HomeMy WebLinkAbout23-789 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE# z3ass 2
INTERSTATE CITY STREET FIRE
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&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# ❑
cowsloN 01 - 18 - 2023 1717 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
KIRKLAND AVE NE BLOCK NO. e✓ 1200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NE 12TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2065732037 0 11
30
6� LAST NAME DEMOURA FIRSTNAME THATIANE MIDDLE D 1 2 31
INITIAL
STREET ✓ 25515 SE ISSAQUAH FALL CITY R CITY ISSAQUAH ST WA Zjp, 98029 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES 2❑
3
LICENSE CFU3829 sTArr WAVIN# 19XF62F83FE263709
10 PI ATE#
-- TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM To
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#'
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 1 34
13 2 2015 HOND CIVC SD DAMAGE vEs 0NO f �LAWkkRS vEs❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ALL STATE 4
IN EFFECT &POLICY# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2066311685
16 a
LAST NAME SALDANA FIRST NAME ALEJANDRO MIDDLE IR
INITIAL
17❑ STREET ❑' 7833 S 128TH ST CITY SEATTLE ST WA ZIP 98178 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK v�Esl❑NOF YES
❑NOF
19 DRIVER # STATE WA SEX M M D.C.B. 10 _ 30 _ 1962 0 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 5 CLASS ❑
21❑ LICENSE I C94552J TAre WA VIN1i 3GTU2UECOEG328172
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED ev Gov HI 44
VEH YEAR 2014 MAKE GMC MODEL SIERRA STYLE PK —TEHICLE
TOWED✓ NOO BLIN BANKERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 4647173EI047AIN I STOP 5
VETILe YES❑ N J
,J� CITATION# CHARGE i o BOTTOM
LEGALLY
25 7INAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26PH SINGER 12056 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED26357
COLLISION REPORT III III III III III 111
1591972 CASE# 23-789
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 failed to stop at the stop sign at ne 12th and Kirkland Ave NE. Unit 2 was struck by unit 1 after
stopping at stop sign and passing through the intersection, northbound, with the right away.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JOSEPH SINGER 01-18-23 06:44 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 111912023 8:09:44 AM
BADGE OR ID# 12056 OR]#' WA0171300 TIME POLICE DISPATCHED 5:18 PM TIME POLICE ARRIVED 5:25 PM
PART I PAGE IT]OF
REPORT NO. ED26357 CASE# ' 23-789 DATE AND TIME 01/18/23 17:17
OF COLLISION
Kirkland Ave NE
�i i ouuuuuuumoioioi oim i�i io
NE 12th ST
NotTo scale
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