HomeMy WebLinkAbout24-01556 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
CASE 24-01556 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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.. 02 - 1-- 2024 1650 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M4600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 200 00 FMILES EET ❑ S ❑ E ❑ DUVALL AV NE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:4254451670 30
5� LAST NAME MAHUJI FIRSTNAME DEBORAH MIDDLE K 1 0 4 31
INITIAL
STREET ❑ 4455 NE 12TH ST APT 24-02 CITY RENTON ST WA 21p 980594444 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]No✓ INTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3❑
,OF
Pi ATNES# BWH8534 sTAr WAV N# 1 N4AZOCP6GC309053
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR $ 7 33
12❑ VIN#' UIN#'
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 $ 34
13 A 2016 NISS LEAFS/ HB DAMAGE vesNo ✓ ves❑ No✓
REGISTERED OWNER INFO ,.ORAH MAHUJI 4455 NE 12TH STAPT 24-02 RENTON WA 980594444 D:4254451670 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
[Al ❑ INSURANCE CO 2 3 4
14 LIABILITY INSURANCE NONE
IN EFFECT &POLICY# 9TOP
LEGALE CHARGE 10BOTTOM 5 35
VH'C Y YES❑No CITATION# 4A0003669 INATTENTIVE DRIVING.OP MOT VEH
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES✓ No D:4254454892
16 a
LAST NAME NIX FIRST NAME GERALD MIDDLE A
INITIAL
17❑ STREET ❑', 3413 NE 8TH ST CITY' RENTON ST WA ZIP 98056 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs❑NOF YEs❑NO❑
19 DRIVER'S STATE WA SEX M D.O.B. 07 02 _ 1951 39
LICENSE# MMDDYY
20 ON DUTYURE OF INJURIES STATUS 3 AIRBAG RESTR EJECT H U EET LASSINIY 5 HEAD INJURY BLEED/POSSIBLE CONCUSSION ❑ 40
❑21❑ LICENSE TArE VI 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED By Gov HI 44
L4 1 ] 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
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID#
26 12651 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE50148
COLLISION REPORT III III III III III 111
1591972 CASE# 24-01556
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 traveling north in parking lot shared by Albertson's, Starbucks, and El Rinconsito Taqueria at
4600 block of NE Sunset Blvd. Unit 1 driver reports making left turn from parking lot aisle towards exit
to NE Sunset Blvd. Pedestrian walking south within parking lot. Unit 1 strikes pedestrian causing
pedestrian to fall backwards and strike the back of his head upon the pavement causing significant
rear bleeding head wound and possible concussion. Unit 1 sustains non reportable non disabling
front end damage. No injury to Unit 1 driver. No witnesses. Unit 1 driver reported not observing
pedestrian because pedestrian was 'hunched' over while walking. Unit 1 driver cited for no insurance
and inattentive driving. No evidence of impairment or any crime.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 02-12-24 06:24 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
BRYAN GROZAV 12489 2/14/2024 12:50:05 AM
BADGE OR ID# 12651 OR]# WA0171300 TIME POLICE DISPATCHED 4:54 PM TIME POLICE ARRIVED',4:58 PM
PART I PAGE IT]OF 3�
REPORT NO. EE50148 CASE# ' 24-01556 DATE AND TIME 02/12/24 16:50
OF COLLISION
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