HomeMy WebLinkAbout23-11509 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
CASE 23-11509 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 STRUCK NONE
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 1313 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RENTON AVE S
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ MILE N❑ FEET e S ❑ E e SW VICTORIA ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066196644 0 11
30
6� LAST NAME MOHAMED FIRSTNAME HODO MIDDLE D 1 2 31
INITIAL
STREET ❑ 5514 S 296TH PL CITY AUBURN ST WA ZIP 980012320 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 11 1- 23 - 1998 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� A6672021 sTArI WAVIN# 4T18K1FK7FU564985
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 5 7 33
12 VIN#' VIN#
>;. FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 7 $ 34
13 2 2015 TOYT CAMER 4D DAMAGE vEs 0NO agW�MEYER vEs❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO FARMERS 534689923 3 4
IN EFFECT &POLICY# 9TOP
VEH" CHARGE 1 5 36
LEGALLY YES❑NO❑ CITATION# 3AO095101 FAIL TO OBEY TRAFFIC CONTROL I o aorrom
15❑ STANDING 6
MOTOR PEDAL-:.❑ ❑ ❑ PROPERTY ❑ O PHONE
UNIT VEHICLE CYCLEPEDESTRIAN ES /OWNER Nrj.LDMET
D:2069407782
16 a
LAST NAME COCKEY FIRST NAME ROBIN MIDDLE I D
INITIAL
17 STREET NEW ADOREss❑' 8033 S 128TH ST CITY SEATTLE ST WA ZIP 981784939 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.C.B. 12 _ 05 _ 1969 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET INJURY 7 NATURE OF INJURIES ❑ 40
USE CLASS CHEST PAIN
❑ILICENSE 21❑ PLA E# ASV7666 TArE 41
WA vIN# JTDK820U487720521 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2008 MAKE TOYT MODEL PRIUS STYLE 4D VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ROBIN COCKEY8033 S 128THST SEATTLEWA98178 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#E CO USAA 006594384C71017IN 9TOP 5
VE""LE ❑ ,J� CITATION# CHARGE to BOTTOM
LEGALLY YES N`L J
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
ALEKSANDRIGNATOV 12619 WA0171300
1
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE06981
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11509
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'
Unit one was traveling northbound on SW Victoria ST at Renton Ave S. Unit one had a stop sign. Unit
two was traveling eastbound on Renton Ave S approaching SW Victoria ST in lane 1 of 2. Unit one
disregarded the stop sign and pulled out in front of unit two causing unit two to collide with unit one.
Unit two did not have a stop sign or any traffic control device.
Photos Uploaded to Axon Digital Evidence. Unit one cited with an infraction.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
ALEKSANDR IGNATOV 10-07-23 02:32 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
D.SKELTON 9139 101812023 4:34:14 AM
BADGE OR ID# 12619 ORI# WA0171300 TIME POLICE DISPATCHED} 1:16 PM TIME POLICE ARRIVED i 1:20 PM
PART I PAGE IT]OF 3�
REPORT NO. EE06981 CASE# ' 23-11509 DATE AND TIME 10/07/23 13:13
OF COLLISION
t @d
k V 4
r
S
w
z'
0
F
z
L9J
t
t
t
i
t
t
r
PAGE 3 OF 3