HomeMy WebLinkAbout23-04981 a POLICETRAFFic" II I f I) 11I1ll(111(111l If( f 11 REPORT NO. ED56955 170
27
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE$# 23-04981 z 0 5
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4200 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF 02 OBJECT 1 1 8 28
UNITS
RESERVATION I STRUCK
2
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 05 - 1-- 2023 1756 17 =.= S IN 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 3RD ST BLOCK NO. e✓ 2500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FMILES EET e S ❑ E e EDMONDS AV NE
2 0 29
MOTOR ✓ PEDAL- DAMAGETHRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES ✓NO D:3609958947 0 1 30
6 LAST NAME BLANKENSHIP FIRSTNAME SHIANNE MIDDLE R 1 1 2 31
INITIAL
STREET ❑✓ 5215 S MEAD ST TTLE WA
NEW ADDRESS ST 21P 98116 2 CITY SEA
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/iNTERLOCKYEs NO INTERLOCKYEs Z/NO YES �No /
LRIIVER # STATE WA SEX'F MM D Y' 12
8❑ - 14 - 2000 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� BV60796 sTArI WAvIN# JF1 VA2Z6XH9836935
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 3 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 4 2017 SUBA WRX SD DAMAGE YES NO YES[:] NO✓
REGISTEREDOWNERINFO DEREK ANDERSON 5215 S MEAD ST SEATTLE WA98118 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
❑ ❑ INSURANCE CO 2 _3 __
14 LIABILITY INSURANCE NONE
IN EFFECT M:
POLICY# 1 9TOP 5
vewcLE CHARGE 10 BOTTOM 36
LEGALLY YES No CITATION# 3A0044271,3A0044271 OP MOT VEH W/OUT INSURANCE,
15❑ STANDING 8 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2064609310
16 a
LAST NAME ROSAS VARGAS FIRST NAME PEDRO MIDDLE J
INITIAL
17❑ STREET ❑', 626 INDEX AVE NE CITY RENTON ST WA ZIP 980563709 37
NEW ADDRESS
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVERS
# STATE WA SEX M Mr D.O.B. 03 _ 31 1998 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BOX2452 TAre WA VIN1 1GNDT13S742289942
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23 43
TRLR RLR
VIN#. 'IN#.
VEH YEAR 2004 MAKE CHEV MODEL TRAILBL STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4 DAMAGE YES NO YES NO
REGISTERED OWNER INFO PEDRO ROSAS VARGAS 626 INDEXAVE NE RENTON WA 98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO PROGRESSIVE 934119453IN 1UQI
VE"LE ❑ ,J� CITATION# CHARGEYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED56955
COLLISION REPORT III III III III III 111
1591972 CASE# 23-04981
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) FILER VALERIE
(LAST FIRST,
ADDRESS&PHONE# D.0
.B.
5215 S MEAD ST SEATTLE WA 98118 SEXi F MMDDYyry 11 - 24 - 2019
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑, 1 POS, 7 2 10 1 USE CLASS 11
NAME
(LAST,FIRST,MIDDLE INITIAL) BATRES BATRES ROSA V
ADDRESS&PHONE# DOB
24620 RUSSELL RD APT N204 KENT WA 980324912 SEX F MMDDYY,Y 02 _ 02 _ 1993
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 2 POS 3 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. _
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Driver Unit 1 fails to yield right of way making right lane change. Unit 1 and Unit 2 both traveling
westbound along 2500 block of NE 3rd St. Unit 1 makes lane change, from left to right into Unit 2's
lane causing reportable non disabling rear passenger side damage to Unit 1 and non disabling front
driver side damage to Unit 2. No injuries. Unit 1 driver cited for failure to yield ROW and no proof of
valid insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 05-02-23 07:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 5/4/2023 3:37.06 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED 6:22 PM TIME POLICE ARRIVED 6:28 PM
PART B PAGE IT]OF 3�
REPORT NO. ED56955 CASE# 23-04981 DATE AND TIME 05/02/2317:56
OF COLLISION
NOT TO SCALE
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