HomeMy WebLinkAbout23-3790 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-3790 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#
cawsloN 04 - 1-- 2023 1049 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SW GRADY WAY BLOCK NO. e✓ 300 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a MAPLE AVE SW
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:6262162769 0 11
30
6� LAST NAME PONCE FIRSTNAME GABRIELLA MIDDLE A 1 2 31
INITIAL
STREET ❑ 425 PELLYAVE N#6 CITY RENTON ST WA ZIP 98057 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 9 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� CBN2410 sTArI WAvIN# JHMZE2H346S007803
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
TRLR. TRLR. 1 7 33
12 3 5 VIN#' VIN#
<:.. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 2 2011 HOND INSIGHT DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO GEICO 6083462223 3 4
IN EFFECT &POLICY# 9TOP
VE"'CLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 3A0327495 INATTENTIVE DRIVING I o aorroM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO DD 2063901411
16 a
LAST NAME JACKSON FIRST NAME FATIMA MIDDLE
INITIAL
17❑ STREET ❑', 300 VUEMONT PL NE APT H2O3 CITY RENTON ST WA ZIP 980564531 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 DRIVER'S STATE WA ]SEX IF D.C.B. 07 28 _ 1970 0 39
LICENSE# MMDDYY
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE ALU4543 TAre WA vIN# 1G1PF5S90B7192643
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
TOWED BV Gov HI 44
VEH YEAR 2011 MAKE CHEV MODEL CRUZE STYLE —TEHICLE
TOWED✓ NOO BLIN GENE MEYER YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE &POLICY#E CO SAFECO OH2156982IN 9TOP 5
VEHICLE ❑ NC[:]— CITATION# CHARGE to BOTTOM
25 LEGALLY YESs 7 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED48312
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3790
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 2 was traveling westbound in the 200 blk of SW Grady Way approaching Maple AVE SW with
the right of way. Unit 1 was stopped at a stop sign on southbound Maple AVE SW, on the north side
of the SW Grady Way, intending to turn right onto westbound SW Grady Way. Unit 1 failed to yield
the right of way to Unit 2 and began this turn pulling into the lane of travel occupied by Unit 2. The
front drivers side of Unit 1 struck the front passenger side of Unit 2 causing moderate damage to Unit
2 and moderate/heavy damage to Unit 1. Unit 2 towed by Gene Meyer. Unit 1 was parked in an
employee lot but appeared to have disabling damage.
Driver 1 cited for Inattentive Driving by not driving with due care and caution in yielding the right of
way to Unit 2 which was the proximate cause 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 04-03-23 01:26 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 4/4/2023 9:55:43 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED 10:51 AM TIME POLICE ARRIVED 10:53 AM
PART I PAGE IT]OF
REPORT NO. ED48312 CASE# ' 23-3790 DATE AND TIME 04/03/23 10:49
OF COLLISION
;X)
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