HomeMy WebLinkAbout24-12949 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF49147OLCERA
COLLISION REPORT 1591971
CASE# 24-12949 2
INTERSTATE CITY STREET FIRE I
RESULTEDSTOLENSTATE ROUTE OTHER VEHICLE LOCAI-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#
DATE OF N E
COLLISION' 12 - 19 - 2024 1040 17 =.= S 8 W e OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE 172ND ST BLOCK NO. e 12200 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 80 1.1 00 FEET e✓ S 8 E e 122ND AVE SE
1 5 29
MOTOR PEDAL- DAMAG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES No �/ D:2407011226 1 3 30
6 LAST NAME ALEM FIRST NAME TEGISTI MIDDLE G 1 1 2 31
INITIAL
STREET ❑ 1124 HARRINGTON AVE NE 202 CITY; RENTON ST I WA ZIP; 98056 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYEs NO✓ INTERLOCKYEs N ✓ YES NO✓
8 DRIVER' # STATE WA SEXI F MMDDYY' 01 - 01 - 1990 32
9 ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 N U EET CLASSY 1 NATURE of INJURIES 2=
10 LI ENSE', BYN8685 STATE WA V IN# KMHDN55DO3U085412 3
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
TRLR zRLR. 0 0 33
12 0 Q VIN#' VIN#
FROM TO
VEH.YEAR 2003 MAKE HYUN MODEL ELANTR STYLE 4H VEHICLE TOWED[n TO ZBLIN TOWEDBY GOVT VEHICLE m 34
13� DAMAGE YES II_II NO YESII_I) NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
3 4
14❑ LIABILITY INSURANCE NSURANCE CO PROGRESSIVE 948377970
IN EFFECT &POLICY#VEH4TOP
VEHICLE
Yes❑ ❑ 4AO886321 CHARGE INATTENTIVE DRIVING s 000Trom z 36
NO CITATION#
15
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE nWNFR D:4255407048
16❑
LAST NAME VELOSA PARGA FIRST NAME JHOMATHAN MIDDLE'
INITIAL
17 F1 STREET ❑
❑ 2176 TIGER VIEW CT NW 412 CITY /SSAQUAH ST, WA ZIP 98027 37
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDfCAL TRANSPORTED 38
INTERLOCKYEs NO✓ INTERLOCK YES NO✓ YES No✓
19 DRIVERS ' STATE WA SEX M D.0.8. 01 23 1986 � 39
LICENSE# MMDDYY —
HELMET INJURY: NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 9 CLASS 1 ❑
21 LICENSE CNW1731 TATe WA VIN# KMHTC6AD4FU241419 I El 41
22❑ PLATE# STATE PLATE# STATE 42
23 TRLR RLR 43
UIN#. 'IN#
VEH.YEAR 2015 MAKE HYUN MODEL VELOSTE STYLE f;,P VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO NO✓
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE
N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSURANCE CO NATIONAL GENERAL 2023965511
IN EFFECT &POLICY# t STOP
L,EILY YES❑ NJ—I, CITATION11 CHARGE to BOTTOM
"IHIC
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
R.ONISHI 5738 WA0171300
PAGE 01 OF
PART A 3000-348-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF49147
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12949
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 NJURY 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
Unit 1 had just made delivery to 12204 SE 172nd St, and was backing out of driveway. Unit 2 was
about to make a delivery to 12204 SE 172nd St, and was parked across the street facing eastbound.
Unit 1 driver Alem backed into Unit 2, left rear corner of Unit 1 to left side of Unit 2. Cited driver 1
Alem for Inattentive Driving.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 12-19-24 11:42 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1212312024 4:05:36 AM
BADGE OR ID# 5738 ORI# WA0171300 TIME POLICE DISPATCHED 10:45 AM TIME POLICE ARRIVED i 10:51 AM
PAST B 3 Da-3mx—attar(t 1Mff) PAGE 2�OF F3
REPORT NO. EF49147 CASE# 24-12949 DATE AND TIME 12/19/2410:40
OF COLLISION
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