HomeMy WebLinkAbout23-7383 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-7383 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4350 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 28
TRIBAL UNITS 03 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 06 - 1-- 2023 1130 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
116TH AVE SE BLOCK NO. e✓ 17400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 9 29
MOTU '�01 VEHtOCLEZ PEAL-CYMLE. El �ESAGE NHORE✓LD MET PHONE O 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNIT{ON PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LIRCIENSRE#
STATE I
SEX u MMDDYY - 1 1 2 32
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE sTATI urN#'
10[9 PI ATE#
TRAILER TRAILER
STATE STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR. TRLR 9 9 33
12 3 5 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 34
13❑ DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VEwcLE 5 36
LECALLv Yes NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:3604717675
16 a
LAST NAME WORMWOOD FIRST NAME CHARLES MIDDLE JE
INITIAL
17 STREET ADDRESS❑', 11050 SE CHERRY ST CITY PORT ORCHARD ST WA ZIP 983668903 37
18� CDL ., IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALTRANSFORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I No� YES NO❑ 11
19[-] D IVEW #
I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
LICENSE I ❑21❑ PLA E# C09838Y TATe 41
WA VIN# 1FTZR15V1XPA83950 4
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 1999 MAKE FORD MODEL RANGER STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CHARLES WORMWOOD PO BOX 291 SOUTHWORTHWA98386 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE I PORGY#ECO BRISTOL WEST INS GROUP G01 1164 322 03 1 STOP
IN EFFECT
'E""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 $
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
J.M/TCHELL 10377 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED82452
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7383
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 062923 1 responded to a 3-vehicle non-injury/non-blocking hit and run collision near the 17400
block of 116th Ave SE.
I contacted the driver of unit 2 who told me they were traveling southbound on 116th Ave Se when
unit 1 (traveling in front of unit 2) came to a complete stop in the roadway for an unknown reason.
Unit 2 slowed and tried to come to a stop to avoid a collision but was unable to stop in time and rear-
ended unit 1.
I contacted the driver of unit 3. Driver says he rear-ended unit 2 after unit 2 came to an unexpected
stop in the roadway.
Driver of unit 1 was never contacted because he/she left the scene immediately after the collision.
But not for the action of UNIT 1 DRIVER the result would not have happened.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.MITCHELL 07-12-23 08:01 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 712412023 11:26:23 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED; 11:30 AM TIME POLICE ARRIVED',11:45 AM
PART I PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. ED82452
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 23-7383
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 3 VEHICLE tSJ CYCLE _) PEDESTRIAN � OWNER � YES NO
D:2063532424
] OF 1 Zg
LAST NAME OJOFEITIMI FIRST NAME BABAJIDE MIDDLE' ',, D r:j INITIAL
STREET 30
NEW AnDRFrtP 520 SMITHERS AVE S APT 4 CITY RENTON ST WA ZIP 980572573
6
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED 1 1 2 31
INTERLOCK YEs No NTERLOCK YES[:]NO[:] YES N
DRIVER'S
LICENSE STATE I WA SEX M MMDDYYv 10 TO]
- 1987
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET I INJURY 1 1 NATURE OF INJURIES
USE :CLASS
8 1 32
LICENSE PLATE#1 9210401 [TAT VIN# NA
9 9] TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 3 5 VEH.YEAR MAKE MORG MODEL OLSON STYLE VEHICLE TOWS E T SABLIN TOWED BY anvi vFHICi P FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFOBABAJIDE OJOFEITIM1520 SMITHERS AVE S APT 4 RENTON WA 980572573 D:2063532424 1 5 33
12 � SHADE IN DAMAGED AREA
4 FROM TO
LIABILITY INSURANCE INSURANCE CO SELF INSURED R"i"Olx
IN EFFECT &POLICY#
VEHICLE 10 6QTTUM 34
13 ❑ Lecnuv YES❑ NO❑ CITATION# CHARGE gg�@
STANDING S} l:9 7 6
14 ❑ UNIT Tr Vd IRE O CYDCLE 1:1OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME INITIAL
36
MIDDLE ❑
STRE
16 NEW ETETnnR"� CITY ST ZIP
CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTANSPORTED
NTERLOCK YES No INTERLOCK YEs NO YEs NO El
17 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE (CLASS
19 ❑ 39
LICENSE rnr vIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
3 4 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LERICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LEGALLv
STANDING 8 7 6
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J,MITCHELL 07-12-23 08:01 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 ORID# 10377 O#I',WA0171300 JACOBS 712412023 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. ED82452 CASE# ' 23-7383 DATE AND TIME 06/29/23 11:30
OF COLLISION
PAGE 4 OF 4