HomeMy WebLinkAbout23-13290 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE$# 23-13290 z 571
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3 Q 7
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 11 - 1-- 2023 1715 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ W e 161STAVESE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:4252560776 0 7 30
6� LAST NAME GILLMAN FIRSTNAME ETHAN MIDDLE C 1 1 2 31
INITIAL
STREET ❑ 27753 215TH AVE SE CITY MAPLE VALLEY WA
NEW ADDRESS ST ZIP', 98038 2
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
8❑ DRIVERS
E#
ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 . EJECT 1 HELMETU E 2 CLASS INJURY6 [NATURE OF INJURIES
COMPLAINT OF NECK/HEAD PAIN 2❑
3
10 9❑ P1 ATNES# CAZ1126 sTAr WAV N# 3FAHPOHAXCR351438
TRAILER STATE TRAILER STATE
11 5 0 PLATE# PLATE# FROM TO
rRLR TRLR 3 7 33
12 5 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2012 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 9 9 34
13 4 FORD FUSION SD DAMAGE YES NO �MEYER YYES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
INSURANCE CO
SHADE IN DAMAGED AREA ❑ 35
4 LIABILITY INSURANCE 4
14 ❑ NO INSURANCE N/A
IN EFFECT &POLICY#
VEH" CHARGE 5 ❑ 36
LEGALLY YES❑NO❑ CITATION# BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:4257533145
16 2
LAST NAME GAMACHE FIRST NAME JOHN MIDDLE S
INITIAL
17 STREET NEW ADOREs7 766 QUEEN AVE NE CITY RENTON ST WA ZIP 98056 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19[—] LDI IVEW # STATE WA SEX M M .C... 12 _ 10 _ 1950 39
20❑ ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 HE 2 INJURY 6 NATURE of INJURIES ❑ 40
USE CLASS CONCUSSION
❑ILICENSE 21❑ PLA E# B23661G TArE 41
WA VIN# 4TAPM62N3TZ193108 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 1996 MAKE 7'Oy7' MODEL TACOMA STYLE PK DAMAGE TOWED NOO✓ BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAGELLAREA
z Cdd
LIABILITY
INSURANCE INSU PORGY#E CO AARP 55PHL461006
IN CTOP
VE—LE CITATION# CHARGE
25 BOTTOM
LEGALLY YES[Z N�
❑ s
7MICAELA
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY26 CASTAIN 7 12573 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE23031
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13290
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) GAMACHE BONNIE S
(LAST FIRST,
ADDRESS&PHONE# D O.B.
766 QUEEN AVE NE RENTON WA 98056 4257533145 SEXi F MMDDYyYv 07 - 01 - 1953
PASSENGER Z WITNESS❑ UNIT# ; 2 pEA 3 AIRBAG 2 RESTR. q EJECT ? HELMET INJURY NATURE OF INJURIES
OS. USE 2 CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) MACARENO ✓ERMY
ADDRESS&PHONE# D O B
RENTON 4257329000 SEX M MMDD Bv- 11 _ 30 _ 1995
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY 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: Ethan Gillman (DOB 01/03/2003); 2012 Ford Fusion (WA/CAZ1126)
Unit 2: John Gamache (DOB 12/10/1950); 1996 Toyota Tacoma (WA/B23661 G)
On 11-17-2023 at approximately 1715 hours I was dispatched to a collision with injuries at Maple
Valley Hwy and 161 st Ave SE, in the City of Renton, King County, WA.
Upon arrival, I contacted both parties. Unit 1 had a complaint of neck and head pain and was
transported to Valley Medical Center. I was unable to speak to Unit 1 regarding the events of the
collision. Unit 1 advised me that he did not have valid vehicle insurance.
Unit 2 had a complaint of head pain. Unit 2 was stopped in the center turn lane (westbound) on Maple
Valley Hwy. Unit 2 was stopped with the left blinker activated and was waiting for traffic to slow so he
could make a left hand turn onto 161 st Ave SE. Unit 1 rear ended Unit 2 causing damage to both
vehicles.
Unit 1 had damage to the entire front end of the vehicle and was towed to the Gene Meyer Towing
Lot. Unit 2 had rear bumper and passenger side rear panel damage. Unit 2's vehicle was drivable.
I spoke to a witness, Jermy Macareno, who advised Unit 1 appeared to be traveling westbound at the
above location at a high rate of speed and collided with Unit 2 from the rear.
Based off the statements made above there is proximate cause for Unit 1 in the collision.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer M. Castain #12573 11/17/2023 Renton, WA
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
MICAELA CASTAIN 11-17-23 08:48 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
G.BARFIELD 6476 1 1112412023 4:48:00 PM
BADGE OR ID# 12573 OR]# WA0171300 TIME POLICE DISPATCHED'; 5:15 PM TIME POLICE ARRIVED'5:15 PM
PART I PAGE 2�OF❑
REPORT NO. EE23031 CASE# ' 23-13290 DATE AND TIME 11/17/23 17:15
OF COLLISION
U
Maple Valley, Hwy
CD
CP
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