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Home My WebLink About23-14176 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c COLLISION REP FIT 1591971 ❑ ❑ FIRE ❑ CASE$# 23-14176 2 0 5 INTERSTATE CITY STREET RESULTED 1 STATE ROUTE OTHER STOLEN ❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 2 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 03 STRUCK RESERVATION 2 3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑ cowsloN 12 - 1-- 2023 1701 17 ❑. S 8 W Li OF e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ SE PETROVITSKY RD BLOCK NO. e✓ --- ----� 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 100 00 FMILES N EET e S ❑ E e 108THAVESE 0 3 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El ,/No D:2068223504 0 11 30 6� LAST NAME SATTLER-FORHAN FIRSTNAME JAYDE MIDDLE E 1 2 31 INITIAL STREET ❑, 7818 S 126TH ST CITY SEATTLE ST WA ZIP 98178 2 NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES 1/ NO 8❑ LRIIVER # ON DUTY❑ STATUS AIRBAG 6 RESTR 9 EJECT 1 HELMET 2 INJURY 7 NATURE OF INJURIES 2❑ USE CLASS COMPLAINT OF PAIN,UNKNOWN 3 10 9❑ LI ENSE BKD4296 STATE WA VIN#' 1HGCG16561AO06951 ATE 14 5 TRAILER STATE TRAILER STATE 11 3 5 PLATE# PLATE# FROM TO rRLR TRLR 5 3 33 12 3 5 VIN#' VIN# >; FROM TO VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34 13 3 2001 HOND ACCOR SD DAMAGE YES NO YES[:] No ✓ REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 SHADE IN DAMAGED AREA ❑ 14 LIABILITY INSURANCE 35 ❑ INSURANCE CO UNKNOWN 4 IN EFFECT &POLICY# 9TOP VEHICLE CHARGE 5 36 LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM 15❑ STANDING MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4253688171 16 a LAST NAME BURRELL FIRST NAME HANNAH ROSEMARY MIDDLE A INITIAL 17 STREET❑ NEW ADOREss❑' 215 21 ST PL SE UNIT A CITY AUBURN ST' WA ZIP 98002 4❑ 37 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38 INTERLOCK YES❑NO� INTERLOCK YEs❑NOF YES ❑NOF,/ 19 DRIVER'S STATE WA SEX F D.C.B. O6 _ 29 _ 1990 39 LICENSE# MMDDYY 20❑ ON DUTY STATUS AIRBAG 6 RESTR 9 EJECT 1 HELMET 2 INJURY 6 NATURE OF INJURIES 40 USE CLASS COMLAINT OF TOE PAIN ❑ 41 21❑ ILICENSE PLATE# BOV7334 TATE WA VIN1 2C4RDGBGXDR606187 1 42 22❑ PILER LATE# STATE pLATE# STATE 23❑ VIN#. 43 TRLR RLR 'IN#. VEH YEAR 2013 MAKE DODG MODEL CARAVAN STYLE VN VEHICLETOWED TO BLIN TOWEDBY GOV HI 44 24❑ DAMAGE YES NO YES NO REGISTERED OWNER INFO JASON BURRELL 21521ST PL SE UNIT A AUBURN WA 98002 VEHICLE NO.2 SHADEDAMAGEDAREA 3 4 LIABILITY INSURANCE &POINSURGY#E CO STATEPARM 195 2052-C18-47DIN STOP 5 """Le ❑ ,J� CITATION# CHARGE to BOTTOM LEGALLY YES N`L J 25 ' a 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. EE29360 COLLISION REPORT III III III III III 111 1591972 CASE# 23-14176 ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL) GARDENIER AUSTIN E (IAST FIRST, ADDRESS&PHONE# D O.B. JBLM TACOMA WA 8503268287 SEX M MMDDYyvv 07 - 12 - 2001 PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES ❑✓ ❑ 1 POS, 3 6 9 1 USE 2 CLASS 1 NAME (LAST,FIRST,MIDDLE INITIAL) SANTOS DENTON S ADDRESS&PHONE# D O B 2344 I ST SE AUBURN WA 98002 2532454953 SEX M MMobvuvv 05 _ 27 _ 1997 SEAT HELMET INJURY NATURE OF INJURIES PASSENGER WITNESS❑ UNIT# 3 POS 1 AIRBAG 2 RESTR. 3 EJECT 1 USE 2 CLASS 1 NAME (LAST FIRST,MIDDLE INITIAL) SANTOS DENTON G ADDREss&PHONE# 23441 ST SE AUBURN WA 98002 2532454968 SEX MM 20 _ 1962 MDDYYYY PASSENGER WITNESS UNIT# ! 3 SEAT 7 AIRBAG 2 RESTR. 9 EJECT 1 HELMET 2 INJURY 1 NATURE OF INJURIES ❑ POS. USE CLASS NARRATIVE' Unit 1 was attempting to make a right turn out of the T-Mobile parking lot off of SE Petrovitsky Rd to go eastbound on SE Petrovitsky Rd while Unit 2 was traveling straight ahead in lane #1 of eastbound SE Petrovitsky Rd and Unit 3 was traveling straight ahead in lane #2 of eastbound SE Petrovitsky Rd. As Unit 1 was turning, Unit 2 was unable to stop in time, causing the front end of Unit 2 to hit the driver side of Unit 1. Unit 1 continued to drive forward towards lane #2 and also collided with the front end of Unit 3. This caused severe damage to the driver side of Unit 1, the front end of Unit 2, and minor damage to the bumper and license plate of Unit 3. The passenger in Unit 1 stated they were unable to see beyond the red light camera on eastbound SE Petrovitsky Rd to see oncoming traffic priot to turning. Unit 1 failed to yield the right of way to Units 2 and 3. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. NATHANIEL BROWN 12-11-23 05:13 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE DESIRES SCOTT 10272 1 1211112023 6:29:47 PM BADGE OR ID# 12765 ORI# WA0171300 TIME POLICE DISPATCHED' 5:02 Pry] TIME POLICE ARRIVED',5:03 PM PART I PAGE 2�OF❑ STATE OF POLICETRAFFICN CORRECTION REPORT NO. EE29360 COLLISION REPORT III III III III III 111 1591972 CASE# 23-14176 ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL) SANTOS BLESILUA S (IAST FIRST, ADDRESS&PHONE# D O.B. 2344 I ST SE AUBURN WA 98002 8184411329 SEX F MMDDYyYv 04 - O6 - 1969 PASSENGER Z WITNESS� UNIT# 3 POS 9 AIRBAG 2 RESTR. 9 EJECT ? HELMET INJURY NATURE OF INJURIES USE 2 CLASS 1 NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE# DOB SEX MMDDYVYV PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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 was attempting to make a right turn out of the T-Mobile parking lot off of SE Petrovitsky Rd to go eastbound on SE Petrovitsky Rd while Unit 2 was traveling straight ahead in lane #1 of eastbound SE Petrovitsky Rd and Unit 3 was traveling straight ahead in lane #2 of eastbound SE Petrovitsky Rd. As Unit 1 was turning, Unit 2 was unable to stop in time, causing the front end of Unit 2 to hit the driver side of Unit 1. Unit 1 continued to drive forward towards lane #2 and also collided with the front end of Unit 3. This caused severe damage to the driver side of Unit 1, the front end of Unit 2, and minor damage to the bumper and license plate of Unit 3. The passenger in Unit 1 stated they were unable to see beyond the red light camera on eastbound SE Petrovitsky Rd to see oncoming traffic priot to turning. Unit 1 failed to yield the right of way to Units 2 and 3. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. NATHANIEL BROWN 12-11-23 05:13 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE DESIRES SCOTT 10272 1 1211112023 6:29:47 PM BADGE OR ID# 12765 ORI# WA0171300 TIME POLICE DISPATCHED' 5:02 Pry] TIME POLICE ARRIVED',5:03 PM PART I PAGE IT]OF SUPPLEMENTAL REPORT NO. EE29360 r`) POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 23-14176 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 DAMAGETHRESHOLD MET PHONE UNIT# 3 �✓ � PEDESTRIAN YES NO 5 VEHICLE CYCLE OWNER ✓ D:2538807121 0 1 Zg LAST NAME SANTOS FIRST NAME BLEZYL-ANNE MIDDLE ',, S INITIAL STREET 30 NEW AnnRFSP' 2344 I ST NE CITY AUBURN ST WA ZIP 98002 6 ❑ 1 1 2 31 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED INTERLOCK YEs NO✓ zERLOCK YES�NO� YEs N ✓ DRIVER'S LICENSE STATE I WA SEX F MMDDYYv 05 TO] - 2001 7 ON DUTY� STATUS AIRBAG' 2 RESTR. g EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES USE CLASS 8 ❑ 1 32 LICENSE BUZ2755 TAr WA VIN# JTMRWRFVXLD071023 PLATE# 9 [9] TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 3 5 VEH.YEAR2020 MAKE TOYT MODELRA V4 STYLE UT I VEHICLE TOVVE E T SABLIN TOWED BY anvi vEH1I' P FROM TO DAMAGE YES 'E ✓ YES NO ✓ REGISTERED OWNER INFOBLEZYL-ANNE SANTOS 23441 ST NE AUBURN WA 98002 0:2538807121 ] $ 33 12 � SHADE IN DAMAGED AREA 3 4 FROM TO LIABILITY INSURANCE INSURANCE CO ALLSTATE 817 q"i"Olx IN EFFECT &POLICY# VEHICLE 34 13 ❑ Lecnuv YES❑ NO❑ CITATION CHARGE 10 BOTTOM STANDING } 8 7 6 14 ❑ UNIT Tr Vd IRE O CYDCLE 1:1OWNER YE YES AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME NID AL ❑ 36 STREET 16 NEW AnnRFS.� CITY ST ZIP CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED INTERLOCK YES No INTERLOCK YEs NO YEs NO ❑ 17 4 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE CLASS 19 ❑ LICENSE TAr VIN# 39 PLATE# 20 ❑ TRAILER' TRAILER El40 PLATE#< STATE PLATE# STATE 21 ❑ ❑ 41 TRLR TRLR 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 3 4 71 LIABILITY INSURANCE INSURANCE CO ' VINE EFFECT &POLICY# i 970P - 4 E:l 44 24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM LECALLv 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. NATHANIEL BROWN 12-11-23 05:13 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 � ORID# 12765 O#II,WA0171300 APPROVED BY 12111/202 PAGE F41 OFF 3000-345-013(R 11118) REPORT NO. EE29360 CASE# ' 23-14176 DATE AND TIME 12/10/23 17:01 OF COLLISION At 108th Ave SE Unt Not to scale } i I kx iy t PAGE 5 OF 5