HomeMy WebLinkAbout23-510 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE z3-s10 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 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 N E IN CITY#
cawsloN 01 - 1-- 2023 1445 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LOGAN AVE N
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e N 6TH ST
1 9 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2066500363 0 81
30
6� LAST NAME KRASUCKI FIRSTNAME JOHN MIDDLE K 1 1 2 31
INITIAL
STREET ❑ 403 LIND AVE NW CITY RENTON ST WA ZIP 980573445 2
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 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES 2❑
3
10❑ P1 aT�S� C94656L sTArI WA vIN# 387KF23622M235535
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 8 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 2 2002 DODO RAM DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO 1.KRASUCKI 1.LINDAVE NW RENTON WA 980573445 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO ST FRAM 503 7426 E02 47B 3 4
IN EFFECT &POLICY# 9TOP
VEwcLE 5 36
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ LEGALLY STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2536702886
16 a
LAST NAME MA SICK FIRST NAME TAMARA MIDDLE I L
INITIAL
17❑ STREET ❑', 714 SHELTON AVE NE CITY RENTON ST WA ZIP 980563802 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19 DRIVER'S STATE WA ]SEX IF D.C.B. 07 29 _ 1962 0 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BT65640 TAre WA vIN# KM8J3CAL8LU253999
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2020 MAKE HyUN MODEL TUCSON STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO TAMARA MASSICK 714 SHELTON AVE NE RENTON WA 980563802 D:2536702886 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO FARMRS 188427686IN 1 9TOP
VE""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES N�
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED26459
COLLISION REPORT III III III III III 111
1591972 CASE# 23-510
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.
M.LEVERTON 01-13-23 03:18 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 111912023 1:00:24 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 2:46 PM TIME POLICE ARRIVED',2:54 PM
PART I PAGE IT]OF 4�
REPORT NO. ED26459 CASE# 23-510 OF COLLISION
01/13/23 14:45
OF CbLLI510N
NARRATIVE
siv 2 foot slip brake wht suv stopped
RTF
Within the city limits of Renton/King/WA I responded to a 2 car non blocking at Logan Ave N at N 6th
St.
I contacted the driver of unit 1 who told me they were both stopped when his foot slipped off the brake
allowing him to roll forward several feet hitting unit 2 in the back end. Unremarkable damage and no
complaint of injury.
I contacted the driver of unit 2 who told me she was stopped when unit 1 bumped her from behind.
She said her neck was stiff, but refused Renton Fire. Damages did not require a tow truck.
Information/Insurance only.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Action Code: FOOT SLIPPED OFF BRAKE PEDAL
**** END OF AUTO-POPULATED SECTION ****
PAGE 3 OF 4
REPORT NO. ED26459 CASE# 23-510 DATE AND TIME 01/13/2314:45
OF COLLISION
t
PAGE 4 OF 4