HomeMy WebLinkAbout23-14788 ITFF' "POLCERA II I !�� I III I III I IIII III II I . B 27c
COLLISION REP FIT 1591971
CASE 23-14788 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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.. 12 - 1-- 2023 0736 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 180TH ST BLOCK NO. e --- ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a LIND AVE SW
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2065501041 0 11
30
6 LAST NAME SANCHEZ CHAVEZ FIRST NAME YOMAYRA MIDDLE D 1 1 2 31
INITIAL
STREET ❑✓ 15029 OLYMPIC LOOP E CITY BONNEY LAKE ST WA ZIP 98391 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ DRIVERS
E# STATE I WA SEX'F MM D�Y' 02 1- 17 - 1992 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 9 EJECT 1 H U SE CLASS ,6 SORE LEFT SHOULDER AND SORE LEGS z❑
3
10[1P1 ATNES# BEN3135 sTAr WAu N# 2T18URHE7HC920193
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM To
TRLR. TRLR 1 5 33
12 3 5 VIN#' VIN#
ROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T /g[ GOVT.VEHICLE 7 $ 34
13 2 2017 TOYT COROL 4D DAMAGE YES NO YES[:]TOWING YES❑ No✓
REGISTERED OWNER INFO DIRECTORS CLEANING CORP 18119 E VALLEY Hwy STE 104 KENTWA 98032 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 4
14 LIABILITY INSURANCE PHILADELPHIA INDEMNITY INSURANCE CO PHPK2466715
IN EFFECT &POLICY# STOP
VEHICLE 5 36
LECALLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM1/ THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO D:3108496275
16 a
LAST NAME BAKER FIRST NAME MARK MIDDLE I S
INITIAL
17 STREET I❑ 1911 SW CAMPUS DR APT 210 CITY FEDERAL WAY ST WA ZIP 980236473 37
NEW ADOREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YES
t l NO
�
19 S STATE WA SEX M D. 07 26 _ 1971 39
DRIVER'
LICENSE# MMDC7YY
WELMET INJURY 6 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 9 EJECT 1 USE CLASS SORE NECK ❑
LICENSE I ❑21❑ PLA E# CEZ3734 TAre 41
WA VIN# 4S4BTANC7P3124117 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN It 'IN#.
VEH YEAR 2023 MAKE SUBA MODEL OUTBAC STYLE VEHICLE TOWED TO BLIN TOWEDeY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO GILEAD SCIENCES INC.666 GARLAND PL DES PLAINES IL 60016 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSU8 PORGY#E CO ZURICH AMERICAN INSURANCE CO BAP 9984171-01 STOP 5
IN EFFECT
VEHICLE ❑ CE] CITATION# CHARGE to BOTTOM
LEGALLY YES N
25 ' a
7JEE
S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
VANDERHOEK 11631 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE35656
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14788
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'
Vehicle #1 was traveling southbound on Lind Ave SW approaching S 180th St. Vehicle #2 was
traveling eastbound on S 180th St approaching Lind Ave SW. The driver of vehicle #1 told me that
she was behind a tall semi-truck and could not see the traffic signal when she proceeded through the
intersection of S 180th St, though as she proceeded through the intersection she looked up and saw
the traffic light for southbound traffic was red. The front end of vehicle #2 then collided with the right
side of her vehicle. The driver of vehicle #2 told me that as he proceeded eastbound on S 180th St
through the Lind Ave SW intersection, vehicle #1 drove through the southbound red light, causing the
front end of his vehicle to collide with the right side of vehicle #1.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 12-26-23 03:16 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 12/30/2023 11:36:17 AM
BADGE OR ID# 11631 ORI# WA0171300 TIME POLICE DISPATCHED 7:51 AM TIME POLICE ARRIVED'7:54 AM
FART I PAGE IT]OF 3�
REPORT NO. EE35656 CASE# 23-14788 DATE AND TIME 12/26/23 07:36
OF COLLISION
AN
Not to scale
r
180th St
Vehicle
PAGE 3 OF 3