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HomeMy WebLinkAboutMINUTES - 06172008 - C.46 AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: 2- 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. (Paragrapli 1V below), given Pursuant to Government Code AMOUNT: �� � Section 913 and 915,4°'-Please note all f pp "Warnings". �`"` CLAIMANT- ATTORNEY: A/a) DATE RECEIVED: ( 208 ADDRESS: Ho .ort-cc. BY DELIVERY TO CLERK ON: ! BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CUL , Clerk Dated: By: Deputy 5W4A 11. FROM:Wouiity Counsel TO: Clerk of the Board of upervisors ( This claim complies substantially with Sections 910 and 910.2. +� r ( ) 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: b Dated: 'U� By: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section,911.3). 1V. 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 entefed in its minutes for this date. Dated: $ JOHN CULLEN, CLERK, By puty Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice iu connection with this matter. If you want to consult an attorney,you sliotdd do so urrnrediately. *For Additional Warnurg See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United " States Postal Service in Martinez, California, postage fully pre paid a certified copy of this Board Ordeir.aud Notice to Claimant, addressed to t ' u tt Rl shown above. Dated:0�9 \ 7)—/ JOHN CULLEN, CLERK By D .puty Clerk AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: c�t�t1� LCA, ZC 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 inailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: ZJ. , f "Warnings". CLAIMANT:K110b,911T Ote ATTORNEY: qcu DATE RECEIVED: a ADDRESS: ? 'l�l�c C. �;('. BY DELIVERY TO CLERK ON: P16UI . . �r �✓ BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CUL , Clerk Dated: By: Deputy � i,C(;lr 'b oia It. FROMZourtty Counsel TO-,Clerk of the Board of upervisors . ( ) This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply.substantially with Sections 910 and 910.2, and weare so notifying claimant. The Board cannot act for. 15 days (Section 910.8). O Clainl 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 9.11.3). O Otlier: Dated: By: Deputy County Counsel 111. FROM: Clerk of.the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3).. IV. BOARD ORDER: By 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certaitr exceptions,you have only six(6)months from the date this notice was personally served or deposited or the mail to file a com-t action ou this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in counection with this matter. If you want to consult an . attorney,you should do so unnrediately. *Pbr Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of pet jury that I ani 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 Alartuiez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed.to the claimant as shown above. Dated: _ JOHN CULL.EN, CLERK By Deputy Clerk May 05 08 11:04a Robert Etter 17076446004 P•4 A. A.claim relating to a cause of action for death or for injury to person or to personal property oI growing crops shall be presented not later tban six m.ontbs after the acmiml of the cause of action. A claim relaxing to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov.Code § 9112.) B. Claims must be filed with the Cleric of the Board. of Supervisors at its office is Room 106, County A in�tion 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 forum. aaaaam■■assassmassaman salassssa■aasaaaaaflsaaeszeisama■mamas sataaagaMagazine anas RE: Claim By: Reserved for Clerk's filing stamp o. z- `At � RE Against the County of Contra Costa or ) MAY 0 6 2008 ill in the name) District) BOAR:U 0 ,F ;'!SORS CONTRA The ti>vdersigued cla;man hwe-by makes claim against the County of Contra Costa or the above-named district in the-sum of S e Q ,,v0 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details;use extra paper if required) C V"'C C L r'n,/,- 4. What'particular act or omission on the part of colmty I district officers, servants, or employees caused the injury or damage i l 3 ILLC 1 ,c-,ir1'Sz't G c� ►t �� 5 What are the names of county or district officers, servants., or employees causing the �f damage or injury? IVlay Ub Uti 11:U4a Kooert tner 11U/044bUU4 p.o 6. What damage or injuries do your claim. resulted? (Give full extent of injuries or damages claimed, Attach two,estimates for auto damage,) cti � I. its c �� t 7. How was the amount ciaimed above computed? (Include the estimated amount of apy prospective injury or damage.) h C/U t t ed Cru 7-C) 8. Names and addresses of witnesses, doctors, and hospitals:Li r, iv j2Yr J r c 9. List the expenditures you a on account of this acciden kj%?:or DATE TDAE AMOUNT ■ ■a a■■■■■a■■a■•■iron■a■■■a■a t■■■■■■■■I■■■■■■■ ■■Kansans monsoon■a■1■■■■a ■a a■■a■■■■■■a 1 ) .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some person on his btl alf." SEND NOTICES TO: (Attor ev) 1 '_Name and address of Attomey } 1 (Claimant's Signa*) } (Address) } Telephone-No. p 7C- ? (`2-Y Z I�'��' p ) Telephone Na. ■NOON Now s■a■aa■ Kozo■manna a■now■■■■aa■■■a■■a■■aaa■■ aa ■aaaa a a a a aar PUBLIC RECORDS NOTICE: Please he nelvicPri that tlh;c 05 08 11:03a Robert Etter 17076446004 p.1 Robert Etter o 7 8 130 Serra Ct Vallejo, Ca. 94690 7076"664 Dear Monica Cooper, I am providing you the face sheet that shows my signature is on the document sent to Penny Bailey along with all my medical documentation. This is my amended copy because additional medical bills have been recieved.I will send this information to Ms. bailey as well. Thank You Gam✓-�' - v 17076446004 P•2 May 05 08 11:03a Robert Etter ---�., SILVANo B. MARCKESE OFFICE OF THE COUNTY COUNSEL 4 COUNTY COUNSEL COUNTY OF CONTRA COSTA a +may ``cwt; _ Administratiar�Building ,� � _ +� SHARON L ANDERSON 651 pine Street;r Floor * �:} � .- �: - + . CirtEF AsstsTAw Martinez,California 94553-1229 GREGORY C. HARVEY 925)335- 800 n', ,,-:: i;,.n` VALERIE J. RANCHE ssisTANTs (925) 648-ioTa(fax) r�. �`� �'' NOTICE OF INSUFFICIENCY AND/OR NC3N-ACCEPTANCE OF CLA.I� May 2,2008 TO: Robert L.Etter, Sr. 130 Serra Court Vallejo, CA 94590 RE:, CLAS OF ROBERT L. ETTER, JR. please Take Notice as Follows: The claim,Jou presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below-: [ ] 1• The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the past office address to which the person presenting the claire desires notices to be sent. ] 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s)of the public employee(s) causing the injury, damage, or`, loss, if known. ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars($10,000). If the claim totals less than ten thousand dollars($10,000), the claim fails to state the amount claimed as of the date of presentation,the estimated amount of an} prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [J] 6. The claim is not signed by the claimant or by some person on his or herr behalf. P 17076446004 P•0 May 05 08 11:04a Robert Etter. Re: Claim of Robert L. Etter, Jr. May 2, 2008 Page Two [ ] You are required to submit your claim on the proper form,which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ ] 8. Other: SIL`%ANO B. MARCHESI COUNTY COUNSEL By:'—�w Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ.Proc., §y 1012, 1013a,2015.5; Evid.Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years,and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,\Martinez, CA 94553-1229. On May 2,2008, I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez,California addressed to Robert L. Etter,Jr., 130 Serra Court, Vallejo,CA 94590,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 is the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on May 2,2008, at>fartinez,California. Kathy O; onnell Enclosure cc: Clerk of the Board of Supervisors(original) Risk Management P. 1 ERROR REPORT ( MAY, 5. 2008 11 : 06AM ) FAX HEADER. C. C. County Counsel FILE PERSONAL NAME ADDRESS MODE TIME PAGE RESULT ----------------------------------------------------------------------------------------------------- 275 17076446004 G3RED 249° P. 5 E PAGE NOT RECEIVED QUICK SERVICE CODE P. 5 06-01 # : BATCH. C :CONFIDENTIAL $ :TRANSFER P : POLLING M :MEMORY TX L :SEND LATER @ : FORWARDING E : ECM S : STANDARD D : DETAIL F : FINE ) : REDUCTION * PC + : ROUTING Q : RECEPT. NOTICE REQ. A : RECEPT. NOTICE r Office of the County Counsel Contra Costa County 651 Pine Street, 9th Floor Phone: (925)335-1800 ' Martinez, CA 94553 Facsimile: (925) 335-1866 Writer's Direct Dial: (925) 335-1885 Date: May 5, 2008 RECEIVED To: Jane Pennington, Chief Clerk MAY 6 2008 Clerk of the Board of Supervisors CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. From: Silvano B. Marchesi, County Counsel By: Monika L. Cooper, Deputy County Counsel Re: Amended Claim of Robert Etter Please process the attached documents from Robert Etter as an amended claim. Thank you for your continued assistance. Please call with any questions. Attachment f AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:_ !7f 2b�g 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 RWe6g 11" 7M )upervisors. (Paragraph IV below), given Pursuant to Government Code MAY 2 .9 2008 Section 913 and 915.4. Please note all AMOUNT: COUNTYCOMSEI "Warnings". CLAIMANT:Mr,jmv1/7 2— MARTiNEZCA IF.. ATTORNEY: DATE RECEIVED: Q ADDRESS. J331 Pa+We, tM_ BY DELIVERY TO CLERK ON: BY MAIL POSTMARKED.f DK �4J a Lizy FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CUL1,YN4 Clerk f Dated: Acm By: DeputyR�k tt.( II: FROMfilounty Counsel T0: 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 910.21 and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timel-yfiled. 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: DatedBy: m Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING ov. 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 Goveniineot 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 attor-irey,you should do so immediately. *For Additional Warning See Reverse Side of 11iis Notice. AFFIDAVIT OF MAILING 1 declare under penalty of per jury that I ant 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 iiiMartinez, Cali foruia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claim, t shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk = ' AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:g")LL.hC" Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV'below), given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: "Warnings'?. CLAWANT:MrJcv 2-k ATTORNEY: DATE RECEIVED: tau,- ADDRESS: t Q 7J3I - BY DELIVERY TO CLERK ON:ka4l- (IA BY MAIL POSTMARKEDf'pK. I�-e�K� rr w�lGt JG��1 FROM:. Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CUL N Clerk Dated: a By: Deputy 11. FROM:' ounty 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). - O Claim isnot timely fled. 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 .111. FROM: Clerk of.the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untiiiiely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Goverrmnetit Code Section 945.6.You may seek the advice of au attorney of your choice in connection with this matter. If you want to consult am attorney,you should do so immediately. *Tor Addilionn!Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service iu Martinez, California,.postage fully prepaid a certified copy of this Board Order surd Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk \1 T BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Qp ((��s /�qx INSTRUCTIONS TO CLAIMANT F// UU 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 t - than one year after the accrual of the cause of action. Penny Bailey (Gov. Code § 911.2.) MAY 1.4 ,2008 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 eacli. public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ■aAararNona araaraearrrBEN ranrrrrraaraareaaaarraaaarXmas aaraaaaenrlaataaaaarEnnI RE: Claim By: QY Reserved for Clerk's filing stamp J Against the County of Contra Costa or ) RECEIVED LMAY 1.6 2008 (Fill in the name) ) CLERK BOARD OF SUPERVISORS VAS-' ; (� Y Y �� CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ SCD,Q�_and in support of this claim represents as follows: T� 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county)# ✓YL-4e � a,", �ir - 1 3. How did the damage or iri ury occur? (Give full details;use extra paper if required). ; G. �/e� 11 0110*;"0J ✓� �5 ),,,1.� ,»,�y, �/l�rn. vV 7,t<Vt& r Y✓�v 7'I1a��in c�i/��✓f�, Tj�e�Vt ' " YMr `a 5 "y��'r ow,,� V � r ►- -�.e. 4. � s Dy t articular act or omission on the art of county or district officers, servants, or employees valln caused the injury or damage? 1V0T6Z_ 1 X53® 5 What are the names of county or district officers, servants, or employees causing the damage or injury? V k,% 5e/y� 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.) Auto Bodl - Jr,� , cz,� A 8. Names and addresses of witnesses, doctors, and hospitals: poryl H Oar zfw f�,,wj- rh CA q*gg3 t1 . 9. List the expenditures you made on account of this accident or injury: DATE TDAE AMOUNT a ■■■a Q a a a a a t a t a unman SEEMS■ a■BEEN REMORSE as monsoon an magnums a a■■a■...r■a.a a Oman a a a r a a a a a 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 ) �` Claimant's Signature) j 122 l CA q-ST3 (Address) Telephone No. )Telephone No. ■a a a r a a!f a a a t a t a a a a a a a a a a a a a a a a a a a a a a s s a a s a a a a a a a a a a a a a a a a a a a a a a a a a a a a RUNK an Mason sung 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. ■aaa0aa■a0aasaaaaaaaaaaa■aaaa■■aaaaaaaaaaaaRon mammas aaamum a■.aaaaaataaaaaaaaaowns aanot 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. .1 J� J & M AUTO CUSTOMS e 895 HOWE ROAD, UNIT F MARTINEZ, CA 94553 (925) 229-3819 FAX (925)229-3898 CD LOG NO 60-1 DATE 05/13/08 Z (70 SHOP: J & M AUTO CUSTOMS INSP DATE: 05 ADDRESS: 895 HOWE RD PHONE 1 : (925) 229-3819 CITY STATE: MARTINEZ, CA FAX: (925) 229-3898 ZIP: 94553— EMAIL: SIX495@SBCGLOBAL.NET OWNER: EAST BAY WORK PHONE: (925) 451-4006 POINT OF IMPACT: 6 LIC# : STATE: VIN: BODY COLOR:: =WHITE MILEAGE: CONDITION: ACCTNG CTL# : *=USER—ENTERED VALUE E=REPLACE OEM NG=REPLACE NAGS EC=REPLACE ECONOMY UE=REPLACE OE SURPLUS UC=RECONDITIONED PRT UM=REMAN/REBUILT PRT EU=REPLACE SALVAGE EP=REPLACE PXN OE=REPLACE PXN OE SRPLS PC=PXN RECONDITIONED PM=PXNREMAN/REBUILT TE=PARTL REPL PRICE ET=PARTL REPL LABOR IT=PARTIAL REPAIR I=REPAIR L=REFINISH BR=BLEND REFINISH TT=TWO—TONE CG=CHIPGUARD SB=SUBLET N=ADDITIONAL LABOR RI=R&I ASSEMBLY P=CHECK AA=APPEAR ALLOWANCE RP=RELATED PRIOR UP=UNRELATED PRIOR 2005 GMC SAFARI SLE 2DOOR PASS. VAN EXTENDED 6CYL GASOLINE 4 . 3 CODE: U6622B/A OPTNS F/24CDEIRSV OPTIONS: TWO—STAGE — EXTERIOR SURFACES TWO—STAGE — INTERIOR SURFACES ELEC REMOTE CONTROL MIRRORS POWER DOOR LOCKS POWER WINDOWS PRIVACY GLASS TILT STEERING WHEEL AIR CONDITIONING CRUISE CONTROL OP GDE MC DESCRIPTION MFG. PART NO. PRICE AJ% B% HOURS R -- --- -- ----------- ------------ ----- --- -- ----- — RI 0231 PNL, INNER DOOR TRIM LT R&I ASSEMBLY 0. 6*1 EC 0229 01 MIRROR,OUTER STANDA LT ECONOMY PART 80. 00* 1. 0*1 2 ITEMS MC MESSAGE (S) 01 CALL DEALER FOR EXACT PART NUMBER / PRICE FINAL CALCULATIONS & ENTRIES PAGE 1 05/13/08 20.0. SAFARI SLE 2DOOR PASS. VAN EXTENDED NO 60-1 OTHER PARTS 80. 00 PARTS & MATERIAL TOTAL 80. 00 TAX ON PARTS & MATERIAL @ 8 . 7500 7 . 00 LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL 73. 00 1. 6 116. 80 2-MECH/ELEC 73. 00 3-FRAME 73. 00 4-REFINISH 73 . 00 5-PAINT MATERIAL 30. 00 LABOR TOTAL 116. 80 SUBLET REPAIRS TOWING STORAGE GROSS TOTAL 203. 80 NET TOTAL 203. 80 SHOPLINK UI051 ES CD LOG 60-1 DATE 05/13/08 11: 49: 32AM R6. 37 CD 03/ HOST LOG (C) 1998 - 2007 AUDATEX NORTH AMERICA, INC. -------------------------------------------------------------------------- J & M AUTO CUSTOMS PAGE 2 05/13%08 lot •05/13/2008 at 11 : 56 AM Job Number: 97164 ADVANCE AUTO BODY, INC. License #:BAR AC171433 Federal ID #: 680280418 917 Howe Rd Martinez, CA 94553 ( 925) 370-7789 Fax: (925) 228-0588 PRELIMINARY ESTIMATE Written By: MARK LINDEN Adjuster: Insured: EAST BAY SERVICE Claim # Owner: EAST BAY SERVICE Policy # Address: Deductible: Date of Loss: Day: Type of. Loss: Evening: Point of Impact: Inspect Location: Insurance Company: Days to Repair 2005 GMC M15 4X2 SAFARI CARGO 6-4 . 3L-FI 3D VAN Int: VIN: 1GTDM19X95B502481 Lic: Prod Date: Odometer: Air Conditioning Intermittent Wipers Dual Mirrors Roof Console Clear Coat Paint Power Steering Power Brakes AM Radio FM Radio Stereo Search/Seek Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Bucket Seats Rear Step Bumper Automatic Transmission Overdrive Styled Steel Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT DOOR 2 Repl LT Mirror stationary manual 1 216 . 60 0 . 3 0 . 5 3 Add for Clear Coat 0 . 1 4 R&I LT R&I trim panel 0 . 4 ------------------------------------------------------------------------------- Subtotals =_> 216. 60 0 . 7 0 . 6" 'Parts 216. 60 Body Labor 0 .7 hrs @ $ 75 . 00/hr 52 .50 Paint Labor 0 . 6 hrs @ $ 75 . 00/hr 45 . 00 Paint Supplies 0 . 6 hrs @ $ 34 . 00/hr 20 . 40 ---------------------------------------------------- SUBTOTAL $ 334 . 50 Sales Tax $ 237 . 00 @ 8 . 2500% 19.55 1 � t 405/13/2008 at 11 : 56 AM Job Number: 97164 PRELIMINARY ESTIMATE 2005 GMC M15 4X2 SAFARI CARGO 6-4 .3L-FI 3D VAN Int: ---------------------------------------------------- GRAND TOTAL $ 354 . 05 ADJUSTMENTS : Deductible 0 . 00 ---------------------------------------------------- CUSTOMER ' PAY $ 0 . 00 INSURANCE PAY $ 354 . 05 I authorize Advance Auto Body Inc. to perform the needed repairs to my vehicle. Repairs include parts, labor, and diagnosis . The above estimate is based on our inspection and does not cover additional parts or labor which may be required after the work has started. Worn or damage parts, not evident on first inspection, may be discovered and you will be contacted for authorization for additional work. Parts prices are subject to change without notice . ACKNOWLEDGEMENT: I have read and understand the above estimate and authorize repair service to be performed, including sublet work and acknowledge receipt of this estimate . An express mechanics lien is hereby acknowledged on the above vehicle to secure the amount of repairs completed. This Estimate Authorized By: i, CLAIM ` F' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: 'Jurw to 7C.� 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 1, California Government Codes. D you is your notice of the action taken~ on your claim.by the Board of Supervisors. (Paragraph IV below), MAY 12'2008 given Pursuant to Government Code AMOUNT: ` e ('�f'� COUNTYCCOUNSEL Section 913 and 915.4. Please note all �V l `P "Warnings". � MARTINEZ CALIF. �� �� CLAIMANT: 'i N.U. f' �sl '�(�,(r'I 3�l ATTORNEY.-JL/0, DATE RECEIVED: Mcul ADDRESS: P�. 8 0968ggQ_ BY DELIVERY TO CLERK ON: =tGU'��1't(,� BY MAIL POSTMARKED: C FROM: Clerk of the Board of Supervisors T0: 'County Counsel Attached is a copy of the above-noted claim. JOHN CUL lerk.-, Dated: o2g By: Deputy' II. FROM . Y P ount 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 90. 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. � 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. 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: QG I ?r/09 JOHN CULLEN, CLERK, By puty Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6) months from tiie date this notice was personal ly 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 Warring See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING . I declare under= penalty of perjury tha"t I ain now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today 1 deposited in the United 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 wn above. Dated: JOHN CULLEN, CLERK By ��leputy Clerk CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Claim Against the County, or District'Governed by ) ' the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ). The copy of this document mailed to California Government,Codes. ) you is your notice of the action taken on your claim.by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code � Section 913 and 915.4. Please note all AMOUNT: •!� (' � .��?1(r .<Warnings". . CLAIMANT: IYl�6"✓ t`l�C l,Lt vLi ATTORNEY:.)l`(L' DATE RECEIVED: � —� ADDRESS: RL). L&i)6 a&jSg17�L BY DELIVERY TO CLERK ON: (tilt CG Iut,, BY MAIL POSTMARKED: M(21,4 V r FROM: Clerk of the Board of Supervisors TO:. County Counsel Attached is a copy of the above-noted claim. JOHN CUL , lerk. Dated: �' '�,� By: Deputy i. , ,' LhILIL, II. FROM.`T .ounty 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). 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 (Sction 911.3). O Other: Dated: By: Deputy County Counsel 111.. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section.911:3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present: O 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 fol". this date. Dated: JOHN CU'LLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the pdviee of an attorney of your choice in connection widi this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warring See Reverse Side of'Tlnis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that .I am now, and at all times herein mentioned, have been a citizen of the United States, 'over age 1.8; and that today .l deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk A R R. S National Document Center P.O. Box 268992 Oklahoma City, OK 73126-8992 clairnsdocuments@farmersinsurance.com Fax: 877-217-1389 05/07/2008 Contra Costa County ® 9 Clerk Of The Bd Of Supry R VE 651 Pine St Rm#106 County Admin Bldg MAY 0 8 2008 Martinez,CA 94553 CLERKCBON RD O OSTA COVISONS Re: Our Insured: Mrs.Aimy Taniguchi Our Claim#: 1011728336-1 Date of Loss: 03/12/2008 Your Insured: Mrs.Marisa Neelon Your Claim#: 64544 Deductible Amount: $500.00 Loss of Use Amount: $100.00 Total Amount Owed: $1,197.84 Dear Contra Costa County Clerk Of The Bd Of Suprv: We have made payment to our insured for damages resulting from this accident.Our investigation has established that the above loss was caused by the negligence of your driver. By virtue of our subrogation rights this letter is to advise you that we expect payment from you for the amount of damages within 14 days of the receipt of this letter. Be advised that no partial payment,which is less than the full amount claimed herein,will be considered in anyway an acceptance of benefits,a novation or an accord and satisfaction of this claim without the express written release of our claim executed by an individual who identifies himself/herself as a member of our subrogation department.Therefore,our legal rights to enforce collection on the remaining amount of the claim shall not be waived or estopped due to a partial payment by you. If you need additional support for our claim or require further information,please call me at 909-801-3327 with your FAX number so that the requested information can be sent to you. Sincerely, Mid-Century Insurance Company Alexis Beltran Auto Subrogation Representative alexis-behran@farmersimurance.com Self Insured ATTACHMENT(S) Self Insured ATTAa-RV ENT(S) BOARD OF SUPERVISORS OF CONTRA Ct?STA 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 latex 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. la as Bananas RUN Rata a aaaas as a as as a a a a a as gnat Its amass a a as aaa Naas as as Ra a as arm as a as al G RE: Claim By: Reserved for Clerk's filing stamp } RECEIVED Ag ' t the County of Contra Costa or ) MAY 0 8 2008 } District) CL6iimm!� (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) D31(4p a.i)-,\ 2. Where did the damage or injury oc ur? (Include city and county) 3. How did the damage or in, y occur? ( ive full details use e a paper if required) �hswre�.i Am tj o �o�� o e t� Ex`+ /fits � CAAe- t, t, `Tl op 4. What'particular act omission on the part of county or district officers, servants, or employees caused the injury or damage? F;Le- ID Slop 5 What are the names of county or district officers,servants,or employees causing the damage or injury? Kwv7� TE� cls, . 6. WLa da-nage 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.) Ste`_. Sfir �1,olo S S. Names and addresses of witnesses,doctors,and hospitals: 9. List the expenditures you made on account';of this accident or injury: DATE TIME AMOUNT 04-tb-l5e 5oQ,va � ,' � jp®,"o ��•'7L di��� °c `T( faL iNSwJ aMERRRRtRatRtanaMals Ellyn iass sang nattRntnRta■■tRtRawRHaRt■■R■RRnnaRRttaRa MEN a it RttRRR! .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 lam-' } (Claimant's Signature) (Address) {nyK 73/L� c/ Telephone No. )Telephone No. x 07 b 01 -33--O aRRRntwwttRatrtanon aMEN raanawrrtRtttwteRRwtetRRRaReRrRRatRtttttrRRaRtwRRRaattRRRaRrR! PUBLIC RECORDS NOTICE: Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form,including medical records, are also subject to public disclosure. a RtRR t R r rRtRRr RR 99%0 9R19aaRRrtrttRaR tRR RraaaR raga tat Rrwe RRR rtRat Rarrn RRwrw as a■Rc3*una! 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. National Document Center P.O. Box 268992 Oklahoma City,OK 73126-8992 clairnsdocuments@farmersinsurance.com Fax: 877-217-1389 05/07/2008 Payment Log Account Number: BBB397700 Date of Loss: 03/12/2008 Insured's Name: Mrs.Aimy Taniguchi Claim Number 099 MD 1011728336-1-2 Loss Type Material Damage Proof of Payment Date: 04/16/2008 Payee: HERT7 TREASURY P.O.BOX 268825 OKLAHOMA CITY,OK,73126 Payment Description: Collision Plus Amount: $88.72 Date: 04/17/2008 Payee: BRUCE D WILBUR 6 SIERRA QR SN RFAEL,CA,94901 Payment Description: Collision Plus Amount: $11.28 Date: 04/23/2008 Payee: CREBASSAS AUTO BODY,INC 3241 KERNER BLVD.BLDG.B SAN RAFAEL,CA,94901 Payment Description: Material Damage Amount: $549.12 Date: 05/07/2008 Payee: Payment Description: Amount: $48.72 Sub Total: $697.84 Deductible Amount: $500.00 Salvage $0.00 Total Amount: $1,197.84 04/1512008 16:09 14154547388 TANIBUR PAGE 06 Apr. 15, 2008 2:3 3 P M _ HERTZ SAN RAFAEL 415 451 1951 No. 7348 P. 1/1 Pfi� W #4 RNKa H14 OS 1AtlUM ANY VEHICLE 09M160OW 1 1110 SNPET40C6BH3a3 X60 UC CA SYXL40 CL8 YC 90 HYUMA FUEL' 0/0 OUT I Mi IN CDP 143M FARMER$COE40D HR5 CLM6 t0ililmd id POOGOD PREPARED BY$9290EASUE01 COMPLE Vi)BY;84 WASUE,11 RENTM. UV/U04110 9 RAN RAFAEL RLE Rfi7t1Rt0y Qdt1A/109012JO 0 SAN RAFAEL HILE RM IN; NW FA KM OUr: RATE CLASS YC MILEA4E IN 22411 TR-X MILES 0 MtlLWE-OUT 2= WEG ALLOWED 9 MILES DRIVEN V4 WS CHARGED 0.00 4 Q 6 20.46 1 DAY S 81.64 ADJUSTMENTS StWOTAL TS 11.66 04 4 Q$ 15.901 MY 60.00 us OEJLKI) i TAK 6.26 46 OKI EST.TAXAPLI:M 161.49 6 8.76 COMPAW CHARGE 1 68.72 WITOMM CMARGE S 60.0; CHARM ON: VI =0000000=94 $ 60.00' CCISTOMifft E3ALar1cE S 0.00 ,4 w� F WE WAS YOM EXPEONCII9 WeD LOO:YOUR FMMACK. 1)VN WWM!lART2 Y.40l6 2)furter Aeras Coies 47243 9TAIA"CHAROPS,NOT VALID FOR RENTAL. Rimm COMM•The"oft cgmwom A 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 CREBASSA'S AUTO BODY,INC. LICENSE #:BAR # AH1412 FEDERAL ID #:680143893 I-CAR GOLD CLASS PROFESSIONALS 3241 KERNER BLVD BLDG B SAN RAFAEL, CA 94901-4863 (415)459-7320 FAX: (415)459-1896 SUPPLEMENT OF RECORD 2 WITH SUMMARY WRITTEN BY: FERNANDO CANDIA 04/10/2008 02:33 PM ADJUSTER: DAVID KAYE INSURED: AIMY TANIGUCHI CLAIM #1011728336-1-2 OWNER: AIMY TANIGUCHI POLICY #0180482435 ADDRESS: 6 SIERRA CIRCLE DEDUCTIBLE: $500.00 SAN RAFAEL, CA 94901 DATE OF LOSS: 03/12/2008 AT 12:00 AM EVENING: (415)454-7388 TYPE OF LOSS: COLLISION OTHER: (415)454-7388 POINT OF IMPACT: 6. REAR INSPECT CREBASSA'S AUTO BODY,INC. OTHER: (415)459-7320 LOCATION: 3241 KERNER BLVD BLDG B SAN RAFAEL, CA 94901-4863 INSURANCE FARMERS CELLULAR: (209)534-2815 COMPANY: P.O. BOX 268994 3 DAYS TO REPAIR OKLAHOMA CITY, OK 73126-9750 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: VIN: 4T1BB46K57U010895 LIC: 5ZED080 CA PROD DATE: 02/2007 ODOMETER: 18544 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS KEYLESS ENTRY STEERING WHEEL CONTROLS DUAL MIRRORS CONSOLE/STORAGE CALIFORNIA EMISSIONS FOG LAMPS CLEAR COAT PAINT METALLIC PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER MIRRORS AM RADIO FM RADIO STEREO SEARCH/SEEK EQUALIZER CD CHANGER/STACKER JBL STEREO SYSTEM ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES CLOTH SEATS BUCKET SEATS AUTOMATIC TRANSMISSION ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER N 2**SO2 REPL OPT OEM BUMPER COVER US BUILT 1 245.00* 1.6 3.0 3 ADD FOR CLEAR COAT 1.2 4# REPL CLEAR STEP PAD 1 58.00 0.2 5# 6# COLOR TINT 1 0.5 7# FLEX ADDITIVE 1 6.00 T 8# SUBL HAZARDOUS WASTE REMOVAL 1 3 .00 X 1 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- SUBTOTALS =_> 312.00 2.3 4.2 LINE 2 : NEW, OEM PART AT REDUCED PRICE NO REMANUFACTURED PART AVAILABLE ------------------------------------------------------------------------------- ESTIMATE NOTES: REPAIR COMPLETED ON 4/10/08. OWNER GIVEN FINAL BILL. PARTS 303.00 BODY LABOR 2.3 HRS @$ 85.00/HR 195.50 PAINT LABOR 4.2 HRS @$ 85.00/HR 357.00 PAINT 4.2 HRS @$ 35.00/HR 147.00 SUBLET/MISC. 9.00 ---------------------------------------------------- SUBTOTAL $ 1011.50 SALES TAX $ 456.00 @ 8.2500°% 37.62 ---------------------------------------------------- GRAND TOTAL $ 1049.12 ADJUSTMENTS: DEDUCTIBLE 500.00 ---------------------------------------------------- CUSTOMER PAY $ 500.00 INSURANCE PAY $ 549.12 THIS DAMAGE REPORT IS BASED UPON OUR DETAILED INSPECTION OF YOUR VEHILCE AND DOES NOT INCLUDE REPAIRS OTHER THAN THOSE ITEMIZED ABOVE. OCCASIONALLY ADDITIONAL DAMAGE WILL BE DISCOVERED ONCE THE WORK HAS BEEN INITIATED AND ADDITIONAL REJPAIRS AND TIME WILL BE REQUIRED. ALL PARTS PRICES ARE SUBJECT TO INVOICE . THIS DAMAGE REPORT VOID AFTER 90 DAYS. EPA I.D. ##CAD981170533. IF YOU HAVE COVERAGE FOR DAMAGE TO YOUR VEHICLE UNDER THIS POLICY IT IS OUR OBLIGATION TO INFORM YOU THAT UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SECTION 2695.8.D.2.E, YOU HAVE THE RIGHT TO SELECT THE VEHICLE REPAIR FACILITY OF YOUR CHOICE. WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE 2 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ABOUT COVERAGE FOR TOWING SERVICES. THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN INSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. 5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR.CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE 3 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) 927-HELP OR (213) 897-8927 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.INSURANCE.CA.GOV ALL SUPPLEMENTS MUST BE PRE-APPROVED BEFORE ANY WORK CAN BE COMPLETED. FARMERS' NON-OEM SHEET METAL PARTS WARRANTY WHEN YOU HAVE YOUR VEHICLE REPAIRED AFTER AN ACCIDENT AND THE REPAIR ESTIMATE INCLUDES THE USE OF CERTAIN NON-OEM SHEET METAL CRASH PARTS (PARTS NOT MADE BY OR FOR YOUR VEHICLE'S ORIGINAL MANUFACTURER) , FARMERS WILL STAND BEHIND THOSE PARTS FOR AS LONG AS YOU OWN THE VEHICLE. IF A SUPPLIER OF A PART LISTED IN YOUR REPAIR ESTIMATE OR THE SHOP THAT PERFORMED THE REPAIRS ON YOUR VEHICLE IS UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY OF THE NON-OEM SHEET METAL PARTS USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED. PARTS COVERED BY THIS WARRANTY ARE LIMITED TO HOODS, FENDERS, DOOR SHELLS, TRUCK BEDS, BOX SIDES, TAILGATES, LIFT GATES, QUARTER PANELS, REAR OUTER PANELS, BODY SIDE PANELS, TRUNK LIDS AND DECK LIDS. FOR ASSISTANCE, CONTACT YOUR NEAREST FARMERS CLAIMS OFFICE OR AGENT. DISCLAIMER THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND ITS BENEFITS EXTEND ONLY TO THE PARTY OWNING THE VEHICLE AT THE TIME OF THE REPAIR. IT IS NOT PART OF YOUR INSURANCE POLICY AND DOES NOT CONSTITUTE AN EXTENSION OF COVERAGE THEREUNDER. WE MUST BE NOTIFIED BY THE REPAIR FACILITY, AND PHYSICALLY INSPECT, ALL REQUESTS FOR SUPPLEMENTAL DAMAGE. FAILURE TO PROVIDE ADEQUATE NOTICE MAY RESULT IN NONPAYMENT OF ADDTIONAL CHARGES NOT CONTAINED IN THIS APPRAISAL. 4 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER 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 0/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. 5 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARM8523, CCC DATA DATE 03/03/2008, 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 RECOND. 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. 6 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT': ------------------------------------------------------------------------------- ESTIMATE NOTES: REPAIR COMPLETED ON 4/10/08. OWNER GIVEN FINAL BILL. PARTS 0.00 ---------------------------------------------------- SUBTOTAL $ 0.00 ESTIMATE 1083.12 FERNANDO CANDIA SUPPLEMENT SO1 -34.00 FERNANDO CANDIA SUPPLEMENT S02 0.00 FERNANDO CANDIA ------ CUSTOMER PAY $ 500.00 JOB TOTAL $ 1049.12 INSURANCE PAY $ 549.12 THIS DAMAGE REPORT IS BASED UPON OUR DETAILED INSPECTION OF YOUR VEHILCE AND DOES NOT INCLUDE REPAIRS OTHER THAN THOSE ITEMIZED ABOVE. OCCASIONALLY ADDITIONAL DAMAGE WILL BE DISCOVERED ONCE THE WORK HAS BEEN INITIATED AND ADDITIONAL REJPAIRS AND TIME WILL BE REQUIRED. ALL PARTS PRICES ARE SUBJECT TO INVOICE . THIS DAMAGE REPORT VOID AFTER 90 DAYS. EPA I.D. #CAD981170533. IF YOU HAVE COVERAGE FOR DAMAGE TO YOUR VEHICLE UNDER THIS POLICY IT IS OUR OBLIGATION TO INFORM YOU THAT UNDER CALIFORNIA CODE OF REGULATIONS, TITLE 10, CHAPTER 5, SECTION 2695.8.D.2.E, YOU HAVE THE RIGHT TO SELECT THE VEHICLE REPAIR FACILITY OF YOUR CHOICE. WE ARE PROHIBITED BY LAW FROM REQUIRING THAT REPAIRS BE DONE AT A SPECIFIC AUTOMOTIVE REPAIR DEALER. YOU ARE ENTITLED TO SELECT THE AUTO BODY REPAIR SHOP TO REPAIR DAMAGE COVERED BY US. WE HAVE RECOMMENDED AN AUTOMOTIVE REPAIR DEALER THAT WILL REPAIR YOUR DAMAGED VEHICLE. IF YOU AGREE TO USE OUR RECOMMENDED AUTOMOTIVE REPAIR DEALER, WE WILL CAUSE THE DAMAGED VEHICLE TO BE RESTORED TO ITS CONDITION PRIOR TO THE LOSS AT NO ADDITIONAL COST TO YOU OTHER THAN AS STATED IN THE INSURANCE POLICY OR AS OTHERWISE ALLOWED BY LAW. IF YOU EXPERIENCE A PROBLEM WITH THE REPAIR OF YOUR VEHICLE, PLEASE CONTACT US IMMEDIATELY FOR ASSISTANCE. AUTO BODY REPAIR CONSUMER BILL OF RIGHTS A CONSUMER IS ENTITLED TO: 1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN INSURANCE COMPANY MAY NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP. 2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE. THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE FOR THE WORK 7 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED, AFTERMARKET, RECONDITIONED, OR REBUILT. 3. BE INFORMED ABOUT COVERAGE FOR TOWING SERVICES. THE INSURER SHALL PAY REASONABLE TOWING AND STORAGE CHARGES INCURRED BY THE INSURED TO PROTECT THE VEHICLE AND PROVIDE REASONABLE NOTICE TO AN INSURED BEFORE TERMINATING PAYMENT FOR STORAGE CHARGES SO THAT THE INSURED HAS TIME TO REMOVE THE VEHICLE FROM STORAGE. 4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED VEHICLE IS BEING REPAIRED. S. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY REPAIRS. COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR COMPLAINTS CONCERNING THE REPAIR OF A VEHICLE BY AN AUTO BODY REPAIR SHOP SHOULD BE DIRECTED TO: TOLL FREE (800) 952-5210 CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS BUREAU OF AUTOMOTIVE REPAIR 10240 SYSTEMS PARKWAY SACRAMENTO, CA 95827 THE BUREAU OF AUTOMOTIVE REPAIR CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.AUTOREPAIR.CA.GOV COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER ANY CONCERNS REGARDING HOW AN AUTO INSURANCE CLAIM IS BEING HANDLED SHOULD BE SUBMITTED TO THE CALIFORNIA DEPARTMENT OF INSURANCE AT: (800) 927-HELP OR (213) 897-8927 CALIFORNIA DEPARTMENT OF INSURANCE CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET LOS ANGELES, CA 90013 THE CALIFORNIA DEPARTMENT OF INSURANCE CAN ALSO ACCEPT COMPLAINTS OVER ITS WEB SITE AT: WWW.INSURANCE.CA.GOV ALL SUPPLEMENTS MUST BE PRE-APPROVED BEFORE ANY WORK CAN BE COMPLETED. 8 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: FARMERS' NON-OEM SHEET METAL PARTS WARRANTY WHEN YOU HAVE YOUR VEHICLE REPAIRED AFTER AN ACCIDENT AND THE REPAIR ESTIMATE INCLUDES THE USE OF CERTAIN NON-OEM SHEET METAL CRASH PARTS (PARTS NOT MADE BY OR FOR YOUR VEHICLE'S ORIGINAL MANUFACTURER) , FARMERS WILL STAND ,BEHIND THOSE PARTS FOR AS LONG AS YOU OWN THE VEHICLE. IF A SUPPLIER OF A PART LISTED IN YOUR REPAIR ESTIMATE OR THE SHOP THAT PERFORMED THE REPAIRS ON YOUR VEHICLE IS UNABLE TO RESOLVE A LEGITIMATE COMPLAINT ABOUT THE QUALITY OF THE NON-OEM SHEET METAL PARTS USED IN THE REPAIR, WE WILL MAKE EVERY EFFORT TO SEE THAT THE PROBLEM IS CORRECTED. PARTS COVERED BY THIS WARRANTY ARE LIMITED TO HOODS, FENDERS, DOOR SHELLS, TRUCK BEDS, BOX SIDES, TAILGATES, LIFT GATES, QUARTER PANELS, REAR OUTER PANELS, BODY SIDE PANELS, TRUNK LIDS AND DECK LIDS. FOR ASSISTANCE, CONTACT YOUR NEAREST FARMERS CLAIMS OFFICE OR AGENT. DISCLAIMER THIS WARRANTY AND ANY REPRESENTATIONS MADE HEREIN ARE NON-TRANSFERABLE AND ITS BENEFITS EXTEND ONLY TO THE PARTY OWNING THE VEHICLE AT THE TIME OF THE REPAIR. IT IS NOT PART OF YOUR INSURANCE POLICY AND DOES NOT CONSTITUTE AN EXTENSION OF COVERAGE THEREUNDER. WE MUST BE NOTIFIED BY THE REPAIR FACILITY, AND PHYSICALLY INSPECT, ALL REQUESTS FOR SUPPLEMENTAL DAMAGE. FAILURE TO PROVIDE ADEQUATE NOTICE MAY RESULT IN NONPAYMENT OF ADDTIONAL CHARGES NOT CONTAINED IN THIS APPRAISAL. 9 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER 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 0/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. } 10 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING GUIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE ARM8523, CCC DATA DATE 03/03/2008, 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 RELY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECOND. 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. 11 04/10/2008 AT 02:33 PM JOB NUMBER: 4350 19622 SUPPLEMENT OF RECORD 2 WITH SUMMARY 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY 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 OPTIONAL OEM PARTS OPTIONAL OEM SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN OPTIONAL OEM PART WAS AVAILABLE: 0 NO. OF OPTIONAL OEM PARTS THAT APPEAR IN THE FINAL ESTIMATE: 1 RECONDITIONED PARTS RECONDITIONED SELECTION METHOD: MANUALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT A RECONDITIONED PART WAS AVAILABLE: 0 NO. OF RECONDITIONED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 RECYCLED PARTS NO. OF TIMES USER WAS NOTIFIED THAT A RECYCLED PART WAS AVAILABLE: 0 NO. OF RECYCLED PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 i 12 04/10/2008 AT 02:07 PM JOB NUMBER: 4350 19622 CREBASSA'S AUTO BODY,INC. LICENSE #:BAR # AH1412 FEDERAL ID #:680143893 I-CAR GOLD CLASS PROFESSIONALS 3241 KERNER BLVD BLDG B SAN RAFAEL, CA 94901-4863 (415)459-7320 FAX: (415)459-1896 SUPPLEMENT OF RECORD 1 WITH SUMMARY WRITTEN BY: FERNANDO CANDIA 04/10/2008 02:02 PM ADJUSTER: DAVID KAYE INSURED: AIMY TANIGUCHI CLAIM #1011728336-1-2 OWNER: AIMY TANIGUCHI POLICY #0180482435 ADDRESS: 6 SIERRA CIRCLE DEDUCTIBLE: $500.00 SAN RAFAEL, CA 94901 DATE OF LOSS: 03/12/2008 AT 12:00 AM EVENING: (415)454-7388 TYPE OF LOSS: COLLISION OTHER: (415)454-7388 POINT OF IMPACT: 6. REAR INSPECT CREBASSA'S AUTO BODY,INC. OTHER: (415)459-7320 LOCATION: 3241 KERNER BLVD BLDG B SAN RAFAEL, CA 94901-4863 INSURANCE FARMERS CELLULAR: (209)534-2815 COMPANY: P.O. BOX 268994 3 DAYS TO REPAIR OKLAHOMA CITY, OK 73126-9750 2007 TOYO CAMRY HYBRID 4-2.4L-G/ 4D SED SILVER INT: VIN: 4T1BB46K57UO10895 LIC: 5ZED080 CA PROD DATE: 02/2007 ODOMETER: 18544 CONDITION: GOOD AIR CONDITIONING REAR DEFOGGER TILT WHEEL CRUISE CONTROL TELESCOPIC WHEEL INTERMITTENT WIPERS KEYLESS ENTRY STEERING WHEEL CONTROLS DUAL MIRRORS CONSOLE/STORAGE CALIFORNIA EMISSIONS FOG LAMPS CLEAR COAT PAINT METALLIC PAINT POWER STEERING POWER BRAKES POWER WINDOWS POWER LOCKS POWER DRIVER SEAT POWER MIRRORS AM RADIO FM RADIO STEREO SEARCH/SEEK EQUALIZER CD CHANGER/STACKER JBL STEREO SYSTEM ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG FRONT SIDE IMPACT AIR BAG 4 WHEEL DISC BRAKES CLOTH SEATS BUCKET SEATS AUTOMATIC TRANSMISSION ALUMINUM/ALLOY WHEELS ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER N 2**SO1 REPL OPT OEM BUMPER COVER US BUILT 1 245.00* 1.6 3.0 3 ADD FOR CLEAR COAT 1.2 4# REPL CLEAR STEP PAD 1 58.00 0.2 5# 6# COLOR TINT 1 0.5 7# FLEX ADDITIVE 1 6.00 T 8# SUBL HAZARDOUS WASTE REMOVAL 1 3.00 X 1 Claim Reference Id 1011728336-1-2 File Name PHOTO11 File Date 04/09/2008 f- Label :t Note Style:7,TOYO,CAMRY HYBRID1 Insured:TANIGUCHI, AIMYJ LossDate:03/12/081 ClaimNumber:1011728336-1 " -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator S0l Claim Reference Id 1011728336-1-2 File Name PHOTO10 File Date 04/09/2008 Label Note Style:7,TOYO,CAMRY HYBRID1 Insured:TANIGUCHI, AIMYj LossDate:03/12/08 ClaimNumber:1011728336-1 z -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator S0l Claim Reference Id 1011728336-1-2 File Name PHOTO9 File Date 04/09/2008 Label Note Style:7,TOYO,CAMRY HYBRID(Insured:TANIGUCHI, AIMYj LossDate:03/12/081 ClaimNumber:1011728336-1 -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. q Photo Taken By Fernando Candia No Label Estimate Indicator S0l Claim Reference Id 1011728336-1-2 File Name PHOTOS File Date 03/28/2008 _ Label Note Style:7,TOYO,CAMRY HYBRIDS Insured:TANIGUCHI, AIMYj LossDate:03/121081 ClaimNumber:1011728336-1 pl -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTO7 File Date 03/28/2008 Label Note Style:7,TOYO,CAMRY HYBRID1 Insured:TANIGUCHI, AIMYJ LossDate:03/121081IIClaimNumber:1011728336-1 -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTO6 File Date 03/28/2008 Label Note Style:7,TOYO,CAMRY HYBRIDS Insured:TANIGUCHI, AIMYJ LossDate:03/12/081 ClaimNumber:1011728336-1. -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTOS File Date 03/28/2008 t Label Note Style:7,TOYO,CAMRY HYBRID1 Insured:TANIGUCHI, AIMYJ LossDate:03/12/081 ClaimNumber:1011728336-1 -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTO4 File Date 03/28/2008 ! ? Label I Note Style:7,TOYO,CAMRY HYBRIDS Insured:TANIGUCHI, AIMYJ LossDate:03/12/081 ClalmNumber:1011728336-1 -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTO3 File Date 03/28/2008 Label ` c Note Style:7,TOYO,CAMRY HYBRIDI Insured:TANIGUCHI, s" AIMYI LossDate:03/12/081 ClaimNumber:1011728336-1 z -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTO2 File Date 03/28/2008 Label P ' Note Styie:7,TOYO,CAMRY HYBRID(insured:TANIGUCHI, y_ AIMYI LossDate:03/12/081 ClaimNumber:1011728336-1 _.' -21 PolicyNumber:01804824351 ClaimRepresent asst" Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 Claim Reference Id 1011728336-1-2 File Name PHOTOI File Date 03/28/2008 pp Label Note S 1e:7,TOYO,CAMRY HYBRID1 Insured:TANIGUCHI, " AIMYI LossDate:03/12/081 ClaimNumber:1011728336-1 -21 PolicyNumber:01804824351 ClaimRepresent Photo Location CREBASSA'S AUTO BODY,INC. Photo Taken By Fernando Candia No Label Estimate Indicator E01 CLAIM BOARD.O.F SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: ty -d0--og Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are.to ) The copy of this document mailed to California Government Codes. ) . you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), MAY 12 2008 given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: ufttw� COUNTY COUNSEL "Warnings". . MARTINEZ CALIF. CLAIMANT: �� Q C1►.� ATTORNEY-. DATE RECEIVED: ADDRESS11W Rr5T 5T, [A) BY DELIVERY TO CLERK ON: ►N� BY MAIL POSTMARKED: q`_57� FROM: Clerkof the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CUL N, Clerk Dated: D By: Deputy { LL 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 910and 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: 09, By: 1V? Deputy County Counsel 111. FROM: Clerk of the Board TO: County.Counsel (]) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section.911.3). 1V. 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. t Dated: I_A-L&B JOHN CULLEN, CLERK, By eputy Clerk WARNING(Gov. code section 913). Subject to certain exceptions,you have only six(6) months from di date this notice was personally served or deposited in the nmil 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 wide this matter. ll'you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury thatI. am now, and at all times herein mentioned, have been a citizen of the United States, over age IS; 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 cfainran.t as hown above. Dated; ©� �J' JOHN CULLEN, CLERK By . De uty Clerk CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are.to ) The copy of this document mailed to California Government Codes. ) you is your notice of the-action taken on your claim.by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: L01161,61 )kj Section 913 and,915.4. Please note all "Warnings". . CLAIMANT: lvU lw.ck. C�U,,hz ATTORNEY: DATE RECEIVED: ADDRESS: (p� ��� ( � X41 BY DELIVERY TO CLERK ON: ; i' '))'y1GL (A r, BY MAIL POSTMARKED: )VI.Gu FROM: Clerk of the Board of Supervisors T0; County Counsel Attached is a copy of the above-noted claim. JOHN CUL EIV, Clef, Dated: a ,�X By: Deputy Ct C-� Cti II. FROM: ounty Counsel TO: Clerk of the Board of Supervisors', 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 wai7iing of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board T0: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: O This Claim is rejected in full. O Other: [ certify that this is a true and correct copy of the Board's Order entered in its minutes for.. this date. Dated: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the 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 connectio+i with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warnij ig See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare. under penalty of perjury y that .[ am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today .I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk of of-2oo9 ien 3i CSRR (_ULUKHLJU 'o"iv4un BOARD OF SCTi ERN ISORS OF CONTRA.COSTA COUNTY N 'STRUCTIONS TO CLAJ1bL NT A. A. claim relating to a cause of action for death or fori.Ljury to person or to personal ptvperry or growing crops shall be presented not later Tian six caonths after the ac�-rual of Tb-& cause of action. A e;aim relatElg to any other ceuse of action sha'_i b-_ presented not 'an'than one year after the acyl of the cage of taction. (Go V*.Code�911.2.) i3- Claims must be filed with the Clezk of the Board of Supervisors at its off-icr in Room 106, Com ry_^kdmiuistration Buildisig, 651 fine Steet,IvWinez,CA.94553. C. If claim is against a district governed by the Board of Supervisors, rather than the C:ouaty. lbe Elaine of the District should be filled in. D. If the claim is agai4& .-mort�than an.. pub?:c ertity,.sp-parate claLzis most be fi'ed aG.iinst oath pubic entity. F. fraq�L See penalty for fraudulent clai=,Penal Code Sec.72 at tete end of this form. ■sa�Y1�v���1PPl PlP P s w P P*/PIPP1•P•a gas Ism arm aaIa PIt's o 4Moo M Pt PPPtY P\aim P PPI P*a am Y P Ki RE, Claim By: Reserved for Clerk's f.Uiz stamp RE - AVED) Against the County of Contra t^ stn or ) E 0 8 2008 _ District) CLERK BOA- 'SUPERVISORS (Fiji in the natne) ) CONI .^.STA CO. } The L dersigned claimant hereby makes :lai,-u against to Couaty of Contra Co;ta or the above-named district in the sum of$�13 _and in support of this clm represenu as f'ollo,Hs, I. % eu did the darnage or iniv-y occur? (Give 5xactt date and hour) 2. Where did the damage or injur3,occur`, (lrclude city and county) &"W a 31V a Ua\%O, CSR, 0 W 4 3. How did theage or injury occur? (GiW,full details;tse extra pa ,r if re utl rt& Ye� 5I Y\� mS. Caged vr_wQ_N �a a Corr ,R\6c 6AO C) a sol" wk�. glnt tJs�3 5 Yd Cr_ �40yy1 bcv�\AO h �av05 tvie\1 th S C oWvN.( V Cr1 . 4. What pvtioular aot or or dssion nn the part of wu y dr officers, sazlMats, or employees �� caused.the,-Wury or ditmaGW7�e;�UV C 4C) Mai`Ak�n �f ���6 �Y QbAd C�� us � talluY,z --gip Mme)-kvi wN 5,-,fT, 5k-0� tvl3 d�5�&VIQC, 1yAmpv \oov; OA , 5 Vr'hat ten the neves of comfy or 61, tliel officers,servants,Or =.D103,ees caln-ing tLe dz mage or injury? �ad Id C`j MAY-05-2008 10:32 —=Htti 6. Rat daimage o; inj,rries do yoltr claim resulted" (Give P-11 extent of injuries or darrages claimed. Attach twa -stimates for auto damage.) /?j Pd �A owls 7. How was the 'aw01.1at clauned above computed? (Include the estimated amount of any prospective injury or damage,) rI a,i r- D 6pen--es u S. Names and addresses of witnesses,doctors,and hospitals: U�en� �• fes , 1�G 1�GA-) r9`- 9�x/7,6 9. List the expenditwea you made on account of this w idem or injury: SOr d r►�-A+ C ,�OLNNT a so Roseate is Knossos s ease/sea h9aa me esegwSawa■■sataMwea•Swansea 11118411\1 logo Iowa ee otasna .Gov.Cade Sec.910.2 provides"T"na claim sha?1 be signed by the dairr=t or by some person on his )behalf., SENT-NOTICES ' C,�(kt__rJ;Uvy) Nance and address of AaorneyJ--' j _(Claimaut`s Sigrat-ure) (Address) Telephone No, j Telephone No. AoI'� b�3 e��t a�o�eS ■secants■■oalsa sabbeba/amwaoasa/•oaeelbaoeemwabnesome%aeweea■b/a saw Ygs a some a wages Seal PUBLIC RECORDS NOTICE: Pleaso be advised that this claim form,or any claim flied with the County uflder aha Tort Claims Act,is subject to public disclosure under the California Public Records Am (Gov, Code, §S 6500 at seq.) Furthesmere., any attaohmet"addendums,or supplements attached to the claim form,includ4 medical records,are also subject to public disclosure. a%bananas Rana brbees e58e11 a■aaennissr raesaesonae as Raver lots se Yee sen Ras as muse a■•woo"aSao NOTICE: Section 71 of the Penal Codprovides: Every psrsotf who, with intent to defraud, presents for allowance or for paymant to acy state board or offier, ,)r to amy county, city, or district board or officer, autborid to atiew a: pay the same if genuina, any false or fraudulect claim„bill, account voucher, or writing, is pmishable either by imprisonment in the County jail for a period of not more than one year, by a tine of not exceeding one thouwd dollars or by both such imprisonment and fits, or by irnpriso=eut in the state prison,by a fine of not exceeding ten thousand dollars ($10,000),or by both such impriso,=estt and fte. 10TAL ?.0-5 f-. ' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: ane, Claim Against the County, or. District Governed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Section refer,ID care � 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 MAY 0.6 2008 Supervisors. (Paragraph IV below), `r� COUNTY"COUNSEL . given Pursuant to Government Code AMOUNT: �S�C`�� MARTINEZ CALIF Section 913 and 915.4. Please note all "Warnings„ CLAIMANT:' ., k� w UI *rwccd ATTORNEY:4�� DATE RECEIVED: ADDRESS: BY DELIVERY TO CLERK ON: 2 wGV+� C, BY BY MAIL POSTMARKED: lq c FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. Qa JOHN CUL N IlClerk. Dated: 0 By: Deputy U.. FROM.: PurifyCounsel 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). O Claim is not timely filed. The Clerk should return claim,on ground that if 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: By: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By 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: d 8 JOHN CULLEN, CLERK, ByDeputy Clerk --<) WARNING ( ov. 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 1.8; and that today ] 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 a hown above. Dated: n (e JOHN CULLEN, CLERK ByD puty Clerk CLAVVI BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: m-e 1,0 ytC Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements; ) NOTICE TOC LAIIVIANT and Board Action. All Section references are.to ) The copy of this document mailed to California Government Codes. r ) you is'your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT. �'S��`G� Section 913 and 915.4. Please note all "Warnings". . CLAIMANT:60VAIU.1- broiced '^A �^ ATTORN.EYNCU DATE RECEIVED: ! at to- ADDRESS: , fes BY DELIVERY TO CLERK ON: z° BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO; County Counsel Attached is a copy of the'above-noted claim. n }tj JOHN CUL4fjN Clerk - Dated: l l F,ln, 0 By: Deputy (Il 'l l I.I. FROM: .ounty 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). O Claim is not timely filed. The Clerk should retui'n claim on ground that'itwas filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: By: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911:3). . W. BOARD ORDER: By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this.claim.See Goyernment Code Section 945.6.You may seek the advice of an attorney of your choice in connection widi this matter. If you want to consult all attorney,you should do so immediately. *For Additional Wariing See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that .1 ann now, and at all times herein mentionied, 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: JOHN CULLEN, CLERK By Deputy Clerk f� 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 rgrowing 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 Roam 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. a■■■■■a■■a a■■■■a a a a a a■■■■a■■a a a a i a a a a s a l■■■a■■■a W a a a a a 1 a a v W a a t l a a a a a a t RE: Claim By: Reserved for Clerk's filing stamp e..- A ew 1\)o�Zw a RECEIVED Against the County of Contra Costa or ) MAY 0 6 2008 Clic ) CanRa Co*OaC( �SU%W �N r �lstrlct) CLERK BOARD OF supERVISORS (Fill in the name) 1 CONTRA C05TA CO. ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ �o6 , 14 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) f� psi 11, 200 C -eto,� -7:Ia Ah-\ + 2:o0 2. Where did the damage or injury occur. (Include city and county) Cortj�f�3,COSAA Cdu(kAy S payl N e uVe.2 Cl'((-\ c (q4!5)33s- q&ja ",v,Y,ho Place (Y1a2+�ne2, Ga. �y553 8`32 3. How did the damage or injury occur? (Give full details;use extra paper if required) - � QR ar_cu wedkgr.► da C(yy psy� w �.- \n� spay ed aoac� d.o cuy-n*),A 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? ''I V e,+ w. io pe-F-6e W)"A 1-- , P(UC6duy-e_ Svc V12oe:eRk -F►e o a vl �c" er`�c� tK i,�as `I/t''c�C�rl0 lttd� Ick,4!a'na" 5 What e e names of county or district officers, se ts, or employees causing the damage or injury? Q R. � na�J aq\� * eym Pla lee- P67N4V�f �; r. 6. )WL-ot dainage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.)�S �,el,pS)\- C�.IfC� Q3 a �-esj\� � %P6.1 ec 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) au pay,-,cock 8. Names and addresses of witnesses, doctors;and hospitals: Com Cosec` Vet-2Cinmy E!yn f�2 (q�s�`xiF-Za0d I�-i10 moru�n,.e.,-(-►61 -W1c$ f 1 A-, 0�uAolo ve,��l�t Cv �r l Co Q_C C< �yq'6 m-� p,,C,.Ua Blvd 9. List the expenditures you made on account of this accident or injury: DATE TIlyIE AMOUNT IgII /0K, 51 13 . ■ ■s a as aaaaaaaa0aa0aataaaaaaasoon Mamma aamammas MEN aaaason Mammon fasaaaaatnaRaaa0aaa9aaa1 ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornev) Name and address of Attorney } (Claimant's Signature) )—ORO DOVER A ELV E (Address) 1Na1 Telephone No. ) Telephone No �d2 S> CH 3' 7 �O Z— ■ aaaaaaaaaaaaaaaaaaaaaaaataaaa■aaaaaaaaaaaaaaaaaaaa2aaaaaaaaaaaaaaaaaaaaaaaaaaa10aIaI 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. ■■aaaaaaaaaaaaaaaaamammas aaaasun man aaaaaaaaRonan gnu aaswans aaaaaaaaaaaaaaaanaaacaaaaal 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. April 4, 2008 Contra Costa County Spay/Neuter Clinic 4800 Imhoff Place Martinez,Ca. 94553 To Whom it May Concern, On Tuesday,April 1, 2008, 1 had my 4%:month old puppy(Gypsy) spayed. I brought her in at the scheduled time at 7:30am. I picked her up at 3:OOpm like I was asked to do. The woman behind the desk,who brought Gypsy out, had a lot of trouble getting her to move. She pulled her a few times by the leash because Gypsy refused to walk. She got her to the gate or swinging door and handed me the leash so that I could take her. I took the leash and pulled her a'I little bit,she walked a few feet and that's it. I did this a few times before I picked her up and then carried her to the ca r. Around 6:15 that evening, my daughter called the Emergency Center on Monument Blvd. in Concord. She explained to them that Gypsy was spayed earlier that day and had been unresponsive since she had been home. She was cold,didn't walk, and her gums were gray. They said to immediately bring her in because she was dying. Within 15 minutes we arrived at the Emergency Center where they immediately took her in and gave her a blood transfusion and oxygen. At this point no one knew if Gypsy was going to survive or not.She was scheduled for emergency surgery with in a%: hour after arriving. We found out that her stomach was full of blood. She had been hemmoraging for quite some time. Fortunately for us, she did pull through. It was touch and go until the next morning. We were able to pick up Gypsy that day April flat 12:30pm. We will have a couple of weeks of watching her closely to make sure she stays calm. (She was a very active puppy.) This is to ensure that she doesn't hinder the healing process. She is taking Tramadol for the pain and Acepromazine to keep her calm. I do not understand why someone at the Contra Costa Clinic could not see that Gypsy was not responding normally to the procedure that she had and how she should have been acting prior to them releasing her to go home. This was very negligent on the part of the staff at the Clinic. We should have been given some paperwork as to what signs to watch for in case something went wrong.The sheet we did receive states that if bleeding or discharge comes from the incision this is not normal, but that's about it. It also states that all animals are examined before leaving the facility. If this is true, how could they have not caught this problem before Gypsy was released to go home. My bill from the Emergency Center was$4,259.13 and the first follow up exam was$161.08. 1 expect to be fully reimbursed for these procedures and any future exams that will be the result of this dreadful emergency. This should not have happened. All paperwork received from the Emergency Center,along with what I received from the County Clinic and our veterinary is attached. Sincerely, Bonnie Rettew 290 Dover Drive Walnut Creek, Ca 94598 (925)943-7962 home (925)899-2842 cell Cc: Dr. Richard Bachman CONTRA COSTA.VETERINARY EMERGENCY-CENTER,INC.` 1410 MONUMENT BOULEVARD, SUITE 108 CONCORD, CA 94520, (925) 798-2900 EMER. FEE LAST NAME. FIRST NAME MIDDLE NAME EXAMINATION ft r` CONSULTATION STREET ADDRESS APT# MEDICATIONS/ RX ._t J r CITY Y STATE ZIP { INJECTIONS ADMISSION DATE&TIME i (HOME PHONE "" OTHER PHONE CURRENT VACCINATIONS ELECTRO- " -AcM. G' f, ' ' CARDIOGRAPHY ::.P.M. ,lt,/ ..,.J / `fC.:F >'•f__.... _ .. PATIET NAME SPECIES BREED; SEX SPAYED AGE COLOsR SEDATION/ NEUT. fJ/;;°;r'.. f<l•LfJ� ANESTHESIA r' l� CASH CHECK VISA M/C RADIOGRAPHY i / A�? PAYMENT O O O O FAMILY VETERINARIAN/' �` '{""° PREFERENCE LABORATORY AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT I HEREBY AUTHORIZE THE DOCTOR ON DUTY(AND ASSISTANTS THE DOCTOR MAY DESIGNATE)TO ADMINISTER TREATMENT AS IS CONSIDERED SURGERY THERAPEUTICALLY AND/OR DIAGNOSTICALLY NECESSARY ON THE BASIS OF FINDINGS DURING THE COURSE OF SAID EVALUATION.I ALSO CONSENT TO THE ADMINISTRATION OF SUCH ANESTHETICS AS ARE NECESSARY AND SURGICAL PROCEDURES OF AN EMERGENCY NATURE. I HEREBY CERTIFY THAT'I HAVE READ AND FULLY UNDERSTAND THE ABOVE AUTHORIZATION.FOR MEDICAL AND/OR SURGICAL TREATMENT;THE REASONS WHY TREATMENT SURGERY IS CONSIDERED NECESSARY,ITS ADVANTAGES AND POSSIBLE COMPLICATIONS IF ANY,AS WELL AS POSSIBLE ALTERNATIVE MODES OF TREATMENT, - WHICH ARE EXPLAINED TO ME BY THE DOCTOR.i ASSUME FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCURRED TO PATIENT,CONSENT TO RELEASE OF MEDICAL INFORMATION,AND AUTHORIZE DIRECT PAYMENT TO THE CONTRA COSTA VETERINARY EMERGENCY CLINIC,INC. FLUID " THERAPY I UNDERSTAND THAT EMERGENCY PATIENTS MUST BE REMOVED FROM THE CLINIC'DAILY BY 8:00 A.M.THOSE RECEIVED ON SATURDAY.OR SUNDAY MAY,IF" ,- NECESSARY,BE HELD UNTIL MONDAY AT 8:00 A.M.IF I FAIL TO REMOVE SAID ANIMAL BY THAT TIME I WILL BE RESPONSIBLE FOR ADDITIONAL CHARGES. l-•r t•. DRESSINGS y [ r IGNATURE OF OWNER OR RESPONSIBLE AGENT WITNESS HOSPITALIZATION ALL PRICES OF TAXABLE ITEMS INCLUDE REIMBURSEMENT FOR SALES ALLERGIES AND/OR MEDICATIONS TAX COMPUTED TO THE NEAREST MILL. NASAL CANNULA ENTERING COMPLAINT: OXYGEN THERAPY HERAPY SPECIAL PROCEDURES TEMP., }'f HR. j{{ y r,=(= r� "vVv-'R.R M.M. O HISTORY O2 PHYSICAL FINDING.'. O.DIAGNOSIS 4O TREATMENT r MISCELLANEOUS: }If 5. a` � �.� x p ��. a.. _� ,. rr'� TOTAL r JII'��'{.�k:ing, 3.2'tk'Argy and, &9pr`�.kne�ms s�_`ce that 3`:eut .^ 1 I METHOD 0: Laterl relacLbency, s1CidlY rasPOSIl ve- Elp„A Pale Pink, Calall<.)t ' DEPOSIT t 1` >"• . _ •1 x _4. 7 A;.. •�.f c •i..1_ r •1 1 J 4 Y.YEi.1i i»I'. 4..4 4. Ab �.titii r"4..s tth'_n >R . Ms , 31 of tati.. 4xv" .u. ., 'METHOD. t+ bungs clear.. ABdi" flu d wave, in;LisioTi clean and dry, BALANCE 3�Z ': i#aic� )i.rac�c~n es s re veils 3cc who'e blood .DUE . I ..� METHOD1 ti i6tit. .acv i c z a L g �.a.�..i a« rT `•: - TOTAL "(I'.��4ir cath., }�I)us Qh �.2.?i�TsY.i s heat:ast.ar C� ,wixi i.c w-hole blood v't1(rlk_nF PAYMENT. ctate KV,/TP pC.IC t 'ilm.ma a..,f`f a e:.g abd Pff t.i P Istat Asa acide;±;da at 7..0, remr aidner WNI I'r � see ed u r t. a3 e�- r a Y$ otenl gal po t op c tplicat�.can�, il�t�.s, D' . data ki:7,kt s s WVQit „.ou t ma.tu acu Lift tzc. 2 CZmg DexSP TV P A en1 I Pit$ sx a r.";)t?dtil-a_r? -n 30min, cefazolin IV -op 400m pre 7: ,d�lal� r1�P;i1 , -'h X;�#/BJ�r� '��J 1T4t'Cab twin main. ls6/2. LI.S at 120Ihr intraob :I.nto sec nd3 DISCHARGE WITH: c--h -.'CALL YOUR REGULAR.VETERINARIAN TODAY." Leases, CARRIER FOR AN_APPT. ON X-RAYS LAB SAMPLES RX ! DATE j r� � a i . } 1(F � ' . _A M•''�tVETERINARIAN DATETIME PrMa r ,r OWNER/AGENTRELEASE O: ... JrY "... TECHNICIAN ?g CLIENT COP • r NAME - / v - 1,. RECORD NO. PAGE See_ %T A, sx r-ep0:rt: acti-vely bleeding left ovarian pedicle:, 240irls whole blood savee for au -transius• on it needed. Ptz41'Rp! �i i10 i`a>r7sraeti tl TV lnaa__n�� n^ir 4n —ac ps°ov 2mCg/kg;/hr elazo_trt or extended per s.Jrgeon Nar-fl aA�zo�r-n r•atrn_ W at- 141�j'n prs, blood pressure q2--4hra CZ'thi�8'4T� A`w'l i Pt; rn�t nr3 ••j?'t ro"i'' c.�r rw �.�t�, •79'�f 233 Fr7gt-C a_I•i.d i:_:.,l.t.�rl",� vo"..a Sung and attention seeking. Sneezing and' epistaxis, therei ort^ PT.- Tiorma l Air 16Pull riasnl nxygAn oath PCV/TP 6AM, waver and 'a and real at that rimae if: doing :4ell- ace hub tv prn to Control agit?!t"-Or. 4art 4/2/08 gad q.,�rh mf It pink crt some blood rioted in orai cavity' s-1 . heirori:hage Erf.7111p - T-;V . git - ausc, mild tachy and-Lai abd. Pall uninformative -Pulses fair lead-2 eeg; sinus thythirt no vpcvs infer soft food/dater: excellarit apr_etite consider .homne later today S C11_C i' t;'Cj X12:j d4:, s alert n{? �.yL't 2.Utl r? ?i a.bt3. 1}c�. Y i?'�.t i^rlra t.iv' . nc. -- rt'r,:x 'l it't t' ' a1 t-!.-r 1'-'li'7 i.- rp rt,?r!n I °1t•1 tl'tP '1-n- ''l"1.4 - nae+ -nldary to swarf l(w"rig bJ_L od,i P 6' n i 1 r CJ c<<' t' a give r� n'o t<, dat on ...... r exceed a r ;l .� e v r _ _ .:i11r. ;;�_'J. S ...F%C{-r?:a l7 ^f_ c _, (:xO; 1.. E:�,i.1'"`_ :. :.'?il _ {�^a \7. �, •_Jl_r CLIENT COPY P ❑ Dwight A.Gaudet,DVM,MA ❑ Charles M.Walls,DVM ❑ Martin L.Aitken,DVM G P. ad ❑ R.Jeffery Todoroff,DVM ❑ Jaur+nl•,irwevDrxr.xSmith, r,s,„yyrw„ ❑ Sharon „r.,D.„Gottfried, ottfried,VIVID uM.I D f :Yr• � R{� ��,' �'� LNa•wrrA al g dV urwYSurywu .py,x.rmrrNr.,,:wrau4ryrufLerrvxw,r>•w,r.n rrV ,.w•aY r rs s is 'r ❑ Sharon Ullman MS,DVM ❑ Leigh E.Glerum,DVM Nick Brebner,DVM -t .5 Jay . �Ylumm�Amv�un.dfayrdxan4wrr5wWu^r IAplu/rm/e Nr,rr,[ru�iWnW rynNrx,uY} VE jETERI YS CIATES ❑ Elisabeth Richardson,DVM tis, r/yrwr, Z YC IV imuthyW H eye W. ❑ Andrew J.Staatz,DVM .xw arvww w eye,, vdw,wrc.M•rvrw•ew+e�rdLw�xxY sxyoN U,ylwrwh•unnun<uHepr.ulYerr,uw„SwAwr• t ,. ❑ Angela Spann,DVM Ec www.vsasurgery.com [] Sean wells,DVM 251 No.Amphlett Blvd.,San Mateo,CA 94401 a 650.696.8196 0 800.834.7874 . Fax:650.696.8191 ❑ 1410 Monument Blvd.,Suite 100, Concord,'CA 94520. 925.827.1777 • 800.834.7874 m Fax:925.827.2364 ❑ 907Dell �Ave.,Campbell,CA 95008 . 408.364.1777 o 800.834.7874 o Fax.408.385.3677 Hospital ' 1,�C-V -� Veterinarian - Date Addres,b w -`'• 9L � � City,State �\ Zip i r a V Telephone 1 yo_ Client's Name ..- � w Pet's Name L �r Address ��l-�c” City,State WdQwdo� Zip \ `V` Breed Age L\ yl\"� Sex Telephone Clinical Diagnosis: . Diagnostic/Surgery Report: " - , `r A-.)• 4. Recommend e Follow-Up: _ VETERINARY SURGICAL ASSOCIATES BILLING STATEMENT 251 No.Amphlett Blvd.,San Mateo,CA 94401 ❑ 1410 Monument Blvd.,Suite 100,Co cord,CA 94520 El 907 Dell Ave.,Campbell,CA 95008 \ Date Hospital �. �1 -C-- Dr.. �ow`r`�'� Client `�\^j UC�oua Nature of Servic � • �� Consultation_ N5 Emergency �y Surgery,-5.W Technician / Thank, You for your confidence and this Equipment Used opportunity to provide L assistance to your patient and yourclient. ' Service: Supplies sed: 17ve Equirpment; Supplies: TOTAL: i S cq toAL 4 tii ri v aaaa a,.�a A r b-O�• ci!—^^—J Coco O O\\!J 2 O O O'II E E E E m rnQ- E E E E\ .py E E E Em E d8 E E E E rn .h-MSN QhOA V-""'o U) C=) , •� iD� � s c c� v i•.'a tll rb O A o� .• C d 0. r^ E 2 �r v — O E :C N N C7 U t0 '1r• w N m 3.in _p z u v LO ,rr m ar a . w u+ .aa s.x m t. M Q �t��i w c� Q_ Q? n.s m ar a x'XUMwU' S 4Q.2mQS U '- C)CL- rnL_JC..) -^CT LnC� C..�.. !`� i- 0..� (V 111roN N Lfl `5 `r O (D CCT �. .. '� L N U'• TM"' `.' L� LCl a C7. 'c`•t :.Cti:l rJ r•_} .D r w tn rr _ N } N. F tj. N C tl fl. ? ni tV tri tom') CS tq o vo p o .E N O C? ._t .-r• C ? +-? V; .L,! CD c, Q c SO v > O O $ ,r (a y G C •�� ..�.r 41: v V VT I LL as L t U n LL P V� fi5 L. , c ai c vi y ca to ¢ E k E cC E k E ¢ E ac E ¢ E ac E Z x E m x E �, x E �, x E �, x E m x E m x E y x E �, 5 Fi is si t5 Fi BS '6 c� C m o c� m m m m k (a ca ca ca �' co R M m W CL V U `� OL CL CL- 1111 {- o[ cr H x C H x x H x ¢ cc ¢ • Q`' a: C CC C a: ¢ x C x i 1 G Z cs CL R E -COD •,.: m o "r 4 a E cu a a. 9-1 Al 06 IM LL c� ca U CL LL C5 C`b CD -aFL Co X I E in j� E A ac E or E ae E ¢ E ac E ¢ E ¢ E E ac E Z = E m x E m x E m x E .�, = E a� x E a� I. E m x E a; x E m x c97`m t`VO , . ca Cd Cd C 1 CL a -9 a a a a a a a a oC m OC (D 0) ac m do m cc' .m ¢ a ac m ac m }as m H CC � Q H CC CC F= .aC CC aC F= CC CC OG CC " CC GC CC x aC cr 13 V 7.7 `D c E , 00LO ca r � L N i cd o �✓ N d fz�\. cc E LL Y N - t U � , a _ coo to �� ? �3 CL LL ca E i� E E E oc E oc E do E ac E ¢ E ac E Z = E m = E m. x E x m x E �, x E m x E m = E m = E m = E ro j CL Cl. a a a a a a a m Q m & N m Q m Q d yN Q m :" , Contra Costa Veterinary Emergency Center 1410 Monument Blvd. Suite 108 BIII for Services Concord, CA 94520 DATE ANV. NUM Tel: 925-798-2900 4/2/2008 65041 S. Norwood & B. Rettew 290 Dover Dr. Walnut Creek, CA 94598 925-943-7962 Acct no.: 35503 Liz Anne Bowman, DVM Qty Date Patient Description Price Ext tx 1 J. 4/1/20081 Gypsy abdominal neoplasia/hemoabdomen 0.001 1 11 4/1/20081 Gypsy 1 Emergency Fee 8am-12am 38.00 38.00 1 1 11 4/1/20081 Gypsy I Examination-Admitting 1 52.00 1; 52.00 1 11 4/1/20081 Gypsy 1 Exam/inpatient evaluation 1 '42.50 1 42.501 1 1 2 4/1/20081 Gypsy Injection-IM or Sq 1 37.25 1 74.50 1 21 4/1/20081 Gypsy 1 Injection-IV w/cath 1 38.25 1 76.50 1 1 1 214/1/20081 Gypsy Fentanyl injection 48.50 1 97.001 1 11 4/1/20081 Gypsy (Anesthesia Ketamine/Valium 1 98.50 1 98.50 1 1 11 4/1/20081 Gypsy 1 Isoflurane Anesthesia/hour 1 202.001 202.001 11 4/1/20081 Gypsy 1 Anes Monitor/Sp02/ecg/bp/etco2/majo 1 98.00 1 98.00 1 1 1 13261 4/1/20081 Gypsy 1 Emergency Surgery VSA 1 1.00,1 1,326.001 1 1 11 4/1/20081 Gypsy 1 Surgery Room 1 135.0011 135.00 1 1 1 1201 4/1/20081 Gypsy 1 Sx assistant/min 1 1.651 198.001 1 1 11 4/1/20081 Gypsy 1 ISTAT 8 1 63.25;1 63.25 11 1 11 4/1/20081 Gypsy 1 PTT and PT 1 96.25 1 96.25 1 21 4/1/20081 Gypsy 1 PCV/TS Lab 31.00 62.00 1 11 4/1/20081 Gypsy Catheter-IV-Peripheral 1 57.5011 57.50 1 1 1 .11 4/1/20081 Gypsy 1 Catheter-IV+Setup+Fluids 1 118.501 118.501 1 2.51 4/1/20081 Gypsy. 1 IVAC/shift 1 29.25 73.13 1 1 1 1 1 4/1/20081 Gypsy 1 Oxygen-Nasal Cath Placement 1 52.50 1 52.50 1 1 21 4/1/20081 Gypsy Oxygen @ 1-3UM per hr 1 25.00 1 1001 4/1/20081 Gypsy 1 Hetastarch per ml 1 1 38.00 1 1 1 11 4/1/20081 Gypsy ( Blood,canine 500cc/Blood Bank 1 1 660.001 1 1 11 4/1/20081 Gypsy 1 Hospitalization-kennel/shift . 1 36.25 1 36.25 1 11 4/1/20081 Gypsy Nursing care/shift Px on IV fluids 93.00 1 93.00 1 11 4/1/20081 Gypsy Nursing Care ICU (on 02,bp,ecg)/shit 1 152.00 152.001 1 1 11 4/1/20081 Gypsy 1 End shift am-hzd.waste 1 10.75 1 10.75 1 1 1 11 4/1/20081 Gypsy 1 Chart#123790, LAB ( 1 0.001 1 1 21 4/1/20081 Gypsy 1 Bair Hugger/hr 1 25.00 1 50.00 1 1 1 11 4/1/20081 Gypsy PT or PTT 1 53.50 1 53.50 1 1 11 4/1/20081 Gypsy 1 ECG-Lead 2 54.50 1 54.50 1 1 126222 Invoice#65041 for S. Norwood &B. Rettew, Page 2 Qty Date Patient Description Price Ext tx 1 1 4/2/2008 Gypsy Exam/inpatient evaluation 42.50 1 42.50 1 I 4/2/20081 Gypsy I Hospitalization-kennel/shift I 36.25 1 36.25 1 151 4/2/20081 Gypsy I Tramadol 50 mgs ( I ' 19.75 1 1 1 4/2/20081 Gypsy Hazardous waste 1 6.751 6.75 1 1 15 4/2/20081 Gypsy 1 Acepromazine 10mg 1 1 19.75 subtotal 4,259.13 tax 0.00 Pmnt 1: V/Mc Amt: (4,124.50) bill total 4,259.13 note: Visa/MasterCard - Pmnt 2: V/Mc Amt: (134.63) prev bal 0.00 note: Visa/MasterCard total due 4,259.13 payment (4;259.13) NEW BAL 0.00 j 126222 i 1 VCTCRIIVflRT CIRR�[fiGl` ; ' € "' ' 1418 MOKKNT BLVD CONCORD. CA 94528 925.798.2980 Sale ID: 75746886 Ref 0: 8005 84/02/08 13:28:40 Batch u: 803 VISA GJ� pear We: W2 Invoice, KIR total: $1H Customer Copy THAW YOU! i ' Contra Costa Veterinary Emergency Center 1410 Monument Blvd. Suite 108 Estimate for Services Concord, CA 94520 DATE EST. NUM Tel: 925-798-2900 4/1/2008 65041 Sharon Norwood 290 Dover Dr. Walnut Creek, CA 94598 Acct no.: 35503 Patient Description Lo qty Hi qty Lo ext Hi ext Gypsy abdominal neoplasia/hemoabdomen 1 1 0.00 0.00 Gypsy Emergency Fee 8am-12am 1 1 38.00 38.00 Gypsy Examination-Admitting 1 1 52.00 52.00 Gypsy Exam/inpatient evaluation 2 12 85.00 510.00 Gypsy Misc. Pharmacy 0 4 0.00 91.25 Gypsy Injection-IV w/cath 3 12 114.75 459.00 Gypsy Analgesia- Morphine sulfate 2 4 86.00 172.00 Gypsy ECG monitor/shift 1 8 82.00 656.00 Gypsy Anesthesia Ketamine/Valium 1 2 ,08.50 197.00 Gypsy Isoflurane Anes/hour/Px over 80# 1 2.5 268.00 670.00 Gypsy Pulse Oximeter/Shift 1 6 40.00 240.00 Gypsy Anes Monitor/Sp02/ecg/bp/etco2/major Sx 1 1 98.00 98.00 Gypsy VSA Sx 60 120 0.00 0.00 Gypsy Surgery Room 1 1 135.00 135.00 Gypsy Sx assistant/min 90 180 148.50 297.00 Gypsy CBC/GHP 0 1 0.00 157.00 Gypsy PTT and PT 1 4 96.25 385.00 Gypsy PCV/TS Lab 3 6 " 93.00 186.00 Gypsy Catheter-IV-Peripheral 0 2 0.00 115.00 Gypsy Catheter-IV+Setup+Fluids 1 1 118.50 118.50 Gypsy IV Fluids/Unit 1 4 34.50 138.00 Gypsy IVAC/shift 1 6 29.25 175.50 Gypsy Oxygen-Nasal Cath Placement 0 1 0.00 52.50 Gypsy Oxygen @ 4-6L/M per hr . 0 12 0.00 156.00 Gypsy Hetastarch 500cc 1 3 116.00 298.00 Gypsy Blood, canine 500cc/Blood Bank 1 2 660.00' 1,300.00 Gypsy Plasma K-9 FF 250ml unit ADMIN 0 2 0.00 755.00 Gypsy Hospitalization-run/shift 1 4 39.75 159.00 Gypsy Nursing care/shift Ox on IV fluids ; 1 4 93.00 372.00 Gypsy Nursing Care ICU (on 02,bp,ecg)/shift 1 4 152.00 608.00 Gypsy Misc.Treatment 0 500 0.00 500.00 Gypsy End shift am-hzd.waste 1 4 10.75 143.00 I Estimate#65041 for Sharon Norwood, Page 2 Gypsy End shift pm=nzd.waste 1 3 10.75 32.25 Gypsy Chart# 123790, LAB 1 1 0.00 0.00 Gypsy Prognosis is guarded-good 1 1 0.00 0.00 Gypsy Bair Hugger/hr 1 4 25.00 100.00 Gypsy Emergency Surgery VSA '1400 2200 1,400.00 2,200.00 Gypsy est for 24-36hrs / 1 1 0.00 0.00 Lo/Hi subtotal: 4,124.50 11,466.0 tax: 0.00 0.00 Lo/Hi Total: 4,124.50 11,466.0 Deposit method: Deposit note: Deposit: 0.00 0.00 Lo/Hi Balance after deposit: 4,1,24.50 11,466.0 Authorization for medical and/or surgical treatment. I hereby authorize the doctor on duty (and assistants the doctor may designate)to administer treatment as is considered therapeutically and/or diagnostically necessary on the basis of findings during the course of said evaluation. I also consent to the administration of such anesthetics as are necessary and surgical procedures of an emergency nature. I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment, the reasons why surgery is considered necessary, its advantages and possible complications if any, as well as possible alternative modes of treatment which are explained to me by the doctor. I assume financial responsibility for all charges incurred to patient, consent to release of medical information and authorize direct payment to the Contra Costa Veterinary Emergency Center. I understand that emergency patients must be removed from the clinic daily by 8:00 AM. Those received on Saturday or Sunday may, if necessary, be held until Monday at 8:00 AM. If I fail to remove said animal by that time, I will be responsible for additional charges. YETERINRRY EMERGENCY 1410 MONUMENT BLVD Authorized Signature Date CONCORD. CA 94520 925-798-2900 Sale ID: 75746006 Ref 0: 0007 Witness Signature Date 044108 19:32:14 Batch b: 801 VISs ��a�1097 Or Code,.9129 Invoicet 011572 CONTRA COSTA Liz Anne Bowman I Total; 41 .9 =_ VETERINARY D.V.M. Customer Coat EMERGENCY 1410 Monument Blvd THANK YOU! CENTER Suite 108 Concord,CA 94520 925.798.2900 24 Hour Care i t INVOICE Mount Diablo Veterinary Medical Center 3344-B Mt. Diablo Blvd. Lafayette, CA 94549 925-284-1350 Printed: 04-05-08 at 10:42a FOR: Vincent Rettew Date: 04-05-08 t' 290 Dover Drive Account: 973 Walnut Creek, CA 94598 Invoice: 210944 Date For Qty Description Net Price Services by Allison Mattingly, DVM 04-02-08 Scooter 20 Prednisone 20 MgO1 to W � U19 � 20.83 04-05-08 Gypsy 1 Office Visit- Brief Exam 30.43 04-05-08 1 General Health Profile 95.69 04-05-08 1 Vet Test-Set-Up Fee 34.96 services by l e 04-05-08 Check payment -181.91 Old balance Charges Payments New balance 0.00 181.91 181.91 0.00 Reminders for: Gypsy Last done 03-06-09 Bordetella-Canine- Injectab 03-06-08 02-26-09 Fecal Flotation 02-27-08 02-12-09 Bordetella-Canine- Intranas 02-13-08 02-12-09 DHLPP-booster 02-13-08 02-15-08 DHLPP+Corona -3rd Reminders for: Scooter Last done 02-26-09 Fecal Flotation 02-27-08 02-12-09 Bordetella-Canine-Intranas 02-13-08 02-12-09 DHLPP-booster 02-13-08 02-15-08 DHLPP+Corona-3rd Doctor's Instructions Prednisone 20 Mg = Prednisone can cause your pet to have an increase in appetite,water consumption and more frequent urination. Please call us if you have any concerns. Long term use of prednisone may adversely affect your pets'health. Yearly monitoring ' blood tests are recommended.0 INVOICE Mount Diablo Veterinary Medical Center 3344-B Mt. Diablo Blvd. Lafayette, CA 94549 925-284-1350 , s Printed: 04-09-08 at 11:13a FOR: Vincent Rettew Date: 04-05-08 290 Dover Drive Account: 973 Walnut Creek, CA 94598 Invoice: 210953 Date For Qty Description Net Price Services by Allison Mattingly, DVM 04-05-08 Gypsy 1 Fluids Dispensed/Supplies IItr 33.79 Old balance Charges Payments New balance 0.00 33.71 0.00 33.71 a Reminders for: Gypsy Last done 03-06-09 Bordetella-Canine-Injectab 03-06-08 02-26-09 Fecal Flotation 02-27-08 02-12-09 Bordetella-Canine- Intranas 02-13-08 02-12-09 DHLPP-booster 02-13-08 02-15-08 DHLPP+Corona-3rd R, X _ d Ryy{ A. w r Y' d ._.�,`,, ,C dS,� s.�"... R,._,.'-" __ .�"�'',-.u ,.. ���... . .ai.,.._ _r .-u..,,� .,'r'.:i?, , .�...!?3 ,. __., �3 ., .: _., J s�,�.._,. _ _.,�__.z_.:� "' z _':�✓w_ �.. INVOICE k Mount Diablo Veterinary Medical Center R' F x 3344-B Mt. Diablo Blvd. Lafayette, CA 94549 925-284-1350 Printed: 04-09-08 at 11:13a FOR: Vincent Rettew Date: 04-09-08 290 Dover Drive Account: 973 Walnut Creek, CA 94598 Invoice: 211020 Date For Qty Description Net Price Services by Allison Mattingly, DVM 04-09-08 Gypsy 1 Chem 12 Blood Profile 72.60 04-09-08 1 Vet Test-Set-Up Fee 34.96 Services by 04-09-08 Check payment . :' '_107.-56"----') Old balance Charges Payments New balance 0.00 107.56 107.56 0.00 Reminders for: Gypsy Last done 03-06-09 Bordetella-Canine- Injectab 03-06-08 02-26-09 Fecal Flotation 02-27-08 02-12-09 Bordetella -Canine-Intranas 02-13-08 02-12-09 DHLPP-booster 02-13-08 02-1"8 DHLPP+Corona-3rd s •3...,._ ..r. .L.. d,g✓k <.,.._,.,::.x+ ._.+ s,,.: ,Mih.wu.r -'�. ` Please Read This! , CONTRA:COSTA COUNTY SPAY/NEUTER CLINIC .48001mhoff Place Martinez, CA 94553 (X of Imhoff Drive) ., :(925) 335-8320 Post-Operative Instructions:. CATS are to be picked up between 3:00 = 4:00 p.m. DOGS are to be picked up between 3:00- 4.00 p.-m. *Please note there is no staff on duty after 4.30 p.m. Most dogs exhibit . no effects of. the anesthesia except. for some mild tranquilization: In cats, the effects of anesthesia may not dissipate for,24 hours. Responses to external stimuli (light; noise; and movement) may be exaggerated, and the cat should be allowed to recover that evening:in a small quiet, darkened area. Pain medication given may-also cause lethargy or grogginess: Feed small amounts if .the. .animal is sufficiently recovered from anesthesia. Animals under four months should definitely eat. Withhold food if any. vomiting . occurs. Sufficient healing occurs after one,week during which animals should be. confined. or leashed. Daily walking is advised. Incision area may show some temporary swelling, particularly in the-female cat, which rarely requires any treatment. We Will.gladly recheck at no charge. .There are generally'no external sutures`and licking is rarely.a concern, however, some male dogs may require the use of an"E-collar'`. No bleeding or discharge from any incision should be considered normal. If you have any concerns, call the Contra Costa Spay Neuter.Clinic at 925:335:8320. All animals are examined before release so the need` for further veterinary services would be rare.. Activity should be restricted.for dogs at least one week. Cats should be kept indoors for up to seven days following surgery. After hours, emergency service is 'available at the Veterinary Emergency Clinic. DC The telephone number is (925).798-2900. A4, f/{v .moi-,-, h,04P Je CC;,. S:Spay euter! ewOwr Instruction SpayNeuterClinicSpayNeuterinstructions8-21-03 07 T / (?-/— ,' 703` Contra Costa County Animal Services SN Clinic, 4800 Imhoff Place,Martinez, CA 94553 (925) 335-8320 Receipt Number: R08-013072 Receipt Date: Tuesday,April 1, 2008 Person Information: BONNIE RETTEW PID: P133501 290 DOVER DR WALNUT CREEK, CA 94598 Received From:BONNIE RETTEW Credit Card No./ Check No: Phone: (925) 943-7962 Item: Animal ID: Reference No: Price: Each: Amount: LICENSE SN DOG 1 YR A518842 L08-048594 $20.00 1 $20.00 VACCINATION A485436 T07-014197 .00 1 .00 VACCINATE DHPP A485436 T07-014198 .00 1 .00 SURGERY A518842 T08-016638 .00 1 00 ,SPAY DOG_MED IUM A518842 T08-017145 95.00 1 95.00 VAGCTIQA A518842 T08-017146 .00 1 00 VACCINATE RAB DOG A518842 T08-017147 5.00 1 5.00 Total Fees Due: $120.00 Payments: Cash: $0.00 Check: $120.00 Credit Card: $0.00 Total Payments Received: $120.00 Thank You! Change: $0.00 Balance Due: $0.00 Animal Information: A485436-3 MONTHS OF AGE, Estim DOB-12/2912006 FEMALE, LABRADOR RETR/MIX,YELLOW DOG A518842 GIPSY -4 MONTHS OF AGE, Estim DOB-11/24/2007 SPAYED, ROTTWEILER/MIX, BLACK AND WHITE DOG zcam .. u m Public Shelter Hours Tuesday-Saturday 10:OOAM -5:00PM* Wednesday 10:OOAM-7:OOPM* Shelters CLOSED Sundays,Mondays,and Holidays Spay/Neuter Clinic:Monday-Friday 7:30 a.m.-12:00 Noon 1:00 p.m.-4:30 p.m.;Some Saturdays 9:00 a.m.-12:00 Noon Clerk:NULL CLINIC Trans Date/time:7:56 am 4/1108 Print Date/Time:4/1/2008 7:56 am C:1Program Files%Chameleon SoftwarelChameleonlcrystalkF3 ReportslReceipt.rpt Page 1 of 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Lk l i > Claim Against the County, or District Governed by ) the Board of Supervisors, Routing n "ii NOTICE TO CLAIMANT and Board Action. All Section ref i� The copy of this document mailed to California Government Codes. you is your notice of the action.taken Mon your claim by the Board of COUNTY OOUNSEL Supervisors. (Paragraph IV below), MARTINEZ CALIF. given Pursuant to Government,Code AMOUNT: Onurluv o f fk Is �►�'�• Section 913 and 915.4. Please note all "Warnings". CLAIMANT: 66-6 Allcn &kbl;a/' ATTORNEY: f7 C G. DATE RECEIVED: Maq Q, Z 099 ADDRESS: 13 15- jrynjyrJ S� BY DELIVERY,TO CLERK ON: u 14 14rj I Z5W BY MAIL POSTMARKED: 7?�(� FROM: Clerk of the Board of Supervisors TO .County Counsel Attached isa copy of the above-noted claim. JOHN CULLEN, lerk Dated: Z By: Deputy_ VIAJ.So, LI: 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: 5" ,(D 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). 1V, 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the 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.[f'you want to consult an attorney,you should do so immediately. *For Additiaial Warning See Reverse Side of'This Notice. AFFIDAVIT OF MAILING I declare under penalty of pei jury that .l. 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:IL I JOHN CULLEN, CLERK \ p Y De ut Clerk CLAI1vI BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: ti�t�lf2 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: i1hur►G+,J wf -��5 '�'�'"�. Section 913 and 915.4. Pleasenoteall "Warnings". . CLAIMANT: Sf^,tf r< Ahern &ems ATTORNEY: n/CL DATE RECEIVED: Z 09 ADDRESS: j3 t5 %rypt`hf j2atn Sf BY DELIVERY TO CLERK ON: klew 6 -209 D 4(l. , Cu. 4q 510 Cl y l BY MAIL POSTMARKED. 77/0 FROM: Clerk of the Board of Supervisors TOr County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, -Jerk.. Dated: Z t )-UA By: Deputy 11. FROM.: County Counsel TO: Clerk of the Board of Supervisors O This claim complies substantially with Sections 910 and 910.2. ( ) .This Claim FALLS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act foi' 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: 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). 1V. BOARD ORDER: By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in.the niail to file a court action on this claim.See Government Code Sectiai 945.6.You may seek the advice of an attorney of'your choice in connection with this matter.Il'you want to consult an attorney,you should do so immediately. *For AddiBaial Waihiiig See Reverse Side of'This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that .l. 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: JOHN CULLEN, CLERK By Deputy Clerk < e- BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT r 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. RE: Claim By: Reserved for Clerk's filing stamp �_ we Allen &ckoya RECEIVED Against the County of Contra Costa 40 ) MAY 0 6 2008 C'onifgCOS�('OUn+� Sl�cx► SkW_1 t t' J0Lo� n 1 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$Ut&owrt a+-W6and in support of this claim represents as follows: -kiwi-�eXeeedS�ZS,000,o� 1. When did the damage or injury occur? (Give exact date and hour) please- su. f *Ac�tvw_+L - A . 2. Where did the damage or injury occur? (Include city and county) Rm%t See, AftcH,,r 10Ai 1"<- 3. How did the damage or injury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers, servants, or employees causing.the -- -- --damage or injury? Pl�c��e C.4k, At1ZJ4Wa_VXA '3 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Exact- ay-viotAm4 "to VzL� pro VtVJ ak- * i0AP lase.- Se-9- Attac l4 rvv_v +- A -Rw 0, c1eSCr I pion of OUI& 'rn�uVr�s . NLMa:o�e . �e kreeA �ZS,1 000 _M a 7. How wthe amount claid4d above computed? (Include, the estimated amount of any prospective injury or damage.) T I_e._ d.e kv-m iyeo1 . Cxpwt W,+KX SS 4-_S1imOnv� �t Yeq,UI rtok . 8. Names and addresses of witnesses, doctors, and hospitals: GV-C,At -sockove<-;N0.VVgS 11544 0.-1 �l c,Vimev�} 3jAbl A. Qureshi , M,D: (q2-5 -93g -- -SSs), Nax % of 0+tvV- w �v�ess�s,oloc arsGzr�Gt loi hosQ,bt,ls 0-re. u 1kjAowwN. 9. List the.expenditures you made on account of this accident or injury: DATE TIME AMOUNT o b2 f rove*-\ of oA FXGItk am0t v',A- UAu-")WYA OL' -h-NqS _;YvN .. Gov. Code Sec. 910.2 provides "The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) (Claimant's Signature) (Address) 0CA-Qe , Cil. qq S U 1 Telephone No. ) Telephone No. 0195 to s - j0lg s- ■■rrrrrrr■rrrrrrrr.■■■rrrrrrrrrrrr■■■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrr■■rrrrrrrr�rrrrrr� PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure., NOTICE: Section 72 of the Penal Code provides: Every person who, with,intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year; by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and -fine, or by imprisonment in the state prison; by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. f. ATTACHMENT A, PAGE 1 OF 2 On or about November 8, 2007, Brent Bockover was placed under arrest and taken into custody in the city of Bay Point, county of Contra Costa, state of California, by the Contra Costa County Sheriff's Department, an entity of Contra Costa County, for a crime he did not commit. Mr. Bockover was forced to endure lengthy interrogations and was forced to spend several nights in the detention facility operated by Contra Costa County, located in the city of yartinez, county of Contra Costa, state of California. Mr. Bockover was released from custody on bail on November 14, 2007. Since the time of his arrest, Mr. Bockover has lived the nightmare of being accused of attempting to commit lewd acts on minors, suspicious kidnaping and child molestation. Mr. Bockover's name and what.he had been wrongfully arrested for was written in newspapers, broadcasted on television, and spread around the community. During this period, the Contra Costa County Sheriff's Department and its deputies failed to properly investigate the crimes that they.were publically accusing Mr. Bockover of committing. The Contra Costa County Sheriff s Department and its deputies acted with deliberate indifference in investigating Mr. Bockover's case, and made several prejudicial errors during the investigation. The police officers included unverified and unreliable information in their police reports. Several of Mr. Bockover's rights were violated by the Contra Costa County Sheriff's Department and its deputies during this time period. Those rights include, but are not limited to, a violation of his due process rights, a.violation of the right to be free from harmful touching and;to be free from fears of harmful touching, a violation his right to not be wrongfully and falsely imprisoned, and a violation of his right to not have his reputation sullied in the community by false statements. In addition to the violation of rights listed above, the Contra Costa County Sheriff s Department and its deputies and employees failed to provide Mr. Bockover adequate medical care as a pretrial detainee, in violation of Mr. Bockover's right to due process of law. Mr. Bockover was severely physically disabled in a car accident approximately three years ago. Now, Mr. Bockover requires constant pain and other medications to simply keep his body functioning. Mr.`Bockover notified the arresting deputies of his disability. However, even with such knowledge, the deputies strained several parts of Mr. Bockover's body during the arrest. At least twice, Mr. Bockover notified triage nurses at the Martinez Detention Facility of his condition, his constant pain, and his need for medications to keep his body functioning. Mr. Bockover also informed a triage nurse at the Martinez Detention Facility of hisinability to sit for long periods of time on a hard surface. Several times while in custody, Mr. Bockover requested that deputies take him to get medical assistance. Mr. Bockover tried to explain to several deputies the reasons why he needed medical attention. The deputies and the triage nurses denied, delayed and/or intentionally interfered with Mr. Bockover receiving necessary medical attention while in custody, and the deputies and nurses were deliberately indifferent to Mr. Bockover's medical needs. Once released from custody, Mr. Bockover's pain had significantly increased and his range of motion had significantly decreased. Mr. Bockover has suffered a major setback in his recovery from his earlier accident because of the deliberate indifference to providing necessary medical treatment of the triage nurses and the deputy sheriffs. Additionally, it is believed that Contra Costa County, Contra Costa County Sheriffs Department, and Sheriff Warren Rupf consciously disregarded, authorized, and/or ratified the l; 1 ATTACHMENT A, PAGE 2 of 2 conduct of the deputy sheriffs and the triage nurses. It is believed that Contra Costa County, Contra Costa County Sheriff's department, and Sheriff Warren Rupf knowingly maintained, enforced, and applied a policy and practice of employing and retaining sheriffs and deputies who have dangerous propensities for abusing and/or neglecting their authority and committing acts of excessive force and denying medical treatment; inadequately supervising, training, controlling, assigning, and disciplining sheriffs and deputies who knew had the afore-described propensities and character traits; maintaining grossly inadequate procedures for reporting, supervising, investigating, reviewing, disciplining and controlling the conduct of the sheriffs and deputies, particularly with respect to illegal acts, acts of excessive force, and acts of denying medical treatment to inmates accused of child molestation; and fostering and encouraging a policy, pattern, and practice of violence and deliberate indifference to providing adequate medical care through their official positions, which proximately resulted in the excessive force and violations of his due process rights on Mr. Bockover. All of this has caused Mr. Bockover severe emotional distress. Moreover, Mr. Bockover has been damages in a sum to be determined at trial, but in excess of$25,000.00. ATTACHMENT B 5. Name of county officers, servants, or employees causingthe damage or injury_ Name/Badge Number: Sheriff Warren Rupf Deputy M. Tegeler Sgt. D. Gomez/Supe. No. 49582 Deputy Kelly Challand 53753 Deputy C. Sanders 66580 Deputy M. Wilhelm Deputy Shiells Supv. M Malone/ Supv. No. 45932 Deputy R. Koci Unknown Sheriff Deputy Unknown Sheriff Deputy Unknown Sheriff Deputy Unknown Sheriff Deputy Unknown Sheriff Deputy Unknown Triage Nurse Unknown Triage Nurse C LA LM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:J Un& ,10, 2_W9, Claim Against the County, or District Governed by ) the.Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section ref re ccs are to ) The copy of this document mailed to California Government Codes, � C�gBd you is your notice of the action taken !7 on your claim.by the Board of MAY 0.6 2008 Supervisors. (Paragraph IV below); given Pursuant to Government Code COUNTYCOUNSEL Section 913 and 915.4. Please note all AMOUNT: � S�S++ SI MARTINEZ CALIF. n "Warnings". . CLAIMANT jdyY 6, Pa1fVL-er ATTORNEY:.rL/d__ DATE RECEIVED: M aU 5 . Z ADDRESS: 95 )Wl"1.& L el BY DELIVERY TO CLERK ON: 2D�tS / � �w P'54` fy9kr BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a appy of the above-noted claim. / pip JOHN CUL -N Clerk.. Dated: z0b By: Deputy U. FROM.: Ubunty Counsel TO: Clerk of the Board of Supervisors (v)"lnis 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). ( Other: 0X4./;-/) /S 6�1 /�')c' �GC O l/1 6410 a s vv 8': Dated: By: Deputy County Counsel III. FROM: Clerk of the Board T0: 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. 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: JOHN CULLEN, CLERK, B7yN]_:==Deputy Clerk WARNING (Gov. code section 913). Subject to certain exceptions,you have only six(6) months from theate 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 theadvice 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 Wartinijig See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am_now, and at all times herein mentioned, have been a citizen of the United States, over, age 1.8; and that today .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 tl innan.t as shown above. Dated; "a / I JOHN CULLEN, CLERK By Depu Clerk 000 CLAIM BOARD OF SUPERVISORS OF.CONTRA COSTA COUNTY BOARD ACTION: C1e Claim Against the County, or.District Governed by ) . the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are.to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: I � �i �v� Section 913 and 915.4. Please note all P "Warnings". . CLAIMANT:JJ)l n lid I`C�.byL,.U— ATTORNEY: ft/,Z, DATE RECEIVED: . CP 5 2zys ADDRESS: Af�el& tl BY DELIVERY TO CLERK ON: r—) L ' 0/4uc i"C vk, CA_ BY MAIL POSTMARKED:���'` c � FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a cppy of the above-noted claim. fj JOHN CUL N Clerk. Dated: z n By; Deputy I.I. FROM.: unty Counsel TO: Clerk of the Board of Supervisors 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 retum claim on ground that it was filed late and send wai-ning of claimant's right to.apply for leave to present a late claim (Section 9.11.3). O Other: Dated: By: Deputy County Counsel 111. FROM: Clerk of the Board T0: County Counsel (1). County,Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD'ORDER: .By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By . Deputy Clerk WARNING(Gov. code section 913) Subject to ceilain 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 idviee of an attorney of your choice in connection wide this matter. If.'you want to consult an attorney,you should do so immediately. -*For Additional Warning See Reverse Side orris Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that [ 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: JOHN CULLEN, CLERK By Deputy Clerk MAY, 2. 2008 11 : 18AM PIEDMONT LUMBER OAK N0. 080 n P, 2 BOARD OF SUPFR'VBGPS OF CONTRA C&STA COUNTY -- ---- _ _Il�7S'FRUCTIONS TO Y-710 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 laxer than six months after the accrual of the cause of action A claim relating to any other cause of action shall be.presented nat 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 frilled in. D. If the claim is against more t= one public entity, separate claims must be filed against each E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this fora lm. ■RRRRan Earn MEN a WE as f Ri t RSR Rua BEa an WEE AnatKarp t/nf Wxx an ROME R■■Ivan a WKR[R/■C rig■.1 RE: Claim.By; Reserved for Clerk's filing stamp -1;5O44-j JQP44- ) RECEIVED Against the County of Contra Costa or ) MAY 0 5 2008 District) CLERK BOARD OF SUPERVISORS (Fill is 1-e n=e) ) CONTRA COSTA CO. The undersip.ed cl.abwat hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ /1f and in support of this claim represents as follows: L When did the damage or injury occur? (Crive exact date'and h6ii5 _ _ _ ____-- __--•_ MIA42C,4 qV-' APPAM 5-Pm 2. Where did the damage or injury occur? (Include city and county) c,va&,'-r� C�k- e-,,a. �,� Carj- � 3. How did the damage or injury occur? (Give full details;use extra paper if required) .17 400OW $`if P4-D Foe -r.4C TR.Ar-rid- L.,9f*r OVU c f )20� 47 '1'i4es 12A*G ft 5&,,G- AN A w+tS 94PIZIFAW r31{ 90f A "-"ft7-& FAD Tram?-SLS 4. What particular act or ouaission on the part of county or district officers, servants, or employees caused the injury or damage? ry 5-rop i.v 5 What axe the names of county or district officers, servants, or employees causing the damage or injury? kufP C�.Tf�a'+�G 1N5,P�CrZ12� MAY. 2. 2008 11 : 30AM PIEDMONT LUMBER OAK NO. 083 P. 2 6. "What damage or injuries do your claim resulted.? (Give foil extent of injuries or damages claimed, Atta--h two estimates for auto dama e.) A t 5 o ?w%4 a b ht� '-'7d i i Zvi RrA2 Di Fk�1 1 E3 GAS��2. S �sV WFSO C.E� rue SGS�v, 7. How was the amount claimed above computed? Claclude the estimated amount of any prospective injury or damage.) 8� -w-T aa;>I strap 4 S. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT It■•i■■■rma=■■{■■■r`■=Rr■man-Wr■■aa NNE■■am{m R■■t■an allWN,■a1M■■■■m[■■•■ma■RtIts m=■■■�rm*■'s ial .Gov. Code Sec. 910.2 provides"The claim shall be )signed by the clairau r b so person on his )behalf" SEND NOTICES TO: (Attorney)_ ) Name and address of Attorney ) (Claimant's Signature) (Address) ' 9 9,Sf 7 Telephone No. ) Telephone No. r■■■■attmto■MINE mass o■'■►aa■■■rrem�{eur■a■a{ta{r■amounts■n■■meas■■rtrm{ao9 a a aNil■■melts r■■Ns — .- '- _ - — '.'�TJDJ1x{,:1kJiC�}i1i+"�1'v i�i.��:�. _. .. .�_.,..__. � •- - --- 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 re:orris,are also subject to public disclosure. r{lar m■■■■■mta■a■\■■■■mama an No■cam{■■g NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for paymeut to any state board or officer, or to any county, city, or district board or off eer, 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 jai] 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 imprisomnent 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. MAY. 2. 2008 11 : 18AM PIEDMONT LUMBER OAK N0. 080 P. 3 6_ What damage or injuries do your claim resulted? (Give M extent of injuries or damages claimed Attach two estimates for auto dama.)U ,> --r14-e_ 36V � ( LII —rs c/q,i.a P( Lrp, A 4 5 o Pas-1.1E2) P"F_ /vroi rJ 96w2 Os A /71 5 13Aa?- S �r4sV !.;)FLO G�S7'rte SCcAiv, 7. How was the amount claimed above computed? (Iaclude the estimated amount of any prospective injury or damage.) 8� -TAC &o;,y st4af, 4 8. Natnes.and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TRAB AMOUNT a aaa{{Ll Mataaaa as\{a{{Raaa ar f{s{aaaaf{{■11c�{{��t{l{R�{sem{{{�1Rai�t{{{{�ti�E l[{w R�RCi1{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 ) (Claimant's Signature) (Address) Telephone No. ) Telephone No. {{ap an"WHEN a a I Rank al■{Nits a{{{■■■a{1{a■<RRaat1{man a{aaaa{■{Ra Ra{Rs A R1 -Puft3C RITC_eF1DS 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, 95 6$00 at seq.) Furthermore, any attachments,addendums, or supplements attached to to claim form, including medical records, are also subject to public disclosure. or RA■Ann MRSo•■0Ran%a{{{{■a{{\{{mal{{■f{■aRa!\■iAaaaaMINN aaat{aRRaaa{amps aaa{SWARM gas L NOTICE: Section 72 of the Penal Code pravides: 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 f audulent 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. MAY. 2, 2008 11 : 18AM PIEDMONT LUMBER OAK N0. 080 P. 4 04/09/2008 at 04:21 PM Job Number: 76703 PLEASANT SILL COLLISION REPAIR CENTER License #:AA187241 Federal ID #:680370217 1581 Oak Park Blvd Pleasant Hill, CA 94523 (925) 939-1160 Fax: (925) 939-1280 PRELIMINARY ESTIMTE Written By: Cory Spragens Adjuster: Insured: John Palmer cladM Owner: John Palmer Policy # Address: 45 Arends La Deductible: Walnut Creek, CA 94597 Date of Loss: Cellular: (925) 212-5626 Type of Loss: Other: (925) 934-1790 Point of Impact: Inspect Location-. Insurance _ ,. an Days to Repair 1991 TOMO STANDARD 4X2 4-2.4L-FX 2D P/U Red Int: VIN: JT4RN81A9M0083559 Lic: 4J17746 CA Prod Date: 07/1991 Odometer: Clear Coat paint Power Brakes 5 Speed Transmission Overdrive Styled Steel Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H bumper assy 1.5 3 Rept Step bumper assy chrome 1 347.39 Incl. premium 40 Repl RT Mount bracket 1 30. 29 Incl. 5 REAR TAMPS 6 R&I RT Tail lamp assy 0.3 7 PICK UP BOX 8 Repl Set back box assy 1 1. 5 9# Set-up for floor pull 1 1. 5 10# Pull RT Side panel lower 1 1. 5 11# Pull upper bedsides to align 1 1. 5 gaps 12* Rpr RT Panel assy side short bed 2.5 2 .0 13 Add for Clear Coat O , 8 14# R&I Camper Shell 1 . 0 15 R&I Fuel door 0 . 3 16 R&I RT Wheelhouse cover 0. 3 17 R&I RT Skirt 0.3 18# Subl Haz Waste 1 3. 50 X 194 Repl Cover car exterior 1 5 . 00 T 0 . 3 20# Rpr Colorsand and Buff 0. 8 1 MAY, 2. 2008 11 : 18AM PIEDMONT LUMBER OAK NO. 080 P. 5 04/09/2008 at 04:21 PM Job Number: 76703 PRELIMINARY ESTn4ZLTE 1991 TOYO STANDARD 4X2 4-2. 4L-FI 2D P/U Red Int: ------------------------------------------------------------------------------- NO. OP ., DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 214 Rpr Color Match 0.5 ------------------------------------------------------------------------------- Subtotals =_> 386. 18 13.8 2. 8 Parts 377. 68 Body Labor 13. 8 hrs @ S 80.00/hr 1104 .00 Paint Labor 2. 8 hrs @ $ 80 . 00/hr 224. 00 Pairit Supplies 2. 8 hrs @ $ 34.00/hr 95. 20 Sublet/Misc. 8.50 ----------------------------------------------- SUBTOTAL $ 1809.38 Sales Tax $ 477. 88 @ 8 .2500% 39.43 ---------------------------------------------------- GRAND TOTAL $ 1848 . 81 ADJUSTMENTS: Deductible 0 . 00 ------ .---------------------------------------------------- CUSTOMER PAY , - D -00 INSURANCE PAY $ 184H.81 2 p� SAY. 2. 2008 11 : 30AM PIEDMONT LUMBER OAK N0, 083 P. 1 I' —1♦ SINCE 1934 r 1000:11 IOU ! 351 -40th Street OaWand, CA 94W9 • (SIO)658-lue FAX(510)654161 arm , � � -----� capsea rraw wandcftk MAY 0 5 2008 (70'7)2Wl&4W (SIO)424111 (707)4&i*Mt (299)a92-6499 (510)WS&W Fax 80ARE)OF St1PERViSOR8 CONTRA COSTA CO. &Olt ------------ 4 epty 'E�Please RecyUe i enny Baihoj, Y HAY 0 2 .2000 ( ytended oniy for the petsanal and confidential use of ker of flus message is not the intended recipient or C ped recipient, you are hereby noi>fie d that you have ;View, dissemination, distribution or copying of this ived this communication in error, please notify me 7 i f II �j CLAIM ` BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACT10NdMe 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), n Pursuant to Government Code �� D6� ion 913 and 915.4. Please note all AMOUNT.-, „ ' MAY 1 3 2008 rnings . . CLAIMANT: COUNTY COUNSEL { l.- r MARTINEZ CALIF. ATTORNEY: � � �� DATE RECEIVED: � n ADDRESS: �[�� V9 W/1,,t Ob BY DELIVERY TO CLERK ON: � YIGQ coj UGI BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CUL E , Clerk Dated: 12 2W5 By: Deputy II. FROM.: unty 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). 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 111. FROM: Clerk of the Board TO: County Counsel (l.) 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: 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: o JOHN CULLEN, CLERK, By Dep ty Clerk WARNING(Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this�clahn.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connectim with this matter. Ifyou want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side ofTbis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that .l. am now, and at all times herein mentioned, have been a citizen of the United States, overage 1.8; 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, gocel JOHN CULLEN, CLERK By Dep ty Clerk CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTIONV W)e (T, 2CC)6, Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are.to ) The copy of this document mailed to .California Government Codes. ) you is your notice of the action taken on your claim.by the Board of Supervisors. (Paragraph IV below); given Pursuant to Government Code e�,�� Section 913 and 915.4. Please note all AMOUNT: -+' Ott) •`warnings". . CLAIMANT: ATTORNEY: - DATE RECEIVED: PCM4 A , tl au St✓ ADDRESS: Ave_ jbb BY DELIVERY TO CLERK ON: XtSlcoI C-n BY MAIL POSTMARKED: rn(,�,� q, FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is.a copy of the above-noted claim. JOHN CUL` E .lerk ell Dated: By: Deputy lQi u� flL I.I. FROM.: unty Counsel TO: Clerk of the Board of Supervisors . 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). 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: By: Deputy County Counsel . III. FROM: Clerk,of the Board T0: 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:. . O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section.913) Subject to certain exceptions,you have only six(6) months from the date this notice was personalty served or deposited in the snail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. 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 per jury that .i. am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice.to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INISTRUCTIONS TO CLAIlVIANI' 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, Count),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 nine 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. a ..a El.....r■.<. l i i t R e ERRORS NONE HEX ON e e MEN ME 9 e R A&Now a MtN!e go e a RE: Claim By: Reserved for Clerk's filing stamp ) RECEIVED Against the County of Contra Costa or ) MAY 2 99 2008 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$x_(000 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 20 0 tp r 7; S a. . . 2. Where did the damage or injury occur? (Include city and county) AAHONO 61.viD. r0tJ0.10 Al�-, _�p>,licna0 Cb,;t"cnA (bs�� �'ova� 3. How did the damage or injury occur? (Give full details;use extra paper if required) r10'"fa2 ✓ tCt lACG,O � CSRrolf-oT ��/�rt -Ur. o, fay COVAI-r' VO-y4+L.LL�, 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 0A--w C6-rJr oftnw7oiu OF A YqON if- V o,-14/ eLcr' 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 6..',. `A7L-z_t=-dainage or injuries do your claim resulted? (Give full extent of injuries or' damages_ claimed. Attach two estimates for auto damage.) n �ccv4-1 f�'T17iG- saw«W&O- A 6P- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Ccoa�� `�rwN _ Std D(3 M,q tip 8. Names and addresses of witnesses, doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TH\JE AMOUNT ■ .[[[[.[[..[[a0.............[a..[[.■aam[nmasawn[anEms aa■omaa0aaaaamonmmn'anoaaa[na.aRl .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 ) LAW 0,'FICES OF Duo KRAUSZ,P.C. ) (Claimant's Signature) 2140 Van N���s M.me 300 San Francisco,CA 94109 (Address) ter- Telephone No. glY,L567—Ot"D )Telephone No. 37_(Q_ZX�_5_- a m■[s■s s a■■■Rona NOR.mass■an R....[...............on !.f......[.[..a■■a■■a KENN an■[ PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■■a.■■aaaa■■an■■a[aaSamoa a■an■■naaaamssmswoman Ingo■Oman Ran massaRRRsnaanow man wassa[nal 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. LAW OFFICES OF DAVID A. KRAUSZ, P.C. 2740 VAN NESS AVENUE,SUITE 300 SAN FRANCISCO,CA 94109-1463 TELEPHONE:(415)567-5000 FACSIMILE:(415)202-0394 e-mail:david@lodak.com May 9, 2008 Clerk FRECEIVEDContra Costa Board of Supervisors 651 Pine Street, Room 106 2 2008 Martinez, CA 94553 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. RE Our Client(s) LEUNG, April Dept Agriculture Employee GUISE, Vincent Lyon Claim No. 64556? Date of Loss 3/14/08 Our File No. 4827-1 Dear Clerk: Enclosed please find the original and one copy of a claim for damages, along with a copy of the demand letter which was forwarded to your risk management department. Please file the claim and endorse the copy and return it to me in the envelope provided. Thank you. Sincerely, DID A. KRAUS DAK Enclosures . f LAW OFFICES OF DAVID A. KRAUSZ P.C. 2740 VAN NESS AVENUE,SUITE 300 SAN FRANCISCO,CA 94109-1463 TELEPHONE:(415)567-5000 FACSIMILE:(415)202-0394 e-mail:david@lodak.com May 9, 2008 Penny Baily CONTRA COSTA COUNTY Risk Management 2530 Arnold Drive, Suite 140 Martinez, CA 94533 RE Our Client(s) LEUNG, April Dept Agriculture Employee GUISE, Vincent Lyon Claim No. 64556? Date of Loss 3%14/08 Our File No. 481 Dear Ms. Bailey: Accompanying this letter is a claim form which has been filed withthe Board of Supervisors. This letter is intended to resolve this matter without resorting to litigation. Demand for settlement of the above-referenced claim is hereby made as follows: FACTS & LIABILITY Ms. Leung was the operator of a vehicle which was negligently rear-ended by a Contra Costa County vehicle driven by Contra Costa Employee Vincent Lyon Guise at the interchange of Diamond Boulevard and Concord Avenue in Concord, California. MEDICAL SPECIALS As a result of the accident, our client(s) received treatment from the following healthcare provider(s.) Please see the enclosed medical records for further information regarding examination, diagnosis, treatment, billing and prognosis: Healthy Spine Chiropractic 402 W. Harder Road Hayward, CA 94544 (510) 887-4348 Examination and treatment (3/14/08 -4/11/08) $1,506.00 Penny Baily CONTRA COSTA COUNTY May 9, 2008 Page 2 PROPERTY DAMAGE Collision damage deductible $500.00 RECOMMENDED SETTLEMENT AMOUNT: $90,000.00 Please contact me within the next thirty days with your settlement offer(s). Thank you. Sincerely, D ID A. KRAUS Attorney at Law DAK Enclosures I � • � � C LA M BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION. 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. D Inv you is your notice of the action taken V on your claim.by the Board of MAY 15 2008 Supervisors. (Paragraph IV below); f given Pursuant to Government Code 3 , 5� COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: 5i MARTINEZ CALIF. "Warnings". CLAIMANT: C. Cab CPI&I ATTORNEY: jn �. DATE RECEIVED: ADDRESS: �0�tnQ S$4M BY DELIVERYTO CLERK ON: Ala- 'fO� : i Vtit . BY MAIL POS MARKE� q 4010 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached-is.a copy of the above-noted claim. Q' JOHN CUL , clerk. Dated: �� v By: Deput It. FROM.: N unty 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). 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 — 15- yy By: /7* 7 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: ©(Q o JOHN CULLEN, CLERK, By Deputy Clerk WARNING ( ov. code section 913). Subject to certain exceptions,you have only-six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter:ff'you want to consult an attorney,you should do so immediately. *For Additional War nirig See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that [ am now, and at all times herein ►nentioned, 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 tlhe claimant as shown above. Dated; bCo IAl— o 9, _ JOHN CULLEN, CLERK By Deputy Clerk CLAIM BOARD OF SUPERVISOAS OF CONTRA COSTA COUNTY BOARD ACTION. Claim Against the County, or.District Governed by the Board of Supervisors, Routing .Endorsements, ) NOTIGE 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.liy the Board of i Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: �j`j�Z_S O.Z� "Warnings". s3 and 915.4. Please note alt .. „ CLAIMANT: t ATTORNEY: ���L DATE RECEIVED: , ADDRESS: �� So�c��� BY DELIVERY TO CLERK ON: IV(? r� -; OS M� �BY MAIL POS�MARKE�: �� �'�'IG� Z 4011) FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is.a copy of the above-noted claim. 1 I JOHN CUL Clerk. Dated: I 1, 6 J. By: Deput L� �•C��C� 11. FROM: . unty 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): 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: By: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 91 l;3). LV. BOARD ORDER: By unanimous vote of the Supervisors present: - O 'This Clairn 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. jthis date. , Dated JOHN CULLEN, CLERK,,By Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the 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 per jury that i am :now, and at ail times herein mentioned, have been si citizen of the United States, over age 1.8; 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:; JOHN CULLEN, CLERK By Deputy Clerk ®®/03/2014 04:56 FAX IQ001 ®�� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY :.' INSTRUCTIONS TO A. A claim relating to a cavies of action for death or for injury to Amon or to personal property or growing crops shall be presented not later ihm six montbs after tlaa accrual of the r,-awe of action- A claim relA{ agr to any other aeras of action shall be presented aot than,one year after the accrual of the cause of action. enny Bailey (Gov. Code § 911.2.) MAY z 3 2008 B. Cl?!= must be Med with the Clerk of the Board of Supervisors at its office in Room. 106, Couoty Administration Building, 651 Pine Street•,Martinez, CA 945 53. C. If claim is against a district governed by to Board of Supervisors, rather than the County, the nage of the Dist ict should be filled in. D. If the claim is against more thm one public entity, separate claims must be filed against each public e�iity, E. ELapqd. See.penalty for fraudulent olalms,Penal Code Sec.72 at the end of this form, Msaw■aaa■a■Ana MRMMas11MMMINN AMovew■a■■■KMR89IMRREIM EackRARE zIKne:MRweVacciMteRsI RE: Claim By: R esmved for Clerk's filing stamp Y CA 1H�. > RECEIVED Against the County of Contra Costa or MAY 1 5 2008 District) CLERK BOARD OF SUPERVISORS (,Fill in the:name) )' CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contxa Costa or the above-named district is the sum of S S 2 z�;.5(n and in support of this claim represents as follows: 1. When did the darn a oz injury occur? (Give exact date and hour) o10 �9 31 Pr`j 2. Where did the damage or injiay occur? (Include city and county) a. a. How did the darn a or injury occur. (Give frill de lls;use extra pap if regwrec� . 4. Wbat'paxticular act or omission on the partof cotmty or district officers servants, or employees caused the injury or damage? b0 C q CO A. f e-�- Y- 4 5 ghat are the names of county or district officers, a=mts,or unplo (®es eaysing the damage or injury? E 'd ERZ 'ON 1N3W3DVNVN �SA 000 MS: [ 8001 'Z� 'AVN Zvi v4:5'P FAX [a 002 4' 6.' 'Wzat cimnage or injuries do your claim rued? ( dive fuv exuat of injuries or damages claimed, Attach two eS1JMztegS for azrto damages)' q 7. Hover was the amount claimed above computed? (Include the estimated amount of any prospective Wary or damage.) 9. N•ames.and Otessas of witnesses,doctors,and hospitals: --� -S .9. List the expenditures you made on awotmt of this accident or amimy.a DATE MVIE AMOUNT aiaaakagas aaaaaaaaaaatRIMS saa■aaaaaNORM*NORM*■aaaaOarr:aaaataaaaaaaRUN IItaaRa:a:aaaaaanI Gov..Coda Sec.910.2 provides"",the claim shall.be the claim=or by some person on has -3 (Address). b �cel ( ■aaisaaRQr■aR■Knoxaaataaaaa[aagas aaaapes$# i 'T TS NOTICE: ! C.9h the County ander the Tart Claims Act, is snbj act to Z3 ,� Ick (Gov. Code; 05 6500 of seq.) Furthermore, =Y form, including medical r=rds,are also sob,jest to I aaa■0aaaaaaaaaaaaaaaaaaaIaaaUXaaaaaaaaaaa s 4 voce or for paymomt to any state board or officer, or �a to allow or pay the same if genuine, any ha sa or 1 Mable either by imprisonment in&e Coutty jail far a 1 g one thousand dollars ($1000.00), or by both such 30a, by a foie of not oxomIj g t=t4ousamd dollars i I t 4 a . 'd H6 'ON 1N3W3DVNdN }ISIS DOS Wd65 G 80Q� 'Zl '1�dW Aw CLAIM C . l BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: P��i ©�8 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 AV;a LS�� on your claim.by the Board of Supervisors. (Paragraph IV below), MAY 14 2008 given Pursuant to Government Code AMOUNT: MILL) COUNTY Section 913 and 915.4. Please note all INEOZOCALIF. "Warnings". MART CLAIMANT: ATTORNEY: ArtQ(A .btt bt,KJ DATE RECEIVED: ALiy ,— ADDRESS: 8o7 1' 1 op t"ionery -Sfit BY DELIVERY TO CLERK ON: n Q hua&o f CA BY MAIL POSTMARKED: /' 451 Z�U �l�-133 FROM; Clerk of the Board of Supervisors T0: County Counsel Attached isa copy of the above-noted claim. s r L JOHN CUL , Clerk Dated: �`� ��� By: Deput II. FROM.: County Counsel TO: Clerk of the Board of upervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are.so notifying claimant. The Board cannot act for 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). (Other: 71-e W. Ptoblo vSkhaol Z)t5Atc� is ho,- ai�cdt�Z�. Dated: By: �VDeputy 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. BOARD ORDER: By unanimous vote of the Supervisors present: X 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:0(0 ff — JOHN CULLEN, CLERK, By --B�puty Clerk WARNING Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the Le this notice was personally served or deposited in.the n><ail 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 witfi this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warring See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury ;that i am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today .l 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(oh JOHN CULLEN, CLERK By eputy Clerk 'Sly. . -- CLAiM HOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION. (_Ln C'� , )c Claim Against the County, or.District Governed by:) the Board of Supervisors, Routing Endorsements; ) NOTICE TO CLAIMANT and Board Action. All Sect ion.references are to ) The copy of,this document mailed to California Government Codes. ) you is your notice of the action taken on your claim.by the Board of Supervisors.`(Paragraph IV below), given Pursuant to Government Code �I- �C�; Section 913 and 915.4. Please note all AMOUNT: "Warnings". CLAIMANT: C.,CCGS Qar ATTORNEY: r-ho A Utdo DATE RECEIVED: ,��� IL 2 ADDRESS: E.107 1` 1 OIjtgoin-erU SL,{ BY DELIVERY TO CLERK ON: .1 �`iZ�'1 Gc�SC�' CA BY MAIL POSTMARKED: /�'�t' l 2010 � lt13 FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is.a copy of the above-noted claim. JOHN CULLE CleKk. Dated: 11A,cuf— By: Deput ) L� II. FROM.: bounty ounsel T0: Clerk of the Board of upervisors ( ) 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: By: Deputy County Counsel 1.11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 9'11.3). W. BOARD ORDER: By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the 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 innnediately. *For Additional Warning See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING I declare under penalty of per jury that [ am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today .1 deposited in the United States Postal Service ,in f4artinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk ,r- 04/04/2008 13:48 CONTRA COSTA COUNTY CLERK OF THE 4 914152968841 NO.238 D01 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAWANT 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 i public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this fonn.' 80a00bBa®©o Wsa aa®Doti®aotio pdda 80090do9 aaaa 9nda0 aoW©®on a®d Wa9®aP®ad®Flo Doevno®no 01 RE: Claim By: Reserved for Clerk's filing stamp RECEIVED iAgainst the County of Contra Costa or ) MAY 1 4 2008 (�7 DI 0 6/0 0,1714 of SCG/od/ � District) CLERK BOARD OF SUPERVISORS CFM in the name) ) CONTRA COSTA CO. The undersigned claimant hereby ruakes claim against the County of Contra Costa or the above-named I district in the stun of %d 0 vy61r) and in support of this claim,represents as follows: I. When did the damage or injury occur? (Give exact date and hour) f0 bt) v OO 2, Where did the damage or injury occur? .(Include city and county) idXi ,/,goo COnCOrC COO#O CQs7 3. How did the damage or injury occur? (Give full details; use extra paper if required) ClaIMaliif &10-4 a ach�eal6y 1516 4. What particular act or omission on the part of county or district officers, servants, or employees caused the in'ury or damage? Groo/ o a�/0via ee a/f'2rZ L1 b1S' a 0 W 041'ol 10&4.1;0 os 5 What are the names of county or district offsets, servants, or employees causing the damage or injury? sur Pe c,yQN2 �rr�r C,Pa � Cha r Swa hSot�, ��,Azo ow•v aro/ cSv�QYv/cS'd,2S'_ � � F 04/04/2008 13:48 CONTRA COSTA COUNTY CLERK OF THE 4 914152968841 NO.238 P02 C- . 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) cov?cussioy� rhev bo" ~W�J htul.,C" 717i-ocfvre 2 000& er , (ac¢✓afr'oh b-21011 righf ✓eYc.iv.,na epi Lteo 7.. How was the amount claimed above computed? (Include the estirna-ted—amount of any , injury or data e P �° _e d,2�/ , prospective j Y g ) S Pciovl ata/rtirc� �X�P O '55 ---c cahfivcv2 �ccRue . !/!✓NQ l d�A,;,►og'e5 k, 8. Names and addresses of witnesses, doctors,and hospitals: � e 0//0 06.era! 9. List the expeaditur6s you made on account of this accident or injury: DATE TIME AM.Qi.1NT' �. -9-17- (75' o/dor� /%Q7q. �7!5 J06A/ Alvis 3-10 —)e 01k-140Wk7 y� 810 RO won ago neDu DO O a 0 CPU aabbD as 00agog soup Po m a D0 vacua D@ 00Pmm a 000 DDa GURU 000400 woo baaa 01 i Gov_Code Sec. 91 .2 provides"The claim shall be signed by the c t or by me rso his }behalf." SEND NOTI S TO: (Attorney 1 Name and address of Attorney ) O/Q/ l_Q t) ) (Claimanfignature) F0 7 c-,,Woo o aw,�� S- j (Address) Jcl ti �ao W, co 04 ) Telephone No. 416 -:362 CIO Z._)Telephone No. i Da00000OBDDD@bdROD0Oone DoDevoe 0000DPbb0tl0DOtl0OOODRRObmB0a000OOOODDOPWDbatabbDCoo one 0@1 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, §S 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including rnedical records, are also subject to public disclosure. 0 0 0 D 0 0 D 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 P moon 0 tl 0 B 0 0 0 B a D R D 0 0 0 0 p 0 DODO 0 0 0 0 0 0 D 0 O o P O a b 0 a 0 a u 0 u 0 Doug up—Pa-4 NOTICE-. Section 72 of the Panel Cote provides: Every person who, with intent to defraud,presents for allowance or for payment to any state hoard 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 tine of not exceeding one thousand dollars ($1,000.00), or by both sueh 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. - i Supplement to Lucas Lazar's Claim Form - Date of Injury 2/19/08 Witnesses: Megan King Seven Rachel Ranch Clayton, CA 94517 925-673-3633 Demetri Penuelas 5213 Pine Hollow Road Concord, CA 94521 925-673-5068 Sonoma Jay 1451 Bahan Drive#203 Concord, CA 94521 925- 915-1863 Kimberly Loyola 5606 Bettencourt Drive Clayton, CA 94517 925-672-1147 ---------------------------------=-------------------------------------- Doctors: . Michael Cohen, M.D. 1800 Sullivan Avenue Suite#602 Daly City, CA 94015 650-755-2455 .Jeff Idelson, Ph.D 1966 Tice Creek Blvd, Suite#248 Walnut Creek, CA 94595 925-938-7057 -------------------------------------------------------------------------- Hospitals: John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek, CA 9459 925-939-3000 CLAIM c 1, BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY yy BOARD ACTION:�.J Me. 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: D �}-j you is your notice of the action taken v on your claim by the Board of MAY ¢ ZOOS Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: MARTINEZ CALIF. "Warnings". . J CLAIMANT: Ar\3 V4`t' -CO ATTORNEY: I�U �21'7�CI.i"Cv DATE RECEIVED: i ADDRESS: �" ` ` G BY DELIVERY TO CLERK ON: r 3 333 C,oWk kvo-d `;8 BY MAIL POSTMARKED: C06a[J1 CA J FROM: Clerk of the Board of Supervisors T0: County Counsel Attached isa copy of the above-noted claim. JOHN CULE , Clerk Dated: /4 2000 By: Deputy, Ut( IX,� II. FROM.:Ctouniy 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). 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: 5- 0 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). I.V. 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: to-Z— JOHN CULLEN, CLERK, By Deputy Clerk WARNING Gov. code section 913). Subject to certain exceptiars,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a courtaction this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection widr this matter. Ifyou want to consult an attor-irey,you should do so immediately. *For Add itio+ial 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, overage 1.8; and that today .l 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 clafman:t shown above. 1 Dated: o8 JOHN CULLEN, CLERK By uty Clerk 6 5 1(4/'20 C1 3 14: 55 9 25 9 335 6 20 OFF CHAFETZ PAGE 02/03 G VERINWINY,�CLtAjM RECEIVED TO: Contra Costa County MAY 1 4 2008 Clerk of the Board of Supervisors I CLERK BOARD OF SUPERVISORS 651 Pine Street, Room 106 CONTRA COSTA CO. Martinez, CA 94553 Attention: Clerk of the Board of Supervisors The following clain, is Submitted pursuant to Govenirrient Code section.910. I Claimant's name and address: Angela Federigi c/o K,--ith J. Ferrara Law Offices, Inc. 3333 Cowell Road Co neord, CA 94518 (925) 363-4516 2: Send-Notices-to: Keith J. Ferrara Law Offices, Inc. 3333 Cowell Road Concord, CA 94518 (925) 363-453.6 3. a. Date: November 15, 2007 b. Place: I Jnincorporated Bay in Contra Costa, on Cummings Skyway eastbowid, .4 miles East of Crockett Blvd C. Circumstances: Angela FedeTigiwas driving her vehicle behind a County employee named Lucky Merlin Chestnut who was driving his county vehicle while on-duty. Mr. Chestnut W.Med on his rcar amber lights and pulled off the road onto the fight shoulder behind a big-rig truck that had also pulled onto the �ibouldcr- 11cdid not turn on lids emergency lights or his siren. Ms.Federigi continued driving for-ward as these vehicles slowed down,but seddertly, and wittiout warning or signaling his intent., Mr. Chestnut turned his vehicle back onto the road and attempted to make a U- tuna,acrross the. road. When he did so, be cut in front of Ms. Federigi leaving her no room to maneuver her vehicle, and causing her to collide with his vehicle, causing darnages to Podn vehicles and to her person. ORIGIN AlL �JSr`14/:'0136 14: 55 9"2553356''0 L"":4J OFF ..r=''` CH.":FET% PAGE 03/03 Police Report 11-207 was written concerning this event. Claimant claims that this report is inaccurate and contests its conclusion. Claimant intends to assert all possible causes of action and thenries.arising out of the above circumstances, including but not limited to negligent constnLction and maintenance of the sheriffs vehicle and emergency light system. negligence on the part of Mr. Chestnut, negligent hiring of Mr. Chestnut, negligent training of Mr. Chestnut, and negligence on.the part of employees hired by the public entity responsible for Mr. Chestnut- negligence in the firing of those employees, and delegation or attempted delegation of responsibilities; negligent hiring, training and supervision; violation of Government Code sections 815.2, 815.4, 315.6, 820, 835, and 840.2. 4. General_Description of indebtedne.,51.yf�li ata,un,ui�ur.y. dim_ awe or loss: Damagcs for per3onal injuries to Ms. Fede.igi, including medical expenses., wage losses, and pain and suffering. Also property damage to her vehicle_ _`i, Names otfgoverru�tt emUloxee sl. causing the toss: At least Mr. Lucky Merlin Chestnut. There may be others. 6. Amount _Claimed: The amount claimed would fall within the jurisdictivn or the superior court unlimited jurisdiction.. Dated: May 13. 2008 eith J. Fehr Attorney for Claimant 9259335620 05/14/:2008 .14: 55 9259335620 LAW OFF J Y CHAFETZ PAGE 01/03 FAX TRANSMISSION Date: May 14, 2008 Total Pages: 3 From: Keith J. Ferrara To: Clerk of the Board Fax Number: (925) 335-1913 Re: Claiin of Angela Federigi, Comments: Cathy: Thank you for speaking with me. Pei, your instructions, I am faxing my client's claim to the clexk and placing the original in the mail. Please ale the claim as of today b/c my client's six month time limit is up. Should you not receive the original in the mail within.two days, please do not hesitate to call. --• Y.•CJ.'P yZ 54e�f��'.Q���`r'1i�.�. G•-•�-k:K- J.�..srp,G�L}�-F✓^"'�_ PLEASE TELEPHONE US AT 925-933-5890 Tr- YOU HAVE MOBLE:MS RECEIVING PHIS TRAivSMTSSTON OR TF AN-Y'PAAOr-5 ARE NUSSING. The document being faxed is intended only .)r use by the individual to which it is addressed, and Pittv contain information that is privileged, coy fdcntial and exempt from disclosure under applicable lain. if the; reader of this nwsage isnot the intended recipient, or the employee or-agent the message tc:dns 5 initeaded recipient, you are hereby noti ied that any dissemination, distribttuon or copying of the communication is strictIr prohibited If you have received this coininunicati GOVERNMENT CLAIM TO: Contra Costa County Clerk of the Board of Supervisors 651 Pine Street, Room 106 Martinez, CA 94553 Attention: Clerk of the Board of Supervisors The following claim is submitted pursuant to Government Code section 910. 1. Claimant's name and address: Angela Federigi c/o Keith J. Ferrara Law Offices, Inc. 3333 Cowell Road Concord, CA 94518 (925) 363-4516 2. Send Notices to: Keith J. Ferrara Law Offices, Inc. 3333 Cowell Road Concord, CA 94518 (925) 363-4516 3. The Occurrence: a. Date: November 15, 2007 b. Place: Unincorporated Bay in Contra Costa, on Cummings Skyway eastbound, .4 miles East of Crockett Blvd C. Circumstances: Angela Federigi was driving her vehicle behind a County employee named Lucky Merlin Chestnut who was driving his county vehicle while on-duty. Mr. Chestnut turned on his rear amber lights and pulled off the road onto the right shoulder behind a big-rig truck that had also pulled onto the shoulder. He did not turn on his emergency lights or his siren. Ms. Federigi continued driving forward as these vehicles slowed down, but suddenly, and without warning or signaling his intent, Mr. Chestnut turned his vehicle back onto the road and attempted to make a U- turn across the road. When he did so, he cut in front of Ms. Federigi leaving her no room to maneuver her vehicle, and causing her to collide with his vehicle, causing damages to both vehicles and to her person. 1 L) ORIGINAL Police Report 11-207 was written concerning this event. Claimant claims that this report is inaccurate and contests its conclusion. Claimant intends to assert all possible causes of action and theories arising out of the above circumstances, including but not limited to negligent construction and maintenance of the sheriff's vehicle and emergency light system, negligence on the part of Mr. Chestnut, negligent hiring of Mr. Chestnut, negligent training of Mr. Chestnut, and negligence on the part of employees hired by the public entity responsible for Mr. Chestnut; negligence in the hiring of those employees, and delegation or attempted delegation of responsibilities; negligent hiring, training and supervision; violation of Government Code sections 815.2, 815.4, 815.6, 820, 835, and 840.2. 4. General Description of indebtedness, obligation, injury, damage or loss: Damages for personal injuries to Ms. Federigi, including medical expenses, wage losses, and pain and suffering. Also property damage to her vehicle. 5. Names of government employee(s) causing the loss: At least Mr. Lucky Merlin Chestnut. There may be others. 6. Amount Claimed: The amount claimed would fall within the jurisdiction of the superior court unlimited jurisdiction. Dated: May 13, 2008 eith J. F a Attorney for Claimant 2 FAX TRANSMISSION Date: May 14, 2008 Total Pages: 3 From: Keith J. Ferrara To: Clerk of the Board Fax Number: (925) 335-1913 Re: Claim of Angela Federigi Comments: Cathy: Thank you for speaking with me. Per your instructions, I am faxing my client's claim to the clerk and placing the original in the mail. Please file the claim as of today b/c my client's six month time limit is up. Should you not receive the original in the mail within two days, please do not hesitate to call. P PLEASE TELEPHONE US AT 925-933-5890 IF YOU HAVE PROBLEMS RECEIVING THIS TRANSMISSION OR IF ANY PAGES ARE MISSING. WARNING The document being faxed is intended only for use by the individual to which it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of the communication is strictly prohibited. If you have received this communication in error,please contact us immediately by telephone and return the original message to us at the address above via the United States Postal Service. CLAIM y BOARD Of SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:_ SL+ � . � Claim Against the County, or District Governed by ) the Board of Supervisors, Routing :Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken. :. _on your claim.by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: rT7�' Section 913 and 915.4. Please note all "Warnings". CLAIMANT: E patio.. Obopozr ATTORNEY: " DATE RECEIVED: . A(au 2-001 J . ADDRESSION COr)df RL• BY DELIVERY TO CLERK ON: ,Z BY MAIL POSTMARKED: ���•� 2 of FROM: Clerk of the Board of Supervisors TO; County Counsel Attached is a copy of the above-noted claim. Maw JOHN CULLEN, Clerk Dated: I"l By: Deputy II. FROM.: Co my 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). 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: By: Deputy County Counsel' III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator•(2) O Claim was returned as untirrely with notice to claimant(Section 911.3). 1V. . BOARD ORDER: By unanimous vote of the Supervisors present: . This Claim is rejected in full. O Other: I certify that thisis a true and correct copy of the Board's Order entered in its minutes for. this date. Dated: JOHN[CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 91;3). Subject to certain exceptions,you have only six(6) months from the to this notice was personally served or.deposited in the mail to file a court action on this claim.See Government Code Section 945.f�You may seek the advice of an attorney ol'your choice in connection widr this matter. If you want to consult on attorney,you should do so immediately..'Tor Additional Warring See Reverse Side ofThis Nptice. AFFIDAVIT OF"MAILING I declare under penalty of per jury that i. am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today .l deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified 'cohy of this Board Order and Notice to Cla mmit, addressed to the claimant as shown above. Dated: 0(o 3- Q JQHN CULLEN, CLERK By ' eputy Clerk CLAiM . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: .Claim Against the County;or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim.by the Board of Supervisors. (Paragraph IV below); given Pursuant to Government Code AMOUNT:�'77F `IO Section 913 .and 915.4. Please note all "Warnings". CLAIMANT: E CWpQr ATTORNEY: — DATE RECEIVED: �(�x 200y ADDRESSg18 00r?& RL• BY DELIVERY TO CLERK ON: ,Z BY MAIL POSTMARKED:. n 200 FROM: Clerk of the Board of Supervisors TO County Counsel Attached isa copy of the above-noted claim. n / JOHN CULLEN, Clerk Irl Dated: By: Deputy LI. FROM.: Co my 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). O Claim is not timely filed. The Cl':erk should retui�i 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: 0 Dated: By: Deputy County Counsel'. III. FROM: Clerk of the Board. T0: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant(Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present: O 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING(Gov. code section 913). Subject to certain exceptions,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court,action on this claim.See Government Code Section 945.6.You niay seek the advice of an attorney of yor choice in connection.wide this matter. if you want to consult nn 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 .l. 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 Maetinez,.California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By Deputy Clerk Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for'injuryto person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented no 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. 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 filling stamp Against the County of Contra Costa ECEIE® or ) MAY 0 6 2008 District ) (Fill In name) ) CLERK BOARD Y SUPERVISORS CONTRA COSTA CO. ) 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: 2ooF 9 '30 1. When did&e damage or injury"occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full det ils; use extra aper if required) 4j 4. What particular act or omission on the part of county or district officers, servant4 or OO,.�g employees caused the injury or damage? '� ;L (,, 01 9 v 2 O-t,ja-y act *� & &- l -1�e-ll Qr � aQV( WCL 5 t��` (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries oramages claimed.) Attach two estimates for auto damage. c� 1 roo ?18T I 7. How was-the afnount claimed above computed? (Inclu e the estimated amount of any prospective injury or damage. ) lo-Vt.\ o� k �Tl� . �© 8. Names and addresses of witnesses, doctors and hospitals. S\a,oa CADo 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO : (Attorney) or by some person on his behalf." Name and address of Attorney (Claimant's Signature) (Address) Telephone No. Telephone No. NOVICE 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 on 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 ($10,000, or by both such imprisonment and fine. ) CLAIM BOARD Of SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:_ ul `-=-I'0-,: Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken on your claim_Uy the Board of Supervisors. (Paragraph IV below), MAY 08 2008 given.Pursuant to Government Code AMOUNT:$���'`'� COUNTY COUNSEL Section 913.and 915.4. Please note all MARTINEZ CALIF. "Warnings". . CLAIMANT: E fano- C[wper ATTORNEY: — DATE RECEIVED: � 2_00f ADDRESS 78 C r)(Yf'� AL• BY DELIVERY'TO CLERK ON: BY MAIL POSTMARKED: Dn C �2 of FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Clerk. Dated: By: Deputy Il. FROM: Co my Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. (vYThis 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: 5_ 1z _0V 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: ( ) 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: JOHN CULLEN, CLERK, By Deputy Clerk WARNING(Gov. code section 913) Subject to certain exceptions,you have only six(6) months fi•om 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 connectiaa wide this matter. If you want to consult an attorney,you should do so immediately. *For Additioial Warning See Reverse Side of This 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 in Martinez,.California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: JOHN CULLEN, CLERK By . Deputy Clerk r OFFICE OF THE COUNTY COUNSEL SILVANO B. MARCHESI COUNTY OF CONTRA COSTA ��j% � COUNTY COUNSEL Administration Building_— 651 Pine Street, 91h Floor •` ��,. '�� . _ - SHARON L. ANDERSON Martinez, California 94553-1229f i CHIEF ASSISTANT (925) 335-1800 t°�; e u,R t1 y; _� -`�� GREGORY C. HARVEY (925) 646-1078 (fax) ;�, '• SOL VALERIE J. RANCHE ASSISTANTS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM May 13, 2008 TO: Elana Cooper RE: CLAIM OF: Elana Cooper 978 Condit Road Lafayette, CA 94549-4100 Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the.reasons checked below: [ X] 1. The claim fails to state the name and post office address of the claimant. [ X ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [X ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000): If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. r a [ X ] 6. The claim is not signed by the claimant or by some person on his or her behalf [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SILVANO B. MARCHER COUNTY COUNSEL By: � Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a,2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor,Martinez, CA 94553-1229. On May 13, 2008, I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to Elana Cooper, 978 Condit Road, Lafayette, CA 94549-4100, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on May 13, 2008, at Martinez, California. Enclosure cc: Clerk of the Board of Supervisors (original) Risk Management Page 2