HomeMy WebLinkAbout23-1405 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED31542 170
27
COLLISION REP FIT 1591971
CASE 23-1405 z
INTERSTATE ❑ CITY STREET FIRE R/RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4100 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 03 STRUCK NONE
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 02 - 1-- 2023 1231 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
TALBOT RD S MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET ❑ S ❑ VV❑ S 55TH ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:4252192966 0 11
30
6� LAST NAME LAW FIRSTNAME MELISSA MIDDLE R 1 1 2 31
INITIAL
STREET ❑1 24702 MARINE VIEW DR S CITY DES MOINES ST WA Zjp, 981983824 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs Z/NO YES �No /
LRIIVER # STATE WA SEX'F MM D Y' 05
8❑ — O6 — 1986 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
❑10 9❑ P1 aTES� CEY4004 sTArI WA vIN# WAUGN74F37N032586 3
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 3 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T �pN GOVT.VEHICLE 5 1 34
13 2 2007 AUDI S6 DAMAGE vEs ONO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO DANIEL KASKO 11117 ELLISON RD MOUNT VERNON WA 98274 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICV# I 9TOP 5
VEwcLE CHARGE 10 BOTTOM 36
LEG'LLY YEs NO CITATION# 3AO095049,3AO095049 OP MOT VEH W/OUT INSURANCE,
15❑ STANDING 8 7 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:2537973014
16 a
LAST NAME RAZAVI FIRST NAME MONIR MIDDLE I S
INITIAL
17❑ NEW STREETREs7 9411 S 203RD PL CITY KENT ST WA ZIP 980311420 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs❑NOF YEs❑NOF,/
19 DRIVER'S STATE WA SEX F D.C... 05 _ 17 1963 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET INJURY 6 NATURE OF INJURIES ❑ 40
USE CLASS RIGHT HAND PAIN
❑21❑ PLATE# BGL3245 TArE WA VIN# 41
SJKCHSCR4HA025757 1
42
22❑ PLATE# STATE PLATE# STATE
T
23❑ VIN 43
IN##. IN RLR
' #.
VEH YEAR 2017 MAKE INFI MODEL QX30 STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ D YES NO BANKERS YES NO
REGISTERED OWNER INFO MONIR RAZAVI9411 S 203RD PL KENT WA 98031 AMA VEHICLE NO.2
SHADE DAGED AREA
4
LIABILITY INSURANCE INSU8 PORGY#E CO COMMERCE WEST INS COM ACPA-002306366 STOP 5
IN EFFECT
VE""LE ❑ ,J� CITATION# CHARGE io BOTTOM
LEGALLY YES N`LJ 6
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 77P�1300
26
ALEKSANDR IGNATOV 12619
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED31542
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1405
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 one was traveling Southbound on Talbot Rd S attempting to make a left hand turn onto S 55th St
in lane 1 of 1. Unit two was traveling Northbound on Talbot Rd S at S 55th St in lane 1 of 1. Unit three
was stopped at a stop sign on S 55th St facing westbound. Unit one failed to yield the right of way to
unit two and collided with unit 2 which then pushed her into unit three. After the collision unit two
caught on fire. Photos of the collision are uploaded into Axon Evidence. Infractions issued to unit one.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 02-02-23 03:08 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
QUINT TIBEAU 07691 2/6/2023 10:53:51 AM
BADGE OR ID# 12619 OR]# WA0171300 TIME POLICE DISPATCHED 12:32 PM TIME POLICE ARRIVED 12:39 PM
FART I PAGE IT]OF 4]
SUPPLEMENTAL REPORT No. ED31542
r`I POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 23-1405
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USL70r ICC# VEHICLE TYPE CARGO BODY
TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST' ZIP'
4 ❑ NAME # PLACARD: :❑
GI NAME 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:2063006655
OF 8 29
LAST NAME JONES FIRST NAME DAVID MIDDLE'.. J
INITIAL
STREET r:i 30
NEW AnDRFSP' 10215 SE 192ND ST CITY RENTON ST WA ZIP 1 980556430
6 ❑ 1 1 2 31
CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED
INTERLOCK YEs NO NTERLOCK YES❑N0� YEs N
DRIVER'S
LICENSE STATE I WA SEX M MMDDYYv 03 - 22 - 1955
7
ON DUTYl STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET INJURY 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE PAINTRS TAr WA VIN# 1GT49REY3LF256080
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 0 0 VEH.YEAR2020 MAKE GMC MODELSIERRA STYLE VEHICLE TOVVE E T SABLIN TOWED BY anvi vEH1I' P FROM TO
DAMAGE YES 'E YES NO
REGISTERED OWNER INFODAVID JONES 10215 SE 192ND ST RENTON WA 98055 J 9 33
12 � SHADE IN DAMAGED AREA
3 4 FROM TO
LIABILITY INSURANCE INSURANCE CO STATE FARM 508373580747 q"i"Olx
IN EFFECT &POLICY#
VEHICLE 34
13 ❑ Lecnuv YES❑ NO Z CITATION# CHARGE gg�@ 10 BOTTUM
STANDING } l:9 7 6
14 ❑ UNIT Tr Vd 1RE O CYDCLE 1:1OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME NIITIA 36
L
❑
STRE
16 NEW ETETnnR"F] CITY ST ZIP
CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED
NTERLOCK YES No INTERLOCK YEs NO YEs NO ❑
17 4 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE CLASS
19 ❑ LICENSE TAT VIN# 39
PLATE#
20 ❑ TRAILER TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ ❑ 41
TRLR TRLR
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 AREA 43
3 4 71
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.
ALEKSANDR IGNATOV 02-02-23 03:08 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
BADGE O#II APE /26 ORIID# 12619 WA0171300 APPROVED BY
26/2 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. EU31542 CASE# 23-1405 DATE AND TIME 02/02/2312:31