Collins v. County of Monterey Et Al. Complaint for Damages 6-11-14

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  • 8/12/2019 Collins v. County of Monterey Et Al. Complaint for Damages 6-11-14

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    28-1-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    H.NelsonMeeksCBN#175800LAWOFFICESOFH.NELSONMEEKS

    870MarketStreet,Suite700SanFrancisco,CA94102

    (415)989-9915(415)989-9914(FAX)

    AttorneyforPlaintiff

    STEPHENCOLLINS

    UNITEDSTATESDISTRICTCOURT

    FORTHENORTHERNDISTRICTOFCALIFORNIA

    ATSANFRANCISCO

    STEPHENCOLLINS

    PLAINTIFF,

    v.

    CountyofMonterey,CurtisWeeks,CharlesMcKee,IrvGrant,LouisR.

    Calcagno,DavidPotter,RobertMacLean,California-AmericanWater,

    AND

    DOES1--50

    Defendants.

    CASENO:

    COMPLAINTFORDAMAGES

    1. 42USCA19832. Fraud

    I. COMPLAINT1. PLAINTIFF, STEPHENCOLLINS (COLLINS),was amember of an

    advisoryboard [hereinafter ADVISORY BOARD] appointedby the Monterey County

    BoardofSupervisors[hereinafter,SUPERVISORS]foraperiodoftimeofapproximately

    16yearsendingonApril1,2011.

    2. Thiscomplaintconsistsof twocausesofaction.The first is fordamagessufferedonaccountoflocalgovernmentdeprivingCOLLINSofhisconstitutionalrights.

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    28-3-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    7. Plaintiff, STEPHENCOLLINS (COLLINS), is a citizen of theUnitedStatesandaresidentofMontereyCounty,California.

    8. Defendant, COUNTY OF MONTEREY (COUNTY) is a municipalcorporation,organizedunderthelawsoftheStateofCaliforniadoingbusinessinCalifornia

    as a government subdivision under colorof State authority and subject to the laws of this

    StateandtheUnitedStatesofAmerica.

    9. Defendant,CURTISWEEKS(WEEKS),atall timesmentionedhereinwasGeneralManageroftheMontereyCountyWaterAgencyandisaresidentofMonterey

    County,California.

    10. Defendant, CHARLES MCKEE (MCKEE), at all times mentionedhereinwastheCountyCounselforMontereyCounty.

    11. Defendant, IRVGRANT(GRANT),atall timesmentionedhereinwasDeputyCountyCounselfortheCOUNTY.

    12. Defendant, LOUIS R. CALCAGNO (CALCAGNO), at all timesmentioned herein was a member of the Monterey Board of Supervisors which is the

    governingboardoftheCOUNTY.

    13. Defendant,DAVIDPOTTER(POTTER),atalltimesmentionedhereinwas amember of theMontereyBoardofSupervisorswhich is thegoverningboard of the

    COUNTY.

    14. Defendant,ROBERTMACLEAN(MACLEAN),atalltimesmentionedhereinwasthePresidentofCalifornia-AmericanWaterCompany.

    15. Defendant, CALIFORNIA-AMERICAN WATER COMPANY (CAL-AM), is, and all times relevant mentioned hereinwas, aCalifornia corporation andwater

    utilityregulatedbytheCaliforniaPublicUtilitiesCommission,with itsprincipaladdressat

    1033BAvenue,Suite200,Coronado,CA92118. CAL-AMisawhollyownedsubsidiaryof

    AmericanWaterCompanyheadquarteredinVoorhees,NewJersey.

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    28-4-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    16. AtalltimesrelevanttothisComplaint,eachdefendantwhooccasionedtheacts and omissionswhich causeddamage toPlaintiff was actingwithin the scope of their

    officeoremployment.

    17. Plaintiff is ignorant of the true names and capacities of the defendantssuedasDOES1-50.Atallrelevanttimes,DefendantsDOES1through50(alsoreferredto

    hereinafter as the "DOEdefendants"), eachofwhomPlaintiff sues in hisorher individual

    capacity, were agents, employees, or otherwise representatives of the COUNTY or other

    businessentitiesdoingbusinesswiththeCOUNTY.Atallrelevanttimes,DOES1through

    25actedundercolorofCalifornialaw.Plaintiffisinformedandbelievesandthereonalleges

    that thatmany, if not all, ofDOES1 through 50 are residents of theNorthernDistrict of

    California. Plaintiff is informedandbelievesandthereonallegesthatDOES1through50,

    inclusive, are legally responsible for the wrongs committed against Plaintiff, as alleged

    herein.WhenPlaintiffbecomeawareofthetrueidentitiesofoneormoreDOEdefendants,

    PlaintiffswillamendthiscomplainttoaddorsubstitutethemasnamedDefendants.

    18. Plaintiff is informedandbelievesandthereonallegesthattheDefendantsCOUNTY,WEEKS,MCKEE,GRANT,CALCAGNO,andPOTTER,andtheDOEdefendants1-

    25caused,andareliablefortheunconstitutionalandunlawfulconductandresultinginjuries,

    by,amongotherthings,personallyparticipatinginsaidconductoractingjointlywithothers

    whodidso;byauthorizing,acquiescingorsettinginmotionpolicies,plansoractionsthatled

    totheunlawfulconduct;byfailingtotakeactiontopreventtheunlawfulconduct;byfailing

    or refusing with deliberate indifference to refrain from violating Plaintiffs constitutional

    rights;and/orbyratifyingtheunlawfulconducttakenbyemployeesundertheirdirectionand

    control.

    V. FACTSCOMMONTOALLCLAIMSFORRELIEF19. In 2009, the State Water Resources Control Board issued a cease and

    desistorderhavingtheeffectofreducingwateravailabletocitizensofMontereyCounty.

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    28-5-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    20. In response, the SUPERVISORS commenced an effort to obtainpermitting to allow for theproduction of drinkable waterby way of aprocess called

    desalinationwhichtakesoceanwaterandremovesthesalt[hereinafter,thePROJECT].

    21. Defendant,WEEKS,whowasthentheGeneralManageroftheMontereyCountyResourceAgency,wasappointedbytheBoardofSupervisorstoleadthePROJECT

    permittingeffort.

    22. In late 2009, the SUPERVISORS believed that WEEKS could notaccomplishthetaskandcertainmembersconcludedthatCOLLINSshouldbehiredtopursue

    PROJECTpermittingandengageinrelatedeffortstomakedesalinationareality.

    23. In early January 2010, Defendant CALCAGNO, called COLLINS andsaid that the Project was falling apart and COLLINS needed to take over and close the

    deal. CALCAGNOstatedIknowyoudontworkforfree. CALCAGNOstatedhewould

    figureouthowtogetCOLLINSpaid.

    24. About the same time, CALCAGNO called James Heitzman (HEITZMAN)toarrangeforCOLLINStobepaid.

    25. Thereafter, WEEKS called COLLINS and HEITZMAN to arrange ameetingtodiscussterms. WEEKStoldCOLLINSthatLouismovingquicklyandwantsto

    getyouhired.

    26. OnJanuary11,2010ameetingwasheldatWEEKSofficewithWEEKS,HEITZMAN andCOLLINS in attendance. LYDELLMELTON, aprinciple of theRMC

    Environmental consulting firm, was contactedby telephone to work out the terms of the

    agreementwherebyRMCwouldpayCOLLINStoworkonthePROJECT. Atthatmeeting,

    COLLINSbroughtupthepossibilitythattherecouldbeaconflictof interestandsuggested

    thatheresignhisdirectorshipwiththeADVISORYBOARDtoavoidthepotentialproblem.

    WEEKSstatedhewouldconsultwithcountycounseltocheckonthepotentialconflictissue

    raisedbyCOLLINS.

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    28-6-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    27. OnJanuary12,2010,WEEKScontactsCOLLINSandadvisesthathehasdiscussedtheconflictof interestissuewithbothcountycounselandCALCAGNOandboth

    state that COLLINS does not have a conflict of interestproblem and can enter into the

    contract with RMC without resigning his directorship with the ADVISORY BOARD.

    WEEKScommunicatedthatcountycounselhadissuedanopinionletter. WEEKSalsostated

    that county counsel stated you are entitled to earn a living as long as you dontbill for

    agencyorBoardofSupervisormeetings,yourefine.

    28. Later thatday,COLLINScontactsCALCAGNOwhoassuresCOLLINSthatthereisnoconflict,so,shut-upaboutthisresigningcrap,youarethegluethatholdsthe

    advisoryboardtogether,youcannotresign.

    29. OnJanuary13,2010COLLINSsignstheRMCcontractinSanFrancisco.30. OnJanuary14,2010variousparties interested in thePROJECTmeet in

    San Francisco. WEEKS, GRANT, MACLEAN, HIETZMAN and a variety of others

    principalsandcounselfortheinterestedpartieswerepresent. ThepartiesincludeCAL-AM,

    MarinaCoastWaterDistrict,theCOUNTY,andRMC. COLLINSandWEEKSwerethere

    onbehalfoftheCOUNTY. WEEKSadvisedthegroupthattheconflictofinterestissuehad

    beenaddressedanddidnotpresentaproblem.

    31. Later inJanuary,COLLINSmeetswithDefendant,POTTER,whostateshewasgladCOLLINSwasworkingon thePROJECT. POTTERstates, CALCAGNOS

    beenbeatingtheshitoutof[WEEKS].

    32. In early March 2010, counsel for Marina Coast Water District, LloydLowery,expressesconcernovertheconflictofinterestissueandrequestanopinionfromthe

    DowneyBrandfirm.

    33. OnJune3-4, 2010,COLLINS andWEEKSmetwithDanCarroll fromDowneyBrand regarding the conflict of interest issue. COLLINS is advisedbyGRANT,

    DanCarrolland,MarkFogelman(counselforMarinaCoastWaterDistrict),thathedoesnot

    haveaconflictofinterestproblem.

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    28-7-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    34. On December 2, 2010, the Public Utilities Commission grants thePROJECT.

    35. On December 7, 2010, COLLINS meets with the SUPERVISORS andadvisesthatsitforme,Imdone. WEEKS,GRANT,CALCAGNO,POTTERandothers

    were inattendance. CALCAGNOstatedno, Idont think so,POTTERstated,no, that

    wontwork,whowillpay? At leastPOTTERandCALCAGNOwereseekingadditional

    sourcestopayCOLLINStocontinueworkingonthePROJECT.

    36. OnJanuary11,2011,inCALCAGNOSoffice,COLLINSisadvisedthatheneedstokeepworkingonthePROJECTandthatCALCAGNOwillfindasupplemental

    sourcetopayCOLLINSforhiswork.

    37. OnJanuary11,2011,theSUPERVISORSvotetoapprovethePROJECTasapprovedbythePublicUtilitiesCommissiononDecember2,2010.

    38. OnApril11,2011,COLLINSresignsfromtheADVISORYBOARD.39. OnJune16,2011,CALCAGNOisreportedinthenewspaperassayingI

    had no inclination that Stevewas hiredbyRMC if I had, let me tell you, Iwouldve

    advisedhimhebettergethisacttogetherrightaway.

    40. OnNovember 1, 2011, the Monterey CountyDistrictAttorneysOfficecirculates andpresents to the SUPERVISORS and a number of staff members including

    MCKEEitsdraftcomplaintcriminallycharging,COLLINSforthepurposeofcommentand

    review.

    41. OnNovember15,2011,theMontereyCountyDistrictAttorneysOfficefilesacomplaintcriminallychargingCOLLINSwithconflictofinterestandembezzlement.

    42. OnMarch18,2014,COLLINSacceptstheplea.

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    28-8-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    FIRSTCLAIMFORRELIEF

    (ViolationofSection1983ofTitle42oftheUnitedStatesCode:

    DueProcessClauseoftheFourteenthAmendment)

    (AgainstDefendantsCOUNTY,WEEKS,MCKEE,

    GRANT,CALCAGNO,POTTER,andDOES1-25)

    43. PLAINTIFFreferstoandincorporatestheaboveasthoughfullysetforthherein.

    44. DEFENDANTS, WEEKS, MCKEE, GRANT, CALCAGNO, ANDPOTTER,activelyassuredPLAINTIFF,fromJanuary11,2010throughMarch2010thathis

    conduct in connection with receiving money from RMC while simultaneouslybeing a

    memberofADVISORYBOARDwaslawful.

    45. During this period of time said DEFENDANTS repeatedly assuredPLAINTIFF that his conductwas not illegalorotherwiseunlawful. PLAINTIFF is led to

    believebyDEFENDANTSthattheCOUNTYsupportshiseffortsandthatheisnotat-risk

    frombeingprosecutedforanyallegedwrong-doingandcertainlynotbytheCOUNTY.

    46. SaidDEFENDANTSwereauthorizedgovernmentofficialsempoweredtorenderadviseonbehalfoftheCOUNTY.

    47. Said DEFENDANTS were aware of all relevant historical andcontemporaneousfactsatthetimeoftheirrenderingtheirassurances.

    48. Said DEFENDANTS communicated under the color of their officialcapacity.

    49. SaidDEFENDANTSaffirmativelytoldPLAINTIFFthathisconductwasdesiredbytheCOUNTY,thathisproposedconducthadbeenreviewedbytheCOUNTYS

    attorneys,andthathisconductwaspermissible.

    50. PLAINTIFFreasonablyrelieduponsaidassurances.51. PLAINTIFF offered to resign from the ADVISORY BOARD, thereon

    eliminatinganypotentialconflictofinterest,andhewasdirectedbysaidDEFENDANTSnot

    toresign.

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    28-9-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    52. PLAINTIFF was sincerely desirous of obeying the law andproceededwith his unlawful conduct solely on account of the repeated assurances by said

    DEFENDANTSthatallwaswell.

    53. SaidDEFENDANTSadvicewasfalse.54. PLAINTIFFwascriminally chargedby theCOUNTYonNovember15,

    2011forconductwhichhadbeenpreviouslyratifiedbysaidDEFENDANTS.

    55. PLAINTIFFS14thAmendment right todueprocesswasviolatedby theforegoingallegations.

    56. PLAINTIFFwasdamagedonaccountoftheforegoing.57. PLAINTIFFdiscoveredhewasdamagedsometimeafterSeptember2011

    and he has suffered monetary damages therefrom. PLAINTIFFs damages accrued on or

    afterMarch18,2014.

    58. PLAINTIFF is informed andbelieved that DEFENDANTS at all timeseither knew or recklessly and callously disregarded the unlawful nature of COLLINS

    conduct.

    SECONDCLAIMFORRELIEFFRAUD

    (AgainstDefendants,COUNTY,WEEKS,MCKEE,GRANT,CALCAGNO,

    POTTER,MACLEAN,CAL-AMandDOES1-50)

    59. PLAINTIFF refers to and incorporates the aboveparagraphs as thoughfullysetforthherein.

    60. DEFENDANTSrepresented toPLAINTIFF thathis actionsasdescribedhereinwerelawful.

    61. Saidrepresentationswerefalse.62. DEFENDANTSknewthattheirrepresentationswerefalsewhenmade,or

    thattheymadetherepresentationsrecklesslyandwithoutregardforthetruth.

    63. DEFENDANTSintendedthatPLAINTIFFrelyontheirrepresentations.

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    28-10-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    64. DEFENDANT, CAL-AM,benefitted from PLAINTIFFbeing chargedwithaconflictofinterestbecausethisallowedCAL-AMtoseekaconstructionprojectworth

    $250million.

    65. PLAINTIFFreasonablyreliedonDEFENDANTSrepresentations.66. PLAINTIFFwasharmedonaccountofhisrelianceontherepresentations

    madebyDEFENDANTS.

    PRAYERFORRELIEF

    WHEREFORE,PLAINTIFFpraysthat:

    1. JudgmentbeenteredinfavorofPLAINTIFFonallclaimsforrelief;2. Actual andcompensatorydamagesagainsteach andeveryDefendant in

    anamounttobedetermined;

    3. AttorneyfeesandcostsofsuitagainsteachandeveryDefendant,pursuantto all applicable statutory, common law, or constitutional provisions

    includingbutnotlimitedto42U.S.C.1988;and

    4. SuchadditionalreliefastheCourtmaydeemjustandproper.Dated: June11,2014

    Respectfullysubmitted,

    __________SS______________________

    H.NelsonMeeks,Esq.

    AttorneyforPLAINTIFF

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    28-11-

    COMPLAINT

    LawO

    fficesofH.NelsonMeeks

    870MarketStreet,

    Suite700

    SanFrancisco,

    CA94102

    Collinsv.Weeks

    DEMANDFORJURYTRIAL

    Plaintiffherebydemandsatrialbyjuryonallissuessotriabletothefullextentpermittedby

    law.

    Dated: June11,2014

    Respectfullysubmitted,

    ____________SS____________________

    H.NelsonMeeks,Esq.AttorneyforPLAINTIFF

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    JS-44 (Rev (, 13 Rl) CIVIL COVER SHEETI. (a) PLAINTIFFS DEFENDANTS County of Monterey, Curtis Weeks, Charles McKeeStephen Collins Irv Grant, Louis R. Calcagno, David Potter, Robert MacLean,California-American Water and Does 1-50

    (b) County of R e s i d t : : n c ~ of First Listed Plaintiff Monterey County of Residence of First Listed Defendant M o n t e r ~(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONL )NOTE: IN LANO CONDEMNATION CASES, USE THE LOCATION OF THE

    (c) At1omey's (Finu Nam< , Addrc:ss, ~ n d Telephone Number) LA" D INVOLVED.H. Nelson Meeks Allorneys (lfl(nown)LAW OFFICES OF H. NELSON MEEKS870 Market St., Ste. 700, San Francisco CA 94102

    II. BASIS OF JURISDICTION (Place an ..X in One Box Only) I l l. CITIZENSHIP OF PRINCIPAL PARTIES (Place an x in One Box for Plaintiff(For Divctsily C a ~ t : ~ Only) an

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    V. ORIGI'\ Place an hX In One Bo'\: Only)

    Ell 02 03 04 os 06 07Original Removed from Rc1nandcd from Reinstated or Trans felTed from Multidistrict p p ~ a l to District J m i g ~Proce.:dmg Stote Coutt Appellate Court Reopened another distiicl Litigation From M:tgijtrate Judgment(Speedy)

    Cite the U.S. Ci\'il t a t u t ~ uudcO r \vhich yau an:- tiling Do not cite jurisdlctional statutes unlus diversity):

    42 usc 1983VI. CAUSE OF ACTION Blic descliption of cau5c:

    VII. REQUESTED IN 0 Check if this is a Class Action DEMANDS JURY DEMAND I I Yes 0 NoCOI\TPLAINT Cndcr F.R.C.P. 23 (Check Y E S ~ 1f detmnded in compLJint)

    VIII. RELATED CASE(S)IF ANY JUDGE DOCKET NUMBER

    Because of the need for accurate and complete mformatton, you should ensure the accuracy of the mformat1on prov1ded pnor to stgmng the form.

    une 11 2014D a t ~

    INSTRUCTIO'IS FOR COMPLETING CIVIL COVER SHEET JS-44Authority for Civil Cover Sheet

    The JS-44 civil cover sheet and the infonnation contained herein neither replaces nor supplements the filings and service of pleadings or other papers as requitedby law, except as provided by local rules of court. This fonu, approved by the Judicial Conference of the United States in September 1974 is required for the use of the Clerkof Court for the puqJosc of initiating the civil docket sheet. Consequentl y a civil cover sheet is submit ted to the Clerk of Cottt1 for each civil compla int filed. List ed belowarc tips for completing the civil cover sheet. These tips coincide with the Roman Numerals on the Cover Sheet.

    I COUNTY OF RESIDENCE OF FIRST LISTED PLAINTIFF DEFENDANT (b) County of residence: For each civil case filed, except U.S. plaintiffcases, enter the name of the county where the first listed plaintiff resides at the time of filing. In U.S. plainti ff cases, enter the name of the county inwhich the first listed defendant resides at the time of filing. (NOTE: In land condemnation cases, the county of residence of the "defendant" is thelocation of he tract of land involved.)

    111. CITIZENSHIP OF PRINCIPAL PARTIES: This section is c o m p l e t e d ~ if diversity of citizensl1ip was selected as the Basis of Jurisdiction underSection II.

    IV. NA TUIU: O SUIT: Place an X in the appropriate box. Make sure to select the Natme of Suit from the categ01y which hest describes the primaJy causeof action found iu your complaint. You must select only one nature of suit.

    Vlll. RELATED CASES, IF ANY: This section of the JS-44 is used to reference related pending cases if any. If there are related pending cases, insert thedocket numbers and the corresponding judge names for such cases.

    FOR OFFICE USE ONLY

    Receipt# A m o u n t ~ Applying IFP ~ Judge Mag. Judge

    Violation of substantive and procedural due process. Plaintiff's liberty interest inreputation, profession, integrity were violated by defendants' fraudulent conduct.

    5,000,000.00

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    AO 440 (Rev. 06/12) Summons in a Civil Action

    UNITED ST TES DISTRICT COURT

    Stephen Collins

    Plaintiff(s)v.

    for theNorthern District of California [ ]

    Civil Action No.County of Monterey, Curtis Weeks, Charles McKee,lrv Grant, Louis R. Calcagno, David Potter,Robert Maclean California-American Waterand Does 1-50

    Defendant(s)

    SUMMONS IN CIVIL CTIONTo: (Defendant s name and address) o u r t ~ t y W o f Mkonterey 168 West Alisal Street, 3rd Floor, Salinas CA 93901u IS ee s -- 82 Corral de Tierra Road., Salinas CA 93908Charles McKee -- 168 West Alisal Street, 3rd Floor, Salinas CA 93901lrv Grant -- 168 West Alisal Street, 3rd Floor, Salinas CA 93901Louis R. Calcagno -- 168 West Alisal Street, 3rd Floor, Salinas CA 93901David Potter -- 168 West Alisal Street, 3rd Floor, Salinas CA 93901Robert Maclean -- 1033 B Avenue, Ste. 200, Coronado CA 92118California-American Water-- 1033 B Avenue, Ste. 200, Coronado CA 92118

    A lawsuit has been filed against you.Within 21 days after service of this summons on you (not counting the day you received i t - or 60 days if you

    are the United States or a United States agency, or an officer or employee of the United States described in Fed. R Civ.P. 12 (a)(2) or 3 - you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 ofthe Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff s attorney,whose name and address are: H Nelson MeeksLAW OFFICES OF H. NELSON MEEKS870 Market St., Ste. 700San Francisco CA 941 02

    If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.You also must file your answer or motion with the court.

    CLERK OF OURT

    Date:Signature ofClerk or Deputy Clerk

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    AO 440 (Rev. 06112) Summons in a Civil Action (Page 2)Civil Action No.

    PROOF OF SERVICEThis section should not be filed with the court unless required by Fed. R Civ P 4 l))

    This summons for (name o ndividual and title, iwas received by m on (date)

    I personally served the summons on the individual at (place)on (date) ; or

    left the summons at the individual's residence or usual place of abode with (name)

    on (date), a person of suitable age and discretion who resides there,

    , and mailed a copy to the individual's last known address; orserved the summons on (name o ndividual) , who is

    designated by law to accept service of process on behalfof (name o organization)on (date) ;or

    returned the summons unexecuted because ; orOther (specifjY:

    My fees areS for travel and for services, for a total of 0.00

    I declare under penalty ofperjury that this information is true.

    Date:Server s signature

    Printed name a nd title

    Server s address

    Additional infonnation regarding attempted service, etc: