HomeMy WebLinkAbout23-02109 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-02109 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 02 - 1-— 2023 1821 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NE 3RD ST BLOCK NO. e✓ 2000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV a MONTEREYDR NE
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2062351072 0 11
30
6� LAST NAME CAMPBELL FIRSTNAME DIANE MIDDLE J 1 1 2 31
INITIAL
STREET ❑ 568 NEWPORT AVE NE CITY RENTON ST WA ZIP' 980563983 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ PI ATFBit ARG7100 sTAr� WA urN#' 1 HGCR2F82EA210453
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# ROM ro
TRLR. TRLR. 5 3 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2014 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 4 HOND ACCOR SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO DIANE CAMPBELL 568 NEWPORTAVE NE RENTON WA 98056 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO USAA CAS INS 0017041 93C 3 4
IN EFFECT &POLICY# 9TOP
VE—L' 1 5 36
LEGALLY
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:4252817540
16 2
LAST NAME HARPER FIRST NAME CHLOE MIDDLE M
INITIAL
17❑ STREET ❑', 12311 171ST PL SE CITY' RENTON ST WA ZIP 980596531 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 NO
�
19 DRIVER'S STATE WA SEX F D.O.B. 05 _ 05 _ 2006 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BLZ7872 TAre WA VIN# JT3FJ80W1N0042411
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 1992 MAKE TOYT MODEL LAND STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CARINA HARPER 12311171STPL SE RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO TRAVELERS 61186881203 1IN CQVE"LLE
❑ ,J� CITATION# CHARGE i o
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED37012
COLLISION REPORT III III III III III 111
1591972 CASE# 23-02109
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 stopped at intersection on Monterey Dr NE, facing north, making free right turn onto NE 3rd St,
attempting to drive east on a red light. Unit 2 traveling eastbound on NE 3rd St on a green light at the
intersection of Bronson Way NE/Monterey Dr NE. Unit 1 strikes Unit 2 causing non reportable non
disabling damage to the front of Unit 2 and reportable non disabling rear driver side damage to Unit 1.
No injuries reported. Unit 1 driver failed to yield right of way when making a right turn.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 02-21-23 08:41 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
J.CHRISTIANSEN 10437 2/24/2023 5:42:15 PM
BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED', 6:32 PM TIME POLICE ARRIVED 6:49 PM
PART I PAGE IT]OF
REPORT NO. ED37012 CASE# ' 23-02109 DATE AND TIME 02/21/23 18:21
OF COLLISION
NOT TO SCALEr
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