HomeMy WebLinkAbout24-7732 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-7732 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 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# ❑
cowsloN 07 - 1-- 2024 0731 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 43RD ST BLOCK NO. e✓ 100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 400 00 FMILES EET e S ❑ E e EAST VALLEYRD
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2065664239 0 11
30
6� LAST NAME SKACHKO FIRSTNAME TETIANA MIDDLE 1 2 31
INITIAL
STREET ❑✓ 14300 SE 171 ST WAY J9 CITY RENTON ST WA 21p 98058 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� CKS7073 sTArI WAvIN# JM16M1 U7XE1122831
TRAILER STATE TRAILED STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>;. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 3 2014 MAZE) 323 4D DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 550 1698-E20.47A
IN EFFECT z &POLICY# STOP
15 LE
vEGALLv HICLe 1 5 36
re5�No D CITATION# 4A0559434 CHARGE IMPROPER LANE USAGE I o aorrom
❑ STANDING 8 6
MOTOR PEDAL- 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2064327693
16 a
LAST NAME MOHAMED FIRST NAME ZAMZAM MIDDLE
INITIAL
17❑ STREET , 214065 2ND WAYS CITY' KENT ST WA ZIP 98032 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YES
t l NO
19 LICENSE# STATE WA SEX F M .C... 03 _ 05 _ 1975 39
HELMET I INJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CLD6632 TAre WA VIN# JTMABACA9PA039750
❑ 41
PLATE#
42
22❑ PLATE# STATE TILER PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2023 MAKE TOYT MODEL BX4X STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ABDI HAID 2140652ND WAY S KENT WA 98032 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO GEIC04178-79-88-33IN IUQI
'E""LE ❑ ,J� CITATION# CHARGELEGALLYYES N`L J25
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. EF08328
COLLISION REPORT III III III III III 111
1591972 CASE# 24-7732
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 eastbound in lane 1, 100 block of S 43rd St. Unit 2 eastbound in lane 2, 100 block of S 43rd St.
Unit 1 moved into lane 2, striking unit 2. Driver 1 Skachko told Officer VanderHoek that she attempted
to change lanes, looked right and did not see any traffic, then moved right and ran into unit 2. Driver 2
Mohamed told me that she was travelling eastbound when unit 1 suddenly moved right and hit unit 2.
Skachko cited via complaint for improper lane usage.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 07-23-24 11:02 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 8/25/2024 1:29:53 PM
BADGE OR ID# ( 5738 OR]# WA0171300 TIME POLICE DISPATCHED; 7:33 AM TIME POLICE ARRIVED';7:39 AM
FART I PAGE IT]OF 3�
REPORT NO. EF08328 CASE# 24-7732 DATE AND TIME 07/23/24 07:31
OF COLLISION
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