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i .., ___ 1 <br /> PAGE 1 OF 3 <br /> I . <br /> 9 EVERETT POLICE INCIDENT REPORT - <br /> INCIDENT CASE NUMBER <br /> D WARRANT SERVICE/FALSE STATEMENTS/POSSESSION OF DRUG PARA DD11- 24894 <br /> OCCURRED ON OCCURRED TO REPORTED ON <br /> MONTH DAY YEAR TIME MONTH DAY YEAR TIME MONTH DAY YEAR TIME <br /> A <br /> 12 3 11 0722 12 3 11 0722 <br /> ! ADDRESS/LOCATION OF INCIDENT ❑ FORCE CODE POL.BEAT <br /> T 1122 BROADWAY AVE UNIT 211 EVERETT WA,98201 0 NO FORCE 351 11 <br /> OFFENSE 0OFFICER SAFETY• RESP ASGN b JUVENILE ❑COMPUTER USED 0 HATE/BIAS <br /> 1 OBSTR PARA0 CHILD ABUSE ®DRUG RELATED 0 ARSON-LOSS S <br /> A CODES A❑C® A❑C® ❑OFFICER ASSAULT 2 2 0 DOM.VIOLENCE 0 ALCOHOL RELATED ❑ POSS.GANG REL. <br /> NO. RACE ETH SEX HGT WGT EYES HAIR <br /> p 01 W N M 511 165 BLU BRO <br /> 3 3 <br /> I <br /> E CITY STATE ZIP <br /> RESIDENCE PHONE BUSINESS PHONE CELL PH 1 NE EMPLOYMENT/OCCUP./SCHOOL HATE/BIAS VICTIM INJURY <br /> R ( ) ( ) ( ) <br /> 4 5 6 <br /> NO. RACE ETH SEX HGT WGT EYES HAIR <br /> p 02 W N F 501 120 BLU BRO <br /> 3 3 <br /> CITY STATE ZIP <br /> E <br /> RESIDENCE PHONE BUSINESS PHONE CELL PHONE EMPLOYMENT/OCCUP./SCHOOL HATE/BIAS VICTIM INJURY <br /> R ( ) ( ) ( ) <br /> 4 5 6 <br /> NO. CIN/IDENTIFICATION NO. BOOKED/WHERE LOCATION OF ARREST ARRESTEE ARMED WITH <br /> S Al SCJ 1122 BROADWAY AVE#211 <br /> RACE ETH SEX HGT WGT EYES HAIR <br /> U W N M 606 240 BRO BRO <br /> 3 3 <br /> CITY STATE ZIP <br /> S <br /> ' RESIDENCE PHONE BUSINESS PHONE CELL PHONE EMPLOYMENT/OCCUPATION/SCHOOL <br /> P ( ) ( ) ( ) <br /> ALIAS NAME(S) SOC.SEC:NUMBER DRIVER'S LIC./I.D.CARD STATE EXP <br /> E <br /> MISC. IDENTIFIERS <br /> C WARR EPD 1175652,SO 110542 <br /> CHARGES&CITATION#OR WARRANT#&AGENCY CHARGES&CITATION#OR WARRANT#&AGENCY <br /> T 1. ®M 0 F CHARGE PDP/FALSE STATEMENTS CIT 1Z0824621 2. 0 M 0 F CHARGE WARR SO 118733 CIT <br /> NAME/RELATIONSHIP OF PERSON NOTIFIED(JUVENILE) DATE/TIME NOTIFIED NOTIFIED BY <br /> V VEH.NO. LICENSE NUMBER STATE YEAR MAKE MODEL STYLE COLOR <br /> SPECIAL IDENTIFYING FEATURES/V.I.N. DAMAGE$ REGISTERED OWNER'S NAME <br /> V VEH.NO. LICENSE NUMBER STATE YEAR MAKE MODEL STYLE COLOR <br /> SPECIAL IDENTIFYING FEATURES/V.I.N. DAMAGE$ REGISTERED OWNER'S NAME <br /> I certify(or declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. (RCW 9A.72.085.) <br /> OFFIC/� ,�SJQN�[/ T DATE: FORCE USED FLEEING VEHICLE <br /> AT EVERETT WASHINGTON 12/2/2011 YES D NO CO YES 0 NO El <br /> OFR", <br /> OFFICER NAME/NUMBER UNIT PROVED: :/PE• . O. L V <br /> WALLACE, N 1334 122 i - <br /> CLEARANCE: ❑ UNFOUNDED DISTRIBUTION: ❑DV , ❑JUV ❑TRAF OTHER: LOGG 1 <br /> ❑ ARR/A ❑ EXC/A ❑ PA ❑CPS ❑ HO ❑DET DATE I • S <br /> ❑ ARR/J ❑ EXC/J WI <br /> ❑ ADMIN ❑DSHS ❑ MH ❑PAT <br /> 1. fENTERED RMS V( ❑ENTERED WACIC/NCIC / ❑CLEARED WACIC/NCIC / <br /> IN LS DATE INITIALS DATE INITIALS <br /> PD 03(REV.6/08 JML) FORM ID:IRF00.07.W95 <br />