HomeMy WebLinkAbout23-8486 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
CASE 23-8486 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AGENCI WA0171300 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 2$
TRIBAL UNITS 02 STRUCK M/SC OBJECT OR DEBRIS ON ROAD
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 07 - 24 - 2023 1313 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LIND AVE SW BLOCK NO. e✓ 720
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 1 5 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO �/ D:2062802313 1 4 30
6� LAST NAME KAUR FIRSTNAME BALWINDER MIDDLE 1 1 2 31
INITIAL
STREET ❑, 4832 S 172ND PL CITY SEATAC ST WA Zjp, 98188 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYES NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER # STATE SEX F MID
.OB 05 - 19 - 1995 32
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USEET IINIJAU RY 1 NATURE OF INJURIES z❑
3
,OF]
0❑ p7 ATES 4 BHC4303 STATE WA VIN# JHMFA362X6S004134
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR. O 0 33
12 0 0 VIN#' VIN#'
F77 34
M TO
VEH.YEAR ZOO6 MAKE HOND MODEL CIVIC STYLE SD VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13❑ DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO GEICO 4365881640 3 4
IN EFFECT &POLICY# 9TOP
VE"'CLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES NO ,/ D:2068831097
16❑
LAST NAME ISLAMOVA FIRST NAME ZULAYKHO MIDDLE N
INITIAL
17❑ STREET ❑', 9705 S 245TH PL CITY' KENT ST WA ZIP 980305038 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NO� INTERLOCK YEs It I NOF YES t l NOF,/
19 LDI IVERIS STATE WA ]SEX IF M D.O.B. 12 _ 25 _ 1982 0 39
HELM EET LASS 6
Y FEELS PAIN ON RIGHT WRIST AND LEFT LEG—NATURE OF INJURIES 40
20 ON DUTY STATUS AIRBAG,2 RESTR y EJECT 1 9
21❑ LICENSE I CCY6878 TATe WA VIN# 5TDFZRBHXNS213372
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
GI
VEH YEAR 2022 MAKE 7'Oy7' MODEL HIGHLAN STYLE UT DAMAGE TOWED NOO✓ BLIN TOWED BY ov HYES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO GEIC04376782589IN 1 9TOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
SULIASI TAMAIVENA 12788 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED84303
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8486
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) PASHALEVA D/LARM
(LAST FIRST,
ADDRESS&PHONE#
9705 S 245TH PL KENT WA 980305038 2068831097 SEXi F MMDDYyry 05 - 04 - 1959
SEAT HELMET I INJURY NATURE OF INJURIES
PASSENGERWITNESS[:] UNIT# 2 POS, 13 AIRBAG 2 RESTR. 9 EJECT 1 USE CLASS 6 LEFT HAND INJURED,POSSIBLE
FRACTURES
NAME
(LAST,FIRST,MIDDLE INITIAL) MUHAMMAD ISLAM M
ADDRESS&PHONE# D O B
9705 S 245TH PL KENT WA 980305038 2068831097 SEX M MM 7Dvyv1Y O6 _ 09 _ 2021
SEAT HELMET I INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 2 pOS 13 AIRBAG 9 RESTR. 9 EJECT 1 USE CLASS 6 HEADACHES
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
The driver of vehicle #1, identified as BALWINDER KAUR, was backing her vehicle out of her parking
stall in the parking lot. The back left corner of vehicle #1 collided with two shopping carts that were
then pushed into the back right corner of vehicle #2, which was not occupied. This caused damage
to one of the shopping carts as well as to the back right corner of vehicle #2. KAUR stated she is not
familiar with driving an automatic transmission, but claimed that the ultimate cause of the collision
was vehicle #1's brakes failing.
One of the shopping carts that vehicle #1 backed into was being pushed by an associate of vehicle
#2, identified as DILARAM PASHALEVA. Inside of this shopping cart was a toddler, identified as
MUHAMMAD ISLAM. The owner of vehicle #2 was identified as ZULAYKHO ISLAMOVA, and was
also standing near the shopping carts. When the shopping carts were struck, this caused ISLAM to
fall out of the shopping cart he was in and sustain a headache. It also caused PASHALEVA to fall
over and injure her left hand as well as ISLAMOVA to sustain a small scratch to her right wrist and
soreness to her left leg. Based on the totality of the circumstances, it appeared vehicle #1 caused
this collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
SULIASI TAMA/VENA 07-25-23 05:09 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 713012023 7:36:15 AM
BADGE OR ID# 12788 OR]# WA0171300 TIME POLICE DISPATCHED; 1:18 PM TIME POLICE ARRIVED:1:26 PM
FART I PAGE IT]OF 3�
REPORT NO. ED84303 CASE# ' 23-8486 DATE AND TIME 07/24/23 13:13
OF COLLISION
Not to scale
Second shopping Islam in cart ,Vehicle #1
Vehicle #2--- -*
x
Pashal ' �``Zulaykha
F irst shopping cart _^
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