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Claim Breitbach, Susan K.CLAIM AGAINST THE CITY OF DUBUQUE, IOWA This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1.Name of Claimant: Susan K. Breitbach 2. Address: 1700 1/2 Rhomberg Ave 3. Telephone Number: (563) 583 0331 4. Date of Incident: May 18, 2003 Sunday 5. Time of Incident: 3:30 P.m. - 4:00 P.M. 6. Location of Incident (Be specific): 1/2 mile before the Grandview Exit over pass on 52 South - Above Arby's Restaurant 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.) A big piece of steel or something (I have the piece) I hit and blew out my tire - other Car's almost hit it too. It was right in the middle of the road. 8. What were weather conditions like? Nice out / sunny 9. Give name and address of any witnesses: Rick Fen's. He helped me fix my tire. He also seen me hit it. 10. Did police investigate? (If so, give names of officers.) No 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). No 12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of damages or describe basis for ascertaining extent of damage.) Yes, Flat tire - blow out of tire 13. What other damages do you claim, if any? None 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) No 15. What amount do you claim from the City of Dubuque? For a new tire at least $40-$50. 16. Why do you claim the City of Dubuque is responsible? They need to keep things like this out of the road - keep the highways clean - instead of putting their money other places. 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) No 18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount? Dated at Dubuque, Iowa this 20th day of May , 2003. /s/ Susan K Breitbach (Signature) (Print Name) (Rev. 1/00 & 7/01) This written report constitutes your claim against the City of Dubuque, Iowa. You should complete this form in full and attach any additional information that supports your claim. The Claim must be filed with the City Clerk at City Hall, 50 W. 13th St., Dubuque, IA 52001. It will then be referred by the City Council to the appropriate department for investigation. Once that investigation is completed, a report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and recommendation. THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU AS TO WHETHER YOUR CLAIM WILL OR WILL NOT BE PAID. 1, Name of Claimant: ~/~ ~ 2. Address: [~ ~i~ ~~ 3. Telephone Number: ~-~ 4. Date of Incident: ~ 5. Time of Incident: ~;~ ~ - 6. Location of Incident (Be specific): __ 7. DESCRIBE ACCIDENT OR OCCURRENCE THAT CAUSED INJURY OR DAMAGE. (Give full details upon which you base your claim. If a City employee was involved, give the employee's name.)~ ~, ~. ~ ~ ~ ~~ ~ ~ ~1~ S. What were weather conditions like? 9. Give name and address of any witnesses: 10. Did police investigate? (If so, give names of officers.) 1 1. Was anyone injured? (If so, give names, addresses, and extent of injuries). 12. Was any damage done to property? (If so, describe property and the extent of dama'ges~ Attach estimates of damages or describe basis for ascertaining extent of damage.) 13. What other damages do you claim, if any? 14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and address of insurance company and amount paid.) 15. What amount do you claim from the City of Dubuque? -~--F CL~ ~/~C~_3 --~L~ ~-~-- 16. Why do you claim the City of Dubuque is responsible? 17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and address.) 18. and if so, in what amount? ~ Dated at Dubuque, Iowa this ~_~-~-~ day of If the answer to Question i7 is yes, have you received any payment from that source, ,20 ~ (Signature) (~rint Name) (Rev. 1/00 & 7/01) QUOTE 445568 05/2~0/~2003° NO CUSTOMER ~tore~ 64~120 EXPERT TIRE 555 JFK BLVD DUBUQUE, IA. 52001 LIC # IN 01/01/70 12:00AM QUOTE SERVICE ADVISOR: 05 TERRY 563.557.7321 VIN # EST. MILEAGE 0 Description Article Extended Job Number T# Qty Part Labor Price Total BRIDGESTONE '~ RE WITH U~i-m AQ~A-Q ~ PACKA~ -- ...... 108979 TURANZA LS-T P205/70R14 TLBL PS 108979 1 87.99 87.99 101.97 WHEEL BALANCE WEIGHT WHEEL BALANCE LABOR RUBBER VALVE STEM TIRE DISPOSAL FEE (1) TIRE INSTALLATION 7018708 1 3.99 3.99 7018716 1 5.00 5.00 7015040 1 2.00 2.00 7075078 1 2.99 2.99 7015016 1 N/C N/C THIS IS NOT AN INVOICE- DO NOT PAY Pa.g(~ 1 o,f 1 See ~1~ reverse s~oe ~or WarrantyO Information Quote1 N010809 L~,~T~ Expert Tire® Service & Darts WHAT :S WARRANTED AND ~OR HOW LONG? Auto parts purchase~ at any Exper~ Tire location are warranted to be free from defects for a period of s~x [8] months or 6,000 ~i,as, whichever comes first, and a~l auto service work performed at such location ~s warranted for the same per od, Sorae parts and servces are warranted for bnger per~ods as listed below. Tires and bameCes are warranted separate'y and not covered by this warranty. Tbs warranty applies to parts ns~al;ed and service performed on prvate Oassenger cars and i~ght trucks. WHAT iS OHFEREO UNDER TH~ WArrANTY? If any autcmotve repair cr servce per~ormed by us proves to be mprooer[y performed durin~ the six [8) month-800O m~ie warranty osr:,od we w~li, at Cbs Customer's option, re-perform the work at no additiona~ charge ', ~ -~ -" refund the amount the CL~stomer has paid for the specific service work for parts or bbor ~x~ept as performad by us. Auto cares wh~c:~ prove cc be unserviceable during the warranty meBod except as ~dentifie6 below, will be rep',aced free of any add]floraE charge for parzs or labor excep~ as ro~ed under ~c us one, bebw. ~ LIMITED WARRANTY ON: PARTS ! LABOR , LIFETIME {1 ) I Stearin9 & Suspension Parts Universal Joints [Exc!uding CV Joints & Scots) I Pe~{ormanoe Gas Shock L ~Gas Iruck ~hock LIFETIME Months / o,000 Miies Months / B,O00 Miles LIFETIME [1 ) LIFETIME UFET[ME [1 ] [2) i LIFETIME i LIFETIME ~ * q*~' * o* Car~id~¢ LIFETIME [I} Lifetime Crake Service - B~ake Shoes, Disc Pads, Ceiipers and/or Wheel LIFETIME [1 ~ UFETtME Cy'.indera and ali other hardware (See *) Basis Brake Service - Brake Shces, Disc Pads (See * *) 12 Months / l 2,000 Miles i 12 Months / 12,030 Miles i Remanufactured Starters and Alternators 24 Months / 24,000 Miles [1) For as ion9 as the orignal purchaser owns the vehic!e; [2} Performance Gas Truck Shocks, lasts ed on a commercial use ve'hicla, ars also warranted against defects and wear-out for I year from date of purchase or 100.000 miles, which ever occurs first, labor included, £~¢~si¢ms: Replacement of anti-freeze or clamps is nat included in the warranty on belts/radiator hoses. Cost of refrigerant and recharging of the air conditioning system is not included with the warranty on air conditioner parts or air cord t crier com~aressors. of additions! brake system components and/or iaber to restore Brake System to its safe prcper operation is not included the lifetime warran~ on Brake Shoes, Disc Pads, Ca,~pers and/or Whee Cyiinders sad al! other hardware. . . · ~a~or to restore Brake System to its safe Cost of additional araxe system components. ~ncluo ng rotors and drums and/or ' h L~rouar ooeretion s not included with the 12 month/12,000 mi e warranty on Brake Shoes and Disc Pads. GENERAL PROV SONS [Applicable to alt warranties) WHO IS COVERED BY THE WARRANTIES LISTED !N TH!S DOCUMENT? This warranty covers only the original purchaser. WHERE WILL THE WARRANTIES BE HONORED? Take your car to the Expert Tire which sold the warranted parts and/or service work, or to any other Expert Tire location, HOW CAN A CLAIM BE MADE UNDER THE WARRANTIES? The original inveice from the Expert Tire at which the erigina[ work was per- formed must be presented in order to get the benefit of the warran~. the above items and conditions, WH, A, 0~, ,ER CONu,,,ON~ APPLY? The obligations undertaken in these warranties a~a offered only on and may not be enlarged or altered by anyone. This warranW document does not appiy to products or vehicles used for commercial racing, Dr off-road purposes, or to damage caused by abuse or accident. ~o ~he e~en~ permitted b~ la~, ~id~est~n~/Firestone, Inc. and ~ts E~per~ Ti~e ~cat~¢~ ~c~ ~ab~:~ fo~ ~cid~a~ ang c~se~¢e~a~ g~es. Some states do not a~low the exclusion or limitation of incidental or consequenti~ damagBs, so the above ]~mitsdon or exclusion may not apply to you. CONSUMER RIGHTS: Th~s warranty gives you specific legal rights, and you may aisc have other righ~ which vary from state to state, GIVEN BY: Expert Tir8 identified in stamp or, if none, by Nridgestone/F~estone. I~c.. 50 Century City, Nashville, Tennessee 37214. Your satisfaction is important to us. if fop 8ny reason, you are not satisfied w~th the service you ~ece(ve, con.ct the Manage~ of the store where your service was provided. If you feel your probiem hbo not been hand,ed to your complete satisfaction, or you need the address of the ~pert Tire neare~ you, please ca(i Firestone Consumer Affairs, !-80~367-3872.