HomeMy WebLinkAbout23-13509 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13509 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD ❑ PRIVATE WAY INVOLVED
2 1 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 0748 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M4000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 100 00 FEET e S B W e UNION AVE NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4255454473 2 2 30
6❑ LAST NAME TESCHENDORF FIRSTNAME STEPHANIE MIDDLE N 1 1 2 31
INITIAL
STREET 01 1400 UNION AVE NE 1016 CITY RENTON ST WA ZIP 98059 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 09 — 11 — 1980 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10❑ P1 ATE 14 BMV6576 STATE WA VIN# 2HKYF18623H557225
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# Rom ro
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#'
2003 HOND PILOT SWa ❑ RO�34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 9 DAMAGE YES NO YES NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO FOREMOST G01 3760795 00 4
INEFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YEs NO 1/ D:4255918168
16❑
LAST NAME MACEDA PEREZ FIRST NAME LUIS MIDDLE JA
INITIAL
17❑ STREET ❑', 1190 UNION AVE NE C5 CITY RENTON ST WA ZIP 98059 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NO� INTERLOCK YEs❑NOF YES
❑NOF,/
19 DRIVER'S STATE WA SEX M D.O.B. 09 _ 07 1999 0 39
LICENSE# MMDDYY
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 9 1
CLASS ❑
21❑ LICENSE I D618546 TATe WA VIN1t JW686C1H1YL006702
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GoI
VEH D
YEAR 2000 MAKE MIFU MODEL FE434 STYLE $T AMAGE TOWED NOO✓ BLIN TOWED BY v HYES NO 1/ 44
24❑ fj
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#ECO STATE FARM 4000077-A27-47AIN 1GQVE""LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE25461
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13509
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 2 parked at Chevron, at the front of two pumps (unnoccupied); . Unit 1 pulled in behind unit 2.
Per driver 1 Teschendorf, she intended to stop at the rear pump, but confused her brake and
accelerator. Teschendorf accelerated her car into the back of unit 2. No injuries; damage to unit 2
limited to a row of marker lights on the right rear of truck, but unit 1 suffered heavy front end damage.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 11-24-23 01:42 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 121112023 4:20:21 PM
BADGE OR ID# 5738 ORI# WA0171300 TIME POLICE DISPATCHED 8:14 AM TIME POLICE ARRIVED',8:28 AM
PART I PAGE IT]OF
REPORT NO. EE25461 CASE# 23-13500 DATE AND TIME 11/24/2307:48