HomeMy WebLinkAbout22-354 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE# 22-354 2 0 7
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
COLLISION.. 01 — 09 — 2023 1940 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RENTON AVE S BLOCK NO. e✓ 13600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252603945 0 81
30
6 LAST NAME HOLLEMBAEK FIRSTNAME BROOKLYN MIDDLE M 1 2 31
INITIAL
STREET ❑, 10910 SE 252ND PL APT FF304 CITY KENT ST WA 2jp, 98030 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 1❑ PI ATFBit BXJ9560 sTArr WA urN#' JM16L1UP8D1777118
TRAILER STATE TRAILED STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#
>;. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 4 2013 MMAZE) 3 SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 4455836A2147B 3 4
IN EFFECT &POLICY# 9TOP
vECALLv HICLe 1 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LE STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2068838423
16 a
LAST NAME DI EP FIRST NAME AN MIDDLE Q
INITIAL
17❑ NEW STREETR 12033 7
7 0TH AVE S CITY SEATTLE ST' WA ZIP 98178 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER'S STATE WA SEX M D.O.B. 09 _ 07 1978 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
❑ILICENSE 21❑ PLA E# APA7463 TArE 41
WA VIN# 2T3RFREV7DW095804 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2013 MAKE TOYT MODEL RAV4 STYLE SV VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO AN DIEP 1203370TH AVE S SEATTLE WA 98178 D:2068838423 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#ECO ECONOMY PREFERRED INSURANCE COMPANY 7802323970 1 9TOP 5
IN EFFECT
vE""LE CITATION If CHARGE
LEG
25 i o BOTTOM
ALLY YES NEI
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.ARNOLD 12509 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED24994
COLLISION REPORT III III III III III 111
1591972 CASE# 22-354
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 01/09/2023 at 1949 hours I was dispatched to a blocking collision at the 13600 blk of Renton Ave
S. When I arrived, I spoke with the driver of Vehicle 2 who told me that he was stopped for the
pedestrian crosswalk facing West in the number 2 lane. Driver 2 said that when he stopped, Vehicle 1
made contact with Vehicle 2 by colliding into the rear driver side of Vehicle 2 with the front passenger
side of Vehicle 1. The driver of Vehicle 1 stated that she observed the pedestrian crosswalk signals
activated and thought that Vehicle 2 should have proceeded through which is against the law. the
driver of Vehicle 1 stated that she attempted to avoid the collision but did not have enough time to
stop and was only able to angle Vehicle 1 slightly to the left of Vehicle 2 which resulted in Vehicle 1
colliding with Vehicle 2 by hitting the rear drivers side of Vehicle 2 with the front passenger side of
Vehicle 1. The driver of Vehicle 1 also stated that she slid due to the wet road conditions.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.ARNOLD 01-09-23 08:58 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1 111512023 1:31:09 AM
BADGE OR ID# 12509 OR]# WA0171300 TIME POLICE DISPATCHED 7:49 Pry TIME POLICE ARRIVED'7:55 PM
PART I PAGE IT]OF 3�
REPORT NO. ED24994 CASE# ' 22-354 DATE AND TIME 01/09/23 19:40
OF COLLISION
***NOT TO SCALE—
13600 blk
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