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Home My WebLink About23-4136 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c COLLISION REP FIT 1591971 CASE 23-4136 z INTERSTATE ❑ CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4200 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 02 STRUCK NONE RESERVATION z 3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑ CowsloN 04 - 1-- 2023 1430 17 ❑.= S 8 IN e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ MONSTER RD SW BLOCK NO. e✓ 555 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ ❑ FEET e S B W e 68TH AVE S 0 1 29 MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE El ,/No D:4255858050 0 81 30 6� LAST NAME KILLIAN FIRSTNAME NICKOLAS MIDDLE N 1 1 2 31 INITIAL STREET ❑ 19209 8TH AVE NW CITY ARLINGTON ST WA 2jp, 982238318 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3 1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/ 8❑ LDRIVER # STATE WA SEX'M MID -O B 02 1— 18 — 1964 2 32 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE ICNLJAUSSY 1 NATURE OF INJURIES z❑ 3 10� Pi aT�S� C18234F sTArI WAurN# 2NKHlJ9X2GM130082 TRAILER STATE TRAILER STATE 11 0 0 PLATE# PLATE# FROM TO TRLR. YRLR. 5 1 33 12 0 0 VIN#' VIN# >; FROM TO VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE g 9 34 13 2 2016 KW CONST TR DAMAGE YES NO TOWING YEs❑ NO REGISTERED OWNER INFO WRECKING BALL DEMOLITION LLC 3310 CHESTNUT ST EVERETT WA 98201 D:4255858050 VEHICLE NO. 1 ❑ SHADE IN DAMAGED AREA 35 14 ABILI V INSURANCE INSURANCE CO HUB INT.NW LLC CPP1274323 3 4 IN EFFECT &POLICY# 9TOP VEHCLE CHARGE 5 36 LEGALLY YES❑NO❑ CITATION# 3AO095068 FOLLOW VEHICLE TOO CLOSELY io sorrow 15❑ NDING 6 MOTOR PEDAL- 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:9727419099 16 a LAST NAME NJUGUNA FIRST NAME JOHN MIDDLE N INITIAL 17❑ STREET NEW ADDREs�' 4352 S ALDER ST CITY' TACOMA ST WA ZIP 984095518 37 18� CDL ., IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL t—T�RANSPORTED 38 INTERLOCKYES�NO� INTERLOCK YEs I I NOF YES t l NOF,/ 19[ DRIVER'S STATE WA SEX M D.C.B. 05 _ 29]_ 1974 39 LICENSE# MMDDYY 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET INJURY 7 NATURE B INJURIES 40 USE CLASS UPPER BACK PAIN ❑ILICENSE 21❑ PLA E# 3475357 TArE 41 IN VIN1 1FUJGLDR1ALAP8387 1 42 22❑ TRAILER P760626 STATE IN TRAILER STATE PLATE# PLATE# 43 23❑ uRNL#R LJRC54268JT005401 IN RR YEAR 2010 MAKE FRET MODEL TRACTO STYLE DS VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44 VEH 24❑ DAMAGE YES NO YES NO REGISTERED OWNER INFO J B HUNT TRANSPORT INC 9200 E 146TH STREET NOBLESVILLE IN 46060 D:9727419099 VEHICLE NO.2 SHADE IN DAMAGEbAREA 2 3 Cd LIABILITY INSURANCE INSU&PORGY#E CO ACE AMR INS.CO.XSAH10764609IN 1 9TOP Le L..LLY YES❑ N C[Z CITATION# CHARGE i o BOTTOM LEGA 25 $ ' OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY J 26 �ALEKSANDRIGNATOV 12619 WA0171300 PAGE 01 OF PART A 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. ED50837 COLLISION REPORT III III III III III 111 1591972 CASE# 23-4136 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' Unit one and Unit two were traveling northbound on MONSTER RD SW near the 555 BLK in lane 1 of 1. Unit two stopped for a pedestrian cross signal. A pedestrian was attempting to cross the roadway. Unit one was behind unit two. Unit one was following too closely and struck unit two in the rear. **** AUTO-POPULATED SECTION **** THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER": Motor Vehicle Unit 1 Traffic Control: PED CROSS LIGHT Motor Vehicle Unit 2 Traffic Control: PED. CROSS SIGNAL **** END OF AUTO-POPULATED SECTION **** I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. ALEKSANDR IGNATOV 04-12-23 04:20 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE D.SKELTON 9139 1 411312023 4:41:55 AM BADGE OR ID# 12619 ORI# WA0171300 TIME POLICE DISPATCHED 2:34 PM TIME POLICE ARRIVED:2:43 PM PART I PAGE IT]OF 5� SUPPLEMENTAL REPORT NO. ED550837 r`I POLICE TRAFFIC 1 27 COLLISION REPORT CASE#1 23-4136 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE ✓ G UNIT# 1 USDOT 1921339 ICC# 000000 VEHICLE TYPE 3 CARGO BODY 5 TYPE 2 ❑ 1 28 CARRIER NAME WRECKING BALL DEMOLITION ....... 3 CARRIER ADDRESS 3310 CHESTNUT ST CITY EVERETT ST WA ZIP'', 98201 4 ❑ NAME # PLACARD: :❑ NAME IF NO NUMBER SOURCE 1 AXLES 03 GI50000 + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES NO i MIDDLE'... 29 LAST NAME FIRST NAME INITIAL STREET 30 NFW AnnRFrtP. CITY ST ZIP 6 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31 INTERLOCK YES No INTERLOCK YESE]NO� vES N LLIICIENSE STATE I SEX M��DYRYY' 2 7 F-1 ON DUTYl STATUS AIRBAG' RESTR. EJECT HELMET INJURY NATURE OF INJURIES USE CLASS 8 ❑ ' 1 32 LICENSE+ rar VIN.# PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWS E T SABLIN TOWED BY anvi vEHIG P FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFO. m 33 12 SHADE IN DAMAGED AREA FROM TO LIABILITY INSURANCE❑ INSURANCE CO IN EFFECT &POLICY# tGQ EHICLE 34 13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE STANDING } 8 7 6 14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE': INITIAL ❑ 36 STREET 16 NFln+AnntxFs.� CITY'. ST 21P CDL IGNITION REQUIRED IGNITtGN PRESENT MEDICALTANSPORTED INTERLOCK YES No INTERLOCK YEs NO YEs NO El 17 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE (CLASS 19 ❑ vIN 39 LICENSE # PLATE# rnr 20 ❑ TRAILER TRAILER ❑ 40 PLATE# STATE PLATE# STATE 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO SHADE IN DAMAGED 3 4 4 AREA F 43 z LIABILITY INSURANCE INSURANCE CO ' VINE EFFECT &POLICY# i 970P - 4 E:l 44 24 LEwGLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM C=DLv STANDING 8 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. ALEKSANDR IGNATOV 04-12-23 04:20 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED APPROVED BY DATE 26 OR ID# 12619 O#II,WA0171300 SKELTON 4113/2023 PAGE�OF 3000-345-013(R 11118) SUPPLEMENTAL REPORT NO. ED550837 r`I POLICE TRAFFIC 1 27 COLLISION REPORT CASE#1 23-4136 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE ✓ G UNIT# 2 USDOT 0080806 ICC# 000000 VEHICLE TYPE 6 CARGO BODY 9 TYPE 2 ❑ 1 28 CARRIER NAME. JB HUNT TRANSPORT ..... 3 CARRIER ADDRESS 9200 E 146TH ST CITY NOBLESVILLE ST IN ZIP 46060 4 ❑ NAME # PLACARD: :❑ NAME IF NO NUMBER SOURCE 1 AXLES 03 GI80000 + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES NO i MIDDLE'... 29 LAST NAME FIRST NAME INITIAL STREET 30 NFW AnnRFrtP. CITY ST ZIP 6 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31 INTERLOCK YES No INTERLOCK YESE]NO� vES N LLIICIENSE STATE I SEX M��DYRYY' 2 7 F-1 ON DUTYl STATUS AIRBAG' RESTR. EJECT HELMET INJURY NATURE OF INJURIES USE CLASS 8 ❑ ' 1 32 LICENSE+ rar VIN.# PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWS E T SABLIN TOWED BY anvi vEHIG P FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFO. m 33 12 SHADE IN DAMAGED AREA FROM TO LIABILITY INSURANCE❑ INSURANCE CO IN EFFECT &POLICY# tGQ EHICLE 34 13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE STANDING S} MOTOR 8 7 6 14 ❑ UNIT Tr Vd 1RE O CYCLE OWNER RTY YES AGE NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE': INITIAL36 STREETIAL ❑ 16 NFln+AnntxFs.� CITY'. ST 21P CDL IGNITION REQUIRED IGNITtGN PRESENT MEDICALTANSPORTED INTERLOCK YES No INTERLOCK YEs NO YEs NO El 17 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE (CLASS 19 ❑ vIN 39 LICENSE # PLATE# rnr 20 ❑ TRAILER' TRAILER ❑ 40 PLATE# STATE PLATE# STATE 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO SHADE IN DAMAGED 3 4 4 AREA F 43 z LIABILITY INSURANCE INSURANCE CO ' VE EFFECT &POLICY# i 970P - 4 E:l 44 24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM C=DLv STANDING 8 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. ALEKSANDR IGNATOV 04-12-23 04:20 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 � OR ID# 12619 O#I',WA0171300 APSKELTON 41113/2023 PAGE�OF 3000-345-013(R 11118) REPORT NO. ED50837 CASE# ' 23-4136 DATE AND TIME 04/12/23 14:30 OF COLLISION w L L[7 PAGE 5 OF 5