HomeMy WebLinkAbout23-12434 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-12434 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 2$
TRIBAL UNITS 02 STRUCK' POLE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GawsloN 10 - 1-- 2023 0620 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MONSTER RD SW BLOCK NO. e✓ 1200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 700 00 FMILES EET e S B OF JACKSON PE SW
0 1 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElDESA✓NHORESHOLD MET PHONE 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY Sr zlP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8 DRIVER'S. STATE : SEX.U D.Q.B. 1 32
❑ :LICENSE# MMDDYY —=
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H USEEr 9 CLAY 0 NATURE OF INJURIES z❑
3
10❑ PI ATNE 14 CFU1292 sTAT WAv N# 1NXBR12EX2Z570950
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
TRLR. A'RLR. 1 5 33
12❑ vIN#' VIN#
Rom 34
13❑ VEH.YEAR 2002 MAKE TOYT MODEL COROL STYLE 4D VEHICLE TOWED 0 TOO
ffBLIN TQ yEq.BLRs yOS❑ENO
DAMAGE ILJI tSA1Vi�6
REGISTERED OWNER INFO HYNNIE GEORGE 1610 WJAMES PL A201 KENT WA 98032 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ ABILIT INSURANCE❑ INSURANCE CO 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY ✓ DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:8882255773
16❑
LAST NAME PS E FIRST NAME MIDDLE
INITIAL
17 STREET ITH AVE NE CITY BELLEVUE ST WA ZIP 98004 37
NEW ADOREs�' 355 110
18� IGNITION REQUIRED IGNITION PRESENT
RESENT MEDICAL TRANSPORTED 38
YECDL ERLOCKYES�NORINTERLOCKYEs --1NOF s ]
NO❑
19 LLIICENS # STATE SEX U MMDDYY —�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TATE 41
IN#LICENSE V `1
PLATE#
42
22 [TRAILER T
❑ PLATE# STATE PLATE#ILER STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO IGQVE""LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 771�NCY
26
ALEKSANDR IGNATOV 12619 0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE14783
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12434
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 one was traveling southbound on MONSTER RD SW near the 1200 BLK, in lane 1 of 1. Unit one
left the roadway and struck a light/utility pole. The driver then left the scene prior to police arrival.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 10-30-23 07:41 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
D.SKELTON 9139 1013112023 4:07:30 AM
BADGE OR ID# 12619 ORI# WA0171300 TIME POLICE DISPATCHED 6:21 AM TIME POLICE ARRIVED 6:25 AM
PART I PAGE IT]OF 3�
REPORTNO. EE147 3 CASE# 2y42 3 A m°M} ]±3 g3 0:2
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