HomeMy WebLinkAbout23-3014 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-3014 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
cawsloN 03 - 1-- 2023 1325 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE N BLOCK NO. e✓ 600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2062096315 0 7 30
6� LAST NAME HASHI FIRSTNAME SALMA MIDDLE A 1 1 2 31
INITIAL
STREET ❑✓ 9716 S 204TH CT CITY KENT ST WA 2jp, 98031 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USEET 2 CLASS 1 NATURE OF INJURIES z❑
3
,OF
P1 ATNES# BKH6531 sTAr WAvN# 4T48F1FK4CR178918
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# IR.. To
TRLR. TRLR 5 1 33
12 VIN#' VIN#
>;. FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE J 9 34
13 2 2012 TOYT CAMRY DAMAGE vE8 0NO agW�MEYER vEs❑ No
REGISTERED OWNER INFO LUL KAYNAN 9111 S 104TH CT KENT WA 98031 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILI INSURANCE INSURANCE CO NATIONAL GENERAL 201 7231793
IN EFFECT &POLICY# 9TOP
vECEHA"LE 5 36
LLLv Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2068517648
16 a
LAST NAME AMOS FIRST NAME RAJANIQUE MIDDLE I D
INITIAL
17❑ STREET ❑', 1806 PIERCE AVE SE CITY RENTON ST WA ZIP 980584746 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NOF,/
19 RRIS LDIIVE STATE WA ]SEX IF M .C.B. 01 28 _ 1999 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE CDX9481 TAre 41
WA vIN# 2HGFG126X8H557990
❑
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2008 MAKE HOND MODEL CIVIC STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO RAJANIQUE AMOS 1806 PIERCE AVE SERENTONWA98058 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE &PORGY#E CO PERMANENT GENERAL 53-WA 5623284 1GQO`
25❑ IN EFFECTVEHICLe CITATION# CHARGE
LEGALLY YES NC�
JAGENCY
s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED42621
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3014
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 was traveling behind Unit 2 northbound in the 600 blk of Rainier AVE N. An unknown vehicle
traveling in front of these two units suddenly slowed to conduct an unlawful U-turn. Unit 2 was able to
slow and stop in time after heavy braking. Unit 1 failed to slow and stop in time and the front end of
Unit 1 struck the rear end of Unit 2. Unit 2 sustained moderate rear end damage while Unit 1
sustained heavy front end damage. Unit 1 towed by Gene Meyer. This report is to document the
circumstances 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 03-14-23 02:25 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 311512023 10:52:43 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED; 1:27 Pry TIME POLICE ARRIVED',1:34 PM
PART I PAGE IT]OF
REPORT NO. ED42621 CASE# ' 23-3014 DATE AND TIME 03/14/23 13:25
OF COLLISION
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