HomeMy WebLinkAbout23-13706 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13706 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I 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# ❑
cawsloN 11 - 1-- 2023 0830 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
PARK AVE N BLOCK NO. e
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e N 4TH ST
2 0 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
NO ,/ D:2534095603 0 11
30
LAST NAME RIVERA ALEJANDRE FIRSTNAME LUIS MIDDLE M
6 INITIAL 1 2 31
STREET ❑, 4336 S WARNER ST APT F CITY TACOMA ST WA 2jp, 98409 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/INTERLOCK YES[:]NO INTERLOCKYEs Z/NO YES �No /
LRIIVER # STATE WA SEX'M MI MIT Y
8❑ ' 12 — 12 — 1996 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� D70894A sTArr WAurN# 1 FDNF7AN5PDF04968
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 1 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2023 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 4 FORD F750 TR DAMAGE YES NO YES[:] ✓
REGISTERED OWNER INFO HERO RENTALS INC50154THAVE S SEATTLE WA 98134 VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA 35
4 INSURANCE CO 3 4
14 LIABILITY INSURANCE NATIONAL UNION FIRE INS CO OF PITTSBURGH 9767501
IN EFFECT &POLICY# 9TOP
CHARGE
VE—LE
15❑ EC to BOTTOM 5 36
LALLv YES❑NO❑ CITATION# 5
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2067349516
16 a
LAST NAME CARRILLO-ESCOBEDO FIRST NAME JUAN MIDDLE Ij
INITIAL
17❑ NEW STREETREs7 11003 SE 182ND ST CITY' RENTON ST WA ZIP 98055 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs❑NOF YEs❑NOF
19 DRIVER'S STATE WA SEX M D.D.S. O6 �_ 23 _ 1977 39
LICENSE# MMC...
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 9 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
LICENSE I ❑21❑ PLA E# BBZ2883 TArE 41
WA vIN# JT2AC52L1T0181848 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 1996 MAKE TOYT MODEL TERCEL STYLE SO VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO DANIRA MONREAL ZUNIGA 11003 SE 182ND ST RENTON WA 98055 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO PROGRESSIVE 907643034IN I STOP 5
vE""LE ❑ N`L J
,J� CITATION# CHARGE
LEG i o BOTTOM
ALLY YES
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
NATHANIEL BROWN 12765 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE26488
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13706
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, a 2023 Ford F750, was traveling in lane # 1 while unit 2, a 1996 Toyota Tercel, was traveling
in lane # 2 of northbound Park Ave N. Just south of the Park Ave N and N 4th St intersection, unit 1
attempted to change from lane #1 to lane #2. However, unit 1 did not realize unit 2 was right next to
him. This caused unit 1 to collide with unit 2, causing severe damage to unit 2 including denting both
left side doors, both bumpers, and scraping both left side wheels. Unit 1 had minor dents and
scrapes. Unit 1 failed to pay attention to his surroundings prior to lane-changing.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
NATHANIEL BROWN 11-29-23 06:31 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.KORDEL 9676 1 121412023 12:52:42 PM
BADGE OR ID# 12765 OR]# WA0171300 TIME POLICE DISPATCHED 8:49 AM TIME POLICE ARRIVED 8:58 AM
PART I PAGE IT]OF 3�
REPORT NO. EE26488 CASE# ' 23-13706 DATE AND TIME 11/29/23 08:30
OF COLLISION
Not to scale
Unit
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