HomeMy WebLinkAbout23-05929 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-05929 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF 02 OBJECT 1 1 8 28
UNITS
RESERVATION I STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 05 - 1-- 2023 1943 17 ❑.❑ S IN 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
HARRINGTON AV NE BLOCK NO. e✓ 1500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FEET ❑ S ❑B E ❑ INDEX AVE NE❑
0 1 29
UNIT 01 V�ICLE PI CYCLE ElDYEB /NO AMAFGETHRESHOLD MET PHONE 0 1 30
LAST NAME GUADARRAMABERNAL FIRSTNAME LUIS MIDDLE E
6 INITIAL 1 1 2 31
STREET ❑ 1150 UNION AV NE 18-3 CITY RENTON ST WA ZjP, 98059 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 03 — 30 — 1996 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 JHELMJ
USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
❑10 9� P1 ATNFS14 NONE STATE WA VIN# 5FNRL38746B423286 3
TRAILER STATE TRAILER STATE
11 2 51 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 2 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 2 2006 HOND ODYSSE VN DAMAGE YES NO YES❑ NO✓
REGISTERED.WNERINFO JOSE DE HARO-RODRIGUEZ 70737TH STSE AUBURN WA 98002 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
❑ ❑ INSURANCE CO 2 3 4
14 LIABILITY INSURANCE NONE
IN EFFECT &POLICY# 9TOP
VEwcLE CHARGE 10BOTTOM 5 36
LEGALLY YES No CITATION# 3AO044273,3AO044274, OWLS 3RD DEGREE,OP MOT VEH
15❑ STANDING 8 7 6
MOTOR PEDAL- : PROPERTY DAM THR OLD MET PHONE
16 a UNIT 02 VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNFR ❑ YES,/ NO D:4255459596
LAST NAME SANCHEZ-LOPEZ FIRST NAME KENNETH MIDDLE
INITIAL
17❑ STREET ❑', 4415 NE 5TH ST G203 CITY' RENTON ST WA ZIP 98059 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCKYES�NO INTERLOCK YEs❑NOF YES
❑NoF,/
19[—] D IVEW # STATE WA SEX U M D.C.B. 11 05 _ 2003 El 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CFE5010 TATE WA VIN# JT2BG22K410569877
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2001 MAKE TOYT MODEL CAMRY STYLE SO VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO EDGAR SANCHEZ AMBROCIO"15 NE 5TH ST G203 RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE 8 POINSURGY#E CO STATE FARM 1449143415IN 1 9TOP
VE"LE ❑ Nu,J CITATION# CHARGE i o BOTTOM
LEGALLY YES
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED65015
COLLISION REPORT III III III III III 111
1591972 CASE# 23-05929
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 and Unit 2 both traveling north at 1500 block Harrington Av NE approaching Index Av NE. Unit
1 following too closely and rear ends Unit 2 causing reportable non disabling front end damage to
Unit 1 and reportable non disabling rear end damage to Unit 2. No injuries reported. Unit 1 driver
admits to speeding and also admits that his driver license is DWLS/R 3rd. A check of WA DOL
confirmed that Unit 1 driver status was suspended revoked. Unit 1 cited for DWLS/R3rd, following too
closely, and no vehicle insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 05-25-23 08:51 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 512912023 10:52:06 PM
BADGE OR ID# 12651 ORI# WA0171300 TIME POLICE DISPATCHED 7:48 Pry TIME POLICE ARRIVED',7:53 PM
PART B PAGE IT]OF 3�
REPORT NO. ED65015 CASE# 23-05929 DATE AND TIME 05/25/2319:43
OF COLLISION
NOT TO SCALE
1500 BLOCK
4 �r,
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