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HomeMy WebLinkAbout24-12008 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c COLLISION REP FIT 1591971 SASE 24-12008 2 INTERSTATE ❑ CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIC;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# ❑ COLLISION.. 11 - 1-— 2024 0730 17 ❑.= S 8 IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ 108TH AVE SE BLOCK NO. e✓ 18800 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 100 00 FEET MILES e S B W e SE 188TH ST 2 0 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El ✓NO D:2063000360 0 11 30 6� LAST NAME STEFFAN FIRSTNAME ROBERT MIDDLE H 1 2 31 INITIAL STREET ❑✓ 13613 SE 266TH ST CITY KENT ST WA 2jp, 98042 z= NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/ 8❑ LRIIVER # ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES z❑ 3 10 9❑ PI ATE 14 842371E STATE WA u N# 2HJYK16348H533735 11[-j- TRAILER STATE TRAILER STATE 11 3 5 PLATE# PLATE# IR.M ro TRLR. TRLR 3 7 33 12 3 5 VIN#j VIN# :: FROM TO VEH.YEAR 2008 HOND RIDGELI PK MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 1 34 13 4 DAMAGE YES No �LII� RS YES[:] No REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 ❑ SHADE IN DAMAGED AREA ❑ 35 14 LIABILI INSURANCE INSURANCE CO PEMCO CA 0628281 3 4 IN EFFECT &POLICY# 9TOP VE"'CLE CHARGE 5 36 LEGALLY YES❑NO❑ CITATION# 10 BOTTOM 15❑ STANDING 6 MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA. YES 1/ NO D:2064991765 16 a LAST NAME GOMEZ MARENTEZ FIRST NAME OVET MIDDLE INITIAL 17❑ NEW STREETR 10562 S 7 E 228TH ST CITY KENT ST WA ZIP 98031 4❑ 37 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL-T�RANSPORTED � 38 INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES t l NOF,/ 19 D IVERI # ❑ ON DUTY STATUS I AIRBAG 1 RESTR 9 EJECT 1 HEJ EET 2 NJAURSY 1 NATURE OF INJURIES 40 ❑ 41 21❑ LICENSE I PLA E# C95012Y TATE WA vIN1 W1Y5ECHY8MT069179 1 42 22❑ PLATE# STATE pLATE# STATE 23❑ VIN#. 43 TRLR RLR 'IN#. Gov HI VEH D YEAR 2021 MAKE MERZ MODEL SPRINTS STYLE CG AMAGE TOWED NOO✓ BLIN TOWED BY 44 fj YES NO 1/ 24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2 SHADEDAMAGEDAREA 3 4 LIABILITY INSURANCE &POINSURGY#E CO STATE FARM 500 2945-CO7-47CIN IULlliKOTlTlfll;0- "'--SVEHICLE ❑ C—I CITATION# CHARGELEGALLY YES N25 7B- NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY J 26 MIN FLICK 12825 WA0171300 PART A PAGE 01 OF C7 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. EF37999 COLLISION REPORT III III III III III 111 1591972 CASE# 24-12008 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 02 was driving northbound in the turn lane preparing to turn left at the next opportunity to so. Unit 01 was driving northbound in the lane next to the turn lane. Unit 01 changed lanes into the turn lane and did not see unit 02 approaching, colliding with the front passenger side bumper area of unit 02. 1 declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Electronically signed by B. Flick 12825 on 11-20-2024 in Renton, WA. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. BENJAMIN FLICK 11-20-24 10:44 AM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE C.JACOBS 1953 1 1112112024 10:08:44 AM BADGE OR ID# 12825 ORI#' WA0171300 TIME POLICE DISPATCHED 7:33 AM TIME POLICE ARRIVED!7:39 AM PART I PAGE IT]OF 3� REPORT NO. EF37999 CASE# ' 24-12008 DATE AND TIME 11/20/24 07:30 OF COLLISION lZi k� y i 4 t i t 1t,sore... t: s Y r ¢ t ' ti � .la SlQ2 1 M i 1 R, PAGE 3 OF 3