HomeMy WebLinkAbout24-03460 ouCE OF ASHINGcN I� I �I) , II� I I I (III I�I I) SUPPLEMENTALREPORT NO. EE65890 0 7 27
COLLISION REPOFIT 1591971
SASE# 24-03460 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE OTHER ❑ VFHICI F ❑ LOCAL AGENCY 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 STRUCK'
RESERVATION
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E CITY# ❑
CowsloN 03 - 1-- 2024 1810 17 ❑.❑ S E IN 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 2400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 1000 FMILES EET e S ❑ E e SE 5TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2064239957 0 3 30
6� INITIAL
LAST NAME JAMES FIRSTNAME BRANDON MIDDLE E 1 1 2 31
STREET ❑, 24833 234TH PL SE CITY MAPLE VALLEY ST WA ZIP 98038 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]No✓ INTERLOCKYEs NOD,/ YES R No✓
8❑ LDRIVER # STATE WA SEX'M MID
-O B 08 1— 05 — 1976 2 32
9 ON DUTY✓❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 P1 ATE 14 72902D sTAT WAu N# 1 FMCU9GX5FUA45781
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 4 0 VIN#' VIN#
:.: FROM TO
❑ VEH.YEAR 2015 FORD ESCAPE UT MAKE MODEL STYLE VEHICLE TOWED TO BLIN T/yj�)��p/ggYTE GO VT.VEHICLE 1 7 34
❑13 4 DAMAGE YES NO �"-"--" 'Es NO✓
REGISTERED OWNER INFO CITYOFSEATTLE 7005THAVSTE 5200 SEATTLE WA 98104 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
3 4
14 UABILI VINSURANCE INSURANCECO CITY OF SEATTLE SELF INSURED
IN EFFECT &POLICY# 9TOP
ErIICLE CHARGE 5 36
LvECALLv res❑NO❑ CITATION# 1 o BOTTOM
MOT
15❑ STAIN,DIING 8 7 6
UNIT U2 VEHIOCLE CYCLE PEDAL ❑ PEDESTRIAN ❑ OWNFRRTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME ADAMS FIRST NAME BRYAN MIDDLE R
INITIAL
17❑ STREET ❑', 16228 145TH AVE SE CITY RENTON ST WA ZIP 980588227 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LDIIVER # STATE WA SEX M M .O.B. 08 _ 12 _ 1956 0 39
HELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BYH7926 TATe WA VIN1t 2FMDK4KC4ABA31287
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2010 MAKE FORD MODEL EDGE STYLE UT VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO BRYAN ADAMS 16228145TH AVE SE RENTON WA 98058 D:2063167673 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE INSU&PORGY#E CO AMERICAN FAMILY 410633092380 1U
9TOP
IN EFFECT
"'LE ❑ ,.I— CITATION# CHARGE o BOTTOMLEGALYYES N`LJ25 '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE65890
COLLISION REPORT III III III III III 111
1591972 CASE# 24-03460
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'
Units 1 and 2 both heading south along the 2400 block of Maple Valley Hwy. Unit 2 slows to make
legal right hand turn into the parking lot of Classics Sports Bar at 2431 Maple Valley Hwy. Unit 1 rear
ends Unit 2 causing reportable disabling rear end damage to Unit 2 and reportable disabling front end
damage to Unit 1. No injuries. Unit 1 later privately towed. Unit 2, though disabled, remained parked
at lot.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 05-30-24 04:17 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 4/6/2024 4:25:03 PM
BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 6:12 PM TIME POLICE ARRIVED 6:15 PM
PART I PAGE IT]OF
REPORT NO. EE65890 CASE# ' 24-03460 DATE AND TIME 03/30/24 18:10
OF COLLISION
Not To Scal,,,e
L
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