2834-24 Mitchell-Valley-All-Way-Stop-Report.pdf

14 15 16 19. To: 17. Cross Road Name/Route No. NB EB 119b 07 4. Date of Crash 5. Day of Week 6. Time 7. Municipality 8. Total 9. Total Ramp From: - SB WB - 20 Route Name/Route No. 100a mm - - - - (use 2400 hrs.) dd yy Code KilledSu M Tu W Injured 21. Latitude 22. Longitude 120a 01 1 0 0 3 1 9 OTh -F -Sa 07 5 1 0 7 22 - - - - - - . - - - - - - - - . - - - - - - 01 100b 23. Veh. # 24. Policy No. 25. NJ Ins. Code 53. Veh. # 54. Policy No. 55. NJ Ins. Code 120b 04 01 0938747C3030A 962 02 3700515540 945 - 101 Parked Ped Pedalcylist Resp. to Emergency Hit & Run Parked Ped

- 101 Parked Ped Pedalcylist Resp. to Emergency Hit & Run Parked Ped Pedalcylist Resp. to Emergency Hit & Run 121a 02 26. Driver's First Name Initial Last Name 29. Sex 56. Driver's First Name Initial Last Name 59. Sex 01 102 DANIEL A TACURI M MARK - LAPINSKI M 121b 02 27. Number & Street 57. Number & Street - 103 501 MONROE STREET 119 SUMMIT AVE 02 28. City State Zip 58. City State Zip 104 ORANGE NJ 07050 ELMWOOD NJ 07407 122 02 30. Eyes DL Class

122 02 30. Eyes DL Class Restrictions Endorsements 31. State 60. Eyes DL Class Restrictions Endorsements 61. State 0 2 D- - - - - - - 0 2 D- - - - - - - 01 NJ NJ 123 105 32. Driver's License Number 33. DOB mm dd yy 34. Expires mm yy 62. Driver's License Number 63. DOB mm dd yy 64. Expires

64. Expires mm yy 01 03 T0086 15361 07722 0 7 2 7 7 2 0 6 2 0 L0516 52100 06002 0 6 1 6 0 0 0621 35. Owner's First Name Initial Last Name 65. Owner's First Name Initial Last Name 106 124 Same as Same as - Driver Driver STANISLAW LAPINSKI 08 107 36. Number & Street 66. Number & Street 125 - -

66. Number & Street 125 - - 119 SUMMIT AVE 08 108 37. City State Zip 67. City State Zip 126a 05 - ELMWOOD NJ 07407 26 109 38. Make 39. Model 40. Color 41. Year 42. Plate No. 43. State 68. Make 69. Model 70. Color 71. Year 72. Plate No. 73. State 126b 01 FORD PKUP BL 2002 C21JBF NJ SUBARU FORESTE GN 2010 G86AYA NJ - 110 44. VIN 45. Expires 74. VIN 75. Expires 126c 01 1 F T N X 2 1 L 8 2 E B 7 5 2 2 2 07/20 J F 2 S H 6 D C 1 A H 7 8 5 1 4 2 07/20 - 111 126d

126d 46. Vehicle Removed to: 76. Vehicle Removed to: 01 - - - 112 126e Driven Towed Disabled Towed Disabled & Impounded Driven Towed Disabled Towed Disabled & Impounded - Left at Scene Towed Impounded Left at Scene Towed Impounded 26 113 127a 47. Authority 77. Authority - Owner Driver Police Owner Driver Police

Owner Driver Police 26 114 127b 48. Alcohol Drug Test 49. Hazardous Material 78. Alcohol Drug Test 79. Hazardous Material - Given: No Yes Refused None On Board Spill Given: No Yes Refused None On Board Spill - 115 Type: Breath Blood Urine Type: Breath Blood Urine 127c - - - - - - - - - - - - 116 Results: 0. - - % Pending Hazard Class Placard No. Results: 0. - - % Pending Hazard Class Placard No. 127d 04 50. Carrier No. 51. GVWR / GCWR (trucks & buses only) 80. Carrier No. 81. GVWR / GCWR (trucks & buses only) 10,000 lbs.

81. GVWR / GCWR (trucks & buses only) 10,000 lbs. 10,000 lbs. - 117 USDOT - - - - - - - None USDOT - - - - - - - None 127e 10,001 - 26,000 lbs. 10,001 - 26,000 lbs. 03 MC/MX - - - - - - - 26,001 lbs. MC/MX - - - - - - - 26,001 lbs. 26 128 52. Motor Carrier or Government Entity 82. Motor Carrier or Government Entity - - 26

- 26 129 Number & Street Number & Street - - 04 130 City State Zip City State Zip - - - - - - 03 131 135. Damage to Other Property Yes (If Yes, describe) No - 12

12 132 12 Oper. 136. Charge 137. Summons No. Oper. 138. Charge 139. Summons No. 133 - - - - - - 03 Oper. 140. Charge 141. Summons No. Oper. 142. Charge 143. Summons No. 134 - - - - - - 03 83 84 85 86 87 88 89 90 91 92 93 94 95 Names & Addresses of Occupants If Deceased, Date & Time of Death A 01 01 01 05 47 M -