HomeMy WebLinkAbout23-9253 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-9253 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 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# ❑
COLLISION: 08 - 1-- 2023 1123 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M4400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2533323670 0 6 30
6� LAST NAME PELTZER FIRSTNAME ROBERT MIDDLE L 1 1 2 31
INITIAL
STREET ❑, 3901 S 302ND ST CITY AUBURN ST WA ZIP 98001 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� D04429A sTArr WAVIN# 1FTPW14554KD31109
TRAILER 4567WL STATE WA TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR TRLR 7 3 33
12 0 0 VIN# YIN#'
:: ;.... FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE 7 3 34
13 3 2004 FORD F150 PK DAMAGE vE6 0NO agW�MEYER ves❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCECO STATE FARM 5230636-CO2.47 3 4
IN EFFECT &POLICY# 9TOP
AR
VEHICLE CHGE 5 36
LEGAL
'C Yes❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4254432466
a
LAST NAME ZHAO FIRST NAME YUPING MIDDLE
INITIAL
17❑ STREET ❑' 5722 122ND PL SE APT 237 CITY BELLEVUE ST WA ZIP 98006 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK vEs❑NOF YES
❑NOF
19[—] D IVEW #
{NJURY 7 NATURE OF INJURIES 40
20 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS HEAD PAIN
21❑ LICENSE BWS9944 TAre I WA VIN# 5N1AT2MV7LC736476
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2020 MAKE jyl$$ MODEL ROGUE STYLE (/T —FEHICLE
TOWED✓ NOO BLIN GENE MEYER YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 4450755-D13-47AIN 1 9TOP
VE""LE ❑ N`L J
,J� CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES $ '
7FIR' NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
PH SINGER 12056 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED88771
COLLISION REPORT III III III III III 111
1591972 CASE# 23-9253
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(/AST FIRST,MIDDLE INITIAL) U/ SOPHIE
ADDRESS&PHONE#
BELLEVUE SEX i U MMDDYyry 09 - 14 - 2017
PASSENGER{�WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
L`!1 ❑ 2 POS. 9 2 4 1 USE 1 2 CLASS 1
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. 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'
Unit 2 was traveling east on NE Sunset Blvd approaching the intersection at Anacortes Ave NE. The
light changed from green to orange and Unit 2 stopped for the light. Unit 1 was unable to stop in time
behind unit 2 and rear ended unit 2. Unit 1 was towing a small utility trailer.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JOSEPH SINGER 08-12-23 12:07 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIREE SCOTT 10272 1 8/13/2023 12:44:11 PM
BADGE OR ID# 12056 ORI#' i WA0171300 TIME POLICE DISPATCHED; 11:25 AM TIME POLICE ARRIVED',11:29 AM
PART I PAGE 2�OF❑
REPORT NO. ED88771 CASE# ' 23-9253 DATE AND TIME 08/12/23 11:23
OF COLLISION
3
Not to scale,for reference only
a
N
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a
a
i
NE Sunset Blvd'
s
a
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