HomeMy WebLinkAbout23-3963 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-3963 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4250 3
HIT&RUN ✓ CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT ❑2$
TRIBAL UNITS 02 STRUCK' FIRE HYDRANT
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
GawsloN 04 - 08 - 2023 0304 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RAINIER AVE S BLOCK NO. e✓ 200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e S 2ND ST
1 9 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElDESA✓NHORESHOLD MET PHONE 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST ZIP z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES NO YES No
DRIVERS
STATE SEX D '❑- 328 LICENSE MMDYY❑
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H USEEr 9 CLAY 0 NATURE OF INJURIES z❑
3
10❑ P1 ATNES# AYV0182 sTAT WAv N# VNKKTUD31FA042389
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# IR.. ro
TRLR. A'RLR. 1 5 33
12❑ VIN#j VIN#
Rom 34
13❑ VEH.YEAR2015 MAKE TOYT MODEL YARIS STYLE SD VEHICLE TOWED0NOOffBLIN TSIgWgYMEYER v�s❑ENO✓
DAMAGE IILLJJII (��IV6
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILIT INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
IC VENLE CHARGE 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
UNIT 02 VE IOOR ❑ CYCLE ❑ PEDESTRIAN ❑ PROPE OWNFRRTY ✓❑ DYES✓ NO�TFIRrIOLDMET PHONE
16❑
LAST NAME RENTON FIRST NAME CITY OF MIDDLE
INITIAL
17❑ NEW STREETREs7 1055 S GRADY WAY CITY' RENTON ST WA ZIP 98057 37
18❑ CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 DRIVEW # STATE SEX IX M .C.B. 01 01 194 0 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TATE vIN# 41
`1
PLATE#
42
22 [TRAILER TILER
❑ PLATE# STATE pLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO IGQVE""LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.ARNOLD 12509 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED56945
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3963
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,FIRST 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'
On 04/08/2023 at 0306 hours I was dispatched to a single vehicle collision involving Vehicle 1 and a
fire hydrant. When I arrived on scene, I observed that Vehicle 1 was unoccupied and appears to have
been traveling Southbound on Rainier Ave S. Vehicle 1 has significant front end damage and the fire
hydrant was completely removed from its original spot.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.ARNOLD 04-08-23 03:54 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1 5/4/2023 3:19:25 AM
BADGE OR ID# 12509 OR]# WA0171300 TIME POLICE DISPATCHED 3:06 AM TIME POLICE ARRIVED 3:11 AM
PART I PAGE IT]OF 3�
REPORT NO. EU56045 CASE# 23-3063 DATE AND TIME 04/08/2303:04
RainierOF COLLISION
-NOT TO SCALE
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