Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_06-cv-00554/USCOURTS-caed-1_06-cv-00554-0/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Carole Henry
Plaintiff

Document Text:

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

CAROLE HENRY, )

)

Plaintiff, )

v. )

)

MICHAEL J. ASTRUE, )

Commissioner of Social )

Security, )

)

Defendant. )

)

 )

1:06-cv-00554-AWI-SMS

FINDINGS AND RECOMMENDATION RE:

PLAINTIFF’S SOCIAL SECURITY

COMPLAINT (DOC. 2)

Plaintiff is proceeding in forma pauperis and with counsel

and is seeking judicial review of a final decision of the

Commissioner of Social Security (Commissioner) denying an

application for benefits. The matter has been referred to the

Magistrate Judge pursuant to 28 U.S.C.§ 636(b) and Local Rule 72-

302(c)(15). The matter is currently before the Court on the

parties’ briefs, which have been submitted without oral argument.

I. Procedural History

On September 4, 2003, Plaintiff applied for Disability

Insurance Benefits (DIB), alleging disability since May 23, 2003,

due to pain in her hands, wrists, thumbs, and shoulders, muscle

spasms, chronic tendinitis, inability to stand for very long,

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swelling and stiffness in the hands, asthma, allergies, irritable

bowel syndrome, depression (A.R. 83-86, 90-108, 134-37.) After

Plaintiff’s claim was denied initially and on reconsideration,

Plaintiff requested a hearing. Plaintiff appeared with an

attorney and testified at a hearing before the Honorable Sean

Techan, Administrative Law Judge (ALJ) of the Social Security

Administration (SSA), which took place on August 24, 2005. (A.R.

236-301, 12.) On December 30, 2005, the ALJ denied Plaintiff’s

application for benefits. (Id. at 12-19.) Plaintiff appealed the

ALJ's decision to the Appeals Council. After the Appeals Council

denied Plaintiff’s request for review on March 22, 2006,

Plaintiff filed the complaint in this action on May 4, 2006. (Id.

at 4-6.) Briefing commenced on March 9, 2007, and was completed

on April 9, 2007.

II. Scope and Standard of Review 

Congress has provided a limited scope of judicial review of

the Commissioner's decision to deny benefits under the Act. In

reviewing findings of fact with respect to such determinations,

the Court must determine whether the decision of the Commissioner

is supported by substantial evidence. 42 U.S.C. § 405(g).

Substantial evidence means "more than a mere scintilla,"

Richardson v. Perales, 402 U.S. 389, 402 (1971), but less than a

preponderance, Sorenson v. Weinberger, 514 F.2d 1112, 1119, n. 10

(9th Cir. 1975). It is "such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion."

Richardson, 402 U.S. at 401. The Court must consider the record

as a whole, weighing both the evidence that supports and the

evidence that detracts from the Commissioner's conclusion; it may

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not simply isolate a portion of evidence that supports the

decision. Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9 Cir. th

2006); Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). It

is immaterial that the evidence would support a finding contrary

to that reached by the Commissioner; the determination of the

Commissioner as to a factual matter will stand if supported by

substantial evidence because it is the Commissioner’s job, and

not the Court’s, to resolve conflicts in the evidence. Sorenson

v. Weinberger, 514 F.2d 1112, 1119 (9 Cir. 1975). th

In weighing the evidence and making findings, the

Commissioner must apply the proper legal standards. Burkhart v.

Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must

review the whole record and uphold the Commissioner's

determination that the claimant is not disabled if the

Commissioner applied the proper legal standards, and if the

Commissioner's findings are supported by substantial evidence.

See, Sanchez v. Secretary of Health and Human Services, 812 F.2d

509, 510 (9th Cir. 1987); Jones v. Heckler, 760 F.2d at 995. If

the Court concludes that the ALJ did not use the proper legal

standard, the matter will be remanded to permit application of

the appropriate standard. Cooper v. Bowen, 885 F.2d 557, 561 (9th

Cir. 1987). 

Here, the ALJ concluded that although Plaintiff, a fiftyseven-year-old person with a high school education and three

years of college, suffered severe impairments of obesity,

osteoarthritis, degenerative joint disease with multiple

arthralgia, and chronic obstructive pulmonary disease that did

not meet or medically equal one of the listed impairments;

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Plaintiff had the residual functional capacity to lift and carry

ten pounds occasionally and frequently; stand and walk two to

four hours in eight and sit six hours, but was limited from

forceful and frequent use of the lower extremities, limited to

occasional climbing, balancing, stooping, kneeling, crouching,

crawling, and reaching overhead with both arms; and should avoid

fumes, dusts, gases and uneven terrain. Mentally she was able to

follow work rules, relate to coworkers, deal with the public,

interact with supervisors, function independently, and

understand, remember, and carry out detailed job instructions as

well as maintain personal hygiene and demonstrate reliability.

Plaintiff could perform her past relevant work as a legal

secretary and secretary as performed and as generally performed

in the regional and national economy. Thus, Plaintiff was not

disabled. (A.R. 13, 18.)

III. Disability

In order to qualify for benefits, a claimant must establish

that she is unable to engage in substantial gainful activity due

to a medically determinable physical or mental impairment which

has lasted or can be expected to last for a continuous period of

not less than twelve months. 42 U.S.C. §§ 416(i), 1382c(a)(3)(A).

A claimant must demonstrate a physical or mental impairment of

such severity that the claimant is not only unable to do the

claimant’s previous work, but cannot, considering age, education,

and work experience, engage in any other kind of substantial

gainful work which exists in the national economy. 42 U.S.C.

1382c(a)(3)(B); Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th

Cir. 1989). The burden of establishing a disability is initially

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28 All references are to the 2005 version of the Code of Federal Regulations unless otherwise noted. 1

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on the claimant, who must prove that the claimant is unable to

return to his or her former type of work; the burden then shifts

to the Commissioner to identify other jobs that the claimant is

capable of performing considering the claimant's residual

functional capacity, as well as her age, education and last

fifteen years of work experience. Terry v. Sullivan, 903 F.2d

1273, 1275 (9 Cir. 1990). th

The regulations provide that the ALJ must make specific

sequential determinations in the process of evaluating a

disability: 1) whether the applicant engaged in substantial

gainful activity since the alleged date of the onset of the

impairment, 20 C.F.R. § 404.1520 (1997); 2) whether solely on the 1

basis of the medical evidence the claimed impairment is severe,

that is, of a magnitude sufficient to limit significantly the

individual’s physical or mental ability to do basic work

activities, 20 C.F.R. § 404.1520(c); 3) whether solely on the

basis of medical evidence the impairment equals or exceeds in

severity certain impairments described in Appendix I of the

regulations, 20 C.F.R. § 404.1520(d); 4) whether the applicant

has sufficient residual functional capacity, defined as what an

individual can still do despite limitations, to perform the

applicant’s past work, 20 C.F.R. §§ 404.1520(e), 404.1545(a); and

5) whether on the basis of the applicant’s age, education, work

experience, and residual functional capacity, the applicant can

perform any other gainful and substantial work within the

economy, 20 C.F.R. § 404.1520(f). 

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With respect to SSI, the five-step evaluation process is

essentially the same. See 20 C.F.R. § 416.920.

IV. Pulmonary Impairment Found Not to Meet a Listing

Plaintiff argues that the ALJ’s finding that Plaintiff’s

chronic obstructive pulmonary disease did not meet or equal

listing 3.03(B) was not supported by substantial evidence in the

record.

Plaintiff’s history of treatment for chronic obstructive

pulmonary disease included acute exacerbation in June 2004 which

involved being seen in the emergency room and which Dr. Wageneck

noted was accompanied with abuse of tobacco. Plaintiff was

treated with medication and an inhaler and was strongly advised

to quit smoking due to lung disease and risks of surgery if she

continued to be a smoker. (A.R. 204, 232-35.) Plaintiff continued

to smoke at that time. (A.R. 232.) She experienced hypoxia and

acute exacerbation again on August 18, 2004, resulting in the use

of oxygen and transfer to the Selma Hospital for further

treatment. (A.R. 200.) Plaintiff was treated with continued

oxygen therapy and medication, and her condition stabilized in

September 2004. (A.R. 198-99.) In August, Plaintiff stated that

she had quit smoking about a month before. (A.R. 227-31). 

Plaintiff was given emergency room treatment on October 16, 2004,

for dyspnea, with a diagnosis of bronchitis treated with

medication, and thereafter resolving (A.R. 196); she again

received treatment at the Selma emergency room for sinusitis and

cough in January 2005. (A.R. 192.) Plaintiff stated she had

stopped smoking six months before. (A.R. 221-25, 223.) In April

2005, Dr. Wageneck’s progress notes reflected Plaintiff had acute

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exacerbation of her COPD and was prescribed QVAR twice a day and

nebulizer treatements four times a day (A.R. 190); in July 2005,

an oxygen request was faxed to Pacific Pulmonary Services (A.R.

189).

Plaintiff states that she was again hospitalized on April 7,

2005, but the progress notes for this date indicate treatment for

followup for COPD, with an assessment of acute exacerbation, but

not any emergency hospitalization. (A.R. 191 [progress note], 190

[typed progress note].)

In his decision, the ALJ recited Plaintiff’s history of

treatment for chronic obstructive pulmonary disease (COPD),

including acute exacerbation in April 2005 and oxygen treatment

in 2005; emergency treatment on June 7, 2004, October 16, 2004,

and January 11, 2005; and hospitalization beginning August 18,

2004, until August 21, 2004. (A.R. 14-16.) The ALJ noted that in

June 2004, Plaintiff was still smoking despite advice to quit.

(A.R. 14.) The ALJ recited Plaintiff’s position that she met

listing 3.02 for chronic obstructive pulmonary insufficiency;

however, the ALJ stated that Plaintiff provided no pulmonary

function tests to support the position. (A.R. 15.) Further,

although Plaintiff suffered attacks requiring emergency treatment

and/or overnight hospitalization, these phenomena had not

occurred at the frequency required by listing 3.03. Although

Plaintiff had been receiving in-home oxygen, the ALJ noted

Plaintiff’s testimony that she continued to smoke five cigarettes

per day, and although she was trying to quit, it was

exceptionally hard because she lived in a house with others who

smoked. (A.R. 15, 16, 257-58.) 

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Contrary to Plaintiff’s argument, the record supports the

ALJ’s conclusion that Plaintiff’s condition did not meet the

listing. Listing 3.03(B), which pertains to asthma, requires:

B. Attacks (as defined in 3.00C), in spite of 

prescribed treatment and requiring physical intervention,

occurring at least once very two months or at least six

times a year. Each in-patient hospitalization for longer

than 24 hours for control of asthma counts as two

attacks, and an evaluation period of at least 12

consecutive months must be used to determine the

frequency of attacks.

Section 3.00(C) provides in substance that when a respiratory

impairment is episodic in nature, as can occur with exacerbations

of asthma, the documentation for exacerbations should include

available hospital, emergency facility and/or physician records

and clinical and laboratory findings on presentation, such as the

results of spirometry and arterial blood gas studies. Further, §

3.00(C) defines attacks of asthma as referred to in paragraph B

of 3.03 as follows:

...prolonged symptomatic episodes lasting one or more

more days and requiring intensive treatment, such as 

intravenous bronchodilator or antibiotic administration

or prolonged inhalational brochodilator therapy in 

a hospital, emergency room or equivalent setting.

20 C.F.R., Pt. 404, Subpt. P, App. 1, § 3.03. It further provides

that hospital admissions are defined as inpatient

hospitalizations for longer than 24 hours, and it states that the

medical evidence must include information documenting adherence

to a prescribed regimen of treatment as well as a description of

physical signs. For asthma, the section expressly states that 

the medical evidence should include spirometric results obtained

between attacks that document the presence of baseline airflow

obstruction. Id. 

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Here, the regulation requires incidents either every two

months, which was not shown by the evidence, or six times within

a year. Plaintiff had only five incidents (three emergency room

visits and one in-patient hospitalization counting as two

incidents, for a total of five) in the year following June 7,

2004. Plaintiff argues that the episode of April 7, 2005, counts

as an incident. However, the record of April 7, 2005, consists of

progress notes from United Health Centers, and not from a

hospital; although acute exacerbation of COPD was part of the

assessment, Plaintiff had presented herself not for emergency

treatment, but rather for followup on left hip pain and on COPD

after running out of Doxepin and starting to have allergy

symptoms with worsening dyspnea. (A.R. 190.) There was scattered

wheezing but no rhonchi or rales. Peak flow was 90, 100, 110,

with pulse oximetry 93 per cent on room air. The plan was to

continue QVAR, 80 meg. two puffs twice a day, and Albuterol and

Atrovent nebulizer treatments four times a day, with Singulair 10

mg. daily and Doxepin 25 mg. at bedtime. (Id.) There is no

indication that Plaintiff received any intensive treatment,

required or otherwise, in a hospital, emergency room, or

equivalent setting. Further, the evidence supports the ALJ’s

finding that Plaintiff continued to smoke cigarettes despite

medical advice to the contrary. Although Plaintiff testified that

Dr. Whiteneck had said that second-hand smoke was worse for her

than smoking, it was clear that Plaintiff had been advised to

quit smoking and simply had not complied. (A.R. 258.)

One who claims upon review that the ALJ erred in not

determining and finding that a claimant’s combined impairments

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met a listing must offer a theory of how the impairments combined

to equal a listed impairment and point to evidence that shows

that his combined impairments equal a listed impairment. Lewis v.

Apfel, 236 F.3d 503, 514 (9 Cir. 2001). It is Plaintiff’s burden th

to establish that his impairment met a listing. Bowen v. Yuckert,

482 U.S. 137, 146 n.5 (1987). Mere diagnosis of a listed

impairment is not sufficient to sustain a finding of disability;

there must also be the findings required in the listing. Young v.

Sullivan, 911 F.2d 180, 183 (9 Cir. 1990); 20 C.F.R. § th

416.925(d). Generally, specific medical findings are needed to

support the diagnosis and the required level of severity. 20

C.F.R. §§ 404.1525(c)-(d), 416.925(c). The Commissioner is not

required to state why a claimant failed to satisfy every

different section of the listing of impairments; rather, it is

sufficient to evaluate the evidence upon which the ultimate

factual conclusions are based. Otherwise, an undue burden would

be put on the social security disability process. Gonzales v.

Sullivan, 914 F.2d 1197, 1200-01 (9 Cir. 1990). th

Therefore, the Court concludes that the ALJ’s finding

concerning Plaintiff’s COPD was supported by substantial

evidence, and it was articulated in a manner consistent with the

pertinent legal standards and sufficient to permit meaningful

review.

Finally, Plaintiff argues that because Plaintiff had other

impairments consisting of degenerative joint disease with

multiple arthralgia, osteoarthritis, and obesity, she necessarily

had an impairment that was equivalent to a listed impairment.

However, the ALJ evaluated her other impairments, concluding that

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Plaintiff was not receiving the types or amounts of medication

normally associated with a chronic pain syndrome or treatment at

a pain clinic. Further, her treating physician had prescribed

weight loss, cessation of smoking, and exercise, and had not

precluded Plaintiff from working. (A.R. 16.) Further, the ALJ

noted that Plaintiff’s obesity had not affected her ability to

work and thus did not appear to create greater severity to her

level of disability when considered in combination with her

asthma/chronic obstructive pulmonary disease. (A.R. 16.)

Plaintiff cites to no evidence contradicting these findings and

does not specifically challenge the sufficiency of the evidence

in this regard. 

V. Failure to Find that Plaintiff’s Depression was Severe 

Plaintiff attacks the ALJ’s conclusion that Plaintiff

suffered from depression/anxiety that was not severe. (A.R. 13.)

Plaintiff argues that there is substantial evidence in the record

of Plaintiff’s depression, pointing to a treating physician’s

prescription of the anti-depressant Doxepin and references to

Plaintiff’s depression. (A.R. 172 [mention in April 2003 of

depression with anxiety in assessment, but no findings]; 173

[mention in January 2003 of depression in assessment,

prescription for Wellbutrin, but no findings]; 199 [reference in

August 2004 to prescription for Doxepin 50 mg. at bedtime due to

insomnia and itching, and to limit her evening nebulizer

treatment if breathing was good and she was having trouble

sleeping, but no findings]; A.R. 274-75 [testimony of Plaintiff

that she took Doxepin for anxiety and depression, but she did not

talk about depression with Dr. Whiteneck, the doctor who was

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prescribing the medication for depression, because due to a lack

of transportation, Plaintiff could not go to mental health].)

At step two, the Secretary considers if claimant has "an

impairment or combination of impairments which significantly

limits his physical or mental ability to do basic work

activities." 20 C.F.R. §§ 404.1520(c), 416.920(c). This is

referred to as the "severity" requirement and does not involve

consideration of the claimant's age, education, or work

experience. Id. The step-two inquiry is de minimis screening

device to dispose of groundless claims. Bowen v. Yuckert, 482

U.S. 153-54 (1987). The Secretary is required to "consider the

combined effect of all of the individual's impairments without

regard to whether any such impairment, if considered separately,

would be of [sufficient medical] severity." 42 U.S.C. §

1382c(a)(3)(F).

Basic work activities include the abilities and aptitudes

necessary to do most jobs, such as physical functions of walking,

standing, sitting, lifting, pushing, pulling, reaching, carrying,

or handling; capacities for seeing, hearing, and speaking;

understanding, carrying out, and remembering simple instructions;

use of judgment; responding appropriately to supervision, coworkers and usual work situations; and dealing with changes in a

routine work setting. 20 C.F.R. §§ 404.1521(b), 416.921(b).

An impairment or combination thereof is not severe when

medical evidence establishes only a slight abnormality or a

combination of slight abnormalities which would have no more than

a minimal effect on an individual's ability to work. An

impairment is not severe if it does not significantly limit a

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claimant’s physical or mental ability to do basic work

activities. 20 C.F.R. §§ 404.1521(a), 416.921(a); Soc. Sec.

Ruling 85-28; Smolen v. Chater, 80 F.3d 1273, 1289-90 (9 Cir. th

1996).

Here, the ALJ noted Plaintiff’s treatment for depression

(A.R. 14) and the opinion of state medical consultants Drs.

Archimedes Garcia and Brian Ginsburg, who in July 2004 opined

that Plaintiff’s affective disorder was brought on by physical

problems, which were mostly within normal limits, and was not

severe. (A.R. 14, 174-78.) The ALJ also noted Plaintiff’s

argument that she had been limited to simple, repetitive tasks

(opinion of ALJ pursuant to a previous application [A.R. 179]),

but the ALJ then stated:

However, I note that two months after the prior

decision, the claimant went back to work as a legal

secretary, earning monies consistent with substantial

gainful activity and continued to perform this skilled

work for three years until she turned 55 in 2003. By her 

work activity she has demonstrated that she is capable

of performing work involving complex instructions and

greater than simple, repetitive tasks. Further,

while her treating source prescribed an anti-depressant

(Exhibit B12E), she is not receiving any mental health

treatment to suggest a significant worsening since

she stopped working. Also, her past relevant work from

2000 to 2002 is sedentary work, which is within her

exertional limitations.

A.R. 16.) Further, the ALJ noted that based on the evidence

before him, Plaintiff’s treating source had not precluded

Plaintiff from working. (A.R. 17.) Finally, the ALJ expressly

stated that the psychiatric assessment of nonseverity rendered by

the state agency medical consultant was appropriate and

consistent with the objective medical evidence. (A.R. 17.)

Substantial evidence supports these findings. (A.R. 246-48

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[Plaintiff testified having worked for over two years, until

2002, for law firms as a legal secretary and paralegal,

performing word transcription, mail and word processing, copying,

intake, editing of criminal appeals, answering telephones, and

filing].) 

Further, the finding did not constitute legal error. Social

Security regulations provide that although all medical and

vocational evidence will be considered in determining whether an

applicant has the ability to engage in substantial gainful

activity, employment during any period of claimed disability may

be probative of a claimant’s ability to work. 20 C.F.R. §§

404.1571, 416.971; Moore v. Commissioner of Social Sec. Admin.,

278 F.3d 920, 924 (9 Cir. 2002). If the SSA finds that an th

applicant was able to work at the substantial gainful activity

level, it will find the applicant not disabled. Id. Even if the

work was not substantial gainful activity, it may show that the

claimant was actually able to do more work than was actually

done. Id. 

Here, the ALJ considered work that ended before the claimed

period of disability and that post-dated a previous finding of

limitation to simple, repetitive tasks. The highly skilled work

done by Plaintiff at the three law firms was inconsistent with

the claimed limitation to simple, repetitive tasks. The ALJ drew

reasonable inferences from the evidence, as he was entitled to

do. See, Sample v. Schweiker, 694 F.2d 639, 642 (9 Cir. 1982). th

Further, Plaintiff does not cite to any evidence of record

inconsistent with the ALJ’s characterization of the record as

lacking any opinion from a treating source that Plaintiff was

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disabled.

Finally, although the other evidence was sufficiently

extensive and weighty to support the ALJ’s findings, the state

agency physicians’ opinions were based on clinical findings of

physicians who had examined Plaintiff and were not inconsistent

with any opinions rendered by such physicians. As such, they

constituted additional substantial evidence supporting the ALJ’s

finding. The findings of a nontreating, nonexamining physician

can amount to substantial evidence so long as other evidence in

the record supports those findings. Saelee v.Chater, 94 F.3d 520,

522 (9 Cir. 1996). th

It is concluded that the ALJ did not err in finding that

Plaintiff’s depression/anxiety was not severe. Plaintiff did not

meet her burden of establishing that her depression had anything

other than a minimal effect upon her ability to perform basic

work activities. 

VI. Duty to Contact a Consultative Psychiatrist

Plaintiff argues that the ALJ erred in not seeking a

consultative psychiatric evaluation to determine the effect of

Plaintiff’s mental impairment on Plaintiff’s ability to work.

However, the duty to develop the record arises where the record

before the ALJ is ambiguous or inadequate to allow for proper

evaluation of the evidence. 20 C.F.R. §§ 404.1512(e) and

416.912(e); Mayes v. Massanari, 262 F.3d 963, 968 (9 Cir. 2001). th

Here, there was no ambiguity or inadequacy; rather, the Plaintiff

simply failed to present evidence warranting a finding that her

impairment was severe.

/////

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VII. Recommendation

Pursuant to the foregoing analysis, it is concluded that

Plaintiff’s arguments should be rejected. The ALJ’s decision was

reached by the use of proper legal standards and is supported by

substantial evidence.

Accordingly, it IS RECOMMENDED that

1. Plaintiff’s social security complaint BE DENIED; and

2. Judgment for Defendant Michael J. Astrue, Commissioner of

Social Security, and against Plaintiff Carole Henry, BE ENTERED.

This report and recommendation is submitted to the United

States District Court Judge assigned to the case, pursuant to the

provisions of 28 U.S.C. § 636 (b)(1)(B) and Rule 72-304 of the

Local Rules of Practice for the United States District Court,

Eastern District of California. Within thirty (30) days after

being served with a copy, any party may file written objections

with the court and serve a copy on all parties. Such a document

should be captioned “Objections to Magistrate Judge’s Findings

and Recommendations.” Replies to the objections shall be served

and filed within ten (10) court days (plus three days if served

by mail) after service of the objections. The Court will then

review the Magistrate Judge’s ruling pursuant to 28 U.S.C. § 636

(b)(1)(C). The parties are advised that failure to file

objections within the specified time may waive the right to

appeal the District Court’s order. Martinez v. Ylst, 951 F.2d

1153 (9th Cir. 1991).

IT IS SO ORDERED.

Dated: January 24, 2008 /s/ Sandra M. Snyder 

icido3 UNITED STATES MAGISTRATE JUDGE

Case 1:06-cv-00554-AWI -SMS Document 29 Filed 01/24/08 Page 16 of 16