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HomeMy WebLinkAbout23-9588 iiTFiNII IIIII III IIIII II IIII IIIII I . 27c REPORT NO ED92882oc� RA COLLISION REPORT 1591971 ASE# 23-9588 2 INTERSTATE CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL AGENC'Y 4100 3 COUNTY RD ❑ NVOLVED CODING PRIVATE WAY 2❑ TRIBAL TOTAL 1 UNITS#OF 02 SO BJECT TRUCK 1 8 28 RESERVATION 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# DATE OF'. N E COLL.ISION'. 08 - 20 - 2023 1613 17 =.= S 8 W E IN OF M 1070 a 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION �✓ NON INTERSECTION ❑ NE 4TH ST BLOCK NO. e 4700 .� 4a❑ MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 . FEET S 8 w e DUVALL AVE NE 0 1 29 MOTtlR ✓ PEDAL- DAMAG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2065791143 0 4 30 5 LAST NAME CALVIN FIRST NAME AALIYAH MIDDLE P 1 1 2 31 INITIAL STREET ❑ 2224 S 146TH ST NEW CITY, SEATTLE ST WA ZIP 98108 2 7 CDL IGNITION REQUIRED IGNITION PRESENT MEflICAL TRANSPORTED 3 INTERLOCKYES ND✓ INTERLOCKvEs N ✓ YES NO�/ 8� LICENSE# STATE WA SEX F MMor YY' 12 — O6 — 1999 1 2 32 9� ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 N USEET 2 1 INJURY CLASS 1 NAruRE of INJURIES 2 LICENSE, CCW0818 STATE WA VIN# JNICV6AR5CM973289 3 10 PI ATF# TRAILER STATE TRAILER ,STATE 11 3 5 PLATE# PLATE# ROM TO TRLR rRLR 3 7 33 1 3 5 VIN# vI. ( FROM TO 2 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN 7 v GOVT VEHICLE 7 1 34 13 8 2012 INFI G37 P4 DAMAGE YES ONO (M MEYER TOWING YEs❑ No✓ REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 ❑ SHADE IN DAMAGED AREA 35 LIABILITY INSURANCE❑ INSURANCE CO 14 ✓ STATE FARM 516-4044-F04-47 IN EFFECT &POLICY# vEnic�E CHARGE 36 Lemur yes❑NO❑ CITATION# CIO 1 5❑ STML ING MOTCYR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT 02 VEHICLE ❑ CYCLE' ❑ ❑ nWNFR YEs,/ No D:3605033387 16� LAST NAME ROBBINS FIRST NAME ALLAN MIDDLE' INITIAL STREET ❑ 17 ❑ 811 S 30TH ST CITY MOUNT VERNON ST, Wq ZIP 98274 4 37 NEW ADORESS 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED.. 38 INTERLOCKYEs No✓ jNTERLO'KYEs No✓ vEs No;✓ 19 DRIVER'S STATE WA SEXIM I D.O.B. 09 19 1976 39 LICENSE# MMDDYY — 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U ET 2 INJ 1 RY NATURE OF INJURIES 40 21 LICENSLATE E C65620S TATE WA VIN# 1GCHK23G84F241714 41 42 22❑ TRAILER ' ,71842AH STATE WA TRAILER STATE PLATE# PLATE 43 23 lVfN#TRLR 5RVDt 1429NP114223 VEH.YEAR 2004 MAKE CHEV MODEL SILVHR A STYLE TR VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES �/ No GENE MEYER TOWING ves No✓ REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 70810219 IN EFFECT &POLICY# 9TOP vemae YES N J ❑ ,.I—I CITATION# CHARGE t080TTOM E—Y 25 7DNE 'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 SON 12421 WA0171300 PAGE 01 OF PART A 3000-345-159(R 11/18) POLIICFETRAFFICN CORRECTION REPORT NO. ED92882 COLLISION REPORT III III III III III 111 1591972 CASE# 23-9588 ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL} BERGSETH MAXWELL S (LAST,FIRST, ADDRESS&PHONE# DOB 21016 5TH AVE S DES MOINES WA 98198 5068345957 SEX' M MMDDYYYY 02 - 26 - 2000 SEAT HELMET NJURY NATURE OF INJURIES PASSENGER z WITNESSEl I UNIT# 1 POS. 3 AIRBAG i 2 RESTR. 4 EJECT 1 USE 2 CLASS '6 COMPLAINT OF HEAD/FACE PAIN 'NAME LAsr F RST,MIDDLE INITIAL) MONTANO PHILLIP L ADDRESS&PHONE# 6912 88TH PL NE MARYSVILLE WA 98270 SEX' M MMDDYVYv 03 _ 28 _ 1968 PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES ❑ �✓ POS. USE CLASS ----� '.NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE# SEX' D.O.B.M � II MDDYYYY PASSENGER WITNESS UNIT# USE CLASS SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF wJURIEs ❑ Q POS. NARRATIVE I was dispatched to a report of two motor vehicle collision in the intersection of NE 4th St and Duvall Ave NE. RRFA was enroute to an involved subject with a complaint of head pain. 1 arrived on scene and located both vehicle, a tan 2004 Chevrolet Silverado (WA/C65620S) towing a utility trailer (WA/71842AH) and a black 2012 Inifinit G37 (WA/CCW0818). The Silverado was stopped in the intersection and was missing its front driver side wheel.The driver of the truck advised he was in the left turn lane to turn north on Duvall Ave NE when he was struck by the Identifying, he said that he had a yellow left hand turn signal at the time of the collision. The driver advised he was uninjured. The truck and trailer were removed from the scene by Gene Meyer Towing. The Initiating was stope facing west on NE 4th, the vehicle was also missing its driver side front tire and had damage to the front bumper, quarter panel, driver door, and drivers side passengers door. The driver advised she was heading west on NE 4th approaching the intersection with a yellow light, she said the Silverado turned in front of her. The driver was uninjured, the passengers had a complaint of head/face pain and was evaluated by RRFA and cleared at the scene. The Initiating was removed from the scene by Gene Meyer Towing. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. D.NELSON 08-20-23 05:32 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY E DAT P.SUMMERS 8887 812512023 7.53:09 PM BADGE OR ID# 12421 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 4:14 PM TIME POLICE ARRIVED 4:17 PM PART B 3aaa-345-,aa(RI1Y1s) PAGE 27OF 37 REPORT NO• ED92882 CASE# 23-9588 DATE AND TIME 08/20/23 16:13 OF COLLISION Duvall Ave NE NE 4th St 4 Vehicle 2 Vehicle 1 1 38th Ave SE PAGE 3 OF 3