HomeMy WebLinkAbout22-13736 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 22-13736 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 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 1824 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
AIRPORT WAY S
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET ❑ S ❑ VV❑ LAKEAVE S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2064128531 0 11
30
6❑ LAST NAME LUNDGREN FIRSTNAME ZACHARY MIDDLE M 1 2 31
INITIAL
STREET ❑ 7001 OLD REDMOND RD APT#D113 CITY REDMOND ST WA 2jp, 98052 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX' ID
M MELO B 11 1- 18 - 1996 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
❑
10 9❑ PI ATFBit BJX6207 sTArI WA urN#' WBAV813526PT19281 3
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR 2006 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 4 BMW 325 SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO WING KWA17011 OLD REDMOND RD APT#113 REDMOND WA 98052 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO eq�T3 4
LIABILITY INSURANCE
IN EFFECT &POLICV# 9TOP 5
VEwcLE CHARGE 10 BOTTOM 36
LE�ALLv YES No CITATION# 2A0521637,2A0521637 OP MOT VEH W/OUT INSURANCE,
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
�U—NIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2065127553
16 a
LAST NAME LI FIRST NAME SHUYI MIDDLE
INITIAL
17 STREET NEW ADOREs7 5621 S LAWRENCE ST APT B CITY TACOMA ST WA ZIP 98409 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑No� INTERLOCK YEs❑NOF YES
❑NoF,/
19 DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES ❑ 40
LICENSE I ❑21❑ PLA E# CAE3857 TArE 41
WA VIN# JHMES26741S003472 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
TOWED BY GOV HI 44
VEH YEAR 2001 MAKE HOND MODEL CIVIC STYLE $D DAMAGE TO WED NOO✓ BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE I PORGY#ECO LIBERTY MUTUAL AOS-261-960960-70-26 1 9TOP 5
IN EFFECT
VE—LE ❑ ,J CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES Nu
$ '
7BRYAN
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26GROZAV 12489 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED22014
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13736
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
PM 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'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
BRYAN GROZAV 12-26-22 08:39 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1 11512023 2:28:25 AM
BADGE OR ID# 1Y489 ORI# WA0171300 TIME POLICE DISPATCHED 6:41 PM TIME POLICE ARRIVED',6:49 PM
PART I PAGE IT]OF 4�
REPORT NO. ED22014 CASE# 22-13736 OF COLLISION
12/26/22 18:24
OF CbLLI510N
NARRATIVE
CASE 22-13736
SECTOR TRAFFIC INFRACTION: 2AO521637
This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events.
On Monday December 26th, 2022 at approximately 18:49, 1 responded to a 911 call regarding a two-
vehicle collision in the area of Airport Way S and Lake Ave S in the City of Renton, King County,
Washington.
'CALL REMARKS: 2 MVA NI/NB... BOTH VEHS PULLED INTO THE PLOT 111 AIRPORT WAY.
-UNIT ONE: BLACK 2006 BMW 325 WASHINGTON LICENSE BJX6207
-UNIT ONE DRIVER: ZACHARY M. LUNDGREN (DOB: 11.18.1996)
-UNIT TWO: GRAY 2001 HONDA CIVIC WASHINGTON LICENSE CAE3857
-UNIT TWO DRIVER: SHUYI LI (DOB: 4.01.1984)
1 arrived on scene and contacted Zachary who reported the following; he was traveling east on Airport
Way S behind unit two. Unit two slammed on the brakes but he wasn't able to stop in time causing
him to crash into the back of unit two. Zachary was not injured and did not want medical attention.
Zachary was the sole occupant of the vehicle at the time of the collision. Unit one had minor front end
damage and was still drivable. Zachary informed me he did not have insurance.
After speaking to Zachary, I contacted Shuyi who said Zachary crashed into her. Shuyi was not
injured and did not want medical attention. Shuyi was the sole occupant in the vehicle at the time of
the collision. Unit two had minor rear end damage and was drivable.
I issued Zachary a traffic infraction (2A0521637) for the following traffic violations:
OP MOT VEH W/OUT INSURANCE RCW 46.30.020
INATTENTIVE DRIVING RMC R10-12-25
I informed Zachary that 1 was going to forward traffic infraction to court for mailing.
I provided both Zachary and Shuyi a SECTOR exchange of information form while on scene.
This concludes my involvement in this case.
I certify/declare under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct.
Electronically signed by B. Grozav #12489 on 12.26.2022 at 20:30 hours in Renton, WA
PAGE 3 OF 4
REPORT NO. ED22014 CASE# ' 22-13736 DATE AND TIME 12/26/22 18:24
OF COLLISION
LAKE AVE S
NOT TO SCALE
AIRPORT WAYS
e ua d�
PAGE 4 OF 4