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Home My WebLink About2-18-25_Redacted.pdfOPCO TRANSIT, INC. 124 CAST F STREET — SWTE 10 —Ontario, CaiifOrnia 91754 TEL: (909) 293-7654 FAX: (909) 667-4564 Accident/Incident Vehicle Forms bZ Vehicle Number117, Driver Number 71-v sx�" Driver Name Date of Incident 2 2` By signin ,bel w, I acknowledge that everything in this report is true and accurate. 02 ZS� Contents Contents FORM A: DRIVER ACCIDENT/INCIDENT NOTIFICATION FORM ................. ... ,., . Accident Scene Information....................................................................................................,......1 FORMB: Medical Treatment Waiver Form............................................................................................................................3 Form C: Witness Form ............................................. ................................................................................ Form D: Accident/Incident Diagram....................................................6 j::�- 02 j S'--LR/"i' CC' --At M 016975� � � Bell and Yellow Cab Companies Accident/Incident Vehicle Forms FORM A: DRIVER ACCIDENT/INCIDENT NOTIFICATION FORM (TO BE COMPLETED BY DRIVER) PERPARED IN ANTICIPATION OF LITIGATION This Report is subject to the work product or attorney -client communication privilege and, as such, is confidential and not a public record under the California Public records Act. If the reader of this Report is not an intended recipient, you are hereby notified that any review, use, dissemination, forwarding or copying of this Report is strictly prohibited. Bell and Yellow Cab Companies 1 Accident/incident Vehicle Forms P1 YES NO Medical Attn Regaired? If No, complete Form B "Medical Waiver Form" Paramedics Called? Paramedic Company Name: Transport to Hos ital? Medical Facili game and Address: Alle ed In'uries: P2 L E010 Attn Re uired? If No, cone lete Form B " ical Waiver Form" Paramedics a medic Com ame; Trans ort to Hos ital? Medic ci d Address: Alle ed Injuries: P3 YES NO Medical Re aired? If No, complete Form B "Medical Waiver Form" P edits Called? Paramedic Com an Name: Transport to Hos ital? Medical Facili Name and Address: Alleged Iniurien, Driver Name Address Phone Number City, State, Driver License, including State: �3 r- Vehicle Make/Model/Year License Plate # and State: Insurance company: Insurance Policy#. Yes No 0 Damaged Vehicle?-� _ �` -T Yes? Please describe: Vehicle Tawed? Passenger(s) in vehicle, other than driver? Number of passengers: Passenger injuries? Yes No Witnesses? if Witness Full Name Wl W2 the "Witness For Horne Address and Phone Number Bell and Yellow Cab Companies Accident/Incident Vehicle Forms Accident Scene Information Date of incident5L — \ - Time of Incident: Location of Incident (Cross ` Streets): I G. �i ��RL�� Nearest Street Address and Ci : Photos Taken? Police at Scene? No Yes Police 1)e t. and Name: No Police Report? If yes, obtain face 61e page of report and officer's I No business card /mod eC—f��-T 7-1 N Number of Vehicles in the Accident j-211 Area Posted S eed Limit Estimatec�.s a for to accident Your vehicle: i Qther Vehicle: Was a t ffiT. si stop sign Yes No Facing Other vehicle? es facingNo you? -- Color of Traffic Si al facing ou? Facing Other vehicle? (z TRAFFIC:_ Hea Moderate lg t WEATHER; Clear Hazy Cloudy Foggy Raining Visibility: o Fair Poor Impaired/Obstructed If vision was obstructed please describe the type of obstruction`" ROAD CONDITIONS: la 13um Potholes U hill -Grade What kind of area did the accident happen in? Residential rad�eD Wet Sl[ttiness trial Other If "other", please describe: Did the accident occur in/at an intersection? Nb FOR COMPANY VEHICLE: The name of the street/freeway you were on? b What direction were you traveling/facing? ,t J How many TRAVEL lanes are therein each direction on the street you were on? 3 What lane was the COMPANY vehicle in (lane closest to center is No.l): Is there a parking lane at the curb? Yes Any parking prohibitions posted? /\_ j If on the freeway, was there a "diamond" or carpool lane?Yes No Solid center divider/med' ian. Ye No Painted center divider lane? Yes No Describe center dividing lines: One Soil One Broken Line line One Solid and one broken Two solid lines Two sets of solid lines lines Other type of Divider/Lines? Describe: Did your street have a designated left turn pocket? Name of the closest cross street/exit ahead of you; Two =U of alternating solid and broken M R_ No Name of the closest cross street/exit behind you: What type of traffic controls or traffic signs were present? - The name of the street/freeway the other car was on? What direction was it traveling/facing? WOR How many TRAVEL lanes are there in each direction on that street. What lane was the OTHER vehicle in (lane closest to center is No.1): 2 Is there a parking lane at the curb? Yes Any parking prohibitions posted? !Q D 5oiid center divider/med' Bell and Yellow Cab Companies I Accident/incident Vehicle Forms C- L � G `� R-t pan, a No Painted center divider lane? Yes No Describe center dividing lines: ne S line - n One Broken Line OnP cnra �-A ,..... L- Two solid lines Two sets of solid lines lines Two; of alternating solid and broken Other type of Divider/Lines? Describe: Did your street have a designated left turn pocket? No What type of traffic controls or traffic signs were present? _ OTHERINFORMATION/CQMMENTSABOUTTHELOCATION: �� Bell and Yellow Cab Companies Accident/Incident Vehicle Forms Form D: Accident/Incident Diagram Make sure to attach either a Google maps print out or some sort of diagram explaining what happened. T'ek-A PL.FL - I A 4 O P v t'zz!) Lkc tt-t I2 b X'-k: e- � --- fn. -?� SA DRIVER LICENSE California C6'16435 i CLASS c a,1 roe 19a28 FIND NONE CkP THIS VALIDATED REGISTRAT' o:ASHRAF VEHICLE FOR WHICH IT IS ] Fo ooHAMMADJOHN VEHICLE IS LEFT UNATTENDE OFFICER UPON DEMAND. IF Y -°oriN _ fiSTR NONE - TO PAY YOUR RENEWAL FEES PLANNED NON -OPERATIONAL S BE PAID ON OR BEFORE THE DUE PURSUANT TO CALIFORNI. 3 BE KEPT WITH THE APPLY WHEN THE ENT IT TO ANY PEACE �, USE THIS FORM SEX!M HAIRSLK EYES SLK VEHICLES OF THE HGT 5"10" WGT 168Ib '" I1sf0112022 '•ENEWAL FEES MUST DD jralrzazz61s1zra4Foza ,'NALTIES . WILL BE 9554. EVIDENCE OF LIABILITY INSURANCE FROM YOUR INSURANCE COMPANY MUST BE PROVIDED TO THE DEPARTMENT WITH THE PAYMENT OF RENEWAL FEES. EVIDENCE OF LIABILITY INSURANCE IS NOT REQUIRED WITH REGISTRATION RENEWAL OF OFF -HIGHWAY VEHICLES, TRAILERS, VESSELS, OR IF YOU FILE A PNO ON THE VEHICLE. WHEN WRITING TO DMV, ALWAYS GIVE YOUR FULL NAME, PRESENT ADDRESS, AND THE VEHICLE MAKE, LICENSE, AND IDENTIFICATION NUMBERS. DO NOT DETACH - REGISTERED OWNER INFORMATION ************** I 11111illll 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111�IIIVIII�IVIIIIiIIIiIIIVII!IiIVIIIiuUIIIiIIVllll' REGISTRATION CARD VALID FROM: 11/02/2024 TO MAF;E YR MODEL TOYT 2022 YR 1ST SOLI] VI,F 2022 CLASS TYPE VEIJ Kx 120 0 BODY TYPE MODEL MP No 4H Q FK TYPE VEHICLE USE AUTOMOBILE DATE ISSUED 11/05/24 CC/ALCO 30 DT FEE RECVD Pz8 11/05/24 REGISTERED 019NER ASHRAF MOHAMMAD JOHN BREA CA 92821 LIENHOLDER TOYOTA MTR CRDT CORP PO BX 105386 ATLANTA GA 30348 11/02/2025 TYPE LTC LICENSE NUMBER 11 9DTN281 VEHICLE ID NUMBER JTDKAMFP8N3222860 STICKER TSSUED T9767835 PR EXP DATE: 11/02/202Z AMOUNT PAID MISC#: M257543 $ 494.00 AMOUNT DuE AMOUNT RECVD $ 494.00 CASH CHICK 494.00 CRDT H00 C91 50 0049400 0004 CS HDO 110524 11 9DTN281 860