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tfi, SUPPLEMENTAL REPORT NO. E861624 27 <br /> : ' <br /> COLLISIONE ORT <br /> CASE#` 2018-131612 <br /> 013197 2 <br /> 1 2 COMMERCIAL MOTOR CARRIER INTERSTATE E INTRASTATE Ej <br /> 's <br /> UNIT# USDOT ICC# VEHICLE TYPE CARGOB <br /> 2 2 1 28 <br /> CARRIER <br /> NAME 2 <br /> 3 CARRIER <br /> ADDRESS <br /> J <br /> • <br /> CffY ST ZIP <br /> 4 NAME II GVWR: PLACARD + NAME IF NO NUMBER <br /> SOURCE ALES.. El <br /> 29 <br /> (a ADDITIONAL UNITS <br /> MOTOR PEDAL- PROPERTY DAMAGE THRE4OLD MET PHONE <br /> 5 J UNIT#, 3 vEHIOLE CYCLE . Cl PEDESTRIAN . OWNER YESn NO I I I <br /> 'r I D:4253214810 <br /> MIDDLE <br /> LAST NAME RINNER FIRST NAME DARRYL INITIAL 6 <br /> • 38 <br /> STREET r'1 <br /> NEW ADOREScI 6613 LARIMER RD <br /> 55 <br /> CITY EVERETT ST WA ZIP. 98203 <br /> CDL RESTRICTIONS ENDORSEMENTS. <br /> 1 31 <br /> 7 <br /> DRIVER'S STATE SEX M D.O.B. 06 - 13 - 1966 <br /> LICENSE# MMDDYYYY 2 <br /> 8 NATURE OF INJURIES <br /> ON DUTY USE STATUS AIRBAG RESTR. EJECT HELMET CLARY <br /> CLASS 3 <br /> 9 LICENSE <br /> PLATE# STATE VIN# 1 32 <br /> 10 TRAILER TRAILER <br /> PLATE# STATE PLLjATTE#E STATE�.V E� 2 <br /> 11 VEH.YEAR MAKE MODEL STYLE YESll INOI I TOWED BY YE ENO I - <br /> LJ LJ LJ 3 <br /> REGISTERED OWNER INFO. SHADE IN DAMAGED AREA <br /> 12 2 3 4 <br /> LJ INSURANCE CO \ 08DM RI <br /> IN EFFECT <br /> INSURANCE &POLICY II (-10 <br /> 9 TOP Bonoa33 <br /> 13 i ff g. YESu NO u CITATION w CHARGE <br /> STANDING 8 7 6 <br /> ROOM TO <br /> MOTOR -0- PEDAL- 0 :. - - 0 PROPERTY D THR LD MET I PHONE <br /> 14 UNIT,# 4 VEHICLE.: CYCLE PEDESTRIAN OWNER IYE NO I D:4252578800 34 <br /> 15 LAST NAME CITY OF EVERETT FIRST NAME PUBLIC WORKS MIDDLE <br /> INITIAL 35 <br /> 15 STREEDPflES i 3200 CEDAR STNEW 36 <br /> CITY EVERETT ST WA ZIP 98201 <br /> 3 <br /> 17 7 <br /> CDL RESTRICTIONS ENDORSEMENTS 38 <br /> 18 <br /> DRIVER'SSTATE SFX U D.O.B. - 39 <br /> LICENSE 4 MMDDYYYY <br /> 19NATURE OF INJURIES <br /> ON DUTY - STATUS AIRBAG RESTR. EJECT HELMET INJURY 48 <br /> USE. CLASS <br /> 20 LICENSE <br /> PLATE# STATE VIN* <br /> 21 TRAILER TRAILER <br /> PLATE# STATE :PLATE# STATE <br /> 22 VEH.YEAR MAKE MODEL STYLE YESI NO TOWED BY YEE NIOn <br /> 23 REGISTERED OWNER INFO. SHADE IN DAMAGED AREA <br /> 41 <br /> 2 3 4 <br /> WBILITY WSURANCE ❑ INSURANCE CO (k <br /> IN EFFECT &POLICY# I 9 TOP 5 <br /> 24 YES[] NO El CITATIONS CHARGE I O BOTTOM <br /> Nag, 42 <br /> __1L�JI � <br /> STANDING 8 7 6 <br /> I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.(RCW 9k72.085) <br /> MARK GIST 11-16-18 05:36 PM <br /> 25 INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED: PLACE SIGNED <br /> 261 <br /> I I 1 <br /> BADGE OR ID .I 1419 ORI WA0310300 APPAOVEABY D1A4117/201 PAGE 3 OF 4 <br />