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HomeMy WebLinkAbout23-07528 ("7— STATE.w,-" .:.. TFFiN27CERAc REPORT NO. ED76224 ,one COLLISION REP OF 1591971 CASE# 23-07528 2 INTERSTATE CITY STREET El 1 1 STATE ROUTE OTHER LOCAL AGENCY 4250 3 CODING COUNTY RD PRIVATE WAY 2 TRIBAL UN 75 TOTAL#OF STRUCK 1 8 OBJECT 2$ RESERVATION 1 2 3 M M D D Y Y Y Y TIME I2400) COUNTY# MILES CITY# coAT sloN 07 - 02 - 2023 2355 17 a. e W 8 OF IN 8 1070 3 S 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ SUNSET BLVD NE BLOCK ST 8 1150 .� 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 100 00 FEET e✓ S e W 8 NE 10TH PL 0 1 29 ♦� MOTOR PEDAL- : DAM ETHRESHOLD MET PHONE UNIT 01 VEHICLE CYCLE YES NO 1 2 30 6 LAST NAME : UNKNOWN FIRST NAME MIDDLE 1 2 31 INITIAL STREET F� CITY S7 ZIP 2 NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED a INTERLOCKYEs No INTERLOCKYEs No YES No $❑ LLIICENSE# STATE SEX'.U MMDDYY -=-[__________� 1 1 2 32 9 ON DUTY STATUS AIRBAG 9 RESTR 9 EJECT 1 H USEE7 9 CLASS 0 NATURE OF INJURIES 2 3� 10� PICATF it UNKNOWN STATE Wm TRAILER 11 3 0 PLATE#FTRAILER STATE PLATE# STATE FROM To rRtR rRtR 5 1 33 12 3 0 VIN#' VIN# FROM TO 13 4 VEH.YEAR MAKE UNKN MODEL UNKNO STYLE VEHICLE TOWED jtlJlrNO2fBLIN TOWED BY GOVT.VEHIICLNOF✓ 3 7 34 ❑ REGISTERED OWNER INFO UNKNOWN IIIL—llll VEHICiLE c�NO. 'II 1 J�jSHADE IN DAMAGED AREA ❑ 35 14 LIABILITY INSURANCE❑ NSURANCE CO 4 IN EFFECT &POLICY# 9TOP v""L' CHARGE i 5 ❑ 36 E L,Y YES❑NO❑ CITATION# 10 ftOTTOM 15❑ s—1Hc a i 6 UNIT 02 MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE VEHICLE CYCLE: OWNER YES NO 16� LAST NAME VANN FIRST NAME SADE MIDDLE M INITIAL 17❑ STREET El 27238 212TH AVE SE CITY MAPLE VALLEY ST', WA ZIP 98038 5 NEW ADDRESS ❑ 37 18❑ CDL IGNITION REQUIRED IGNITION pRESEIJT MEDfCALTRANSPORTED ❑ 38 W7ERLOCKvB No INTERLOCkCvEs no ves No,� 19 DRIVER'# ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SET CLASS 1 NATURE of INJURIES 40 ❑21❑ PLATE 41 CDX3176 TATE,WA VIN# 2GNFLFEK6E6344095 4 TRAILER TRAILER ❑22 PLATE# STATE PLATE STATE 42 23 43 TRLR RLR VIN#. '[N#, 2014 CHEV EQUINOX SV TOWED BY Go HI 44 VEH.YEAR MAKE MODEL STYLE DAMIAGE TOWED NOO✓ BLIN YES NO 24 REGISTERED OWNER INFO SADE VANN 272382127H AVE SE MAPLE VALLEY WA 98038 VEHICLE NO.2 SHADE IN DAMAGED AREA LIABILITY INSURANCE INSURANCE CO E 3 4 IN EFFECT &POLICY# 4TOP - 5 VEHICLE ❑ 1— CITATION# CHARGE tOBOTTQM L-ALLY YES NC[:] 25= s 6 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY 26 HANSEN HSU I i 12651 WA0171300 PART A . PAGE 01 OF 9000-345-159(R 11(181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. ED76224 COLLISION REPORT III III III III III 111 1591972 CASE# 23-07528 ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY) '.NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE SEXi D.O.B. - MMDDYYYY PASSENGER❑WITNESS❑;UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURECFINJURIES POS. ' USE CLASS 1 ----� :NAME (LAST FIRST MIDDLE INITIAL) ADDRESS&PHONE# SEX D.O.B. - MMDDYYYY PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURECFINJURIES POS. USE CLASS ----� :NAME (LOST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE# SEX MMDDYY D.O.B. YY PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES ❑ ❑ POS. I USE CLASS NARRATIVE Unit 1 traveling north along 1150 Sunset Blvd NE. Unit 2 entering traffic from private drive off east entrance of 1150 Sunset Blvd NE. Unit 1 side swipes the front of Unit 2, causing non disabling non reportable damage to the front of Unit 2, stripping the front license plate off Unit 2. Unit 1 does not remain on scene and continues driving east on Sunset Blvd NE. No actionable information for Unit 1 or Unit 1 driver. No injuries reported. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. HANSEN HSU 07-03-23 01:06 AM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE C.TOLLIVER 10540 1 7/3/2023 6:34:13 PM BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 12:05 AM TIME POLICE ARRIVED 12:18 AM PART B 3000-845.160(R1Vt8) PAGE 0 OF F3 REPORT NO. ED76224 CASE# 23-07528 DATE AND TIME 07/02/2323:55 OF COLLISION E-i kc�tel- sloftl e lm*ftl o t o b s e ry e d PAGE 3 OF 3