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' r e <br /> To be Date Stamped By Clerk <br /> ?•; •OG of the Board of Supervisors. <br /> County of San Joaquin <br /> CLAIM FOR DAMAGE OR INJURY L11Df,,e, <br /> INSTRUCTIONS: r t a ®®a <br /> Prepare in ink or typewriter.File original and one copy with Clerk of the Board of Supervisors, <br /> San Joaquin County,222 East Weber Avenue,Room 701,Stockton,California 95202.Use addi- <br /> tional paper as necessary. <br /> Name of Claimant: Mr. Delta Funding L.P. - <br /> Isu First MI <br /> Home Address/Phone: 5361 N. Pershing, Suite B, Stockton, CA 95207 <br /> City/StateMp oda phone <br /> Send Correspondence To: <br /> SheKirk The Kirk Law Firm, ti01 Univ rsity Ave, <br /> (916) 567-3960 <br /> Na CRY/State/Zip code CA 9 825 Pane <br /> When did Injury or Damage Occur. 1/3/01 <br /> Month/Day/Year Time of Day PM <br /> WHERE DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> HOW DID INJURY OR DAMAGE OCCUR: SEE ATTACHED CLAIM <br /> Identity of County Vehicle: (if applicable) Not applicable <br /> Name(s) of County Employee(s) involved: Robert McClellon (SJCEHD, Public Health Services); <br /> Steve Mindt (SJCEHD); Mike Huggins (SJCEHD); Alan Biedermann (SJCEHD) <br /> WHAT INJURIES OR DAMAGE DID CLAIMANT SUFFER: SEE ATTACHED CLAIM <br /> tv <br /> C:) <br /> x> � <br /> rn <br /> AMOUNT OF DAMAGE OR LOSS: Excess of $10,000 om <br /> PruMq Damage or Medical Biala t.n:s of In C/-,:5,- r Eve.of Repair Past/Eoimated Future PastiFnt C c), <br /> Excess of $10,000 tom' Vim . C <br /> Total Claim <br /> ` < rn <br /> I declaand penalty of perjury that the forgoing is true and correct. o '0 <br /> Attorney CA 12/04/01 <br /> I/Vgreareue Relationship to Signer,if no die claimant gate <br /> White-County Counsel <br /> Yellow-County Counsel NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY <br /> Pink-Claimant Pers.8(4/96) <br />