HomeMy WebLinkAbout#584 - R. Landis � _z
�-� CI � Y Of PF� �1 DESERj
73-5�0 FRED WARING DRIVE
�'sr�-:�^� ,- � PALM DFSERT, CAttFoxrru qaz6o-2578
:
T�.: �60 346-06»
F�x: 76o 340-0574
iafo@p�lm-deserc.org
TO: CJPIA (c/o CARL WARREN & CO.), CITY MANAGER, CITY ATfORNEY,
ACM FOR DEVELOPMENT SERVICES, DlRECTOR OF PUBLIC WORKS,
RISK MANAGER
FROM: CITY CLERK
DATE: MAY 15, 2007
SUBJECT: CLAIM NO. 584 -CLAIM AGAINST THE CITY BY RICHARD LANDIS IN AN
UNSPECIFIED AMOUNT
The attached Claim No. 584 is being transmitted to you for the following:
❑ Information only.
or
Review and recommendation to the Claims Review Committee for any action
required by the City of Paim Desert.
We would appreciate your report, if requested, by June 15, 2007, for timely response to
the Claimant.
Note: Attached to this report is a copy of City Contract No. C24100 -"Construction of the
Fred Waring Drive Widening Soundwall(Project No.654-01)"with Sukut Construction, fnc.,
Santa Ana, Califomia, which may be related to the incident giving rise to the subject claim.
�o"�
. s�Y �°
. �� .
RACHELLE D. KlASSEN, CMC `�
CITY CLERK
Attachments (as noted)
c��.�,� .
u �
R�CElV�D
CIT Y CL£R�('g pF�fCE
PAtM DESFRT, CA
__. zoa�►�dr 23 QM ro: 2s
May 17, 2007
TO: The City of Pa1m Desert
ATTENTION: Rachelle D.Klassen, City Clerk
--- - - -• ---- R R• r�t��.,, �---._._,- ----Isa�dis vs:The Ei���.nes� -- - _�._ . ,_.. ...
Claimant . Richard Landis
D/Event : 1/5/2007
Rec'd Y/Office : 5/15/2007
� Our File . 5-1452239-PMQ
We have received and reviewed the above claim and request that you take the action indicated below:
CLAIM REJECTION: Send a standard rejection letter to the claimant
Please provide us with a copy of the notice sent, as requested above. If you have any questions please
contact the undersigned.
Very truly yours,
C _ W N& COMP
_._.. . . � � -
Richard D. arque
cc: CJPIA w/enc.
Attn.: Execurive Director
CARLW N & CO.
CLAIMS MANAGEMENT CLAIMS ADJUSTERS COPa(TO r w �n
770 Placenti�Avenue,Placearia,CA y2870-6832 �
Ma�L•P.O.Box 25180 •Santa Ana,Ca 92799-5180
Phone:(71�572-5?AO •(800)572-6900•Fax:(714)9G1-8131 �ATE— �` �3—n7
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Page 1 of 1
� � '
Klassen, Rachelle
From: Greenwood, Mark
Sent: Monday, June 04, 2007 12:47 PM
To: Klassen, Rachelle
Subject: Claim No. 584
Rachelle,
If is recommended that Ciaim No. 584 be rejected and referred fo Sukut Construction, Inc., as they were responsible for
the construction zone where the incident occuned.
Mark Greenwood, P.E.
Director of Public Works
City of Palm Desert
6/4/2007
'u �
R�CE3d£D
�lPALM DESER�FCA�
May 22,200� . Zfl41 ,lUN —6 dM I!� 53
GOVERNMENTAL ENTITY PRELIMINARY REPURT
TO: Carl Warren&Company
PO Box 25180
Santa Ana, CA 92799-51$0
Principal: CJPIA Our File: S 1452239PMQ
City: Palm Desert Date of Loss: 1-5-2007
Claimant: Richard Landis Date Received: 5-17-2007
�. _,_ -- Facts• ---- .__ . _.— -- ._ _ .�. _
The City contracted with Sukut Construction for Fred Waming Drive VVidening Soundwall.
A contractor was backing up in a Caterpillar Loader,the front of the loader veered into the
travel lane,with its load extended out into the travel lane. Claimant collided with Loader or
its load.
Government Code Reauirements:
a) Date Verifled C[aim Filed: 5-15-2007
b; Action by Publlc Entity: City to reject.
c) Statute of Ltmitations: 1-5-2009 until rejected.
Possible Co-Defendants:
Sukut Construction, and/or their subcontractor.
Liabili :
By contract, Sukut Construction has to defend and indemnify the City.
DamaEes:
Landis received a broken shoulder,mild concussion, and cuts and bruises.
Claim• Reserve:
- _- 1)LBI-Richard Landis Open .
Comment/Work to be Comuleted:
The City has pravided the contract with Sukut and the police report. We will communicate
with American Contractors Ins. Group,who insured Skit. We will determine a status of their
investigation, adjustment and whether a sub-contractor was involved. We will tender the
claim as warranted.
CARL WARREN& CO.
Pete McNulty
cc: City of Palm Desert Attn. Rachelle Klassen
cc: CJPIA- Attn.: Executive Director
CARL WAA;REN & CO.
An EmpCoyee-Owne�f Campany C 0 PY�0 • P
CLAIMS MANAGEMENT • CLAIMS ADJUSTERS _ 4. .T, �SGr1 /u w�
770 Placentia Avenue,Placentia,CA 92870-6832
Mail: P.O. Box 25180,Santa Ana,CA 92799-5180 DATE � �+ — � 7
ah�►,A� r�,a����_5�nn.�anrn���-Fsann.Far f71d1UFi1-R1A1
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P A L M D E S L t'��T`fCO� PALM QESER7
VIA CERTIFIED MAIL #7006 081 0 0001 1 336 1 SO���j ��Y �SI��t���M NO.�F�T•,
CLAINI AGAINS? "THE CITY OF PALM DESERT I
(For Damage(s) to Person(s) or Personal Property)
Received by:
via: U.S. Mail Interoffice Mail Over-the-Counter
A CLAIM MUST BE FILED WITH THE CITY CLERK OF THE CITY OF PALM DESERT WITHIN SIX
MONTHS AFTER WHICH 7'HE INCIDENT OR EYENT OCCURRED. BE SURE YOUR CLAIM IS
AGAINST THE CITY OF PALM DESERT, 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 PALM DESERT, 73-510 FRED WARllVG DRIVE, PALM DESERT, CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The undersigned respectfully submit(s) the fotlowing claim and information relative to damage{s) to
person(s) and/or personal property: '� �'
o �--i
� A�
I. CLAIMANT INFORMATION: ;;,
r
• --�c 3('n-tT:
NAME Richard Landis " ���'
- - �
ADDRESS ,.r,""
PHONE NO. l DATE OF BIRTH: � _ �v'rn
SOCIAL SECUKI"1�Y N�. -' - - DRIVER'S LtC:tNSE NO. ���
•• C�-n
2, l�iame, telephone number and post office address to which claimant desires notices�p b�m
sent, if other than above:
Wal tar ['1 ark T.agal C,rnt�n
�_(17S F.1 P�an_T_Sta A-5
��m L�as e t, C a q2 2 6 0 �
r760) 568-5661
3. Occurrence or event from which the claim arises:
a. DATE: b. TIME: � � -nnam c. PLACE (exact and specific
location FreC�—j�lari ng nr,y �2n fAPt wPst of TEnnessee Ave.
d. How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or ommission you claim caused the injury or damage. (Use
additional paper if necessarv.) City of Palm �esert failed to properly
and . safely regulate and direct traffic through construction directed
by the City and negligently__retained, supervised and controled
workers operating heav� equipment carrying a steel plate which plate
was t�rust into traffic causi.r��a .�. .c�l.ii$?on with r_1�.�*TJ3nf '_^,��.phicle,
i�j u���gp�r�i�����actton by the City, or its employees, caused the alleged damage or
injury? �PP �ri
Page 1 of 2
4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred
so far as it may be known at the time of presentation of the claim. If there were no
injuries, state "no injuries": n„P tn thP r; t-�• nf Pa 1 m D G _r ' s neg�?gence
C'laimant qL,ff@rnr3 carinitc in3itr� anrl nt'har r3amageS� all 1IL ari
�.� ..� t� �,o ,ao�srmiu.ca.d--��"—th� ��;,-+-
5. Give the name(s) of the City employee(s) causing the damage or injury:
..0 .�hi G t i me
6. Name and address of any other person(s) injured:
Unknown
7. Name and address of the owner of any damaged property: Richard Landi.s_.
f
8. Damages ciaimed:
a. Amount claimed as of this date: $
b. Estimated amount of fufiure costs: $
c. Total amount claimed: $
d. Basis for computation of amounts claimed include copies of a!1 bills, invoices,
estimates, etc.):
***.T"r' S6��C�3�3A �dGlLilA �'cSt 111 the $Ll{Lnrinr ('rnirt-**�Y
9. Names and addresses of a!1 witnesses, hospitals, doctors, etc.:
�' ^�.,= s^' the—attach.P��a�irQ.,.�pn��t (E�iihit A��nr� MP�; �a i
�,i�mm�,,.. �L X�Ll}1�'lt B�
10. Any additiona! information, including police reports, which might be helpfu! in considering
this claim: Attached hereto
GVARNIIVG:IT LS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (PENAL CODE 72;
INSURANCE CODE 556.1).
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 upon information or belief as to such matters
I believe the same to be true. I certify under penalty of perjury that the foregoing is TRUE AND.
CORRECT.
Signed this ll �day of /y�-� ,20 0 7, at ,j`' �� ,��ia� �'�i�.,;q��
_,
,'Loc/��C.� ,.. �C�
SIGNATURE OF CLAIMAINT SIGNATURE OF CL IMANT
Office of the City Clerk, Palm Desert, California DOC. NO. DATE FILED
Page 2 of 2
EXHIBIT "A"
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� YICTIM OF VIOLENT CRIME NOTIFlED
PREPARER'SNAME I.D.NUMBER MO. DAY YE4R REI�IEWER'SNAME MO. DAY YEAR
V.TREVINO 2126 1/5/2007 � .- -d 7
ATE OF CALIFORNIA
�-,r•_c.H.pIAGRAM s K� ( G� Pe9a y or tE
iP 555 PaGe 4(Rev. 1-03) OPI 061
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_.. -- - _ . .... -- : ._. — ...__ _ -i OSP03>SSiA
STATE OF CALIFORNIA
NARRATIVE/SUPPLEMENTAL PAGE 6 OF 11
DATE OF INCIDENT TIME NCIC NUMBER OFFtCER I.D. NUMBER
01/05/2007 1111 3300 2126 T07005093
1 FACTUAL DIAGRAM LEGEND
2
3
4
5 VEHICLES POtNT OF REST
6 Veh # Whl Ft Dir 1� Reference Point Ft Dir 2nd Reference Point
7
8 1 LF 16 S Fred Waring Dr. 649 W Tennessee Ave.
9 1 LR 18 S Fred Waring Dr. 638 W Tennessee Ave.
10
'i 1 2 LF 5 S Fred Waring Dr. 1050 W Tennessee Ave.
'f 2 2 LR 7 S Fred Waring Dr. 1041 W Tennessee Ave.
13
14
15 PHYSICAL EVIDENCE
16 ITEM DESCRIPTION
17
18 A 6' x 20' Steel Plate
19 B Truck's rear window
20 C Camper shelt approx 5' x 5'
21
22
23 PHYSICAL EVIDENCE LOCATION
24 Item # Ft Dir 1� Reference Point Ft Dr 2"d Reference Point
25
26 A center 30 S Fred Waring Dr. 632 W Ternessee Ave.
27 B center 43 S Fred Waring Dr. 643 W Tennessee Ave.
28 C center 10 S Fred Waring Dr. 839 W Tennessee Ave.
.:::. .,•� ,,:�,� -,�,,�/,��•
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PREPARED BY I.D.NUMBER DATE RE�� ER'S NAME DATE
V. TREVINO 2126 01/05/2007 �1//,c/ _�?�?
STATE OF CALIFORNIA
�VARRATNE/SUPPLEMENTAL PAGE 7 oF �1
DATE OF INCIDENT TtME NCIC NUMBER OFFICER I.D. NUMBER
01f05/2007 1111 3300 2126 T0700�093
1 FACTS
2
3 N�TIFICATION:
4 t was dispatch� to this major-injury traffic collision at about 1114 hours. I responded from SR 111
5 �and Fred Waring Dr. and arrived on scene at about 1119 hours. Ail times; speeds and
6 measurements are approximate. Measurements were obtained by using a Rolatape.
7
8 SCENE DESCRIPTION:
9 This collision occurred on Fred Waring Dr. west of Tennessee Ave. Fred Waring Dr. is an
10 east/west four lane asphalt paved roadway. The eastbound lanes are separated from fhe
11 westbound lanes by a set of double yellow painted lines, an approximately 2 foot median. At this
12 �section of Fred Waring Dr., from Wamer Tr. to Califomia Ave. it is oonsidered a construction zone
13 with properly marked construction signs, orange and white delineators as well as posted 40 mph
14 speed limit signs, At the time of this collision the #2 westbound lane was closed using orange
15 delineators. A white painted line and the white delineators are used to separate the#2 westbound
'i 6 lane from the north side of the paved shoulder. The lane was closed due to men and equipmerrt .
17 working on the block wall on the north shoulder of Fred Waring Dr.
'(8
19 PARTIES:
20 Vehicle#1 fCatapillar) was located on its wheels facing in a northwest direction just to the north of
21 the #2 westbound lane of Fred Waring Dr. within the construction area. V-1 did not sustain any
22 visible damage.
23
24 Driver#1 (Hall) was found walking around in front of V-1. Hall was identfied by a valid California
25 driver's license. He was established as the driver of V-1 by his statements. Hall did not sustain
26 any injuries.
27
, ,,.,� ��.-.el,; �.y
` :f n. .�� :•r,.-� T,��:�•d ,�,' .
PREPARED BY I.D.NUMBER DATE R IEWER'S NAME DATE
V. TREVINO 2126 01/05/2007 � �d ?
STATE OF CALIFORNIA
NARR�TIVE/SUPPLEMENTAL PAGE 8 oF t1
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
01/05/2007 1111 3300 2126 T07005093
1 Vehicle #2 (Tovota) was located on its wheels facing in a northwest direction north of the #2
2 westbound lane of Fred Waring approximate(y 7 feet from the north curb. V-2 sustained major .
3 damage to the cab and doors of the tnack. The camper shell on the bed of the truck was ripped
4 away and sustained major damage as well.
_ . 5
6 Driver#2 (Landis) was lying on a gumey and was being treated by paramedics at fhe scene. He
7 was located near the north curb of Fred Waring Dr. behind V-2. D-2 was ider�tified by a va(id
8 Califomia drivePs (icense and was estabfished as the driver by the paramedics who removed him
9 from his vehicle.
10
11 Vehicle#3 (DodQe) was moved prior to my arrival and was parked near the north curb of Fred
'i2 Waring Dr. V 3 sustained minor damage to the front bumper,area.
13
14 Driver#3 (Jonesl was located standing in front of her truck. She was identified by a valid
15 Califomia driver'.s license and established as the driver of V-3 by her statemerrts and passenger
16 statements. D-3 did not sustain any injuries.
17
18 Passenqer#3 (Dvlan Jones) was located standing in front of V-3. He was identified by name.
19
20 Passenqer#4 (Scott)was located standing in front of V 3. She was identified by name.
21
22 PHYSICAL EVIDENCE:
23 The steel plate was located in the#1 westbound lane, the rear truck window was located in the
24 center median and the camper shell was located near the north curb of Fred Waring Dr.
25 Refer to Factual Diagram and Physical Evidence Legend for measurements and locations on the
26 roadway.
27
28
� ,__ ,;� , ,� ��. �.
. . . � F.� r �
PREPARED BY I.D.NUMBER DATE R ER'S NAME DATE
V. TREVI NO 2126 01/�5/2007 ���v�N f��7..v 7
�
STATE OF CALIFORNIA
'�VARRATtVE/SUPPLEME�JTAL PAGE 9 oF �1
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
01/05/2007 1111 3300 2126 T07005093
1 STATEMENTS:
2 D-1 (Hall) said he was the driver of the loader and had "the forks' attached to the front bucket of
3 the loader. Hall stated he was carrying a steel plafe flat on the forks at a height of about 3-4 feet
4 and was backing the loader from one er�d oi fhe job site to the oiher end (west end to the east
5 end,-�pprox %. rrii) at about 3 mph. D-1 said as he was backing he was looking over his right
6 shoulder and had the cenfer of V 1 positioned directly over fhe white delineators, using them as a
7 guide to maintain a straight course of travel. D-1 said the white delineators are permanently
8 placed on the roadway and are used to separate the#2 westbound lane from the north side of
9 Fred Waring Dr. where the consfrucfion equipment usually travels and materials are kept. D-1 said
10 he used them as a guide as they were set far enough away ftom the#1 lane enabling him to carry
11 the 6' x 20' steel plate without it extending into the#1 lane. D-1 added, as he was backing up he
12 heard "a crash sound" and tumed to his left and saw the plate hitting the ground where it landed
13 flat on the roadway across the#1 and#2 westbound lanes. D-9 then noficed a red truck rolling
14 forward toward the right curb of Fred Waring Dr. as well as a camper shell sliding along the#2
15 lane. D-1 said he sfopped V-1 and lowered the forks to the ground and ran toward the truck
16
17 D-2 (Landis) was contacted at Desert Regional Medical Center. D-2 stated he was driving V-2
18 (Toyofa) and was on his way to the bank and had just tumed right off Elkhom Tr. onto "the
19 designated lanep (#1) on westbound Fred Waring Dr. D 2 said he was traveling °with the flaw of
20 traffic" when "out of the comer of my eye I saw a forklift coming into my lane.� D-2 said the forklift
21 braked and the Ioad which D-2 stafed was at a height of 4-5 feet slipped off toward his truck. D-2
22 remembers leaning toward his left and "ducking" and did not remember anything thereafter.
23
24 D-3 (Jones) was contacted at the scene and said the following; She was driving V-3 and traveling
25 in the #1 lane of westbound Fred Waring Dr. at about 40 mph. D-3 said her son who was the right
26 front passenger told her to slow down as she looked toward the right side of the road and noticed
27 the #2 iane was blocked aff due to construction. D-3 said she noticed a "tractor" backing up in the
28 #2 lane and as she got closer she saw the vehicle in front of her (red truck) collide with a piece of
. { >.<. ,_�, ��`,.. a'°'�
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PREPARED BY I.D.NUMBER DATE IEWER'S NAME DATE
V. TREVINO 2126 01/05/2007 �✓i ���7-U7
STATE OF'CAL1FORr]IA
NARRATIVE/SUPPLEMENTAL PAGE 100F il
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
01/05/2007 1111 3300 2126 T07005093
1 metal that was on top of the forks of the tractor. D-3 added when the truck co((ided wifh the forks,
2 the entire fop of the truck as wel! as the camper shell was sheered off causing the shell to strike
3 the front of her vehicle.
4 �
5 Pass-3 (Dyllan Jones) said he was a passenger in V-3 and was seated in the right front seaf. He
6 said they were traveling westbound in fhe#1 lane when all of a sudden he noticed the red truck
7 which was directly in front of them collide with a forklift that was backing up in the#2 lane and
8 moving toward the#1 lane.
9
10 Pass-#4 (Scott) said she was a passenger in V-3 and was seated in the left side of the rear seat.
11 Scott said she was looking forward and noticed a red truck traveling directly in front of them in the
12 #1 lane. She then noticed a aforklifP that was badcing in the#2 lane began to move toward the#1
13 lane af which time she saw the red truck coflide with the forklift causing the cab of the truck and
14 camper shell to be ripped off.
15
16 OPINIONS AND CONCLUSIOIdS
17
18 SUMMARY:
19 V-1 (Catapillar) was carrying a 6 x 20 ft steel plate which was positioned flat on the forks that were
2a attached to the front bucket af the loader. V-1 was backing east on Fred Waring Dr. over the white
21 delineators which separates the#2 lane and the right side of the roadway within the construction
22 area. D-1 was looking over his right shoulder while backing the loader, and while doing so the
23 front end of the loader and the steel plate on the forks began to veer left causing the steel plate to
24 extend into the#1 lane. V-2 who was traveling west on Fred Waring Dr. suddenly noticed V-1 and
25 did not have time to avoid a collision and strudc the load (steel plate) which landed flat on the
26 roadway across the #1 and #2 westbound lanes. The impact from V-2 striking V-1 caused the cab
27 to partially be sheared off and camper shell to be sheared off and land in the#1 lane where it was
28 struck by V-3 who was traveling behind V-2.
�., '�v -%�i: C
iJ�:.a:.:[ !: ... i. ,S�,�.^��..�� �7 ��:
PREPARED BY I.D.NUMBER DATE EWER'S NAME DATE
V. TREVINO 2126 01/OS/2007 r/ � �
STATE OF CALIFORNIA
�VARRATIVE/SUPPLEMENTAL PAGE ttOF 1�
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
01/05/2007 1111 3300 2126 T07005093
1 AREA OF IMPACT:
2 AO( #1 (V-2 Toyota vs V-1 Catapillar) was determined to be 620 feet west of the west curb
3 prolongation of Tennessee Ave. and 34 feet south of the north curb of Fred Waring Dr.
4
5 AOI #2 (V-3 Dodge vs camper shell}was determined to be 735 feet west of the west_curb
6 prolongation of Tennessee Ave. and 36 feet so�th of the north curb of Fred Waring Dr.
7 The AO! was determined by vehicle debris, physical evidence and statements made by involved
8 parties.
9
10 CAUSE:
11 V-1 caused this collision due to unsafe backing. V-1 (Catapillar) was carrying a 6 x 20 ft steel plate
12 on the forks which were attached to the front bucket of the loader. V-1 was backing east on Fred
13 Waring Dr. directly over the white delineators which were placed between the#2 lane and the
14 right side of the roadway within the consfruction area. D-1 was fooking over his right shoulder
15 while backing, and while doing so the fronf end of the ioader and the steel plate began to veer left
16 causing the load to extend into the#1 lane of westbound Fred Waring Dr.
i7
18 RECOMMENDATIONS:
19 None
, _ . .�`, �, `�3�:��:
3 :�.y.: ,
°- '�4A�;_�� s
PREPARED BY I.D.NUMBER DATE R IEWER'S NAME DATE
V. TREVINQ 2126 01/05/2007 �' r „a '
ATE G1F GAUFORNIA
:PA72TMEN7 OF CALIFORNIA HIGHWAY PATROL
NOTE: CHP 180 tS FURNISHEO TO ALL PEACE
'EHICLE REPORT OFFICERSBYTHECALIFORNIAHIGHWAYPATROL
HP 1 SO(F�ev.2-99)f OPI 061
POpTING DEPARTMENT �,QCATION CODE DATE/TIME.OF REPORT NOTICE OF STORED VEHICLE FII,�O.
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:HICLE IDENTIFICATION NO._ , , . , ENGINE NO. VALUATION BY �OFFICER �OWNER
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�yi 1�j � YES NO � 1 � 2 �YES NO �JUNK �UNK �YES � NO
CONDfT10N yES NO �T�S YES IJO �Mg YES NO �Mg YES NO �1�S�MH�EEL3 COMdT10N
RECKED SEAT(FROP(T) REGISTRATION CAMPER LEFT FROHT �{�
JRNED HULK psr 431(c)VC SEAT(REAR) ALT./GENERATOR VESSEL AS LOAD X RIGHT FROHT
WDALlZED RADIO BATTERY FIRFJV2MS LEFT REAR
VG./TRANS.STRIP TAPE DECK DIFFERENTL4L OTHER RIGHT REJ�R
ISC.PARTS STRIP TAPES TRANSMISSION X SPARE _
DDY METAL STRIP OTHER RADIO AUTOMATIC HUB G1PS \1�!1.�
URGICAL STRIP pst431(b)VC IGNfT10N I�Y MANUAL SPECIAL WHEELS n�y�t
ELEASE VEHICLE TO: Wp OR AGENT �AGENCY HOLD �22850.3 VC , iGE ti IP AGENT STORING VEHICLE(SJGNA7UREJ DA /T E
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AME OF PERSON/AGENCY AUTHORIZING RELEASE I.D.NO. DATE C2kTIFIC� : 1,T}IE UNDERSICNED,DO HEREBY CERTIFY THAT I AM LE Y
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IGNATURE OF PERSON AUINORIZING RELFASE SIGNATURE OF PERSON TAKING POSSESSION
❑ STOLEN VEHICLE I COMPONENT ❑ EMBEZZLED VEHICLE ❑ PLATE(S}REPORT
ATE/TIME OF OCCURRENCE DATE!TIME REPORTED NAME OF REPORTING PARTY(R/P) ORIVER LICENSE NO./STATE
AST DRNER OF VEHICLE DATE f T1ME ADDRESS OF WP TELEPHONE OF R/P
� �
CERTIFY OR DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF SIGNATURE OF PERSON MAKING REPORT
HE STATE OF CALIFORNIA THAT TNE FOREOOING IS TRUE AND CORRECT.
REMARKS
�UST PROPERTY,TOOLS,VEHICLE DMAAGE,ARRESTS�
)RIVER'S NAME ARRESTED/SECTION7 REPORTED BY CARGO/TYPE7 VALUE S
�jl(,6{,�.�.D J�-}���S. �YES �NO TR-f-�l f'l�J 1.lZ.,b ❑YES ❑NO � BILLOF L4DINGATTACHED
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i1GNATURE OF OFFICER TAKING REPORT I.O.NO. SU R REDUIRED NOTICES SENT TO REGISTERED �YES DATE NOTIFIED
MA{��I�.1 �� L y�� G AND LEGAL ONMERS PER 22852 VC7 � NO
� INCIDENT REPORT
- p . 010507 I INITIAL UPP
�Tc REPARED. RIVERSIDE COUNTY SHERIFF CA0330000 � ❑ S LEMENTAL
FlLE NUAIBER 2 DATE/T1ME REPORTED 3.WTE 1TIME ASSIONED 4.QATE TIME NV.START 5.DATElTIME NV.TERM E.Adult ARR 7.Jw ARR
T01005093 010507 1111 10507 1114 Q10507 1119 010507 1235
�FBdS�S�CODE SECT10l1(AdE a Chsi W bl CRLLff �5 O.EDP CODE
1-80 Major Injury Traffic Accident 1 18J4M
OFFBJSES CODE SECTION(AAA arCh�W to) CRNIE COUNfS 11.EDP CODE
OFF@ISES COUE SECTION(A00 of C�aip�lo) S 3.
LOGATION OF OCCURRBiCE 15.REP.OIST. 1Q OCCURRED ON- OV1TE/71ME /7.OR BEi�NffN� DATE/TIME
•ed Waring Dr.wlof Tennessee Ave., Palm Desert T34G4 010507 1111
pUSNESSNMAE 1�.BUSNESSPHONE CASESTATUS/CLEARANCE
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1CTIM REPORTINCi PARTY -WITNESS -OTHER: �See Additional Persons Report
.NVL �.WMAE(Wl FtM.M� 21.SOC 4.RACE 75. ZE.AfiE 7.FR 7!.N? .FW R �0.EYE6 t.S10J
Refer to CHP 555
.RESIDBICE ADDRESE cmr � . ar a�. s.
BU9iES5 AOORESS �m'
LP ]6.BUS.PI/ONE
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.RESIOB�CE ADORESS GTY LP �6.RES.R10NE
.BUSNESSADDRE55 � CfTY . . .
L � 70.lU.i PHONE
SUSPECT: � Adult � Juverlile ❑ Pa�ole ❑P�obBUon ❑ see I►ddiUonal Penons Repon ❑ ARRESTED
.SZ1S� R.NAME<l+R R'Y.MAdM .SE7( .RACE .DOB 5B.AOE 7.!1T 60.N? 6D.W11R B0.EYES 7.SION
!.DRNERS LICBdSE NUMBER I D NU\6ER Si.STIRE 61.SOCIAL SEG11RlTY MAYIBER o3.ATII NUAADER EE.CII NUMBER
'.IIESIDB�CE ADDRESS CtTY ZIP 8!.RESIDBdCE Pl/ONE
i.BUSINESSAOORESS CT' ZIP 70.BUS.RIONE
JUVENILE �ISPOSITION: I1�W Crt-P�- []��►�����wt []�etaln�C [] Not O�talned
GANG DATA TATTOOS/SCARS/MARKS/CLOTHING DESCRIPTION
3ang Name{s):
❑Member ❑Assoc�ate ❑Sa1t Admk ❑ Prior Knowledge � -� � � ; ;� � ��� "
TAT7'OOS/SCARS I MARKS ��' ��-�-•�-�� � � �
�Face �Neck �]R.Arm []L.Arm []Harbs QTorso QBack �Legs
VEHICLE: � REFER TO CHIP 180 FORM FOR STOLEN,RECOVERED,TOYVED OR IMPOUNDED
4.INL 75.LICENSE 75.STATE 77.YEAR 78.AIAKE 7D.MODF1 !D.BODY STYLE: 1.STN/ CV AUTO VALU
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12.COLOR/ OR 83.VINN BI.OTHER IOFMIFIERS 65.OISPOSRION OF VQ11C1.E
-0.REOISTERED ONMER 87.ADpRESS CRY STIITE ZIP B8.PHqJE
B9• DAMAGED PROPERTY VALUE
❑ PROPER7Y REPORT ATTACHED FOR STOlEN, RECOVERED, OR DAMAGED PROPERTY s
tEPORTIN6 OFFICER OFF.ID REVIEWED BY 7 DATE ENTERED BY I DATE ENTERED BY/OV1TE
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EXHIBIT "�"
Landis, Mr. Richard S.
206377 MEDICAL S]PECIALS
5l1/2007
Total Charges
UCLA Medical Center
Patient Business Services Unknown at this time
10920 Wilshire Blvd. #1600
Los AngeIes, CA, 900246502
(310) 825-8021
Visiting Nurse Association "
of the Inland Counties Unknown at this time
42-600 Cook Street ..
Suite 202
Palm Desert, CA,92211
(760)346-3982
Hyde,M.D.,Gilbert
Hyde Spine & Orthopedic Care Unknown at this time
72-301 Counhy Club Drive
Suite 104
Rancho Mirage , CA,92270
(760)340-3773
Johnson,Dr.Eric
Unknown at this time
„
(310)206-1 I 69
Desert Regional Medical Center O1-OS-2007 $ 128,217.58
1150 N Indian Canyon Drive 1�rough
O 1-10-2007
Palm Springs,CA,92262
(760)323-6511
Cooper,PT,Shelley A. 02-12-2007 $ 1,109.00
78078 Country Club Drive T1�rough
Suite 205 03-01-2007
Bermuda Dunes, CA, 92203
(760)345-9934
Total Specials $129,326.58
PROOF OF SERVICE
STATE OF CALIFORNIA, COUNTY OF RIVERSIDE
I, Amy Mann, declare as follows:
I am employed in the County of Riverside, State of California. I am over the
age of 18 and not a party to the within action; my business address is 74-075 EI
Paseo Avenue, Suite A-5, Palm Desert, California 92260.
On May 14, 2007, I served the foregoing document(s) described as Claim
� Against the City of Palm Desert for Damage to Person and Personal Propertv
on the interested parties in this action by placing an original copy thereof enclosed
in a sealed envelope addressed as follows:
City Clerk
City of Palm Desert
73-510 Fred Waring Dr.
Palm Desert, DCA 92260
(X) BY CERTIFIED MAIL. I am readily familiar with the firm's practice of collection
and processing correspondence for mailing. Under that practice it wou(d be
deposited with the U.S. postal service on that same day with postage thereon fully
prepaid at Palm Desert, California, in the ordinary course of business. Return
Receipt No. 7006 0810 0001 1336 1502
( ) BY FAX. In addition to service by mail as set forth above, a copy of said
document(s) were also delivered by facsimile transmission to the addressee
pursuant to Code of Civil Procedure §1013(e).
( ) BY FEDERAL EXPRESS I caused such envelope(s) to be placed for Federal
Express collection and delivery at Palm Desert, Califomia. I am "readily familiar"
with the firm's practice of collection and processing correspondence for Federal
Express mailing. Under that practice it would be deposited with the Federal
Express office on that same day with instructions for overnight delivery, fully
prepaid, in the ordinary course of business. I am aware that on motion of the party
served, service is presumed invalid if the Federal Express delivery date is more
than one day after date of deposit with the local Federal Express office, pursuant to
this affidavit.
( ) BY PERSONAL SERVICE. I hand-delivered said document(s) to the addressee
pursuant to Code of Civil Procedure §1011.
Executed May 14, 2007, at Palm Desert, California.
I declare under penalty of perjury under the laws of the State of California
that the foregoing is true and correct.
�
MY MANN