HomeMy WebLinkAbout23-10414 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10414 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENC 4200 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 CITY# ❑
cawsloN 09 - 08 - 2023 2113 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 10 00 FEET MILES e S B W e S 7TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2063078710 0 81
30
6� LAST NAME CHEN FIRSTNAME DEHE MIDDLE 1 1 2 31
INITIAL
STREET ❑1 15907 JADE ST SE YELM WA
NEW ADDRESS STjP', 96597 2 CITY
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ DRIVERS
# STATE WA SEXI M MIDI 12 — 21 — 1984 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10[1 PI P1 ATE 4 AWJ8005 sTAr WAv N#' 2HKRL 1857YH603272
---- TRAILER STATE PLAT STATE
11 3 5 PLATE# PLATE# Rom To
TRLR. A'RLR. 1 5 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE J 9 34
13 3 2000 HOND ODYSSE VN DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO LM GENERAL AOS-261959198.7026 3 4
IN EFFECT &POLICY# Q
VEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION#
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066186666
16 a
LAST NAME NGUYEN FIRST NAME VY MIDDLE T
INITIAL
17 STREET I❑ s❑' 317 SW 112TH ST APT 303 CITY SEATTLE ST WA ZIP 98146 4❑ 37
NEW ADDREs
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 LICENSE# STATE WA SEX F M D.C.B. 04 25 _ 1983 39
20 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET INJURY 6 NATURE OF INJURIES 40
USE CLASS HEAD PAIN
LICENSE ❑21❑ PLA E# BXW1962 TArE 41
WA VIN1 WINOGSEB6MF915385 1
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
Gov HI
VEH YEAR 2021 MAKE MERZ MODEL GLC STYLE UT DAMAGE TOWED NOO✓ BLIN TOWED BY 44
YES
NO
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 2651085-E01-47FIN 1 9TOP
VEHICLE CITATION# CHARGE i o BOTTOM
LEGALLY YES NC�
25❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JASON JONES 11635 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED98988
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10414
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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'
On 9-8-23, at about 2119 hours, I was dispatched to a collision that occurred in about the 600 block
of Rainer AVE S.
Upon I arrival, I observed Unit 1 with major damage to the front driver's side and Unit 2 to have major
damage to the rear.
I contacted the driver of Unit 1 who evaluated by the fire department due to airbag deployment. No
injuries were reported: The driver of Unit 1 stated he was traveling south on Rainier AVE S, did not
see the vehicle in front of him stop, and struck Unit 2.
1 contacted the driver of Unit 2 who was evaluated by the fire department for head pain. The driver of
Unit 2 stated they were stopped for a red light at the intersection of Rainier AVE S and S 7th ST and
was stuck from behind by Unit 1.
The driver of Unit 1 was given a verbal warning for inattention.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON JONES 09-08-23 11:20 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.TRADER 4553 1 911412023 11:36:14 PM
BADGE OR ID# 11635 OR]# WA0171300 TIME POLICE DISPATCHED; 9:99 Pry] TIME POLICE ARRIVED',9:24 PM
PART I PAGE IT]OF 3�
REPORT NO. ED98988 CASE# 23-10414 DATE AND TIME 09/08/23 21:13
OF COLLISION
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