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HomeMy WebLinkAbout24-6483 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c COLLISION REP FIT 1591971 CASE 24-6483 z INTERSTATE ❑ CITY STREET FIRE ❑RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 1 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 03 STRUCK RESERVATION z 3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑ cowsloN 06 - 1-- 2024 1006 17 ❑.❑ S 8 W e IN e 1070 3 4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ 108TH AVE SE BLOCK NO. e✓ 17600 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 500 00 FMILES N EET e S ❑B E e SEPETROVITSKYRD 1 2 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El ,/No D:4254431126 0 11 30 6� LAST NAME JOLLIFFE FIRSTNAME CHERYL MIDDLE L 1 1 2 31 INITIAL STREET ❑, 12630 SE 161 ST ST CITY RENTON ST WA ZIP 98058 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO Z/ YES R No�/ 8❑ LRIIVER # ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑ 3 10 9❑ PI ATFBit BZD9375 sTArI WA urN#' 1N46t4 BV2KC228959 TRAILER STATE TRAILED STATE 11 0 0 PLATE# PLATE# FROM TO TRLR. TRLR 3 1 33 12 3 5 VIN#' VIN# >; FROM TO ❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 5 1 34 13 9 2019 NISS ALTIMA 4D DAMAGE vE5 ONO agW�MEYERS ves❑ No REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 SHADE IN DAMAGED AREA ❑ 35 14 LIABILI INSURANCE INSURANCE CO HARTFORD 55PHG536434 3 4 IN EFFECT &POLICY# 9TOP ve FFE CHARGE 1 5 36 LEGALLY res No CITAnoN# 4AO435204 FAIL YIELD PRIVATE RD MOTOR o sorro6 15❑ STANDING 6 1,1 MOTOR PEDAL-: PROPERTY DAM THR OLD MET PHONE UNIT 02 VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER ❑ YES,/ No D:2065350743 16 a LAST NAME FELTSAN FIRST NAME MARIIA MIDDLE INITIAL 17❑ STREET ❑', 10609 SE 248TH ST CITY' KENT ST WA ZIP 98030 37 NEW ADDRESS ❑ 18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38 INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/ 19 DRIVER # STATE WA SEX F M.C... 11 19 _ 1974 39 WELMET INJURY 7 NATURE OF INJURIES 40 20 F1 ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 USE CLASS SHAKEN UP,VOMITING 21❑ LICENSE I CFV3669 TAre WA VIN1I 5XXGM4A7XCG067522 ❑ 41 PLATE# 42 22❑ PILER LATE# STATE pLATE# STATE 23❑ VIN#. 43 TRLR RLR 'IN#. TOWED BV GOV HI 44 VEH YEAR 2012 MAKE /(//� MODEL QP'I'/fllJ/� STYLE $D DAMAGE TOWED✓ NOO BLIN GENE MEYERS YES N,%/ 24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2 SHADE DAGED AREA 4 LIABILITY INSURANCE I PORGY#ECO STATE FARM 5263124EI447IN 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 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. EE89471 COLLISION REPORT III III III III III 111 1591972 CASE# 24-6483 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' Both northbound lanes of traffic backed up waiting for red signal. Unit 3 was in lane 1, just north of driveway into 17630 108th Ave SE. Unit 1 exiting 17630 108th Ave SE driveway, attempting to cross both lanes and enter left turn lane. Unit 2 northbound in turn lane. Unit 1 crossed both through lanes and entered left turn lane, in path of Unit 2. Unit 2 struck left front of Unit 1, pushing Unit 1 into back left side of Unit 3. Driver 1 issued NOI for Failure to Yield Right of Way - Vehicle Entering Highway From Private Road or Driveway. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. R.ONISHI 06-20-24 12:04 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE D.SKELTON 9139 1 6/24/2024 3:51:23 AM BADGE OR ID# 5738 OR]# ! WA0171300 TIME POLICE DISPATCHED 10:09 AM TIME POLICE ARRIVED 10:17 AM PART I PAGE IT]OF 4] SUPPLEMENTAL REPORT NO. EE89471 r`) POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 24-6483 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY ;TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER ADDRESS ` CITY ST ZIP—1 I ' 4 ❑ NAME # PLACARD: :❑ GI PLACARD IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# 3 VEHICLE tSJ CYCLE I_) PEDESTRIAN OWNER YES NO D:2064067898 OF 7 29 LAST NAME GRANBERG FIRST NAME LYNN MIDDLE'.l M] r:j INITIAL STREET 30 NEW AnDRFrtP 27730 1521VD AVE SE CITY KENT ST WA ZIP 98042 6 ❑ 1 1 2 31 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED INTERLOCK YEs NO zERLOCK YES❑N0� YEs N DRIVER'S LICENSE STATE I WA SEX F MMDDYYv 05 - 13 - 1964 7 ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES USE CLASS 8 ❑ 1 32 LICENSE BJD2401 TAr WA VIN# 5XYKTCA67EG544291 PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.It VIN.#. 11 3 5 VEH.YEAR2014 MAKE KIA MODELSORENT STYLE SW VEHICLE TOWS E T SABLIN TOWED BY anvi vEH1Ci P FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFO OWNED BY DRIVER J 9 33 12 � SHADE IN DAMAGED AREA 34 FROM TO LIABILITY INSURANCE INSURANCE CO ALLSTATE 964176849 GQ IN EFFECT &POLICY# 1VEHICLE 34 13Lecnuv YES NO❑ CITATION# CHARGE STANDING } 8 7 14 ❑ UNIT Tr Vd IRE O CYDCLE 1:1OWNER YE YES AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME NITIAL ❑ 36 STRE 16 NEW ETETnnR"F] CITY ST ZIP CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED INTERLOCK YES No INTERLOCK YES NO YES NO El 17 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE (CLASS 19 ❑ 39 LICENSE rnr VIN# PLATE# 20 ❑ TRAILER' TRAILER El40 PLATE#< STATE PLATE# STATE 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO_ SHADE IN DAMAGED 3 4 4 AREA F 43 z LIABILITY INSURANCE INSURANCE CO ' VINE EFFECT &POLICY# i 970P - 4 E:l 44 24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM LECALLv STANDING S 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. R.ONISHI 06-20-24 12:04 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 ORID# 5738 O#II,WA0171300 APSKELTON 6/24/2024 PAGE F OF 4 3000-345-013(R 11118) REPORT NO. EE89471 CASE# ' 24-6483 DATE AND TIME 06/20/24 10:06 OF COLLISION UJ U n it Unit 2 Unit 1 ! �V B •i 7( 1 �41 i �d PAGE 4 OF 4