HomeMy WebLinkAbout23-3003 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-3003 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' UT/LITYPOLE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 03 - 1-- 2023 0710 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LK WASHINGTON BLVD N BLOCK NO. e✓ 4000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 30
6� LAST NAME ROLLINS FIRSTNAME IRVIN MIDDLE W 1 1 2 31
INITIAL
STREET ❑1 7311 COAL CREEK PKWY SE APT A CITY NEWCASTLE ST WA 2jp, 980593058 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LRIIVERS STATE WA SEXI M MM DAY' 04 - 17 - 1952 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� CCL7832 sTArI WAurN# WDBRF52H87F842452
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 1 33
12❑ VIN#j VIN#
FROM
34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE
13 2007 MERZ C DAMAGE YES NO MEYER YES[:] NO✓
REGISTERED OWNER INFO IRVIN ROLLINS 7311 COAL CREEK PKWY SE APT A NEWCASTLE WA 98059 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO THE GENERAL AUTO INS 53-WA 5565579 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LECALLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY ✓ DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES�/ NO D:4254307500
16❑
LAST NAME RENTON FIRST NAME CITY OF MIDDLE
INITIAL
17❑ STREET ❑', 1055 S GRADY WAY CITY RENTON ST WA ZIP 98056 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19 LLIICENS # STATE SEX U MMDDYY —�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE LICENSE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN It 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1GQ
VEHICLE ❑ C[:] CITATION# CHARGE
LEGALLY YES N`LJ
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED42619
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3003
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 was traveling northbound in the 4000 blk of LK Washington BLVD N. Driver 1 states that there
were deer in the roadway which caused him to swerve to the right to avoid the deer. Unknown if deer
were actually present. Unit 1 drifted to the right (east) and off the roadway. Unit 1 struck a wooden
crosswalk sign (Unit 2), destroying it, before the front end struck a large wooden utility pole. Unit 1
sustained heavy front end damage. Unit 1 towed by Gene Meyer.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 03-14-23 08:24 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 3/15/2023 10:51:11 AM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED', 7:11 AM TIME POLICE ARRIVED',7:19 AM
PART I PAGE IT]OF
REPORT NO. ED42619 CASE# 23-3003 DATE AND TIME 03/14/23 07:10
OF COLLISION
,,,Unit 2
,r
DRIVEWAY EASTPORT SHORES
I
LIB VWASHIN TON BLVD N
to
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0
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co
***NOT TO SCALE***
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