HomeMy WebLinkAbout22-13121 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 22-13121 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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.. 12 - 1-— 2022 0845 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
108TH AVE SE BLOCK NO. e✓ 17800
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET MILES e S B W e S 180TH ST
0 8 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2069601220 0 11
30
6� LAST NAME JOCK FIRSTNAME KALIN MIDDLE A F 2 31
INITIAL
STREET ❑ 515 116TH AVE NE CITY BELLEVUE ST WA 21p 98004 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BYS2271 sTArI WAvIN# 3CZRU6H50MM745794
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 3 2021 HOND HRV UT DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO PVHOLD.CORP 15820 INTERNATIONAL BLVD TUKWILA WA 98188 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCECO P.V.HOLDING CORP SELF INSURED 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY
Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:2535619486
LAST NAME FIELDS FIRST NAME ERNEST MIDDLE T
INITIAL
17❑ STREET ❑', 25429 157TH AVE SE CITY COVINGTON ST WA ZIP 98042 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LICENSE# STATE WA SEX M M D.O.B. 12 _ 21 1987 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BUP1286 TAre WA vIN# 1FM5K8F87EGB95553
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2014 MAKE FORD MODEL EXPLORE STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CHAWNTEE DUNCAN PMB 7529 OLYMPIA WA 98507 VEHICLE NO.2
SHADE DAGED AREA
4
LIABILITY
INSURANCE INSU&POLICY#E CO PEMCO CA2079795IN 1 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE to BOTTOM
LEGALLY YES N`LJ
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
M.THOMPSON 10499 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED13822
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13121
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) HOSTON MYQUEEN
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
25429 157TH AVE SE COVINGTON WA 98042 SEXi F MMDDYyry 03 - 08 - 2010
PASSENGER WITNESS UNIT# SEAT : AIRBAG RESTR. EJECT ' HELMET NJURY NATURE OF INJURIES
❑✓ 2 POS. 7 2 4 1 USE CLASS 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 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 north on 108th AVE SE in the 17800 block. Unit 2 was traveling in lane 1. Unit 1
was exiting the driveway in the 17800 block to turn north. Unit 1 pulled out slowly. Unit 2 and Unit 1
collided causing damage to the passenger side of Unit 2 and damage to the front drivers side of Unit
1.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.THOMPSON 12-12-22 09:37 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 1211212022 4:28:57 PM
BADGE OR ID# 10499 ORI# WA0171300 TIME POLICE DISPATCHED; 8:47 AM TIME POLICE ARRIVED',8:53 AM
PART I PAGE IT]OF
REPORT NO.! ED13822 CASE# 22-13121 DATE AND TIME 12/12/22 08:45
OF COLLISION
i
f
Unitl
ZZ/
Unit
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