HomeMy WebLinkAbout23-7084 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-7084 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 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#
cowsloN 06 - 1-- 2023 0835 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
PARK AVE N BLOCK NO. e✓ 200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e N 2ND ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252089103 0 11
30
6� LAST NAME RISPOLI FIRSTNAME JEANNE MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 26631 CARNABY WAY CITY KENT ST I WA 2jp, 980327634 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� BVX4070 sTArI WAurN# JM3KFBCM8L0807055
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2020 MAKE MAZE MODEL CX5 STYLE VEHICLE TOWED 0 TO
ffBLIN TSIgWgYMEYERS VEHICLE
5 1 34
DAMAGE ILJI (�ciV6
13 REGISTERED OWNER INFO WILLIAMRISPOLl400NPOTLATCHDRN HOODSPORTWA98548 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO ALL STATE 907336 011 4
IN EFFECT &POLICY# 9TOP
VEwcLE CHARGE 5 36
LEGALLY ves❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2532450549
16 a
LAST NAME DEB ORD FIRST NAME COURTNEY MIDDLE JA
INITIAL
17❑ STREET ❑', 10301 194TH AVE E CITY BONNEY LAKE ST WA ZIP 983915965 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 DRIVER'S STATE WA ]SEX IF D.C.B. O6 _ O6 _ 2001 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CBK8664 TAre WA VIN# WDBJF65J4Y6057100
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2000 MAKE MERZ MODEL C CLASS STYLE VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
24❑ DAMAGE YES NO GENE MEYERS YES NO
REGISTERED OWNER INFO COURTNEYDEBORD 10301 194TH AVE E BONNEY LAKE WA 983915965 D:2532450549 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE I POLICY#E CO SAFECOIN 9TOP 5
'E""LE ❑ Nu,J CITATION# CHARGE
LEGAL io BOTTOM
LY YES
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J.M/TCHELL 10377 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED76153
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7084
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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 062223 1 responded to a 2-vehicle non-injury/blocking collision at N 2nd and Park Ave N.
I contacted the driver of unit 1 who told me they were on eastbound N 2nd, crossing Park Ave N. She
was involved in a collision with unit 2 who was traveling northbound on Park Ave N. Driver said she
did not see unit 2 approaching on Park Ave N prior to the collision. There were no reported injuries.
Unit 1 sustained heavy passenger side damage and side airbag activation. Her vehicle was towed by
Gene Meyers.
I contacted the drivers of unit 2 who told me she was involved in a collision while she was traveling
northbound in the #1 lane of Park Ave N. Driver did not report any injuries. Her vehicle was towed by
Gene Meyers due to heavy front-end damage.
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 06-22-23 10:22 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 7/3/2023 3:15:53 PM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED 8:39 AM TIME POLICE ARRIVED 9:15 AM
PART I PAGE IT]OF 3�
REPORT NO. ED76153 CASE# 23-7084 DATE AND TIME 06/22/23 08:35
OF COLLISION
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N 2N D S'T it
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