HomeMy WebLinkAbout23-14165 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-14165 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HIT& F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 12 - 10 - 2023 1221 17 ❑.❑ S H W H OF 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SMITHERS AVE S BLOCK NO. e✓ 4300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ MILES❑ FEET e S ❑ W e S CARR RD
0 6 29
MOTOR PEDAL- DAMETHRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ElYES AG�/No D:2532251371 0 1 30
6 LAST NAME SADAT FIRSTNAME SAVED MIDDLE N 1 1 2 31
INITIAL
STREET ❑ 12210 SE PETROVITSKY RD K301 CITY RENTON ST WA ZIP 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� CFE9233 sTAT� WAVIN# 1 NXBR30E05Z523218
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 7 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 2005 TOYT COROL 4D DAMAGE YES NO YES[:] No
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 rI LIABILITY INSURANCE U INSURANCE CO GEICO 6119-96.51.16 <1�3 4
IN EFFECT &POLICV# TOPVEHICLE CHARGE 36
LEGALLY YEs❑NO CITATION# 3A0838524 SPEED TOO FAST FOR CONDITIONS orrom
15❑ STANDING 6
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
�UNIT 02 ❑✓ ❑ PEDESTRIAN ❑ ❑ D:2533557614
VEHICLE CYCLE OWNER YES�/ NO
16 a
LAST NAME DIETRICH FIRST NAME JACOB MIDDLE JA
INITIAL
17❑ STREET ❑', 2110 104TH ST S M102 CITY' TACOMA ST WA ZIP 98444 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38
INTERLOCK YES❑NO� INTERLOCK v�Esl❑NOF YES
❑NO�
19 DRIVERS
# STATE WA SEX M Mr D.C.B. 01 28 _ 1999 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 2 EJECT 1 USE CLASS ❑
21❑ LICENSE 504S60 TATE NV vIN1 3C6MRVJG1ME536265
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2021 MAKE DODG MODEL RAM VAN STYLE C(� VEHICLE TOWED TO BLIN TOWED ev GOV HI 44
24❑ DAMAGE YES NO BANKERS YES NO
REGISTERED OWNER INFO AMAZON 1165 SANCTUARY ALPHARETTA GA 30009 VEHICLE NO.2
SHADEd DAGAAGED AREA
4� L3 4
LIABILITY
INSURANCE I PORGY#E CO OLD REPUBLIC ALA201655-25IN 1 5
VEwGLE ❑ ,J� CITATION CHARGE
25 GQ
LEGALLY YES N`L J
s 7 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
R.ON/SHl 5738 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE30257
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14165
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SADAT WIDA
(LAST FIRST,
ADDRESS&PHONE#
12210 SE PETROVITSKY RD K301 RENTON WA 98055 SEXi F MMDDYyry 01 - 29 - 1992
PASSENGER WITNESS UNIT# AT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 S.S.P 3 2 4 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) I SADAT ZAHRA
ADDRESS&PHONE# D O B
12210 SE PETROVITSKY RD K301 RENTON WA 98055 SEX: M MMDDYv- 09 _ 09 _ 2010
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS❑ UNIT# 1 POS 7 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIRST,MIDDLE INITIAL) SADAT NIDA
ADDREss&PHONE# 12210 SE PETROVITSKY RD K301 RENTON WA 98055 SEX F D.O.B. 10 _ 10 _ 2016
MMDDYYYY
PASSENGER WITNESS UNIT# ! 1 SEAT 1 9 AIRBAG 2 RESTR. 4 EJECT 1 HELMET INJURY 1 NATURE OF INJURIES
❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 traveling E to W on S Carr Rd, approaching intersection. Unit 2 entered intersection S to N on
green light, and was struck by unit 1. Driver 1 Sadat told me that he saw the light turn red, attempted
to stop, and lost traction on the wet pavement and slid into unit 2. Driver 2 Dietrich told me that his
light turned green, he drove into intersection, and unit 1 struck his Amazon van. Witness Sara Moore
told me that she was driving directly behind unit 1, and saw the light turn red when they were about
100 feet short of the intersection. Moore said that she saw unit 1 slow but not stop before striking unit
2.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 12-10-23 01:47 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.EDWARDS 9070 1 12/14/2023 5:19:27 AM
BADGE OR ID# 5738 OR]#' WA0171300 TIME POLICE DISPATCHED; 12:23 PM TIME POLICE ARRIVED 12:27 pM
PART B PAGE IT]OF 3�
REPORT NO. EE30257 CASE# 23-14165 DATE AND TIME 12/10/2312:21
OF COLLISION
1
�I
4
rI
S Garr Ltd
,I
I
�c
�. v
PAGE 3 OF 3