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HomeMy WebLinkAbout24-7977 )STATE
TFcN 0 5 27i t
Oc� RA EF02468
COLLISION REPRT 1591971
CASE# 24-7977 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCCO AGENCY. 4200 3
COUNTY RD NVOLVED CODING
2❑ TOTAL 1
PRIVATE WAY
TRIBAL UNITS#OF 02 SO BJECT TRUCK 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
GDLLISION' 07 - 29 - 2024 1736 17 =.= S 8 W E IN OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION [Z NON INTERSECTION ❑
NE SUNSET BLVD BLOCK NO.
❑
MILE POST e
4a
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 �. FEET H S 8 W e KIRKLAND AV NE
0 1 29
MOTtlR PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE' ❑ YES Vl NO D:2063277801 0 1 30
5 LAST NAME JOHNSON-HERRING FIRST NAME JAILEN MIDDLE K 1 2 31
INITIAL
STREET ❑ 3101 NE 18TH ST APT 3 CITY RENTON ST I WA I Zip 9805632 66 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYEs NOR] INTERLOCKYEs No�/ YES NoF,/
8 LICIENS# STATE WA SEX M MMOCSYY' 07 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET INJURY
CLASS 1 NAruRE of INJURIES 2
10 LI ENSE BXG8804 STATE WA VN# 2C3CDXCT8JH143991 3
11[—j— TRAILER STATE TRAILER ..STATE ROM TO
11 3 0 PLATE# PLATE#
TRLR TRLR 1 5 33
12 3 5 VIN#' vI.
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN GOVT VEHICLE 7 $ 34
13 4 201$ DODG CHARG SD DAMAGE YES ✓ NOIMW{� RS Yes❑ No
REGISTERED OWNER INFO JAILENJOHNSON-HERRING 3101 NE 18TH STAPT 3 RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4 LIABILITY INSURANCE INSURANCE CO 4
14 GEICO 4130025762
IN EFFECT &POLICY# 9TOP
vEH ' CHARGE t 5 36
IALL� yes❑NO❑ CITATION# 70 80TTOM
15❑ sTnNowc s 7 e
MOTCYR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHIC6E CYCLE' ❑ ❑ nWNFR YES,/ No D:4259225055
16�
LAST NAME AYOUB FIRST NAME RICHARD MIDDLE I E
17 F1 INITIAL I
STREET ❑ 37
'NEW ADDRESS❑ 3907 NE 11TH CT CITY I RENTON ST, WA ZIP 980563558
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 38
INTERLOCKYEs No�/ INTERLOCKYEs 0N-S/ll vEs No
19 DRIVER' # STATE WA SEX M MMDDYv 07 13 1978 ❑ 39
HELMET INJURY' NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21 LICENSEBKE7450 TATE WA VIN# 1HGCR2F39FA126068 41
22❑ [TILER AILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2015 MAKE HOND MODEL ACCORD STYLE SD VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
24 DAMAGE YE
s�/ NO GENE MEYER YES No
REGISTERED OWNER INFO RICHARD AYOUB 3907 NE 11TH CT RENTONWA98056 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSURANCE CO WA INS 4883404DO147B
IN EFFECT &POLICY# 4TOP
vemae ❑ CITATION11 CHARGE t080TTOM
LecnLLy YES N J
25 e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EF02468
COLLISION REPORT III III III III III 111
1591972 CASE# 24-7977
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — [----------�
MMDDYYYY
PASSENGER F-1 WITNESS El UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES--�
POS. USE CLASS
'NAME
(LAST FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — L----------�
MMDDYYYY
PASSENGER DWITNESSD UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. — L----------�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS �____ ----j
NARRATIVE
Unit 1 traveling south on Kirkland Av NE at the intersection of NE Sunset Blvd. Unit 2 traveling east
on NE Sunset Blvd at intersection of Kirkland Av NE. Unit 1 failed to yield right of way through heavy
traffic. Unit 1 driver proximate cause of collision. Unit 1 sustains disabling reportable front passenger
damage. Unit 2 sustains reportable disabling front end damage. No injuries. Both vehicles privately
impounded.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 07-29-24 08:08 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 8/5/2024 2:22:13 PM
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 5:37 PM TIME POLICE ARRIVED 5:37 PM
PART IS 3 Da-3m5-,aa(R11ras) PAGE 27 OF 37
REPORT NO. EF02468 CASE# 24-7977 DATE AND TIME 07/29/24 17:36
OF COLLISION
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