HomeMy WebLinkAbout23-02953 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
CASE 23-02953 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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#
cowsloN 03 - 1-- 2023 2257 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
DUVALL AV NE BLOCK NO. e✓ 400 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e NE 4TH ST
1 5 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:4257616105 0 81
30
6� LAST NAME POWERS FIRSTNAME DAVID MIDDLE W 1 2 31
INITIAL
STREET ❑✓ PO BOX 11071 CITY RENTON ST WA 21p 980573933 z
NEW ADDRESS
]❑ 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 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 1❑ 1 PI ATE 14 6472P6 STATE WA uN#' 1G1ZA5EB3AF138120
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# IRM To
TRLR. TRLR. O 0 33
12 3 0 VIN#' VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 4 2010 CHEV MAL/BU SD DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO DAVID POWERS PO BOX 1171 RENTON WA 98057 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# � STOP
vewcLE CHARGE 36
LEGHALLY YES❑NO CITATION# 3AO044264 OP MOT VEH W/OUT INSURANCE o eorrom
15❑ STANDING 8 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER
❑ YES NO ,/ D:9712276537
16 a
LAST NAME ERE FIRST NAME ABDIHAKIM MIDDLE H
INITIAL
17❑ STREET ❑', 19334 142ND PL SE CITY' RENTON ST WA ZIP 980589446 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX M D.C.B. 04 10 _ 2001 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CBL7498 TATe WA VIN# 5YFBURHE3HP615337
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2017 MAKE TOYT MODEL COROLL STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO ABDIHAXIM ERE 19334 142ND PL SE RENTON WA 98058 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU8 PORGY#E CO AMERICAN FAMILY 41026-43447-41 5
IN EFFECT
VE
25 C�Q
LEGALLY YES Nu
❑ s a
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. ED47091
COLLISION REPORT III III III III III 111
1591972 CASE# 23-02953
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 and 2 both waiting for red light at intersection of Duvall Av NE and NE 4th St. Unit 1 driver
backed into Unit 2 as he believed that he was too far into the intersection on a red light. Unit 1
sustains minor non disabling non reportable rear end damage. Unit 2 sustains minor non disabling
non reportable front end damage. Unit 1 driver cited for no insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 03-13-23 01:06 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 3/31/2023 1:37:29 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED! 11:01 PM TIME POLICE ARRIVED 11:07 PM
PART I PAGE IT]OF 3�
REPORT NO. ED47091 CASE# 23-02953 DATE AND TIME 03/12/23 22:57
OF COLLISION
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