HomeMy WebLinkAbout23-8901 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-8901 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 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 08 - 1-- 2023 1510 17 ❑.❑ S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAIN AVE S BLOCK NO. e✓ 226
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252813055 0 11
30
LAST NAME BEARBOW-NEDBLAKE FIRSTNAME GILLIAN MIDDLE R
6 INITIAL 1 2 31
STREET ❑1 16915 424TH AVE SE CITY NORTH BEND ST I WA 2jp, 980459635 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES NO
LRIIVER # STATE WA SEX'F MM D Y' 01
8❑ - 27 - 2000 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� BQt0603 sTArI WAurN# 1N4620CPOHC308678
TRAILER STATE TRAILED STATE
11 2 5 PLATE# PLATE# Rom ro
TRLR. A'RLR. 1 5 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2017 MAKE NISS MODEL LEAF STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
DAMAGE YES NO YES[:] NO✓
13❑ REGISTERED OWNER INFO OILLIANBEARBOW-NEDBLAKE16915424THAVESE NORTH BEND WA98045 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO STATE FARM 4578171 C0347 3 4
IN EFFECT &POLICY# 9TOP
ve'CLE CHARGE 5 36
LEGALLv Ye8❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:8322381102
16 a
LAST NAME GOMEZ LAZARO FIRST NAME ANGELICA MIDDLE I N
INITIAL
17❑ STREET ❑', 1300 EAGLE RIDGE DR S APT J10 CITY RENTON ST WA ZIP 980553412 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NoR INTERLOCK YEs I I NOF YES
t l NO❑
19 DRIVER'S STATE WA SEX F D.C... 07 05 _ 1978 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CHM6805 TAre WA vIN# 5TDZT38A83S157595
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2003 MAKE ]'DY)' MODEL S"E(,�(�DI STYLE DAMAGE TOWED NOO✓ BLIN TOWED BY Gov HYES N.7 44
24❑ YES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY INSURANCE INSU&PORGY#E CO STATE FARM 5321715 A1947A 001 IULlliKOTlTlfll;0-
(PRINT)IN EFFECTvE""LE ❑ ,J� CITATION# CHARGELEGALLYYES N`L J25 OFFICER'S NAME 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. ED89722
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8901
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) BEARBOW-NEDBLAKE ASHLEYS
(LAST FIRST,
ADDRESS&PHONE# D O.B.
16915 424TH AVE SE NORTH BEND WA 980459635 SEX F MMDDYyYv 02 - 28 - 2000
PASSENGER Z WITNESS❑ UNIT# 1 POST 3 AIRBAG 2 RESTR. 4 EJECT ? HELMET INJURY NATURE OF INJURIES
USE CLASS 11
NAME
(LAST,FIRST,MIDDLE INITIAL) PETERSON CINDY K
ADDRESS&PHONE# D O B
2066603959 SEX: U MMDYVYY
PASSENGER [:]WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY
POS. NATURE OF INJURIES
USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 080423 1 responded to a 2-vehicle non-injury/non-blocking collision at 226 Main Ave S.
I contacted the driver of unit 2 who told me they were traveling southbound in the #2 lane of Main Ave
S when unit 1 collided with the front passenger quarter panel of her vehicle. Driver was not injured.
Damages did not require tow.
I contacted the driver of unit 1 who told me they were traveling southbound in the #1 lane of Main Ave
S. Driver says while making a lane change from lane #1 to #2, they collided with unit 2. Driver
admitted that they did not see unit 2 while making the lane change. Driver was not injured.
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 08-14-23 01:42 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 8/16/2023 8:25:10 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED 3:10 PM TIME POLICE ARRIVED f 3:20 PM
PART I PAGE 2�OF❑
REPORT NO. ED89722 CASE# ' 23-8901 DATE AND TIME 08/04/23 15:10
OF COLLISION
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