HomeMy WebLinkAbout23-01764 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE$# 23-01764 2 571
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4200 3 6 6
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2� TOTAL#OF OBJECT 1 �2$
TRIBAL UNITS 01 STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GawsloN 02 - 12 - 2023 0056 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLEYVALLEYHWY BLOCK NO. e✓ 2600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 500 00 FEET e S ❑ W e SE 5TH ST
2 3 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 30
6� LAST NAME SUTTON FIRSTNAME ISAIAH MIDDLE O 0 5 31
INITIAL
STREET ❑, 14300 SE 171 ST WAY APT T5 CITY RENTON ST WA ZIP 980588741 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NOZ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
LICENSE CGE0662 sTAr1 WAvrN# SAJKV1640JC528388
10❑ PI ATE i4
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
rRLR TRLR 7 3 33
12❑ VIN#j VIN#
FROM
34
13 4 VEH.YEAR 1988 MAKE JAGU MODEL VANDEN STYLE SD VEHICLE TOWEDNOO pLSSBLIN TQ yEq.BLRs YES[:]
❑ HICLE
DAMAGE ILJI tSA1Wl6
REGISTERED OWNER INFO 1SA.1.31 TON 14300 SE 171ST WAYAPT T5 RENTON WA 980588741 VEHICLE NO. 1 ❑
❑ SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE❑ INSURANCE CO NONE
IN EFFECT &POLICY# 9TOP_
15❑ LE
vECALLv wcLE I 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
STAIN.D'ING 8 7 6
UNIT 02 MOTVE IOOR El CYCLE PEDAL- ❑ PEDESTRIAN ❑ OWNER
❑ DYES H OLD MET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
17❑ NEW ADDRESS❑' CITY ST ZIP ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIICENS # STATE SEX MMDDYY -�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TArE VIN# 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO IGQVE"LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED45508
COLLISION REPORT III III III III III 111
1591972 CASE# 23-01764
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 traveling eastbound along 2600 block of Maple Valley Hwy. Unit 1 driver reports tire blow out
and loses control of vehicle, striking the south sidewalk as the vehicle sustains heavy reportable
disabling tire damage to both passenger side tires and undercarriage damage. No signs of
impairment for Unit 1 driver. No injuries reported. Unit 1 privately impounded.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 02-12-23 05:30 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 3/25/2023 5:23:07 PM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED! ?:01 AM TIME POLICE ARRIVED 1:06 AM
PART I PAGE IT]OF 3�
REPORT NO. ED45508 CASE# 23-01764 DATE AND TIME 02/12/23 00:56
OF COLLISION
� �"'"'' .� 2�00 blk Maple Valley Hwy
NOT TO SCALE
PAGE 3 OF 3