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HomeMy WebLinkAbout26-1266 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG79873OLCERA Xr, j COLLISION REPORT 1591971 INTERSTATE CITY STREET FIRE I CASE# 26-1266 2 RESULTED STOLENSTATE ROUTE OTHER VEHICLE LOL`CODIOENC'Y 4100 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# DATE OF N E IN eDLLISION' 02 - 13 - 2026 16?5 17 =.= S 8 W E OF M 1070 a 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION BLO❑ MAPLE VALLEY HWY MILE POST e 1800 .� 4a❑ MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5 �. FEET e S 8 W e PRIV DRIVE 1820 MVH 0 1 29 MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:9176539859 0 4 30 5 LAST NAME NIKIEIENKO FIRST NAME MYKOLA MIDDLE t 1 2 31 INITIAL STREET ❑ 16948 SE 183RD PL CITY; RENTON ST WA ZIP; 980588812 2 NEW ADDRESS 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED' 3 INTERLOCKYEs No✓ INTERLOCKVEs NO✓ YES NO✓ 8 DCIENSE# STATE WA SEXI M MMDDYY' 05 - 22 - 1982 1 2 32 9� ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 N USEET CLA SY'? NATURE of INJURIES 2= 10 PI ENSttEI D94449G STATE WA V 5FPYK3F13MB008011 3 TRAI STATE TRAILER LE STATE 11 3 5 ,LATE# PLATE# FROM To TRLR TRLR 3 7 33 12 3 5 VIN# vIN# FROM TO VEH.YEAR ZO21 MAKE yOND MODEL RIDGELI STYLE VEHICLE TOWED[n TO ZBLIN TOWED BY GOVT VEHICLE 7 1 34 13� DAMAGE YES II_II NO YESII_I) NO✓ REGISTERED OWNER INFO MYKOLA NIKIEIENKO 16948SE 183RD PL RENTON WA 98058 VEHICLE NO. 1 SHADE IN DAMAGED AREA 35 4 LIABILITY INSURANCE INSURANCE CO 4 14 PROGRESSIVE 861471452 IN EFFECT &POLICY# 9TOP VEn" CHARGE 5 I < 36 Lec Ly YES❑NO❑ CITATION# t a 80TTOM 15❑ STM ING 7 e MOTCYR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT 02 VEHICLE CYCLE nWNFR YES�/ NO D:2064712505 16� LAST NAME HARRISON FIRST NAME PERCELL MIDDLE L INITIAL STREET ❑ 37 17 ❑ 16504 139TH AVE E CITY PUYALLUP ST, WA ZIP 983749591 NEW ADDRESS 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38 INTERLOCKYEs N©✓ [NTERLOCKYEs No✓ vEs No✓ 19 DRIVER'S MMIDDYYJ I — HELMET INJURY: NATURE OF INJURIES 40 20❑ ON DUTY� STATUS AIRBAG 2 RESTR 4 EJECT '1 7 ❑ USE CLASS COMPLAINT OF INJURY NOT SPEC 21 LICENSE C21218T rare WA vIN# 1GBOGRFPXK1211051 41 22❑ PLATE# STATE PLATE# STATE 42 23 TRLR RLR 43 UIN#. 'IN# VEH.YEAR 2019 MAKE CHEV MODEL BOX STYLE VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES NO VES NO✓ REGISTERED OWNER INFO SUPERIOR FIRE AND ELECTRICAL 1804 S MALLARD WAY ELLENSBURG WA 98926 VEHICLE NO.2 SHADE IN DAGED AREA 2 4 LIABILITY INSURANCE INSURANCECO STATE FARM 4411121E1147B IN EFFECT &POLICY# 9TOP ve w1— ❑ ,.I—I CITATION11 CHARGE to BOTTOM L','—�Y YES N 25 a e OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 HANSEN HSU 12651 WA0171300 PAGE 01 OF PART A 3000-345-189(R 11/18) STATE OF POLICETRAFFICN CORRECTION REPORT NO. EG79873 COLLISION REPORT III III III III III 111 1591972 CASE# 26-1266 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 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 1 traveling westbound along 1800 block of Maple Valley Hwy approaching the intersection leading into the Mizu restaurant parking lot at 1820 Maple Valley Hwy. Unit 2 making left turn at intersection, west to north at same light. Unit 1 fails to yield ROW at intersection proximate cause of collision, causing reportable disabling front end damage to Unit 1 and reportable non disabling passenger side damage to Unit 2. Unit 2 driver reported undisclosed injury but declined further aid on scene. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. HANSEN HSU 02-13-26 05:06 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE CASEY PROCTER 12123 212212026 10:52:04 AM BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 4:18 Pry] TIME POLICE ARRIVED i 4:Y7 PM PAST B 3 Da-lmx—attar(t 1Mff) PAGE 2�OF F3 REPORT NO. EG79873 CASE# 26-1266 DATE AND TIME 02/13/2616:15 OF COLLISION 1 T ,q trc� 3 \ a 4 4 1' �1 . Yh» � F$ 5 sdV� ov,n`c t � s ,�S �t 4nl �'w�rk,3�aa PAGE 3 OF 3