HomeMy WebLinkAbout23-6801 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-6801 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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# ❑
cowsloN 06 - 1-- 2023 1724 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAIN AVE S BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2533108746 0 11
30
6� LAST NAME STONER FIRSTNAME JENNIFER MIDDLE L 1 1 2 31
INITIAL
STREET ❑✓ 3303 PARK AVE N CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVERS STATE WA SEX'F MM DAY' 06 1— 20 — 1984 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� BXG4694 sTArI WAurN# 5FNRL388X58075274
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# IR.. ro
TRLR. YRLR. 5 1 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 2 2005 HOND ODYSSE DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO JENNIFER STONER 2307177TH STE TACOMA WA 98445 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO NATIONAL GENERAL 2016946465
IN E 3 4
FFECT & 36
POLICY# GE STOP
veE CHAR 1 5
LEGALLYG YES❑NO CITATION# 3A0357737 FLD SIGNAL STOPS/TURNS-UNSAFE o BorroM
15❑ NDIN 8 6
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:2533081452
16 a
LAST NAME GAFUROV FIRST NAME ELDAR MIDDLE
INITIAL
17❑ STREET ❑', 26213 123RD AVE SE CITY KENT ST WA ZIP 980308665 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t l NOF,/
19 LICENSE# STATE WA SEX M M .C... 10 �_ 02 _ 1986 El 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE CGF4791 TAre 41
WA VIN# 3N1A67AP5DL733515
❑
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2013 MAKE NISS MODEL SENTRA STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO ISRAIL GAFUROV 29321 121ST AVE SE AUBURN WA 98092 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSURANCE
#E CO NATIONAL GENERAL 2018432678 1 STOP 5
IN EFFECT
VEHICLE ,.I—I CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES❑ N
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED72240
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6801
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 was traveling northbound in the 300 blk of Main AVE S in the left of two northbound lanes of
travel. Unit 2 was traveling northbound in the 300 blk of Main AVE S in the right of two northbound
lanes of travel directly next to Unit 1. Unit 1 intended to change lanes to the right to enter a parking
lot but did not check to assure this lane change could be done safely. Unit 1 initiated a lane change
from the left lane into the right lane which was occupied by Unit 2. The front passenger corner of Unit
1 struck the driver's side of Unit 2 causing moderate damage to both vehicles.
Driver 1 was cited for an unsafe lane change by not checking to assure a lane change could be done
safely and changing lanes into a lane occupied by another vehicle which was the proximate cause of
the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 06-17-23 07:10 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 6/21/2023 10:40:57 AM
BADGE OR ID# 10008 ORI#` WA0171300 TIME POLICE DISPATCHED 5:26 PM TIME POLICE ARRIVED',5:26 PM
PART I PAGE IT]OF 3�
REPORT NO. ED72240 CASE# ' 23-6801 DATE AND TIME 06/14/23 17:24
OF COLLISION
'NOT TO ALE***
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