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V SPECIALNOTE DING BOXES A7L STATE OF CALIFORNIA CALIFORNIA HIGHWAY PATROL 10-11-12-13 ARREST OR CITATION .TRAFFIC.ACCIDENT. REPORT 21-22-23-24 35-5.70..7 .35 25 (COUNTY AREA (SEAT (ACCIDENT ACCIDENT.OCCURRED ON (ROUTE NO. (MILE POST) DAY OF WEEK . Rw. 26 AT INTERSECTIONWITH KIGHWAYROADSTREETALLEY NO.OF OCCUPANTS VEH.NO.1 VEHNO.2 DATE TIME P.M 27-29 THERDESCRIPTION FEEt SOSTd OF.JACKSON.S.T 2 TOTAI OIA 23-30 .PEDESTRIAN 2. other motor veh. 3.parked motor 4.TRAIN 5. BicycliST 6.ANIMAL 7.OTHER OTOR VEHICLE IN TRAFFIC VEHICLE OBJECT 31.35 VOLVED WITH EIXDOBECI 9RANOEESQAD 1Q.OVERIURNED.INROAD .OIHER.NONCOLLISIO RES.PHONE. ARLOJ SRONSON CAT2 DRIVEN.BY EMPLOYER STI YEARS) FHON) DR.LI 50 ION DESC. -01 CTYPE. AGE (HAR) (RYES (NT.) (2) (SIATHDATE) (NUMBER) (STATE) REG..RESTR..TEMP. VEEICLE VEHICLE .....VEH.LIC.. (COLOR (TEAR) (UMBERS) STATK) 32 5 EPORX.3S7 CHiAUSA PRESENT OWNER 53-54 (ADDRESS EXTENT:.MinoR. MAJOR PARTS GoingDOTH .ON.. MODERATE TOTAL 55 FREQUENTL NEVER BEFORE USED ROA RARELY D PRIOR TO ACCIDENT 56 ON ORDERS OF. CHP.POL DRIVER ALSOLIST PEDESTRIAN BICYCLIST ENGINEER 57-55 RES.PHONE. DRIV DRIVEN BY. 53.60 (TRARS 2 EMPLOYER... AME OF PERSON. COMTANT OR ORGANIZATION FAODRESS No. R.LC UPATION. 5/850 DESC. C 150 AGE) MAR) (EYES) T (ET.) (SIATHDATE) Vehicle NUMBE (STATE) REG.RESTR.,TEMP. 50 VEHICLE NCLUDE TRAILERS COLOR TYPE CooK (STATE) S1 Present owner. ADDRESS) CITY) ACROSS(rED. Extent: minor MAJOR PARTS ..ON moderate Uses RoAD OR"stReet re9yy) RARELY Date driver last* osed road....... 23-54 NEVER BEFORE Veh. Moved to...!?... MR PRIOR TOACCIDENT .ON ORDERS OF... OCATION 55 ROPERTYDAMAGED OTHER THAN VEHICLES. (DESCRISK JWNED BY .NOTIFIED? MAM (ADDRESS) (CITY) YES INDEX 57.58 WITNESSES COPY FILE XCD 59.60 (WANE) (AGE)" (CHECK ONE ONLY N VEHICLE 79 STAT 1.KID No AGE SEX 2.SEVERE WOUND 3.OTHER VISISLE INJURIES. 4.MOMENTARY UN VEHICLE CONSCIOUSNESS POSITION EJECTED BY THERNUMBERLR X DIST YEs ENG. NAME...... ADDRESS TAKEN TO ROAE VICTIMS DEPT Yxs NAME. ADDress MIL. YEs NAME. ADDRESS TAKENTO 0 NAME DDRESS P.D. TAKENT A8 REPORT MADE BY b6 b7C