HomeMy WebLinkAbout23-4320 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-4320 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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# ❑
COLLISION: 04 — 1—— 2023 1333 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LOGAN AVE N BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e N 3RD ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:3609087775 0 11
30
6� LAST NAME SCOTT FIRSTNAME DONALD MIDDLE J 1 2 31
INITIAL
STREET ❑ 10403 65TH AVE CT NW CITY GIG HARBOR ST WA 2jp, 98332 z=
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8 LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET USE 2 1 CLASS NATURE OF INJURIES z❑
3
10[1 PI PI ATE 14 BJF8543 sTAr WA V N#' WBA3N7C5XEF719188
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR. 1 3 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE 5 1 34
13 2 2014 BMW 428 SD DAMAGE vE5 0NO agW�MEYER vEs❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 958633312 35
IN EFFECT &POLICY# �1'OP
ve'CLE CHARGE ❑ 36
LEGALLv res❑NO❑ CITATION# BOTTOM
15❑ �STA"
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2067872947
16 a
LAST NAME THEODORE FIRST NAME MARVIN MIDDLE K
INITIAL
17❑ STREET ❑' 21511THAVEE CITY' SEATTLE ST' WA ZIP 98102 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK vEs❑NOF YEs❑NOF
19[—] DRIVER #
{NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE I WHP212 TAre WA VIN1i VC24245H1112093
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
roweD ev Gov HI 44
VEH YEAR 19]] MAKE VDLV MODEL 2422D STYLE $D DAMAGE TOWED✓ NOO BLIN GENE MEYER YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE❑ I PORGY#E CO pROGRESSIVE 902838281IN STOP 5
VETILE ❑ ,J� CITATION# CHARGE
25 to BOTTOM
LEGALLY YES N J
' a
7FIR' NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
PH SINGER 12056 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED52136
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4320
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'
Vehicle 1 was traveling norhboung on Logan ave N. Vehicle 2 was waiting to turn left (east bound)
from traveling southbound on Park Ave N. Vehicle 1 claims someone stopped to wave them through
the interction. When they made their left, they were struck by vehicle 2.
Vehicle 2 claimed the same. Both claimed the other were "speeding."
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JOSEPH SINGER 04-17-23 02:28 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 411712023 5:43:05 PM
BADGE OR ID# 12056 OR]# WA0171300 TIME POLICE DISPATCHED! 1:38 PM TIME POLICE ARRIVED 1:38 PM
PART Ei PAGE IT]OF
REPORT NO. ED52136 CASE# ' 23-4320 DATE AND TIME 04/17/23 13:33
OF COLLISION
Log—.Ave:N
not to scale.
E
N&d St
A E
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