HomeMy WebLinkAbout23-14728 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-14728 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.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 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 12 - 1-- 2023 1836 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 3RD ST BLOCK NO. e✓ 1000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e MAIN AVE S
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2065303520 0 11
30
6� LAST NAME LAUKALA FIRSTNAME PAISLEY MIDDLE E 1 2 31
INITIAL
STREET ❑ 24505 229TH CT SE CITY MAPLE VALLEY ST WA Zlp 98038 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 H USE 2 1 CLASS NATURE OF INJURIES 2❑
3
10 1❑ p7 ATE 14 AZN9566 STATE WA u N# 1 C4PJMCB8EW303306
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. YRLR. 5 1 33
12 0 0 VIN#' VIN#
:: FROM TO
VEH.YEAR 2014 JEEP CHERO UT MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 4 DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO ASHLEY PETERSON.505229TH CT SE MAPLE VALLEY WA 98038 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 4089420550 3 4
IN EFFECT &POLICY# 9TOP
VEHICLe 1 5 36
LEGALLY
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES NO ,/ D:2068183002
16 a
LAST NAME DURBIN FIRST NAME AMBRA MIDDLE I L
INITIAL
17 STREET NEW ADOREs7 116 LOGAN AVE S APT 2 CITY RENTON ST WA ZIP 980572019 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 LDI IVER # STATE WA SEX F MMr O.B. 08 _ 29 _ 1982 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
LICENSE ❑21❑ PLA E# BPW8732 TATE 41
WA VIN# KNDJT2A2987275352 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2011 MAKE KIA MODEL SOUL STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YESfj
NO,/ YES NO
REGISTERED OWNER INFO AMBRA DURBIN 325 FACTORYAVE N APT 2 RENTONWA98057 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO GEIC04522003104IN IGQVE""LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
7CA
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26LAN 12007 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE37457
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14728
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On December 23, 2023, at 1836 hours dispatch requested that I respond to a possible hit and run that
occurred at S 2nd St. and Main Ave. South. the reporting party, later identified as Ambra Durbin,
stated that he white Jeep Cherokee had just struck her vehicle and appear to be fleeing the scene.
Later, Ambra advised that she followed the other vehicle to Classic's Sports Bar off Maple Valley
highway.
Upon my arrival I spoke with Ambra the driver of unit 2, a Kia Soul bearing Washington plates
BPW8732. Ambra stated the collision occurred near the intersection of S 3rd St. and Main Ave.
South. She explained she was in the number two lane going northbound merging from Main Ave S to
S 3rd St. as she made her right turn, unit 1 was in the number one lane also going northbound.
During the turn, unit 1 abruptly made a lane change and struck the back bumper of unit 2 causing
minor damage.
I then spoke with the driver of unit 1, a Jeep Cherokee bearing Washington plates AZN9566. The
driver was identified as Paisley Laukala. She also recalled a similar story and mentioned she was
possibly at fault when she made a lane change going left. Initially she did not believe she had struck
the vehicle, so she proceeded as if nothing happened. After noticing that unit 2 continued to follow
her, she decided to pull over and make contact.
After speaking with both drivers no one needed medical assistance and an exchange of information
form was given to both parties.
I did observe new damage to both vehicles and the damage was consistent with what the two drivers
recalled.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.CATALAN 12-23-23 08:05 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 11512024 9:50:08 AM
BADGE OR ID# 1Y007 OR]# WA0171300 TIME POLICE DISPATCHED 6:39 PM TIME POLICE ARRIVED 6:50 PM
PART I PAGE IT]OF
REPORT NO. EE37457 CASE# ' 23-14728 DATE AND TIME 12/23/23 18:36
OF COLLISION
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