HomeMy WebLinkAbout23-850 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE# z3-sso 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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 0720 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
116TH AVE SE
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e SE 164TH ST
0 1 29
UNIT MOTOR
VEHICL Z CYCLE ElDDAMYESA✓THRESHOLD PHONE 0 11
30
6� LAST NAME HENDERSON FIRSTNAME JAMES MIDDLE E 1 1 2 31
INITIAL
STREET ❑ 14566 167TH PL SE CITY RENTON ST WA ZIP 980597940 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 9❑ P1 aT�S� INDEEGO sTArI WAurN# 1N6ED1EK4NN684441
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
TRLR. TRLR 3 7 33
12 3 0 VIN#j VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 2022 NISS FRONTI DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO JAMES HENDERSON 11566167TH PL SE RENTONWA 98059 D:4253014491 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE z INSURANCE CO SAME. 4
LI EFFECT I POLICY# TOPVEHICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# 3AO081017 FAIL STOP AT STOP <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
�UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2069143660
16 a
LAST NAME PHELPS FIRST NAME LINDSEY MIDDLE R
INITIAL
17❑ STREET ❑', 12741 SE 163RD ST CITY RENTON ST WA ZIP 980585521 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LDI IVER # STATE WA ]SEX IF M D.O.B. 04 O6 _ 1982 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CAZ9113 TAre WA VIN1t JTNKHMBX9M1128705
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2029 MAKE TOYT MODEL C_HR STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO BANKERS YES NO
REGISTERED OWNER INFO LINDSEY PHELPS 12741 SE 163RD ST RENTON WA 980585521 D:2069143660 VEHICLE NO.2
SHADE IN DA GEbAREA
z Cdd
LIABILITY
INSURANCE INSURANCE
#E CO USAA 0089253317106IN 1G'E""LE
TOP❑ ,J� CITATION# CHARGE OTTOM
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED30169
COLLISION REPORT III III III III III 111
1591972 CASE# 23-850
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(IAST FIRST,MIDDLE INITIAL) BOGDEN .
ADDRESS&PHONE# D.O.B.
4255457901 SEX' U MMDDYYYY -❑
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
'(LASTr FIRS' MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYY. -=
PASSENGER ❑WITNESS❑ UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
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 01-20-23 08:34 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 113112023 4:32:12 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 7:54 AM TIME POLICE ARRIVED',8:00 AM
PART I PAGE IT]OF 4�
REPORT NO. ED30169 CASE# 23-850 OF COLLISION
01/20/23 07:20
OF CbLLI510N
NARRATIVE
blue truck/unit 1 crossing 164 unit2 small sedan gray nb 116th
CC
Within the city limits of Renton/King/WA I responded to a 2 car crash near 116th ave SE at SE 164th
St.
I contacted the driver of unit 2 who told me she was going about 30 mph in a 30 zone northbound
when unit 1 crashed into the side of her spinning her out. She did not complain of injury and
damages did require a tow truck.
I contacted the driver of unit 1 ID'd by picture WADL. Unit 1 said he stopped for the stop sign and
checked left and right as he believed it was clear. He said unit 2 was going too fast and hit him as he
proceeded. So I clarified with unit 1 that he didnt see any cars, it was clear, but saw unit 2 going way
too fast and pulled out anyhow. He told me he wasnt sure and that it all happened so fast. He did not
complain of injury and he chose not to have his truck tow for damages.
I cited Unit 1 ref RCW 46.61.190 FTYROW from stop sign 2 car crash via complaint.
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 1/20/2023
PAGE 3 OF 4
REPORT NO. ED30169 CASE# ' 23-850 DATE AND TIME 01/20/23 07:20
OF COLLISION
ON t
PAGE 4 OF 4