HomeMy WebLinkAbout23-12569 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-12569 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT 8 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#
cowsloN 11 - 01 - 2023 1212 17 �. S 8 W H OF e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SUNSET BLVD N
0 4 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO �/ D:4252098282 0 4 30
6� INITIAL
LAST NAME SHEW FIRSTNAME TRAV►S MIDDLE W 1 1 2 31
STREET ❑ 16645 228TH AVE SE CITY MAPLE VALLEY ST I WA 2jp, 98038 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
LOB 06 1— 30 — 1976 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 1❑ P1 ATNES# C5553C sTAT WA V N# 1XPCP4EXOKD626423
0 TRAILER D0243C STATE WA TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR TRLR 1 3 33
12 3 0 VIN# VIN#'
:: ;.... FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 3 34
13 2 2019 PETS 567 DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO KING COUNTY SOLID WASTE 16645228TH A VE SE MAPLE VALLEY WA 98038 D:2062632250 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO KING COUNTY SELF 3 4
IN EFFECT &POLICY# 9TOP
AR
VEwcE CHGE 5 36
LEGALLL YEs Y ❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM1/ THR OLD MET PHONEUNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES No D:4258668483
16 a
LAST NAME 1 77771ABUSA GAMUCHU FIRST NAME DANEAL MIDDLE
INITIAL
17❑ STREET ❑', 17220 3OTH AVE S APT G5 CITY SEATAC ST WA ZIP 981883508 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NOF,/
19 D IVERI #
{NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE I BKY3989 TATe WA VIN# JTDKN3DU7C5476973
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2012 MAKE TOYT MODEL PRIUS STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES�/ NO BANKERS YES NO
REGISTERED OWNER INFO DANEAL ABUSA GAMUCHU 1772030TH AVE S APT G5 SEATACWA98188 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU PORGY#E CO GENERAL 53-WA 6457762IN STOP 5
VEHICLE ❑ C[ CITATION# CHARGE io BOTTOM
LEGALLY YES N
25 s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE15739
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12569
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'
This collision occurred when both vehicles were turning left from southbound Sunset BLVD N onto
eastbound Maple Valley HWY. This roadway and turn has two lanes authorized to make this left turn.
Unit 2 was in the left most turn lane while Unit 1 (A semi-truck with long dump style trailer) was in the
lane to the right of Unit 2's lane. As the light turned green and both Unit's accelerated forward
making the left turn, the rear trailer wheels of Unit 1 began to drift to the left towards Unit 2 based
upon the vehicle dynamics of Unit 1 in this turn. As the vehicle's continued in the turn, these rear
trailer wheels of Unit 1 struck the front end of Unit 2 on the front passenger corner and ripping off the
bumper. Unit 1 sustained only scuff marks to the driver's side rear trailer tires (pictures available).
This report is to document the circumstances of the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 11-02-23 09:39 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 11/2/2023 5:34:04 PM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 12:14 PM TIME POLICE ARRIVED 12:21 PM
PART I PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE1 55739
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-12569
1 COMMERCIAL MOTOR CARRIER INTERSTATE ✓ INTRASTATE G
UNIT# 1 USDOT ICC# VEHICLE TYPE 4 CARGO BODY d
TYPE
2 ❑
CARRIER 1 28
KING COUNTY SOLID WASTE
NAME
3 CARRIER
ADDRESS 16645 228TH AVE SE
CITY MAPLE VALLEY ST WA ZIP 98038
4 ❑ NAME # PLACARD: :❑
NAME IF NO NUMBER
SOURCE 1 AXLES 08 GI98000 +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES NO
i MIDDLE'... 29
LAST NAME FIRST NAME INITIAL
STREET 30
NEW AnnRFSP CITY ST ZIP
6 5
CDL GNITIttN REQUIRED GNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YES No zERLOCK YES❑N0� vES N
LLIICIENSE STATE I SEX M��DYRYY' 2
7 F-1
ON DUTYl STATUS AIRBAG' RESTR. EJECT HELMET INJURY NATURE OF INJURIES
USE CLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHIC P FROM TO
DAMAG EE YES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
EHILLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING } 8 7 6
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME MIDDLE': INITIAL ❑ 36
STREET
16 NEW AnntxFs.� CITY'. ST SIP
CDL IGNITION REdUiRED IGNITION PRESENT MEDICALTANSPORTED
INTERLOCK YES No INTERLOCK YEs NO YEs NO El
17 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE (CLASS
19 ❑ vIN 39
LICENSE #
PLATE# rnr
20 ❑ TRAILER TRAILER ❑ 40
PLATE# STATE PLATE# STATE
21 ❑ TRLR TRLR 41
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWED DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO SHADE IN DAMAGED 3 4 4 AREA F 43
z
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwGLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 11-02-23 09:39 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 OR ID# 10008 O#IL WA0171300 JOHNSON 11/2/2023 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO.! EE15739 CASE# ' 23-12569 DATE AND TIME 11/01/23 12:12
OF COLLISION
a
S ,.
I
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