HomeMy WebLinkAbout23-03992 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-03992 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 2$
0 5
RESERVATION
TRIBAL UNITS 02 STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
CowsloN 04 - 08 - 2023 2210 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 1800 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e I-405
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4253625465 0 4 30
6� LAST NAME NIGMATJONOV FIRSTNAME KHASAN MIDDLE B 1 1 2 31
INITIAL
STREET ❑✓ 300 VUEMONT PL NE R301 CITY RENTON ST I WA 2jp, 980568549 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs Z/NO YES R NoF,/
LRIIVER # STATE WA SEXI M MMDD
$❑ 11 — 16 — 2000 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET IINLJAURY 1 NATURE OF INJURIES z❑
3
10❑ PI ATE BZD2889 sTArI WAurN# 4T18E32K22U104054
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR $ 1 33
12 3 5 VIN#' VIN#
FROM TO
VEH.YEAR 2002 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 3 34
13 4 TOYT CAMRY SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO KHASANNIGMATJONOV3815NE4THSTAPT148 RENTONWA98056 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO STATE FARM 530-2182-FOS-47A 4
IN EFFECT &POLICY# STOP
VEHICLE 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LEGALLY STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2065787732
16 a
LAST NAME WAYMAN FIRST NAME JULIA MIDDLE R
INITIAL
17❑ STREET ❑', 30618 4TH AVE S CITY FEDERAL WAY ST WA ZIP 980034010 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED ❑ 38
INTERLOCKYEs❑No� INTERLOCK ves No� YEs NDF
19 DRIVER'S STATE WA SEX F D.C... 04 19 _ 2004 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CFG7408 TAre WA VIN# JHMEJ6677WS000891
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 1998 MAKE HOND MODEL CIVIC STYLE SD VEHICLE TOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO JULIA WAYMAN 306184TH AVE S FEDERAL WAY WA 980034010 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE &PORGY#E CO ENUMCLAW MUTUAL INS AB10047607 1GQIN EFFECT
"'LE ❑ ,.I— CITATION# CHARGE
LEGALLY YES N`LJ
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. ED56946
COLLISION REPORT III III III III III 111
1591972 CASE# 23-03992
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 1 traveling northbound on Maple Valley Hwy approaching the unmarked signaled intersection to
the east of 1-405. Unit 2 traveling southbound on Maple Valley Hwy making left turn into driveway at
Best Western at 1850 Maple Valley Hwy. Unit 1 driver claimed that he had the green light. Unit 2
driver also claimed that she had the green left turn arrow. Observation of signals at intersection
indicate that lights were functional and operative.
Unit 2 fails to yield ROW. Unit 1 strikes Unit 2 causing reportable non disabling front passenger side
damage to Unit 1 and reportable disabling rear passenger side damage to Unit 2. 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 04-08-23 11:28 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 5/4/2023 3:18:27 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED; 10:15 PM TIME POLICE ARRIVED',10:22 PM
PART I PAGE IT]OF 3�
REPORT NO. ED56946 CASE# 23-03992 DATE AND TIME 04/08/23 22:10
OF COLLISION
y
ee s_ GGe�4
ENTRANCE TO BEST WESTERN DRIVEWAY
yi 5
NOT TO SCALE
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