HomeMy WebLinkAbout22-13540 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 22-13540 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 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 2035 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET MILES e S B W e NE 10TH ST
0 1 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYYESA�NO GE THRESHOLD MET PHONE 0 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST zIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNIT{ON PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
LVERS
ICIENSE# STATE SEX'F MMDDYY _ - 1 2 32
8❑
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EET 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE CJE STATE MT VIN#' UNK
10 9❑ Pr ATE�
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM ro
rRLR. TRLR 1 5 33
12 3 5 VIN#' VIN#'
FROM TO
❑ VEH.YEAR MAKE MAID MODEL UNK STYLE SV VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
DAMAGE YES NO Y
13 4 ES❑ NO✓
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE❑ NSURANCE CO 3 4
IN EFFECT &POLICV# 9TOP
VEHICLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
uNiT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2067128285
16 a
LAST NAME THOMAS FIRST NAME ALECIA MIDDLE lK
INITIAL
17 STREET❑ NEW ADDRESS❑' 2801 NE 4TH CT CITY RENTON ST WA ZIP 98056 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCK YES�NO INTERLOCK YEs It I NO YES t l NOF
STATE IWASEXF 07 3919 DIVE MMDDYYLI #
HELMET I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
❑ILICENSE 21❑ PLA E# BWX4770 TATe 41
WA vIN# 3VWD17AJOFM333364 4
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2015 MAKE VOLK MODEL JETTA STYLE SD VEHICLE TOWED TO BLIN TOWEDeY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ALECIA THOMAS 2801 NE 4TH CT RENTON WA 98056 D:2067128285 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ &POINSURGY#E CO NO INFORMATION PROVIDEDIN STOP 5
VE"LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N 6
25 =HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED24993
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13540
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'
Unit 1 reported hit and run vehicle, red Mazda SUV partial MT plate of CJE. Unit 1 traveling south
along 900 blk NE Sunset Blvd. Unit 2 traveling north along 900 blk NE Sunset Blvd. Unit 2 driver
reports Unit 1 veered into her lane and struck her vehicle causing non disabling reportable damage to
Unit 2's driver side door panels, side swiping damage. Unit 1 sustained non disabling reportable front
and driver side damage. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 12-26-22 08:13 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 111512023 1:11:59 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED! 8:41 PM TIME POLICE ARRIVED f 8:42 PM
PART I PAGE IT]OF 3�
REPORT NO. ED24993 CASE# 22-13540 DATE AND TIME 12/21/22 20:35
OF COLLISION
G E N E N 0 T E E r
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