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OFFICER I.D. NUMBER NUMBER 018767 9265-2018-02430 TIME (2400) 1328 NCIC NUMBER 9265 DATE OF COLLISION 07/31/2018 0 - Not a Bus 1 - School (Public or Private) 2 - Transit 3- !Meaty 4 - Charter 5- Other Yes lxi No HM # or name from diamond or box: HM Class # from bottom of diamond: Was Haz-Mat released from THIS vehicle's cargo') El Not In Commerce - Other Trucks (Over 10,000 lbs. GVVVR / GCWR) CHECK ONE: 0 Interstate Carrier II Intrastate Carrier Ei Not In Commerce - Government USDOT# MC/MX# State# CA 5934 Carrier ID Number(s): NONE 18 3 18 Event 3: Event 2: Event 4: 13 Event 1: NON-COLLISIONS 1 Ran Off Road 2 Jackknife 3 Overturn (Rollover) 4 Downhill Runaway 5 Cargo Loss or Shift 6 Explosion or Fire 7 Separation of Units 8 Cross Median / Centerline COLLISION INVOLVING / WITH (Continued) 15 Train 16 Pedalcycle 17 Animal 18 Fixed Object 19 Work Zone Maintenance Equipmenl 20 Other Moveable Object 98 Other (Describe): NON-COLLISIONS (Continued) 9 Equipment Failure (Tires, Brakes, Steering. etc.) 10 Other Non-Collision COLLISION INVOLVING / WITH 12 Pedestrian 13 Motor Vehicle In-Transport 14 Parked Motor Vehicle DATE 018767 Zachary .1 Yosh PREPARED BY 08/13/2018 REVIEWED BY J. T. Jordan 015408 STATE OF CALIFORNIA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL TRUCK / BUS COLLISION SUPPLEMENTAL REPORT CHP 555D (Rev. 1-07) OPI 062 PARTY NUMBER 2 VEHICLE INFORMATION VEHICLE CONFIGURATION (Enter one code from below) 9 1 - Passenger Car (only if vehicle has Hazardous Materials Placard) 2 - Light Truck (Only if vehicle has Hazardous Materials Placard) 3 - Bus (seats for 9-15 people, including driver) 4 - Bus (seats for 16 people or more, Including driver) 5 - Single-Unit Truck (2 axles, 6 tires) 6 - Single-Unit Truck (3 or more axles) 7 - Truck / Trailer(s) (Single-Unit Truck with Trailer(s)) B - Truck / Tractor (without trailer, bobtail, or saddlemount) 9 - Tractor / Semi-Trailer (one trailer) 10. Tractor / Doubles (two trailers) 11 - Tractor / Triples (three trailers) 99- Other Truck 10,000 lbs. (not listed above) GVWR / GCWR (Enter one code from below, Use GCWR for truck comblnallons) 3 1 - 10,000 lbs. or Less 2 - 10,001 -26,000 lbs. 3. Greater than 26,000 lbs. Bus Use (Enter one code from below) 0 CARGO BODY TYPE (Enter one code from below) 3 - Not Applicable / No Cago Body -Bus (seals for 9-15 people, including driver) 2 - Bus (seats for 16 people or more, Including driver) 3 - Van / Enclosed Box 4 - Cargo Tank 5 - Flatbed Dump Concrete Mixer - Auto Transporter 9 - Garbage / Refuse 10- Grain, Chips, Gravel 11 - Pole Vehicle Towing Another Motor Vehicle Intermodal Chassis Logging 98- Other Cargo Body (not listed above) HAZARDOUS MATERIALS INVOLVEMENT DID THE VEHICLE HAVE A HAZ-MAT PLACARD? 0 Yes 11] No IF YES, INCLUDE THE FOLLOWING INFORMATION FROM THE PLACARD: MOTOR CARRIER INFORMATION Carrier Name: SUPERIOR TRUCK LINES Carrier Street Address (P.O. Box Only if no street address): 165 LAUREL AVE City / State / ZIP Code: Gustine, CA 95322 Phone Number: (209)854-6445 PAGE 13 OF 13 AT THE TIME OF THE CRASH, THIS VEHICLE WAS: 0 Operating on a Trafficway open to the public (In-Transport) n Parked on or off the Trafficway TOTAL INVOLVED VEHICLES IN THE CRASH 2 NUMBER OF PERSONS SUSTAINING FATAL INJURIES 0 COMMERCIAL DRIVER LICENSE (CDL) 0 Yes 0 No CDL LICENSE CLASS (Check one): 111 Class A fl Class B Class C El Class D Class M NUMBER OF INJURED PERSONS TRANSPORTED FOR IMMEDIATE MEDICAL TREATMENT 1 NUMBER OF VEHICLES TOWED FROM SCENE DUE TO DISABLING DAMAGE 2