HomeMy WebLinkAbout23-13638 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13638 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 28
0 5
RESERVATION
TRIBAL UNITS 02 STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 11 - 1-- 2023 1900 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 2000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NB/405 ON RAMP
0 4 29
MOTUNIT U1 VEHIOR Z CLE CYCLE ElYYESA✓NO GE THRESHOLD MET PHONE 0 1 30
6� LAST NAME GRESHAM FIRSTNAME SHANE MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 12311 SE 158TH ST CITY RENTON ST WA ZIP 980584729 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 6 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10[1P1 ATE 14 CHW2540 STATE WA u N# JF1 VA2V64H9830456
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 1 33
12 3 5 VIN If VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 3 2017 SUBA WRX DAMAGE YES NO ✓ YES❑ NO✓
REGISTERED OWNER INFO SHANE GRESHAM 12311 SE 158TH ST RENTONWA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO ST FARM 188804373
IN EFFECT &POLICY# 9TOP
VEHICL' CHARGE 5 36
LEGALLY, YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STAIN.D" 8 6
UNIT 02 VE IOOR CYCLE ❑ PEDESTRIAN ❑ OWNER RTY [:]I
DYES✓ NO OLDMET PHONE
16 a
LAST NAME NEWCOMB FIRST NAME MALIK MIDDLE A
INITIAL
17❑ STREET ❑', 21900 SE WAX RD F104 CITY' MAPLE VALLEY ST WA ZIP 98038 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑NO� INTERLOCK YEs I I NOF YES t l NOF,/
19[—] DRIVER'S STATE WA SEX M D.C... 07 27 1997 El 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CHR2346 TATe WA vIN# 4A3AC44G73E106489
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2003 MAKE MITS MODEL ECLIPSE STYLE SD VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO MALIK NEWCOMB 21900 SE WAX RD F104 MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE❑ INSURANCE CO NONE
IN EFFECT &POLICY# 9TOP 5
LEGALLY
YEs Nc❑ CITATION# 3A0522000 CHARGE OP MOT VEH W/OUT INSURANCE o BOTTOM
25 ' e
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY26 12651 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE27732
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13638
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) WILLEY BRITTANY
(LAST FIRST,
ADDRESS&PHONE# D O.B.
NONE 8016916590 SEX' U MMDDYYYY - -
PASSENGER UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
[:]WITNESS❑✓ POS. USE 4CLASS :
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 traveling eastbound on Maple Valley Hwy making a left turn onto NB 1-405. Unit 2 traveling
westbound on Maple Valley Hwy approaching same intersection. Unit 1 driver reports having
protected left turn light at intersection. Unit 2 driver reports having green light. Witness reported that
Unit 2 ran the red light. Unit 2 strikes Unit 1 causing reportable disabling damages to the front of Unit
2 and to the passenger side of Unit 1. No injuries reported. Unit 2 driver cited for no insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 11-27-23 09:00 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 121712023 2:03:46 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED' 7:25 PM TIME POLICE ARRIVED'8:00 PM
PART I PAGE IT]OF 3�
REPORT NO. EE27732 CASE# ' 23-13638 DATE AND TIME 11/27/23 19:00
OF COLLISION
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