HomeMy WebLinkAbout23-3078 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-3078 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 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# ❑
cawsloN 03 - 1-- 2023 1706 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE CARR RD BLOCK NO. e✓ 10300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FEET MILES e S ❑ W e MAIN AVE S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066839028 0 7 30
6� LAST NAME ASHTON FIRSTNAME TAYLOR MIDDLE N 1 2 31
INITIAL
STREET ❑, 21265 40TH WAYS,UNITE CITY SEATAC ST WA ZIp 98198 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATE BWS9089 sTArI WAVIN# JM16K34t691249774
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR 2009 MAZD MAZDA 4H MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE J 9 34
13 4 DAMAGE YESNo YES[:] NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO ESURANCE#PAWA-005238051 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY Yes❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UN�T VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YEs NO 1/ D:4255162643
16 a
LAST NAME DALEY FIRST NAME DENNIS MIDDLE IL
INITIAL
17❑ NEW STREETR 14528 S
7 E 167TH ST CITY RENTON ST WA ZIP 98058 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 2 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES 40
❑21❑ PLATE# 41
C33371Y TArE WA VIN1 1FTEW1EP8MFC51318 1
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2021 MAKE FORD MODEL F150 STYLE PK DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE I PORGY#E CO PROGRESSIVE 9943475492 I STOP
IN EFFECT
VEHICLE CITATION# CHARGE i o BOTTOM
LEGALLY YES[Z NC�
25❑ s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JASON JONES 11635 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED43069
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3078
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'
On 3-15-23, at about 1709 hours, I was dispatched to a collision that occurred in the 10300 block of
SE Carr RD (just west of the intersection of SE Carr RD and Main AVE S).
Upon I arrival, Unit 1 and Unit 2 were pulled off to the side of the road and did not require a tow.
I contacted the driver of Unit 1 and she stated she was not injured, nor did she need medical
attention, but was seen by fire as a precaution due to air bag deployment. She relayed the following:
she told me Unit 2 stopped suddenly in front her, she was unbale to stop in time, and struck Unit 2
causing damage.
I contacted the driver of Unit 2 and he stated he was not injured, nor did he need medical attention.
The driver of Unit 2 stated he stopped for traffic and was stuck from behind by Unit 1 causing little to
no damage to Unit 2.
1 gave the driver of Unit 1 a verbal warning for inattention.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON JONES 03-15-23 07:18 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 311712023 12:37:24 AM
BADGE OR ID# 11635 ORI# i WA0171300 TIME POLICE DISPATCHED; 5:09 Pry TIME POLICE ARRIVED',5:19 PM
PART Ei PAGE IT]OF
REPORT NO. ED43069 CASE# ' 23-3078 DATE AND TIME 03/15/23 17:06
OF COLLISION
w
NOT TO SCALE
<L
SE CARR RD
PAGE 3 OF 3