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Home My WebLink About23-1276 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c COLLISION REP FIT 1591971 CASE 23-1276 z INTERSTATE ❑ CITY STREET FIRE ❑RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENC 4200 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 2 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 03 STRUCK RESERVATION z 3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑ dowsloN 01 - 1-- 2023 1450 17 ❑.= S 8 IN e 1070 3 4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ N SOUTHPORT DR BLOCK NO. e✓ 1300 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ ❑ FEET e S ❑ W e 0 1 29 MOTOR PEDAL- DAM THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El YEs No ,/ D:4255519206 0 7 30 6� LAST NAME MEZA FIRSTNAME JORDAN MIDDLE 1 2 31 INITIAL STREET ❑, 4803 152ND ST SE CITY EVERETT ST WA 2jp, 982088823 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/ 8❑ LRIIVER # ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET 2 CLASS 1 NATURE OF INJURIES z❑ 3 10 9❑ PI ATE BKD8768 sTArI WAurN#' 1ZVBP8AM4C5276268 TRAILER STATE TRAILER STATE 11 3 5 PLATE# PLATE# FROM TO TRLR. TRLR 7 3 33 12 0 0 VIN#' VIN# >; FROM TO VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34 13 2 2012 FORD MUSTAN DAMAGE YES NO YES[:] NO✓ REGISTERED OWNER INFO JORDAN M.4803112ND ST SE EVERETT WA 98208 VEHICLE NO. 1 ❑ SHADE IN DAMAGED AREA 35 14 LIABILI INSURANCE INSURANCE CO AMERICAN FAMILYBX12148991 3 4 IN EFFECT &POLICY# 9TOP CITATION# CHARGE 5 36 15❑ vEEGHrACLLLEY YES❑NO❑ INATTENTIVE DRIVING STANDING 8 7 6 MOTOR PEDAL- 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE iT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES,/ No D:2536913185 16 a LAST NAME DAINS FIRST NAME ISAIAH MIDDLE I L INITIAL 17❑ STREET ❑', 10407 46TH PL SE CITY LAKE STEVENS ST WA ZIP 982585774 37 NEW ADDRESS ❑ 18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38 INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NOF,/ 19 DRIVER'S STATE WA SEX M D.Q.B. 07 02 _ 1997 39 LICENSE# MMDDYY —NATURE OF INJURIES H USE CLASS NJAURSY COMPLAINT OF HEADACHE ❑ 40 20 ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 2 7 21❑ LICENSE BLS0011 TAre I WA vIN# JM1BK343681149110 ❑ 41 PLATE# 42 22❑ PLATE# STATE PLATE# STATE 23❑ UIN#. 43 TRLR RLR 'IN#. VEH YEAR 2008 MAKE MAZp MODEL M3H STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44 24❑ DAMAGE YES NO,/ YES NO REGISTERED OWNER INFO ISAIAH DAINS 1040746TH PL SE LAKE STEVENS WA 98258 VEHICLE NO.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE &POINSURGY#E CO PROGRESSIVE 941829098IN STOP VEHICLE CITATION# CHARGE 25❑ i o BOTTOM LEGALLY YES N� J s a 7KLANE S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 10008 WA0171300 PAGE 01 OF PART A 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. ED30172 COLLISION REPORT III III III III III 111 1591972 CASE# 23-1276 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 3 was in the 1300 blk of N Southport DR, facing eastbound and stopped for traffic back from a traffic signal. Unit 2 was stopped directly behind Unit 3 also eastbound in the 1300 blk of N Southport DR. Unit 1 was traveling eastbound in the 1300 blk of N Southport DR approaching the stopped traffic and Units 2 and 3. Driver 1 states they attempted to brake, but inadvertently hit the accelerator instead. The front end of Unit 1 struck the rear end of Unit 2 causing moderate damage both. The force of that collision sent Unit 2 forward and the front end of Unit 2 struck the rear end of Unit 3. Unit 2 sustained moderate damage and Unit 3 sustained light damage. All vehicles were able to pull off the road under their own power. Driver 1 was cited for Inattentive Driving by not driving with due care and caution to the vehicle controls and inadvertently hitting the accelerator which was the proximate cause of the collision. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. K.LANE 01-30-23 04:07 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY E DAT CO.JOHNSON 0505 113112023 4:47:05 PM BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED 2:55 PM TIME POLICE ARRIVED',3:03 PM PART I PAGE IT]OF 4� SUPPLEMENTAL REPORT NO. ED301 72 r`) POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 23-1276 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY ;TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER ADDRESS ` CITY ST ZIP—1 I ' 4 ❑ NAME # PLACARD: :❑ GI PLACARD IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# 3 VEHICLE tSJ CYCLE I_) PEDESTRIAN OWNER YES NO D:8506192710 0 7 29 LAST NAME : CAIN FIRST NAME MARISSA MIDDLE'.. N INITIAL STREET 30 NEW AnDRFrtP 26031 72ND AVE NW APT E219 CITY STANWOOD ST WA ZIP 98292 6 CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 1 2 31 INTERLOCK YEs No NTERLOCK YES[:]NO[:] YES N DRIVER'S LICENSE STATE I WA SEX F MMDDYYv', 03 — 17 — 1995 7 ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES USE CLASS 8 ❑ 1 32 LICENSE I CFS0768 [TAT WA VIN# 2HKRS4H77PH404145 PLATE# 9 9] TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 0 0 VEH.YEAR2023 MAKE HOND MODELCR-V STYLE VEHICLE TOWS E T SABLIN TOWED BY anvi vFH1I' FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFOMARISSA CAIN 26031 72ND AVE NW APT E219 STANWOOD WA 98292 J 9 33 12 � SHADE IN DAMAGED AREA 3 4 FROM TO LIABILITY INSURANCE INSURANCE CO GEIC04549393801 q"i"Olx IN EFFECT &POLICY# 1 VEHICLE 34 13 2 Lecnuv YES NO❑ CITATION# CHARGE 10 BOTTUM STANDING } 8 7 6 14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNER RTY YES[—]AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE INITIAL TIAL ❑ ET 16 STRETRE "F ' CITY ST ZIP NEW CDL IGNITION REdUiRED IGNITION PRESENT MEDICALTANSPORTED NTERLOCK YES No NTERLOCK YEs NO YEs NO El 17 37 LICENSE# STATE SEX MMDDDYBYY —� II 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of 1NJURIEs 38 USE (CLASS 19 ❑ 39 LICENSE rnr VIN# PLATE# 20 ❑ TRAILER' STATE TRAILER STATE ❑ 40 PLATE#< PLATE# 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO_ SHADE IN DAMAGED 3 a 4 AREA F 43 z LIABILITY INSURANCE INSURANCE CO ' VINE EFFECT &POLICY# i 970P - 4 E:l 44 24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM LEGALLv STANDING 8 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. K.LANE 01-30-23 04:07 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED APPROVED BY DATE 26 ORID# 10008 O#IL WA0171300 JOHNSON 1131/2023 PAGE 3 OF 4 3000-345-013 IR 11t18) REPORT NO. ED3017 RASE# 2y427 A m°M\ 01g±23 ]¢5 « : COLLISION < 2 � ^ O%9SCALE- PAGE 4 0 «