Motor Vehicle Driver's
Resume:
FULTON
At Its Intersection
With
GEORGIA
MOTOR VEHICLE CRASH REPORT 11/17/2022
Date Time
15:48 11/17/2022
Vehicles
2
Fatalities
0
Injuries
0
Inside City Of
Atlanta
Road of
Occurence PONCE DE LEON AVE NE MONROE DR NE
Hit And Run?
Suppl. To Original?
11/17/2022
Private Property?
Time
11/17/2022 15:50
Date
Dispatch Arrival Total Number of
15:57
Estimated Crash
Date Time
Not At Its
Intersection But
Miles
Feet
North
South
East
West Of
Latitude (Y) Longitude (X)
(Format) 00.00000 (Format) -00.00000
33.773650 -84.370910
Agency Case Number Agency NCIC No. County Date Rec. by DOT Posted Speed:
GA
State
TEMPLE (CARROLL)
City
State
30179
Insurance Co.
ALLSTATE FIRE & CASUALTY
LAST NAME FIRST MIDDLE
Address
Zip DOB
Driver's License No Class
Policy No.
Year Make Model
Telephone No.
VIN Vehicle Color
Tag # State County Year
Trailer Tag #
Same as Driver Owner's Last Name First Middle
Address
State Zip
Removed By:
Yes No
Alcohol Test: Type: Results: Drug Test: Type: Results: Direction of Travel:
Vision Obscured:
Operator Factors:
Vehicle Maneuver: Non-Motor Maneuver:
Most Harmful Event:
Vehicle Class: Vehicle Type:
Traffic Control: Device Inoperative:
MEDINA DIEGO
902 CREEK RUN PL
10/11/2000
059955839 C
GA
2013 CHEVROLET TAHOE
1GNSCBE08DR225490 Red
RLH7001
GA
2023
MEDINA JUAN DIEGO
TEMPLE (CARROLL) GA 30179
West
Not Obscured
Changed Lanes Improperly
Changing Lanes
Privately Owned Sports Utility Vehicle (SUV)
Traffic Signal
902 CREEK RUN PL
Request List
Unit #
1
Driver
Ped
Susp At Fault
Bike
Country
United States
State County Year
First Harmful Event: Operator/Ped Cond:
Vehicle Factors: No Contributing Factors Roadway Factors: No Contributing Factors Number of Occupants:
1
Area of Initial Contact:
Left Side-Far Front
Damage to Vehicle:
Functional Damage
Traffic Way Flow:
Two-Way Trafficway with no physical
separation
Road Composition:
Black Top
Road Character:
Straight and Level
Number of Lanes: 2 Work Zone: None
City
35
Motor Vehicle In Motion Motor Vehicle In Motion Not Drinking No No
Citation Information:
Citation # 6018698 O.C.G.A. § 40-6-48
Citation # O.C.G.A. §
Citation # O.C.G.A. §
COMMERCIAL MOTOR VEHICLES ONLY
Carrier Name
No. of Axles G.V.W.R
Cargo Body Type
Yes No
Vehicle Config.
U.S. D.O.T. #
Interstate
Intrastate
C.D.L. ? Yes No
Vehicle Placarded? Yes No
Hazmat Released? Yes No
C.D.L. Suspended? Yes No
Hazardous Materials? Yes No
If YES: Name or 4 Digit Number from Diamond or Box: Ran Off Road Down Hill Runaway Cargo Loss or Shift Separation of Units One Digit Number from Bottom of Diamond:
Fed. Reportable
Address City State Zip
Posted Speed:
GA
State
ATLANTA (FULTON)
City
State
30310
Insurance Co.
GEICO
LAST NAME FIRST MIDDLE
Address
Zip DOB
Driver's License No Class
Policy No.
Year Make Model
Telephone No.
VIN Vehicle Color
Tag # State County Year
Trailer Tag #
Same as Driver Owner's Last Name First Middle
Address
State Zip
Removed By:
Yes No
Alcohol Test: Type: Results: Drug Test: Type: Results: Direction of Travel:
Vision Obscured:
Operator Factors:
Vehicle Maneuver: Non-Motor Maneuver:
Most Harmful Event:
Vehicle Class: Vehicle Type:
Traffic Control: Device Inoperative:
MCEWEN MARLON LAMARK
965 SELLS AVE SW APT 3301
7/9/1986
070408297 C
LA
UNKNOWN
2011 NISSAN ALTIMA
1N4AL2EP0BC180827 Red
ZOC209
GA
2023
RUDOLPH E LAURENT
NEW ORLEANS LA 70119
West
Not Obscured
No Contributing Factors
Straight
Privately Owned Passenger Car
Traffic Signal
2726 ST BERNARD AVE
Request List
Unit #
2
Driver
Ped
Susp At Fault
Bike
Country
United States
State County Year
First Harmful Event: Operator/Ped Cond:
Vehicle Factors: No Contributing Factors Roadway Factors: No Contributing Factors Number of Occupants:
1
Area of Initial Contact:
Right Side-Near Front
Damage to Vehicle:
Functional Damage
Traffic Way Flow:
Two-Way Trafficway with no physical
separation
Road Composition:
Black Top
Road Character:
Straight and Level
Number of Lanes: 2 Work Zone: None
City
35
Motor Vehicle In Motion Motor Vehicle In Motion Not Drinking No No
Citation Information:
Citation # O.C.G.A. §
Citation # O.C.G.A. §
Citation # O.C.G.A. §
COMMERCIAL MOTOR VEHICLES ONLY
Carrier Name
No. of Axles G.V.W.R
Cargo Body Type
Yes No
Vehicle Config.
U.S. D.O.T. #
Interstate
Intrastate
C.D.L. ? Yes No
Vehicle Placarded? Yes No
Hazmat Released? Yes No
C.D.L. Suspended? Yes No
Hazardous Materials? Yes No
If YES: Name or 4 Digit Number from Diamond or Box: Ran Off Road Down Hill Runaway Cargo Loss or Shift Separation of Units One Digit Number from Bottom of Diamond:
Fed. Reportable
Address City State Zip
GDOT-523 (07/17)
Page 1 of 3
Weather: Clear
COLLISION FIELDS
Manner of Collision: Sideswipe-Same Direction Location at Area of Impact: On Roadway - Roadway Intersection Surface Condition: Dry Light Condition: Daylight NARRATIVE
on 11/17/22 at approximately 03:57 P.M Unit, 3603 was dispatched to Ponce De Leon and Monroe Dr. NE regarding a motor vehicle accident. Upon arrival, I met with driver #1 and driver #2.
Driver #1 stated he was behind a bus traveling westbound on Ponce De Leon Ave and came too close to driver #2 land and made contact with his vehicle. Driver #2 stated he was traveling westbound on Ponce De Leon Ave Ne when driver #1 who was also traveling westbound on the far right lane came over into her lane and collided with his vehicle. Both vehicles sustained function damages. Both parties denied injuries. Driver #1 was was a fault, was cited for OCGA Failure to maintain lane 40-6-48 Nothing further.
DIAGRAM
PROPERTY DAMAGE INFORMATION
Damage Other Than Vehicle: Owner:
Name (Last, First) Address City State Zip Code Telephone Number WITNESS INFORMATION
GDOT-523 (07/17)
Page 2 of 3
OCCUPANT INFORMATION
Sex:
Name (Last, First): Address:
Age: Position: Safety Eq: Ejected: Extricated: Air Bag: Injury: Front Seat-Left Side
MEDINA, DIEGO 902 CREEK RUN PL TEMPLE (CARROLL), GA 30179 22 Male 1 No Apparent Injury
(O)
Unknown Not Applicable No Non-Deployed Air No
Unit #
Injured Taken To: By: EMS Notified Time: EMS Arrival Time: Hospital Arrival Time: 1 Taken for Treatment:
Sex:
Name (Last, First): Address:
Age: Position: Safety Eq: Ejected: Extricated: Air Bag: Injury: Front Seat-Left Side
MCEWEN, MARLON LAMARK 965 SELLS AVE SW APT 3301 ATLANTA (FULTON), GA 30310 36 Female 2 No Apparent Injury
(O)
Unknown Not Ejected No Non-Deployed Air No
Unit #
Injured Taken To: By: EMS Notified Time: EMS Arrival Time: Hospital Arrival Time: 2 Taken for Treatment:
Sex:
Name (Last, First): Address:
Age: Unit # Position: Safety Eq: Ejected: Extricated: Air Bag: Injury: Injured Taken To: By: EMS Notified Time: EMS Arrival Time: Hospital Arrival Time: 3 Taken for Treatment:
Sex:
Name (Last, First): Address:
Age: Unit # Position: Safety Eq: Ejected: Extricated: Air Bag: Injury: Injured Taken To: By: EMS Notified Time: EMS Arrival Time: Hospital Arrival Time: 4 Taken for Treatment:
ADMINISTRATIVE
Photos Taken: Yes No
Report By: Agency: Report Date:
By:
DAVIS, DILLON (7887) Atlanta Police Department 11/17/2022 18:26 Officer Note: If collision resulted in a fatality, please send prompt notification to the GDOT Crash Reporting Unit via either email at ***********@***.**.*** or Fax at
Checked By: Date Checked:
Haslam, Cameron 11/17/2022
GDOT-523 (07/17) [Printed: 11/17/202*-*******] MAIL TO: Georgia Department of Transportation, CRASH REPORTING UNIT, 935 United Ave, SE, Atlanta, GA 30316-2590 Page 3 of 3
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