HomeMy WebLinkAbout24-433 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE RESULTED ❑ CASE 24-433 z
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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'. 01 - 1-- 2024 1504 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE PETROVITSKY RD BLOCK NO. e✓ 12200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO �/ D:2064747521 0 81
30
6� LAST NAME GUZMAN FIRSTNAME LUIS MIDDLE M 1 1 2 31
INITIAL
STREET ❑, 10605 RAINIER AVE S CITY SEATTLE ST WA 2jp, 981782738 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVERS STATE WA SEXI M MM DAY' 06 1— 22 — 1961 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H U EET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 Pi ATNES# A6911966 sTAT WA v N# 3C7WRKFL4PG531269
[----� TRAILER 20444AG STATE WA TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
rRLR TRLR 3 7 33
12 3 5 VIN# YIN#'
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 2 2023 DODG RAM PK DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO APAMILAS LANDCARE LLC NONE 10605 RAINIER AVE S SEATTLE WA 98178 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE KRAFT LAKE INSURANCE AGNECY,INC BAS 63073600
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LECALLv Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:4256330160 N:4256476806
16 2
LAST NAME ZAGURNA FIRST NAME NATALIYA MIDDLE M
INITIAL
17❑ STREET ❑', 495 RENTON CENTER WAY SW APT CITY' RENTON ST WA ZIP 980573504 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.C... 04 04 1956 El 39
LICENSE# MMDDYY
20 �NATURE OF INJURIES
❑ ON DUTY STATUS AIRBAG 2 RESTR y EJECT 1 WEB EET LASSY 6 SORE BACK,SORE NECK,AND STOMACH PAIN ❑ 40
21❑ LICENSE I CDV0176 TATE I WA VIN# JF2GTAEC1LH213884
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2020 MAKE SUBA MODEL CROSSJ" STYLE HB VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO NATALIYA ZAGURNA 495 RENTON CENTER WAY SWAPT RENTON WA 98057 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#ECO THE STANDARD FIRE INSURANCE COMPANY 607874338 203 1 1GQO,
IN EFFECTVEHICLE CITATION# CHARGE
LEGA YES[Z N�
25❑ LLY JAGENCY
s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
JESSE VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE39992
COLLISION REPORT III III III III III 111
1591972 CASE# 24-433
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'
Vehicle #1 was traveling westbound in the inside lane of the 12200 block of SE Petrovitsky Rd.
Vehicle #2 was stopped for a school bus with it's stop sign out and was facing west in the inside lane
in front of vehicle #1. Vehicle #1 did not stop in time to avoid a collision, which caused the front end
of vehicle #1 to collide with the rear end of vehicle #2. The driver of vehicle #1 advised she had slight
back pain, right shoulder pain, and a sore stomach from the collision, but declined aid. Based on the
totality of the circumstances, it appeared vehicle #1 caused this collision.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Traffic Control: SCHOOL BUS STOP SIGN
Motor Vehicle Unit 2
Traffic Control: SCHOOL BUS STOP SIGN
**** END OF AUTO-POPULATED SECTION ****
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 01-12-24 04:31 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 111312024 3:59:45 AM
BADGE OR ID# 11631 OR]# WA0171300 TIME POLICE DISPATCHED 3:16 PM TIME POLICE ARRIVED 3:26 PM
PART I PAGE IT]OF 3�
REPORT NO. EE39992 CASE# ' 24-433 DATE AND TIME 01/12/24 15:04
OF COLLISION
AN
Not to scale SE Petrovitsky Rd
m ,.
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