HomeMy WebLinkAbout23-12694 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE#r` 23-12694 2
RESULTED
1 STOLEN
STATE ROUTE � OTHER ❑ VFHIC;I F ❑ LOCAL AGENC 4'I00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 11 - 1-- 2023 2025 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 2500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ J.❑ FEET MILES e S B W e SE FIFTH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066125895 0 7 30
6� LAST NAME ROSE FIRSTNAME JALEN MIDDLE A 1 1 2 31
INITIAL
STREET ❑ 15022 204TH AVE SE CITY RENTON ST WA ZIP 98059 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO 1/ I INTERLOCK YES NO YES R NO
8❑ LDRIVER # STATE WA SEX'M MID
-O B 06 1- 08 - 1999 2 32
9 ON DUTY❑ STATUS AIRBAG 9 RESTR 4 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES 2❑
3
10 9❑ Pi ATE 14 BDS5514 STATE WA VIN# JHMCG5649XCO06421
11[-� TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# IR.. ro
TRLR. A'RLR. 1 5 33
12 4 0 VIN#' VIN#
:: FROM TO
❑ VEH.YEAR 1999 HOND ACCOR P4 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 9 34
13 4 DAMAGE YESNo YES❑ NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO STATE FARM 541 3201 F2247 4
INEFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLYYEs NO CITATION# 3AO489812 INATTENTIVE DRIVING <1�3
orrom
15❑ STANDING 6
1,1 MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT�2 ❑ PEDESTRIAN ❑ ❑
VEHICLE CYCLE OWNER YES�/ NO
16 a
LAST NAME TAN FIRST NAME LICHAN MIDDLE
INITIAL
17 STREET NEW ADOREs7 8034 BEACON AVE S CITY SEATTLE ST WA ZIP 98118 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YES t l NOF,/
19 LDI IVER # STATE WA SEX DDY
F M D.O.B.
O6 1_ 14 1965 39
20 ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 HE 2 INJURY 6 NATURE of INJURIES 40
USE CLASS COMPLAINT CHEST PAIN
❑ILICENSE 21❑ PLA E# BWP0933 TATE 41
WA vIN1 JTJGARDZ3M5019494 1
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2021 MAKE LEXS MODEL NX 300 STYLE UT VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO SHIM YU 25478 SE 276TH CT MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU8PORGY#ECO STATE FARM 4729246-A23-47BIN 1U
9TOP
VE""LE CITATION# CHARGE o BOTTOMLEGALYYES Nu25❑ J
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
C. —11VER 10540 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE22446
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12694
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
PM 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'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.TOLLIVER 11-15-2312:04AM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1112212023 2:30:41 PM
BADGE OR ID# 10540 ORI# WA0171300 TIME POLICE DISPATCHED; 8:27 Pry TIME POLICE ARRIVED',8:Y7 Pry
PART I PAGE IT]OF 4�
REPORT NO. EE22446 CASE# 23-12694 OF COLLISION
11/03/23 20:25
OF CbLLI510N
NARRATIVE
While on patrol, I observed U1 and U2 stopped in the #1 travel lane of westbound Maple Valley Hwy
at about the 2500 block.
Investigation showed that D2 was traveling west on Maple Valley Hwy and stopped for an
approaching emergency vehicle (RFA engine responding to a call for service with all it's emergency
equipment activated), as required by RCW. D1 stated he was unable to stop due to the wet roads and
collided with the rear bumper area of U2.
D2 complained of chest pain associated with this collision. RFA paramedics responded and treated
her on the scene.
Both vehicle sustained minor to moderate non-disabling damage.
During this incident I was equipped with body-worn camera which records both audio and video. My
vehicle was also equipped with a dash mounted camera. Portions of the incident were recorded. This
report is merely a summary of the incident and is not intended to be an exact transcription of the
entire investigation or what may have been captured with the recording system.
Any criminal history associated with this case was sent with the case to Iva Clark, Renton Municipal
Court Prosecutor's Office for misdemeanor cases or to Dan Satterberg, King County Superior Court
Prosecutor's Office for felony and juvenile cases.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Sgt C. Tolliver#10540
PAGE 3 OF 4
REPORT NO. EE22446 CASE# ' 23-12694 DATE AND TIME 11/03/23 20:25
OF COLLISION
PAGE 4 OF 4