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Carrier ID Number(s): NONE USDOT# MC / MX # State# CA 433667 SEQUENCE OF EVENTS NOTE. FOR THIS VEHICLE, LIST UP TO FOUR EVENTS 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)) 8- 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 combinations) 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 0 - Not a Bus 3- Intecity 1 - School (Public or Private) 4 - Charter 2 - Transit 5 - Other HAZARDOUS MATERIALS INVOLVEMENT DID THE VEHICLE HAVE A HAZ-MAT PLACARD? Yes 0 No IF YES, INCLUDE THE FOLLOWING INFORMATION FROM THE PLACARD: HM 4-Digit # or name from diamond or box: HM Class # from bottom of diamond: Was Haz-Mat released from THIS vehicle's cargo? Liii Yes E No CARGO BODY TYPE (Enter one code from below) 5 0 - Not Applicable / No Cago Body 1 - Bus (seats 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 6 - Dump 7 - Concrete Mixer 8 - 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) MOTOR CARRIER INFORMATION Interstate Carrier 0 Intrastate Carrier 0 Not In Commerce - Government Not In Commerce - Other Trucks (Over 10,000 lbs. GVWR / GCWR) Carrier Name: S&M TRANSPORTATION Carrier Street Address (P.O. Box Only if no street address): 547 REAL COURT City! State / ZIP Code: Newman, CA 95360 Phone Number: (209)862-4212 STATE OF OALIFORNrA DEPARTMENT OF CALIFORNIA HIGHWAY PATROL TRUCK / BUS COLLISION SUPPLEMENTAL REPORT CHP 5550 (Rev. 1-07) OPI 062 PARTY NUMBER 1 PAGE 12 OF 13 NUMBER 9266-2018-01002 TIME (2400) 0710 DATE OF COLLISION 08/14/2018 NCIC NUMBER 9266 OFFICER I.D. NUMBER 014808 GENERAL INSTRUCTIONS - COMPLETE THIS FORM FOR EACH QUALIFYING VEHICLE IF THE CRASH MEETS CRITERIA ON BACK OF THIS FORM. QUALIFYING INFORMATION THIS FORM IS BEING COMPLETED BECAUSE THIS VEHICLE IS 1=1A truck or truck combination > 10,000 lbs. GVWR / GCWR 0 A bus with seats for 9 or more persons, including driver EA vehicle of any type with a hazardous materials placard (includes auto, light truck, van, 10,000 lbs. or less) AT THE TIME OF THE CRASH, THIS VEHICLE WAS: E Operating on a Trafficway open to the public (In-Transport) El Parked on or off the Trafficway TOTAL INVOLVED VEHICLES IN THE CRASH 2 NUMBER OF PERSONS SUSTAINING FATAL INJURIES 0 NUMBER OF INJURED PERSONS TRANSPORTED FOR IMMEDIATE MEDICAL TREATMENT 1 NUMBER OF VEHICLES TOWED FROM SCENE DUE TO DISABLING DAMAGE COMMERCIAL DRIVER LICENSE (CDL): Yes 0 No CDL LICENSE CLASS (Check one): E! Class A Class Class C Class D I Class ri./1 VEHICLE INFORMATION Event 1: Event 2: Event 3: 13 Event 4: 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 NON-COLLISIONS (Continued) 9 Equipment Failure (Tires, Brakes, Steering, etc.) 10 Other Non-Collision COLLISION INVOLVING / WITH (Continued) 15 Train 16 Pedalcycle 17 Animal 18 Fixed Object 19 Work Zone Maintenance Equipment 20 Other Moveable Object 98 Other (Describe): COLLISION INVOLVING / WITH 12 Pedestrian 13 Motor Vehicle In-Transport 14 Parked Motor Vehicle PREPARED BY C A DUNCAN 014808 REVIEWED BY S. A. Mc Crary 013652 DATE 08/17/2018