HomeMy WebLinkAbout23-10302 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10302 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 02 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GowsloN 09 - 1-- 2023 1205 17 ❑.❑ S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 4300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 8 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252816794 0 11
30
6� LAST NAME RICCHIO FIRSTNAME ELLA MIDDLE L 1 2 31
INITIAL
STREET ❑ 16425 241 ST AVE SE CITY ISSAQUAH ST WA 2jp, 980278431 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� P1 aT�S� BVY4197 sTATI WAurN# 5NMS2CAD7KH090840
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. A'RLR 1 7 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2019 MAKE HYUN MODEL SANTA STYLE VEHICLE TOWED Na pLSSBLIN T,QVyEq.BLRs yOS❑ENO✓ 3 7 34
DAMAGE ILJI tSA1Wlc
13 REGISTERED OWNER INFO 1.RICCH10I..115THAVESE RENTONINA98059 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14❑ LIABILITY INSURANCE INSURANCE CO STATE FARM INS 3676096 D2947B
IN EFFECT &POLICY# 9TOP
VEHlcl.e CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:6192472904
16 a
LAST NAME DREBOT FIRST NAME ELENA MIDDLE N
INITIAL
17❑ STREET ❑', 26300 235TH AVE SE CITY MAPLE VALLEY ST WA ZIP 980386725 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs It I NOF YES
t t- l NO❑ 11
19 LDI IVEW # STATE WA ]SEX IF M DDY
.C... 11 � 1988 27 El 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE A6664665 TATe WA VIN# KM8KMDAF2PU168762
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov H 44
VEH YEAR 2023 MAKE yyU/)/ MODEL /ON/(,� STYLE —TEHICLE
TOWED✓ NOO BLIN BANKERS YES N.7
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO SAFE COINS H2516931IN STOP 5
VE""LE ❑ Nu,J CITATION# CHARGE
LEGAL to BOTTOM
LY YES
25 ' a
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. ED97766
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10302
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) GORBUL VASILE
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
ISSAQUAH SEX M MMDDYYYY 11 - 10 - 1938
PASSENGER I�I WITNESS[ UNIT# 2 SEA ! 3 AIRBAG'6 RESTR. q EJECT ? 1 HELMET INJURY NAruRE of INJURIEs
L�!1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) ENATI VICTOR
ADDRESS&PHONE# ISSAQUAH SEX M D.O.B. 02 _ 02 _ 1959
MMDDYYYY
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 2 POS 4 AIRBAG 6 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) ENATI VICTORIA
AppREss&PHONE# ISSAQUAH SEX 01 21 _ 2004
. F D.O.B. -
MMDDYYYY
PASSENGER WITNESS UNIT# ! 2 SEAT g AIRBAG 6 RESTR. 4 EJECT 1 HELMET NJURY 1 NATURE OF INJURIES
❑ POS. USE CLASS -----�
NARRATIVE'
On 090623 1 responded to a 2-vehicle non-injury/blocking collision at 4700 NE 4th ST
I contacted the driver of unit 2 who told me they were traveling westbound in the #1 lane of NE 4th,
when they were involved in a collision with unit 1. The driver was not injured. Damages (front right
end) required an impound to unit 2.
1 contacted the driver of unit 1 who told me was exiting a private way to westbound NE 4th St when
she was involved in a collision with unit 2. The driver was not injured. Unit 1 was impounded 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 09-08-23 09:50 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 911112023 10:24:49 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED 12:05 PM TIME POLICE ARRIVED 12:16 PM
PART I PAGE IT]OF 4�
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED97766
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10302
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) DREBOT TYLER
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
/SSAQUAH SEX M MMDDYYYY 03 - 24 - 2022
PASSENGER Z WITNESS[ UNIT# 2 FOS ! 5 AIRBAG'6 RESTR. 1 EJECT ? 1 HELMET INJURY NATURE OF INJURIES
USE CLASS '1
NAME
(LAST,FIRST,MIDDLE INITIAL) ENATI SVTLANA
ADDRESS&PHONE# ISSAQUAH SEX F D'O.B. 08 _ 04 _ 1969
MMDDYYYY
SEAT HELMET I INJURY NATURE of INJURIES
PASSENGER Z WITNESS UNIT# 2 POS 6 AIRBAG 6 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 090623 1 responded to a 2-vehicle non-injury/blocking collision at 4700 NE 4th ST
I contacted the driver of unit 2 who told me they were traveling westbound in the #1 lane of NE 4th,
when they were involved in a collision with unit 1. The driver was not injured. Damages (front right
end) required an impound to unit 2.
1 contacted the driver of unit 1 who told me was exiting a private way to westbound NE 4th St when
she was involved in a collision with unit 2. The driver was not injured. Unit 1 was impounded 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 09-08-23 09:50 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 911112023 10:24:49 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED 12:05 PM TIME POLICE ARRIVED 12:16 PM
PART I PAGE 3�OF 4�
REPORT NO. ED97766 CASE# ' 23-10302 DATE AND TIME 09/06/23 12:05
OF COLLISION
NE 4TH ST
PAGE 4 OF 4