HomeMy WebLinkAbout23-272 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE# z3-z72 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION.. 01 - 1-— 2023 1425 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 15500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 300 00 FMILES EET e S ❑ E e 154TH PL SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:2067191291 0 7 30
6� LAST NAME HANSEN FIRSTNAME COLTON MIDDLE J 1 1 2 31
INITIAL
STREET ❑ 30754 229TH PL SE CITY BLACK DIAMOND ST WA 2jp, 98010 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� BCH5671 sTArI WAvIN# 1G1Z65ST6GF329727
TRAILER STATE TRAILER STATE
11 5 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 5 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 4 2016 CHEV MAL/BU SD DAMAGE YES NO YES❑ ✓No
REGISTERED OWNER INFO .11?LYJACKSON.754229THPL SE BLACKDIAMOND WA 98010 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO THE GENERAL 53-WA9878405 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY Yes❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES NO ,/ D:4256987912
16 a
LAST NAME SANDERS FIRST NAME ZEKELIA MIDDLE q
INITIAL
17❑ STREET ❑', 19435 SE 176TH ST CITY RENTON ST WA ZIP 98058 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER #
INJURY 7 NATURE OF INJURIES 40
20 F1 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS NECK PAIN
21❑ LICENSE I CDV5489 TAre WA VIN1t 1C4RDHAGOGC483875
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2016 MAKE DODG MODEL DURANG STYLE UT VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ZEKELIA SANDERS 19435 SE 176TH ST RENTONWA 98058 D:4256987912 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#E CO BRISTOL WEST G01-0769772-03IN 1 9TOP
VEHICLE CITATION# CHARGE i o BOTTOM
LEGALLY YES[Z NC[:]25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
M.THOMPSON 10499 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED22817
COLLISION REPORT III III III III III 111
1591972 CASE# 23-272
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) KNOX JONATHAN
(LAST FIRST,
ADDRESS&PHONE#
19435 SE 176TH ST RENTON WA 98058 SEX M MMDDYyvv -�-
PASSENGER Z WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT H U SE CLASS 1 NAruRE of INJURIEs
NAME
(LAST,FIRST,MIDDLE INITIAL) KNOX ZARYAH
ADDRESS&PHONE# DOB -
19435 SE 176TH ST RENTON WA 98058 SEX F MMDDvvvv
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS❑ UNIT# 2 PGS 7 AIRBAG 2 RESTR. 10 EJECT 1 USE CLASS 1
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On January 7, 2023 at about 1428 hours I observed two vehicle stopped in the number 2 lane of
northbound Maple Valley HWY in the 15500 block. It was apparent that they had just been in a
collision.
The driver of Unit 2 relayed that they had been stopped for traffic in the number 2 lane. The light
ahead turned green but they had not yet started travel. Unit 2 was then struck by Unit 1 from behind.
The driver of Unit 2 complained of neck pain and stated they were two juveniles in car seats in the
back seat of the vehicle.
The driver of Unit 1 stated they were traveling northbound (compass direction of west) on Maple
Valley HWY. Unit 2 had stopped in front of Unit 1. Unit 1 stated they stopped sooner than expected
and Unit 1 was unable to stop in time to avoid the collision. Unit 1 collided with the rear end of Unit 2.
The driver of Unit 1 stated they were no injured.
Based on the damage and location of the vehicles upon arrival at the scene. Unit 1 had collided with
the rear end of Unit 2.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.THOMPSON 01-07-23 04:44 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.MOYNIHAN 11288 1 11712023 5:01:22 PM
BADGE OR ID# 10499 ORI# WA0171300 TIME POLICE DISPATCHED; 2:28 Pry] TIME POLICE ARRIVED 2:28 Pry]
PART I PAGE IT]OF 3�
REPORT NO. EU22817 CASE# 23-272 DATE AND TIME 01/07/231425