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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 ., .. tr Itt:x nn ape sq V 5r �. PAGE 3 OF 3