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Chevron <br />IOW <br />ONO <br />CSI STATION CUSTOMER CLAIM REPORT <br />Facility # 2-109°/1 Date of Incident 12 <br /> <br />r2, 12_1 Time of Incident 11'44 -Awl LI Incident # <br /> <br />Customer must fill out sections 1 and 2 <br />Section 1 <br />Customer Namer-Teve4en -DeVe_On —f,,pnoct_tep <br />Address: 2„0-1Oi yet\fn CrA) rflOYC OLC <br />Phone number(syra"&:00A 9-001 qO2t54%- 1\1030n Y-6c01 /4.) 1.-iCitaern (11-164 26:1 01 ILI <br />Descri tion of Incident <br />Section 2 <br />Fall (slip or trip) E Criminal Activity (on customer) Equipment Failure (injured customer) <br />LI Gas Spray (on person or car) LII Food Contamination • Other Bodily Injury Complaint , <br />Incorrect Fuel volume E Fuel Contamination • Carwash damage • Motor Vehicle Crash <br />I=1 Incorrect Fuel Product qFuel Spill on ground • Fire/Explosion 11 General Customer Complaint <br />Describe the Incident: CA.,-\-60n.e_A-- ty()‘\-QA l V - lAkAr) Dxsvens.ex--- -ns74- Tocr-) vevklc <br />t• tea.. ,..#. a' li 6 'Al a Aat .0 04.. • . • . f Nthie_ <br />cldAr)i-- yyInvtte -Pi 1 "IvttlAVX-rF:c_WO-kn TA)rec v_Zri c:TC'S <br />Brief descriptiorlf)Mjury or damage: <br />nie(S i-lepum,a w*0 0-4scxyy-\ c-v-e,.\\() <br />Type of Vehicle: Make: oDe\J .k Model: 'elc5?r()S5 Year: '2t) \ c j License Plate #: et) <br />Witnesses to Incident <br />Name: Address: Phone Number: <br />Name: Address: Phone Number: <br />Signature acknowledges that the above information is an accurate account of the circumstances surrounding this incident. For carwash claims <br />signature also acknowledg• . a WARN G DISCLAIMER — ,T41., e: : . wash entrance. <br />Customer Signature: / -r 04. • Date: <br />Friction Carwash WARNING DISCLAIMER: Do not enter if vehicle has rear spoiler, overhead or side racks, non standard accessories, body damage, loose trim, <br />extended mirrors, convertible tops, cb antennas or exposed propane tanks. No campers, vans, mini-vans, Fieros, Blazers, Jeeps, pick-ups or similar vehicles. Station <br />operator is not responsible for damage. <br />Touch-Free Carwash WARNING DISCLAIMER: Vehicle must not exceed height and width clearances. No non-standard vehicle accessories. No loose trim, body <br />damage or loose items in pick up beds. Station Operator is not responsible for vehicle damage. <br />The information on this form does not constitute liability admission on the part of Chevron Stations Inc. The information will be used in <br />evaluating the claim. <br />Employee Information: tCA5kS--\-OVIA-- <br />Tille/Position tint Name <br />Privacy Notice: The personal information you provide will be used to expedite your claim and will be shared with third party claim administrators as <br />appropriate. <br />Distribution: Original to Station Copy to Customer <br />vArcifc2JQeve_ g44-. <br />MS-10004 (6-14)