HomeMy WebLinkAbout23-13050 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13050 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 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 1817 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
140TH WAY SE BLOCK NO. e✓ 15200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 500 00 FMILES N EET e S ❑B E e MAPLE VALLEYHWY
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLDHONE
UNIT 01 VEHICLE ❑ CYCLE El MET P
YES ✓NO D:2067151082 0 11
30
6� LAST NAME DAVIES FIRSTNAME JAKE MIDDLE D 1 2 31
INITIAL
STREET ❑ 15205 140TH WAY SE,APT D301 CITY RENTON ST WA ZIP 98058 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� SH2O776 sTArI WAvIN# 1 N6ADOEV5AC402610
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 1 33
12 4 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE 1 $ 34
13 3 2010 NISS FRONTI PK DAMAGE YES ONO a �MYERS ves❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14� LIABILITY INSURANCE INSURANCECO GEIC04334351857 3 4
IN EFFECT &POLICY# 9TOP
VE"'CLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2063967302
16 a
LAST NAME ZIMNISKY FIRST NAME LAURENCE MIDDLE ,/
INITIAL
17❑ STREET ❑', 16201 SE 178TH PL CITY RENTON ST WA ZIP 98058 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK vEs It I NOF YES
t l NOF,/
19 DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE D53383C TAre WA vIN1t 3TMCZ5AN5PM612177
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
TOWED BV Gov H 44
VEH YEAR 2023 MAKE 7'Dy7' MODEL TACOMA STYLE PK DAMAGE TOWED✓ NOO BLIN GENE MEYERS YES N.7
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO USAA USAA 0271527987101IN 9TOP 5
VEHICLE YES[:] NC[:]I CITATION# CHARGE to BOTTOM
LEGALLY
25 N.HVCe
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
M.THOMPSON 10499 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE20375
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13050
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'
On November 12, 2023 at about 1817 hours I was dispatched to the area of Maple Valley HWY and
140th WAY SE for an unknown if injury collision. Upon arrival I observed Unit 1 and Unit 2 with
significant damage, stopped in the northbound lanes of 140th WAY SE just east of the entrance to
15202 140th WAY SE. Spoke with both drivers and this is the information I received from them. Unit 2
was traveling southbound on 140th WAY SE in the number three lane of travel. Unit 1 was pulling out
of the driveway of 15205 140th WAY SE traveling east to turn north on 140th WAY SE. 140th WAY
SE is a major through road with no traffic control signs at that area. The driveway of 15205 140th
WAY SE has a stop sign. Unit 2 did not have time to stop when Unit 1 pulled out of the driveway. Unit
2 collided with the drivers side of Unit 1. No reported injuries. Both Unit 1 and Unit 2 were towed from
the scene. Neither driver requested aid on scene and were picked up by friends or spouses.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.THOMPSON 11-12-23 07:44 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 888 1 1111612023 4:32:07 PM
BADGE OR ID# ! 10499 OR]# WA0171300 TIME POLICE DISPATCHED 6:17 PM TIME POLICE ARRIVED',6:25 PM
PART I PAGE IT]OF 3�
REPORT NO. EE20375 CASE# ' 23-13050 DATE AND TIME 11/12/23 18:17
OF COLLISION
Unit2
i4
Unit 1
PAGE 3 OF 3