CLAIM PRESENTED TO THE CITY OF PITTSBURG Please read the instructions on the back before completing. 1:mt- 1. Claimant' Name: (Pleaqe Printi

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1 CLAIM PRESENTED TO THE CITY OF PITTSBURG Please read the instructions on the back before completing. 1:mt- 1. Claimant' Name: (Pleaqe Printi L (-Johr)k))1 () dre Claimant's ). s City State Zi ' Day Phone: (T i--t):1 0. ) C A qii 565 igs(deve: (? e When did the dama g e or injury occur? Day: it Month: k.-' i Year: - qd City Claim No.:. Oi) Time: Ar a.m. or p.m. D / UV 3. At which location did the dama g e or in ury occur?. _OA) Ayiyce D. H. /1:1115RM -ril" APR APR HUMAN RESU uhcity CLERK 7---q-- R PAO- n R EC E or Police Report No.: t`ii Uorth ktmy fr om_1t) LeAvv) pi. Ap at)0.1'0.00 e- 1 (00 refe) -rmin -1-1Te- eoraer )1 -lhe r)01- )-)r1 happened and why is t e City responsible?. a. A rev- Abie in e i_de. /o J ) /Ore7i //tk b. ei)gs rt-spr5' bie.f". 6-^ Lodi (»Col p955 '.. : Name and position oi..v-sponsible Cit Emplo yee(s ' "et' n known:. Mt listf... A t. 5. What dama g e or injury occurred? i.-.2i idk t&trr befrrfl --71-rek5 or --1M....:11 arf Al a _ It. 2 ofirve 9/ oh.t.eiraly8/1/ 6. Claim amoun (only if less than $1 000):A 2 t.9 j If the amount exceeds $10000 please check the court for appropriate jurisdiction: Municipal Court (claims up to $25000) Superior Court (claims over $25000) 7. Row did you arrive at the amount clai VI A A i ed? Please attach do umentation.. _ ::e I ell /50 --Por t % I i wh ) 1-1# g_'6. yr I 8: I declare under penalt y of perjury under the laws if th t... e pf Californi. that the followinfrpiation is true and correct and that this declaration was executed :I I at IA (... / II/ ' AT. 1r Si. ature if Cie'. or Representa ye 9. Official Notices and Correspondence If represented by an insurance company or an attorney please provide the information requested below: Name and Capacity:(p/ease print) (56 Address: City State Zip: Daytime Phone: Evening: CA.

2 Page: 1 QUOTE ONLY Quote No Date 03/1/2011 Salesperson BIGO TIRES # NORTH PARK BLVD PITTSBURG CA 9565 Phone (925) (925) Part Number DPW OPWHL OPW OPACC OPT OPTIRE LAB BAL LAB N2 FEE TO FEE EF BAR No. ARD21339 EPA No. Not an Invoice - Do not Pay CAL Description Qty FET Each Extended 2" HELO 86 CHROME INSTALL KIT R2 GENERAL UHP MOUNT & WHEEL BALANCE *THIS IS NOT A BIG 0 BRAND TIRE ' THIS TIRE IS COVERED ONLY BY *MANUFACTURER'S WARRANTY *AGAINST MATERIALS DEFECTS *BIG 0 ROAD HAZARD WARRANTY *DOES NOT APPLY VALVE STEM & NITROGEN TIRE DISPOSAL FEE ENVIRONMENTAL FEE All Parts are new unless otherwise specified. Quote Totals Shop Supplies 0.00 FET 0.00 SubTotal Sales Tax Total:

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4 TREDS ED WHEEL QUOTE Pittsburg CA 9565 The Tred Shed - Tire Pros 50 Bliss Ave. Pittsburg CA 9565 Phone: Fax: BAR #AG EPA #CAL MgfigrarikeeP.7/2"V: Workorder # Printed: 11:30:55 AM 3/ Ordered on Monday March LICENSE NO. MAKE-11 MODEL MILES 1N/OUT FLEET NO. PHONE REP CS H PO # KYLE SCE-10 VIN TORQUE ENGINE SIZE TRANSMISSION COLOR TERMS Cash 1PRD DATE I CATALOG XXW PNW PNW1 DESCRIPTION 219 PACER 777C PLEASE RETURN AFTER 250 MILES TO RE-TORQUE WHEELS. QTY I PARTS LABOR DISC I FET I TOTAL I Code $ KCS XXT PTP 22.TB WEIGFIT2 PTP1 CT OF P275/30R2 GENERAL EXCLAIM UHP STANDARD TIRE PACKAGE: 2" MOUNT & BALANCE STEEL WHEEL WEIGHTS RUBBER VALVE STEMS CAL TIRE RECYCLING FEE ENVIRONMENT TIRE DISPOSAL FEE $ KCS $ $.00 KCS $8.00 KCS $7.00 $12.00 'CUSTOMER INFORMED THESE WILL NOT FIT ON VEHICLE WITHOUT MAJOR MODIFICATIONS. Visit Us at Our Web Site vvww.tredshect.com Parts Labor Freight Other FET Supplies $ $ $1900 Taxable Non-Taxable Local 9.25% Estimate $ $ $ $ Parts and Labor warranties 100% 90 days or 000 mile.whichever comes firsithis wanan6itimited to the work on this form only. Vehicle must be returned to our shop any Tire Prosor American CarCere Coolers. at customers expense to honor warranty. 1 herby euthmize the repair wed( to be done along with the necessary materials. You all your employees may operate vehicle for purposes of testing inspecren or defivery at my risk An express Medi ernes lien is acknowledged on vehicle to secure the amount of repairs thereto. You WI not he held responsible for loss or damage to vehicle or articles left in vehicle in case of lire/heft accident or any other cause beyond your Con ho!. Because of the eaent of the teardown and inspection the vehicle may not perform as wall es before No refunds on installed Tires and or Wheels Special Orders or discontinued items. All returns are subject to 15% handling charge. My deposits ere subject to!eget if cancelled. Print Name Signature Date Page 1 of 1

5 The Tred Shed - Tire Pros 50 Bliss Ave. Pittsburg CA 9565 Phone: Fax: BAR #AG EPA #CAL Cus -OniOr Workorder # WHEEL QUOTE Pittsburg CA 9565 Printed: 11:31:17 AM 3/1/2011 Ordered on Monday March LICENSE NO MAKE & MODEL FLEET NO. PHONE REP GBH PO # TERMS KYLE SCHO Cash MILES IN/OUT VIN TORQUE ENGINE SIZE TRANSMISSION COLOR I PRD DATE I CATALOG I DESCRIPTION QTY I PARTS I LABOR I DISC FET 'ET I I TOTAL I Code MVA MODIFIED VEHICLE ALIGNMENT INC. LOWERED/LIFTED VEHICLES CUSTOM WHEELS 20' OR LARGER Visit Us at Our Web Site $ KCS Parts Labor $ Freight $000 Other FET Supplies Taxable Non-Taxable Local 9.25% Estimate $ $ Parts and Labor warranties 100% for 90 days or 000 m9e.whichever comes firslthis warranty limited to the work on this farm only. Vehicfe must be returned to our shop any The Prosor American Car Care Centers at customers expense to honor warm* I herby authorize the repair work to herons along with the necessary materials. You and yore -employees may operate vehicle forputposes. of testing. inspection or delivery at my risk An express Mecheinct lien is acknowledged on vehicle to secure the amount of repairs thereto. You will nol be held responsible for Joss or damage to vehicle or articles leh in vehicle in case of firethell accident or any other cause beyond your control. Because of the extent of the leap:lawn arid inspection the vehicle may not perform as well as before. No refunds on installed Fres and or Wheels Special Orders or discontinued items. All returns are suhfect to 15% handling charge My deposits are subject to fionset if cancelled Print Name Signature Date Page 1 of 1

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