HomeMy WebLinkAbout23-503 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE RESULTED ❑ CASE 23-503 z
INTERSTATE CITY STREET FIRE
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 01 - 1-- 2023 1204 17 ❑.❑ S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 2ND ST BLOCK e✓ 700
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 20 00 FMILES N EET e S ❑ E e BURNETT AVE S
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2069997594 0 11
30
6� LAST NAME BRAR FIRSTNAME AMARJEET MIDDLE K 1 1 2 31
INITIAL
STREET ❑ 1128 S 47TH PL CITY RENTON ST WA 21p 980557308 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
LICENSE 369YUA sTATI WA vIN# JM3TB38A880161835
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 2 ZOO8 MAID CX-9 UT DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO GURJOTBRAR1128S47THPL RENTONWA98055 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE USAA GENERAL INDEMNITY INSURANCE 01836 3166 G
IN EFFECT &POLICY# 9TOP
VEHICLe Yes 5 36
LEGALLY
❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:2062933050
LAST NAME KADUSHIN FIRST NAME CLAYTON MIDDLE I D
INITIAL
17❑ STREET ❑', 5147 S LEO ST CITY' SEATTLE ST WA ZIP 981782149 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 D IVE
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 USE CLASS ❑
21❑ LICENSE I C60078S TATE WA vIN# 3(BNFK12317Co141691
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2007 MAKE CHEV MODEL AVALANC STYLE PK VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO✓
REGISTERED OWNER INFO CLAYTON KADUSHIN 5147 S LEO ST SEATTLE WA 98178 VEHICLE NO.2
SHADE DAGED AREA
4
LIABILITY INSURANCE INSU&PORGY#ECO AMERICAN FAMILY INSURANCE 41051-47672-73 1GQI
IN EFFECTVEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`LJ
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED24766
COLLISION REPORT III III III III III 111
1591972 CASE# 23-503
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,FIRS 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'
Vehicle #1 was in lane number 3, traveling westbound in the 700 block of S 2nd St. Vehicle #2 was
in lane number 2, just to the left of vehicle #1, also traveling westbound in the 700 block of S 2nd St.
Vehicle #1 then merged to the left, causing the front left corner of vehicle #1 to collide with the right
side of vehicle #2. It should be noted I was only a few cars ahead of these vehicles at the time of the
collision and witnessed the collision in my rearview mirror. Based on the totality of the
circumstances, it appeared 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 01-13-23 02:31 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 111412023 4:20:28 AM
BADGE OR ID# 11631 OR]# WA0171300 TIME POLICE DISPATCHED; 4Y:04 PM TIME POLICE ARRIVED 12:04 PM
PART I PAGE IT]OF 3�
REPORT NO. ED24766 CASE# ' 23-503 DATE AND TIME 01/13/23 12:04
OF COLLISION
N
Y Q Not to sole
S 2nd S
Vehicle#1
Vehicle#2
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