HomeMy WebLinkAbout26-3873 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 26-3873 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION'. 05 - 1-- 2026 0950 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S GRADY WAY BLOCK NO. e✓ 400 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ V\e S GRADYWAY
1 9 29
UNIT 01 MOTOOR � PEDDAL ❑ YESAGE NHORE✓LDMET PHONE O 1 30
6❑ LAST NAME GONZALEZ ROJAS FIRST NAME MANUEL MIDDLE E 1 2 31
INITIAL
STREET ❑ 7544 MARTIN LUTHER KING JR WA APT 501 CITY SEATTLE ST WA ZIP, 981183735 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO I INTERLOCKYEs NO YES NO
8❑ LICENSE# STATE WA SEX'M MD- 09 - 03 - 1983 1 2 32
9 ON DUTY❑ ' AIRBAG 2 RESTR 9 EJECT 1 H USEET CLASS 7 [NATURE OF INJURIES
HEAD AND NECK
STATUS 2❑
3
10 1❑ P1 ATE 14 CTF0427 STATE WA VIN# JTDKN3DU960260277
IT STATE TRAILER STATE
11 0 0 PLATE# I PLATE# I I FROM TO
TRLR. TRLR 9 3 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR N MAKE TOYT MODEL PRIUS STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
DAMAGE YES NO YES[:] NO✓
13❑ REGISTERED OWNER INFO MAN.GONZALEZROJAS13445MARTINLUTHERKINGJRWSEATTLEWA98178 VEHICLE NO. 1
❑ SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE❑ INSURANCE CO NONE 3
IN EFFECT &POLICY# 9TOP
VEIF" CHARGE 36
LEGALLY YEs❑NO CITATION# 6A0119774 OP MOT VEH W/OUT INSURANCE o aorrom
15❑ STAIN,"' 8
UNIT 02 VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES NO OLD MET PHONE
16 a
LAST NAME ZARATE LEON FIRST NAME JUAN MIDDLE D
INITIAL
17❑ STREET ❑', 26630 127TH AVE SE CITY KENT ST WA ZIP 980307959 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19� DCENSE# STATE I WA SEX M M ODY
D.C.B.
O6 �_ 24 1977 El 39
WELMET INJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG,3 RESTR 9 EJECT 1 USE CLASS BOTH ARMS
21❑ LICENSE I CPC0030 TATe WA VIN# 1G1JC1243VM120773
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 1997 MAKE CHEV MODEL CAVALIE STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CAROL WILSON 26630127TH AVE SE KENTWA98030 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# 9TOP 5
VEHICLE YES❑ NC[:] CITATION# 6A0119775,6AO119776 CHARGE DWLS 3RD DEGREE,OP MOT VEH ,o BOTTOM
CA�Y
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
SULIASI TAMAIVENA 12788 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EH04694
COLLISION REPORT III III III III III 111
1591972 CASE# 26-3873
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRS MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
PLEASE SEE OFFICER SI.TAMAIVENA'S CASE SUPP REPORT FOR HIS NARRATIVE.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Action Code: STOPPPED AT THE RED LIGHT
**** 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.
SULIASI TAMAIVENA 05-20-26 10:57 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
D.SKELTON 9139 512112026 3:54:14 AM
BADGE OR ID# 1Y788 ORI# WA0171300 TIME POLICE DISPATCHED! 9:50 AM TIME POLICE ARRIVED 9:57 AM
PART I PAGE IT]OF 3�
REPORT NO. EH04694 CASE# 26-3873 DATE AND TIME 05/20/26 09:50
OF COLLISION
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