HomeMy WebLinkAbout25-6343 T �Fi II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG16646POLICER�
COLLISION REPORT 1591971
CASE# 25-6343 2
INTERSTATE CITY STREET❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL AGENCY 4200 3
COUNTY RD PRIVATE WAY ❑✓ INVOLVED CODING
2❑ TRIBAL TOTAL 1
UNITS#OF 02 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
GoulsloN' 07 - 23 - 2025 2025 17 =.= S 8 W E IN OF M 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
NE SUNSET BLVD BLOCK ST e 4411 .=
4a❑ MILE POST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 1❑ 50 1.1 00 FEET e S 8 W ✓ ANACORTES AVE NE
IF51
29
MOTOR PEDAL- DAMAG THRESHOLD MET PHON
UNIT 01 E
VEHICLE ❑ CYCLE ❑ YES No �/ D:2067471543 1 1 30
5 LAST NAME SOUZA FIRST NAME ROBERT MIDDLE M 1 2 31
INITIAL
STREET ❑ 1122 E PIKE ST#516
NEW CITY SEATTLE ST WA ZIP; 98122 2
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSP€)RTED 3
INTERLOCKYEs NOW] INTERLOCKYEs N �/ YES F Nor,/
8❑ LICIENS# STATE WA 8EK'U MMor YY' O6 — 25 — 1980 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 N USEET INJURY
CLASS 1 NAruRE of INJURIES 2
LICENSE 3
10� PI ATP rt UNK STATE WA vN# UNK
TRAILER STATE TRAILER ,STATE
11 0 0 PLATE# PLATE# ROM TO
TRLR TRLR Q Q 33
1 0 Q VIN# VIN#
FROM TO
2
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE 5 1
13 UNKN UNK DAMAGE YES NO ✓ YEs_ No 34
REGISTERED OWNER INFO UNKNOWN UNKNOWN SEATTLE WA 98000 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ NSURANCE CO NONE 3 4
IN EFFECT &POLICY#
VEHICLE CHARGE t 5 ❑ 36
ecnur YES❑NO❑ CITATION# 7 0 80TTOM
15❑ owc s e
VEHICLE
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT 02 CYCLE (7WNPR Q ❑ PEDESTRIAN ❑ D:4257617264
YES NO
16�
LAST NAME SHAMKHI FIRST NAME HALAH MIDDLE I H
INITIAL
STREET ❑
17 ' 5❑ 511 NE 13TH PL CITY RENTON ST, Wq ZIP 98059 37
NEW ADDRESS
1g❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDIGALTRANSPORTED. 38
INTERLOCKYES No INTERLOCK YES No ves NO
19[ LICIENSE# STATE SEXj U MMDDYY 06 07 1975 39
HELMET INJURY' NATURE OF INJURIES 40
20❑ ON DUTY❑ STATUS' AIRBAG 2 RESTR 9 EJECT 1 USE CLASS 1 ❑
21 LICENSLATE E CHP9481 TATE WA VIN# WDDHF5KB6FB120045 � 41
22❑ [TILER AILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2015 MAKE MERZ MODEL E CLASS STYLE $D VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO HALAH SHAMKHI 5511 NE 13TH PL RENTON WA 98059 D:4257617264 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSURANCE CO ALLSTATE 979032994
IN EFFECT &POLICY# 9TOP
veHlaE ❑ ,.I—I CITATION11 CHARGE t08OTTOM
LEGALLY YES N J
25 a e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EG16646
COLLISION REPORT III III III III III 111
1591972 CASE# 25-6343
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. - [----------�
MMDDYYYY
PASSENGER F-1 WITNESS El 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
Unit 2 driver reports that Unit 1 was in front of her in the drive thru at the McDonald's at 4411 NE
Sunset Blvd. Unit 1 improperly backs into Unit 2 causing reportable non disabling front passenger
side damage to the headlight and bumper of Unit 2 and unknown non disabling damage to the rear of
Unit 1. Unit 1 driver provides Unit 2 driver with valid identification and phone number. No injuries. Unit
2 driver did not obtain license plate of Unit 1 and reported that it was some sort of large white work
van. Units 1 and 2 both gone from scene prior to police notification.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 07-23-25 10:55 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
8/6/2025 8:17:41 PM
J.CHRISTIANSEN 10437
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 8:28 PM TIME POLICE ARRIVED 9:00 PM
PART B 3aaa-345-,aa(R11Y1s) PAGE 27OF 37
REPORT NO. EG 16646 CASE# 25-6343 DATE AND TIME 07/23/25 20:25
OF COLLISION
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