HomeMy WebLinkAbout22-13341 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 22-13341 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AGENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 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 1515 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
108TH AVE SE
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e SE 181ST ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2533279767 0 11
30
6❑ LAST NAME HYATT FIRSTNAME XIOUDAN MIDDLE E 1 2 31
INITIAL
STREET ❑ 10605 SE 240TH ST APT 110 CITY KENT ST WA 2jp, 980314903 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO,/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 09 1— 20 — 1988 2 32
9 ON DUTY❑ STATUS AIRBAG 1 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� CDt4680 sTArI WAurN# 1HGCM55127A181379
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2007 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 4 HOND ACCOR SD DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
15❑ vewCLE CHARGE 10BOTTOM 5 36
YES No CITATION# 3A0111446,3A0111446 NO VALID OPER LICENSE WITH
NDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2063755408
16 a
LAST NAME LOPEZ ESPINAL FIRST NAME TERESA MIDDLE I D
INITIAL
17❑ NEW STREETREs7 375 UNION AVE SE UNIT 140 CITY RENTON ST WA ZIP 980595172 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INERLOCKYEs❑No� INTERLOCK ves No� YEs NoF
19 DRIVER'S STATE WA ]SEX IF D.C... 09 _ 07 1990 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET 2 INJURY 7 NATURE OF INJURIES ❑ 40
USE CLASS HEAD,NECK,BACK
❑LICENSE I 21❑ PLA E# CCW4634 TArE 41
WA vIN# 1VWAT7A31HC003946 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
TOWED BY Gov HI 44
VEH YEAR 2017 MAKE VOLK MODEL Pq$$q 7' STYLE $D DAMAGE TOWED TOO✓ BLIN YES NO,�
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#E CO PROGRESSIVE 951754574IN 1GQO,
VEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`E]
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
E.CHANG 10065 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED24570
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13341
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MUNOZBONILLA MARYY
(LAST FIRST,
ADDRESS&PHONE#
375 UN/ON AVE SE RENTON WA 98059 4253890416 SEXi F MMDDYyry 12 - 29 - 1976
{� SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER Z WITNESS UNIT# 2 POS 8 AIRBAG 2 RESTR. 4 EJECT USE 2 CLASS 7 NECK
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 Vehicle: WA plate CDL4680 Driver: Hyatt, Xioudan E (09-20-1988)
Unit 2 Vehicle: WA plate CCW4634 Driver: Lopez Espinal, Teresa (09-07-1990)
Both drivers were identified via a WADL.
On 12-17-2022 at about 15:15 hrs., I was sent to a collision that occurred at the intersection of 108th
Ave SE and SE 181 st St, in the City of Renton, King County, Washington.
Upon arrival, Hyatt informed me of the following. She was the driver of unit 1 and she said she was
headed northbound on 108th Ave SE approaching SE 181 st St. Hyatt looked down at something and
struck unit 2. Hyatt believed she was going at a slow rate when the collision occurred.
A DOL check showed Hyatt's DOL status was canceled. She also admitted that she did not have
insurance for her vehicle.
I spoke with Teressa via a smartphone translator. She informed me she was headed northbound on
108th Ave Se approaching SE 181 st St when unit 1 struck her from the rear. Teressa said she was in
lane 1 and was going about 35 mph. Teressa said due to the collision she now has pain in her head,
neck, and back. Her passenger also has neck pain. She was seen by Fire prior to my arrival but did
not go to the hospital.
I inspected the damage on both vehicles and found non-reportable damage.
Hyatt was cited for no insurance and no valid operator's license.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.CHANG 01-05-23 01:27 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 111312023 11:52:48 AM
BADGE OR ID# 10065 OR]# WA0171300 TIME POLICE DISPATCHED 3:25 PM TIME POLICE ARRIVED 3:42 PM
PART I PAGE IT]OF
REPORT NO. ED24570 CASE# ' 22-13341 DATE AND TIME 12/17/22 15:15
OF COLLISION
N
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