HomeMy WebLinkAbout26-4010 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE# 26-4010 2 0 5
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AGENCI 4200 3 6 5
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OS STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 05 - 1-- 2026 1300 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 4000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FEET e S ❑ E e UNION AVE NE❑
0 2 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2536049265 0 7 30
6� LAST NAME RIVERA-AYALA FIRSTNAME ERICK MIDDLE 1 2 31
INITIAL
STREET ❑✓ 20927124TH AVE SE CITY KENT ST WA ZIP 98042 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO 1/ I INTERLOCK YES NO YES NO
8 LRIIVERCENS # STATE SEX'M MDMDD 05 - 18 - 2010 1 2 32
9 ON DUTY❑ STATUS AIRBAG 9 RESTR 9 EJECT 1 HELMET USE 2 1 CLAY NATURE OF INJURIES 2❑
3
10❑ P1 aTES� D68235J sTAr� WAvIN# 1FTEXIEPOJKC42886
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE J 9 34
13 4 2018 FORD F150 PK DAMAGE YES NO � �MEYERS ves❑ No✓
REGISTERED OWNER INFO YULISSAALVARADO 2150 M STSE,APT85 AUBURN WA 98002 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
❑ ❑ INSURANCE CO 3 4
14 LIABILITY INSURANCE NONE
IN EFFECT &POLICY# Q
vewcLE CHARGE t5 36
LEGALLY res No CITATION# 6A0215028,6A0215029, RECKLESS DRIVING,RECKLESS
15❑ NDING 6
MOTOR PEDAL- pROpER7y
16 DAM THR OLD M PHONE
UNIT�2 ❑✓ ❑ PEDESTRIAN ❑ ❑ D:2062538218
VEHICLE CYCLE OWNER YES�/ ET NO
a
LAST NAME GORNOWICH FIRST NAME AMANDA MIDDLE
INITIAL
17❑ NEW STREETRE--- 3815 NE 4TH ST#A8 CITY RENTON ST WA ZIP 98056 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 F] DRIVERIS
ON DUTY STATUS AIRBAG,3 RESTR 4 EJECT 1 WEB SET 2 NJAU SY 6 [-�A—TUREOF INJURIES SEATBELT BURN AND AIRBAG 40
❑21❑ PLATE# A9263150 TArE 41
WA VIN# KNDJ53AF4L7059011 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
H 44
I
VEH YEAR 2020 MAKE KIA MODEL SOUL STYLE SD DAM AG rowed ev
24❑ E TOWED✓ NOO BLIN GENE MEYERS YESGov No�/
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE DAGED AREA
4
LIABILITY
INSURANCE I POLICY#E CO VERNFONKIN I STOP 5
VEHICLE CITATION# CHARGE to BOTTOM
LEGALLY YES NC�
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
J.CARSTENSEN 11648 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EHO5604
COLLISION REPORT III III III III III 111
1591972 CASE# 26-4010
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SAR/NANA-CONTRERAS JOSE
(LAST FIRST,
ADDRESS&PHONE#
1660 S 246TH PL DES MO/NES WA 98198 SEX M MMDOYyry 01 - 27 - 2003
PASSENGER Z WITNESS❑ UNIT# 1 Pas 7 AIRBAG'9 RESTR. 9 EJECT ? 1 HELMET INJURY NATURE OF INJURIES
USE 2 CLASS +1
NAME
(LAST,FIRST,MIDDLE INITIAL) HUERTA AYALA XOVANI
ADDRESS&PHONE# D O B
33125 35TH AVE SW FEDERAL WAY WA 98023 SEX/ M MMDDYvvv 04 _ 08 _ 2002
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 1 POS 3 AIRBAG 9 RESTR. 9 EJECT 1 USE 1 2 CLASS 1
NAME MIDDLE INITIAL) VAZQUEZ ABNER
(LAST FIRST,
AooREss&PHONE# 14604 SE 140TH PL RENTON WA 98059 _
SEX M. D.O.B.M -
MDDYYYY
PASSENGER WITNESS UNIT# ! 3 SEAT 7 AIRBAG 2 RESTR. 4 EJECT 1 HELMET 2 INJURY 1 NATURE OF INJURIES
❑ POS. USE CLASS
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.CARSTENSEN 05-24-26 04:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
PHILIP DAVIS 12018 1 5/24/2026 4:20:17 PM
BADGE OR ID# 11648 OR]# WA0171300 TIME POLICE DISPATCHED! 4:00 pry] TIME POLICE ARRIVED',1:05 PM
PART I PAGE IT]OF 9�
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EHO5604
COLLISION REPORT III III III III III 111
1591972 CASE# 26-4010
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) VAZQUEZ ELEANOR
(LAST FIRST,
ADDRESS&PHONE# D O.B.
14604 SE 140TH PL RENTON WA 98059 SEX F MMDDYyYv - -
PASSENGER Z WITNESS UNIT# 3 POS. 9 AIRBAG 2 RESTR. 4 EJECT ? 1 HELMET NATURE OF INJURIES
USE 2 CLASS
'1
NAME
(LAST,FIRST,MIDDLE INITIAL) i HOGINS KAYLEE
ADDRESS&PHONE# DOB
RENTON SEX F MMDDYYvv - _
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER Z WITNESS UNIT# 3 pOS 8 AIRBAG 2 RESTR. 4 EJECT 1 USE 2 CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) OMAN REBECCA
AooREss PHONE# 1925 S 116TH ST BURIEN WA 98168 SEXF 11 28 _ 1996
. D.O.B. _
MMDDYYYY
PASSENGER WITNESS UNIT# ! 4 SEAT 1 3 AIRBAG 2 RESTR. 4 EJECT 1 HELMET 2 INJURY 1 NATURE OF INJURIES
❑ POS. USE CLASS ��— ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.CARSTENSEN 05-24-26 04:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
PHILIP DAVIS 12018 1 5/24/2026 4:20:17 PM
BADGE OR ID# 11648 OR]# WA0171300 TIME POLICE DISPATCHED! 4:00 Pm TIME POLICE ARRIVED',1:05 PM
PART I PAGE 3�OF 9�
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EHO5604
COLLISION REPORT III III III III III 111
1591972 CASE# 26-4010
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) OMAN DECLAN
(LAST FIRST,
ADDRESS&PHONE#
1925 S 116TH ST BURIEN WA 98168 SEX M MMDOYyvv 04 - 04 - 2026
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT H USEET 2 CLASS 1 NAruRE of INJURIEs
❑✓ ❑ 4 POS, 11 2 4 1
NAME
(LAST,FIRST,MIDDLE INITIAL) GARCIA ELIZABETH
ADDRESS&PHONE# D O B
4909 NE 7TH PL, RENTON WA 98059 4259700337 SEX F MMDDYvvv O6 _ 27 _ 1999
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS❑ UNIT# 5 POS 3 AIRBAG 2 RESTR. 2 EJECT 1 USE 2 CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) DEMIRKAN HALUK
AooREss&PHONE# 4805772019 _
SEX U. I. -❑
MDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ Z POS. USE CLASS ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.CARSTENSEN 05-24-26 04:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
PHILIP DAVIS 12018 1 5/24/2026 4:20:17 PM
BADGE OR ID# 11648 OR]# WA0171300 TIME POLICE DISPATCHED! 4:00 Pm TIME POLICE ARRIVED',1:05 PM
PART I PAGE 4�OF 9�
REPORT NO. EH05604 CASE# 26-4010 OF COLLISION
05/24/26 13:00
OF CbLLI510N
NARRATIVE
On 5/24/26 at about 1300 hours I was working uniformed patrol in my unmarked patrol vehicle when I
was dispatched to a collision at NE 4th ST/ Union Ave NE in the City of Renton, King County, WA.
I contacted the witness, Haluk Demirkan, who relayed the following:
Haluk was driving eastbound on NE 4th ST approaching Union Ave NE. He was behind Unit 2 and
witnessed the entire crash. Haluk saw Unit 1 weaving between cars from lane to lane, and speeding
while driving eastbound on NE 4th ST, approaching Unit 2. He saw Unit 1 try to change lanes to the
middle turn lane, which caused Unit 1 to hit Unit 2 and Unit 3. He then saw Unit 1 unable to stop in
time and run into Unit 5.
Police contacted the driver of Unit 1, who was identified by his Kentridge High School ID Card, Erick
Rivera-Ayala (DOB: 5/18/2010), and he relayed the following:
Unit 1 was driving eastbound on NE 4th ST, approaching Union Ave NE. Unit 1 wanted to make the
left turn at Union Ave NE. Unit 1 moved over into the middle turn lane and collided with Unit 2. This
caused damage to the front right side of Unit 2. Unit 1 then collided with the back of Unit 5. Unit 1
does not have insurance.
I contacted Unit 2, who was identified by her WADL, and she relayed the following:
Unit 2 was traveling eastbound on NE 4th ST towards Union Ave NE. Unit 2 was in the middle lane,
waiting to turn left into the 7/11 parking lot. All of a sudden, Unit 2 was hit, causing the right two tires
to lift off the ground. The car leaned towards the driver side on the left two tires before coming back
down. Unit 2 did not see who hit them. There was damage to the front right and front end of Unit 2.
1 contacted Unit 3, who was identified by her WADL, and she relayed the following:
Unit 3 was traveling eastbound on NE 4th ST, approaching Union Ave NE. Unit 3 was in the left lane.
All of a sudden, Unit 3 was struck from behind. This pushed Unit 3 into the back of Unit 4. Unit 3 didn't
see who hit her. There was damage to the rear and front of Unit 3.
Unit 4 was contacted, who relayed the following:
Unit 4 was traveling eastbound on NE 4th ST, approaching Union Ave NE. Unit 4 was in the left lane.
All of a sudden, Unit 4 was struck from behind. Unit 4 then pulled over into the nearby parking lot.
Unit 4 had minor damage to the back end.
I contacted Unit 5, who was identified by his WADL, and he relayed the following:
Unit 5 was driving eastbound on NE 4th ST, approaching Union Ave NE in the left lane. Unit 5 was
possibly slowing down for a yellow light at Union Ave NE. Unit 5 was hit from behind and pushed
forwards multiple car lengths. Unit 5 was extreme damage to the rear end, pushing the entire trunk
towards the cab. Unit 5 remembers the collision, hitting the brake, and continuing to move forward.
I looked at a large pile of broken glass, which appeared to come from the rear window of Unit 5. It
appears that is where Unit 5 was hit from behind. I estimate it to be about 15-20 yards from the
stopping point.
All parties were checked out by Renton Fire on scene.
I gave all parties a business card with the case number.
Units 1, 2, and 5 were towed away.
By driving his vehicle in willful or wanton disregard for the safety of persons or property, Erick Rivera-
Ayala (DOB: 5/18/2010) committed the crime of Reckless Driving.
PAGE 5 OF 9
REPORT NO. EH05604 CASE# 26-4010 OF COLLISION
05/24/26 13:00
OF CbLLI510N
NARRATIVE
By driving recklessly, where he crashed with such speed and force that he pushed another vehicle 15
-20 yards, completely totaling Unit 5, and putting the occupants of Unit 1 at risk of being seriously
injured, Erick Rivera-Ayala (DOB: 5/18/2010) committed the crime of Reckless Endangerment.
Citation 6AO215028 and 6AO215029 were forwarded to the Prosecutor's Office for Review.
Infraction #6A0215030 was sent via Court Mail to Unit 1 for No Insurance, Failure To Yield Right of
Way When Changing Lanes, No Valid Operating License- With ID, Too Fast For Conditions.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing information provided by me is true and correct.
Electronically signed: J. Carstensen #11648
PAGE 6 OF 9
SUPPLEMENTAL REPORT NO. EH055604
r`I POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 26-4010
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USL70r !CC# VEHICLE TYPE CARGO BODY
TYPE
2 ❑ 1 1 8 28
CARRIER
NAME
3 CARRIER
ADDRESS `❑
CITY ST' ZIP'
4 ❑ NAME # PLACARD: :❑
GI NAME IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 3 VEHICLE tSJ CYCLE I_) PEDESTRIAN � OWNER �I YES✓ NO
D:2066029209
0 1 29
LAST NAME RUIZ DURAN FIRST NAME LOIDA MIDDLE
INITIAL
0 1 30
STREET
NFW AnDRFSP 14604 SE 140TH PL CITY RENTON ST WA ZIP 98059
6 [2 1 1 2 31
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED
INTERLOCK YEs NO✓ zERLOCK YEs❑NO❑✓ YES N ✓
DRIVER'S
LICENSE STATE I WA SEX F MMDDYYv 02 - 13 - 1991
7 ❑ ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 1 2 32
LICENSE CKM2822 TAr WA VIN# 1N4BZOCPXHC300667
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 TRLR TRLR
VIN.#. VIN.#.
11 3 5 VEH.YEAR MAKE MODEL STYLE VEHICLE TOME E T SABLIN TOWED BY anvi vEH1O F FROM TO
2017 NISS LEAF S/ SD DAMAGE YES NO ✓ YES NO ✓
REGISTERED OWNER INFOLOIDA RUIZDURAN 14604 SE 140TH PL RENTONWA 98059 D:2066029209 ] $ 33
12 3 5 SHADE IN DAMAGED AREA
4 FROM TO
LIABILITY INSURANCE INSURANCE CO STATE FARM 5856399-801.47 TOP
IN EFFECT &POLICY# 7 3
vewcLe 10 BOTTOM 34
4 ❑ ❑ CITATION# CHARGE
13 �Fcnuv YES NO gg�@ g�
STANDING a Q
DAMAGE THRESHOLD MET PHONE ❑ 35
14 UNIT# 4 MOTOR ❑✓ PEDAL- ❑ PEDESTRIAN ❑ PROPERTY ❑ YES NO
VEHICLE CYCLE OWNER ✓ D:2069407069
OMAN MARK MIDDLE
❑ 36
15
LAST NAME FIRST NAME INITIAL
2 STREET
16 ❑ ❑; 1925 S 116TH ST CITY BURIEN ST WA ZIP 98168
NFn+AnntxFss
CDL IGNITION REOUIREE7 IGNITION PRESENT MEDICALTANSPGRTED
17 ❑ INTERLOCK YEs NO✓ INTERLOCK YEs NC7✓ YES
No�/ ❑
DRIVER'S D.O.B 4 37
LICENSE# STATE WA SEX M MMDDyYY' 09 - 20 - 1992
18 ❑
ON DUTY❑ STATUS' AIRBAG 2 RESTR, 4 EJECT 1 1 HELMET 2 INJURY 1 NATURE OF INJURIES 38
19
USE CLASS
❑ ❑
LICENSE
CTE9772 TAr WA v!N# 1HGCY2F81SA046059 3 39
20 ❑ TRAILER' STATE TRAILER ST 40
PLATE#< PLATE# ATE
21 ❑ ❑ 41
TRLR TRLR
ViN# YIN#i
42
22 VEH.YEAR2O25 MAKE HOND MODEL ACCOR STYLE SD VEHICLE TOWED DUET SABLIN TOWED BY GOVT.VEHICLE 1
DAMAGE YES NO ✓ YES NO ✓
23 ❑ REGISTERED OWNER INFO OWNED BYDRIVER SHADE IN DAMAGED AREA 43
z s
LIABILITY INSURANCE IN INSURANCE CO GEIC04617-44-30-82 9'1'OP
❑ EEFFECT &POLICY# 44
VEHICLE LE ALE YES[:] NO❑ CITATION CHARGE iq BOTTOMLEGALLY
E:l
STANDING 8 7
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J-CARSTENSEN 05-24-26 04:09 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
26 ❑ ',ORID# 11648 O#I',WA0171300 APPROVED
DAVISBY 5/24/2026 PAGE F71OFF
3000-345-013(R 11118)
SUPPLEMENTAL REPORT NO. EH055604
r`I POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 26-4010
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USL70r !CC# VEHICLE TYPE CARGO BODY
TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST' ZIP'
4 ❑ NAME # PLACARD: :❑
GI NAME IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 5 VEHICLE tSJ CYCLE I_) PEDESTRIAN � OWNER � YES� NO
D:2532616019
0 1 29
LAST NAME CARIVEAU FIRST NAME : COLTON MIDDLE
INITIAL
STREET 30
NEW AnDRFSP' 4909 NE 7TH PL CITY RENTON ST WA ZIP 98059
6 ❑ 1 1 2 31
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED
INTERLOCK YEs NO zERLOCK YES❑N0� YES N
DRIVER'S
LICENSE STATE I WA SEX M MMDDYYv 07 - O6 - 1999
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE I CEP4271 [TAT WA VIN# 1ZVFT80N675272803
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 3 5 VEH.YEAR2007 MAKE FORD MODELMUSTAN STYLE SD I VEHICLE TOWE E T SABLIN TOWED BY anvi vEH1C P FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFO COLTON CARIVEAU4909 NE 7TH PL RENTON WA 98059 D:2532616019 ] $ 33
12 � SHADE IN DAMAGED AREA
7 FROM TO
LIABILITY INSURANCE INSURANCE CO TRAVELERS 943386911.101 2
IN EFFECT &POLICY# 1 4 TLSP
LEGA LE 34
CITATION CHARGE 100QT1Y)M
13 LEGALLY YES NO
STANDING �}
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME INITIAL
❑ 36
STREET
16 NEW An F]% CITY ST ZIP
CDL IGNITION REdUiRED IGNITION PRESENT MEDICALTANSPORTED
INTERLOCK YES No INTERLOCK YEs NO YES NO ❑
17 4 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE CLASS
19 ❑ LICENSE TAT VIN# 39
PLATE#
20 ❑ TRAILER TRAILER El40
PLATE#< STATE PLATE# STATE
21 ❑ ❑ 41
TRLR TRLR
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
3 4 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J-CARSTENSEN 05-24-26 04:09 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 OR ID# 11648 O#II,WA0171300 DAVIS 5/24/2026 PAGE OF
3000-345-013(R 11118)
REPORT NO. EH05604 CASE# ' 26-4010 DATE AND TIME 05/24/26 13:00
OF COLLISION
At4
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PAGE 9 OF 9