HomeMy WebLinkAbout25-80901 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG62817OLCERA
COLLISION REPORT 1591971
INTERSTATE CITY STREET FIRE I
CASE# 25-80901 2
RESULTED STOLENSTATE ROUTE OTHER VEHICLE LOCAI-AGENCY 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 28
TRIBAL UNITS 02 STRUCK
RESERVATION : 1 1
2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
eaCL s on' 12 - 20 - 2025 1830 17 =.[� S 8 W e OF IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NE 12TH ST BLOCK NO. e Y900 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 1. FEET e S 8 W e KIRKLAND AV NE
0 1 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2066839030 0 1 30
5 LAST NAME DIAZ MORAN FIRST NAME MARIELA MIDDLE I3 1 1 2 31
INITIAL
STREET ] 1174 HARRINGTON AVE NE CITY; RENTON ST WA ZIP; 980563079 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YEs No✓ INTERON KVEs NO✓ YEs ND✓
8 DRIVER # STATE WA SEXI F MMDDYY' 10 - 09 - 1992 1 2 32
9 ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 N USE ET CLASSY 1 [NATURE of INJURIES 2
LICENSE, CPA8469 STATE WA VIN# 4S4BRBCC4A3344510 3
10 F PI ATF#
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
TRLR zRLR 5 1 33
12 2 5 VIN#' vIN#
FROM TO
VEH.YEAR 2010 MAKE SUBA MODEL OUTBA STYLE VEHICLE TOWED[n TO ZBLIN TOWEDBY GOVT VEHICLE 3 7 34
13� DAMAGE YES II_II NO YESII_I) NO
REGISTERED OWNER INFO HENRY VILLALOBOS TRIGUEROS 1174 HARRINGTON AVE NE RENTON WA 98056 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
2 3
14 4 LIABILITY INSURANCE El
NSURANCE CO NONE
IN EFFECT &POLICY#
VEHICLE CHARGE 7 0 80TTOM 36
srnNoiNc YES❑NO❑ CITATION# 5A0875567,5A0875567 NO VALID OPER LICENSE WITH
15 s 7 e
MOTCSR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE nWNFR D:2068527542
16�
LAST NAME KISMET FIRST NAME ALEXANDRIA MIDDLE' N
INITIAL
17 F1 STREET ❑❑ 37 4700 35TH AVE S APT 203 CITY SEATTLE ST, WA ZIP 981181764
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICALTRANSPORTED 38
INTERLOCKYES NO✓ INTERLOCK YES R NO✓ YES NO✓
19[� DRIVERS STATE WA SEX,F I D.o.e. 07 24 1991 � 39
LICENSE# MMDDYY —
HELMET INJURY: NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21 LICENSLATE E CSD1214 TATe WA VIN# 1C4AJWAG2HL574254 41
22❑ PLATE# STATE PLATE# STATE E 42
23 TRLR r RLR 43
UIN#. 'IN#
VEH.YEAR 2017 MAKE JEEP MODEL WRANGL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO✓ VES NO✓
REGISTERED OWNER INFO ALEXANDRIA KISMET 9551 RAINIER AVE S APT 410 SEATTLE WA 98118 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE[Z INSURANCE CO FOREMOST INS G01 6000877 00
IN EFFECT &POLICY# 9TOP
vewcLE ❑ ,.I—I CITATION CHARGE OUR,
EEGnEEY YES N
25 s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-348-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG62817
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80901
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 GLASS 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 1 traveling northboun on Kirkland Av NE at intersection of NE 12th St. Unit 2 traveling westbound
on NE 12th St at intersection to Kirkland Av NE. Both drivers reported that neither stopped fully at
four way intersection with marked stop signs. Unit 2 strikes Unit 1 causing reportable non disabling
damage to the rear passenger side of Unit 1 and non reportable non disabling front end damage to
Unit 2. Unit 1 driver was cited for no insurance and no valid operator license with valid ID. No
injuries reported.
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 12-20-25 07:23 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
M.BRAUN 2194 1 12/26/2025 12:20:14 AM
BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 1 6:33 PM TIME POLICE ARRIVED i 6:36 PM
PART B a Da-3mx-attar(t 1Mff) PAGE 2�OF F3
REPORT NO. EG62817 CASE# 25-80901 DATE AND TIME 12/20/2518:30
OF COLLISION
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