HomeMy WebLinkAbout23-8068 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-8068 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT 8 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 07 - 14 - 2023 0605 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SUNSET BLVD NE BLOCK NO. e
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e BRONSONWAYNE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252182366 0 11
30
6� LAST NAME CHAPA FIRSTNAME TRINA MIDDLE D 1 1 2 31
INITIAL
STREET El 300 VUEMONT PL NE APT S301 CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES NO
DRIVERS
E# STATE WA SEX'U I EL MI D�Y
8❑ ' 04 - 11 - 1977 1 2 32
—, [NATURE OF INJURIES
9� ON DUTY❑ STATUS' AIRBAG 6 RESTR 9 . EJECT 1 H U EET CLASS 7 I BRUISED LEFT ARM z❑
3
10 9❑ P1 ATE 14 C225975 STATE WA VIN# 1GCHSBEN3K1271323
TRAILER STATE TRAILER STATE
11 3 5 PLATE# I PLATE# I I FROM TO
rRLR. TRLR. 3 5 33
12 3 5 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T /g[ GOVT.VEHICLE 5 1 34
13 2 2019 CHEV COLOR PK DAMAGE YES NOBS TOWING YES[:] No✓
REGISTERED OWNER INFO NONE COCHRAN INC PO BOX 33524 SEA TTLE WA 98133 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE� PARKER,SMITH,&FLEEK INSURANCE CO AS2291464121013
IN EFFECT &POLICY# 9TOP
LEGAH'CLY LE YES❑ 5 36
ENO❑ CITATION CHARGE 10 BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2533749203
16 2
LAST NAME CAMPOS FIRST NAME RIKI MIDDLE M
INITIAL
17❑ STREET '� 1126 E 69TH ST CITY''' TACOMA ST' WA ZIP 98404 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YES
❑NO❑ 11
19 DRIVERS
# STATE WA SEX M MMor w 03 _ 01 1996 39
—NATURE OF INJURIES
H USE
ET LASSY SORE RIGHT ARM AND PAIN TO BACK OF HEAD ❑ 40
20 ON DUTY STATUS AIRBAG,6 RESTR 4 EJECT 1 7
21❑ LICENSE I CCL5174 TATe WA VIN# 2G1FK1EJ4A9156585
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2010 MAKE CHEV MODEL CAMARO STYLE CP VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24= DAMAGE YES✓ NO BANKERS TOWING YES NO
REGISTERED OWNER INFO NONE SELCO COMMUNITY CU PO BOX 7487 SPRINGFIELD OR 97475 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE I PORGY#ECO NATIONAL GENERAL INSURANCE CO 2017590822 1GQI
IN EFFECTVEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`E]
25 s � a
7JEE
S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED79647
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8068
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 stopped at a stop sign, facing west, on Bronson Way NE at the intersection of Sunset
Blvd NE. Vehicle #2 was traveling northbound on Sunset Blvd NE, approaching Bronson Way NE.
Vehicle #1 attempted to make a left turn onto Sunset Blvd NE, but did so in front of vehicle #2,
causing the front left corner of vehicle #1 to collide with the front right corner of vehicle #2. Based on
the totality of the circumstances, it appeared vehicle #1 caused this collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 07-14-23 07:36 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
QUINT TIBEAU 07691 1 711412023 3:46:57 PM
BADGE OR ID# 11631 ORI# ( WA0171300 TIME POLICE DISPATCHED 6:08 AM TIME POLICE ARRIVED';6:13 AM
FART I PAGE IT]OF 3�
REPORT NO. ED79647 CASE# 23-8068 DATE AND TIME 07/14/23 06:05
OF COLLISION
S
Not to scale
Vehicle � wl'�hicle #2
ouu4 lui ".
Bronson Way NE
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Cn
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