HomeMy WebLinkAbout23-4664 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-4664 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICCI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 28
TRIBAL UNITS 02 STRUCK NONE
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 0532 17 ❑-= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
TALBOT RD S BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e S GRADYWAY
0 4 29
UNIT 01 MOTOOR Z PED
AL ❑ YEMAGE NHORE✓LDMET PHONE O 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 2 31
INITIAL
STREET ❑ CITY ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES No YES No
8 DRIVER'S. STATE SEX.U D.O.B. 1 1 2 32
❑ :LICENSE# MMDDYY —❑
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE sTATI urN#'
10❑ PI ATE 14
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR 5 7. TRLR 33
12 0 0 vIN# VIN#'
FROM TO
VEH.YEAR MAKE UNKN MODEL UNKNO STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13❑ DAMAGE YES�NO� YES❑ NO
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VE— CHARGE 5 36
LEGALLY res❑NO❑ CITATION# 1 o BOTTOM
15❑ 1.STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ No D:2536914053
16 a
LAST NAME YU FIRST NAME SUN MIDDLE A
INITIAL
17 STREET I❑ 22833 134TH AVE SE CITY KENT ST WA ZIP 980423217 37
NEW ADDREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL t—T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YES It1 I NoF t l YES NO
19 LDIIVEW # STATE WA ]SEX IF M .C.B. 01 22 _ 1957 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# BYG0127 TATE WA VIN# 41
5J8TC2H59ML019183 4
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
TOWED BY Gov HI 44
VEH YEAR 2021 MAKE /a C(fR MODEL RDX STYLE UT DAMAGE TOWED NOO✓ BLIN YES NO
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 0581962BO247LIN I STOP 5
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N 6
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
ALEKSANDRIGNATOV 12619 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED55126
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4664
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SAEPHANH FEUYF
(IAST FIRST,
ADDRESS&PHONE# D O.B.
10912 SE 212TH ST KENT WA 980312155 SEX F MMDDYyYv 03 - 29 - 1960
PASSENGER L,WITNESS UNIT# 2 POS AIRBAG 2 RESTR. 4 EJECT ? 1 HELMET NATURE OF INJURIES
USE CLASS LASS '1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
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 one was traveling northbound on Talbot Rd S at the intersection of S Grady Way, in lane 2 of 4
(left turn only lane to go westbound on S Grady Way). Unit two was traveling northbound on Talbot
Rd S at the intersection of S Grady Way, in lane 3 of 4 (straight ahead only lane). Unit one made an
unsafe lane change (when the light turned green) in the middle of the intersection from lane 2 of 4
into lane 3 of 4 and struck unit two who was going straight across. Unit one then took off from the
scene and did not exchange information with unit two.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 04-26-23 06:33 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 412712023 2:42:40 PM
BADGE OR ID# ( 12619 OR]# WA0171300 TIME POLICE DISPATCHED', 5:40 AM TIME POLICE ARRIVED';5:43 AM
FART I PAGE IT]OF 3�
REPORT NO. ED55126 CASE# 23-4664 DATE AND TIME 04/26/23 05:32
OF COLLISION
S GRADY Vi�AY
M0
W
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