HomeMy WebLinkAbout23-06917 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE#r` 23-06917 2
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AGENC 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 1 7 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 06 - 1-- 2023 2200 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LOGAN AV N BLOCK NO. e✓ 780
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FEET MILES e S B W e N 8TH ST
1 4 29
UNIT MOTOR
VEHICL Z CYCLE ElDDAMYESA✓NOESHOLDMET PHONE O 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE �31
INITIAL
STREET ❑ CITY Sr zIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYES NO 1/ INTERLOCKYEs NO�/ vES No�/
8❑ LICIENSE#
SrA fE I
SEX u MMDOBYY - 1 1 2 32
9❑ ON DUTY❑ STATUS' AIRBAG 9 RESTR 9 EJECT 1 H USE 9 CLASSY 0 N[NATURE OF INJURIES 2❑
3
10 9❑ pI ATNES14 BFM9563 STATE WA VIN# 19UUA56653AO62274
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
TRLR. TRLR m
33
12 0 0 VIN#' VIN#'
2003 ACUR 32TL SD p ❑ �34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO �I yES NO
13 REGISTERED OWNER INFO KRISTIETABADER08112WOLCOTTAVES SEATTLE WA98118 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO PEMCO CA 0835488 3 4
IN EFFECT &POLICY# 9TOP
VENICLE CHARGE 5 36
LECALLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STAIN,DIING 7 6
UNIT U2 VEHIMOTOCLE CYCLE ❑ PEDESTRIAN ❑ OWNER PEDAL- RTY ❑ DYES NO ✓OLD MET PHONE
16 a
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY SEATTLE ST ZIP $
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL t—T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YES It1 I NoF t l YES NO
19 LLIICENS RIVERS# STATE SEX U MMDDYY —=_ 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT '1 USE 9 CLASS 0 ❑
❑21❑ LICENSE TATE 41
VIN# `1
PLATE#
42
22 [TRAILER T
❑ PLATE# STATE PLATE#ILER STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE DAMAGE TOWED NOO✓ BLIN TOWEDBY GoYES v N HIO 44
24❑ YES
REGISTERED OWNER INFO UNKNOWN SEATTLE VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ &POLICY#E CO UNKNOWNIN QVE"LE
❑ ,J� CITATION# CHARGE i o
LEGALLY YES N`L J
25
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED72491
COLLISION REPORT III III III III III 111
1591972 CASE# 23-06917
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'
Hit and run within parking lot. Minimal suspect information. Unit 1 RO reported vehicle left parked
within Top Golf lot at 780 Logan Av N. Unit 1 reported sustaining front driver bumper damage.
Damage does not appear disabling. No injuries. Hearsay note left on Unit 1 vehicle described
offending Unit 2 as a red VW Jetta WA tag APW9112. No further evidence or witnesses can
conclusively corroborate said evidence.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 06-18-23 03:14 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 6/22/2023 3:32:00 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED 2:35 AM TIME POLICE ARRIVED 2:42 AM
PART I PAGE IT]OF 3�
REPORT NO. ED72491 CASE# 23-06917 DATE AND TIME 06/17/23 22:00
OF COLLISION
G E N E N 0 T E E r
PAGE 3 OF 3