HomeMy WebLinkAbout23-10920 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10920 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I 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 RESERVATION STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 09 - 1-- 2023 1830 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
E VALLEY RD BLOCK NO. e✓ 3600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 3000 FEET e S B W e SW41ST ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2066585380 0 3 30
6� LAST NAME MAHNA FIRSTNAME KARAN MIDDLE 1 2 31
INITIAL
STREET ❑ 21330 52ND WAYS CITY KENT ST WA ZIP 98032 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aTES� BGH9365 sTArI WA urN# JTNB11HK7J3014880
11[-j-� TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
TRLR. TRLR 5 1 33
12 3 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR 2018 TOYT CAMRY 4D MAKE MODEL STYLE VEHICLE TOWED fn TO VBLINJ TOWED By I GOVT.VEHICLE 5 3 34
13 4 DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO SAFECO H2O53814 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4254200024
16 a
LAST NAME FONSECA FIRST NAME ANTONIO MIDDLE
INITIAL
17 STREET❑ NEW ADDREss❑' 325 217TH PL SW CITY BOTHELL ST WA ZIP 98021 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑NO� INTERLOCK yEs It I NOF YES
t l NOF,/
19[-] DRIVER'S STATE I WA SEX M D.O.B. 01 14 1978 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES 40
❑21❑ PLATE# 41
C24000A TArE WA VIN1 1FTFW1CT7CFB95570 1
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ VIN#. N#. 43
RLR
'I
Gov HI
VEH YEAR 2012 MAKE FORD MODEL F150 STYLE PK DAMAGE TOWED NOO✓ BLIN TOWED BY 44
ES YES
NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO TRAVELERS 6140262342031IN I STOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JASON JONES 11635 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE03604
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10920
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MAHNA K/ARA
(LAST FIRST,
ADDRESS&PHONE#
21330 52ND WAYS KENT WA 98032 2066585380 SEXi F MMDDYyry 10 - 13 - 2019
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET LASS NATURE OF INJURIES
❑✓ ❑ 1 POS. 6 2 10 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
Ex MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIRST 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 9-22-23, at about 1832 hours, I was dispatched to a collision that occurred in the 3600 block of E
Valley RD.
I arrived and observed Unit 1 to have major front-end damage and Unit 2 to have damage the rear
passenger side.
I contacted the driver of Unit 1 who reported no injures to the occupants of his vehicle. When asked
about the collision, the driver told me they were not paying attention, did not see Unit 2 slowing to
make a right turn, and struck Unit 2 in the rear.
I contacted the driver of Unit 2 who also reported no injuries. They confirmed Unit 1 drivers account of
the incident.
I gave the driver of Unit 1 a verbal warning for inattention.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON JONES 09-22-23 07:20 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 912812023 9:45:28 PM
BADGE OR ID# 11635 OR]#` WA0171300 TIME POLICE DISPATCHED; 6:32 PM TIME POLICE ARRIVED';6:40 PM
PART Ei PAGE 2�OF❑
REPORT NO. EE03604 CASE# ' 23-10920 DATE AND TIME 09/22/23 18:30
OF COLLISION
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