HomeMy WebLinkAbout24-432 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE 24-432 2
INTERSTATE CITY STREET FIRE
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# ❑
COLLISION: 01 — 1—— 2024 1459 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 2ND ST BLOCK e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e WILLIAMS AVE S
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2064097495 30
6❑ LAST NAME FORTMAN FIRSTNAME MICHAEL MIDDLE R 1 2 31
INITIAL
STREET ❑, 13312 SE 233RD ST CITY KENT ST WA ZIP 98042 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
LOB 08 — 26 — 1993 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� 856949E sTAr� WAvrN# 1 GCHG35K7TF117098
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. YRLR. 3 5 33
12❑ VIN#j UIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 4 1996 CHEV G VN DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO AMICA 94074623 3 4
IN EFFECT &POLICY# 9TOP
vECALLv HICLe 1 5 36
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15 LE❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES,/ NO D:2534527026
16 a
LAST NAME JOHNSTON FIRST NAME MATTHEW MIDDLE F
INITIAL
17❑ NEW STREETR 11712 S
7 E 258TH ST CITY' KENT ST WA ZIP 98030 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YEs❑NO❑
19 LICENSE# STATE SEX M M .C.B. 02 _ 15 _ 1961 39
20 ON DUTY❑ STATUS 3 AIRBAG RESTR EJECT HELMET 2 INJURY 6 [NATURE OF INJURIES SCRAPED KNEES/BACKPAIN 40
❑21❑ TArE LICENSE vIN# 41
1
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 1 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I—e E ❑ ,J� CITATION# CHARGE25 GQ
LEGALLY YES N J
s � e
7JAWEBER
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
12532 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE39847
COLLISION REPORT III III III III III 111
1591972 CASE# 24-432
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'
On 01/12/2024 1 was dispatched to the intersection of S 2nd St and Williams Ave S for a non-injury,
non-blocking vehicle vs pedestrian accident. I arrived on scene and met with both parties who
advised the following. Pedestrian (Matthew Johnston) was crossing Williams Ave S at S 2nd ST in
the marked crosswalk with a walk signal when he was struck by driver 1 (Michael Fortman) who was
making a left hand turn from S 2nd ST onto Williams Ave S. Driver 1 advised he had not seen the
pedestrian while making the turn, and he stopped immediately after striking the pedestrian. The
pedestrian advised he was knocked to the ground and suffered scraped knees and back pain. The
pedestrian declined medical evaluation on scene. Both parties' stories corroborated with each other.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JACOB WEBER 01-12-24 04:04 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.KORDEL 9676 1 111212024 5:51:53 PM
BADGE OR ID# 12532 OR]# ': WA0171300 TIME POLICE DISPATCHED', 3:00 PM TIME POLICE ARRIVED';3:16 PM
PART I PAGE IT]OF 3�
REPORT NO. EE39847 CASE# ' 24-432 DATE AND TIME 01/12/24 14:59
OF COLLISION
1 :
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