HomeMy WebLinkAbout23-3911 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-3911 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;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# ❑
COLLISION.. 04 - 1-- 2023 1700 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
ABERDEEN AVE NE BLOCK NO. e✓ p ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET ❑ S ❑ W❑ NE 20TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLDHONE
UNIT 01 VEHICLE ❑ CYCLE El MET P
YES ,/NO D:2068190531 0 11
30
6� LAST NAME MA TA FIRSTNAME JONATHAN MIDDLE L 1 1 2 31
INITIAL
STREET ❑✓ 12101 193RD AVE E CITY BONNEY LAKE ST WA 2jp, 98391 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 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
❑P1 aT�S� DP41507 sTAr� WWAvIN# 1D7yL38X83S227254 3
10 9❑
TRAILER STATE PLA STATE
11 2 5 PLATE# PLATE TE## FROM ro
TRLR. TRLR 3 7 33
vIN#
12 2 5 ' VIN#
ROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE 1 $ 34
13 2 2003 DODO DAKOTA DAMAGE vE6 0NO agW�MEYER ves❑ No
REGISTERED OWNER INFO JESSEMATA 2245 S 216TH ST DES MOINES WA 98189 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE❑ INSURANCE CO 3 4 ❑
IN EFFECT &POLICY# STOP
VErIICLE 5 36
LEGALLY YES No CITATION# 3A0327499,3A0327499 CHARGE FAIL YIELD AT YIELD o aorroM
15❑ NDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2532411219
16 2
LAST NAME ZDROJEWSKI FIRST NAME DEBRA MIDDLE I S
INITIAL
17❑ STREET ❑', 2025 NE 15TH ST CITY RENTON ST WA ZIP 980562844 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK vEs❑NOF YEs❑NOF,/
19 LDICENS STATE WA SEX F MMDDW O6 _ 18 _ 1985 0 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE BNW6546 TAre WA vIN1t 1HGCR3FOXGA015459
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2016 MAKE HOND MODEL ACCORD STYLE 7EHICLE
TOWED✓ NOO BLIN GENE MEYER YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO SAFECO H2495911IN 1 5
VEHICLE ❑ ,.I— CITATION# CHARGE UR
LEGALLYYESN J
25 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. ED50932
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3911
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) HYDE ECKA'LANA S
(LAST FIRST,
ADDRESS&PHONE# D O.B.
2025 NE 15TH ST RENTON WA 980562844 SEX F MMDDYyry 11 - 08 - 2000
PASSENGER WITNESS UNIT# 2 POS 3 AIRBAG 6 RESTR. q EJECT ? 1 HELMET NJURY NATURE OF INJURIES
USE 2 'CLASS 11
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
BEd MMDDYYYY
PASSENGER [:]WITNESSO UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.
MMDDYYYY. —
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 was traveling southbound on Aberdeen AVE NE approaching NE 20th ST with the right of way
and no traffic control. Unit 1 was stopped on westbound NE 20th ST at a stop sign at Aberdeen AVE
NE. Driver 1 states he did not see Unit 2 and proceeded from the stop sign failing to yield the right of
way to Unit 2. The front end of Unit 1 struck the driver's side of Unit 2 causing moderate/heavy and
disabling damage to both vehicles. Driver 1 stated he could not locate the insurance for the vehicle
and was unsure if it was insured. Both vehicles towed by Gene Meyer.
Driver 1 cited for failure to yield the right of way at a stop sign by, after stopping at the stop sign,
proceeding into the intersection failing to yield to Unit 2 which was the proximate cause of the
collision. Driver 1 was also cited for operating a motor vehicle without insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 04-06-23 06:01 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 4/13/2023 11:38:55 AM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 5:01 PM TIME POLICE ARRIVED 5:06 PM
PART I PAGE IT]OF
REPORT NO. ED50932 CASE# ' 23-3911 DATE AND TIME 04/06/23 17:00
OF COLLISION
'NOT TO SCALE*** >
Era
m
m
m
m
m
NE 20TH ST
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