HomeMy WebLinkAbout24-03457 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-03457 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT O 7 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# ❑
cawsloN 03 - 30 - 2024 1620 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M4000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 MILES❑ 50 00 FEET e S ❑ W e UNION AV NE
0 7 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ D:2098081733 0 11
30
6� LAST NAME WILLIAMS FIRSTNAME CANDELARIA MIDDLE N 1 2 31
INITIAL
STREET ❑ 22306 92ND AVE W CITY EDMONDS ST WA ZIP 980204504 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 04 1— 17 — 1989 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CAJ0980 sTArI WAvIN# 19XFC2F81LE211567
11[-� TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# ROM ro
TRLR. TRLR 9 9 33
12 4 0 VIN#' VIN#
:: FROM TO
VEH.YEAR 2020 MAKE MODEL STYLE VEHICLE TOWED TO BLIN 7 3 TOWED BY GOVT.VEHICLE 34
13 HOND CIVIC DAMAGE YES NO YES❑ No✓
REGISTERED OWNER INFO CANDELARIA WILLIAMS 330 VUEMONT PL NE APT 209 RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4 INSURANCE CO 3 4
14 IN EFFECT
INSURANCE BRISTOL WEST G01350227501
IN EFFECT &POLICY# � 9TOP
VEwcLE CHARGE 36
LEGALLY Yes NO❑ CITATION# 10 BOTTOM
15❑ STAIN,DIINMOTOG 8 6
UNIT 02 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES NO OLDMET PHONE
16 a
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY EDMONDS ST ZIP
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 LLIICENS # STATE SEX U MMDDYY 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
❑21❑ LICENSE TArE VIN# 41
PLATE#
42
22❑ PIR I I TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE UNKN MODEL UNK STYLE VN VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO UNK EDMONDS VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO 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# AGENCY
26 12651 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE65889
COLLISION REPORT III III III III III 111
1591972 CASE# 24-03457
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 driver reports hit and run which occurred along 4000 block of NE Sunset Blvd. Unit 1 driver
reports stopped for traffic facing eastbound on NE Sunset Blvd west of Union Av NE. Unit 1 driver
reports that Unit 2 rear ended Unit 1 causing non reportable non disabling rear bumper damage to
Unit 1. Police observed minor scuff and circular indents to rear bumper of Unit 1 indicating front
license plate contact from Unit 2. No actionable information obtained for Unit 2, only that it was an
older green van with a Hispanic driver. Unknown license plate, definitive make or model. Though
Unit 1 driver initially reported head pain, there were actual injuries reported. Unit 1 driver completed
her Door Dash delivery service before returning to meet with police to complete investigation off
scene.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 03-30-24 05:35 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 4/6/2024 4:25:13 PM
BADGE OR ID# ! 12651 OR]#' > WA0171300 TIME POLICE DISPATCHED; 4:22 Pry] TIME POLICE ARRIVED',4:38 PM
PART I PAGE IT]OF 3�
REPORT NO. EE65889 CASE# ' 24-03457 DATE AND TIME 03/30/24 16:20
OF COLLISION
v L�
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