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HomeMy WebLinkAbout24-5402 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-5402 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 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 05 - 1-- 2024 1541 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK
OAKESDALEAVESW ST e✓
MILEPOST UNKNOW
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e MONSTER RD SW
1 9 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2067735766 0 11
30
6❑ LAST NAME JOHN FIRSTNAME JASON MIDDLE W 1 2 31
INITIAL
STREET ❑, 37303 29TH PL S,FEDERAL WAY CITY FEDERAL WAY ST WA ZIP 98003 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LDRIVER # STATE WA SEX'M MID
LOB 05 1— 25 — 1974 2 32
9 ON DUTY❑ STATUS AIRBAG 3 RESTR 3 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BQD5223 sTArI WAVIN# KM8R5DHE3LU070309
IT STATE TRAILER
STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR. RLR 1 7 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2020 MAKE HYUN MODEL PAL/SA STYLE 4D VEHICLE TOWEDNOO pLSSBLIN TSIYY.Ep9vMEYERS VEHICLE
7 3 34
13❑ DAMAGE LJI (5ciV6
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14[Al
LIABILITY INSURANCE INSURANCE CO ENCOMPASS ONE 282510150 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ No D:2533154927
16 a
LAST NAME SOK FIRST NAME SIMON MIDDLE
INITIAL
17❑ STREET ❑', 4102 45TH AVE NE CITY TACOMA ST WA ZIP 98422 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YEs❑NO❑
19 LICENSED
IVER # STATE WA SEX U M .C.B. 09 _ 05 _ 1989 39
—NATURE OF INJURIES
H USE
ET LASSY CHEST,RIGHT HAND AND RIGHT LEG 40
20 ON DUTY STATUS AIRBAG 3 RESTR 3 EJECT 1 6
21❑ LICENSE BTW8936 TAre WA VIN# JF1SG63687G736053
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2007 MAKE S(JB�Q MODEL FORESTE STYLE P4 DAMAGE TOWED✓ NOO BLIN GENE MEYERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE DAGED AREA
4
LIABILITY
INSURANCE INSU&PORGY#E CO ALLSTATE 817-833-008IN STOP 5
VEHICLE ❑ C[:] CITATION# CHARGE to BOTTOM
LEGALLY YES N
25 e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
SULIASI TAMAIVENA 12788 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE79424
COLLISION REPORT III III III III III 111
1591972 CASE# 24-5402
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 advised that he was at a stopped at a stop sign on Monster RD SW in lane #2, attempting to
make a left turn onto Oakesdale AVE SW. He mentioned that he looked in both directions before
making a left turn. While turning he advised that his vehicle was hit by Unit#2. Unit#1 stated he
cleared both directions before his vehicle was hit and believed that Unit#2 was speeding. Unit#1
was not injured, and his vehicle was undrivable. He received heavy damage in the front area of his
vehicle.
Unit#2 advised that he was on Oakesdale Ave SW in lane #1, traveling eastbound. He stated that
while passing the intersection of Monster RD SW, his vehicle was hit by Unit#1. He advised his
vehicle continued to roll down the street until the vehicle came to a stop. The vehicle had heavy front
and right passenger side areas damaged. The vehicle was unable to drive. He was checked by the
Fire Department for chest, right hand, and leg injuries, which he was medically cleared. He later
advised me he would be going to Urgent Care later today.
Both Units were provided with exchange information forms and my business card.
Photos were taken and uploaded into evidence.
No signs of DUI.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
SULIASI TAMA/VENA 05-21-24 05:37 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 512212024 1:14:45 PM
BADGE OR ID# 1Y788 OR]# j WA0171300 TIME POLICE DISPATCHED; 4:03 PM TIME POLICE ARRIVED';4:08 PM
PART I PAGE IT]OF
REPORT NO. EE79424 CASE# ' 24-5402 DATE AND TIME 05/21/24 15:41
OF COLLISION
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