HomeMy WebLinkAbout23-13988 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-13988 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 TRIBAL TOTAL#OFOBJECT 1 2$
UNITS 1U STRUCK FENCE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION.. 12 - 06 - 2023 0656 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
TALBOT RD S BLOCK NO. e✓ 3100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 200 00 FEET MILES e S B W e S 32RD ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2063037892 30
6� LAST NAME DADOLE FIRSTNAME JEROLD MIDDLE R 1 1 2 31
INITIAL
STREET ❑ 16828 6TH AVE W CITYF
WOOD ST WA ZIP 980373300 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 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� BJK4154 sTArI WAvIN# JNICV6AR6DM358770
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 5 33
12❑ VIN#' VIN#
RomM TO
34
13 2 VEH.YEAR2013 MAKE INFI MODEL G37 STYLE VEHICLETOWED0NOOffBLIN TSIgWgYMEYER vOs❑ENo /
❑ DAMAGE IILLJJII (�ciV6
REGISTERED OWNER INFO UEROLD DADOLE 168286THAVE W LYNNWOOD WA 980373300 D:2063037892 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILI INSURANCE INSURANCE CO ST FARM 1172625115
IN EFFECT &POLICY# 9TOP
vECALLv HICLE 5 36
res❑NO❑ CITATION# CHARGE INATTENTIVE DRIVING 1 o BOTTOM
15❑ LE STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2062763876
16❑
LAST NAME SMITH FIRST NAME BRIAN MIDDLE I A
INITIAL
17❑ STREET ❑', 3117 TALBOT RD S CITY' RENTON ST WA ZIP 980555015 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19 F] LDI IVEW # STATE SEX M M D.O.B.
12 — 11 _ 195 8 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE LICENSE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
23❑ TRLR R 43
LR
VIN#. N I #.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
M.LEVERTON 2517 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE32472
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13988
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'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 12-06-23 09:38 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 12/20/2023 10:09:53 AM
BADGE OR ID# 2517 OR]# WA0171300 TIME POLICE DISPATCHED', 6:57 AM TIME POLICE ARRIVED 7:03 AM
PART I PAGE IT]OF 8�
REPORT NO. EE32472 CASE# 23-13988 OF COLLISION
12/06/23 06:56
OF CbLLI510N
NARRATIVE
9 mail boxes and a fence plus a car with info exchng
CC
Within the city limits of Renton/King/Wa I responded to a vehicle into a fence at the 3100 block of
Talbot Rd S,
While enroute Dispatch advised unit 1 had contact with another vehicle but they did an info exchange
and unit 2 was gone before I arrived. However, unit 1 while southbound had left the roadway for
about 100 feet, struck several mailbox stands and came to rest in a front yard 3117 Talbot Rd S
damaging the fence.
I contacted the driver of unit 1 ID'd by his picture WADL. He provided very little information other than
he saw something on the roadway, swerved and hit this fence. He had a large piece of wood through
his windshield and after walking back I could see where he traveled about 100 feet off the roadway
nearly missing a power pole by inches along with mailboxes laying all over.
When I told him I could see the path of his vehicle, not consistent with swerving but rather someone
who was not paying attention or distracted by a cell phone or something he did not reply.
I cited unit 1 ref RMC 10-12-25 Driver inattention with 8 mailboxes and a fence damages via
complaint.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 12/6/2023
PAGE 3 OF 8
SUPPLEMENTAL REPORT NO. EE32472
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-13988
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER L
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 3 VEHICLE I_J CYCLE u PEDESTRIAN � OWNER � YES IN
MIDDLE' 29
LAST NAME : UNK FIRST NAME INITIAL
STREET 30
NEW AnnRFSP 3037 TALBOT RD S CITY RENTON ST WA ZIP 1 98055
6
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YEs MNCTEll 3NTERLOCK YES❑N0[:] YEs N
DRIVER'S STATE I SEX U M��DYSYv' —� 2
LICENSE
7
ON DUTY STATUS AIRBAG RESTR. EJECT HELMET I INJURY NATURE OF INJURIES
USE cLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9F-I TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHIC E FROM TO
DAMAGE Y E ES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
((ABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
EHILLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING �} MOTOR
8 7 6
14 ❑ UNIT# 4 MO VEHICLE � FEDDAL � � OWNER
RTY � I YESAGE NOHRE3/HOLD MET PHONE ❑ 35
PEDESTRIAN
35
15 ❑ UNK MIDDLE
LAST NAME FIRST NAME INITIAL
16 ❑ STREET ❑; 3036 TALBOT RD S CITY RENTON ST' WA ZIP 98057
NEW AnnRES.9
CDL IGNITION REtIUiR rD IGNITION PRESENT MEDICAL TANSPORTEL
1-1
17 ❑ INTERLOCK YES No INTERLOCK YEs N0 rEs NO ElDRIVER'S STATE SEX U D.O 37
18 ❑ LICENSE# MMDDYYY
ON DUTY STATUS AIRBAG RESTR, EJECT HELMET INJURY NATURE of INJURIES ❑ 38
USE (CLASS
19 ❑ 39
LICENSE rnr vIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
ViN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO DI
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
s a 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LeGALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 12-06-23 09:38 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
25 OI BADGE 2517 O#I',WA0171300 APJACOBS 12120/202 PAGE 4 OF F
3000-345-013 IR 11t18)
SUPPLEMENTAL REPORT NO. EE32472
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-13988
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER L
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 5 VEHICLE I_J CYCLE u PEDESTRIAN � OWNER � YES IN
MIDDLE' 29
LAST NAME : UNK FIRST NAME INITIAL
STREET 30
NEW AnnRFrtP 3124 TALBOT RD S CITY RENTON ST WA ZIP 1 98057
6
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YEs NOEll 3NTERLOCK YES❑N0[:] YEs N
DRIVER'S STATE SEX
LICENSE
U M��DYSYv' —� 2
LICENSE
7
ON DUTY STATUS AIRBAG RESTR. EJECT HELMET I INJURY NATURE OF INJURIES
USE cLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9F-I TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWS E T SABLIN TOWED BY anvi vEHII' E FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
((ABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
VEHICLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING S} 8 7 6
14 ❑ UNIT Tr 6 VEO IOCRLE O CYCLE 1:1OWNERRTY YES AGE THRESHOLD MET PHONE ❑ 35
PEDESTRIAN
36
15 ❑ LINK FIRST LAST NAME FIRST NAME 71 INITIAL
16 ❑ STREET ❑; 3120 TALBOT RD S CITY RENTON ST' WA ZIP 98057
NEW AnnRES.9
CDL IGNITION REtIUiR rD IGNITION PRESENT MEDICAL TANSPORTEL
17 1- YES N INTERLOCK YEs N0 YEs NO ElDRIVER'S STATE SEX U D.O 37
18 ❑ LICENSE# MMDDYYY
ON DUTY STATUS AIRBAG RESTR, EJECT HELMET INJURY NATURE of INJURIES ❑ 38
USE (CLASS
19 ❑ 39
LICENSE rnr vIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
ViN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
s a 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P _ 4 E:l
44
24 LEHIcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LeGALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 12-06-23 09:38 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 OI BADGE 2517 O#I',WA0171300 JACOBS 12120/202 PAGE 5 OF F
3000-345-013 IR IIII8l
SUPPLEMENTAL REPORT NO. EE32472
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-13988
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER L
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 7 VEHICLE I_J CYCLE u PEDESTRIAN � OWNER � YES IN
MIDDLE' 29
LAST NAME : UNK FIRST NAME INITIAL
STREET 30
NEW AnnRFSP' 3101 TALBOT RD S CITY RENTON ST WA ZIP 1 98057
6
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YEs NOEll 3NTERLOCK YES❑N0[:] YEs N
DRIVER'S STATE I SEX U M��DYSYv' —� 2
LICENSE
7
ON DUTY STATUS AIRBAG RESTR. EJECT HELMET I INJURY NATURE OF INJURIES
USE cLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9F-I TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHIC P FROM TO
DAMAGE Y E ES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
((ABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
EHILLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING S} MOTOR
8 7 6
14 ❑ UNIT Tr $ MO VEHICLE � CYCLE � � OWNER
RTY � I YESAGE NOHRE3/HOLD MET PHONE ❑ 35
PEDESTRIAN
35
15 ❑ UNK MIDDLE
LAST NAME FIRST NAME INITIAL
16 ❑ STREET ❑; 3100 TALBOT RD S CITY RENTON ST' WA ZIP 98057
NEW AnnRFS.9
CDL IGNITION REtIUiR rD IGNITION PRESENT MEDICAL TANSPORTEL
17 ❑ INTERLOCK YES No INTERLOCK YEs NO rEs NO
DRIVER'S STATE SEX U D.O.B El37
18 ❑ LICENSE# MMDDYYY
ON DUTY STATUS AIRBAG RESTR, EJECT HELMET INJURY NATURE of INJURIES ❑ 38
USE (CLASS
19 ❑ 39
LICENSE rnr vIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
ViN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
s 4 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEHIcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LeGALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 12-06-23 09:38 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
25 OI BADGE 2517 O#I',WA0171300 JACOBS 12120/202 PAGE 6 OF F
3000-345-013 fR 11t18)
SUPPLEMENTAL REPORT NO. EE32472
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-13988
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER L
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 9 VEHICLE I_J CYCLE u PEDESTRIAN � OWNER � YES IN
MIDDLE' 29
LAST NAME : UNK FIRST NAME INITIAL
STREET 30
NEW AnnRFSP 3107 TALBOT RD S CITY RENTON ST WA ZIP 1 98057
6
CDL IGNITIttN 12EQUIREb IGNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YEs MNCTEll 3NTERLOCK YES❑N0[:] YEs N
DRIVER'S STATE I SEX U M��DYSYv' —� 2
LICENSE
7
ON DUTY STATUS AIRBAG RESTR. EJECT HELMET I INJURY NATURE OF INJURIES
USE cLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9F-I TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHIC E FROM TO
DAMAGE Y E ES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
((ABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
EHILLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING �} 8 7 6
14 ❑ UNIT Tr 10 MOTOR
O CYCLE OWNER
RTY YES AGE NOHRE3/HOLD MET PHONE ❑ 35
PEDESTRIAN
35
15 ❑ UNK MIDDLE
LAST NAME FIRST NAME INITIAL
16 ❑ STREET ❑; 3112 TALBOT RD S CITY RENTON ST' WA ZIP 98057
NEW AnnRES.9
CDL IGNITION REtIUiR rD IGNITION PRESENT MEDICALTANSPORTED
17 1-1
INTERLOCK YES N-1-1 INTERLOCK YEs NC7 YES No El
DRIVER'S STATE SEX U D.OY 37
18 ❑ LICENSE# MMDDYYY
ON DUTY STATUS AIRBAG RESTR, EJECT HELMET INJURY NATURE of INJURIES ❑ 38
USE (CLASS
19 ❑ 39
LICENSE rnr vIN#
PLATE#
20 ❑ TRAILER' TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ TRLR TRLR 41
ViN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO DI
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
s a 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 12-06-23 09:38 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
25 OI BADGE 2517 O#I',WA0171300 APJACOBS 12120/202 PAGE 7 OF F
3000-345-013 IR 11t18)
REPORT NO. EE32472 CASE# 23-13988 DATE AND TIME 12/06/23 06:56
OF COLLISION
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PAGE 8 OF 8