HomeMy WebLinkAbout22-13289 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED20661 170
27
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE# 22-13289 z 177
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 12 - 1-- 2022 2153 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK NO.
MAPLE VALEY HWY
e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 100 00 FEET e S ❑ W e BLA/NE DR SE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066838896 0 11
30
6� LAST NAME CABUGON FIRSTNAME JASMIN MIDDLE K 1 2 31
INITIAL
STREET 01 6815 S FIFE ST CITY TACOMA ST WA ZIP 98409 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 P1 ATE 14 AZD6552 srAT WA V N# 1 YVFP80C345N32375
IT STATE TRAILER STATE
11 5 0 PLATE# PLATE# ROM TO
TRLR. TRLR $ 7 33
12 $ 0 VIN#' VIN#'
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 7 $ 34
13 8 2004 MAZD 6 SD DAMAGE YES NO MEYERS YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
8 INSURANCE CO 3 4
14 LIABILITY INSURANCE z STATE FARM
IN EFFECT &POLICY# 9TOP
Ela.e CHARGE to BOTTOM 5 36
LvECALHLv res❑NO❑ CITATION# $
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2065880570
16 a
LAST NAME JEFFERS FIRST NAME SCOTT MIDDLE A
INITIAL
17 STREET NEW ADOREs7 1225 183RD ST SE APT J204 CITY BOTHELL ST WA ZIP 98012 37
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LDI IVER # STATE WA SEX M M D.C.B. 11 12 _ 1995 39
20 ON DUTY STATUS AIRBAG,4 RESTR 4 EJECT 1 HELMET 2 INJURY 7 NATURE OF INJURIES 40
USE CLASS LEGS FEELING NUMB
❑ 41
21❑ PLATE# BWT0269 TATE WA VIN# USE
1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2006 MAKE 7'Oy7' MODEL CORO!! STYLE $D —FEHICLE
TOWED✓ NOO BLIN N/A YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSU POLICY#E CO N/A N/AIN 9TOP 5
VE—LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 =TURNER
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 12650 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED20661
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13289
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'
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.
JASON TURNER 12-16-22 02:08 AM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 12/31/2022 7:06:23 PM
BADGE OR ID# 12650 ORI# WA0171300 TIME POLICE DISPATCHED 9:55 PM TIME POLICE ARRIVED',9:57 PM
PART I PAGE IT]OF 4�
REPORT NO. ED20661 CASE# 22-13289 OF COLLISION
12/15/22 21:53
OF CbLLI510N
NARRATIVE
22-13289
On 12/16/2022 at 2153 hours I was dispatched to an unknown if injury accident located at 2201
Maple Valley Hwy.
The notes on the call stated that it was a two-vehicle collision. One vehicle was blocking the east
bound lane while the other was in the middle turn lane.
The accident was described as follows:
Unit 1:
Driver: Jasmin K. Cabugon DOB:05/04/1997
Vehicle: 2004 Green Mazda 6 WA LIC: AZD6552
Unit 2:
Driver: Scott A. Jeffers
Vehicle: 2006 Silver Toyota Corolla WA LIC: BWT0269
Unit 1 was attempting to make a left turn from Blaine Drive SE to go west on Maple Valley Hwy. Unit
1 attempted to make a left turn into the center turn lane but ended up driving with half her vehicle in
the east bound lane. When asked why, the driver of unit 1 said that her windows were foggy and it
was hard to see. Unit 2 was driving east bound on Maple Valley Hwy in the number 2 lane. Unit 2 saw
that Unit 1 was driving in his lane. Unit 1 attempted to swerve out of the way, but the two vehicles
ended up colliding.
Unit 2 had significant damage to the passenger side of his vehicle. There was an airbag deployment
on the passenger side. Fire was called to the scene and evaluated him.
Unit 1 had significant damage to her front passenger side.
While speaking to the drivers of both vehicles 1 assessed them for intoxication. Utilizing my training
and experience I came to the conclusion that neither driver was intoxicated.
Both vehicles met the damage threshold. I photographed the damage on both vehicles and uploaded
the photos to Evidence.com
I provided both drivers with an exchange of information at the scene.
There is no further information.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electrically signed by Officer J. Turner/ 12650 on 12/16/2022 at 0156 hours in the City of Renton
PAGE 3 OF 4
REPORT NO. ED20661 CASE# 22-13289 DATE AND TIME 12/15/22 21:53
OF COLLISION
Case number 22-13289
N
4.
4
Not drawn to scale.
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