HomeMy WebLinkAbout22-12939 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 22-12939 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4'/00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 4 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION.. 12 - 1-- 2022 0450 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 10 00 FEET MILES e S B W e S 3RD ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:8017935527 30
6� LAST NAME MONFEDA FIRSTNAME ARTEMIO MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 504 MORRIS AVE S CITY RENTON ST WA 21p 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs No✓ INTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
LICENSE CAS0834 sTAr1 WAvIN# 1GNEC13T9YJ177877
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12❑ vIN#' VIN#
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 A 2000 CHEV TAHOE DAMAGE YES NO ✓ YES❑ NO✓
REGISTERED OWNER INFO ROGELIO MONFEDA 516 SHATTUCK AVE S APT 202 RENTON WA 98057 D:8017935527 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
V 'CLE CHARGE 1 5 36
LEcnlly YES NO CITATION# 10 BOTTOM
15❑ ...... 8 6
UNIT U2 VEHICCMOTOLE ❑ CYCLE ❑ PEDESTRIAN ❑✓ OWNER YES
❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME URIOSTEGUI FIRST NAME JOSE MIDDLE A
INITIAL
17 STREET❑ NEW ADOREss❑' 1601 W MEEKER ST.STE 201 CITY KENT ST WA ZIP 98032 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NO❑
19 DRIVER'S STATE SEX M D.O.B. 03 �_ 14 1991 39
LICENSE# MMDDYY
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT I HELMET 2 INJURY 5 NATURE OF INJURIES 40
USE CLASS INJURY TO LEFT FOOT
❑21❑ TArE 41
LICENSE VIN# 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 1 5 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
7NE
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
ON 12327 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED12101
COLLISION REPORT III III III III III 111
1591972 CASE# 22-12939
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 12-07-2022 at approximately 0459 hours I was dispatched to Seven Eleven at 300 Rainier AVE S,
in the City of Renton, County of King, WA for a fire assist. When I arrived, I gathered that a subject,
Uriostegui, was struck by a vehicle in the northeast corner of the parking lot. Uriostegui had a non life
threatening injury to his left foot. The driver of the only involved vehicle, Monfeda, advised that he did
not see Uriostegui who was lying down on the ground in the parking lot, and ran over his foot with the
front passenger side tire. It should be noted that Uriostegui was previously trespassed from the
aforementioned Seven Eleven and has been repeatedly warned not to return but continues to do so.
It should also be noted that I know Uriostegui to often lay down in the northeast corner of the parking
lot which he is trespassed from. Based on my prior knowledge of Uriostegui's patterns, and what
Monfeda advised, 1 do not believe Monfeda violated any traffic or other laws. Uriostegui and Monfeda
were provided with my card and the case number.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
T.NELSON 12-07-22 08:01 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 121812022 3:56:19 AM
BADGE OR ID# 12327 ORI# WA0171300 TIME POLICE DISPATCHED 4:89 AM TIME POLICE ARRIVED 5:09 AM
PART I PAGE IT]OF 3�
REPORT NO.! ED12101 CASE# 22-12939 DATE AND TIME 12/07/22 04:50
OF COLLISION
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