HomeMy WebLinkAbout25-3090 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF80149OLCERA
COLLISION REPORT 1591971
CASE#I 25-3090 2
INTERSTATE CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL A`GENC'Y 4250 3
COUNTY RD NVOLVED CODING
PRIVATE WAY
2❑ TOTAL 1
TRIBAL UNITS#OF 03 SO BJECT TRUCK 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E E IN
GoulsloN' 04 - 06 - 2025 1214 17 =.�� S W OF 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
MONSTER RD SW BLOCK NO. e 500 .�
4a❑ MILE POST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FEET e✓ S 8 W e BEACON COALMINE RD
0 1 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:9373138138 0 9 30
6 LAST NAME NAVDEEP FIRST NAME MIDDLE t 0 1 31
INITIAL
STREET ❑✓ 21428 INTERNATIONAL BLVD APT C202 CITY SEATAC ST WA ZIP 98198 2
NEW ADDRESS
7 CDL IGNITIQN REQUIRED IGNITION PRESENT MEflICAL TRANSPORTED 3
INTERLOCKYEs NO✓ INTERLOCKYEs NO✓ YES D NO✓
8❑ LICIENS# STATE WA SEX M MMDr YY' 08 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET INJURY
CLASS 1 NAruRE of INJURIES 2
LICENSE, CPW2596 STATE WA VIN# 3VWEB7BU8LM043086 3
10[9� as ATP rt
11[-j- TRAILER STATE TRAILER ,STATE
11 3 5 PLATE# PLATE# FROM TO
rRLR TRLR 5 1 33
12 3 5 vIN# vIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE 9 9 34
13 2 2020 YOLK JETTA SD DAMAGE YES�NO ✓� YES NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ABILITY INSURANCE INSURANCE CO DAIRYLAND 11409822040 3 4
IN EFFECT &POLICY# 4TOP _
srg NOLNG Yes❑NO❑ CITATION# 5A0399256 CHARGE FOLLOW VEHICLE TOO CLOSELY s o ooTrob 36
15
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT 02 Q ❑ PEDESTRIAN ❑ D:2534879614
VEHICLE CYCLE OWNER YES✓ NO
16�
LAST NAME FROZ FIRST NAME HAROON MIDDLE'
INITIAL
STREET II��II ❑
17 NEW ADDRESS ':1r 1 2201 S JACKSON ST APT C406 CITY SEATTLE ST, WA ZIP 98144 37
1 g❑ IGNITION REQUIRED IGNITION PRESENT MEDIOAL TRANSPORTED' ❑ 38
CDL INTERLOCKYES NO✓ INTERLOCK YES NO✓ YEs Na!✓
19[� DRIVER'S STATE WA SEXI M D.O.B. 02 01 1983 39
LICENSE# MMDDYY —
HELMET INJURY' NATURE OF INJURIES 40
LATE
20❑ ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21 LICEN� CLH8716 rare WA vIN# JTDKN3DU8F1926657 41
22❑ PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2015 MAKE TOYT MODEL PR/US STYLE I-IB VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSURANCECO STATE FARM 4850896-A26.47A-001
IN EFFECT &POLICY# 9TOP
HICL
LIAIL YES� NCO CITATION# CHARGE t080TTOM
VEE
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
R.ONISHI 5738 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EF80149
COLLISION REPORT III III III III III 111
1591972 CASE# 25-3090
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — [----------�
MMDDYYYY
PASSENGER F-1 WITNESS Ej UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES--�
POS. USE CLASS
'NAME
(LAST FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — L----------�
MMDDYYYY
PASSENGER DWITNESSD UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. — L----------�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS �____ ----j
NARRATIVE
Unknown large truck northbound on Monster Rd SW, stopped in roadway waiting for traffic to clear so
it could turn onto westbound Beacon Coal Mine Road. Unit 3, described only as a black SUV,
stopped in roadway behind truck. Unit 2 stopped behind unit 3. Unit 1 also northbound on Monster Rd
SW. Unit 1 struck back of unit 2, front of unit 2 struck back end of unit 3. Unit 3 drove away without
making attempt to exchange information. Driver 1 Navdeep told me that he had recently had his car's
brakes repaired, but that they failed to stop him in time when he tried to stop behind unit 2. Unit 1
suffered relatively minor damage to right front bumper and clip. Unit 2 suffered minor rear end
damage, but heavy front end damage. Unknown extent of damage to unit 3. Photos taken and
uploaded into Evidence.com.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ON/SH/ 04-06-25 02:02 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 4/6/2025 3:30:29 PM
BADGE OR ID# 5738 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 12:17 pM TIME POLICE ARRIVED 12:27 PM
PART IS 3aaa-345-,aa(R11Y1s) PAGE 27OF 47
SUPPLEMENTAL REPORT NO. EF80149
POLICE TRAFFIC
1 1 8 27
µ ^'� COLLISION REPORT CASE#+ 25-3090
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.
GWUR NAME IF� NO NUMBER
SOURCE AXLES 1:1 +
4a ❑ ADDITIONAL UNITS
,µ MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
UNIT# ' 3 PEDESTRIAN �', YES NO
5 VEHICLE CYCLE OWNER F,/
0 9 29
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET 30
NEW ADDRFS. : 'I TY SEATTLE ST ZIP
6 2 PRESENT MEDICALTANSPORTED 1 2 31
CDL IGNITION {GNi710N + .
INTERLOCK YREQUIRED ES. NO INTERLOCK YEs NOLI YES NO[_]
DRIVER'S STATE SEX U MmDDDYBYY —F-1—
LICENSE;
7
ON DUTY STATUS: AIRBAG 9 RESTR. 9 EJECT 1 HELMET 9 INJURY 0 NATUREDFINJURIES
USE CLASS
8 ❑ #LICENSE vtN 1 32
PLATE# rAr
9 TRAILER TRAILER 2
PLATE#r STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 3 5 VEH.YEAR MAKE MODEL STYLE UT VEHICLE TOWE E T ABLIN TOWED BY GOVT.VFHICI F FROM TO
DAMAGE YES NO 1,/l
REGISTERED OWNER INFO.UNKNOWN SEATTLE 9 9 33
12 � SHADE IN DAMAGED AREA
4 FROM TO
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# iGQO
m 34
13 ❑ v...... YES NO CITATION# CHARGE
`e Ly
sTnNoimc � �
MOTOR PEDAL_ ' PROPERTY DAMAGE THRESHOLD MET PHONE ❑ 35
14 ❑ UNIT# VEHICLE CYCLE PEDESTRIAN OWNER YES NO E:i
15 LAST NAME FIRST NAME INITIAL E
❑ 36
16 ❑ STREET CITY ST ZIP
NEW ADDRESS"
GDL IGNITION REQUIRED .IGNITION PRESENT MEl7'CALTANSPORTED
INTERLOCK YES NO INTERLOCK YES NO .YES NO.
17 E
37
LICENSE# STATE SEX MD,O _=
18 ❑
HELMET NJURY NATURE OF INJURIES 38
ON DUTY STATUS AIRBAG RESTR. EJECT USE GLASS
19 ❑ ❑ 39
LICENSE viN
PLATE# rAT #
20 ❑ TRAILER TRAILER ❑ 40
PLATE#, STATE PLATE,# STATE
21 ❑ TRLR TRLR [441
VIN#�. VIN#i
42
22 VEH.YEAR MAKE I MODEL I STYLE VEHICLE TOWED DUE T SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO. SHADE IN DAMAGED AREA 43
2 3 4
LIABILITY INSURANCE[—] INSURANCE CO
IN EFFECT &POLICY# t.K-99
44
vEHic�F ❑ ❑ CITATION# CHARGE 24 ITGA VES NOSTWN3 3 6
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 04-06-25 02:02 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
7D# ORI APPROVED
126 BADGE
5738 # WA0171300 SKLTN 46120 PAGE 0OF
0-345-013(R 11l18)
REPORT NO. EF80149 CASE# 25-3090 DATE AND TIME 04/06/25 12:14
OF COLLISION
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