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HomeMy WebLinkAbout24-12664 IT �i " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF49330OLCERA COLLISION REPORT 1591971 CASE# 24-12664 2 INTERSTATE CITY STREET FIRE I RESULTED STATE ROUTE OTHER STOLEN vEwCLE LOCALANG 3 HIT&RUN C©DIN6 COUNTY RD PRIVATE WAY INVOLVED 2 TOTAL#OF OBJECT 1 1 7 28 TRIBAL UNITS 03 STRUCK FENCE i RESERVATION 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# eaCL s on' 12 - 10 - 2024 1200 17 =.= S e W e IN OF e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑ 102ND AVE SE BLOCK NO. ❑ MILE POST e 4a ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 MILES 1.1 FEET e S 8 W e SE 187TH ST 0 1 29 MOTOR PEDAL- DAM AG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2065916794 0 4 30 6 LAST NAME JACKSON FIRST NAME AYR/SS MIDDLE M 1 1 2 31 INITIAL STREET ❑ 18615104THPL SE CITY; RENTON ST WA ZIP 98055 2 NEW ADDRESS 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCKYEs NO Z/ INTERLOCKYES No�/ YEs �NO / 8❑ DRIVER # STATE WA SEXI F MMDDYY' 05 — 30 — 2006 t 1 2 32 9 ON DUTY STATUS' AIRBAG 2 RESTR 9 EJECT 1 HELMET INJURY 6 NATURE OF INJURIES 2 USE CLASS CUT TO UPPER LIP AND SORE RIGHT WRIST 10 LI ENSE', BCM6400 STATE WA vIN# 5NPD84LF2HH028933 3 TRAILER STATE TRAILER STATE ROM To 11 2 5 PLATE# PLATE# TRLR TRLR 5 1 33 12 2 5 VIN#' VIN# FROM TO 13 2 VER YEAR 2017 MAKE HYUN MODEL ELANTR STYLE 4D VEHICLE TOWED NO�iS46LIN Tl� {J RS TOWING YESE] -o�VT VEHICLE 5 7 34 DAMAGE IIII._IIII REGISTERED OWNER INFO CORRINA WELLS 18615 f04TH PL SE RENTON WA 98055 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35 2 LIABILITY INSURANCE INSURANCE CO 4 14 STATE FARM INSURANCE 439 4969-D15-47C 11 IN EFFECT &POLICY# 9TOP t VEHICLE CHARGE S 36 Ec LgLLY YES❑NO❑ CITATION# t a 60TTOM 15❑ sTnNowc s 7 e MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT VEHICLE CYCLE nWNFR D:4252357267 16� LAST NAME BLOMQUIST FIRST NAME STEVEN MIDDLE R INITIAL 17 F1 STREET ❑❑ 10012 SE 187TH ST CITY RENTON ST, WA ZIP 980556330 4 37 NEW ADDRESS 18❑ CDL IGNITION REQUIRED 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'2 RESTR g EJECT 1 USE CLASS 6 SORE LEFT LEG AND CUT TO LEFT SIDE HEAD ❑ 21 LICENSE I PLATE# B59059S TATE I WA vIN# 4TARN81A9RZ221373 41 22❑ PLATE# STATE PLATE# STATE 42 23 TRLR r RLR 43 UIN#. 'IN# TOWED BY GOV HI 44 VEH.YEAR 1994 MAKE TOYT MODEL PU STYLE PK VEHICLE TOWED✓ No BLIN BANKERS TOWING 24 REGISTERED OWNER INFO STEVE BLOMOUIST 10012 SE 187TH ST RENTON WA 98055 VEHICLE NO.2 SHADE IN DAGED AREA 2 4 LIABILITY INSURANCE INSURANCE CO GEICO INSURANCE 4402-93-46.67 IN EFFECT &POLICY# t STOP VEHICLE ❑ ,.I—I CITATION# CHARGE LEGALLY YES N 25 9s ;,Q 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. EF49330 COLLISION REPORT III III III III III 111 1591972 CASE# 24-12664 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 CIASS ----� :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 The driver of vehicle #1 stated she was driving northbound on 102nd Ave SE approaching SE 187th St. She advised the pickup truck (which was vehicle #2) in front of her was using the pull-out on the right side of the road to get turned around. She advised that from what she could remember, this pickup truck pulled out in front of her as soon as she started to drive by it, though she could not remember if it backed out or pulled out forward. She stated that as the pickup truck pulled out, the front right side of her vehicle collided with the pickup truck. The drvier of vehicle #2 stated he was driving northbound on 102nd Ave SE approaching SE 187th St. He advised he normally drives a large trailer, so he is used to taking wide turns, which he said he did when he made this left turn. He stated he wasn't sure where vehicle #1 came from, but it collided with the back left side of his pickup truck. Police checked the neighboring houses for video surveillance to confirm what actually occurred, but no video was availabe. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. JESSE VANDERHOEK 12-10-24 01:44 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE 12/12/2024 8:59:33 AM JESSE VANDERHOEK 11631 BADGE OR ID# 11631 ORI# WA0171300 TIME POLICE DISPATCHED 12:03 PM TIME POLICE ARRIVED i 12:11 PM PAST B 3 Da-3m5—attar(t 1Mff) PAGE 2�OF 4 SUPPLEMENTAL REPORT No. EF49330POLICE TRAFFIC 1 27 ... ^'� COLLISION REPORT CASE# 24-12664 t113197 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE UNIT# USDOT ICC# VEHICLE TYPE CARGO BODY: TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER L ADDRESS CITY ST ZIP 4 ❑ NAME # PLACARD GWVR NAME IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGETHRESHOLD MET PHONE UNIT# 3 PEDESTRIAN YFs No D:2063533389 5 VEHICLE CYCLE OWNER 29 LAST NAME LA POINT FIRST NAME , THEODORE MIDDLE; J INITIAL STREET 30 NEW AnnRF STG 10104 SE 187TH ST UNIT#A CITY RENTON WA ZiP 98055 6 CDL PRESENT MEDICAL TANSPORTEII 1 31 IGNITION REQUIRED 1{iNi7iON INTERLOCK YES NO .INTERLOCK YES 0 N YES N L DRIVER'S STATE SEX M MMIDDYY 12 - 17 - 1965 LICENSE; 7 ON DUTY STATUS AIRBAG RESTR. EJECT HELMET INJURY NAruREofINJURIES USE CLASS 8 ❑ 1 32 LICENSE TAT VIN. PLATE# 9 TRAILER I I TRAILER L PLATE# STATE PLATE# STATE 0 10 ❑ TRLR TRLR VIN.#. VIN#. 11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWE E T ABLIN TOWED BY GOVT.VFHICI F FROM TO DAMAGE YES NO YES NO m 33 REGISTERED OWNER INFO.� SHADE IN DAMAGED AREA 12 LIABILITY INSURANCE❑ INSURANCE CO TOP 4 FROM TO IN EFFECT &POLICY# I ""`-" S m 34 13 YES NO CITATION# CHARGE 1080TTOM ecauv sTnNoiNc MOTOR PEDAL_ ' 1:1PROPERTY : DAMAGE THRESHOLD MET PHONE 35 14 ❑ UNIT# VEHICLE CYCLE PEDESTRIAN OWNER YES NO 36 15 LAST NAME FIRST NAME IN L 16 ❑ STREET �' CITY ST ZIP NEW AODRFS9 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED INTERLOCK YES[]NO INTERLOCK YES NO .YES N. 17 37 LLIICENSE# STATE SEX Moog 18 ❑ ❑ HELMET 'INJURY NATURE OF INJURIES 38 ON DUTY STATUS' AIRBAG RESTR. EJECT USE CLASS. 19 ❑ ❑ 39 LICENSE TAT vIN# PLATE# 20 TRAILER' TRAILER 40 PLATE#, STATE STATE PLATE# - ❑ 21 ❑ TRLR TRLR 41 VIN#�, VIN#: 42 22 VEH.YEAR MAKE I MODEL I STYLE I VEHICLE TOWED DUET ABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO. SHADE IN DAMAC ED AREA 43 2 3 4 LIABILITY INSURANCE INSURANCE CO IN EFFECT I &POLICY# .. ) E 44 24 YES❑ NO CITATION# CHARGE OM SWG 8 3 G 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. JESSE VANDERHOEK 12-10-24 01:44 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 OR Ib# 11631 O#RI WA0171300 APPROVED 12112/202 PAGE OF� 3000-345-013(R 11/18) REPORT NO.; EF49330 CASE# 24-12664 DATE AND TIME 12/10/24 12:00 OF COLLISION �aoro� t Z T k t s � � s T T i t PAGE 4 OF 4