HomeMy WebLinkAbout25-4668 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF98482OLCERA
COLLISION REPORT 1591971
INTERSTATE CITY STREET FIRE I
CASE# 25-4668 2
RESULTEDSTOLENSTATE ROUTE OTHER VEHICLE LOCCODICENC'Y 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#
eDCL s on' 05 - 28 - 2025 1930 17 =.= S 8 W e OF IN e 1070 s
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SUNSET BLVD NE BLOCK NO.
❑
MILE POST e
4a
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 1. FEET e S 8 W e 1405 ON RAMP
0 4 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2534484602 0 1 30
6❑ LAST NAME SOULIERE FIRST NAME TRYSTAN MIDDLE M 1 2 31
INITIAL
STREET ] 10934 SE 254TH PL F305 CITY; KENT ST I WA Zip; 98030 2
NEW ADDRESS
7❑ +CDL IGNITION REQUIRED IGNITION ENT MEDICAL TRANSPORTED 3
INTERLOCKYES Z/No INTERLOCKYePRES Na�/ YES NoF,/
8 DCIENSE# STATE WA SEXI M MMDDYY' 08 — 22 — 2002 1 2 32
9 ON DUTY STATUS' AIRBAG 4 RESTR 4 EJECT 1 NELM USEET 2 CLASSY',1 NATURE of INJURIES 2
LICENSE, CSG4736 STATE WA VIN#; 3G1BE6SM8HS512213 3
10 Fq I as ATP rt
TRAILER STATE TRAILER STATE ROM To 11 0 0 PLATE# PLATE#
TRLR TRLR. 7 1 1 33
12 0 0 VIN#' VIN#
FROM TO
LE
13 1 VEH.YEAR 2017 MAKE CHEV MODEL CRUZE STYLE SW VEHICLE TO YED NO fiS46LIN diW9YMEYER GESr`-IVT ENp 1 5 34
DAMAGE IIII._IIII I_I
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE RED 1
SHADE IN DAMAGED AREA 35
3 LIABILITY INSURANCE INSURANCE CO 2
14 DIRECT AUTO 2028424361
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE t 5 36
Lemur YES❑NO❑ CITATION# 70¢OTTOM
15❑ sTANowc s 7 a
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE nWNFR D:2536703521
16�
LAST NAME SAND FIRST NAME JORDAN MIDDLE' A
INITIAL
17 F1 STREET ❑
❑ 13001 SE 305TH PL CITY AUBURN ST, WA ZIP 98092 q 37
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED' 38
INTERLOCKYEs No INTERLOCK YES No YEs No
19 DRIVERS STATE WA SEX F D.os. 12 13 1999 � 39
LICENSE# MMDDYY —
20❑ ON DUTY STATUS AIRBAG 1 RESTR 4 EJECT 1 H U ET 2 INJU 6Y 1 NATURE OF INJURIES 40
CLA
21 LICENSE I PATE# CKW6178 TATE I WA VIN# WBAVC53548FZ82395 41
22❑ [TILER TAILER
PLATE# STATE PLATE# STATE 42
23 TRLR RLR 43
UIN#. 'IN#
VEH.YEAR 200$ MAKE BMW MODEL 32$ STYLE SD VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO NO
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE
NQ.2
SHADFY DAMAGED AREA
3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# 9TOP
YEmaE CHARGE
EEGAEY YES❑ N`L] CITATION 11
t080TTOM
25 a e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
BRYAN GROZAV 12489 WA0171300
PAGE 01 OF
PART A 3000-345-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF98482
COLLISION REPORT III III III III III 111
1591972 CASE# 25-4668
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 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
Unit one was merging onto i405 on ramp and failed to yield to oncoming traffic. There was a non-
obstructed yield sign posted at the location. Unit two was traveling south on Sunset Blvd NE when
unit one pulled in front causing the crash. No injuries reported. Unit one was towed due to the curtain
airbags being deployed. Unit two was able to driveaway and only sustained minor front-end damage.
Unit one had had valid insurance while into two did not. No other passengers involved.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
BRYAN GROZAV 05-29-25 01:16 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 6/6/2025 8:46:08 PM
BADGE OR ID# 12489 ORI# WA0171300 TIME POLICE DISPATCHED 1 7:35 PM TIME POLICE ARRIVED i 7:41 Pry
PAST B 3 Da-345,aas(txIMR) PAGE 2�OF F3
REPORT NO. E F98482 CASE# 25-4668 DATE AND TIME 05/28/25 19:30
OF COLLISION
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