HomeMy WebLinkAbout23-7794 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED77945 170
27
COLLISION REP FIT 1591971
CASE 23-7794 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 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# ❑
COLLISION: 07 - 08 - 2023 1300 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LOGAN AVE N BLOCK NO. e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e E PERIMETER RD
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:2067982899 0 11
30
6� LAST NAME GACEK FIRSTNAME ANTHONY MIDDLE M 1 1 2 31
INITIAL
STREET 1517 290TH ST E CITY ROY ST WA 21p 98580 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ DRIVERS
E#
ON DUTY❑ STATUS' AIRBAG 4 RESTR 4 EJECT 1 H U EETI I INJURY [NATURE OF INJURIES
CLASS ju BRUISE TO LEFT SIDE z❑
3
10 9❑ p7 ATNES14 BQD2676 STATE WA VIN# 19XF62F24CE306896
11[-j- TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# IR.. ro
TRLR. TRLR 8 5 33
12 3 5 VIN#j VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 1 $ 34
13 2 2012 HOND CIVIC 4D DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILIT INSURANCE INSURANCE CO ALLSTATE 987199850 3
IN EFFECT &POLICY# STOP
vE—LE CHAR 36
LEGALLY YES❑NO CITATION# 3A0535119 GE VEHICLE ENTERING STOP OR YIELD 1 o aorrom
15❑ STANDING 8
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT 02 ❑✓ ❑ PEDESTRIAN ❑ ❑ D:4254448952
VEHICLE CYCLE OWNER YES�/ NO
16 a
LAST NAME HENDERSON FIRST NAME DANIEL MIDDLE W
INITIAL
17❑ STREET ❑ 151 BREMERTON PL NE CITY RENTON ST WA ZIP 98059 37
NEW ADDRESS I I I I I ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSFORTED 38
INTERLOCK YEs❑No� INTERLOCK YYEEsI❑NOF YES
No�
19� DRIVER'S STATE WA SEX M D.O.B. 08 29 _ 1976 39
LICENSE# MMDDYY
HELMET I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I CHX3999 TATe WA vIN1t WAUC4AF49JA003926
❑ 41
PLATE#
42
22❑ PLATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 201E MAKE /�(fDI MODEL S4 STYLE $D DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO FARMERS 188780780IN 1UQI
'E""LE ❑ ,J� CITATION# CHARGELGALYYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED77945
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7794
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 Gacek was on E Perimeter Dr, at stop sign controlling entry onto Logan Ave N. Unit 2
Henderson was southbound on Logan Ave N. Unit 1 pulled onto Logan Ave N, making right turn in
front of Unit 2, which struck Unit 1. Left front corner of Unit 2 impacted left rear corner of Unit 1. Unit 1
driver Gacek cited for Vehicle Entering Stop or Yield Intersection (RCW 46.61.190(2)(a)).
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 07-08-23 03:23 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.EDWARDS 9070 1 7/9/2023 5:27.24 PM
BADGE OR ID# 5738 OR]# WA0171300 TIME POLICE DISPATCHED 1:14 PM TIME POLICE ARRIVED 1 1:19 PM
PART I PAGE IT]OF 3�
REPORT NO. ED77945 CASE# ' 23-7794 DATE AND TIME 07/08/23 13:00
OF COLLISION
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