HomeMy WebLinkAbout23-11746 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-11746 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 O 7 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# ❑
cowsloN 10 - 14 - 2023 0955 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S PUGET DR BLOCK NO. e✓ 1900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FMILES EET e S ❑ E e TALBOT RD S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:4255456739 0 11
30
6� LAST NAME ZHUSOPUV FIRSTNAME MARLES MIDDLE 1 2 31
INITIAL
STREET ❑ 2020 GRANT AVE S A202 CITY RENTON ST WA ZIP 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 1❑ P1 ATE 14 CHT2673 STATE WA u N# JTNBB46K473001837
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# IR.. ro
TRLR. TRLR 3 7 33
12 3 5 VIN#j VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 3 7 34
13 2 2007 TOYT CAMRY SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO MARLES ZHUS0PU12020 GRANTAVE S A202 RENTON WA 98055 D:4255456739 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# � 9TOP
vewcl.e CHARGE 36
LecALLv YES❑NO❑ CITATION# 3A0629776 OP MOT VEH W/OUT INSURANCE aorroM
15❑ STANDING 8 7 6
MOTOR PEDAL- ❑ ❑PEDESTRIAN PROPERTY DAM THR OLD M PHONE
UNIT 02 VEHICLE ❑ CYCLE OWNER ❑LIES NO ET NO D.9735086665
16 a
LAST NAME BOXTON FIRST NAMEJ CHRISTIAN MIDDLE JA
INITIAL
17❑ STREET �', 2020 GRANT AVE S L301 CITY RENTON ST WA Zip 98055 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NO� INTERLOCK yEs❑NOF YEs❑NOF,/
19 LICENSE STATE I WA SEX M MMDDW 08 _ 01 1990 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE AWK9531 TATe WA vIN# 4T1BK366X5U055869
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
GoI
VEH YEAR 2005 MAKE 7'Oy7' MODEL AVALON STYLE $D DAMAGE TOWED NOO✓ BLIN TOWED BY v HyES NO,/ 44
24❑ fj
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO USAA 0186565237101IN"F""LE, YEs Nc❑ CITATION# 3A0629777 CHARGE FOLLOW VEHICLE TOO CLOSELY
25 C�Q
LY
s � a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE12309
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11746
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 westbound, approaching intersection with one car ahead between Unit 1 and intersection. Unit
2 following unit 1. When signal changed to yellow, car ahead of unit 1 stopped. Unit 1 stopped, unit 2
struck unit 1 from behind. Driver 1 Zhusupov issued NOI, as he did not have insurance in force, driver
2 Boxton issued NOI for following too closely.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 10-14-23 11:15 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.EDWARDS 9070 1 1012412023 8:06:12 AM
BADGE OR ID# 5738 OR]#' WA0171300 TIME POLICE DISPATCHED 9:55 AM TIME POLICE ARRIVED',9:55 AM
PART I PAGE IT]OF 3�
REPORT NO.! EE12309 CASE# 23-11746 DATE AND TIME 10/14/23 09:55
OF COLLISION
ti
3
CA
S,
0�. Unit:1.
4, � � ...
C7
Unit
i
I
S 15th st,
j
Puget bt
cr
CL
co
0
PAGE 3 OF 3