HomeMy WebLinkAbout23-3799 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-3799 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 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 04 - 1-- 2023 1337 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 2400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 8 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252367263 0 11
30
6� LAST NAME EVANS FIRSTNAME ERIC MIDDLE G 1 F 2 31
INITIAL
STREET El 23724 7TH PL W CITY BOTHELL ST WA Zlp' 980218507 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 4❑ I P1 ATNES# C91201 V sTAr WAu N# 1 GTHK23D16F214542
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 3 33
12 4 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 7 $ 34
13 A 2006 GMC SIERRA DAMAGE vEs 0NO f �LAWkkRS vEs❑ No
REGISTERED OWNER WFO ERIC EVANS 237247TH PL W BOTHELL WA 98021 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 900534473 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEcntty YES❑NO❑ CITATION# 10 BOTTOM
15❑ TANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4253063385
16 a
LAST NAME CRAIA FIRST NAME JON IN DOLE
NITIAL
17❑ STREET ❑', 6231 LAKE WASHINGTON BLVD SE CITY BELLEVUE ST WA ZIP 980066329 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 DRIVERS
{NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE I CFG0863 TAre WA VIN# 1J4GZ58S7WC135128
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 1998 MAKE JEEP MODEL GRAND STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI �44
24❑ DAMAGE YES�/ NO BANKERS YES NO
REGISTERED OWNER INFO JON CRA/A 6231 LAKE WASHINGTON BLVD SE BELLEVUE WA 98006 VEHICLE NO.2
SHADE IN DAGELLAREA
z Cdd
LIABILITY
INSURANCE INSU&POLICY#E CO GEICO 2025808813IN 1 9TOP 5
VEHICLE ❑ C[ CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED48311
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3799
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) GABR/EL KEVEN M
(I.P.ST FIRST,
ADDRESS&PHONE#
32418 4TH AVE BLACK DIAMOND WA 98010 2064369879 SEX M MMDDYyry 01 - 02 - 1981
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# Id I
DOB
E MMDDYVYV
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B. -❑
MMDDYYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 was traveling east (southbound) in the 2400 blk of Maple Valley Hwy in the left of two lanes.
Unit 1 was in the east entry/exit to the parking lot of 2439 Maple Valley Hwy, on the south side of the
roadway, facing north, and planning to turn left onto westbound Maple valley HWY. There was
another motorist in the right of two eastbound lanes that wanted to pull into the same entry/exit
driveway but could not due to the vehicle size and was stopped in the roadway. This other motorist
motioned for Unit 1 to pull out but Driver 1 stated he could not see and was unsure. Driver 1 and
Witness state that there was a backup caused by this other motorist and they began honking causing
Driver 1 to attempt and enter traffic. Unit 1 pulled out into the lanes of travel just as Unit 2 was
passing. The front end of Unit 1 struck the rear passenger side of Unit 2. This collision sheared the
metal body skin off of Unit 2 at the impact area and caused it to rotate clockwise before coming to
rest. Unit 2 sustained heavy damage, Unit 1 sustained moderate/heavy but disabling damage. Both
units towed by Bankers.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 04-03-23 03:26 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 4/4/2023 9:59:56 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED; 1:39 PM TIME POLICE ARRIVED',1:43 PM
PART I PAGE 2�OF❑
REPORT NO. ED48311 CASE# ' 23-3799 DATE AND TIME 04/03/23 13:37
OF COLLISION
2400 blk Maple Valley HVVY
i
f t
iiu ii�op op goopgo
PARKING LOT
439 Maple Valley HWVY
***NOT TO SCALE'S**
PAGE 3 OF 3