HomeMy WebLinkAbout24-7679 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
SASE 24as7s 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING'
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF 03 OBJECT 1 1 8 28
UNITS
RESERVATION STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 07 - 1-- 2024 0915 17 ❑.❑ S IN 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 4900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FEET MILES ❑ S ❑ W❑ GRAHAM AVE NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F I D:2536516899 0 9 30
6 LAST NAME YE FIRSTNAME JUNRONG MIDDLE 1 2 31
INITIAL
STREET ❑, 8043 S SHERIDAN AVE CITY TACOMA ST WA ZIP 98408 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 03 — 29 — 1986 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
❑10 9❑ P1 aT�S� BRL0085 sTArI WWAvIN# 1C46JWDG4El231814 3
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM ro
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE g 9 34
13 4 2014 JEEP WRANG UT DAMAGE YES NO YES : No
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14� LIABILI INSURANCE INSURANCECO STATE FARM 5082947-A28.47 3 4
IN EFFECT &POLICY# 9TOP
VE—LLE o CITATION# 4A0559433 FOLLOW VEHICLE TOO CLOSELY CHARGE 5 36
EGA YEs N o Borrom
15❑ STANDING 8 6
MOTOR PEDAL-: PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:9195185871
16 a
LAST NAME JOSYABHATLA FIRST NAME NIKHIL MIDDLE
INITIAL
17❑ STREET ❑', 460 ROSARIO PL NE CITY RENTON ST WA ZIP 98059 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs❑NOF YEs❑NOF,/
19 LDIIVERS STATE WA SEX M MMDDW 04 23 _ 1990 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CKH7860 TAre WA VIN# 7SAXCAE52PF417148
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2023 MAKE TESL MODEL MODE!X STYLE 4D DAMAGE TOWED No0✓ BLIN TOWED BY ov HyES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO pROGRESSIVE 923413027IN
VE""LE CITATION# CHARGE LEGAL
25 <E��
LY YES Nu
❑ s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE98099
COLLISION REPORT III III III III III 111
1591972 CASE# 24-7679
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) JOSYABHATLA AKHIL B
(I.P.ST FIRST,
ADDRESS&PHONE#
1675 S MILPITAS BLVD 133 MILPITAS CA 95035 4087723431 SEX i M MMDDYyry 01 - 22 - 1993
PASSENGER Z WITNESS� UNIT# 2 PO5 3 AIRBAG j 2 RESTR. q EJECT ? HELMET INJURY NATURE OF INJURIES
USE CLASS '1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX: MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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'
All vehicles eastbound on NE 4th St, #1 lane. Unit 3 stopped to let ducks cross the road. Unit 2
stopped behind unit 3; unit 1 failed to stop, striking rear of unit 2. Unit 2 was pushed into the back of
unit 3. No injuries to any of the involved. Rear end damage to unit 3, front and rear damage to unit 2,
front end damage to unit 1. Collision captured on video by unit 2, all video and photos of damage
uploaded to Evidence.com. Unit 1 driver Ye cited via complaint through RMC for following too closely.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 07-21-24 10:49 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 712212024 11:24:42 AM
BADGE OR ID# ( 5738 OR]# WA0171300 TIME POLICE DISPATCHED; 9:22 AM TIME POLICE ARRIVED',9:26 AM
PART B PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE98099
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 24-7679
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
❑ 1 28
2
CARRIER
NAME
3 CARRIER L
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 I_) PEDESTRIAN OWNER YES NO
D:2962952004
0 9 29
LAST NAME ERICKSON FIRST NAME BONITA MIDDLE' ',, J
INITIAL
STREET 30
NEW AnDRFSP' 2019 MST NE CITY AUBURN ST WA ZIP 98002
6 ❑ 1 1 2 31
CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED
INTERLOCK YEs NO zERLOCK YES❑N0� YEs N
DRIVER'S
LICENSE STATE I WA SEX F MMDDYYv 09 - O6 - 1945
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET I INJURY 1 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE BWF0793 [TAT WA VIN# 2HKRW2H57LH698633
PLATE#
9 9] TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.It VIN.#.
11 3 5 VEH.YEAR2020 MAKE HOND MODEL CR-V EX STYLE UT I VEHICLE TOME E T SABLIN TOWED BY anvi vFH1C P FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFO OWNED BY DRIVER g g 33
12 � SHADE IN DAMAGED AREA
3 4 FROM TO
LIABILITY INSURANCE INSURANCE CO SAFECO H1807468 gTOp
IN EFFECT &POLICY# 1 ________ 5
EHICLE 34
13 4 LEGALLY TAGFlG YES NO❑ CITATION# CHARGE 0 BOTTOM
STANDING S} 8 7 6
14 ❑ UNIT Tr Vd IRE O CYDCLE 1:1OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME MIDDLE: INITIAL ❑ 36
STREET
16 NEW AnnRFs.�' CITY'. ST ZIP
CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED
INTERLOCK 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 VIN#
PLATE# rnr
20 ❑ TRAILER' STATE TRAILER STATE ❑ 40
PLATE#< PLATE#
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
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 07-21-24 10:49 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
BADGE O#I' APE /26 ORID# 5738 WA0171300 APPROVED BY
722/2024 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. EE98099 CASE# 24-7679 DATE AND TIME 07/21/24 09:15
OF COLLISION
PAGE 4 OF 4