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HomeMy WebLinkAbout24-5506 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c COLLISION REP FIT 1591971 SASE 24-5506 2 INTERSTATE ❑ CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENC 4100 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 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 IN CITY# cawsloN 05 - 1-- 2024 1538 17 ❑-= S 8 IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑ LAKE AVE S/S TOBIN S BLOCK ST e✓ MILEPOST 200 ❑ 4a❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ ❑ FEET e S ❑ W e LAKE AVE S/S TOBIN S 1 9 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El NO F,/ I D:7209493927 0 11 30 6❑ LAST NAME PHILLIPE FIRSTNAME EITHAN MIDDLE S 1 1 2 31 INITIAL STREET ❑ 2223 BENSON RD S,APT U201, CITY RENTON ST WA ZIP 98055 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/ 8❑ LDRIVER # STATE WA SEX'U MID LOB 05 1- 01 - 1997 2 32 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H U SE ICNLJAUSSY 1 NATURE OF INJURIES z❑ 3 10 9❑ P1 aT�S� C366692 sTArI WAVIN# 1D7HW42K65$171473 TRAILER STATE TRAILER STATE 11 0 0 PLATE# PLATE# ROM ro TRLR. TRLR 5 1 33 12 0 0 VIN#' VIN# ROM TO VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34 13 A 2005 DODO DAKOTA TR DAMAGE YES NO YES[:] No✓ REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1 SHADE IN DAMAGED AREA ❑ 35 14[Al LIABILI INSURANCE U NSURANCECO GEIC06043493927 4 IN EFFECT &POLICY# 9TOP VE— CHARGE 1 5 36 LEGALLv res❑NO❑ CITATION# 1 o BOTTOM 15❑ STANDING 8 7 6 MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE 16 a UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2067992934 LAST NAME YAMAMOTO FIRST NAME KATHERINE MIDDLE K INITIAL 17❑ STREET ❑' 19618 110TH PL NE,BOTHELL WA CITY BOTHELL ST WA ZIP 98011 37 NEW ADDRESS ❑ 18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED ❑ 38 INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/ 19 DRIVE ❑ ON DUTY STATUS AIRBAG,3 RESTR y EJECT 1 HELMET INJURY 7 NATURE OF INJURIES ❑ 40 USE CLASS HEAD 21❑ LICENSE I BKZ6988 TArE I WA VIN# 5NPE24AF7GH274464 ❑ 41 PLATE# 42 22❑ PLATE# STATE PLATE# STATE 23❑ VIN#. 43 TRLR RLR 'IN#. GI VEH YEAR 2016 MAKE yyU/� MODEL SONATA STYLE $D DAMAGE TOWED NOO✓ BLIN TOWED BY ov HYES NO 1/ 44 24❑ ES REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2 SHADEDAMAGED AREA 3 4 LIABILITY INSURANCE I PORGY#E CO ALLSTATE 964 970 809IN 9TOP 5 VEHICLE YES[:] NC[:]I CITATION# CHARGE io BOTTOM LEGALLY 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. EE80526 COLLISION REPORT III III III III III 111 1591972 CASE# 24-5506 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 he was on Lake Ave S, stopped at the stop sign, and traveling north. He stated he thought he cleared the intersection before entering. While passing the intersection, he was hit by Unit #2. He said he was not injured, and his vehicle was still drivable. He had minor damage to his front passenger's door, which he noted could not open. Unit#2 advised that she was on S Tobin ST traveling West. She advised that while attempting to pass Lake Ave S, Unit#1 tried to cross over the intersection, which caused her vehicle to hit Unit#1's vehicle. She advised that she was feeling dizzy. The Fire Department was called to the scene, and she was medically cleared to drive again. Unit#2's vehicle was still drivable, and it had minor damages on its front bumper. It should be noted that it's a one-lane in both directions on both streets only. Photos were taken and uploaded to evidence. Information was exchanged with both parties. 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 05-24-24 04:44 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE DESIRES SCOTT 10272 1 5/26/2024 9:46:09 AM BADGE OR ID# 12788 OR]# WA0171300 TIME POLICE DISPATCHED 3:41 PM TIME POLICE ARRIVED;3:58 PM PART Ei PAGE IT]OF REPORT NO. EE80526 CASE# ' 24-5506 DATE AND TIME 05/24/24 15:38 OF COLLISION `3 W� t 0 PAGE 3 OF 3