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DATE OF COLLISION <br />08/14/2018 <br />NUMBER <br />9266-2018-01002 <br />OFFICER I.D. NUMBER <br />014808 <br />NCIC NUMBER <br />9266 <br />TIME (2400) <br />0710 <br />Class C <br />COMMERCIAL DRIVER LICENSE (CDL): <br />1:1 Yes El No <br />CDL LICENSE CLASS (Check one) <br />El Class A Class B <br />c;iEcr <br />0 Interstate Carrier El Intrastate Carrier <br />Carrier Name: HER VAC TRUCKING <br />0 Not In Commerce - Government 0 Not In Commerce - Other Trucks (Over 10,000 lbs. GVVVR / GCWR) <br />DATE <br />08/17/2018 <br />REVIEWED BY <br />S. A. Mc Crary 013652 <br />PREPARED BY <br />C A DUNCAN 014808 <br />• <br />STATE OF 'oALIFO.RNI°A <br />DEPARTMENT OF CALIFORNIA HIGHWAY PATROL <br />TRUCK / BUS COLLISION SUPPLEMENTAL REPORT <br />CHP 555D (Rev. 1-07) OPI 062 <br />PAGE 13 OF 13 <br />PARTY NUMBER <br />2 <br />MOTOR CARRIER INFORMATION <br />VEHICLE INFORMATION <br />USDOT# <br />Carrier Street Address (P.O. Box Only if no street address): <br />City / State / ZIP Code: Tustin, CA 92780 <br />Carrier ID Number(s): NONE State# CA 401942 MC / MX # <br />13921 TUSTIN EAST DR 65 <br />Phone Number: (714)206-6855 <br />0 - Not a Bus <br />1 - School (Public or Private) <br />2 - Transit <br />NON-COLLISIONS <br />1 Ran Off Road <br />2 Jackknife <br />3 Overturn (Rollover) <br />4 Downhill Runaway <br />5 Cargo Loss or Shift <br />6 Explosion or Fire <br />7 Separation of Units <br />8 Cross Median / Centerline <br />COLLISION INVOLVING / WITH <br />12 Pedestrian <br />13 Motor Vehicle In-Transport <br />14 Parked Motor Vehicle <br />Event 1: Event 2: <br /> <br />Event 3: 13 <br />NON-COLLISIONS (Continued) <br />9 Equipment Failure (Tires, Brakes, Steering, etc.) <br />10 Other Non-Collision <br />Event 4: <br />COLLISION INVOLVING (WITH (Continued) <br />15 Train <br />16 Pedalcycle <br />17 Animal <br />18 Fixed Object <br />19 Work Zone Maintenance Equipment <br />20 Other Moveable Object <br />98 Other (Describe): <br />Bus Use (Enter one code from below) <br />0 <br />Intecity <br />Charter <br />5 - Other <br />CARGO BODY TYPE (Enter one code from below) <br />3 <br />0 - Not Applicable / No Cago Body <br />1 - Bus (seats for 9-15 people, including driver) <br />2- Bus (seats for 16 people or more, including driver) <br />3 - Van / Enclosed Box <br />4 - Cargo Tank <br />5- Flatbed <br />6 - Dump <br />7 - Concrete Mixer <br />8 - Auto Transporter <br />9 - Garbage / Refuse <br />10 - Grain, Chips, Gravel <br />11 - Pole <br />Vehicle Towing Another Motor Vehicle <br />Intermodal Chassis <br />Logging <br />98- Other Cargo Body (not listed above) <br />HAZARDOUS MATERIALS INVOLVEMENT <br />DID THE VEHICLE HAVE A HAZ-MAT PLACARD? <br />0 Yes El No <br />IF YES, INCLUDE THE FOLLOWING INFORMATION FROM THE PLACARD: <br />HM 4-Digit # or name from diamond or box: <br />HM Class # from bottom of diamond: <br />Was Haz-Mat released from THIS vehrcle's cargo') Yes 11 No <br />1 -10,000 lbs. or Less <br />2 - 10,001 - 26,000 lbs. <br />3 - Greater than 26,000 lbs. <br />GVWR I GCWR (Enter one code from below. Use GCWR for truck combinations) <br />3 <br />VEHICLE CONFIGURATION (Enter one code from below) <br />9 <br />1 - Passenger Car (only if vehicle has Hazardous Materials Placard) <br />2 - Light Truck (Only if vehicle has Hazardous Materials Placard) <br />3 - Bus (seats for 9-15 people, including driver) <br />4 - Bus (seats for 16 people or more, including driver) <br />5 - Single-Unit Truck (2 axles, 6 tires) <br />6 - Single-Unit Truck (3 or more axles) <br />7 - Tritk / Trailer(s) (Single-Unit Truck with Trailer(s)) <br />8 - Truck / Tractor (without trailer, bobtail, or saddlemount) <br />9 - Tractor / Semi-Trailer (one trailer) <br />10- Tractor / Doubles (two trailers) <br />11 - Tractor/ Triples (three trailers) <br />99 - Other Truck > 10,000 lbs. (not listed above) <br />AT THE TIME OF THE CRASH, THIS VEHICLE WAS: <br />1:1 Operating on a Trafficway open to the public (In-Transport) <br />El Parked on or off the Trafficway <br />TOTAL INVOLVED VEHICLES IN THE CRASH <br />2 <br />NUMBER OF PERSONS SUSTAINING FATAL INJURIES <br />0 <br />Class D I I Class M <br />NUMBER OF INJURED PERSONS TRANSPORTED FOR IMMEDIATE MEDICAL TREATMENT <br />NUMBER OF VEHICLES TOWED FROM SCENE DUE TO DISABLING DAMAGE