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HomeMy WebLinkAbout24-10862 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF26063OLCERA COLLISION REPORT 1591971 CASE# 24-10862 2 INTERSTATE CITY STREET FIRE I RESULTEDSTOLENSTATE ROUTE OTHER VEHICLE LdCAI-A`NG 4200 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 TOTAL#OF OBJECT 1 s 28 TRIBAL UNITS 02 STRUCK RESERVATION : 1 1 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# eOCL s on' 10 - 18 - 2024 1355 17 =.= S 8 W e OF IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ SE PETROVITSKY RD BLOCK NO. e 10900 .� 4a❑ MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 C------�.� FEET e S B W 2 0 29 MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:4253991246 0 1 30 5 LAST NAME HELM FIRST NAME RANDY MIDDLE L 1 1 2 31 INITIAL STREET ❑✓ 1232 E MARINE VIEW DR CITY; EVERETT I ST WA ZIP; 98201 2 NEW ADDRESS 7 +CDL IGN(TIUN REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED'. 3 INTERLOCKYES NO✓ INTERLOCKYES Na✓ YES NO✓ 8❑ DCIENSE# STATE WA SEXI M MMDDYY' 04 - 16 - 1983 1 2 32 9 ON DUTY STATUS' AIRBAG 2 RE 9 EJECT 1 N USE CLASSY 1 [NATURE of INJURIES 2 10Fq I aiCENSE BNN8807 STATE WA VIN# 1GCWGFCAlC1194923 3� TRAILER 11 3 5 STATE TRAILER STATE PLATE# PLATE# ROM To TRLR rRLR 7 1 3 33 12 3 5 VIN# vIN# FROM TO VEH.YEAR 2012 MAKE CHEV MODEL G STYLE UT V Y EHICLE TOWED TO BLIN TOWED By GOVT V 7 $ EHICLE 34 13� DAMAGE YES II_II NO ✓ YESII_I) NO✓ REGISTERED OWNER INFO MARK YOUNG 11111131ST AVE SE SNOHOMISH WA 98290 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35 2 3 4 2 LIABILITY INSURANCE INSURANCE CO 14 NATIONAL FIRE 8 MARINE INSURANCE COMPANY 72 APB 009756 IN EFFECT &POLICY# 4TOP vEnic�E CHARGE t 5 36 Lemur YES❑NO❑ CITATION# 7 0 80TTOM 15❑ STM ING 7 e MOTOR ✓ PEDAL- PEDESTRIAN1:1 PROPERTY DAM THR OLD MET PHONE UNIT 02 VEHICLE CYCLE nWNFR YES�/ NO D:4259022500 16� LAST NAME PRITCHOW FIRST NAME DAN MIDDLE L INITIAL STREET I�I ❑ 17 2807 S HANFORD ST CITY SEATTLE ST, WA ZIP 98188 q 37 NEW ADDRESS 18❑ CDL IGNITION REDUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38 INTERLOCKYES No✓ INTERLOCK YES NO✓ YES NO✓ 19 DRIVER'S ' MMDDYY — HELMET INJURY NATURE OF INJURIES 40 20❑ ON DUTY� STATUS AIRBAG 4 RESTR g EJECT 1 USE CLASS 1 ❑ 21 LICENSECJP6504 rare WA vIN# JM1BL1MP2D1813594 41 PLATE#22❑ [TILER TAILER PLATE# STATE PLATE# STATE 42 43 23 VfN RLR UIN#. 'IN# VEH.YEAR 201$ MAKE MAZD MODEL MAZDA3 STYLE I-IB VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES NO✓ VES NO✓ REGISTERED OWNER INFO DAN PRITCHOW 2807 S HANFORD ST APT 6-D SEATTLE WA 98188 VEHICLE NO.2 SHADE DA GWREA LIABILITY INSURANCE[Z INSURANCE CO PROGRESSIVE INSURANCE 987692431 AAA IN EFFECT &POLICY# 9TOP LY—ve ❑ ,J—I CITATION# CHARGE 7060TTOM EEGnE YES N`[ 25 a 7 e OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY J 26 JESSE VANDERHOEK 11631 WA0171300 PAGE 01 OF PART A 3000-345-189(R 11/18) STATE OF POLICETRAFFICN CORRECTION REPORT NO. EF26063 COLLISION REPORT III III III III III 111 1591972 CASE# 24-10862 ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY) '.NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE SEXi D.O.B. — MMDDYYYY PASSENGERQ WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ; HELMET INJURY NATURE OF INJURIES 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 Vehicle #1 was traveling eastbound in the outside lane of the 10900 block of SE Petrovitsky Rd. Vehicle #2 was traveling eastbound in the inside lane of the 10900 block of SE Petrovitsky Rd. The driver of vehicle #1 advised he intended to enter the center turn lane and started to merge left toward this lane. This caused the front left corner of vehicle #1 to collide with the right side of vehicle #2. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. JESSE VANDERHOEK 10-18-24 04:36 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE D.SKELTON 9139 10/19/2024 3:47:34 AM BADGE OR ID# j 11631 ORI# WA0171300 TIME POLICE DISPATCHED 1 2:02 Pry TIME POLICE ARRIVED i 2:44 Pry PAST B 3 Da-3mx—attar(t 1Mff) PAGE 2�OF F3 REPORT NO. EF26063 CASE# 24-10862 DATE AND TIME 10/18/2413:55 OF COLLISION ;> r , r Y 1 's� t 4t i l$ �1 N � � vt u� t i u t, f l$ t a t x . PAGE 3 OF 3