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Form I - San Joaquin County Vehicle Accident Form <br /> COUNTY OF SAN JOAQUIN Print Form <br /> tout .goc <br /> x AUTOMOBILE ACCIDENT <br /> Information Reported Herein is <br /> Considered Privileged and Confidential <br /> Please Print-Ril OutPrint Immediately Send One Copyto Public Works-Fleet Servicesan ne to Risk Management Must be*ned by Supervisor <br /> Name of County Driver(V* icle a1) Address Employee ID No. AS. Driver's License No. <br /> 0 Department Division Location Code No. County Phone No. <br /> U <br /> n Date of Accident Time of Accident Location of Accident(Intersection or Address) law Enforcement Notifcd?r yes r No Law Enforaarrenl <br /> it I I r sheriff r City PD r CHP Report No. <br /> y For What Purpose was Vehicle Being Used at Time of Accident or Loss? <br /> DCounty Vehicle No. Vehicle License No. County Vehicle Year I Counh'Vehicic\take Counly Vehic1c.Model <br /> r <br /> i Describe Damage or Loss:iCrhell,Specify Property: N'as County Vehrc a"rowed^. <br /> V r Yes r No <br /> e <br /> r Were you Injured?If yes,Part of Body AlTected. Describe Your Injury <br /> r Ycs <br /> r No <br /> OName of Other Driver(Vehlde F2) Driver's License No. Drone Number Agc <br /> t Address City State Zip Codc <br /> h <br /> e Registered Owner of Vehicle V e rc c nsu y 'o icy No. <br /> r <br /> D Registered Owner Address City State Zip C.d. <br /> r <br /> Other Vehicle License No. Year VU-e Ato \Vas Vehrc e'rowed.' <br /> V r Yes No <br /> e Descn c Damage to er Vehicle Describe Other Driver's Injury <br /> r r None <br /> OInjured Person's Name ..umber <br /> h Address City Slate Zip Code <br /> e Describe Injury Hospitalized Doctor Passenger Vehicle Pedestrian Hit By <br /> r 01 r 02 r N3 I—01 r N2 r e: <br /> I <br /> n Injured Pers.on's Name Age Phone Number <br /> UAddnas City state Zip Codc <br /> r <br /> i Dcscribc Injure limpitalvcd Doctor Passenger Vehicle Pedestrian Hit By <br /> e r 41 r #2 r r ul r p2 r #3 <br /> s <br /> Were Any Injured Persons Transported by Ambulance? r yes No <br /> Witness Name Phenc Number <br /> W Address City Sole LR Codc <br /> i <br /> t Witness Name Phone Number <br /> n <br /> SAddress City StateZ.p Code <br /> s <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 34 <br />