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HomeMy WebLinkAboutClaim No. 695 - B. C. BlaurockCITY OF PALM DESERT CITY CLERK DEPARTMENT STAFF REPORT REQUEST: CLAIM AGAINST THE CITY (#695) BY BURTON CHARLES BLAUROCK IN THE AMOUNT OF $6,949,661.61 SUBMITTED BY: Rachelle Klassen, City Clerk DATE: February 9, 2012 CONTENTS: • Staff Report • Recommendations of Claims Adjusters and Staff • Claim No. 695 Recommendation By Minute Motion, reject the Claim and direct the City Clerk to so notify the Claimant. Background Based on a review of the subject Claim and the recommendation of the Claims Adjuster, Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected. Discussion of this item should be held in Closed Session pursuant to Government Code Section 54956.9(b), potential litigation. Fiscal Analysis City of Palm Desert participates in the self-insurance pool of the California Joint Powers Insurance Authority (CJPIA). Action to reject the subject Claim does not have a fiscal impact on the City at this time. Submitted by: Approved: Ra helle D. Klassen, MM City Clerk qh�nM.tWohlmuth, City Manager rdk ( f Attachments (as noted) CITY COUNCILACTION APPROVED V- DENIED RECEIVED OTHER MEETING DATE -Q-d01 AYES: A�ns�n CinPr��,. nrn1K. coarsen. leQe,l NOES: 6= ABSENT: 11 oA --- - ABSTAIN: ►1 one - VERIFIED BY: Original on File with City Clerk's Oft -ice BE 2012 JAN 25 AH 11 * O7 CARL WARREN & COMPANY Claims Management and Solutions January 23, 2012 TO: The City of Palm Desert ATTENTION: Rachelle D.Klasser_, City Clerk RE: Claim Claimant D/Event Rec'd Y/Office Our File Blaurock vs. The City of Palm Desert Burton C. Blaurock 11 /29/2009 1/19/2012 S-1615068-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, CARL WARREN & COMPANY Richard . Marque cc: CJPIA w/enc. Attn.: Executive Director COPY TO AN EMPLOYEE -OWNED COMPANY DATE 770 S. Placentia Avenue i Placentia, CA 92870 P. 0. Box 25180 i Santa Ana. CA 92799-5180 wvvw.carlwarreri.com i Tel 714-572-5200 i 800-572-6900 i Fax. 866-254-4423 CA License No. 2607296 Klassen, Rachelle From: Greenwood, Mark Sent: Wednesday, January 25, 2012 4:03 PM To: Klassen, Rachelle Subject: Claim No. 695 Rachelle, Claim No. 695 should be rejected as it is the drivers duty to maintain control of their vehicle. The circumstances of this incident suggest that the vehicle was being operated recklessly. Mark Greenwood, P.E. Director of Public Works City of Palm Desert 73-5EU FRED WARING DRIVE PALM DP -SEAT, CALIFORNIA 92260-2578 -rFL:760 346-06iI FAX: 760 340-0574 i n Fo(WpaIm-dcscrr.org TO: CJPIA (c/o CARL WARREN & CO.), CITY MANAGER, CITY ATTORNEY, DIRECTOR OF PUBLIC WORKS, CITY ENGINEER, RISK MANAGER FROM: CITY CLERK DATE: JANUARY 19, 2012 SUBJECT: CLAIM NO. 695 ' - CLAIM AGAINST THE CITY BY BURTON CHARLES BLAUROCK IN THE AMOUNT OF $6,949,661.61 The attached Claim No. 695 is being transmitted to you for the following: O Information only. or Review and recommendation to the Claims Review Committee for any action required by the City of Palm Desert. We would appreciate your report, if requested, by February 21, 2012, for timely response to the Claimant. Note: If there is a current project or contract that may be referenced in this matter, please let me know or provide me with the appropriate materials. U. NLMOOCIV, IVIIVIU CITY CLERK Attachment (as noted) ' j nmioaxemaronru �..! I • .. . � �(1 � ( Via`: CLAIM AGAINST THE CITY OF PALM DESERT (For Damage(s) to Person(s) or Personal Property) Received by: is A CITY OF PALM DESERT HP JE'rr j 9 R � � 1,0: 4 1 ASSIGNED CLAIM NO. C4-51— 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 THE INCIDENT OR EVENT 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 WARING DRIVE, -PALM DESERT CA 92260. TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California: The undersigned respectfully submit(s) the following claim and information relative to damage(s) to person(s) and/or personal property: 1. CLAIMANT INFORMATION: NAME ADDRESS PHONE NO. DATE OF BIRTH: SOCIAL SECURITY NO. - - DRIVER'S LICENSE NO. 2. Name, telephone number and post office address to which claimant desires notices to be sent, if other than above: 3. Occurrence or event from which the claim arises: a. DATE: b. TIME: c. PLACE (exact and specific locationT ' 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 necessary.) e. What particular action by the City, or its employees, caused the alleged damage or injury? Page 1 of 2 ._'ft- c 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": 5. Give the name(s) of the City employee(s) causing the damage or injury: 6. Name and address of any other person(s) injured: 7. Name and address of the owner of any damaged property: 8. Damages claimed: a. Amount claimed as of this date: $ b. Estimated amount of future costs: $ c. Total amount claimed: $ d. Basis for computation of amounts claimed include copies of all bills, invoices, estimates, etc.): 9. Names and addresses of all witnesses, hospitals, doctors, etc.: 10. Any additional information, including police reports, which might be helpful in considering this claim: WARNING:IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM! (PENAL CODE 72; INSURANCE CODE 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 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.] S' ned this ( day of 120 12, at UM� �,t ► 1\(1►V1\L V� L41! 111� ��'I Office of th City Clerk, Palm Desert, California Page 2 of 2 SIGNATURE OF CLAIMANT DOC. NO. DATE FILED ATTACHMENT "A" 1) Claimant Information: This claim for indemnity is based on damages arising from claims set forth in a Complaint filed on November 16, 2011 in the Superior Court for the State of California, for the County of Indio, Case No. INC1109282, on behalf of plaintiff, Amanda Lee Blaurock, born ("plaintiff') (a copy of which is enclosed). The Complaint was served on defendant, Burton Charles Blaurock, ("defendant") on January 11, 2012. 2) Address of Information to be Sent: The instant Government Claim Form is being submitted on behalf of defendant, Burton Charres Blaurock, by and through his attorneys of record: (all notices to be sent to the address below) Kevin D. Smith, Esq., Anne K. McIntyre, Esq. and Raffi H. Ohanian, Esq. Wood, Smith, Henning & Berman 505 N. Brand Boulevard, Suite 1100 Glendale, California, 91203 Telephone: (818) 551-6006 / Fax: (818) 551-6050 Plaintiff is represented by her attorneys of record as follows: Michael A. Killackey, Esq. Killackey Law Offices, LLP 388 East Valley Blvd., Suite 219 Alhambra, California 91801 LEG A L:05858-0028 / 2159665.1 Telephone: (626) 281-4900 / Fax: (626) 284-0100 3) Occurrence or Event Front Which the Claim Arises: a) Date: November 27, 2009. b) Time: Approximately 6:05 p.m. c) Place: El Dorado Road near Frank Sinatra Drive in the City of Palm Desert, California d) How and Under What Circumstances Did Damage or Injury Occur? At the time of the incident, defendant was driving his 2005 Dodge Viper with plaintiff as his passenger on El Dorado Road near Frank Sinatra Drive in the City of Palm Desert, California, when defendant allegedly failed to appreciate the presence of a "Dip" in the intersection as he "rapidly, unsafely and negligently accelerated into a right turn", which ultimately caused him to lose control, and become airborne, thus causing the vehicle to travel onto the curb and into a large hedge wall. Plaintiff further contends that the accident caused her serious personal injuries, including traumatic brain injury. e) What Particular Action by the City, or its Employees, Caused the Alleged Damage or Injury? Defendant contends that he was not speeding at the time of the incident. Rather, defendant contends that the area in question where this incident LEG A L:05858-0028 / 2159665.1 occurred was not lit at all and the sign allegedly warning of a "Dip" ahead in the roadway was obscured by overgrown bushes, all of which are City controlled. Accordingly, the poorly lit area and the obstructed sign warning of the "Dip" caused him to approach the "Dip" without any knowledge or awareness of its existence, causing the incident to occur. Had the City properly lit the area and properly groomed the bushes so that the warning sign of the "Dip" was clear and apparent, the incident would not have occurred. 4) Description of the indebtedness, injicrij and damage: As a result of the incident, plaintiff alleges she suffered serious personal injuries, including traumatic brain injury, as well as hospital and medical expenses, general damages, wage loss, and loss of earning capacity. Defendant has and will continue to incur damages as a result of the filing of plaintiff's Complaint, consisting of miscellaneous costs associated with defending the legal action, including, but not limited to, attorneys' fees, investigative costs, consulting fees, and expert fees, as well as damages claimed by plaintiff including but not limited to past and future medical expenses, loss of earnings and non -economic damages. Said fees and costs are unknown at this time. By its intended Cross -Complaint, defendant is claiming indemnification to all of plaintiff's claimed injuries and damages due to the City of Palm Desert's failure to properly maintain its roads and signs, that led to the event causing plaintiff's injuries and damages. LEGAL:05858-0028 / 2159665.1 5) Name of City Employees Causing the Damage or Injury: The specific identity of the city employees responsible for ensuring the location of the incident was properly lit and that the surrounding bushes around the "Dip" sign was properly maintained are unknown at this time. Defendant contends at this time that the Maintenance Services Division of the Public Works Department of the City of Palm Desert undertook to control and maintain all street signs and streets throughout the City of Palm Desert. Discovery is continuing. 6) Name and Address of Any Other Person(s) Injured: Defendant also had minor injuries as a result of the incident, but that is not at issue in this litigation at this time. 7) Name and Address of the Owner of any Damaged Property: Defendant's 2005 Dodge Viper was damaged as a result of the incident, but said damages are not at issue at this time. 8) Damages Claimed: a) Amount claimed as of this date: Plaintiff claims past medical expenses in the amount of $70,295.43, future medical expenses in the amount of $3,384,000.00, past lost earnings in the amount of $495,366.18, and future loss of earnings to exceed $3,000,000.00 for total economic damages approximately $6,949,661.61. b) Estimated amount of future costs: Unknown at this time. LEGA L:05858-0028 / 2159665.1 c) Total amount claimed: $6,949,661.61 by plaintiff. Defense fees and costs to be determined. d) Basis for computation of amounts claimed: Plaintiff's claimed amounts are based on plaintiff's documents. 9) . Names and Addresses of all Witnesses, Hospitals, Doctors, Etc: Witnesses to the incident include, but may not be limited to, plaintiff and defendant, who may be contacted through their respective attorneys of record. It is believed that plaintiff obtained medical care and treatment from the following facilities and individuals: Abundant Health Associates, Alliance Rehabilitation, Centre for Neuro Skills, Desert Counseling & Assessment Center, Desert Medical Imaging, Eisenhower Medical Center, James R. Merikangas, M.D., Palm Desert Radiology, Quest Diagnostic, Rancho Physical Therapy, Robert Steinberg, M.D., UCI — Brain Imagine Center and West Cal Pharmacy. Discovery is continuing. 10) Additional Information: A Copy of plaintiff's Complaint as well as the Police Report are attached. 11) Explanation for late filing: Plaintiff, Amanda Lee Blaurock, filed her Complaint, Case No INC1109282, in the Indio Superior Court on November 16, 2011. Defendant, Burton Charles Blaurock, was not served with the Complaint until January 11, 2012. LEGA L:05858-0028 / 2159665.1 Accordingly, defendant, Mr. Blaurock, is submitting this Government Claim Form within 6 months of service of the aforementioned Complaint. 1 1 � 2, " rk-44�� Dat Anne K. McIntrye, Esq. Attorney for Defendant, BURTON CHARLES BLAUROCK LEGAL:05858-0028 / 2159665.1 0 0, F ATrom&y RPMWyAM�nWTATPOkhCYpYrua"J'a":�rru+ef0atarls6.hicX �— MRCDiYRflIEO�Y.Y rW ichael A. Rallackey (213570)illackey Law Otficess, LLY 80 East Valley Blvd., Suito 219 lhambra, CA 91801 ;eu%-*t4W.): (626) 791-4900 !626) 284-0100 � �-:,�..�ouas�t��a:�tkC�rktriallawyPrs.Cwe SupElim Count OF CAUFORMA, cOWN OF R:i ve r s i de anr,wAc mam 46-200 Oasis Street Yrnar+cAMAMI aame 0YYN0rwr.xe Tndio, CA 92201RY a p ,,v RNih rwniwxc ZtLdio COurC f�UFRIVE PUYwmm.Amaanda Lee Blaurock, an individual 0OU Novi 6 za» D FENOMT: BalrtGn Charles Blauruck, an individual.; and I NA. MIEDRANO Cpmp.AM-Pemmai htiury, prop" Damage, W*+D qU Osath = AMID= mod: Type (dam* all OW WpIW _ } MOTOR VEHICLE [.� On* R tgmcX ►: Pam! F-3 wmnow tlum ACTMCN 13 A LHOM 13 WVlt_ CASE CAN waee�e ANKxfTt demanded (-1 diaae rqt exoasd 910.t106 �*CTM is Ali IINAaTM MML CASE ( WO � u�,oao ' N C 1 1 0 9 2 8 Z L-::) ACTMN M RLRr ASSIFIED b! 090 amertdPd c=49aW rrom srtled to Wuh- hed scan anamrad to ballad ,. Plon0V(awn arnatneV.-Amanda Lee Blaurock, an individual et"ncausmc(atbvnepa wdeHndant(nw"or»ernea) Burton Charles Blaurock, an individual; and Does 1 to 20 2. TNx pleading induft adadYm is and eWINS. croslsta of the fo%Yaina mm*ff of pa9ec: 5 3. Each pl+*dW namied abort is a aompelwt adult •=W Pwa (mmefi tt) G a WMWj W C to do bush u tt catllbmie f� CJ an ama.nWT (d8=+4: (3) [= a wi Me entl4► (aMoffie): (4) •` _] a rT MW = an adult (e) for wtwm a guud w or ooaasenwim of to adale or a puzdIan ad merit has been "veintad (b) 7OOW ( ): b. eXOWPkb- f 1) j� a colparsO n >uelifa�d to do buanea9 in 04%omis (2) C M AW eritty 0*4amba): (3) a aearaYliitTa� ): (4) xWkW L_J an-adiii (a) !," _j forxthm a auardion or earawvatw of" estate of a gua(d rt ad lib" tree boar aplTointOd uUW' (*0&Y): i bVa mafkm abort 8ddl4orlat praatutit vft ora Tot =npdWj A &C6b )8 s.' W.. ia:v". wn! 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L-- j ene.Pt dekroda* (1) C3 a bjdnm WWrAB9W. tm Ir"O" (z) LJ a mpmaeon (3) = m w*=Wgbd on* (dwaft): (4) [--1 a Wac ar,*y (dowfft): (5) 173 Gar svew: = InIMMUMA"A wIMMNA dekwdWft who WO not ngM* WW" is cwokvd In AftadmOd 5- a. The bm nanm of deftrAmb suadis Dow an W*Wm too- W- a.cii DW4arenaWft(spm*Doe mm*m&), I to 20 - A'QgQ DW 300ft Of eMPIDYe" of OthPr "mmW dderv:bift and ailed vAin *A GWP* Of VW vQWWV Or m"0DVmanL b. [Y] Dow deFendwft (APSCW OW O"916m); 1 to 2 Q-- - wd Pereoeee VAIWO CBPBCZU are unknown to PWWW- 7. C - -1 0*AOxfOnft who are Jokssd under Cads of Gull PrOOD&M section W2 are (rtarttttaJ: 11= amAla1w pop" cocAbomum at WA VW ddiandad WN MOMM In Its ?Jk&dWW WW WMMVW or W*CMVW*Md OSSOCNOM is in 0 pmW*onW oua. on **WAW Ph" of bjWnmw cf a ddbn&M C. F '0 k*My IQ 9"am of OOMCC ID P"W24 PWPtY O=WW In ft WS"Cad VrW d. ri other (SPGM*;: hm campWd m!"h aWcAW c%ims *Wwtw, Or y. nVk^ beevim (sppdfy): is emaM ftm Cc PLt1.PM1 smoRt7mE Blaurock v. Blaurock INC 10. The toikw+bV Causes d Nci m ace attachad and fie tPUPfwrna aooOa appry W airm fwm wffmww.,,,,,�,.s.a ..,r cws&s of ackw amsdtao: a. _O ido0or V*Wda b. Lg-j General Nsglyenos c. C7 ft*w i nW Tat d. __-� Pfod ch t Malty a. Ptvnites t1eiWW f. Other (Auft-A . 11, PlatnWf has suffered a. ( wage lads b, km of nee Of PrOP" G (� boaPR91 and nwdicW swamis d.] flenerat daatags Q O pvWV dmvW f. Gil joys of ass"ampacity 9. = oltwr damage (may)- 12 [_-) Tha dxrmgw loaned fat wmr0d daalh and the felalimuhips of ptafn>f[f to the doceasad am a. �,� iislad in Attadfmattk 12, b. sa fo&mW 13. The ra d sought in $90 cwV4kd lsvrdW tine "Sdc M cf #* Gaut. 14. p mjn if p=p f,3r hjdqn+w+t for wW of salt; for auah reW= is fair. Ji4 wfd egfifaW and for a (iy to —nwwatwv dawaoss w Uw 'rho wma t eddartn$gea Is &I cases 16rperanrwf ktfoyarwf VW I N roe seat cdeott (T)�: (1) Cut aomraviaxw (2) a] jnMGa csad0t$exC*6d9 �uriadictianal limits 4& U The pXWaphs of this cQU*j&K atleped art inramskm and baw are ss folows (paragraph ntrnbers). GPI-1 f W-1 and HV-2 Date- August 22, 2011 c1►ael A �i llackr�. rsa. ,� rruir�erz �rx! � rlw. : A.. ,.way 1, MVI - COWXAlNT—POrWnal RgUtY, ProParty {tgrtl�etrw, U,4--jrt:f:f3 Math Pals 2 VIA EMAIL Electronic Signature Civil Code 1633.7 SHORTYTnF: tlaurock v. Blaurock, et. al. t(Mirm11 p928 2 FrRST _, CAUSE OF ACTION--�3enwd NealkwW-0 Pa" ____� A (numbar3 ATTACHMENT TO 1-0 Comoiehrt 1-3 Crow - Co 08k t (Lba a sapamta muse of acdfoa font fbrsaM caaar or oobM j GN_1. pWir4Ir frAW): Amanda Lee Blaurock, an individual alapsthat defendwl(R&We Burton Charles Blaurock, an Individual; and [—&] now l- to U — res Mr W4* (proRtMM" came or *now* to pt+i"W By t w iaMor N acts or aaubm b acf daf9ttdant w4p ney mused the do-18P io phit M era (for}: Novembet 27, 2009 ato*w): on El Dorado Road near Frank Sinatra Drive in palm Desert, California (din crM&NM br fM ty): on November 21, 2009, Defendant Burton Charles Blaurock was this owner and operator of a 2005 Dodge Viper. on said date, Defendant Burton Charles Blaurock negligently drove said vehicle on 91 Dorado Road in Palm Desert with Plaintiff Amanda Lee Blaurock in his front passenger seat, and thereby caused the vehicle to lose control, which resulted in a collision and serious personal injuries to plaintiff Amanda Lee Blaurock, including traumatic brain injury. Defendants and each of them so negligently owned, operated, entrusted, leased, repaired, modified, maintained or controlled their vehicle in violation of various sections of the California Vehicle Code., including but not limited to cVC 9 22350 lBasic speed Lax), so as to legally cause the aereinabove described injuries and damages to Plaintiff, fan hp7wr+�aNb++M� - -' tkddLMi M,UMrt �rs�� ...;;40 .+wrc.trw.+ CAUSE OF ACTION--C:+Meral N$grfg#Tk--* ,• G aaw.mra) FW, A a.v .sHmTrrLE Dlaurock v. Blaurock, at. al. + k.1 t0928 L Yrrr CAUSE OF ACTION--i�01orW11ilCb (nunbrr) ATTACHMENT TO Complebt E Cross - Compla[M (use a $operate cause of action forlrt Jbr each Ca M Of 8060m) pjW,M (name): Amanda Lee Blaurock, an .individual MV t. Ptainw silage+ toads of d ftwar" were mgkger* d" ads was the"w(pror3ma%) c$nr.+e of [*des and duVapes to pta -M, thv ecb Downed on (data): November 27, 2009 at (places): E1 Dorado Road near Frank Sinatra Drive in Palm Deuert, California MV 2. DEFENDANTS a fX]Tho defu dartls who oparaisd a motor vetdde am ftWMW; Burton ChazlQs Blaurock, an individual; and Q pose Lto Z4...._.. b. W The defsndwks utm wMgoyed the persona who opwoled a motor vehkla in #w oo,rse of their en*Wnw t am (names): 5j Dori I — to 20 - c. Q'f:re defendards who owttied tht+ mobx votrida vchici� was apar�rYd wilt their pernisstan era (nernaal: Burton Charles Blaurock, an individual) and © Does - - b 20 d. LO The deanoarts who w*udw the mew veNde am {name © Does I ._ to .20 e. ® The dohwdwb who were the epenis wW wapioyeeA, of the DOWdefehdaft WO ac bd wWM the eoopa afthespemyrrera(+waes): Burton Charles Blaurock, an individual; and [. boas 1 to f. ® The dg%n&n is who am liabta b pie NM tt r otrenmmna W the reasons for the MbRy eta M Hated In Athadaeert MV-2f �, x iae bkwAL Buxton Charles Blaurock, an individual; and _Y i�oe9 i AlKwomwal r�i,ri•m,pNAea 1W-y, =n to 4A....r.-- CAUSE OF ACTION-410 or Vehicle Arne—0*rNrr VW-0nrarlon*VP"M r.. "W. We,s,..ar Nichael A. Killackey, Esq. Killackey Law Offices, LLP 388 East Valley Blvd. Suite 219 Alhambra, CA, 91803 mnrAwno., (626) 281-4900 Fax,ra_ (626) 284-0100 _LTMff_&UZ&jM Plaintiff skowOR =mr of cAUF mA. cotow t7F Rive rs ids ,,,m,Aaw*w46-200 Oasis street uAaaasamm same cmrwoxFcoot Iadi.o, CA 92201 onntWM4xInd 0 goart: CASEri+ AL- Blaurock v. Blaurock CML CASE COVER SHEET �Coartip4n[ C"o Ussianatlon CAM F11sd vriMr iatt sppearsnoe by detendaN Y s?b (Cal. Ruke of Court, tub 3Z50QQc►r�-......r_.t3A(}4 °�....._.._._._......_.____.-_....... Iftm 1-0 bWow nW be =MiWod Aft i ft cftm an vow 21 1. Chu* am box below for Im rase type that fed dssagm ttds case: Auto ?oft I x'] Aub av I __j ttnamtrsd mwoda (46) cow PW MD twwm+d hyugvropaatir owwagwwrapam G"h) Tat = Aabastoa (04) i uPMdW bbW a4) 1 U0*Ad M*(4m i J otter PiIQ WWD CM N"WVPDM(Ostar,l'a t L_1 l9anoo. W Wmrafr txy xma praMm (07) O awn a0na (M C:} DeftmeMen (73) 1.� Fraud (14} CJ u,�e.�a ptop.rq• t,af = ftaubsineops"0) L,.3 other nan-Pwa w tort (3ry "wrar9U ternria;+wn (3m L._)ar+rrWV nWt(") Coat W = a m%* of W*awaamwr teal' CJ its 3.740 uAeceorrs (09) (Tl oum aoaattD* Non . 1"Urrws covwap (t8) t_ t00r.rewntrad(37) lied PmPat I. "1 Emlr.nt danarrrr,wrs. condpnnsrtioo (14) C_7 VNw%U W&0M (33) t_�_.y-.y odes roac n►ope+tY C,ae) Unterttd UataUlar C_J cons w (31) Cl R"W'rrw av L710aw (A Judicial )faun 1 -1 Assrt torte WW (os) CD PM&a o:.d +don kennel (, t, WA'a en.ad.t. t0 I___1 ot6ar,adioisl,wierrt� tW UNWAIM (cat fm+.e of Gomt., now 3.4003.E 4 L_ A,ggru Utade r o*Wa its C7 oo.atraotid,daart (,o� U man No (40) l ....1 biro - 0 next tort r4 ED iru amm woes" rtaiaa uww tram an abov: 4atnt Provka cvaWan case "(4t) Enilorsemsat of .ilaipnrarrt C7 >=r�mo.tuaac d,tdat�t t�3 tiiawtfaascns 6Yvx C.onrp4tnt [� tiro CM L J oft, Im abary (42) UlaeAiaaseaa OW Podsa . (Y:1 Partaeahip and ctorW to pmnana (21) C1 auwrpsIN (ht •i(43) 2 Thle cne 0 4 [13 Ia rat canpieu under foie 3.A00'of >fie CatYontts Rules of Coot U foe taw (a mmpkx, treerk the a. "� Vote Mffbordsapmalaty'rapreseAW perHes d. � large txttr+berda�ihfeassa b. = Etar iw mutter pnacdco raceme aMmA or novel aloud anions pandln0 )nor* ornvFe oourb !auras !tort u0l be ttn *%*aa uninp b tssofva h direr countiw stadss� oraovtiries. Orin a fades* cant r: L-:] SLOsWagat GnWwd of 4=XnWAKy wAaa w E [� Substers6el Pogj WW= t judr upwv don I. Ramefts sough (cheek &I that apply): a. txj nra*Wy b. rtasnc sWWF. doolwatoy or bjrnx0ve reliaf c. = punitive 4. Nu~dcatFsrtecritratM (sped&). 1- gAnrrel nogl;genrr; and 2- mol-or vehicle S. T1ds raw r Is [ D is not a loss a coon DA 6. 8 %am am any Mom trte;ted =wm, !le and rive a tAm d refuted rase. (You MW we ftu Date: August 22, 2011 IL r f - . PWWlti trust Be tide cover street wtth tM irst paper filed In tM adon of ( rlk=220.) underdw ProbateCode. Family . or Wallace anti b�Utr loci Coda Cad. Rules of Fatltae to tee may res it Wx1io:rs. . Fite Ns aouer Sheet k! knot!ion !a my ewer sheet rsq kW by lock! Lout rule. !r':ffi4 t'� it rY+rlwx lnrrwr n+rn ! t>Xi d seq d Ihrt Cai4fortrie truth of Court, snau must sere a copy d Iltis cover sheet op all other uw0w to be adlon or ptoaendina. • LWesc lhW is a wbecbara rasa tnnder' rule 3.1140 ar a C=91ez case, d" a5rer uwct m&I Lit user} Tar ir21t:t:r al prxpmu or&j. VIA EMAIL Electronic Signature ClvP Code 1633.7 0 Q lhlsT W 3Ns ON taw TO COAAPLE E THE CO' . e 5:1EElr CM41O To Ptatretllis and Others FAbwp Fleet Pagans. A YOU NO MW a Ant p2W (for eorerntr:.d, a campa*4 in a dvI cow yw mist OcivIete and Me, None whh your drat paper, ft Cho! Cow Gnawer Shed eont hM an pop 1. Pile inkmaVon WN be used to eWgft sl6dlU" about We ty "ard rumbas of caeca Mod. You mutt Corrlpwta name t through A on the rhosL In tram 1, you mnmt rl=k one brnr tar the rase type that best des wibas tits ceae. Nths Caee ft bath a pervert red n roars tpodk type of ease 8sled in them 1, check the mots gmcfle one. If ttrs case tas muWe caann of aCf10n; tStssclt the boil thsd beet 6j mle therprfaeary cause of aeon. To a Wd you in cample" We shael, ewr4 iss of the cases that babng Ls der Ouch wore tyre to item 1 era provided blow. A wear shoat moat be mad only m* )=w WN paper. Fakwe to We a cower absed %M Vs 60 pepw Sod to a 4 M1 ame may strt oa a Pray. As oounsal, or bdb to mcdom under rules 2-30mod 3MO of ft» Csifanta Rules of CaurL To Parde t In Rude 3.740 Cailaaboeu Cases. A cobefi a ails' under nds 3740 is lolled as an actlon for rawwwy of money owed in a corn visfed to be awtA i that is not mom MW $4000, o>dukive d 111txwt end WNWT f* IOss, Wising iroM a kwasadon in which pmporty. erinrtoes, or money weir aoqulred on c sak A aWledtohW ease Lion not kmkf a an salon se*kq 1* ft*WM- (1) W datnagw (2) paft Omega& (3) m=ay of rail t+qxety. (4) money of Paa+a l tmp ", or (5) a pMudgtrad wit of anacttmsnt. The tderrlM=Or, I of a case as a « Av 3.T40 c;Aoc:dwa cent on Wm torn tnasea that it ieW bo mom, ham ttte wart W *r*4br-.woke requVemenls and coo rnaonepemant nAsa, u nlaae a rislenriaM No a respwAke plesdkV. A nua 3.740 aINK2ki s caloe earl tw mat vcf to the requkara is for saMce and obtekrina a kxbff ent 1n Aft 3.740. To Pw** Iid Conp4lt Casa& to wmpb* cma only, pw*w rusk alga use theQW Case Cosner Shoot to des*wb %%hW er the case is varopienc tf a p4dniitf bran"" tha CW& is Cornpian under mb 3AW of the U t ni a Wes of Caret. Wo must be tndeeted by bhp the eppropria5e bouas in ltnerea i and 2 K a pla>diif dasigr aitas a an& at complex, the cater Wheat nosed be served vtfh the cvrr%*Ak t on at puMea to the scban. A dabrxIwA may to and asrve no fader then the tints of its first appe *r= a WOW in the plakttiea desip ugm, a courier-de:*s ice tPurt fhd case is rst onvkx, or. iF the pWkW rile made no deeipnedien, W deaipnation that the cam se OWTAW. CAM WKS Ah-J EX RAWO , ALAO Tact CGI*&ot "WAdara ft Caw4041 lostion (Cat. Ruto 04—Prsv" k+) rWpWtw+ty > mat y (CO) Ernes of GaatRuti s3A*-1�411M CastNt(aotuallwkldWkW Anti4trs ftD (W) nof oamar Lin(r►sand itokmas (4d) (F* W C.aretrw�lrxr flrlfed (10) czar aroiw. err vrarnd tbakru hrugMYnp rasa TOK (40) SuLa rt alabr angjed ao t o r tad efnsgysnw� Soax tin LFgaft (26) atta,Taitker;chair.rifeROra Neglow Broach at Contract/ &NkamraftOmt (W basdrsei dilua>! CdW Pitt' VAD tP"nanal M]rpl Other etatd of CenkWdsMharady (e al ig tare pvvthne& omvfex prop" OaeaeaIVw0bout gem) C0y`� (awd, opn osel pfWadakw) (41)Tort �� (04). tkunape � tier Caoe—s kr P►irrr ERt°`°serwt<d (�) Ashedas Pommel k�W q NotdC.okcdere Abet aQ d Judgment (Out of Yttrgrgd DMA (asurance Covers" (eat povisloaw County) Product LIWW bf OW aabestaa or OWWsxl (id) CW*Ssakae Of ju*a nt (rson- tada�pwalwaft (45) (24) cgs "Aladeral �� Oftw Canbad M Adrinkas Ate Agearl Award plarknianl i 3urpsam 0GWtPvA W Ftwd WV" 1094 Oe wrp0*41 "rteamCara OUwrCautaatt]itpufa Prflf�WWArrmaisfntdFapyof laaipr"ellaa Rant Q:4"h sae to Uwakt TI N II 00herPdpoAgo{2J) Of �aftasarartof.krrprna�t w+s �' W� E�cilon 03) trmealtaaeous cavil Caae{eh" and ran OQrer Rash Fopo(y fs F. quWkNo Cam) RICO (M k'aa" 80b V*NitPOMD wilt d Rsewsbs of weal Pop&* antler tnknn(tiiorod iurtgega*Fa.doeuA " r2ukt T7t ho CAnotb al O n of oaur taad ply #W ��,M taad9" gliaief Oaty Nsp6Q"Ai tnllfrian of dwuk*% bacbrdle narx or >oMaia9"a Rs6I Ony (norr Cmseonit of tren L iorodosna) bra asro Other PLVD ND UnWU pertlonr mar Ca rk1 wks Lima F wpvpw" (Other) Tat CaWNMW(31) Case austa"as ToKKkdak eUvi nw ped&m" (M Other CNNCWrn 7< pa�OWO F7) Drugs (38) Nft erase kwokove aMpel (narr�ravrpt-.r) GNd Riwe (64, dbaLnitaa"% OV94, alsok a& amev"afiat ileaaeeaaeas n- Petitiontats"anarl wq(notdW mpxiCww ere/atarAbssdent� aV (oe) .sudlaah ftrviaw PvtnamhO wed Corporate (ea . deader, RA h"Forhhta (OR Oomnance irk) (13) Petleon phl: AMnont Aerwd (f i) O#w PeNat (hot apecded R---id (18) tititit eM it WO'" (rrn c tt.-(43) .ze,racru Irrtskehw(PnoAaviy (19j VIni4 Admht6btliva 1141a UMA Cda tanss WD t't0fescfpnal (�) Wid-AWAammoeUnitedCawt ant As Legal fM"Rnadiaa ZAsa Lal i! duIt adw Protaaaionuf Makw9aim Writ-Wer Lknttaa Card CAN Abuse RovW s3"cnea cantcat (rof mad�a►o (ORW JuiIdai Fw�le1 t=' Nf&n for Watys 0mve Ottbr Nun PUPtJ/INQ Toortit 55) Petition for pelts( hem Late �gYoprnanl "e:'i¢ar M ".-am7lResr r1n1►r Vftngful Tatnrnftlon (M) Notice of ARm"abor C124T, Other Cr%*Ynvri (15i Comr-4rsionar Aptwall Othv 0" Petition 4AA ■ I I M MM STATE OF CALIFORNIA ' d'WvAFFIC CULI,.I i ON REPO IR'll CHP 555 Page 1 (Rev. 0-97) OPI 042 CPECIAL CONUtTIONS Ruaroan toy leUunaO rPLOI f IJUiJ&Gn IOLlGO IaTa COLLISION OCCURRED ON p % /7-0 MILEPOST INFORMATION UFEET/MILES OF CAT INTERSECTION IMTH OR: a /MILER p� � OF 'ARTY DRIVER'S LICENSE NUMBER UI NER NAME (fIRST, MIDDLE, UST) 113e PETITS ISTREETADDRESS BICY• SEX HAIR EYE6 HEIGHT WeH BIRTHOATE CLIST Mo. Dey Yeer OTHER HOME PHONE BUSINESS PHONe INSURANCE CARRIER POLICY NUMBER w -p oo / OIR OF TRAVEL STREET OR HIGHWAY SPEED LIMIT wry 1011 if o o SSA ,ARTY DRIVER'S LICENSE NUMBER STATE CLASS 2 ORNER NAME (fIRST, MIDOLF UST) PEOE]Eb ISTREETADDREss " LUST sex HAIR EYES HEIGHT WEIGHT BIRTFIDATE Mo. Day Yew OTHER HOME PHONE BUSINESS PHONE INSURANCE CARRIER POLICY NUMBER OUT OF TRAVEL I ONSTREET OR HIGHWAY SPEED LIMIT 'ARTY DRIVERS LICENSE NUMBER STATE CLASS 3 ORNBI NAME (FIRST. MIDDLE LAST) Ej PEONS STREETADDRESS OTHER HOME PHONE INSURANCE CARRIER~ DIR OF TRAVEI. I ON STREET OR HIGHWAY PREPARER'S NAME Mo. Day Year PHONE POLICY NUMBER SPEED LIMIT DISPATCH NOTIFIED J�YES Q NO. Q NIA Page/ oT ,`> i9eIAL DISTRICT LOCAL REPORT NUMBER rC%i� REPORTING DISTRICT BEAT MO. DAY YEAR TIME (240%; NEIC S OFFICER I.D. /• T o 0 33 c t* y' Wd DAY OF WE ^ TOW AWAY; PHOTOGRAPHS BY. NONE S M T W T F)S WYES' NO -. STATE REL YES 1 NO r VEK YEAR MAKEIMODELICOLOR LICENSE NUIu1BER�'''{' STATE �5 Da for- v i r� OWNER'S NAME ® SAME AS DRIVER 1 . OWNER'S ADDRESS I� 1 SAME AS DRIVER1 Lys i DISPOSITION OF VEHICLE ON ORDERS : 17n �—y OFFICER ❑ DRIVER ❑ OTHER zo �I PRIOR MECHANICAL DEFECTS: NDNE APPARENT REFERTO NARRATIVE VEHICLE IDENTIFICATION NUMBER CHP USE ONLY DESCRIBE CIF DAMAGE _ SHADE IN DAMAGED AREA VENIClE TYPE UNK F-JNONE MINOR p 1 11 MODAJ . MOR ❑ ROLL-OVER CA DOT CAL.T TCPIPSO MCIMII VEH. YEAR MAKEMEODEL/COLOR i LICENSE NUMBER STATE _ r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ M* DwMEFVS NAME SAAS DRIVER IIOYINER'S ADDRESS ❑ SAME AS DRIVER DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER' DRIVER ❑ OTHER PRIOR MECHANICAL DEFECTS: NDNE APPARENT REFER TO NARRATIVE VEHICLE IDENTIFICATION NUMBER: . CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA VEHICLE TYPE UNK : Q NONE ❑AJ MINOR 1 MOD.' MOR O ROLL-OVER CA DCIT ::9 C:::3 CAL,T TCPJPI0 VEH. YEAR MAICEIMODELECOLOR I LICENSE NUMBER STATE DW&RS NAME SAME AS DRIVER WYR,EITS ADDRESS SAME AS DRIVER IMPOSITION OF VEHICLE ON ORDERS O : 0 OFFICER Q DRIVER OTHER PRIOR MECHANICAL DEFECTS. NONEAPPARENT REFER TO NARRATIVE SHICLE IDENTIFICATION NUMBHt CHP USE ONLY DESCRIBE ICLE'DAMAGF SH(JDE IN DAMAGED AREA v�I Ltd T VPF El LINK� NONE MINOR I MOD. MAJOR[] ROLL-OVER CA GOT C:AL•T TCP/Po'CT_SECI.EX REVIEWER'S NAME DATE REVIEWED !"D3231 1 s t� 1 0�? TE OF ARAFFII FORNIA V. TRAFFIC COLLISION CODINV CHP 555 Page 2 (Rev. 8-97) OPI 042 Page,, ofs DATE OF COLLISION (MO. DAY YEAM ITIMO(2400) /- - 0 NCIC 0 3 3� OFFICER I.D. We-9 FER 09' 33 042-3 PROPERTY OWNER'S NAME A1i0 ONMEWa ADDRESS �4ygw L pZ, NOTIFIED YES . NO DAMAGE DESCRIPTION OF DAMAGE C �JG�J 20 SEATING POSITION 1 2 3 1- DRIVER 2 TO S - PASSENGERS F F4 5 6 T - STATION WAGON REAR 8 - REAR OCC; TRK OR VAN H T 9 - POSITION UNKNOWN J 0 -OTHER K SAFETY EQUIPMENT OCCUPANTS L - AIR BAG DEPLOYED M I C BICYCLE- HELMET A - NONE IN VEHICLE M - AIR BAG NOT DEPLOYED B -UNKNOWN N -OTHER DRR/ER C - LAP BELT USED P - NOT REQUIRED V - NO D - LAP BELT NOT USED W-YES E- SHOULDER HARNESS USED - SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER G - LAPISHOULDER HARNESS USED Q - IN VEHICLE USED X - NO - LAP/SHOULDER HARNESS NOT USED R - IN VEHICLE NOT USED Y - YES - PASSIVE RESTRAINT USED S - IN VEHICLE USE UNKNOWN - PASSIVE RESTRAINT NOT USED T- IN VEHICLE IMPROPER USE U - NONE IN VEHICLE EJECTED FROM VEHICLE 0 - NOT EJECTED 1 - FULLY EJECTED 2 - PARTIALLY EJECTED 3-UNKNOWN. - ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (•) SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR UST NUMBER 11OF PARTY AT FAULT TRAFFIC CONTROL DEVICES 1 2 3 TYPE OF VEHICLE 1 2 3 MOVEMENT PRECEDING COLLISION 1 El A VG8EG71ONVDUTE4 crtEo S C A CONTROLS FUNCTIONING A PASSENGER CAR/STATION WAGON A STOPPED B CONTROLS NOT FUNCTIONING' B PASSENGER CAR WI TRAILER B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING': C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER C RAN OFF ROAD` D NO CONTROLS PRESENT I FACTOR' D PICKUP OR PANEL TRUCK D MAKING RIGHT TURN C OTHER THAN DRIVER' TYPE OF COLLISION E PICKUP / PANEL TRUCK W! TRAILER E -MAKING LEFT TURN D UNKNOV+IN• IA HEAD -ON F TRUCK OR TRUCK TRACTOR I I IF MAKING U TURN E FELL ASLEEP* B SIDESWIPE GTRUCK/ TRUCK TRACTOR W/TRLR. G BACKING C REAR END H SCHOOL BUS H SLOWING I STOPPING WEATHER RK 1 TO 2ITEMS D BROADSIDE I OTHER BUS I PASSING OTHER VEHICLE A CLEAR E HIT OBJECT J EMERGENCY VEHICLE J CHANGING LANES B CLOUDY F OVERTURNED K HIGHWAY CONST. EQUIPMENT K PARKING MANEUVER C RAINING G VEHICLE I PEDESTRIAN I L BICYCLE L ENTERING TRAFFIC D SNOWING H OTHERS I M OTHER VEHICLE M' OTHER UNSAFE TURNING E FOG 1 VISIBILITY FT. I N PEDESTRIAN NTO OPPOSING LANE NO F OTHER % MOTOR VEHICLE INVOLVED WITH O MOPED PARKED WIND A NON -COLLISION P MERGING LIGHTING B PEDESTRIAN • Q TRAVELING WRONG WAY A DAYLIGHT C OTHER MOTOR VEHICLE 1 2 3 OTHER ASSOCIATEDFACTOR(S) (MARK i TO 21TEMS) R OTHER': B DUSK -DAWN D MOTOR VEHICLE ON OTHER ROADWAY C DARK -STREETLIGHTS E PARKED MOTOR VEHICLE A VD SEOMM MLAT16)k cRED YES D DARK - NO STREET LIGHTS F TRAIN E DARK -STREET LIGHTS NOT FUNCTIONING' G BICYCLE B VC SECTM MOATIaIe cnro^ H ANIMAL -NO 1 1.2131 SOBRIETY-DRU G PHYSICAL (MARK f 70 21TEMS) ROADWAYSURFACE vcSEc110NVIDUTm enu C . �� A DRY I FIXED OBJECT: B WET D E VISIONOBSCUREMENT: le I I A HAD NOT BEEN DRINKING C SNOWY -ICY J,OTHEROBJECT: • B HBD-UNDER INFLUENCE D SLIPPERY MUDDY OILY ETC. INATTENTION-: C HBD-NOT UNDER INFLUENCE' ROADWAY CONDITION(S) (MARK f TO217EM5) G STOPS GO TRAFFIC D HBD - IMPAIRMENT UNKNOWN` PEDESTRIAMSACTIONS H ENTERING I LEAVING RAMP E UNDER DRUG INFLUENCE' A HOLES DEEP RUT' A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT - PHYSICAL' ' B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK AT INTERSECTION J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY K DEFECTIVE VEH. EQUIP.: CITED H NOTAPPLICABLE D CONSTRUCTION - REPAIR ZONE C CROSSING IN CROSSWALK- NOT AT INTERSECTION YES �NO I SLEEPY I FATIGUED E REDUCED ROADWAY WIDTH SPECIAL INFORMATION F FLOODED* DCROSSWG- NOT INCROSSWALK L UNINVOLVEDVEHICLE . A HAZARDOUS MATERIAL G OTHER` E IN ROAD - INCLUDES SHOULDER MOTHER': H NO UNUSUAL CONDITIONS F NOT INROAD N NONE APPARENT G APPROACHING I LEAVING SCHOOL BUS Q RUNAWAY VEHICLE SKETCH Jr. Gs�• �J�}..�.I f• j _ ' INDICATE NORTH I MISCELLANEOUS - I, b00 FT SCUT14 U F$ /Af OF FL4NK S.2IVAVA VIM -61 rT WEST OF weS7 Cap 13 LI-ALIT pF crr 00 nn OSP Be 13009 • STATE OF'CALIFORNIA INJURED / WITNESS / PASSENGE, � Paps � oP �- CHP 555 Pao 3 (Rev. 1-03) OPI 061 'DATE OF COLLISION (440. DAY YEAR) TIME (2400) NCIC Y OFFICER I.D. NUMBER :n ntDB ONLY rAssetlscn ONLY AGI SF1I EXTENT OF INJURY ("X" ONE) INJURED WAS ("X" ONE) FARTf NUMB-', SEAT POS. AIR sar-En BAG EQUIP. EJECTED FATAL INJURY SEVER@ INJURY OTHER VISIBLI "JURY COMPLAINT OF PAIN DRIVER PASS. PE0. 01CYCLIBT OTHER ❑ ❑ ❑y� I ❑ ❑ L�J ❑ ,❑ ❑ ..d AA Y NAME / D. O. B.I ADDRESS TFI EPHONE (;;jjUi:c6 OiJL1 j u:iJoi-i.:aTeu li _.. - IAKEN'IU: DESCRIBE INJURIES �OMNGtt T .d �� I ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ 6S M ❑ El`� ❑ Z ❑ ❑ ❑ ❑ erl 'f 0 NAME I D. O. S. /ADDRESS TM FPHI)JE ace ez~ C�3I�32LLx EGAC1�Y.+2C.�1� (INJURED ONLY) TRANSPORTED BY: TAKEN TO: C DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑#' ❑ ❑ ❑ ❑ 111101111.11101 1 NAME I D. O. B. I ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED El NAME ID. O. B./ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED NAME D. O. B. J ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN 70. DESCRIBE -INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑❑❑ ❑ ❑ NAME ID. O. B./ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO , DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED PREPAREWS NAME I.D. GNUMBER MO. DAY YEAR REVIEWER'S ,(N'�A7MEE i MOry DAaY� YEAR �r�sKc� TGt� i,r t- 0=+-8Qe 4(Nev. 7-us) UPI 061 I t Page y of DATE OF COLLISION (MO. DAY YFAR) TIME (2400) NGIC M OFFICER ID. NUMBER 05' 33vG1 0/ 7r 3/ oi23 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE I INDICATE NORTH i I " I I I ti o 1 I' Q I I CA c.4-' /s' /o' r�v'� 9d .SCrs�G� PREPARED BV I.D. NUMBER MO. DAY YEAR REVIEWER'S NAME MO. DAY YEAR I .A.4.4�� OSP 03 75578 PREPARED: //-a -7- oy �\ h INCIDENT REPORT RIVERSIDE COUNTY SHERIFF CA033000D WMIML 0 ISUPPLEMEWAL 1. FILE E NUMBER 2nATE1IVfE REPORTED' %JI3fIL9ETETIM.. &AduMARR 7-JuvARR ? I 0. OFFFASES- CODE SECTION CRIME COUNTS 9. EDP CODE 11.Fr)Pr4DF Q OFFENSES -CODE SECTION (AddorCfiapID) CRIME COUNTS 11 EDP CODE 14. LOCATION OF OCCURRENCE18.0 ON- DATE/TIME 1 17. OR BETWEElk DATE I WE 10:40CI - /ZQ- &A 5. eE2 Q dZZ�r!M_ �r e)'JO BUSINESS NAME 19 BUSINESS PHONE 20. CASE STATUS I CLEARANCE =7-9-A Fast W&) 21 SEX I 21.RACE 2& OM Z. Ur 2&W. aim .7TA m X M.. 32. RESIDENCE ADDRESS cily ZIP 33. RES. PHONE CITY ZIP 3& BUS. PHONE •47. (Last, Fkst MOB) 41 DOB 4L7 I 4ZHI I. aWT 44_.jjjF� �..4&EkX­ 4 SKIN.., RESIDENCE ADDRESS CITY ZIP 40. RES. PHONE 49.BUSWESSADORESS CITY ZIP B&BUS. PHONE SUSPECT: M Arit tit F-I Ativonda MD-1. M 1-1 - - . ... : - . r-1 -F-52-E - - __ - - . . MA Fwst Mi"e) " - '­J� I %G).%A & " rulcatmi sLsa SLAM I 57.11T 5&WT I S.HAIR I MEM OILSKIN 67 DRFVWS LICENSE NUMBER I ID NUMBER 63. STATE SECURITY NUMBER =7,m 6 65. WA NUMBEFt 65. CH NUMBER 67-RESIDENCE ADDRESS CITY zie 68. RES. PHONE 611 BUSWESSADDRESS CITY ZIP 70. BUS. PHONE Im IL I I Lietamw I I M U81011180 I 7Z GANG DATA 73. TATTOOS I SCARS I MAWS I CLOTHING DESCRIPTION Gang Name(s): El member El Associate El SelAdmd 0 Prbr Kwkdg. ..................................... A .4 r El Face El Ned ❑ RAn [I LArm El Hands 0 Tom ❑ Back [3 Legs VEHICLE: R TO CHP 180 FORM FOR STOLEN REMAIMEn T011111.1 OR REFER - - _­ ­i I -IT" 7& LICENSE 7 ffA-TEff 77.YEAR I 7ILMAKE BIL BODY STYLE 81.SIN/ RCV AUTOVALUE 79. MODEL ORICOLOR A2: MVINS St OTHER IDENTFIERS $ ft DMFDSTFIDN OF VEHICLE 86. REMMSTERED OWNER - I 87. ADDRESS CITY STATE Zip a PHONE 1 89. DAMAGED PROPERTY VALUE Fl PROPERTY REPORT ATTACHED FOR STOLEN, RECOVERED, OR DAMAGED PROPER JY I $ I ICER OFF. 10 R BY/D I REPORTING OFF A ENTEREDDYIDATE APRSENT: CD3231 110 COPIESTO- N=E3ff- Las ll 67 Donn 4 IFG rev Vol It 1 89. DAMAGED PROPERTY VALUE Fl PROPERTY REPORT ATTACHED FOR STOLEN, RECOVERED, OR DAMAGED PROPER JY I $ I ICER OFF. 10 R BY/D I REPORTING OFF A ENTEREDDYIDATE APRSENT: CD3231 110 COPIESTO- N=E3ff- Las ll 67 Donn 4 IFG rev Vol It STATE OF CAUFORNIA INJURED / WITNESS / PASSENGE, Pago of CHP 555 Paqe 3 (Rev. 1-03) OPI 061___ DATE OF COLLISION (MO. DAY YEAR( TIME (24001 NCIC M OFFICER I.D. NUMBER ' vnTNES3 ONLY PASSENGER ONLY AOE SIX .. EXTENT OF INJURY ("X" ONE) INJURED WAS ("X" ON PARTY SEAT FOS. AIR SAID RAG EOIP. EJECTED' FATAL INJURY SEVERE INJURY OTTER VISIBLE INJURY COMPLAINT OF PAIN DRIVER PAST PEO. BICYCLIST OTHER MSE ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAMEID. O. B.IADDRE TELEPHONE (INJURED ONLY) TRANSP0 O BY: TAKEN TO: DESCRIBE INJURIES ❑ vICTIM'OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ o 1 ❑ 1 ❑ 11111:111:11 a 1111 NAME/ D. O. B.l ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# El El❑ ❑ ❑ D ❑ ❑ ❑ ; . NAME 1 D. O. B.I ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ lololEll ❑ NAME I D. O. B. I ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES F—lVICTIM OF VIOLENT CRIME NOTIFIED ❑#I ❑ I I 1 ❑ 1❑1 ❑ ❑ 111'o❑❑ NAME/D. O. B. I ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES " 4 ' ❑ VICTIM OF VIOLENT CRIME NOTIFIED NAME 10. O. R. I ADDRESS TELEPHONE (INJURED ONLY) TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES p ❑ VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME I.D. NUMBER I MO. DAY ' YEAR- I REVIEWER'S NAME MO. DAY YEAR f 0 0 0 Ul C:) Ul z3 � o � 7I m p Z (l w Z Gl w a � N O � 7d SD 0 Z 8 O r Ul 0 r C co O tr T