HomeMy WebLinkAbout23-12796 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-12796 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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 - 1-- 2023 1415 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LOGAN AVE N BLOCK NO. e✓ p ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e N 3RD ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2068180730 0 11
30
6� LAST NAME CHAN FIRSTNAME LOUIS MIDDLE M 1 2 31
INITIAL
STREET ❑ 19602 99TH STREET CT E CITy BONNEY LAKE ST WA 2jp, 983915947 z=
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� /aTE2877 sTArI WAvIN# 2T18URHEOFC345223
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR 1 3 33
12 3 5 VIN#' VIN#
ROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 5 1 34
13 2 2015 TOYT COROL DAMAGE YES NO MEYER YES[:] NO✓
REGISTERED OWNER INFO LOUTS 1HA11960299TH STREETCTE SONNEYLAKE WA 98391 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILI INSURANCE INSURANCE CO ALLSTATE 087714630
IN EFFECT &POLICY# 9TOP
15❑ vEGAEHA"LE 5 36
LLLY YES�No D CITATION# 3A0087436 CHARGE FAIL YIELD LEFT TURN MOTOR Io eorroM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
YE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ S 1/ NO D:2064595443
16 a
LAST NAME SOUVANNAVONG FIRST NAME KHAMSENG MIDDLE
INITIAL
17❑ STREET ❑', 3700 NE 9TH CT CITY RENTON ST WA ZIP 980563815 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK Y�EsI❑NOF YES
❑No�
19 D NEST # STATE WA SEX F M.C.B. O6 _ 29 _ 1958 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE ALN7793 TAre WA VIN# JTJBT20X460112797
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2006 MAKE LEXS MODEL GX STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO KHAMSENG SOUVANNAVONG 3700 NE 9TH CT RENTON WA 98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATEFARM L139392-C25-47EIN IUQ,
5VEHICLe ❑ ,.II CITATION# CHARGELEGALLY YES N25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE20366
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12796
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 1 was facing southbound in the left turn lane from southbound Logan AVE N to turn left onto
eastbound N 3rd ST with a flashing yellow arrow indicating they must yield to oncoming traffic. Unit 2
was traveling northbound on Logan AVE N approaching N 3rd ST with a green light intending to
continue northbound. Driver 1 stated that traffic was backed up in the inside oncoming northbound
lane but he could not see traffic in the other northbound lane in which Unit 2 was approaching. Unit 1
initiated his left hand turn and failing to yield the right of way to Unit 2 which was approaching. Unit 2
entered the intersection and the front end of Unit 1 struck the driver's side of Unit 2. Both vehicles
sustained moderate but disabling damage.
Both vehicles towed by Gene Meyer towing.
Driver 1 cited for failing to yield the right of way to a motor vehicle when making a left turn by failing to
yield the right of way to Unit 2 and turning left into Unit 2's path which was the proximate cause 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 11-06-23 03:21 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 11/16/2023 3:52:45 PM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 2:97 Pry TIME POLICE ARRIVED',2:21 PM
PART I PAGE IT]OF
REPORT NO. EE20366 CASE# ' 23-12796 DATE AND TIME 11/06/23 14:15
OF COLLISION
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