HomeMy WebLinkAbout23-05157 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-05157 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
cowsloN 05 - 1-- 2023 2050 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 3100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 200 00 FEET e S ❑ W e MONROE AV NE
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2533941102 0 11
30
6� LAST NAME NGUYEN FIRSTNAME CAM MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 108 HOQUIAM AVE NE CITY RENTON ST WA 21p 980594905 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ D
RI
VERS STATE WA SEX'F MMDDYY' 11 - 09 - 1976 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU SE CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� BNC1521 sTArI WAurN# WAUC4AF46JA234797
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2018 MAKE MODEL STYLE VEHICLE TOWED TO BLIN 7 3 TOWED BY GOVT.VEHICLE 34
13 4 AUDI S4 SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO JIMMY TANG 108 HOQUTAM AVE NE RENTON WA 98059 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ALL STATES17835280
IN EFFECT &POLICY# 9TOP
VE—L' CHARGE 1 5 36
LEGALLY, YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDIN 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2069996058
16 a
LAST NAME KELLY FIRST NAME ELIJAH MIDDLE O
INITIAL
17❑ STREET �' 3721 HST#5 CITY'AUBURN ST' WA ZIP 98001 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 D IVEW #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE 1 BBP0229 TAre WA VIN# 5NPEU4AF4AH586971
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2010 MAKE HYUN MODEL SONATA STYLE SD VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO FARSHID KHORASANIAN 4200 MARY GATES MEMORIAL DR N SEATTLEWA98105 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
VE"LLE ❑ N`LJ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES 6
25 =HSU
AME(PRINT) OFFICER PHONE BADGE OR ID#
26 12651 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED61928
COLLISION REPORT III III III III III 111
1591972 CASE# 23-05157
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) FISHER DAJA R
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
1023 S TRAFTON ST TACOMA WA 984053055 SEXi F MMDDYyry 07 - 20 - 1999
PASSENGER Z WITNESS[— UNIT# 2 SEA 3 AIRBAG 2 RESTR. q EJECT ? 1 HELMET INJURY NATURE OF INJURIES
POS. USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) KELLY MAl',AAI
ADDRESS&PHONE# D O B
3721 HST#5 AUBURN WA 98001 2069996058 SEX: M MMDDUYYv 07 _ 11 _ 2022
SEAT HELMET I INJURY NATURE of INJURIES
PASSENGER Z WITNESS UNIT# 2 PCS 9 AIRBAG 1 RESTR. 11 EJECT 1 USE CLASS 1
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&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 east bound along the 3100 block of NE 4th St. Unit 1 make lane
change, left to right into Unit 2's lane, failing to yield right of way. Unit 1 sustains minor non disabling
reportable damage to the passenger side. Unit2 sustains minor reportable damage to the front driver
side. No injuries reported.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 05-08-23 05:35 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 5/20/2023 11:32:28 AM
BADGE OR ID# 12651 OR]# WA0171300 TIME POLICE DISPATCHED 8:54 PM TIME POLICE ARRIVED',8:57 PM
PART Ei PAGE IT]OF
REPORT NO. ED61928 CASE# 23-05157 DATE AND TIME 05/07/23 20:50
OF COLLISION
NOT TO SCALE
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