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HomeMy WebLinkAbout25-6945 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG28203OLCERA COLLISION REPORT 1591971 INTERSTATE CITY STREET El CASE# 25-6945 2 STATE ROUTE OTHER LOCAL-A`NG 42QQ 3 C©DIN6COUNTY RD PRIVATE WAY 2❑ TRIBAL UN TS#OF 03 OBJESTRUCT 1 1 8 28 TREE OR STUMP i RESERVATION : 1 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# eaCL s on' 08 - 10 - 2025 1306 17 =.= S 8 W e IN OF e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ BLOMAPLE VALLEY HWY MILE POST e 15000 .� 4a❑ MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 MILES 1.1 FEET e S 8 W e 1 9 29 MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:4254963625 0 7 30 5 LAST NAME PEDROZA PEDROZA FIRST NAME ROBERTO MIDDLE 1 1 1 31 INITIAL STREET ❑✓ 14032 SE 192ND ST CITY; RENTON ST WA ZIP; 98056 2 NEW ADDRESS 7� +CDL IGNITION REQUIRED IGNITION PRESENT MEDIQAL TRANSPORTED' 3 INTERLOCKYES NO✓ INTERLOCK VEs No✓ YES NO✓ 8 DCIENSE# STATE WA SEXI M MMDOYY' 05 - 01 - 1987 1 2 32 9 ON DUTY STATUS' AIRBAG 2 RESTR 2 EJECT 1 HELMET 2 CLASSY 1 [NATURE of INJURIES 2 LICENSE, CPD3487 STATE WA VIN#; 1HGCM66544A029994 3 10 Fl I as ATP rt TRAILER 11 4 0 STATE TRAILER STATE ROM To PLATE# PLATE# TRLR TRLR 7 1 3 33 12 4 0 VIN#' vIN# FROM TO VEH.YEAR 2004 MAKE HOND MODEL ACCOR STYLE SD VEHICLE TOWED TO pLS�46LIN 1nwEn B.Y YES VEHICLE 9 9 34 13 DAMAGE YES ✓ NO II_I YSt1V YES NO✓ REGISTERED OWNER INFO ROBERTO PEDROZA PEDROZA 14032 SE 192ND ST RENTON WA 98056 D:4254963625 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35 14 LIABILITY INSURANCE❑ INSURANCE CO "13IN EFFECT &POLICY#srgNOLNG ❑ ❑ 5A0517402 CHARGE OP MOT VEH W/OUT INSURANCEs 36 Yes NO CITATION# 15 MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT VEHICLE CYCLE nWNFR D:4253064818 16� LAST NAME LEE FIRST NAME LEI MIDDLE C INITIAL 17 F1 STREET ❑ 19444 SE 168TH ST CITY RENTON ST, WA ZIP 98058 37 NEW ADDRESS I I I I I 1 ❑ 1$❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38 INTERLOCKYES No✓ INTERLOCI£YES xz ✓ YEs NO'✓ 19 DRIVER'S STATE WA SEXI F I D.co,s. 04 09 1961 39 LICENSE# MMD6YY — HELMET INJURY: NATURE OF INJURIES 40 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS 1 ❑ 21 LICENSLATE E WDCTG4EB2KU016846 TATe WA vIN# 41 El 22❑ PLATE# STATE PLAAILER TE# STATE 42 23 TRLR r RLR 43 UIN#. 'IN# VEH.YEAR 2019 MAKE MERZ MODEL GLA_ STYLE VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES NO VES NO✓ REGISTERED OWNER INFO LEI LEE 19444 SE 168TH ST RENTON WA 98058 D:4253064818 VEHICLE NO.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE INSURANCE CO STATE FARM 556 1837-C13.47A IN EFFECT &POLICY# 1 STOP LVEHICLE '—LY YES N C[] CITATION# CHARGE to BOTTOM LEGALL 25 s ' s OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 K.LANE 10008 WA0171300 PART A PAGE 01 OF 3000-348-189(R 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. EG28203 COLLISION REPORT III III III III III 111 1591972 CASE# 25-6945 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 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 2 was stopped in traffic back from a traffic signal at 152nd AVE SE, on eastbound Maple Valley HWY in the 15100 blk. Unit 1 was either stopped behind, or coming to a stop behind Unit 2 also on eastbound Maple Valley HWY in the 15100 blk. Driver 1 states that his vehicle sustained a mechanical malfunction which caused it to accelerate without any input. The front end of Unit 1 struck the rear end of Unit 2 causing minor damage to Unit 2. Driver 1 states that the malfunction prevented him from putting the vehicle in park, and he could only select reverse. Upon being put into reverse, Unit 1 accelerated heavily westbound (facing eastbound) in the eastbound lanes of Maple Valley HWY. Unit 1 was now approaching Unit 3 which was traveling eastbound on Maple Valley HWY. In an attempt to avoid a collision, driver 1 stated he steered Unit 1 into the woods on the south side of the roadway. Driver 3, also fearing a collision, took evasive action which resulted in the front passenger wheel striking the south curb of Maple Valley HWY. The mechanical malfunction could not be verified. Unit 1 was towed by Ipsen tow, called by driver 1 prior to police arrival. Driver 1 advised he did not have insurance for his vehicle. Driver 1 was cited for operating a motor vehicle without insurance. **** AUTO-POPULATED SECTION **** THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER": Motor Vehicle Unit 1 Action Code: STOPPED, CLAIMS OF UNINTENDED ACCEL. **** END OF AUTO-POPULATED SECTION **** I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. K.LANE 08-12-25 07:39 AM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE C.JACOBS 1953 911012025 2:06:44 PM BADGE OR ID# j 10008 ORI# WA0171300 TIME POLICE DISPATCHED 1 1:08 PM TIME POLICE ARRIVED i 1:44 Pry PART B 3 Da-3mx—attar(txIMR) PAGE 2�OF 4 SUPPLEMENTAL REPORT No. EG28203 POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 25-6945 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 ❑ UNIT{ MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 �T 3 VEHICLE CYCLE C) PEDESTRIAN :.. OWNER YES NO D:2069199444 0 6 29 LAST NAME GUST FIRST NAME CHARLES MIDDLE. M INITIAL STREET 30 NEW ADnRFG 2833 CASCADIA AVE S CITY SEATTLE I ST WA ZIP I 1 98144 6 ❑ 1 1 2 31 CDL IGNITION REZ7UIRED IGNITION PRESENT MECiICALTAN^�PORTED INTERLOCK YES O NO�/ ;INTERLOCK YES NOZ DRIVER'S D.O B 2 LICENSE.: ' STATE WA SEX M MMDDvvY 03 - 31 - 1965 7 ON DUTY STATUS AIRBAG 2 RESTR. 4 EJECT 9 HELMET 2 INJURY 1 NAruREofINJURIEs USE ;CLASS 8 ❑ 1 32 LICENSE.:CMG TAT WA uiN 3FMTK4SX5PMA64126 PLATE# 9 � TRAILER TRAILER L PLATE# STATE PLATE# STATE 0 10 ❑ TRLR TRLR VIN.# VIN#. 11 4 0 VEH.YEAR2023 MAKE FORD MODELMUSTAN STYLE VEHICLE TOWE E T ABLIN TOWED BY GovT.vFHICI E FROM TO DAMAGE YES NO ✓ YES NO CHARLES GUST 2833 CASCADIA AVE S SEATTLE WA 98144 D:2069199444 7 3 33 REGISTERED OWNER INFO. SHADE IN DAMAGED AREA 12 4 FROM TO INSURANCE CO LIABILITY INSURANCE _CO CA0573041 IN EFFECT &POLICY# 1 }TOP 5 m 34 13 ❑ V"'�E YES NO[jj CITATION# CHARGE 10 NOTTOM ecauv sTnNL MOTOR PEDAL_ ' 1:1PROPERTY : DAMAGE THRESHOLD MET PHONE 35 14 ❑ UNIT# VEHICLE CYCLE PEDESTRIAN OWNER YES NO 36 15 LAST NAME FIRST NAME NIT AL 16 ❑ STREET �' CITY ST ZIP NEW ADDRFS9 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED. INTERLOCK YES NO INTERLOCK YES No :YES NO' ❑ 17 37 LLIICENSE# STATE SEX MD owY - C----� 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 PLATE# - STATE ❑ 21 ❑ TRLR TRLR 41 VIN# VIN#:' 42 22 VEH.YEAR MAKE I MODEL I STYLE 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# 7c;Q S. 44 vewc�e ❑ ❑ CITATION# CHARGE 24 I..TF_ YES NO STIWDING 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. K.LANE 08-12-25 07:39 AM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 BADGE 1 OR DD# 10008 O#RI WA0171300 APJACOBS 9110/2025 PAGE OF � 3000-345-013(R 11/18) REPORT NO. EG28203 CASE# 25-6945 DATE AND TIME 08/10/2513:06 OF COLLISION i 7 � t v jY i a $ � u r t k s Y +�z i £2t kn n ca t � n PAGE 4 OF 4