HomeMy WebLinkAbout23-11819 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-11819 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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 1806 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
DUVALL AVE NE BLOCK NO. e✓ 200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NE 2ND ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4254959739 0 11
30
6 LAST NAME RAMIREZ VASQUEZ FIRST NAME JOSE MIDDLE E 1 1 2 31
INITIAL
STREET ❑ 108 HOMER AVE SE CITY PACIFIC ST I WA 2jp, 980471128 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs Z/NO YES R NoF,/
DRIVERS
E# STATE WA SEX'M MI DAY
8❑ ' 10 - 24 - 1996 1 2 32
9 ON DUTY❑ STATUS' AIRBAG 3 RESTR 4 . EJECT 1 H U EET CLASS 7 I RIGHT ARMJURIES z❑
3
10 2❑ P1 AT 14 D14716D STATE WA VIN# 1G63CYCGXHF149959
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 3 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 1 34
13 2017 CHEV SILVER DAMAGE YES No �LII� RS vEs❑ No✓
REGISTERED OWNER INFO JASMINE LANDSCAPING LLC 14547 SE 153RD PL RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14LIABILI INSURANCE INSURANCE CO AMERICAN FAMILY46X3635102 3 4
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2064983567
16 a
LAST NAME GIRIAS FIRST NAME MICHAEL MIDDLE A
INITIAL
17❑ STREET ❑', 23625 SE 216TH WAY CITY' MAPLE VALLEY ST WA ZIP 980388416 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I D51527C TATe WA VIN# 1FTEW1E80PFB12474
❑ 41
PLATE#
42
22❑ PLATE# STATE TILER PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2023 MAKE FORD MODEL F150 STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES✓ NO BANKERS YES NO
REGISTERED OWNER INFO DEBORAH GIRIAS 23625 SE 216TH ST MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO GRANGE 5104440051092IN STOP 5
"'Le ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE10988
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11819
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MATEOPEREZ JAMIEA
(LAST FIRST,
ADDRESS&PHONE# D O.B.
14430 NE 35TH ST L303 BELLEVUE WA 98007 SEX U MMDDYyYv - -
PASSENGER I�I WITNESS� UNIT# j 1 PEST 3 AIRBAG j 2 RESTR. 4 EJECT ? 1 HEUS ET CLASS !1 NATURE of INJURIES
NAME L�1
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYVYV
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 traveling south on Duvall Av NE approaching intersection at NE 2nd St. Unit 2 traveling north
on Duvall Av NE approaching intersection at NE 2nd St. Unit 1 makes left turn causing reportable
disabling front end damage. Unit 2 traveling north and sustains glancing head on disabling front end
damage. Unit 1 driver reports minor abrasions and bruising on arm from airbag deployment. Both
vehicles privately impounded. Unit 1 fails to yield ROW left turn.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 10-16-23 07:30 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIREE SCOTT 10272 1011912023 4:47:22 PM
BADGE OR ID# 12651 OR]# WA0171300 TIME POLICE DISPATCHED! 6:13 PM TIME POLICE ARRIVED',6:19 PM
PART I PAGE IT]OF
REPORT NO.! EE10988 CASE# ' 23-11819 DATE AND TIME 10/16/23 18:06
OF COLLISION
i
NOT TO SCALE
UNIT
NIT 2
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