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HomeMy WebLinkAbout24-6982 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
SASE 24-6982 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ H F ❑ LOCAL AOENC 3
HIT IT&RUN � CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 7 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# ❑
C{YLLISION O7 — 03 — 2024 1959 17 ❑.= S 8 W IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
743 RAINIER AVE S BLOCK ST e✓
MILEPOST 700
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:6017203672 1 51
30
6❑ LAST NAME JONES FIRSTNAME QORNELL MIDDLE A 1 2 31
INITIAL
STREET ❑, 14424 SE 40TH ST CITY BELLEVUE ST WA 7jp, 98006 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NOWINTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 09 1— 07 — 1974 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H U SE 9 1 INJURY CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� CBt0991 sTArI WAvIN# JM16K343671741296
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 5 O
13 A 34
2007 MAZE) 3 SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO FREDRICKJONES 14424 SE 40TH ST BELLEVUE WA 98006 D:6017203672 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑
INSURANCE CO 2 3 4
IN EFFECT &POLICY# � 9TOP
VE'CLE CHARGE 36
LEcnLLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STAIN,"' 8 6
UNIT U2 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES NO OLD MET PHONE
16 a
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY BELLEVUE ST ZIP
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YEs❑NO❑
19 LLIICENS RIVEWS# STATE SEX U MMDDYY 39
WELMET 1NJURY NATURE OF INJURIES 40
20❑ ON DUTY❑ STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
21❑ LICENSE I CKJ5062 TAre WA VIN# WAULT68E95A058372
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
TOWED BY Gov HI 44
VEH YEAR 2005 MAKE AUDl MODEL A4 STYLE SD DAMAGE TOWED TOO✓ BLIN YES
NO 1/
24❑ REGISTERED OWNER INFO UNKNOWN BELLEVUE VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO CQl
VE"LE ❑ ,J� CITATION# CHARGE i o
LEGALLY YES N`L J
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
SITIVEN/TAMAIVENA 12812 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE94140
COLLISION REPORT III III III III III 111
1591972 CASE# 24-6982
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 is traveling southbound inside the Walmart parking lot at 743 Rainier Ave S. Unit 1 stated that
Unit 2 was in front of him. Unit 2 then reversed into Unit 1, causing minor damage to the front bumper.
Unit 1 said that Unit 2 stated that he was too close to his vehicle. Unit 1 said he possibly was driving a
stick shift vehicle. Unit 2 then left the scene.
Unit 1 can identify the driver of Unit 2.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
S/TIVENI TAMAIVENA 07-04-24 06:03 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY E
DAT
J.CHRISTIANSEN 10437 7/9/2024 1:26:23 PM
BADGE OR ID# 1Y892 ORI# WA0171300 TIME POLICE DISPATCHED; 8:09 PM TIME POLICE ARRIVED 8:04 PM
PART I PAGE IT]OF
REPORT NO. EE94140 CASE# ' 24-6982 DATE AND TIME 07/03/24 19:59
OF COLLISION
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