HomeMy WebLinkAboutCC 4 CLAIM #91-20 08-05-91CONSENT CALENDAR NO. 4
E N DA 8-5-91
Inter -COm
DATE: JULY 17, 1991
TO: HONORABLE MAYOR AND CITY COUNCIL
FROM: CITY ATTORNEY
SUBJECT., CLAIMANT: JANET ROWLANDS; D/L: 03-05-91; DATE FILED W/CITY:
05-01-91; CLAIM NO: 91-20; CARL WARREN FILE NO: S 64375 PRL
After investigation and review it is recommended that the
above -referenced claim be r9jected and the City Clerk directed to
give proper notice of the rejection to the claimant and to the
claimant's attorney.
Ver our ,
J S . ROURKE
City Attorney
JGR:j:ib:071791(CL-9120.jab)
Enclosure: Copy of Claim
- 1 City of Tustin
_ 4 AGAINST THE CITY OF TUS . _.J
(For Damages to Persons or Personal Property)
.e law provides generally that a claim must be filed with the City Clerk of
the City of Tustin within 6 months 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 FORM, PLEASE TYPE OR USE BLACK INR
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:
OR
NAME OF CLAIMANT: P 't" KoNJ10.`c�1�
ADDRESS OF CLAIMANT:
CITY/ZIP CODE:
TELEPHONE NO:
SOCIAL SECURITY NO:
DRIVERS LICENSE NO:
Name, telephone and po9t office address to which claimant desires notices
to be sent (if other than above):
3. This claim is submitted against:
a._ The City of Tustin only.
b. The following employee(s) of the City of Tustin only:
C. The City of Tustin and the following employee(s) of the City
of Tustin only:
4.
Occurrence or event from which the claim arises:
a. DATE:
b. TIME:
C. PLACE (Exact and specific location):
Vi"k_ `Cd kVo_o%
d. HOW and under what circumstances did damage or injury occur? Specify
the particular occurrence, event, act or omission you claim caused
I - .fit---��_�._ ^-_i . -a .
)il.
e. WHAT particular _ction by the City, or its employees, caused the
alleged damage or injury? , I
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. '
. 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
CORRECT.
Executed this �_ day of :22�Q.4 (?/L , 19 9/ , at Tustin, California.
DATE FILED: /i(.ni4C��c /nom, 179�
INANT'S SIGNATURE
Bl:CLFORM
Revised 10/23/90
5. Give a description of the injury, property damage or loss so far known
at the time of this claim. If there were no injuries, state "no
injuries". ,
1ell
6. Give the name(s)
of
the City
employee(s). causing the damage or injury:
7. Name and address
of
any other
person injured: f\ny\!Z,
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. '
. 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
CORRECT.
Executed this �_ day of :22�Q.4 (?/L , 19 9/ , at Tustin, California.
DATE FILED: /i(.ni4C��c /nom, 179�
INANT'S SIGNATURE
Bl:CLFORM
Revised 10/23/90
INVOICE
S
., 22522
W
ENFRTIRE-AND-WHEEL INC.
PERFORMANCE TIRES AND WHEELS
1554 W. COMMONWEALTH AVENUE
FULLERTON, CALIFORNIA 92633
714) 526-1252 a B.A.R. #AM 150905
Name �� n f ^ n
Date _
Acct. No.
/
P
o
N
E
BuS.pU6LF2r
Year-Make•Modei C 1
�J
License No.
Odometer
Res.
ESTIMATE AMOUNTS
1 hereby authorize the below repair work to be done along with the necessary material, and
heretry grant you and/or your smplo permission to operate the car, truck or vehicle herein
desatbed on streets, highways Or atsewhere for the purpose of testing and/or inspection. An
express mechanic's lien i. hereby acknowledged s nsiblbove ur, truck r vehicle to secure the
amount of repairs thereto. You will not be held responsible for loss or damage to vehicle or
articles left in vehicle in case of lire, theft. accident or any other cause beyond your control.
Authorized By
Revised Estimate TIME
$
BY
S
CHARGE
WRITTEN BY
QUAN
clOESIPT10N =i ' 4 tom'` a +UNIT
CR t;� t ,.
� ,� « r �,.y%, , .� rs x k� n+�'k.�C 1 •.f {i - «ti" .. S "r;: _ <'
PRICE _
_ `EXTENSION '
.;
F4G, r YZ F
116
TOTAL
WHEEL BALANCE
❑ TIRE REPAIR
WPISMOUNT & MOUNT
❑ RECOMMENDED AIR PRESSURE FRONT LBS. REAR LBS.
: TOTAL-"
QUAN
;;; " , " ' MECHANICAL PARTS
UNIT PRICE
EXTENSION
MECHANICAL LABOR
PRICE C=?
❑ ALIGNMENT
TOTAL
TIRES
TIRE LABOR
/0.570
MECH. PARTS
MECH.LABOR
OUTSIDE LABOR
TOTAL r
MISC.
V (/Q
..0 TSIDE LABOR:
TAX
r
X
Purchases made durinc env ona month app r1nA by thn
RECEIVED BY