HomeMy WebLinkAbout23-7082 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
CASE 23-7082 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 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 0835 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
HARDIE AVE SW BLOCK NO. e✓ 735
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FEET MILES e S B W e RAINIER AVE S
1 5 29
R PEDAL- DAMAGE
MOTO THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES
No ,/ I D:4252837032 0 11
30
6� LAST NAME SANDERS FIRSTNAME JOSEPH MIDDLE E 1 1 2 31
INITIAL
STREET ❑, 2819 N MULLEN ST CITY TACOMA ST WA ZIP 984073947 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER # STATE WA SEX'M MI D Y' 05 - 03 - 1970 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� G431003V sTAT1 GOV VN# 1FBZJC22MXJKA75562
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# Rom ro
TRLR. TRLR. 0 0 33
12 0 0 VIN#' VIN#'
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 ] 34
13 2018 FORT TRANSI VN DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO CHRISTINE RAZEE DHS FEDAIR MARS.l.3ERV`RENTON WA 98057 D:4252837032 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SELF INSURED 3
IN EFFECT &POLICY# 9TOP
VE— CHARGE 36
LEGALLY YFS❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:7347903114
16 a
LAST NAME HAYNES FIRST NAME MARIAH MIDDLE R
INITIAL
17 STREET NEW ADOREs7 3201 W CONCORD WAY,APT 430 CITY MERCER ISLAND ST WA ZIP 98040 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 F] STATEWASEXU .O.B. 03 � _ 39
LICENSE# M _ 0
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES 40
LICENSE I ❑21❑ PLA E# CAR2516 rare 41
WA VIN# 1J4PN5GK3AW180099 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2010 MAKE JEEP MODEL LIBERTY STYLE UT DAMAGE TOWED✓ NOO BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO PROGRESSIVE 966355816IN STOP 5
VEwGLE ❑ ,J� CITATION# CHARGE io BOTTOM
LEGALLY YES N J
25 e
OFFICER'S NAME(Nu
PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
ALEKSANDRIGNATOV 12619 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED73324
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7082
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 one and unit two where pulling into Dutch Bro's Coffee off of Hardie Ave SW. Unit one realised
he was going against the traffic flow of the parking lot. Unit one started to back up and struck unit two
who was behind him in the parking lot/driveway.
Photos uploaded to Axon Evidence.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 06-22-23 11:42 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 6/24/2023 1:09:31 PM
BADGE OR ID# 12619 ORI# WA0171300 TIME POLICE DISPATCHED 8:39 AM TIME POLICE ARRIVED]8:41 AM
PART Ei PAGE IT]OF
REPORT NO. ED73324 CASE# 23-7082 DATE AND TIME 06/22/23 08:35
OF COLLISION
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CU HARDIE AVE SW
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