HomeMy WebLinkAbout23-7668 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-7668 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
cawsloN 07 - 1-- 2023 1828 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SW 16TH ST BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 200 00 FMILES EET e S ❑ E e MAPLE AVE SW
0 6 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2062493069 0 11
30
6� LAST NAME QADEERY FIRSTNAME HASS/BULLAH MIDDLE
INITIAL 1 11 31
STREET El 3834 D PL SE APT 4 CITY AUBURN ST WA ZIP 98002 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/iNTERLOCKYEs NO INTERLOCKYEs Z/NO YES �No /
LRIIVER # STATE WA SEX'M I EL MI MIT Y
8❑ ' 01 - 01 - 1989 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BRH4956 sTArI WAVIN# 4T18D1FK0FU166818
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#
FROM TO
VEH.YEAR 2015 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 4 TOYT CAMRY 4D DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 5249620-C28.47 3 4
IN EFFECT &POLICY# 9TOP
VIC CHARGE 1 5 36
LECALLEHLEv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:8455415102
16 a
LAST NAME MARKS FIRST NAME JASON MIDDLE D
INITIAL
17 STREET❑ NEW ADDREss❑' 1226 TAYLOR AVE N APT3 CITY SEATTLE ST' WA ZIP 98109 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX M D.C... 07 28 _ 1988 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES 40
LICENSE I ❑21❑ PLA E# CDJ7585 TArE 41
WA VIN# SNMJFCAE7NH090379 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2022 MAKE yyU/� MODEL TUCSON STYLE (/T DAMAGE TOWED TOO✓ BLIN YES NO
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO GEICO 6102-98-49-26IN I STOP 5
VEHICLE YES[:] ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY N
25 $
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JASON JONES 11635 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED80073
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7668
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'
On 7-5-23, at about 1843 hours, I was dispatched to a collision that occurred in the 3300 block of SW
16th ST.
Upon I arrival, I saw a Unit 1 and Unit 2 pulled off to the side of the road. Both Units did not require a
tow and both drivers claimed they were not injured.
I contacted the driver of Unit 1. He relayed the following: He received a notice from his vehicle about
a flat tire while traveling west on SW 16th ST, pulled into the middle double turn lane, and was struck
by Unit 2 at one point. It was not clear if Unit 1 was still moving or stopped, but the driver told me he
was slowing down and had his hazards on.
I contacted the driver of Unit 2. He relayed the following: he was traveling west on SW 16th ST, was
passing Unit 1 when Unit 1 entered his lane of travel causing a collision.
Based on the evidence at the scene and the statements made to me, I was unable determine the
cause of the accident.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON JONES 07-05-23 08:21 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 711612023 2:33:19 PM
BADGE OR ID# 11635 ORI#' WA0171300 TIME POLICE DISPATCHED 6:43 PM TIME POLICE ARRIVED 6:46 PM
PART I PAGE IT]OF
REPORT NO. EU80073 CASE# 23-7668 DATE AND TIME 07/05/2318:28