HomeMy WebLinkAbout23-13870 a POLICETRAFFic" II I f I) 11I1ll(111(111l If( f 11 REPORT NO. EE31303 170
27
COLLISION REP FIT 1591971
CASE 23-13870 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4250 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 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 12 - 1-- 2023 2212 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 14000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e 140THAV SE
0 3 29
MOTU '�01 VEHtOCLEZ PEAL-CYMLE. El �ESAGE NHORE✓LD MET PHONE 0 81
30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 9 2 31
INITIAL
STREET ❑ CITY Sr ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ LIRCIENSRE#
SrA fE I
SEX u MMDOBYY '❑— 1 1 2 32
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 9 H USEEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE UNKNOWN sTATI vrN#
10 1❑ PI ATE 14
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
rRLR. TRLR 5 1 3 33
12 4 5 vIN# VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13❑ DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
veHICLe CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
UNIT 02 MOTOOR CYCLE ❑ PEDESTRIAN ❑ PROPE OWNFRRTY ❑ D YES NO VEHILOLD MET PHONE
16 a
LAST NAME SANTIAGO 77771 FIRST NAME LAURA MIDDLE M
INITIAL
17❑ STREET ❑', 14300 SE 171ST WAYAPT A6 CITY RENTON ST WA ZIP 980588712 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL t—T�RANSPORTED ❑ 38
INTERLOCK YES❑No� INTERLOCK YYEESI I I NoF YES t l NO�
19 LICENSE# STATE WA ]SEX IF MMDDW 12 _ 18 _ 1963 39
H USE COMPLAINT
NJAU SY COMPLAINT OF PRE EXIST NECK/BACK ❑ 40
20 [NATURE OF INJURE
❑ ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 7
21❑ LICENSE A WH4366 TATE I WA vIN# 3FAHPOHG8BR312608
❑ 41
PLATE#
42
22 [TRAILER T
❑ PLATE# STATE PLATE#ILER STATE
23❑ 43
TIN# IN RLR
#.UIN#. '
VEH YEAR 2011 MAKE FORD MODEL FUSION STYLE SD VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO LAURA SANTIAGO 14300 SE 171ST WAYAPTA6 RENTON WA 980588712 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#ECO STATE FARM 451-5898-811-47AIN IUQ,
5
"'LE CITATION# CHARGE YES[Z NEI25
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY26 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE31303
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13870
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 unknown driver unknown make or model. Unit 1 heading north to east, making right turn at
intersection from 140th Way SE onto Maple Valley Hwy. Unit 2 reported stopped at light, facing
westbound on Maple Valley Hwy, about to make a left turn south onto 140 Way SE. Unit 1 makes
wide right turn and clips Unit 2, causing non reportable non disabling damage to the driver side rear
view mirror of Unit 2. Unknown damage to Unit 1. Unit 1 continues east on Maple Valley Hwy. No
actual injuries reported. Unit 2 driver stated she had pre existing neck and back injuries.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 12-03-23 11:15 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 12/17/2023 3:02:58 AM
BADGE OR ID# 12651 ORI#; 'i WA0171300 TIME POLICE DISPATCHED 10:22 PM TIME POLICE ARRIVED',10:30 PM
PART I PAGE IT]OF 3�
REPORT NO. EE31303 CASE# 23-13870 DATE AND TIME 12/03/23 22:12
OF COLLISION
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