 24 900500 REF' REFINISH/REPAIR L ROOF RAIL EDGE OVER DOORS Existing 08' 25 801924 BDY REMOVE/INSTALL L ROOF DRIP MOULDING 05 26 803561 BDY REPAIR R QUARTER OUTER PANEL Existing 551# 27 AUTO REF REFINISH R QUARTER PANEL OUTSIDE C 2A 28 803562 BDY REPAIR L QUARTER OUTER PANEL Existing 65'# 29 AUTO REF REFINISH L QUARTER PANEL OUTSIDE C 18 30 802083 REF REFINISH LUGGAGE LID OUTSIDE C ib' 31 SPOT BASE BLEND WITHIN 32 802089 BDY REMOVE/INSTALL LICENSE PLATE GARNISH 03 33 8012090 BDY REMOVE/INSTALL SPOILER 05 34 804500 BDY REPAIR LUGGAGE LID PANEL Existing 1A' 35 803534 BDY REMOVE/INSTALL LUGGAGE LID LOCK CYLINDER Existing 03' 36 802138 BDY REMOVE/REPLACE LUGGAGE LID EMBLEM 75701-S5A-000 17.33 02 37 802315 REF REFINISH FLOOR PAN ASSY 08' 38 SPOT REAR FLOOR 39 802318 BDY REPAIR REAR BODY PANEL Existing 4A'# 40 AUTO REF REFINISH REAR BODY PANEL C 1.1 41 802323 BDY REPAIR REAR BODY FLOOR PAN Existing 3D'# 42 802995 BDY REPAIR R REAR BODY SIDE RAIL ASSY -S Existing 15'# S1 43 900500 BDY' REMOVEIREPLACE TAILLAMP BULB "Qual Rep[Part 158' OA' S1 44 900500 BDY' REMOVE/REPLACE UNDERCOATING "Qual Repl Part 4.02' 02' 45 804530 BDY REMOVE/INSTALL R REAR BODY SIDE TRIM PANEL Existing OA'# 46 900500 BDY' REMOVE/REPLACE ROPE BACKGLASS MLDG "Qual Repl Part 4.00' 0A' 47 804531 BDY REMOVE/INSTALL L REAR B 00 Y SIDE TRIM PA NEL Existing OA'# 48 803013 BDY REMOVE/INSTALL REAR BODY TRIM PANEL Existing 02' 49 802382 BDY REMOVE/INSTALL R REAR COMBINATION LAMP 03 # 50 802383 BDY REMOVE/INSTALL L REAR COMBINATION LAMP 03 # 51 802398 BDY REMOVEIINSTALL R REAR INR COMBINATION LAMP 03 52 802399 BDY REMOVEANSTALL L REAR INR COMBINATION LAMP 03 53 AUTO BDY OVERHAUL REAR BUMPER COVER ASSY 12 SI 54 804280 BDY REMOVEIREPLACE REAR BUMPER COVER 04715-55A-A91ZZ 244BB INC 55 AUTO REF REFINISH REAR BUMPER COVER C 23 56 RE MAN NOT AVAIL,2-NO CORES IN FILE 57 804286 BDY REMOVEIREPLACE REAR BUMPER IMPACT CUSHION 71570-56D-AO1 5658 INC 58 802443 BDY REMOVE/REPLACE REAR BUMPER REINFORCE ME NT BAR 71530-S5D-A00ZZ 113.133 03 # 59 AUTO REF REFINISH REAR BUMPER REINFORCEMENT 1A 60 803024 BDY REMOVE/REPLACE REAR BUMPE R ADHE SIVE NAMEP LATE 75722-S5A-000 18.70 0.1 61 803029 BDY REMOVE/REPLACE REAR BUMPER ADHESIVE NAMEPLATE 75723-S5A-A20 8.37 0.1 62 804669 BDY REMOVE/REPLACE REAR BUMPE R ADHE SIVE NAMEP LATE 75731-S5A-A30 25.13 0.1 63 AUTO REF ADD'L OPR CLEAR COAT 25' 64 933006 FRM ADD'L OPR FRAME/RACK SET UP 15' 65 AUTO ADD'LCOST PAINT 440.10' ESTIMATE RECALL NUMBER: 01/29/07 15:54:20 7175 UltraMate is aTrademark of Mitchell IMemational Mitchell Data Version: JAN 07 V Copyright(C)1994-2003 Mitchell International Page 2 of 4 UltraMate Version: 5.0215 All Rights Reserved Date: 02/19107 12:16 PM Estimate ID: 7175 E slim ate Version: 1 Supplement 1 (F) 02/15417 09:12:40 AM FINAL Profile ID: CSAA 66 AUTO AD D'L COST HAZARDOUS WASTE DISPOSAL 3.00' ' -Judgement Item #-Labor Note Applies C -Included in Clear Coat Calc Remarks FINAL OK TO PAY Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 37.3 62/0 0.00 0.00 2,312.60 Taxable Parts 703.72 Refinish 16.3 62/0 0.00 0.00 1,010.60 Parts Adjustments 33.11- Frame 1.5 62/0 0.00 0.00 93.00 Sales Tax (M 8250% 55.33 Non Taxable Labor 3,01620 Total Replacement Parts Amount 725.94 Labor Summary 55.1 387620 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 440.10 Insurance Deductible WAIVED Sales Tax @ 8.250% 36.31 Customer Responsibility 0.00 Non Taxable Costs 3.00 Total Additional Costs 479.41 I. Total Labor: 3,41620 II. Total Replacement Parts: 725.94 III. Total Additional Costs: 479.41 Gross Total: 4,62155 IV. Total Adjustments: 0.00 Net Total: 4,62155 Less Original Net Total: 4,5fi224 Net Supplement Amount 59.31 S1: COLIN KENDALL 59.31 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Point(s)of Impact 6 Rear Cerner(P) ESTIMATE RECALL NUMBER: 01/2.9/07 15:54:20 7175 UltraMate is aTrademark of Witchell International Mitchell Data Version: JAN 07 V Copyright(C)1994-2003 Mitchell International Page 3 of 4 UltraM ate Version: 5.0215 All Rights Reserved Date: 02/19/0712:16 PM Estimate ID: 7175 Estimate Version: 1 Supplement 1 (F) 02/15/07 09:12:40 AM FINA L Profile ID: CSAA Insurance Co: AAA Address: 2055 MERIDIAN PARK BLVD. CONCORD,CA 94520{767 Telephone: (510)671-2708 Fax Phone (510)6897939 THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY VARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. Company Code: Drop Off Date: 01!26/07 Time:02:00 Repair Dates: Promise Date 02/1607 StartDate: 01/30/07 Pick Up Date: 02/1507 Time:14:00 Completion Date: 0211507 Is Vehicle Driveable(YM)?: N Assisted With Rental(YIN)?: N ESTIMATE RECALL NUMBER: 01/29/07 15:54:20 7175 UltraMate is aTrademark of Mitchell International Mitchell Data Version: JAN-07 V Copyright(C)1994-2003 Mitchell International Page 4 of 4 UltraMate Version: 5.0215 All Rights Reserved m F� r CIA � mire a „ + i am6� WIN Y 1j i.1 1 3 111 g9'{,3aJY wre - s L. k F :aT 4Q•� '� q- Y 3 '. � t 6 � Yt Y � L 3�Xe- r ma) IF rv-,irk " v k 0° b� -� � # »R3 j•�5 ya t' vSV'4ry RRne C 3 4y3g C�"' C g �{^�'✓ aY { R 4 . vil ; la ARM 44 3q j savor �ti N em 9 Rm{4aaz�e: _' k' y� e a P i a5 a �°�' i Y p Y ' EWA A Al �b SII dx s t �r All t� x ani .�,`a• s���� �� a � - �� + a'" � s xi- �, Bi d �a� � �m�� �"�"� �� des .mw� ,� t ✓i � il n3 � Nt ",��s'+�s,� � w,fi-� .. �' _�'ks s w...,k#�� �4x6�r� A 8� ... � �=Sf�p6�9id� ��,y y ro� $ y "`+� '✓•-p�, � °"� "^�'^-�a x `'F ,A F s � '+ a% � ✓� e w `� ,,,�^ ha#� �` ` � �,x m °z R i3'""' F +:$ e :ka tt a ,a m ji 3a { i a a� �E S r x a� b g a a, Ay a a r s^a. f a ., ,r•, All All w 5 ex agi e� n M � g meg `i MEN;, 1,A tl Xg '✓i s q,ae^ 88 Qa r . � a �a 5 IMF fit ,. gotPR`"Ns�'f. z& .,�« w' $. W e.✓a 4 "e' ,. s sdbt�x."e...... Zsww W, egg . ®� 3 bill q ,�, �® `�s c�-a'w.a `�^'�. w� m� ,•�w s as s +' "1'� �a, a �w '� "oma° a m Q . m �, : � . : � ��� , u—�- � . e � � "�� �$ '� ��, �� �w �� � r � � � �� �� �� �� 8 aL. W¢ � sP'��Y°-a � .pf*g m � � a a a ..'` �`.� � � � x�Pa �mmm$ '���"` i _ � �. &� a m`�� a dfi,L r m � ,, _,. P �a_�. �;�a. �a e n '� a ._ �� � �� utl, '. i�� o� �� ���I�. i ® �.. ,I m z � a r.. d� �� ear m �a �� m,. . _ m., v =gym �.�: �:s �.�� ��m _ �`'i�i �a �� ' � , �,. � _ .. �� a y��` ' M a; x A4% a x >w 9 o 0 N N N U CHECK NO: 711 L413596-2-R m DATE: 02-21-2007 uj > NAME AND ADDRESS INFORMATION: Lu U UJ MIKE ROSE'S AUTO BODY INC 2001 FREMONT ST CONCORD CA 94520 INSURED: KIM,TAEJUNG/KEVIN PAYMENT INFORMATION/DESCRIPTION: DATE OF LOSS: 01-25-07 FINAL PYMT CLAIM NO: 03—KC9987-6 CLAIMANT: KIM,TAEJUNG/KEVIN PAYEE: MIKE ROSE'S AUTO BODY INC AMOUNT: $4,621 .55 IN PAYMENT OF: REPS IN FULL ADJUSTER: DEBRA LEARNAHAN ADJUSTER NO.: 32446 KIND OF LOSS: COL 15510702 DETACH AND RETAIN FOR YOM RECORDS No. 711 L413596-2-R DATE OF LOSS CLAIM INSURED'S NAME IDATE 01-25-07 03—KC9987-6 I KIM,TAEJUNG/KEVIN 02-21-2007 POLICY TYPE KIND OF LOSS SUFFIX CLAIMANT'S NAME PAY AUTO COL 01F KIM,TAEJUNG/KEVIN $4,521 .55 D.O. ADJUSTER NO. IN PAYMENT OF BANK OF AMERICA e+�s DR2 32446 REPS I N FULL Bank of Amorica Cuaomor Comoction Ery Bank of America, N.A. TIN: 94-2621349-00 , ANarae, oekaib Cowoy, Geurola PAY «FOUR THOUSAND SIX HUNDRED TWENTY ONE 55/100• MIKE ROSE'S AUTO BODY INC This check must be properly endorsed on the reverse side by all payees. TO THE ORDER OF Cf) am (n b cr C=) clj NJ U� 21 C-3 OZ60-585176 VD'AID unsinS OM X09'Od neaAng wmeinsul-jolul UoRepossv allqowolnV alels v!UJOMe3 California State Automobile Association Inter-Insurance Bureau P.O.Box 920 Suisun City,CA 94585-0920 I I FIpST CLASS M :10 COO UNI?r noA y Dam -k 59- n V1 D� N N npD3 C=) ® o mA� . . M w � v 0 r CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 22, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All SectionEMT eto The copy of this document mailed to California Government Codes. ) p( you is your notice of the action taken APR 2 4 2007 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code MARTINEZ CAME Section 913 and 915.4. Please note all AMOUNT: UNSPECIFIED — EXCEEDS $10,000 AND THEREFORE GOV'T CODE &910 SUBD (f) "Warnings". CLAIMANT= SPECIFIES THAT THE AMOUNT SHOULD NOT BE STATED -- LES MOTYLEWSKI AND MARIO MOTYLEWSKI ATTORNEY: CORRY EVANS DATE RECEIVED: APRIL 24, 2007 EVANS & PAGE APRIL 24, 2007 ADDRESS: 55 NEW MOTGOMERY STREET, `BY.DELIVERY TO CLERK ON: SUITE 607 SAN FRANCISCO, CA 94105 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, rk Dated: APRIL 24, 2007 By: Deputy via II. FROM: County Counsel TO: Clerk of the Board of Su 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). ( ) 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: 4- 2-`7,- o / By: r-y ) 9�G Deputy County Counsel III. FROM: Clerk of the Board TO: County. Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. 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: !LMHN CULLEN, CLERK, ByDeputy Clerk WARNIN Gov. code section 913) z 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 count action 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. Ifyou 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. Dated: 0�7 JOHN CULLEN, CLERK By e-H'eputy Clerk 2/2006 11:44 CONTRA COSTA COUNTY CLERK OF THE 4 914153585855 NO.856 D01 r _ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CI.A DANT 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. •rrrrrr.rrrre.r.rrr��r.rrrr�rr•■r�rr•rrr��Y■■rrrrrrrrr�r rrrrr a�� �r.r��r�.••■ RE Claim By: Reserved for Clerk's filing stamp Les ' Aad jle sk► i RECEIVED �at�o M SkA ) APR 2 4 cuU1 Against the County of Contra Costa or ) CLERK BOARD OF SUPERVISORS District) 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 uvl ;ed and in support of this claim represents as follows- S LP e�eceeds*101000 6W CL }lnerr�oec Cov,� Code s Glb 1. When did the damage or injury occur? (Give exact date and hour) 5wbd CC) SPCciFics JAA4r NOvevv,ber 2000 Oke amour} s�oujd V%0 ' Fit s+abed 2. Where did the damage or injury occur? (Include city and county) 2119 FkaA,6e1('1 ka.) Sar pabto 3. How did the damagPe or injury occur? (Give full details; use extra paper if requlrgg j y :CC►�5 C��Cov��ra CoS+aCownty An;vhal $ervice� unlaw{,,I� e4erA ,ur. Mo{ ewski's 1 fiope-rVy cL(%(t rook line. AAI yletL5 *Is' dO. s amd -fin k*Med one of +Ue_c1 S in uie�at:o,} 4. What particular act or omission on the part of county or district officers, servants, or empi8yees of t►%4- G caused the injury or damage? N . +� IfCcAS did not see "ex��eK� Clrcuvr�s}a.nce5 Jus�� rIK� a wa+ ra.. etS Me�t�lewskis` eAry *WA-o tIAe- ftii ltu ekls' Prope4y®CCCit5 fai6tr 4o Properly noU_ Ow- due e-5 cess 5 What are the names of county or district officers,servants, or employees causing the damage or injury? Ltrkhawh evx F lojeeS CCCfc5 des' owners 0� /heft 0- wvr;-� ol,nd ewe!ar r;140L Me 0f J-%k9,.tc,CI& �y�ewsk\s�4 •r 12/12/2006 11:44 CONTRA COSTA COUNTY CLERK OF THE 4 914153585855 NO.856 002 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ur,t_ c+�,J -ire SIct.Sg wa,S co w. �eLl I-t ao n aiw�2o( l�„n a t was e uet n i 7. flow was the amount claimed above computed? (include the estimated amount of any prospective injury or damage.) S. Names and addresses of witnesses,doctors,and hospitals: �t,nknow+� 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■rr■■■rr.r.r..rrrrr■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrarrr■rrrrrrrrr�r■rrrrrrrrrrrrrrrr ) Gov. Code Sec.910.2 provides"The claim shall be )signed by the claimant or by some person on his )behalf." SEND NOTICES TO: (Attor evl ) Name and ad ess of Attorney ) „�5 P ) o r r�o� IewS>Li5 .i �-' } (Claimant's Sig tore) 55 Ne•� Mo,h�,ornexy� ) 55 N� 0 5�-. �;�-� �o� 1 ) (Ad ess) �— SQ w rovwc i$Lo CA 9 y 10 S j S a 66-A c s co CPQ rr ) Telephone No. y�5 g��0' S�� _)Telephone No._'AN6 .......rrrr■rrrrr■■r.r..rrrr■rrrr...r■rrrr■■r..rrr■rrr............................... 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. •.r.r...rr...rr.rrrrrrrrrrrr rrrrrrrrrrr rrrrrrrrrr■rrr rrrrrrr rrrrrrrrrr■rr rrr�rrr.rr r. 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. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: MAY 22, 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), RPR 2 42007 r given Pursuant to Government Code AMOUNT: $3,500,000.00 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". CLAIMANT: BRIAN R. PEARCE MARTINEZ CALIF. ATTORNEY: JOHN M. ALLEN DATE RECEIVED: APRIL 24, 2007 101 SAND CREEK ROAD, SUITE 305 ADDRESS: BRENTWOOD, CA 94513 BY DELIVERY TO CLERK ON: APRIL 24, 2007 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, Cl 'k Dated: APRIL 24, 2007 By: Deputy II, FROM: County Counsel TO: Clerk of the Board of Sup rvisors ( 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 91.1.3). O Other: Dated: By: Deputy County Counsel III. 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. ARD ORDER: By unanimous vote of the Supervisors present: (I,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: /(16V X°2L!_�HN CULLEN, CLERK, By Deputy Clerk WARNI.N (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional 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: 4/9A:9O JOHN CULLEN, CLERK By eputy Clerk V 1 John M. Allen, SB#46491 Attorney at Law L 2 101 Sand Creek Road, Suite 305 Brentwood, CA 94513AI/(.�.JR 3 Telephone: 925-240-2700 12 4 zoul Facsimile: 925-884-8900 CLERK13 Co'ARD of 4 Attorney for Claimant: N] cos q�ov/SORs 5 BRIAN R. PEARCE 6 7 8 CLAIM OF BRIAN R. PEARCE ) 9 ) CLAIM FOR PERSONAL INJURY AND Against ) VEHICLE DAMAGE 10 ) CITY OF OAKLEY POLICE ) 11 DEPARTMENT; OFFICER L.JONES, ) BADGE#53211; CONTRA COSTA ) 12 COUNTY SHERIFF'S DEPARTMENT;and ) OFFICERS DOES 1-20,inclusive. ) 13 14 15 16 TO THE CITY OF OAKLEY; CONTRA COSTA COUNTY SHERIFF DEPARTMENT; 17 OFFICER L. JONES; OFFICER DEMINNIK; and CONTRA COSTA COUNTY BOARD OF 18 SUPERVISORS: 19 1. Claimant BRIAN PEARCE, whose address is 57 Nettle Court, Oakley, CA 94561, 20 claims damages from the City of Oakley and Officer Jones, Badge#53211, and Officer 21 deMinnik, and other officers of the Oakley Police Department and Contra Costa County Sheriff 22 Department whose identities are unknown at this time and are referenced as Officer Does 1-20, 23 herein. Said claim is in the amount of$3,500,000.00 for the intentional and negligent use of 24 force and assault and battery on Claimant BRIAN PEARCE by Officer L. Jones and other 25 officers at the scene whose identities are unknown to Claimant at this time. 2. Jurisdiction over this claim would rest in Contra Costa County Superior Court. CLAIM FOR PERSONAL INJURY AND VEHICLE DAMAGE -1- k 1 3. This claim is based upon the following circumstances: 2 On November 18,2006, at approximately 1:42 am, Officer I.Jones, Badge #53211 with K-9 3 Bessie, Officer deMinnik and other officers,identities at this time unknown and named as Officers 4 Does 1-20 herein, suspecting that Claimant might be driving under the influence of alcohol, 5 followed him to his home located at 57 Nettle Street, Oakley, California. 6 Upon Claimant's pulling into his driveway and parking, the officers drew their service 7 weapons, opened Claimant's driver's door and ordered K-9 Bessie to attack Claimant. Bessie did so, 8 causing severe bite injuries to Claimant's left arm. Claimant was then removed from his vehicle and 9 placed upon the ground of his driveway. While in this position and surrounded by his own blood, 10 Claimant was berated and kicked and beaten by Officer Jones, Officer deMinnik and Officers Does 11 1-20 prior to the arrival of the ambulance which then transported Claimant to the hospital. 12 The officers subsequently, and wrongfully, had Claimant's vehicle towed from the driveway. 13 The inside of said vehicle was damaged by Claimant's blood and necessitated professional removal 14 to Claimant's additional damage. 15 As a result of the injuries sustained, Claimant has partially lost the use of his left hand. To 16 date, his medical bills exceed the sum of$25,000 including ambulance bills. His medical prognosis 17 is, at this time, uncertain. He faces future surgery(s) and rehabilitation. It is not known whether he 18 will ever regain full use of his hand. 19 4. Claimant does not know the names of the other officers of the City of Oakley or the 20 Contra Costa County Sheriff employees who caused Claimant's loss. 21 5. The loss sustained by Claimant consists of$3,500,000.00 22 6. The losses expected to be incurred in the future includes further surgery(s), physical 23 therapy, lost income and severe emotional distress. 24 7. All notices and communications concerning this claim should be sent to John M. Allen, 25 Esq., 101 Sand Creek Road, Suite 305, Brentwood, California 94513 CLAIM FOR PERSONAL INJURY AND VEHICLE DAMAGE -2- 1 2 DATED: 1/"1 J6 7 3 4 5 �• "� John M. len, Esq. Attorney for Claimant, BRIAN R. PEARCE 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CLAIM FOR PERSONAL INJURY AND VEHICLE DAMAGE -3- Medical bills Exhibit 1 Crrli(orl;ia1=l-ftifiC nIC(liCidCt'llfff a.'tl rile 7s710 STATEMENT DATE: 01/25/07 ADMISSION DATE: 11/18/06 s y t F0.laox hrn,,.o --- 1' an Francisco,CA 94160-37 10 YOUR PORTION DUE: AMOUNT ENCLOSED $14,862.08 OR CHARGED: $ PATIENT: PEARCE,BRIAN R ACCOUNT NO. 5618318 BRIAN PEARCE 57 NETTLE CT OAKLEY,CA 94561 )) )) 1 1! C) For billing address changes or to pay by credit card,check here and please see other side. EMERGENCY ROOM $998.00 PHARMACY $2,179.43 PHYSICAL THERAPY $106.37 CENTRAL DISTRIBUTION $211.28 D3N NURSE STATION $11,367.00 $14,862.08 FINANCIAL ASSISTANCE AVAILABLE-FOR MORE INFO CALL(415)600-7280 ACCOUNTPATIENT • $14,862.08 PEARCE,BRIAN R 5618318 QUESTIONS ABOUT YOUR BILLS? Please pay the amount indicated in the Telephone:(415)600-7280 or(800)710-7721 Fax:(415)600-7105 or(415)600-7135 balance due portion of this statement. Email Addr:CPMCPFSBILL@SUTTERHEALTH.ORG Business Hours:8:00-6:00,Monday thru Friday ie ie PATIENT NAME ACCTX CA EMERGENCY PHYSICIANS *DELTA BRIAN R PEARCE E21 274116 PO BOX 582663 STE D-21 IF PAYING BY MASTERCARD OR VIS4,FILL OUT BELOW. MODESTO, CA 95358-00460 CHECY.CARDUSING FORPAYMENT g ❑ LW!—!] MASTERCARD REM Vr.A CARD NUMBER 3-DIGIT ON BACK AMOUNT ADDRESS SERVICE REQUESTED SIGNATURE IXP.DATE SERVICES WERE RENDERED AT THE HOSPITAL, STATEMENT DATE PAY THIS AMOUNT PAST DUE DATE its BILL IS SEPARATE FROM YOUR HOSPITAL BILL. Ol/02/07 741.00 01/20/07 fi ;d .... _... 17097,3 BRIAN R PEARCE 57 NETTLE CT CA EMERGENCY PHYSICIANS DELTA ?y, OAKLEY, CA 94561 PO BOX 582663 MODESTO, CA 95358-0046 ]Please IM if address or insurance information has changed. Make changes on reverse side. mmmrmenmmmrmmmmmmrmmmmmrmommrmnmmmmmremmrmmmmmmemmmmmmmmmmmmmmmmmmmmmamm 'u D !'d a yw a3 IrIi L� '1r�,.I '...�,tl.� '.,af.� r :'1[�r 1 LE r.,�.t'a R4 ,.+•1,°'a ,� i„sa 4Ri.:!>.n S:._:,f.Gs ' .' .'a?��n-�' �,...a tf�s.x u5.:., s,.rLL.{r,�'_,.e 3.tx+. x... ...,. .... . .. .:1. PLEASE MAKE COPY OF ENTIRE PAGE IF NEEDED FOR INSURANCE THERE ISA$10.00 SERVICE CHARGE FOR ALL RETURNED CHECKS. LALLING OFFICE HOURS: 8 AM-5 PM Phone ► 800 498-7157 ax ID.#r► 942494000 Para ESPan011- 1800-952-8351 kttending Physician ► SUGARMAN, THOMAS, M.D. Referring Doctor ► SUGARMAN, THOMAS, M.D. account Number ► E21 274116 Service Provider ► CEP SUTTER DELTA MED CT 'atient Name ► BRIAN R PEARCE Statement Date ► 01/02/07 DATE POS DIAGNOSIS DESCRIPTION OF SERVICES AMOUNT 11/16/06 23 88120 99285 25 LEVEL 5 EMERGENCY, PHYS 458.00 11/18/06 23 88120 99053 SERVICE 10:00PM & 8:OOAM 27.00 11/18/06 23 88120 29105 LONG ARM SPLINT 128.00 11/18/06 23 88120 73090/26 X-RAY INTERP FOREARM 28.00 11/18/06 23 88120 73110/26 X-RAY, COMPLETE,MIN. OF 48.00 11/18/06 23 30500 94760/26 PULSE OXIMETRY, SINGLE 24.00 11/18/06 23 30500 73080/26 X—RAY INTERP ELBOW COMP 28.00 YOUR A COU T IS 30 DAY PAST DUE. PAYMENT ON THIS ACCOUNT IS YOUR RESPONSIBILITY. EMPLOYER PRIMARY INJURY DATE ADMISSION DATE DISCHARGE DATE BALANCE DUE INSURANCE ** SELF PAY/NO INSUR 11/18/06 741.00 POS (Place of Service Codes) 1 - Inpatient Hospital 2 - Outpatient Hospital 3 - Doctor's Office 4 - Emergency Room °1 JOHN MUIR MEDICAL CENTER Page 1of2 01/19/'07 Thank you for selecting John Muir-Mt. Diablo Health System for John Muir/Tuft. Diablo Health System your health care needs.Your account is now past due and we PO Box 39000 Department 33370 must request full payment. Please contact our Customer can Francisco,CA 94139-3370 1Vo0029 4 Ol lDa394 Service Department if you have questions. This statement may not reflect all open accounts with the hospital at the time of printing. Additional statements may follow. BRIAN PEARCE 57 NETTLE CT OAKLEY CA 94561-2485 Ilrlrlilt tltltlrrIII till lilt lritlttilrrltIII lrtltirltrtltlrlll Guarantor Number 01106394 Balance Forward Of All Accounts $332.50 , Billing questions or changes in insurance coverage? Total Charges $0.00 (925)947-3336 8:15 am to 4:15 pm weekdays • Written correspondence? Total Insurance Payments $0.00 John Muir/Mt. Diablo Health System-Attn. Patient Accounts Total Patient Payments $0.00 PO Box 39000 Total Account Balance $332.50 Department 33370 Patient/Guarantor Responsibility $332.50 San Francisco, CA 94139-3370 See additional detail on reverse side. Please Note: Your physician will bill separately for their professional services. _..... ....................... .. .._. ._....... ...... .... .......... ._........ .........._...................... .__.. .......... ._.... . ..... .... ....... PATIENT INFORMATION 0633100356 $332.50 JOHN MUIR MEDICAL CENTER Statement Date: 01/19107Guarantoi Name "' ` " Due Dafen D John Mtdr/Mt.Diablo Health System ;BRIAN PEARCE c ,t'rt ` ' y 02/0812007` ', +`• �' "ArnountDue�,�¢, ,, ;ar f -�.AmountlAm:Ra"in �=x $332.50 " is REMIT THIS PAYMENT STUB TO: JOHN MUIR/MT. DIABLO HEALTH SYSTEM Check here if your address or insurance information has changed. P.O. BOX 39000 Please indicate changes on the back of this page. DEPARTMENT 33370 dr Name I SAN FRANCISCO,CA 94139-3370 W :I ►'; CarJ J Ill �i l 11 ill l l� 11 ll� 11 llll �ll� 11 l Credit Card No. Exp. Date Signature X JMFSOID7 *Please print your AVS 3 digit code located on the back of your card in the signature box. ATENOT1CLJ ---- LATE NOTICE .• Y1P 1.9'/1 - I -- --- --- www.amr-inc.com American Medical Response DBA AMER CAN MEDICAL RESPONSE P.O. Box 3429 Modesto, CA 95353 7R1P # 401-66296569-00 ACCT #', 003175618 -- pATIEMT!NAME BRIAN PEARCE =" DATE of SERVICE 11/18/2006 =� ACCOUNT NUMBER: 003175618 AMOUNT DUE 1 , 578 . 89 DUEDATE 02/13/200" n4WviW —' BRIAN PEARCE REMIT PAYMENT TO: 57 NETTLE CT OAKLEY CA 94561-2485 AMERICAN MEDICAL RESPONSE I11111111111111111111111I1JI1111Isill 11111111 FILE 73329 PO BOX 60000 SAN FRANCISCO, CA 94160-3329 SE CHARGE MY: ❑VISA ❑MASTERCARD ^ >UNT ❑❑❑❑❑ ❑�❑❑❑�❑ LJ❑ I[I EXPIRATION DATE [1110 11 ATURE PLEASE ENTER AMOUNT PAID: Z PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT PATIENT NAME ACCOUNT N0. I TRIP NO. INVOICE DATE - RIAN PEARCE 003175618-0001 401-66296569-00 01/24/2007 TE OF SERVICE SERVICE FROM I SERVICE TO 1/18/2006 SUTTER DELTA MEMORIAL HOSP K DAVIES MEDICAL CENTER IMPORTANT MESSAGES Dur account is now PAST DUE. Your immediate response is necessary to cease urther collection activity. Please remit payment today . If you have any uestions please contact our Customer Service Department at (800 ) 913-9106 . hank you. CODE DESCRIPTION UNITS UNIT CHARGE TOTAL CHARGE" 0428 BLS N/E 1 584 ,84 584.84 0425 BLS MILEAGE 47 21.15 994 . 05 ALL RCVD: 07:02 TOTAL CHARGES DUE 1 , 578 .89 IAGNOSIS : 8798 SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to: American Medical Response, P.O. Box 3429, Modesto, CA 95353 )ne Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 PJNVQIOE-' www.amr-inc.com Alp S'603 American Medical Response AMERICAN ED 'CAL RESPONSE WEST P.O. Box 3429 Modesto, CA 95353 TkiP 4�1.�:�`:�.�:: ........ .�:: 401-66296468-00 ACCT #: 003174681 PATIENT, NAME BRIAN PIERCE DATE OF.SEAVICE:- 11/18/2006 ACCOUNT NUMBER: 003174681 AM6L1NTDUE:. ::::::::'%,% 707. 48 DUE DATE 02/14/200 BRIAN PIERCE REMIT PAYMENT TO: 57 NETTLE COURT OAKLEY CA 94561-2485 AMERICAN MEDICAL RESPONSE FILE 73329 PO BOX 60000 SAN FRANCISCO, CA 94160-3329 3E CHARGE MY: EIVISA EIMASTERCARD LINT [I Ll[I[][I[I[I[I[I[I[I[I[I[I[I El EXPIRATION DATE kTURE PLEASE ENTER AMOUNT PAID: 11 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT PATIENT NAME ACCOUNT NO. I : '' TRIP NO. INVOICE DATE RIAN PIERCE 003174681-0001 1401-66296468-00 101/25/2007 FE OF SERVICESERVICE FROM SERVICE TO I I 1/18/2006 INEROLY RD / OHARA AVE-OKLY ISUTTER DELTA MEMORIAL HOSP IMPORTANT MESSAGES lease advise us of any medical insurance that may cover this service . If you D not have insurance, please remit payment in full . Please contact our istomer Service Department at (800)913-9106 if you have any questions. aank you. CODE DESCRIPTION UNITS UNIT CHARGE TOTAL CHARGE - 0429 BLS EMERGENCY 1 560 .62 560. 62 0425 BLS MILEAGE 7 20 .98 146.86 ALL RCVD: 01 :49 TOTAL CHARGES DUE 707 .48 IAGNOSIS: 8798 1 )I SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to: American Medical Response, P.O. Box 3429, Modesto, CA 95353 one Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 10 A Sutter Delta Medical Center 3901 Lone Tree Way Master card[:] Discover[] Visa El American Express❑ y Card Number Exp.Date(Required) Antioch CA 94509 Signature Amount Statement Date 12/1/2006 Balance: 5, 191 . 54 Toll-Free (866) 507-2195 ACCT.# 0 0 0 4 0 9 0 2 0 9 0 Pay This Amount 5, 191 . 54 SHOW AMOUNT PAID HERE:$ �— ADDRESSEE: REMIT TO: #BWNKVMJ Sutter Delta Medical Center #6060000409020900# File 74430 PEARCE . BRIAN ROBERT P .O . Box 60000 57 NETTLE CT San Francisco CA 94160 - 0001 OAKLEY CA 94561 - 2485 Ilrlrr,frrl�lrirrflrr�r�lirrf,I�I�rlir�lr�lrlrrlririrrrl�lr�ll Please detach along perforation and return with remittance. BALANCE DUE NOTICE Thank you for choosing our facilities for your medical needs. This statement represents charges that are due from you. Please remit your payment in full or contact Patient Accounting for any assistance we can provide. AVISO DE SALDO PENDIENTE Gracias por escoger nuestros servicios para sus necesidades de salud. Este estado de cuenta representa su saldo de pago pendiente. Nuestro sistema indica que tiene pendiente el pago de seguro medico. Por favor remita el pago en totalidad o Ilame a nuestro Departamiento de Cuenta Financiera de Pacientes para cualquier asistencia que puedamos proporcionar. PEARCE, BRIAN ROBERT Sutter Delta Medical Center 00040902090 11 1e 2006 0.00 nl„"'.,,:::a:i:,.:R \y:0;,•...ii\.:<,.,.na..,»..:....a}\i<}}l}wa m.�..f!i,•::a}k:.:,...:: � 5, 191.54 :ig':Rxf•}.:\¢::: ::u;t(5,w:::�ifi ?}�,:}}:}1fi? ,��:a }.gi. :o:,;.}:»:.} :z„ »...».:,.; •:'C. '<��4"a '�:t�S,,,,\„ ;stir:: :»,...:,,»..:,:��. ::::n.iv.v.\.\.}nv:};.f.�Y6•....}\ii i:::?»:a}4?:: ....v.n... .:.\....,.... ,.....4..v.» ��??}} •<} .}:::' .\c,. ..:.:}::,. . y ;f•v»:.•>.,:}:}.. :,::F:.. '81�.'c: d}�;.?>... ':{i�Q:`: ;•.:fti::>:i::?}}:i,r.,»�:}:,:,,?,.;,.. 5, 191.54 ;.j:•vif\`:i:.:a�'fiy.:..0, •\::'i;:}M:}..v.`:::::.,w:4 .. ::.......::::::..:v: ::}:i.i:iir.•:.:::::v ;,e::::?kv::::::?'::i�:w:.h.::.�) ,(•`.:n\v:.iy:rvv}:}.v.\„'.A...` y,��yff�� {y ,..�.. �\i:::i.y...,. ..\. vMV):41W{�v.. tib}i:C:i:}`:i?}v.. i:•\i}\:. v,. ».r.n`.4 J,'. ,...,anv.,:{}.ij•...:v..::.,. vi?:v}:'i;n:yn�: i}\. ,..»\v :}:,..,\:v:..i::,.,..u..`:::.nl':v..n.. n..::..,.,.i•n:a\ } .. ,. ..}:a ......na.k..}..n»aa,\..».'h}..a.,..a,?..a.,.a\..�....a:.,.}.a.•a,..s..,:».,.:::.»L..»u:•\vi::•;:f•.+.•}:{.`. ny.....n. Upon Receipt Toll-Free 866 507-2195 '>>:> a;><:: ::;::}:>.::::.>::::.:;..::.:::::}:.:'.::.::...: :: :<:c::>><.::;;:;f:<:: yn�t! fr;!htirtci`ra�1 <;':: ;;>:�:a':::� 00040902090 Phone Hours:Mon-Thurs 8am-8 m PST z�:''ti?':>:'s><s:r;:>;;>':s»>c>:;::#>''s».>?;:!i'>'.::::#::<;•.}:.}}::i:;:.>:f.}:i}•.:;::}::;.},:;;•?}^.}:.. P Friday8am-4pm PST Saturday 9am-1 pm PST ?}:.}'.}}:.?„_”.a,.....,...::,..,....,...,.... WE ACCEPT PAYMENTS OVER THE PHONE �111pi@ CNt1p Sutter Delta Medical Center Aceptamos pagos por telefono ;f:}:.,'.::;::::::i».::.:::;:.:::,;::; z" Y1fK #i t ri1�t GI1 'f S File Box If payment in full has been recently made,Thank you. a�:'• .:..::,:;::.l.:::::.::::..... ..::.}.:.,.:::.::. ;.:s�� < •;»>,;,:�; <:>;;::a>;;.>< P.O.Box 60000 Si usted he mandado el pago por com leto recientemente Gracias San Francisco CA 94160-0001 BRIDGEPORT FINANCIAL, INC. 221 Main St,Suite 920 221 Main St, Suite 920 San Francisco,CA 94105 San Francisco, CA 94105 (415) 216-4695 (415)986-7865 FAX Address Service Requested Creditor: BAY IMAGING CONSULTANTS MED GRP 12-18-06 Balance Due: $375.26 Includes Interest: $3.26 it.l�� I �IIfll � IIIIf��tl� IIrIIII � IIN 636869 BRIAN R PEARCE 57 NETTLE CT OAKLEY CA 94561-2485 NOTICE OF ASSIGNMENT * • "his writing contains accounts assigned to our office on 12-18-06 for the above creditor. All contact must be made with Bridgeport financial, Inc. inswers to commonly asked questions: paid the hospital already: When receiving services at a hospital many charges are billed separately. This particular bill is for adiotogy fees and is separate from the hospital fee you may have already paid. A payment to the hospital is NOT a payment for fur client:they are separate companies. by insurance should pay: Insurance provided at the time of service has already been billed. Insurance is a contract between the iatlent and the carrier and in most cases the patient is ultimately responsible for payment. You may want to contact your isurance company to find out why they did not make payment. Even if the hospital is contracted with your insurance - this does jot mean the radiologist is also contracted. 'ATIENT: PEARCE, BRIAN R 3ALANCE DUE:$375.26 'his is an attempt to collect a debt and any information obtained shall be used for that purpose. This communication is sent by a lebt collector. Jnless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, his office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice, this office will: )btain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request his office in writing within 30 days after receiving this notice, this office will provide you with the name and address of the original :reditor, if different from the current creditor. sincerely, Unit Manager %s required by law, you are hereby notified that a negative credit rating reflecting on your credit report may be submitted to a credit eporting agency if you fail to fulfill the terms of your credit obligations. But we will not submit a negative credit report to a credit eporting agency about this credit obligation until the expiration of the time period described above. NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION' PARA INFORMACION IMPORTANTE MIRE AL REVERSO "'In order to credit your account properly,raM thle bottorn portion WlIh your payment"' I authorize Bridgeport Financial, Inc. to charge$ to credit/bank card account# expiration date Social Security Number Date of Birth Cardholder Name Cardholder Signature Credit cardholder's billing address 12-18-06 Creditor: BAY IMAGING CONSULTANTS MED GRP Balance Due: $375.26 Includes Interest: $3.26 Bridgeport Financial, Inc. Account#: 636869 221 Main Street, Suite 920 Amount Enclosed: San Francisco, CA 94105-1923 BRIAN R PEARCE 57 NETTLE CT OAKLEYCA 94561-2485 BPP1 Rica-122=200204JXD3.2 204 Vehicle Damage Exhibit 2 Date: 2/13/2007 05:17 PM Estimate ID: 187 Estimate Version: 0 Committed ® AND ID: CUSTOMIZED V®RNHAGEN E®®�/9 AND PAINT 600 Harvest Park Drive Brentwood,CA 94513 (925)516-1969 Fax: (916)516-9166 Tax ID: 68-0466225 BAR#: AD216007 Damage Assessed By: Williams Travis Condition Cade: Good Deductible: 500.00 Claim Number: 05-5347-27701 Owner BRIAN PEARCE Address: 57 NETTLE CT.OAKLEY,CA 94561 Telephone: Home Phone: (925)584-4634 Mitchell Service: 910647 Description: 2007 Chevrolet Tahoe LTZ Vehicle Production Date: 12/05 Body Style: 4D Ut Drive Train: 5.31-1 n 8 Cyl 4WD VIN: 1GNFK13097RIO7695 License: 5VLC266 CA Mileage: 14,324 OEM/ALT: O Search Code:. None Color: BLK Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation Description Part Number Amount Units 1 000882 BDY REMOVE/REPLACE CTR CONSOLE PANEL ORDER FROM DEALER 295.79' 0.3 2 001231 BDY REMOVE/REPLACE L DOOR OPENING WEATHERSTRIP 15890638 GM PART 44.69' 0.2 3 001016 BDY REMOVE/REPLACE L LWR CTR PILLAR TRIM PANEL 15870876 GM PART 55.47 0.3 4 001022 BDY REMOVE/REPLACE L FRT ROCKER SCUFF PLATE ORDER FROM DEALER 31.56 0.2 5 001023 BDY REMOVE/INSTALL R REAR ROCKER SCUFF PLATE Existing 0.2' 6 001024 BDY REMOVE/INSTALL L REAR ROCKER SCUFF PLATE Existing 0.2' 7 001937 BDY REMOVE/INSTALL R FRT SEAT ASSY 0.3 8 001938 BDY REMOVE/INSTALL L FRT SEAT ASSY 0.3 9 001762 BDY REMOVEIREPLACE DRIVER SIDE SEAT ADJUSTER COVER ORDER FROM DEALER 14.91 ' 0.5' 10 001777 BDY REMOVE/REPLACE DRIVER SIDE SEAT BACK COVER ORDER FROM DEALER 169.57' 0.7 # 11 001939 BDY REMOVE/INSTALL R CTR SEAT ASSY 0.3 12 001940 BDY REMOVE/INSTALL L CTR SEAT ASSY 0.3 13 001731 BDY REMOVE/REPLACE L FRT SEAT BELT ORDER FROM DEALER 91.60 0.5 14 001991 BDY REMOVE/INSTALL L ROOF MOULDING 0.3 15 001999 REF REFINISH L QUARTER PANEL OUTSIDE C 2.6' 16 001653 BDY REPAIR L QUARTER OUTER PANEL Existing 2.0'# 17 001654 BDY REMOVE/REPLACE L QUARTER FUEL DOOR 15845029 GM PART 37.29 0.3 18 001698 BDY REMOVE/REPLACE QUARTER ADHESIVE NAMEPLATE 15925503 GM PART 13.90 0.2 19 001054 GLS REPAIR L QTR GLASS STATIONARY Existing 0.4'# 20 002038 BDY REMOVE/INSTALL L REAR COMBINATION LAMP 0.3 21 002041 BDY REMOVE/INSTALL REAR BUMPER ASSY 0.8' 22 900500 BDY' REMOVE/REPLACE CARPET New 184.33' 6.5' 23 900500 BDY' REMOVE/REPLACE FLOOR MAT New 99.00' 0.0' 24 900500 BDY' REMOVE/REPLACE SEAT COVER New 143.72' 1.3' 25 900500 BDY' REMOVE/REPLACE MAT New 92.16' 0.0' 26 900500 BDYREMOVE/REPLACE MASK FOR OVERSPRAY New 5.00' 0.0' 27 936008 ADD'L COST PAINT 114.00' 28 936010 ADD'L COST DETAIUCLEANUP 70.00' 29 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 1.50' ESTIMATE RECALL NUMBER: 12/20/2006 11:05:48 187 UltraMate is a Trademark of Mitchell International Mitchell Data Version: NOV_06_A Copyright(C)1994-2003 Mitchell International Page 1 of 2 UltraMate Version: 5.0.215 All Rights Reserved Date: 2/13/2007 05:17 PM Estimate ID: 187 Estimate Version: 0 Committed Profile ID: CUSTOMIZED 30 933002 REF ADD'L OPR CLEAR COAT 1.2' 31 933003 BDY` ADD'L OPR TINT COLOR 0.5' -Judgement Item #- Labor Note Applies C- Included in Clear Coat Calc Remarks VEHICLE HAS DAMAGE TO INTERIOR/LT REAR SIDE. Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals Il. Part Replacement Summary Amount Body 16.5 70.00 0.00 0.00 1,155.00 Taxable Parts 1,278.99 Refinish 3.8 70.00 0.00 0.00 266.00 Sales Tax @ 8.250% 105.52 Glass 0.4 70.00 0.00 0.00 28.00 Total Replacement Parts Amount 1,384.51 Non-Taxable Labor 1,449.00 Labor Summary 20.7 1,449.00 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 114.00 Insurance Deductible 500.00- Sales Tax @ 8.250% 9.41 Customer Responsibility 500.00- Non-Taxable Costs 71.50 Total Additional Costs 194.91 I. Total Labor: 1,449.00 Il. Total Replacement Parts: 1,384.51 Ill. Total Additional Costs: 194.91 Gross Total: 3,028.42 IV. Total Adjustments: 500.00- Net Total: 2,528.42 Insurance Cc: STATE FARM INSURANCE CO. ESTIMATE RECALL NUMBER: 12/20/2006 11:05:48 187 UltraMate Is a Trademark of Mitchell International Mitchell Data Version: NOV 06_A Copyright(C)1994-2003 Mitchell International Page 2 of 2 UltraMate Version: 5.0.215 All Rights Reserved i CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 22, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing E n o=rse �'IV, , )� NOTICE TO CLAIMANT and Board Action. All Section refer c s'atO`_!5ED The copy of this document mailed to California Government Codes. ) you is your notice of the action taken APR 24 2007 on your claim Uy the Board of COUNTY COUNSEL Supervisors. (Paragraph IV below), MARTINEZ CALIF. given Pursuant to Government Code AMOUNT: IN EXCESS OF TBE LIMITED ECONOMIC Section 913 and 915.4. Please note all JURISDICTION OF TBE SUPERIOR COURT "Warnings". CLAIMANT: DANIELLE ROMERO ATTORNEY: BENNETT R, GLEN, ESQ. DATE RECEIVED: APRIL 24, 2007 SCRANTON LAW FIRM APRIL 24, 2007 ADDRESS: 2450 STANWELL DRIVE BY DELIVERY TO CLERK ON: CONCORD, CA 94520 BY MAIL POSTMARKED: APRIL 23, 2007 AND RIL 20, 2007 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL 24, 2007 JOHN CULLEN, C 'k Dated: By: Deputy 1.1. FROM: County Counsel TO: Clerk of the Board of Sup •visor (O/This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated: Z4-Z5_ By: r_r1 Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (]) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. $OARD 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: oea 4LOHN CULLEN, CLERK, By Deputy Clerk WARNI.N Gov. code section 913) Subject to certain exceptions,you have only six(6) months fronr the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attontey,you should do so immediately. *For Additiatal Wanting 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: *ZJ oOd4,71 JOHN CULLEN, CLERK By _ Deputy Clerk 04/13./2007 09: 12 CONTRR COSTR COUNTY. CLERK. DF THE 4 96769999 NO.252 P02 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 4 911.2.) 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.' eoae0osasssesaeea**auto 999969099 so sasoa,aa ae Daea9oeaa000eoo seaaeaas eaaaoseaoaa¢r RE: Claim By: - Reserved for Clerk's filing stamp DANIELLE ROMERO ) Against the County of Contra Costa or ) APR 2 4 [uui District) CSR BOARD S CONTRA COSrACOVISORS (Fill in the name) ) SEE ATTACHED "PUBLIC EI\MTY CLAIM" 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: ** In excess of the limited economic jurisdiction of the Superior Court. I. When did the damage or injury occur? (Give exact date and hour) October 26, 2006 2. Where did the damage or injury occur? (Include city and county) In an unincorporated area of Contra Costa County -- See attached "Public Entity Claim" for more comprehensive information. 3. How,did the damage or injury occur? (Give full details; use extra paper if required) Ultimately, Claimant's decedent was struck by a train. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? See attached "Public Entity Claim". 5 What are the,names of county or district officers, servants, or employees causing the damage or injury? Currently unknown. 04/1:/2007 . 09:.12 CONTRR COSTR COUNTY CLERK OF THE 96769999 NO.252 P03 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Claimant's decedent/only child suffered fatal injuries and damages in excess of " limited economic jurisdiction of the Superior Court. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury,or damage.) Claimant's decedent suffered fatal injuries and attendant damages. 8. Names and addresses of witnesses, doctors, and hospitals: See attached "Public Entity Claim". 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Claimant's decedent/only child suffered. fatal injuries and damages. •e e a!e i v e e e e e e a e a a e e v a a e e B a a a C e a e P P P v P P a v e 0 e a e e 0 a e P s s P•P e 0 e 0 i e 0 e a v s O a e P P e e s P e e e e/e e e 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 AttorneyC] ) Bennett R. Glen, Esq. ) Bennett R. Glen, Esq. SCRANTON LAW FIRM ) SCRANTON LAW FIRM. 2450 Stanwell Drive ) Attorneys for Claimant Danielle Romero Concord, CA 94520 ) (Address) 20 Bonnie Drive San Pablo, CA 94806 ) Telephone No. (925) 602-2727 ) Telephone No. (510) 222-6964 Facsimile No. (925)676-9999 v•vvvvvvvvvvae eae PPP vvvssaysssoveoeee aboaovsvv vvev vss ov oevsPv.ovvvvosvov ovv vv v o s P•PP, PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Ton Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6S00 et seq.) Furthermore,.any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. a e e e e e a e e a e of Bugged a a 1 e e v e a P a a e s e•e'o o a 9 e v a e 0 6 s 9 o v 1 v e e 0 e o e e f s e a e 6 s e 8 1 a f a e o v ha u v v s s e e e, 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 Countyjail for a period of not more than one year, by a fine of not exceeding one thousand dollars (11,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars (1)0,000), or by both such imprisonment and fine. April 19, 2007 P p a�E® Sent Via Facsimile and Certified APR,2 4 [uu� Mail Return Receipt Re uested CLERKSOA13DOP p �-- CONTRq CO SUPERVISORS STq O0. PUBLIC ENTITY CLAIM TO: County of Contra Costa CLAIMANTS NAME AND POST OFFICE ADDRESS: Danielle Romero 20 Bonnie Drive San Pablo, CA 94806 POST OFFICE ADDRESS TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT: Bennett R. Glen, Esq. Attorney at Law SCRANTON LAW FIRM 2450 Stanwell Drive Concord, Ca 94520 Telephone: (025) 602-2727 Facsimile: (925) 676-9999 . DATE, PLACE AND OTHER CIRCUMSTANCES OF THE OCCURRENCE GIVING RISE TO THE CLAIM: Date of Loss: October 26, 2006 1 Place of Loss: Railroad tracks in the State of California in an unincorporated area of Contra Costa County near Montalvan Manor and near Seaview Elementary School and near the MonTer0ay Community Center, and ball fields, near the intersection of Birch Court and Cypress Avenue, and near the bay's edge hereinafter referred to as "the area", and/or "aforesaid areas", and/or"afore- mentioned area", and/or"general area", and/or"afore-described area:". The train collision, itself, occurred at the railroad tracks in the afore-described area and claimant's young minor son, Ruben Anthony Torres Ramirez suffered fatal injuries after being struck by an Amtrak train. The owners, and/or supervisors, and/or managers, and/or controllers, and/or lessors, and/or lessees, and/or agents and/or other representatives of the area are City of San Pablo, . and/or West Contra Costa Unified School District, and/or County of Contra Costa; and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway and/or had safety, supervisory, and/or managerial duties owed to Claimant's decedent and/or the elementary school children playing in the subject area. Elementary school children in the area, including claimant's decedent, played in the area, utilizing the ball fields and/or access the bay's shore and/or the grounds of Seaview Elementary School and the life in the area. These children, including claimant's decedent, would ride their bicycles in the afore-mentioned areas, and had to cross railroad tracks in the area that put them in a dangerous situation due to dangerous conditions, which were actually, and legally caused by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National 2 Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in any combination with each other. The dangerous condition or conditions included, but were not limited to the barricading of a bridge/trestle, disallowing school children to,use their bikes on it to safely cross railroad tracks; failure to fence property that the school children would access in the afore-described areas, such as, but not limited to, fencing at.the Seaview Elementary School and/or the afore- described ball fields; failure to maintain fencing in the aforesaid areas which allowed and invited children through and to those areas which were close to the railroad tracks where the subject train collision incident occurred; failure to maintain the roadway crossing the railroad tracks so as to prevent dangerous gaps and/or holes on the roadway at or about the railroad track crossing which posed a dangerous condition and hazard to children attempting to cross there, and, rather, forcing the school children to go to other dangerous areas/areas of dangerous condition(s) within the aforesaid area of the railroad tracks in order to cross, which the school children may have perceived and/or perceived to be less dangerous/hazardous than the road crossing where these dangerous gaps and holes in the road existed; failing to place warning signs at and about the place of the subject incident; failing to place barricades at or about the place of the subject incident to prevent elementary school children, including claimant's decedent from.attempting to and/or crossing the tracks there; failing to slow trains to a very slow speed and/or stop knowing elementary school children were crossing railroad tracks in the area, including but not limited to the train that struck claimant's decedent; failing to post look-outs and/or other safety personnel to ensure the safety of the children in crossing the tracks; failing to place devices in the area to warn 3 train operators of school children close to the tracks as the trains entered the area; failing to communicate with each other—that is failing to communicate between City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other of the dangerous condition(s)and of the young elementary school children in the area attempting to and/or crossing the tracks-and failing to take action to make the area safe for those young elementary school children to cross the railroad tracks in the area; failing to reduce the speed limit for the trains passing through the area, and creating a general area which constituted a dangerous condition for Iany single and/or any combination and/or all of the foregoing reasons to elementary school children playing in the area and/or attempting to and/or crossing the railroad tracks in the general area. Additionally, City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, created "an attractive nuisance"to the children in the general area described hereinabove, which actually and legally (proximately) caused the death of elementary school child/claimant's decedent Ruben Anthony Torres Ramirez. City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or 4 National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway,'and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, knew or should have known that elementary school children were playing in the afore-described area and crossing the railroad tracks and/or attempting to cross the railroad tracks in and about the afore-described area and/or should have known of them doing so and/or had constructive notice of them doing so and City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other knew, and/or should have known, and/or had constructive notice that the dangerous condition(s)as described hereinabove existed on October 26, 2006 and for a long time prior to it. Even a cursory examination of the area by the aforesaid entities their employees, agents or other representatives would have revealed the afore-described dangerous condition(s),and/or the children's presence in the area where the dangerous conditions existed-, as heretofore described. To the extent that the afore-described dangerous conditions were actually and proximately caused by the employee(s) and/or representatives of the Public Entities named herein, had those public entity employee(s) been private persons, the action and/or inaction of those Public employee(s) would constitute negligence. The dangerous conditions, individually and/or in combination with one another resulted in the more likely than not probability of grave harm coming to the school children, including claimant's decedent, playing in the afore- described areas and/or attempting to and/or crossing the railroad tracks in the areas, and, in fact, 5 caused the death of claimant's decedent, claimant's only child, elementary school child Ruben Anthony Torres Ramirez. The afore-described dangerous condition and/or dangerous conditions created by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other through their actions/inactions and/or the.actions/inactions of their employees or other representatives were a substantial factor in actually and legally causing the death of claimant's decedent/claimant's only child/elementary school child Ruben Anthony Torres Ramirez. Had City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California; and/or Union Pacific Railroad; and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, provided safety precautions such as warning signs, barricades, proper fencing, repaired and made safe roadway crossings at the railroad tracks and/or maintained a safe passage for elementary school children, including claimant's decedent herein, this tragedy would not have occurred. As a result of the creation of a dangerous condition/dangerous conditions, hereinabove described, by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or 6 Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, claimant Danielle Romero suffered the loss of her only child, Ruben Anthony Torres Ramirez, and sustained damages in excess of the limited economic jurisdiction of the Superior Court. Claimant's decedent was not killed instantly upon collision with the train and a survivorship action arises and he and/or claimant suffered injuries and damages as a result of same. As discovery is continuing in this matter, claimant reserves the right to supplement the, prospective civil action Complaint, which will be filed in the Superior Court in this action, with further information regarding liability, and/or other facts after the Complaint is filed and as further information becomes known through discovery or other means. GENERAL DESCRIPTION OF THE INJURY: Claimant's decedent and only child is dead as a result of the subject incident. The child, Ruben Anthony Torres Ramirez, did not die immediately upon being struck by the train and suffered and incurred injuries which were eventually fatal. Claimant individually and claimant on behalf of her decedent child suffered injuries and damages as a result of same. NAMES OF PUBLIC EMPLOYEES ALLEGEDLY CAUSING THE INJURY (IF KNOWN): Currently unknown, discovery is continuing. 7 THE AMOUNT OF DAMAGES CLAIMED: In excess of the limited economic jurisdiction of the Superior Court Dated: April 19, 2007 SCRANTON LAW FIRM By:__( L BE TT R. GLEN, ESQ. Att eys for Claimant Danielle Romero 8 w� M6 a , IWO y c� G 3.�i `c P %00.a � a' L4 ON 1 OO�� �. $�1 r- r O A s m m �. o r ' 000 +�' N 00, r i i l V ✓ Fr' ED QCD CD i 1 — I I c, o intraX . � D• pr 6 6 --1 v o. CDOCD Q N D F Z ?; N N Of .moi �. S 0 v p '17 _y n 3 y W T � y oovh D o CD '° m I — - ; c vo W CA — CD —srsxs�--rte c Z r N J ��5 O = _ Ki _ y A CN C0 `^ N QW � Q �v LTIo m = 2 Ln w J pJ W a cn v Z m p = x 4 CD O CLAIM RECEI VED ON APRIL 24, 2007 WITH A POSTMARK DATED APRIL 20, 2007 F04/1.3/2007 99:12 CONTRR COSTR COUNTY CLERK OF THE 4 96769999 NO.252 Det BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY .INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code $ 911.2) B. CIaims 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.' •..•....•...see.eee•.esss•sseses a sesssss eeese Vesss•s.ssse s.ssse.n me some oral s sl RB: Claim By: Reserved for Clerk's filing stamp DANIELLE RomMo RECEWE® Against the County of Contra Costa or ) APR 2 4 LUU/ District) (Fill in the name) ) CLERK BOARoar--suPERvisoRs CON rRA Coss co. SEE ATTACHED "PUBLIC ENTITY CLAIM" The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of S ** and in support of this claim represents as follows: ** " In excess of the limited economic jurisdiction of the Superior Court. 1. When did the damage or injury occur? (Give exact date and hour) October 26, 2006 2. Where did the damage or injury occur? (Include city and county) In an unincorporated area of Contra Costa County -- See attached "Public Entity Claim" for more comprehensive information. 3. Now did the damage or injury occur? (Give full details; use extra paper if required) Ultimately, Claimant's decedent was struck by a train. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? See attached "Public Entity Claim". 5 What are the names of county or district officers, servants, or employees causing the damage or injury? " Currently unknown. 04/13/2007 09:12 CONTRA COSTA COUNTY CLERK OF THE 4 96769999 NO.252 P03 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Claimant's decedent/only child suffered fatal injuries and damages in excess of 1.'1. limited economic jurisdiction of the Superior Court. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Claimant's decedent suffered fatal injuries and attendant damages. 8. Names and addresses of witnesses, doctors, and hospitals: See attached "Public Entity Claim". 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT Claimant's decedent/only child suffered fatal injuries and damages. - eeaeeaeeaeeeraee.ereaaeeaass.raeasrree..eresaeeerae....reaaaeeeaev..e..rerr.rr aasaea� 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 ) Bennett R. Glen, Esq. Bennett R. Glen, Esq, SCRANTON LAW FIRM ) SCRANTON LAW FIRM 2450 Stanwell Drive ) Attorneys for Claimant Danielle Romero Concord, CA 94520 (Address) 20 Bonnie Drive San Pablo, CA 94806 Telephone No. (925) 602-2727 )Telephone No. (510) 222-6964 Facsimile No. (925)676-9999 vaeeaavveeeaae roeresae.s.a.esaaeaa.aa aaraesee•aeaeeaaseaa e.aese.res.aeeaaeeeeerara.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. aaa aaaeareaaaaerase Rosea aseeaear...........a..............................re rr0696691 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.imprisonmant and fine- April 19, 2007 RECE1 �® APR,-2 4 ui Sent Via Facsimile and Certified CLERKSOARpOFsuPERVISORS co. Mail Return Receipt Requested CONTRA Co PUBLIC ENTITY CLAIM TO: County of Contra Costa CLAIMANTS NAME AND POST OFFICE ADDRESS: Danielle Romero 20 Bonnie Drive San Pablo, CA 94806 POST OFFICE ADDRESS TO WHICH CLAIMANT DESIRES NOTICES TO BE SENT: Bennett R. Glen, Esq. Attorney at Law SCRANTON LAW FIRM 2450 Stanwell Drive Concord, Ca 94520 Telephone: (925) 602-2727 Facsimile: (925) 676-9999 DATE,PLACE AND OTHER CIRCUMSTANCES OF THE OCCURRENCE GIVING RISE TO THE CLAIM: Date of Loss: October 26, 2006 1 . Place of Loss: Railroad tracks in the State of California in an unincorporated area of Contra Costa County near Montalvan Manor and near Seaview Elementary School and near the MonTeraBay Community Center, and ball fields, near the intersection of Birch Court and Cypress Avenue, and near the bay's edge hereinafter referred to as"the area", and/or"aforesaid areas", and/or"afore- mentioned area", and/or"general area", and/or"afore-described area:". The train collision, itself, occurred at the railroad tracks in the afore-described area and claimant's young minor son, Ruben Anthony Torres Ramirez suffered fatal injuries after being struck by an Amtrak train. The owners, and/or supervisors, and/or managers, and/or controllers, and/or lessors, and/or lessees, and/or agents and/or other representatives of the area are City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa; and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway and/or had safety, supervisory, and/or managerial duties owed to Claimant's decedent and/or the elementary school children playing in the subject area. Elementary school children in the area, including claimant's decedent,played in the area, utilizing the ball fields and/or access the bay's shore and/or the grounds of Seaview Elementary School and the life in the area. These children, including claimant's decedent, would ride their bicycles in the afore-mentioned areas, and had to cross railroad tracks in the area that put them in a dangerous situation due to dangerous conditions, which were actually, and legally caused by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National 2 Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in any combination with each other. The dangerous condition or conditions included, but were not limited to the barricading of a bridge/trestle, disallowing school children to use their bikes on it to safely cross railroad tracks; failure to fence property that the school children would access in the afore-described areas, such as, but not limited to, fencing at the Seaview Elementary School and/or the afore- described ball fields; failure to maintain fencing in the aforesaid areas which allowed and invited children through and to those areas which were close to the railroad tracks where the subject train collision incident occurred; failure to maintain the roadway crossing the railroad tracks so as to prevent dangerous gaps and/or holes on the roadway at or about the railroad track crossing which posed a dangerous condition and hazard to children attempting to cross there, and, rather, forcing the school children to go to other dangerous areas/areas of dangerous condition(s) within the . aforesaid area of the railroad tracks in order to cross, which the school children may have perceived and/or perceived to be less dangerous/hazardous than the road crossing where these dangerous gaps and holes in the road existed; failing to place warning signs at and about the place of the subject incident; failing to place barricades at or about the place of the subject incident to prevent elementary school children, including claimant's decedent from attempting to and/or crossing the tracks there; failing to slow trains to a very slow speed and/or stop knowing elementary school children were crossing railroad tracks in the area, including but not-limited to the train that struck claimant's decedent; failing to post look-outs and/or other safety personnel to ensure the safety of the children in crossing the tracks; failing to place devices in the area to warn 3 train operators of school children close to the tracks as the trains entered the area; failing to communicate with each other—that is failing to communicate between City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other of the dangerous condition(s) and of the young elementary school children in the area attempting to and/or crossing the tracks—and failing to take action to make the area safe for those young elementary school children to cross the railroad tracks in the area; failing to reduce the speed limit for the trains passing through the area, and creating a general area which constituted a dangerous condition for any single and/or any combination and/or all of the foregoing reasons to elementary school children playing in the area and/or attempting to and/or crossing the railroad tracks in the general area. Additionally, City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, created"an attractive nuisance"to the children in the general area described hereinabove, which actually and legally(proximately) caused the death of elementary school child/claimant's decedent Ruben Anthony Torres Ramirez. City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or 4 National Railroad Passenger Corporation; and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other,knew or should have known that elementary school children were playing in the afore-described area and crossing the railroad tracks and/or attempting to cross the railroad tracks in and about the afore-described area and/or should have known of them doing so and/or had constructive notice of them doing so and City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other knew, and/or should have known, and/or had constructive notice that the dangerous condition(s) as described hereinabove existed on October 26, 2006 and for a long time prior to it. Even a cursory examination of the area by the aforesaid entities their employees, agents or other representatives would have revealed the afore-described dangerous condition(s), and/or the children's presence in the area where the dangerous conditions existed, as heretofore described. To the extent that the afore-described dangerous conditions were actually and proximately caused by the employee(s) and/or representatives of the Public Entities named herein, had those public entity employee(s)been private persons, the action and/or inaction of those Public employee(s)would constitute negligence. The dangerous conditions, individually and/or in combination with one another resulted in the more likely than not probability of grave harm coming to the school children, including claimant's decedent, playing in the afore- described areas and/or attempting to and/or crossing the railroad tracks in the areas, and, in fact, 5 caused the death of claimant's decedent, claimant's only child, elementary school child Ruben Anthony Torres Ramirez. The afore-described dangerous condition and/or dangerous conditions created by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other through their actions/inactions and/or the actions/inactions of their employees or other representatives were a substantial factor in actually and legally causing the death of claimant's decedent/claimant's only child/elementary school child Ruben Anthony Torres Ramirez. Had City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California; and/or Union Pacific Railroad; and/or Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other,provided safety precautions such as warning signs, barricades, proper fencing, repaired and made safe roadway crossings at the railroad tracks and/or maintained a safe passage for elementary school children, including claimant's decedent herein, this tragedy would not have occurred. As a result of the creation of a dangerous condition/dangerous conditions, hereinabove described, by City of San Pablo, and/or West Contra Costa Unified School District, and/or County of Contra Costa, and/or State of California, and/or Union Pacific Railroad, and/or . 6 Amtrak, and/or National Railroad Passenger Corporation, and/or Burlington Northern Santa Fe Railway, and the employees or other representatives of the aforesaid entities, individually and/or in combination with each other, claimant Danielle Romero suffered the loss of her only child, Ruben Anthony Torres Ramirez, and sustained damages in excess of the limited economic jurisdiction of the Superior Court. Claimant's decedent was not killed instantly upon collision with the train and a survivorship action arises and he and/or claimant suffered injuries and damages as a result of same. As discovery is continuing in this matter, claimant reserves the right to supplement the . prospective civil action Complaint, which will be filed in the Superior Court in this action, with further information regarding liability, and/or other facts after the Complaint is filed and as further information becomes known through discovery or other means. GENERAL DESCRIPTION OF THE INJURY: Claimant's decedent and only child is dead as a result of the subject incident. The child, Ruben Anthony Torres Ramirez, did not die immediately upon being struck by the train and suffered and incurred injuries which were eventually fatal. Claimant individually and claimant on behalf of her decedent child suffered injuries and damages as a result of same. NAMES OF PUBLIC EMPLOYEES ALLEGEDLY CAUSING THE INJURY (IF KNOWN): Currently unknown, discovery is continuing. 7 THE AMOUNT OF DAMAGES CLAIMED: In excess of the limited economic jurisdiction of the Superior Court Dated: April 19, 2007 SCRANTON LAW FIRM By: BE TT R. GLEN, ESQ. Atteys for Claimant Danielle Romero 8 I. ^ `^• yx " ''' s A ' '� F{Is,.I7�'r �! p ° f .ES et- ,., �+ # '-b aMf �} e l' t4 y„ 7 d 4�' wlow,,'µvr �'�aau"6' �"rum'1�y Aetfi Ira.i f'k h r e3 � pia u r 8y+'3s. a �1 N ��rP1� t_ N" �.p' 9� .t V I'+ IfJ V 1✓F, FS ev 'IY f�" COX $�,✓ G r} { xy'° 5i.u`i'"''pt 55Rn '1 Nt`"rr12D ✓' y �.Jtj .f p if s a 4 F 1 y'c Y `CI tin & ..°111 r t..ec �fiy t4'f�. �rn ? yf,,� �." N G rte k rbY.+1511 1'-y 4a3rt" t,G$'.J .yrr i�r'A, y r rty x s q,.�' -.. 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N p o 0 0- 5 N 3V o �L os CIA r C— ul c� O l CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY s BOARD ACTION: MAY 22, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section rrertc The copy of this document mailed to California Government Codes. c f) you is your notice of the action taken APR 2 4 2D07 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code AMOUNT: $1,150.00 incl^ffT'carC`�ileWntal Section 913 and 915.4. Please note all "Warnings". CLAIMANT: JENNY LAW ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 25, 2007 ADDRESS: 2026 SPRING LAKE DRIVE, BY DELIVERY TO CLERK ON:APRIL 25, 2007 MARTINEZ, CA 94553 RECEIVED FROM RISK BY MAIL POSTMARKED: nrenTeG>ano+ni'r n4/�5/p7 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. APRIL 25, 2007 JOHN CULLEN, Cl;yk� ' Dated: By: Deputy i 11. FROM.: County Counsel TO: Clerk of the Board of Supervisor rs v (,)"fhis 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: �t oZ �� d By: 10'�C9fl/l Deputy County Counsel III. 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). LV. ,ROARD 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: /"/ oZ� oe OHN CULLEN, CLERK, By Deputy Clerk WARNI.N (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 covet action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side ofTlnisNotice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I. am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today I 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 eputy Clerk - BOARD OF SUPERVISORS OF CONTRA C6STA COUNTY SHARON HYMES-OFFORD INSTRUCTIONS TO CLAIMANT - ------- -. T_ _ _.AYt-2 .3 2007 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 olaiiri is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec.72 at the end of this form. s¢aae■aai■ ¢ ¢¢e■■aaaa ¢a■eaaa®aaeeese¢e¢¢u¢■o¢¢■a a a name en¢¢ae¢n¢e all eaa¢¢¢¢ceI RE: Claim By: Reserved for Clerk's filing stamp J.eriny Lo�i�,l � RECEIVE® Against the County of Contra Costa or ) APR 2 5 2007 District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$I I oO_` and in support of this claim represents as follows: 1. When d> the damage or injury occur? (Give exact date and hour) �pry L 6 2007 7'50 at"t 2. Where did the damage or injury occur? (include city and county) CL9.rfjf C01 �1 �r;use xtra paper if required) i- W&5 d I, i girl Soui h 3. How did�e de or injury occur? (Give full de p p eq ) � ,S on CDnFra Cis a gl near Gr-e9vey ).anz , _- n-han9�! la,u:5 front -�`hP- middle 40 -Fh2 ri yh� !qn P , (h2 1►7x i� 5��p , s W�45 5�dgT f or R L4J1i)e, iq +rACY-hi¢ me 0 m y )2 f' Y�r. p1uMP�= 7hk truc�wa5 dr;vIn� in fhe w�idd 611ne . 4. t particular act or omission on the p o county or district officers, servants, or employees caused the injury or damage? j 1.e-cawly ueh 1 Cl2 jLa')1 eG( O vod rear bu-MF-Qj^, 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 -claimed. -Attach-two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Vehicl2 rLS��m��QS ob- ain-ed from2 raufo 8. Names and addresses of witnesses,doctors, and hospitat� �0� N o N 6 o f' er +I/U Mq �� lirq old Pf49gh*r 14 + W&t�y v lick„ 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT IdDA1 b a sit manage Museum■sata Human a a■vanmgtel e■■lama■l■■■t■■Matte%tm■ate ela[etgnMl9cg■slogs■■1 ) .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 ) %Aimants Signature) I (Address) Mar�in�z eA 14553 Telephone No. )Telephone No. CL J �fi�ven -Thai ■.gnaffeffggsafflagana■aamMRasHasmmatsumMalang an Base ling aIsm 1199■■9gaff nagmmsits aSan Blue asnet 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. g■Iuff Beee■Basso a situ aB■mans sea am%songs■astasage affsam anal■an easaffeanae affass g■■■ma■egttt 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. 04/16/2007 at 12 : 33 PM Job Number : 73920 ELITE AUTOBODY & COLLISION CENTER Federal ID # : 204326297 Tax Id : 20-4326297 BAR# AJ223861 EPA# CAL000230 2180 MARKET ST . CONCORD, CA 94520 (925) 687-3117 Fax: (925) 687-4747 O PRELIMINARY ESTIMATE Written By: Lincoln Haven n Adjuster: F 41 ►7I Insured: Jenny Law Claim # ' IVdePe&dent1 a Owner: Jenny Law Policy # hl.-hen,n, Rved Address: 2026 Spring Lake Dr. Deductible: Day: Martinez,925) 681 215394553 DType of Loss: AS �ate of Loss: �r(YEA Point of Impact: Inspect Location: Insurance Company: Days to Repair 2005 TOYO HIGHLANDER 4X2 6-3. 3L-FI 4D UTV Int: VIN: JTEDP21A750077578 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear Wiper Body Side Moldings Dual Mirrors Privacy Glass Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek CD Player Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Traction Control Cloth Seats 3rd Seat Captain Chairs (2) Automatic Transmission Overdrive Styled Steel Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. . PRICE LABOR PAINT --------------------------------7---------------------------------------------- 1 REAR BUMPER 2 O/H bumper assy 2 . 1 3 Repl Bumper cover 1 224 . 66 Incl . 2 . 6 4 Add for Clear Coat 1 . 0 5# TINT COLOR 1 0 . 5 6VI COVER CAR 1 5. 00 0 .2 7# NIB & BUFF 1 0. 5 8# Subl HAZ MAT 1 7 . 00 ------------------------------------------------------------------------------- Subtotals =_> 236. 66 3 . 3 3 . 6 1 04/16/2007 at 12 : 33 PM Job Number: 73920 PRELIMINARY ESTIMATE 2005 TOYO HIGHLANDER 4X2 6-3 . 3L-FI 4D UTV Int: Parts 236 . 66 Body Labor 3 . 3 hrs @ $ 80 . 00/hr 264 . 00 Paint Labor 3 . 6 hrs @ $ 80 . 00/hr 288 . 00 Paint Supplies 3 . 6 hrs @ $ 35 . 00/hr 126. 00 ---------------------------------------------------- SUBTOTAL $ 914 . 66 Sales Tax $ 362 . 66 @ 8 .2500% 29 . 92 ---------------------------------------------------- GRAND TOTAL $ 944 . 58 ADJUSTMENTS : Deductible 0. 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 944 . 58 2 04/09/2007 at 01 : 58 PM Job Number: 33479 TURBO AUTO BODY, INC. License #:AM 176166 Federal ID #: 100006078 The Ultimate Customer Service Body Shop 1722 International Boulevard Oakland, CA 94606-4504 (510) 534-5454 Fax: (510) 534-3004 PRELIMINARY ESTIMATE Written By: Peter Shin Adjuster: Insured: ;STEVE' S AUTO Claim # Owner: STEVE' S AUTO Policy # Address: Deductible: Date of Loss: Day: Type of Loss: Evening: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2005, TOYO HIGHLANDER 4X2 6-3. 3L-FI 4D UTV Int: VIN:' JTEDP21A750077578 Lic: Prod Date: Odometer: Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Rear; Wiper Body Side Moldings Dual Mirrors Privacy Glass Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek CD Player Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Traction Control Cloth Seats 3rd Seat Captain Chairs (2) Automatic Transmission Overdrive Styled Steel Wheels ----'---=----------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 Repl Bumper cover 1 224 . 66 1 . 5 2 . 6 ;3 Add for Clear Coat 1. 0 ;4 Repl LT Bumper cover clip 3 1. 89 5 Repl RT Bumper cover clip 3 1 .89 6 REAR LAMPS �7 R&I RT Combo lamp assy 0. 5 8 R&I LT Combo lamp assy 0 .5 9 QUARTER PANEL A Repl LT Mud guard blue 1 68 . 56 0 .2 0 .3 11# Repl COVER CAR 1 5. 00 T L2# COLOR MATCH 1 0. 5 i i 04/09/2007 at 01 : 58 PM Job Number: 33479 PRELIMINARY ESTIMATE 2005 TOYO HIGHLANDER 4X2 6-3. 3L-FI 4D UTV Int: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 13# FLEX ADDITIVE 1 7 .50 1;4# Subl HAZARDOUS WASTE 1 5, 00 X 1,5# This is a visual estimate. 1 Reference only. ------------------------------------------------------------------------------- Subtotals =_> 314 . 50 3.2 3. 9 Parts 304 . 50 Body Labor 3.2 hrs @ $ 78 .00 /hr 249. 60 Paint Labor 3. 9 hrs @ $ 78 . 00 /hr 304 .20 Paint Supplies 3. 9 hrs @ $ 34 . 00 /hr 132 . 60 Sublet/Misc. 10 .00 ---------------------------------------------------- SUBTOTAL $ 1000 . 90 Sales Tax $ 442 . 10 @ 8 .7500 °% 38 . 68 ---------------------------------------------------- GRAND TOTAL $ 1039.58 ADJUSTMENTS: Deductible 0. 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 1039. 58 Attention: Turbo Auto Body Shops' Customers 1. Please remember that due to many unforeseen circumstances in the repairing of automobiles, we regret that we can only estimate, not promise, a completion time;. Your undestanding is greatly appreciated. 2. No law requires you to get more than one estimate. 3. Trbo' s people are professionally trained crafsmen who will do a quality job of restoring your vehicle (its pre-loss) at a fair price. 4 . Applies to policyholders only: If you choose to use the repair facility as suggested by your insurance Company, your repair facility will guarantee the damaged vehicle be restored to its pre-loss condition at no cost to you other than as stated in the policy (i.e!,. policy limits or deductible) or allowed depreciation. You must authorize the repairs to your car. 2 04/09/2007 at 01 : 58 PM Job Number: 33479 PRELIMINARY ESTIMATE 2005 TOYO HIGHLANDER 4X2 6-3. 3L-FI 4D UTV Int: Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARM8436 Database Date 03/2007, CCC Data Date 03/2007, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT. OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or i ALT 'OEM parts, may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on,the ''line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. ' The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. i i i i I 3 M IT M ZrA _..•r �..J ,�. et� cy 1.0 f� � n Ca M M PON 457 i..i 1 SFS 1 i `J AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA-COUNTY 69 BOARD ACTION: MAY 22, 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. To -1 Sf)' you is your notice of the action taken DIJI on your claim by the Board of APR 2 4 2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL AMOUNT: $4,621.55 fl.4A!?T!R'.E?CP:LIF. Section 913 and 915.4. Please note all CALIFORNIA STATE AUTOMOBILE ASS. "Warnings". CLAIMANT: FOR: KEVIN AND TAE JUNG KIM BY: KEVIN MATTBEWS ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 24, 2007 ADDRESS: P.O. BOX 920 BY DELIVERY TO CLERK ON:APRIL 24, 2007 SUISUN CITY, CA 94585-0920 RECEIVED FROM BY MAIL POSTMARKED: COUNTY COUNSEL FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL 24, 2007 JOHN CULLEN, r Dated: By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Su ervisors (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). 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: Dated: S 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: (V This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated, "�y '2'', ° OHN CULLEN, CLERK, By Deputy Clerk WARN (Gov. code section 913) 7 � 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 in connection with this matter.If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 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, t Deputy Clerk Fax: Apr 23 2007 10:13am P003/007 INSTRUMONIS TO CLAIMANT �i��rr�•--•�.�•�_'-�-' •'r r�. -rtls���+ •�-w r r-'rT'�-rh.1 t T' o'er ' . .w.r .. _ ' A claim rets to e.cause g1t7 p p T of action for death or� to arson or� enonal • or growing crops *shall be presented not later than &ModhS after the WXrUd of the, Ow 30 of action. A claim rdating to az y otlmr cause of a6oa k all be.presontrd Aot later than year _ afor the aearuel.of em emma of aatiom (Gflv: Code § 911.2.) Claims must be fled vwifh the Clerk of tie Board.of Sgervisors at its offiC0 in. RDOZE 106, County Adi*n�xi Building, 651 Pine Straet,Madinez,CA 94553. ff rtlalm is against a district oov=cd by the Boars of Supervisors, rdhu than.the Co , the ' nm:za of the District should be£ale d hL If the claim 3s against more t= one public eta, aepw s elwma =9 be faad agains each . public entity. baud See penalty for fraudatlenf clai ..%Penal Cody Sec,72 at the end of fhis form. ■li& amXXg%■XZWMango NNW Lieat,lNKEEMlEMEKit{el ■c*ei , ?: CJsim.By. Deserved for Clerk's fif stamp Lu l rJ u FRECEIVED pinst'tbe Colratg of Contra Co=or ) 2 4 cuuI OF SUPERVISORS COSTA CO. Uiathe name) )' o tuidersigned clsimaa hereby maks:s claim against Je ComIty of Contra Costa or the above-1=od tdct is the s>ml of$_ Z ( S ®d in support avl a qWM ripresents W follows: Prop.,fr.� p�-an�tc•,,e. Whey aid the damage or piny occur? (Give exact date and hour) 1- 2f- b- Where did fm damage or injury occur? (Include city and county) 6 Ll v-Lr ,9 How did the damage ori+Ry occttr7 (ave fuIl g��if replr4 i r Fax Apr 23 2007 10:13am P004/007 What damages or injuries (Your rWm resulted? (Give full extern of injures or gee Raw S was tlk* awa=t claimed Bbow oamguted`t (bdude fhe esfrmatad amount a any l ;PeCtY4e k�Wy CYZdamage-) g v t `t C/v...' (8S bQ C C �tsc c�UD Names and addresses of wiiamses,doctors,and hosgitab: Last the evmutzeg you made"on a==of tis acddeut or 4mr. I?A.TB Af4UNT a s tai a s to ata w a s as s as as a altatat a a a acs it saws,it a K a as Not was Nose a s as as It ss ata a a a a a a teas isup a, , } .Cog.Gude Sec.910.2 provides"'the cIsfin abaU be signed by the claimant or by same peuan as his NO'T'ICES mt Nue and address of Amey } ` ' ? fG3simant's 8i�to) j t6 X 210 SVI'SU Ps C(1ft elephone No. }Teslephane 1�iQ. �' 760 --te ?c l�Z / ras ArftKease gas aaa=aaaaa swim me ea a virus,asarialt a ass,as csaasaltsa a a a raaas:sacaa as ses cozmmav PU.SLTC RECORDS NOTICE: Ewse be advised that this claim firm, or ash+claim f9ed with The CwMiy raider fie Tack Claims Ash,is x bi act to ; ablic disciosm tiidar the CaEfawk Public Rwords Act. {Gov. CocI% s§ 6504 at seq.} Ftiifl29 any its,addendums, or sVplameate sttacW to the claim form,iadudiag U140d rewards,ata also 5 949a to abilo d1w1osmr. s as aftKssasa=gas alto sea sea at g atasft*saaah7si�a{{^^t��taxTK�•;-ea�s+K,a Rssaaaaasaaaasr<aaaaasaaa:Naas tags&&# ectidn 71 of Ou Penal Code provides: istery p=04 who,'%% int mt to defraud,p=Vs for allowLu=or ft paymct to any slate bond or , aa• �• -- —2L_ _s N.... •. .,.�. tet, ; cmnttittn Ail tf[ t Fax: Aar 23 2007 10:13am P005/007 STATE OF CALIFORtttA TRAFFIC COLLISION REP&ilT CHF 555 Page i(Rev7-D3j opt 061 >:PlYAAL COMMMN6 WMIGgt NRddtlk C Plge FEW � AMCCMD))WIMor LOG41M3pBTtaIMEQt 9IXY17Y �"czin.(7 7r PgPORTRpp p�:TT BEAY irlJ f OUlt1.,rNom_OxLWRED ON 0 DAY- YQR T9Cdtocll N�6! 11 �Y aPflc£aLn e� PAI wee TOWAWAY P+p70GnAPNSBV; I'41 NONE: P tNita OF S M T T S ❑YES NO Y AT 1WEMEMOMiMTH _ _ YfATEtISYrAF#. OR > Dwroareta NBelaluaeu Ism. Fl yo N4 PAMY 8707E LASS 'BAFETYROUW. VE.VUIR MIDI NUMOR ETA DRIVEw NNAe(gRaf, .LAsp �.4?-.. ��1�Z?4��.- ta"Zc ouT�EaaRArda SAMHASnRNER . ❑ tib- r ��. ADDRE48CA, Gt5 . n!�.42NRq VE�.7A�CRY2TATtd1P �8.AMEAS ORNER BI O@P Of VE}m,E ON O�EReOP. R F 7f�DRIV6t mu "Mc H CLWe�'E0 t¢I57RT tw,rrAg OFFICEY^^ 6[ilE _ ItAOE �hR+fa[ .., (a� Z vworaueq+Ar�tsLngr .�& hBONPAPPARQIf et eS PNCNE wffOlTGt1NSNATAM . // VE}OQ'4�1D8N7&TCA7ION NNNEIEA; bIs � VwI 1+1rl�N!.E O41{gOE WiAD2J1YRiM1A4St VIB4PZNdCE CARRIER VMMBTYPE Pill po�Numuft ❑UI'IX• [3MON'E MlIOR �"� ^�+' �" MOR. MAJOR ROLL-OVER OBiOPTIFAVBI OM$T[tE6TORFooFMIAv / CA DOT GiY PARTY° E - STA'M CIASS AIR BAa :6MEzir Spyry, ,ygoR - NSB NIBB3ER STAT Dw mRuacvl+aBr:A PL&LAM .......... -- -•....._1 '�--.....C., ;Fsnk� C N rAPORBBf OVMCR^NANM t"'i S{1H4EASORN{<R tAAI OnyWATVLP .'KRAW AS ORNER DTII, `I ..0 POgrna.ffvENraE 0"ew[7ERB OF:HEMI 441 ElOFFIOER DR1Yq,2 O 071ER El \2..o p$ \ Yds PRdYtRECJgNICtd oePwTs Nam OTNHI KV111I xxvA 8ePMY!@ APFAR$fi RpFB;TONARRd't}VE VETP[Ow IBaR1FlC4TYON NIA4g7t ' ❑ Q7S Ed���1L1 �n S 3 . �G-lV +ENxueTm D�o�EVENxLccMAunE cAtYtICR PMJOY A.NMER BOE IN WA%GW. DMOD. ❑btA1bRRD C] DtALF7R+l'I'}5-CK,SrTB�>;Et ORNlG7MidY Ay`''e SPEED Lp1tT LL w OOT + CA47 T{ PARTY OReER'e t]CFjd1E NSNteP3t BTAILCues BAO :SAPYW EODIP. VEK YEAR AOR 3 u�Na�Nu�wq� BrATe i oB�� NA61E ........... .... --.-..._-. ------.......... ❑ OL�E�DtD+CUN1Ei'+1'�l` .... ........................ ...... r PRIWt A DI f AM ❑ SAME AS MI ed - CH¢I CE Fol►,t1- vaourr Cf1YlSTATEJDP aVq�CaApQRBSB E] SAME AS DRivM F-1 Released by ` f/r..F)Rt�• (12-bt�r�"7 LUJ Fax: Apr 23 2007 10:1dam P006/007 • $TATE OF CALIFORNIA TRAFFIC COLLISION ConiNG GHP 555 PW 2 Rev_T-D3 OPI 061 PoB�2 DATEOPC0LLW=V= DAY VMA) imeod" Nccs OfFKZR 1,M NWpER o'10 oulb.o' 0'"1 •'Zoc�c . ONNalS PJiM1E, ONNF]e'e'ADDRHB6 NOTi1e PROPERTY ;.; =.. i�!„ YEa DAMAGE D90=%WTIONOFDAMAq SEATING POSITION SAFETY EQUIPMENT INATTENTION CO[ • L-AIRBAOOFSLOYED MICEMaYC!_Tn-HE MET A-CMJPHONBHANOHE ^ A-N�VEWCLE ..• ,.. M-AIRBAGNOTDEPLOYED DRIVER PASSENGER B-CEU,FHONEHANDSF 1 B-UNMOWN N-OTHER V•NO X-NO C-ELECTROMOEQUIPA C-LAPRELTUDEO P-NOT REQUIRED W-YES Y-YES D-RADIO/CD D-LAP BELT NOT USW E-SMOKING _ 1 13 1-DRIVER E-SHWULDERHARIESSUSED F-EATING a 5 S SSE 2 TO 6-PANOERS F-SHOULDER KARNES$tor USED EjpQ=FROM VEHPCLE 0-CHILDREN I-STATIONMOONREAR G-+- ULDERtWtHESSUSED O•IkVF]V USED . C-NOT W2079D H-ANIMALS s.REAR ObC,YkKORVAN H-LAPMOULDERHARREEsWOTUWDR-INvEHICLsNorUSED t-FULLY FrECTED . I-PERBONALHYGIENE •J S-GTKE ON UNKNOWN :K-PASSNERERTRAIINt NOTESTRAINT USED '. T-IN VEHICLE IMPROPER USE s-PARTWJaVyµY EJP•C7E0 . K-OT nING ER 0-OTHER -U-NONE IN VeMi ' IrEle6 MARKED 8ELOW FOLLOWED SY AN ASTERISK r)SHOULD 9E EvLAINED NN THE NARRATIVE. t.IST NUMARY BER(vi FAULT ERR .TRAFFtC l�N7Rpl,oEyiCf:.q. '. 'i .z '3 BPEWLINPORMATION' 1 2 � MOYEME PRcouilpNEOt A�"`®'�'�"`m D ym A CONTROLS FUNCTIONING A HPZARDDUS MATERIAL sToppm t CONTROLS NOT FUNCTIONING'. R CELL PHONENlANDHELD It USE B PROC EDInO B OTHER IMPROPER DRMNG` CONTROLS OBSCURED C CELL PHONE NANDSFM IN USE RAN OAD D NOCONTROLAISENTIFACTOR CELL PHONE NOT IN URE RIOH77u H£R THAN DNAIER- TYPE OF COLL E SCHOOL BUS RELATED E MAPOHO Lwr TURN D UNKNOWN" HEAD.ON ,. 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VWWNOBSCUREMENT. !3 go-UNDER NAMENC PERP DDY OILY ETC. i TTEHTION': C I®D-N(7TUNDEItNNFLL ROAMAYCONOMOKB) STOP806TRAFFIC D HOD-RAPAIRIWENTUNKI (,MRK 1 TO17709a PEORSTRIA 'S H EMTERINC>t LCNVWO RAMP . E UNDER DRUO NFLLIENC HOLES DEIPREI!' NO PEDESTRIANS INVOLVED I PREVIOUS,COLLISION ' F IMPAIRMENT.PHYSICAL B LOOSE MATERIAI.ONROADWAY- g GROSSING INOROSSYW+LK J LWAMWARWTUTROAD IMPAIRMEHTNOT KNm C 088TRt=ION ON ROADWAY' AT INTERSECTM K 0g£CTNE EQUIP_ CIT7':D H�NOT UCABLE coNSTRucnON•REPAIRZONE C CROSSING IN CROSSWALK:NOr ' ' :: �• I IFA E REDUCFA ROADWAY WIDTH AT DITERSECION F FLOODED' CROSSING•NOT N CROSSWALK L UNINVOLVED VEHICLE OTHER- E INROAD-INCLUDES SHOULDER MOTHER: SH NO UNUBUAL CONDRIONS ROT VL ROAD N NONE APPARENT O APPROACHINGILEAVING$CHOOLSUB O RtMAWAYVWfCLE s w Fax: Apr 23 ZUUI 1U:14am PUUI/UUI w 1- <' J } STATE OF CALIFORNIA NARRATI'V&SUPPLEM ENTAL CHP 558(Rvv TSO OPI 442. Date of rnc'Y.lerWOccurr@nce -Fang(2440) NCIC NUMBER OFFICER ID 4 NUMBER 01-25-2007 0744 0704 460 07-2000 -X"ONE 'X"ONE TYPE SUPPLEMENTAL(W-A?pL1CABLE) X I Narrative x f Collision Re late I Hit and run date Su ismentarI Other. I Hazardous materials I I school tars I Other crTY/COUNTY!JUDICIAL viSTRiCT REPORTING DISTIBEAT CITATION NUMBER Concord 1 Contra Costa l ML Diablo 4 LOCATIOWSUBJECT STATE'HIGU W RELATED Drivers Road I Yes x I No NOTIFICATION:• On 01-25-07 approximately 0744 hours,I was dispatched to the area of the Olivera Road an Sanford Street intersection to investigate a two vehicle non-injury accident that had just occurred. I arrived on scene approximately 0745 hours. All speeds and measurements are approximate and were obtained by a pacing SUMMARY: (D-1)told me he was traveling W/B on Olivera Road directly behind(V-2)approaching the Sanf Street intersection. (D-1)told me sincee it was the early morning commute hours so traffic was moving approximately 20-25 mph. (D-1)told me he was going to a call and momentarily looked at his mounted compu screen and then realized(D-2)suddenly applied her brakes. (D-1)told me he immediately applied his brakes however: he was not able to stop in time and subsequently collided with the rear end on (V-2). (D-2)told me th he did not sustain any injuries as a result of the vehicle collision., (D-2)told me she was traveling W/B on Olivera Road approximately 20-25 mph. (D-2)told me while she was traveling;two juvenile pedestrians entered the crosswalk at the Sanford Street intersection. (D»I)told me she immediately applied her brakes in order to give the pedestrians the right of way. (D-2)told me after(V-2)came a complete stop, she was struck from behind by(V-1). (D-2)told me she did not sustain any injuries as a result this vehicle collision. CAUSE: Based on the statements and damage to(V-1)and(V-2) it is my opinion(D-1) caused the collision because(D-1)was following too close to(V-1). This accident occurred due to a violation of 21703 V.C. (Following too close) AREA OF IMPACT: The area of impact was determined to be approximately 5 feet east of west curb line prolongation of Sanford Street and approximately 10 feet south of the south curb line prolongation of Olivera Rc The A.O.T was also determined by driver's statements, damage to (V-1),(V-2)and debris on the roadway. RECOMMENDATIONS: Norte. rax: Hpr zi zuut iu:isam ruui/uur Facsimile Transmittal ® U,lGENo_ Ple¢se h¢rtd deliver to addressee. TO: Monica Cooper Company/Location: Fax No.: 925-335-1866 Phone No. Subject: verified claim form and police report FROM: California State Automobile Association Fax No. 707-863-9052 Phone No. 888-900-6520 ext.6241 Department/D.O.: Subrogation Fax Apr 23 2007 10:13am P002/007 Remarks: Management Approval: Daterrime_ / No. Pages including Cover Page: