HomeMy WebLinkAbout23-11660 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-11660 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4200 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 10 - 1-- 2023 0109 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
PARK AVE N BLOCK NO. e✓ 3921
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4252692636 1 4 30
6� LAST NAME JERABEK FIRSTNAME JULIAS MIDDLE S 1 1 2 31
INITIAL
STREET ❑ 3319 MEADOW AVE N CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I INTERLOCK YES[:]No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVERS STATE WA SEX'M MID
-O B 09 - 09 - 2006 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMET USE 2 1 CLASS NATURE OF INJURIES 2❑
3
10 P1 ATE 14 C75411 R sTAT WAu N# 1 FTFW1 RG2KFC09481
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM ro
TRLR. TRLR. 1 5 33
12 0 0 VIN#j VIN#
2019 FORD F150 TR plsA FROM 34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 2 DAMAGE YES NO ✓ YES[:] NO✓
REGISTERED OWNER INFO MATTHEWJERABEK 3319 MEADOWAVE N RENTON WA 98056 D:2062001234 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
3 4
14 IT INSURANCE INSURANCE CO GEICO 4284475813
IN EF
IN EFFECT &POLICY# 9TOP
VE—LE CHARGE to BOTTOM 5 36
LECALLv YES❑NO❑ CITATION# 5
15❑ STAIN.D" 8 6
UNIT a2 VE ICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES✓ NO OLD MET PHONE
16❑
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ NEW ADDRES7
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 LLIICENS # STATE SEX U MMDDYY 39
WELMET 1NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
❑21❑ PLATE# BNR4048 TATE 41
WA VIN# SFNRL6H9XK8033872 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2019 MAKE HOND MODEL ODYSSEY STYLE VN VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO THANA WAN JITTRETAN 3921 PARK AVE N RENTON WA 98056 D:4254499561 VEHICLE NO.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO TRAVELERS 6126112822031IN 1GQI
vE""LE ❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.ARNOLD 12509 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE10994
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11660
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 10/12/2023 at 0111 hours I was dispatched to a non-injury collision at 3921 Park Ave N. When I
arrived, I spoke to the driver of Vehicle 1. The driver of Vehicle 1 stated that he was coming home
from the office where he was working on his homework because the internet at his residence was not
currently working. The driver of Vehicle 1 stated that he was proceeding South at around the 3900 blk
of Park Ave N and began falling asleep while driving home. The driver of Vehicle 1 said that while he
was falling asleep he veered off the travel lane. Driver 1 stated that Vehicle 1 made contact with
Vehicle 2 that was parked on the West side of the roadway facing North. Driver 1 stated that Vehicle
1's front passenger side bumper collided with the front passenger side of Vehicle 2. The damage I
saw was consistent with what Driver 1 stated. There were no witnesses to the collision, only residents
that head the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.ARNOLD 10-12-23 03:05 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIREE SCOTT 10272 1 1011912023 4:47:54 PM
BADGE OR ID# 12509 ORI#' WA0171300 TIME POLICE DISPATCHED 1:11 AM TIME POLICE ARRIVED',1:17 AM
PART Ei PAGE IT]OF
REPORT NO.! EE10994 CASE# 23-11660 DATE AND TIME 10/12/23 01:09
OF COLLISION
At
z u
Q N
Y
***NOT TO SCALE***
a 2
3900 blk
I
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