HomeMy WebLinkAbout23-6742 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-6742 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 1 1 8 28
TRIBAL UNITS 02 STRUCK NONE
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 06 - 1-- 2023 0942 17 ❑-= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MONSTER RD SW
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ e S ❑❑ FEET OFBEACON COAL MINE RD
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2066699813 0 4 30
6� LAST NAME DUONG FIRSTNAME XUAN MIDDLE P 1 1 2 31
INITIAL
STREET ❑1 3707 S PERRY ST TTLE WA
NEW ADDRESS ST ZIP 981185241 z CITY SEA
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
$❑ LICENS
DRIVER # STATE WA SEX'M MMDDYY 02 - 10 - 1969 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H U EET ICNLJAURY I NATURE OF INJURIES 2❑
3
10 9❑ PI ATE BJB9865 sTArI WAvIN# 1HGCE1894SA006244
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 7 34
13 2 1995 HOND ACCOR DAMAGE YES NO /4I� /�Y(TOW 'Es❑ NO
REGISTERED OWNER INFO XUAN DUONG 3701 SPERRYST SEATTLE WA 98118 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ABILI V INSURANCE INSURANCE CO SAFECO H2366944 3 4
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 3AO095092 FOLLOW VEHICLE TOO CLOSELY io sorrow
15❑ STANDING 7 6
MOTOR PEDAL- ❑ PEDESTRIAN PROPERTY DAM THR PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ OWNER ❑ YES 1/ No OLD MET D:2065843854
16 a
LAST NAME SEVERSON FIRST NAME JAMARI MIDDLE N
INITIAL
17 NEW STREETREs7 4218 S 116TH ST CITY TUKWILA ST WA ZIP 981681968 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES ❑ 40
❑LICENSE I 21❑ PLA E# CGU8605 TArE WA VIN# 19UUA76517A803111 41
1
42
22❑ PLATE# STATE PLATE# STATE
T
23❑ 43
IN# IN RLR
#.UIN#. '
VEH YEAR 2007 MAKE ACUR MODEL TL STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO JAMARI SEVERSON 4218 S 116TH ST TUKWILA WA 98168 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&POLICY#E CO 4466614585IN 1U�VE""LE
TOP❑ ,J� CITATION# CHARGE TTOMLEGALLYYES N`L J25 '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 77P�1300
26
ALEKSANDR IGNATOV 12619
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED70652
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6742
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,FIRS 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 one was traveling northbound on Monster Rd SW at Beacon Coal Mine Rd in lane 1 of 1. Unit
two was in front of unit one traveling northbound on Monster Rd SW at Beacon Coal Mine Rd in lane
1 of 1. Unit two slowed down to make a left hand (westbound) turn on to Beacon Coal Mine Rd. Unit
two was traveling too closely and struck unit two in the rear.
Photos of crash have been uploaded to Axon Evidence. Unit one cited with an infraction.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 06-13-23 10:49 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 6/16/2023 3:31:21 AM
BADGE OR ID# 12619 ORI# WA0171300 TIME POLICE DISPATCHED 9:44 AM TIME POLICE ARRIVED 9:52 AM
PART I PAGE IT]OF 3�
REPORT NO. ED7 6 2 CASE# 2y6 4 A mTIME 0 d 3/23 0:4
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