HomeMy WebLinkAbout23-11489 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-11489 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 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# ❑
cawsloN 10 - 1-- 2023 1940 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 3400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET e MILES S ❑ W e MONROE AV NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:4046429219 0 11
30
6� LAST NAME ABDELLA FIRSTNAME ANWAR MIDDLE A 1 1 2 31
INITIAL
STREET ❑, 4433 S 146TH ST CITY TUKWILA ST WA 2jp, 981684444 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED I IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs 1/ I NO NTERLOCKYEs NO Z YEs No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU SE CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BRH5106 sTArI WAvIN# JTDKN3DU6F1998621
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 3 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2015 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 4 TOYT PRIUS HB DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO ANWARABDELLA4433 S 146TH ST TUKWILA WA 98168 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 5359203C3047 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LEGALLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a : OWNER ❑ YES 1/ NO D:3233632063
LAST NAME CASTELLANOS FIRST NAME MIGUEL MIDDLE A
INITIAL
17❑ STREET ❑', 229 AND PARK E UNIT 1403 CITY TUKWILA ST WA ZIP 981883085 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO INTERLOCK YEs It I NOF YES
t l NOF,/
19 LDI IVEW # STATE WA SEX M M D.C.B. 09 _ 29 _ 1994 0 39
H USE
ET LASSY [-�A—TURE OF INJURIES NECK PAIN DECL AID ON SCENE 40
20 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 7
21❑ LICENSE I CDJ2612 TAre WA YIN# 2T3G1RFV3NC277359
El41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2022 MAKE TOYT MODEL RAV4 STYLE SV VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YESfj
NO,/ YES NO
REGISTERED OWNER INFO MIGUEL CASTELLANOS 13210106TH PL NE KIRKLAND WA 98034 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE INSU&PORGY#E CO STATE FARM 4820891FI147BOOl 1U
9TOP
IN EFFECT
"'LE ❑ ,.I— CITATION# CHARGE o BOTTOMLEGALYYES N`LJ25 '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE07089
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11489
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'
Both Units 1 and 2 were traveling along 3400 block of NE 4th St approaching Monroe Av NE. Unit 1
rear ends Unit 2 causing reportable disabling damage to the front of Unit 1 and reportable non
disabling damage to the rear of Unit 2. Unit 2 driver reports neck pain from collision. Aid declined on
scene.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 10-06-23 08:29 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 101812023 5:19:16 PM
BADGE OR ID# 12651 ORI#l i WA0171300 TIME POLICE DISPATCHED; 7:44 PM TIME POLICE ARRIVED',7:50 PM
PART Ei PAGE IT]OF
REPORT NO. EE07089 CASE# ' 23-11489 DATE AND TIME 10/06/23 19:40
OF COLLISION
N NOT TO SCALE
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