HomeMy WebLinkAbout24-5319 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-5319 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l 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: 05 - 19 - 2024 1603 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SW 41ST ST BLOCK NO. e✓ 601
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 200 00 FEET e S MILES N B W e LIND AVE SW
1 5 29
MOTU '�01 VEHtOR Z CLE CYDCLE. El �ESAGE NHORE✓LD MET PHONE O 1 30
6� LAST NAME MOSKALOFF FIRSTNAME TERRY MIDDLE J 1 1 2 31
INITIAL
STREET ❑1 3703 W KENNEWICK AVE APT C121 CITY KENNEWICK ST WA 2jp, 99336 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ DRIVERS
CENSE STATE WA SEX'M I D-MIDIAY' 08 - 29 - 1977 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU SE CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATE 14
CAF3159 sTAT WA V N#' 5N1AT2MKXFC780871
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 0 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 3 ] 34
13 A 2015 NISS ROGUE SW DAMAGE YES NO YES[:] No✓
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 UABILI VINSURANCE INSURANCE CO STATE FARM 3384571.310.470 3 4
IN EFFECT &POLICY# 9TOP
VE'CLE CHARGE 1 5 36
LEcnLLv YES NO CITATION# 10 BOTTOM
15❑ ...... 8 6
UNIT MOTOVEHICR CYCLE ❑ PEDESTRIAN ❑ PROPERTY ❑ DYES NO OLD MET PHONE
16 a
LAST NAME DAVIS FIRST NAME TAMMY MIDDLE L
INITIAL
17❑ STREET ❑, 3616 S J ST CITY' TACOMA ST WA ZIP 98418 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38
INTERLOCK YES❑NO INTERLOCK YEs❑NOF YES
❑NOF,/
19 DRIVER'S STATE WA SEX F D.O.B. 03 _ 30 _ 1968 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CCZ7913 TATe WA VIN1i JF2SKAMC7NH466256
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2022 MAKE $(JB�Q MODEL FORESTE STYLE $W DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&POLICY#E CO GEICO 6121-25-55-30IN 1GQVE""LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE79257
COLLISION REPORT III III III III III 111
1591972 CASE# 24-5319
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'
Private property collision, minor damage complaint by unit 2, unit 1 claims there was no impact. Case
drawn for information exchange.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 05-19-24 04:48 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 512212024 4:03:20 AM
BADGE OR ID# 5738 OR]# ! WA0171300 TIME POLICE DISPATCHED'; 4:05 Pry] TIME POLICE ARRIVED'4:10 PM
PART I PAGE IT]OF 3�
REPORT NO. EE79257 CASE# ' 24-5319 DATE AND TIME 05/19/24 16:03
OF COLLISION
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