HomeMy WebLinkAbout23-8945 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-8945 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 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' FENCE
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 08 - 1-- 2023 1605 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MONSTER RD SW BLOCK NO. e✓ 550
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064199405 30
6� LAST NAME ABDI FIRSTNAME ABDIKENI MIDDLE Z 1 1 1 31
INITIAL
STREET ❑, 13445 MARTIN LUTHER KING JR W UNIT E102 CITY SEATTLE ST WA ZIP 981785227 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO I INTERLOCK YES NO YEs NO
8❑ DRIVERS
# STATE WA SEX'M I ELMMDDYY' 01 — 01 — 2005 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ P1 ATE 14 BZZ4168 sTAr WAv N# 5TDJGRFH7JS051155
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12❑ VIN#j VIN#
2018 TOYT HIGHLA UT pL FROM 34
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 2 DAMAGE YES No YES[:] NO✓
REGISTERED OWNER INFO KEDIJA.EL13445MLKJRWAYSUNITE102 SEATTLEWA98178 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO ALLSTATE 817 333 148
IN EFFECT &POLICY# 9TOP
vEI" CHAR 36
EGALLY res No CITATION# 3A0379290 GE OPERATING A MOTOR VEHICLE o eorrom
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2064774727
16❑
LAST NAME NONE FIRST NAME BLACK RIVER PUMP STATION MIDDLE
INITIAL
17❑ STREET ❑' 550 MONSTER RD SW CITY' RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YES
❑NOF
19 LLIICENS RIVERIS# STATE SEX U MMDDYY 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE LICENSE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1 9TOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED86657
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8945
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 traveling westbound in the 500 block of Monster Rd SW. The driver of vehicle #1
advised me he heard a "clunking" sound and then lost control of the vehicle's steering, which caused
his vehicle to veer to the right and off the roadway. This caused the right side of vehicle #1 to collide
with a chain link fence on the north side of the road, knocking it over. This fence appeared to be
owned by Black River Pump Station. Photos were taken of the scene. I attempted to contact Black
River Pump Station by phone but was unable to make contact with them. I left an exchange of
information form and my business card with the case number on it in an "Official Police Business"
weather proof envelope in a conspicuous spot on the the damaged fence.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 08-05-23 06:36 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 8/6/2023 6:00:53 AM
BADGE OR ID# 11631 OR]# WA0171300 TIME POLICE DISPATCHED! 4:37 Pry TIME POLICE ARRIVED 4:41 PM
PART I PAGE IT]OF 3�
REPORT NO. ED86657 CASE# ' 23-8945 DATE AND TIME 08/05/23 16:05
OF COLLISION
F.K3
Not to scale Fence
Vehicle#1
s`
Monster Rd SW
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