HomeMy WebLinkAbout23-1753 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 5 27c
COLLISION REP FIT 1591971
CASE 23-1753 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 01 STRUCK CONCRETE/JERSEYBARRIER
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
GawsloN 02 - 1-- 2024 1955 17 ❑-= S 8 IN e 1070 3
4 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LAKEWASHINGTON BLVD BLOCK NO. e✓ 4800 ❑
4a 1❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NE 48 ST
0 1 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElDESA✓NHORESHOLD MET PHONE 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 0 6 31
INITIAL
STREET ❑ CITY TAYUHA ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
DRIVERS
STATE SEX D '❑- 328 LICENSE MDYY❑ M
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET USE 2 CLAY S:R0 NATURE OF INJURIES 2❑
3
10❑ P1 ATNES# C476555 sTAT WAv N# 1 FTDX1729VK659749
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FRom To
TRLR. TRLR 3 7 33
12❑ vIN#' VIN#
FR.. 34
13� VEH.YEAR 1997 MAKE FORD MODEL F150 STYLE PK VEHICLE TOWED NOO pLSABLIN T� kkRS TOWING YOVT.V
DAMAGE IILLJJII
REGISTERED OWNER INFO VICTOR DELL 121 NE RANCH DR TAYUHA WA 98588 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY#
VEHCLE CHARGE ❑ 36
LEGAL
Lv res❑NO❑ CITATION# BOTTOM
15❑ STAIN,DIING
UNIT 02 TFIR
vEHIMOTOCLE ❑ CYCLE ❑ PEDESTRIAN ❑ OWNER PEDAL
❑ DYES NOAM OLD MET PHONE
16❑
LAST NAME FIRST NAME ' MIDDLE
INITIAL
STREET
CITY' Sr ZIP 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIICENS # STATE SEX 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 TILER
❑ PLATE# STATE PLATE# 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 I VEwcLE ❑ ,J� CITATION# CHARGE25 GQ
LEGALLY YES N`L J
s � e
7BRYAN
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26GROZAV 12489 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE53471
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1753
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 was traveling east on NE 48th St. Failed to stop at the posted stop sign, struck the cement jersey
barrier causing the vehicle to the flip over the jersey barrier and come to a stop on its roof. Several
reporting parties indicated driver and passenger leaving crash scene on foot. Officers checked the
area for driver and passenger but were unable to located them. Vehicle had extensive damage all
over and was towed from the scene. Jersey barrier was not damaged but moved from original
position. No other vehicles or subjects were involved. Unknown who the driver and passenger were
since they were unable to be located. Impound form completed.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
BRYAN GROZAV 02-17-24 11:57 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIREE SCOTT 10272 1 2/24/2024 3:14:59 PM
BADGE OR ID# 12489 ORI# WA0171300 TIME POLICE DISPATCHED 7:88 Pry] TIME POLICE ARRIVED';8:04 PM
PART I PAGE IT]OF
REPORT NO. EE53471 CASE# ' 23-1753 DATE AND TIME 02/17/24 19:55
OF COLLISION
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