HomeMy WebLinkAbout22-13926 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 22-13926 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 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: 12 - 1-— 2022 0957 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE CARR RD BLOCK NO. e✓ 10600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FMILES EET e S ❑ E e 106TH PL SE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2067129647 0 11
30
6� LAST NAME TAAMU FIRSTNAME TAUAVEAVE MIDDLE N 1 2 31
INITIAL
STREET ❑, 4702 DAVIS AVE S APT DO104 CITY RENTON ST WA ZIP 980556256 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ DRIVERS
E#
ON DUTY❑ STATUS' AIRBAG 3 RESTR 9 EJECT 1 H U EET CLASS 6 SORE CHEST INJURIES z❑
3
LICENSE CAP6830 STATE WA VIN# 1FMCU9GD2HUD90601
10 9❑ Pr ATF�
TRAILER STATE TRAILER STATE
11 3 5 PLATE# I PLATE# I I FROM TO
TRLR. RLR 1 3 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 3 ] 34
13 2 2017 FORD ESCAPE UT DAMAGE YES NO � �MEYER TOWING YES[:] No
REGISTERED OWNER INFO TAUAVEAVE TAAMU 4702 DAVIS AVE S APT DD104 RENTON WA 98055 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14� LIABILITY INSURANCE INSURANCE COAMERICAN FAMILY INSURANCE 41085-71844.98
IN EFFECT &POLICY# 9TOP
VE"'CLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:4253068990
16 a
LAST NAME ALEXANDER FIRST NAME CHANELL MIDDLE
INITIAL
17❑ STREET �', 28011 316TH WAY SE CITY RAVENSDALE ST WA ZIP 98051 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YES❑NOF
19[—] LDI IVE STATE WA SEX U M D.C.B. 03 _ 25 _ 2002 0 39
WELMET INJURY 6 NATURE OF INJURIES 40
20 F1 ON DUTY[:I]
STATUS AIRBAG,2 RESTR 4 EJECT 1 USE CLASS SORE NECK
21❑ LICENSE I C14001X TATe WA VIN1i 3C6UR5S18MG576780
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2021 MAKE DODG MODEL RAM 2500 STYLE pK I VEHICLE TOWED TO BLIN TOWED eY GOV HI 44
24 DAMAGE YES NO BANKERS TOWING YES No
REGISTERED OWNER INFO STEVEN ALEXANDER 28011316TH WAY SE RAVENSDALE WA 98051 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#ECO STATE FARM 3874712 F1847GIN 5VEHICLELLY ❑ ,.IICITATION# CHARGE25 C�Q
LEGA YES N`LJ
s � a
7JEE
S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED20618
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13926
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) TAAMU MATALAS/F
(LAST FIRST,
ADDRESS&PHONE#
4702 DAVIS AVE S APT DD-104 RENTON WA 98055 2067129647 SEXi F MMDDYyry 10 - 13 - 1962
{� SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER Z WITNESS❑1 UNIT# 1 POS. 13 AIRBAG 3 RESTR. 9 EJECT 1 USE CLASS 6 SORE CHEST
NAME
(LAST,FIRST,MIDDLE INITIAL) t VALLEJO JULIANNA M
ADDRESS&PHONE# D O B
18716 109TH LN SE RENTON WA 98055 5092953130 SEX: F MMODYvvv 05 _ 30 _ 2000
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER ZWITNESSO UNIT# 2 POS 3 AIRBAG'2 RESTR. 4 EJECT 1 USE CLASS 1 6 SORE KNEES
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS.WITNESS UNIT# SEAT AIRBAG RESTR. USE CLASS ----�
NARRATIVE'
Vehicle #1 was facing south, preparing to turn left out of a parking lot on the north side of the 10600
block of SE Carr Rd. Vehicle #2 was traveling westbound on SE Carr Rd, approaching 106th PI SE.
Vehicle #1 turned out onto the roadway, directly in front of vehicle #2. The driver of vehicle #2 stated
she swerved to the left to try to avoid colliding with vehicle #1, but was unable to avoid the collision.
The front left corner of vehicle #1 collided with the front end of vehicle #2. Based on the totality of the
circumstances, it appears vehicle #1 caused this collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 12-31-22 01:21 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 12/31/2022 3:14:36 PM
BADGE OR ID# 11631 OR]#' > WA0171300 TIME POLICE DISPATCHED 10:02 AM TIME POLICE ARRIVED',10:07 AM
FART I PAGE IT]OF 3�
REPORT NO. ED20618 CASE# 22-13926 DATE AND TIME 12/31/22 09:57
OF COLLISION
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