HomeMy WebLinkAbout23-03951 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-03951 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF OZ OBJECT 1 1 8 28
UNITS
RESERVATION I I
STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 04 - 1-- 2023 1825 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
SUNSET BLVD NE M480
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 1000 FEET MILES e S B W e N 3RD ST
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064220479 0 11
30
6� LAST NAME FARAJ FIRSTNAME RADWAN MIDDLE I 1 2 31
INITIAL
STREET ❑, 13730 2ND AVE NW CITY SEATTLE ST WA ZIP 981773918 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi ATE 14 BCW3395 STATE WA v N# JTDKN3DUOA0230938
11[-jTRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# IR.. ro
TRLR. A'RLR. 1 5 33
12 3 0 VIN#' VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 $ 34
13 3 2010 TOYT PRlUS 4H DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO RADWAN FARAJ PO BOX 1332 MERCER ISLAND WA 98040 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 4593019070 4
IN EFFECT &POLICY# 9TOP
VEHICLe CHARGE 5 36
LEGALLY, YES❑NO❑ CITATION# 1 o BOTTOM
15❑ NDIN 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ :4254436696
16 a NO D
LAST NAME HORA FIRST NAME TRETEN MIDDLE A
INITIAL
17❑ STREET ❑', 2621 AB AVE NE CITY RENTON ST WA ZIP 980562213 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES t l NOF,/
19 DRIVER'S STATE I WA SEX M I D.O.B. 04 19 _ 1993 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BWS1475 TATe WA vIN# 3N1A67AP5KL611136
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2019 MAKE NISS MODEL SENTRA STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24 DAMAGE YES NO GENE MEYER YES NO
REGISTERED OWNER INFO TRETEN HORA 2621 ABERDEEN AVE NE RENTON WA 98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 458-1479-E17-47IN IURVE"LLE
❑ ,J� CITATION# CHARGELEGALYYES N
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED56944
COLLISION REPORT III III III III III 111
1591972 CASE# 23-03951
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'
Units 1 and 2 both traveling southbound in left lane of Sunset Blvd NE passing overpass of 1405 and
SB 1405 off ramp along the 480 block approaching N 3rd St. Unit 2 traveling behind Unit 1 and
changes lanes into right lane initially and is passing Unit 1 on the right. Unit 1 also makes lane
change and veers into Unit 2 causing reportable non disabling damage to the front passenger side of
Unit 1 and reportable non disabling damage to the front driver side of Unit 2. Unit 2 veers into raised
curb along the west side of the roadway from the initial impact and sustains disabling axle/wheel
damage to the front passenger side. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 04-07-23 07:16 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 5/4/2023 3:00:10 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED 6:28 Pry TIME POLICE ARRIVED 6:33 PM
PART I PAGE IT]OF 3�
REPORT NO. ED56944 CASE# ' 23-03951 DATE AND TIME 04/07/23 18:25
OF COLLISION
NOT TO SCALE
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