HomeMy WebLinkAbout06 CLAIM #94-22 08-01-94AGENDA____
NO. 6
8-1-94
I nte r-Corn
DATE:
July 12, 1994
TO:
FROM:
SUBJECT:
HONORABLE MAYOR AND CITY COUNCIL
CITY ATTOP~TEY
CLAIMANT: RAQUEL BARIL; CLAIM NO: 94-22;
FILED W/CITY: 5/5/94; CARL WARREN FILE NO:
D/L: 4/9/94; DATE
S 78284 PRL
After investigation and review it is recommended that the
above-referenced claim be rejected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney. This incident occurred on the I-5 freeway.
The City's adjuster has informed the claimant about contacting
Caltrans.
City Attorney
Enclosures: Copy of Claim
cc:
Carl Warren & Co.
Finance Director
City Manager
City of Tustin
CLAIM AGAINST T~tE CITY OF TUSTIN
(For Damages to Persons or Personal Property)
The law provides generally that a claim must be .filed with the City Clerk
the City of'Tustin ~onth~ after the incident or event occurred. Be
sure your claim is against the city of Tustin, not another public entity.
Where space is insufficient, please use additional paper and identify
information by paragraph number. Completed claims must be mailed or
delivered to the City Clerk, City-of Tustin, 300 Centennial Way, Tustin,
California 92680
WHEN COMPLETING THIS FOR/~, PLEASE TYPE OR USE BI~%CK INK
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California:
The undersigned respectfully submits the following claim and information
relative to damage to person and/or property:
b. ADDRESS OF CLAIMANT:_~_¥~t~?j (_~_~ ~' - ~
c. CITY/ZIP CODE: ~
d. TELEPHONE NO: ¢ - ~
f. SOCIAL SECURITY NO: ~ ~
g. DRIVERS LICENSE NO: ~
Name, telephone and post office address to which claimant desires notic
to be sent (if other than above):
3. This claim is submitted against:
a. X The City of Tustin only.
b. The following employee(s)
of the City of Tustin only:
The City of m" ~
.-stun and ~o-..- fo!!~wing e-~vo~=)...=_..__,_ of the C~ty_
of Tustin only:
4. Occurrence or event
b.
c.
from which the claim arises:
TIME: r ,
PLACE (Exact and specific location): ~CLOe~f~f~ ~-~ ~ ~
and under what circumstances ~id damage 0r inj~ occur? -Specify
the particular occurrence, event, act or omission you claim caus~=
the.injury or damage (Use additional paper if necessary):
WHAT particul, aion by the City, o..~ta mployees,
alleged damage or inju~-y?
caused the
5. Give a description of the injury, property damage or loss so far known at
the time of this claim. If there were no,~inj~ries, state "no injurie,s~
6. Give the name(s) of the City emplpyee(s)_ca~sing, the damag~ or inju~:
7. Name and address of any other person znjured:/~
8. Name and address of the owner or any damaged property:
9. Damages claimed:
a. Amount claimed as of the date:
b. Estimated amount of future costs:
c. Total amount claimed:
d. Attach basis for computation of'amounts claimed (include copies of
all bills, invoices, estimates, etc.
10. Names and addresses of all witnesses, hospitals, doctors, etc.
WARNING:
IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!!
(Penal Code Section 72; Insurance Code Section 556.0)
I have read the matters and statements made in the above claim and I know the
same to be true of my own knowledge, except as to those matters stated to be
upon information or belief and as to such matters I believe the same to be
true. I certify under penalty or perjury that the foregoing is TRUE AND
CORP~CT.
,19~q , at Tustin, California.
BI:CLFORM
Revised 4/29/91
30 AUTO CENTER DRIVE
TUSTIN, CALIF. 92680
{714) 669-8282.
s ACCO~ NO. !0 s
o H
L ~H-~T~L
D p
O o
ALL CLAIMS AND RETURNED GOODS MUST BE1
ACCOMPANIED BY THIS INVOICE.
NO RETURNS AFTER 10 DAYS.
NO RETURNS ON ELECTRICAL PARTS.
NO RETURNS ON SPECIAL ORDER PARTS,
20% RESTOCKING CHARGE.
INVOIC[
PAGE 1 OF 1
VIA ~'L~M, BIL NO. F.O.B.
IJ.D,-M~SI I'~.~H' I TUSTIN. ~A
'Y, I BIN IPART NUMBER DESCRIPTION ~ L~ST ~ NET AMOUNT
~ S/O 72712-D9001 G~S-WINE 305.89 305.89 305.8~
~ ~OR INST~L 50.00 50.00 50.0C
******* I N V 0 I C E Q U 0 T E *******
ST~ NISS~ & B~ ~ORTS ~E NOW I
ST!N NISS~-S~-~FA-~E~TI :~*~TSj ~55. ~9
5~I~ ~ O~ER P~TS ~OUGH YO~ SUBLET ~
~ CO~A~S ~ PHONE ~E~S FREIGHT 0. 0Q
~P~C~TE YO~ BUS--SS ~RY ~CH SALES TAX 23. 73
TOTAL ~ S379.60
CUSTOMER COPY
MAY-O~-Ig.~d l~:Sd FROM
c UTO GL ~ CEHTERS
** QUOTE **
TO 6695ZS0 P.O1
05/83/94
Tnt
NISSA ALTIMA I 4D
FW007~7 GYN f 957. ~0 287.
KIT255FC /~. 15.08 5.
$*NOT AN INVOICE DO NOT ~y, GOOD FOR ~ DAYS**
REPAIR COMPLETED?
0 YES ~ NO
CA 1B. ~6 TAX
ORANGE l,. 38
PAYMENT
RECEIVED
Z34.8
STATEMENT OF FINAL AND SATISFACTORY COMPLETION AND AUTHORIZATION TO PI
**NOT AN INVOICE DO NOT PAY, GOOD FOR 3~ DP, YS**
Auto ~lass CentErs
SANTA ANA CA 9~701
(71~) 531-8550
MOBILE SERvIcE LOCATION