HomeMy WebLinkAbout23-4609 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-4609 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 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 1703 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 2ND ST BLOCK e✓ 100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:5094054815 0 11
30
6� LAST NAME BAYONA FIRSTNAME RUBEN MIDDLE 1 2 31
INITIAL
STREET El 5127 REAGAN WAY CITY PASCO ST WA Zjp, 993019285 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER # STATE WA SEXI M MI D Y' 10 - 24 - 1957 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� CFM4476 sTArI WAVIN# JT2BK18U720049935
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 2 5 VIN# YIN#i
FROM TO
3 ]VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 34
13 1 2002 TOYT PRlUS DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO NELLYBAYONA 5127 REAGAN WAY PASCO WA 99301 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO CONNECT A102321671 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 1 5 36
�LGALL,v Yes❑NO CITATION# 10 BOTTOM15❑ GMOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
NIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:2063563945
16 2
LAST NAME EMNETU FIRST NAME CALEB MIDDLE E
INITIAL
17❑ STREET �' 500 4TH AVE#653 CITY SEATTLE ST' WA ZIP 98104 37
NEW ADDRESS ❑
18� CDL ., IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALTRANSFORTED 38
INTERLOCKYES�NOR INTERLOCK YYEEsI I I No� YES NO�
19 LDICENS STATE WA SEX M M.C... 12 _ 17 1986 El 39
WELMET {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT '1 USE 2 CLASS 1 ❑
21❑ LICENSE 97803C TAre I WA VIN1i 5FYH5YU05A6038410
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2010 MAKE NEW MODEL BUS STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ AMAGE YES NO,/ YES NO
REGISTERED OWNER INFO KING COUNTY DOT TRANSIT 5004TH AVEAVE#653 SEATTLEWA98104 VEHICLE NO.2
SHADEDAMAGED AREA
3 4
LIABILITY INSURANCE INSU&PORGY#E CO KING COUNTY METRO SELF INSURED IULlliKOTlTlfll;0-
NAMEIN EFFECTVEHICLE ❑ ,.I—I CITATION# CHARGELEGALLY YES N`LJ25 OFFICER'S (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. ED55408
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4609
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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 2nd from the left of 4 westbound lanes of travel in the 100 blk of
S 2nd ST which is a one-way roadway. Unit 1 was also traveling westbound in the 100 blk of S 2nd
ST in the 3rd from the left lane of travel (to the right of Unit 2) slightly in front of Unit 2. Unit 1
intended to make a lane change to the left and failed to assure this could be done safely. Unit 1
initiated this lane change to the left and pulling into the lane occupied by Unit 2. The front passenger
side of Unit 2 impacted the front driver's wheel area of Unit 1. Unit 1 sustained moderate but
disabling damage. Unit 2 sustained minor damage. This report is to document the circumstances 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 04-24-23 05:48 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 412812023 2:31:23 PM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED; 5:04 PM TIME POLICE ARRIVED';5:08 PM
PART I PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. ED55408
r`I POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-4609
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE ✓ G
UNIT# 2 USDOr ICC# ' VEHICLE TYPE 1 CARGO BODY 1
TYPE 2 ❑ 1 28
CARRIER NAME. KING COUNTY METRO
.....
3 CARRIER
ADDRESS 500 4TH AVE#653
CITY SEATTLE ST WA ZIP'', 98104
4 ❑ NAME # PLACARD: :❑
NAME IF NO NUMBER
SOURCE 1 AXLES 03 GwvR 30000 +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES NO
i MIDDLE'... 29
LAST NAME FIRST NAME INITIAL
STREET 30
NEW AnnRFrtP. CITY ST ZIP
6 �
CDL GNITIttN REQUIRED GNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YES No INTERLOCK YES❑N0� vES N
LLIICIENSE STATE I SEX M��DYRYY' 2
7 F-1
ON DUTYl STATUS AIRBAG' RESTR. EJECT HELMET INJURY NATURE OF INJURIES
USE CLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHIG P FROM TO
DAMAGE Y EES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
VEHICLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING S} 8 7 6
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNER
YES AGE NOHRESHOLD MET PHONE El
35
PEDESTRIAN
15 LAST NAME FIRST NAME MIDDLE': INITIAL36
STREETIAL
❑
16 NEn+AnnRFs.�' CITY'. ST 21P
CDL IGNITION REdUiRED IGNITION PRESENT MEDICALTANSPORTED
INTERLOCK YES No INTERLOCK YEs NO YEs NO El
17 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE (CLASS
19 ❑ vIN# 39
LICENSE
PLATE# rnr
20 ❑ TRAILER' TRAILER ❑ 40
PLATE# STATE PLATE# STATE
21 ❑ TRLR TRLR 41
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWED DUE T SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO El
23 REGISTERED OWNER INEO_ SHADE IN DAMAGED 3 4 4 AREA F 43
z
LIABILITY INSURANCE INSURANCE CO '
IN EFFECT � &POLICY# i 970P - 4 E:l
L 44
24 EMCLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
..GALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 04-24-23 05:48 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 OR ID# 10008 O#I,WA0171300 JOHNSON 4/28/2023 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. ED55408 CASE# ' 23-4609 DATE AND TIME 04/24/23 17:03
OF COLLISION
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