HomeMy WebLinkAbout23-1573 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-1573 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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.. 02 - 1-— 2023 1329 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ ----� ❑
NE 3RD ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ W e JEFFERSON AVE NE
0 1 29
UNIT MOTOR
Z PEDAL-
❑ YESA,GEE NHORESHOLD MET PHONE 0 7 30
6� LAST NAME BLAKE FIRSTNAME ZACKERY MIDDLE T 1 0 11
31
INITIAL
STREET ❑, 600 ELLINGSON RD APT K8 CITY PACIFIC ST WA ZIP 980471279 z
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 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 1❑ P1 ATE 14 BfV0125 STATE WA ,r,# KNAFE161865345481
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
TRLR. TRLR 7 3 33
12 0 0 VIN If UIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE J 9 34
13 2 2006 KIA SPECTR DAMAGE YES No� �LWkRS OR No
REGISTERED OWNER INFO ZACKERY BLAKE 280 SW CLARK ST UNIT B104 ISSAQUAHWA 98027 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14� ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
ve EFFECT
CHARGE to BOTTOM 5 36
YES No CITATION# 3A0081028,3AO081028 OP MOT VEH W/OUT INSURANCE,FL
15❑ MOTO PEDAL-STANDING 8 7 6
UNIT a2 VE ICCLE CYCLE ❑ PEDESTRIAN PROPEOWNER
❑ DYES 1/ NO THR OLD MET PHONE
16 a
LAST NAME LEWIS FIRST NAME GRAYLIN MIDDLE I D
INITIAL
17❑ STREET ❑', 2307 NE 4TH ST APT K305 CITY RENTON ST WA ZIP 980568826 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK v�Esl I I NOF YEs t l No❑
19 DRIVER # STATE WA SEX M M D.C.B. 09 _ 15 _ 1963 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BNJ5076 TATe WA VIN# 5J6RW2H5XJA001342
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 201E MAKE HOND MODEL CR-I/ STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO GRAYLIN LEWIS 2307 NE 4TH ST APT K305 RENTONWA98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO ALLSTATE 917640036IN 1U
9TOP
vE""LE CITATION# CHARGE o BOTTOMLEGALYYES Nu25❑ J
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED32151
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1573
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 02-07-23 03:38 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.MORRIS 2613 2/8/2023 9:21:27 AM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED' 1:30 PM TIME POLICE ARRIVED',1:39 PM
PART I PAGE IT]OF 4�
REPORT NO. ED32151 CASE# 23-1573 OF COLLISION
02/07/23 13:29
OF CbLLI510N
NARRATIVE
slv suv/ 2 stopped lane 2 blk coupe unit 1 def brakes 2-27-2022 no ins
CC
Within the city limits of Renton/King/WA I responded to a 2 car blocking crash at NE 3rd St at
Jefferson Ave NE.
Ref RCW 46.16A.030
Ref RCW 46.30.020
1 contacted the driver of unit 2 who told me he was eastbound lane 2 on NE 3rd stopped for traffic
when he was hit front behind by unit 1. He did not complain of injury and damages did not require a
tow truck.
I contacted the driver of unit 1 ID'd by picture WADL. He told me his brakes "skipped" when he tried to
stop for traffic. I checked his brake pedal both running and ignition off. Both checks the brake pedal
had no resistance and went to the floor. He was unable to provide valid proof of insurance. His tabs
displayed 2-2022. A WACIC/DOL check revealed tabs were expired 02-27-2022. He did not
complain of injury and damages required a tow truck.
I cited Unit 2 ref the above listed RCW 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 2/7/2023
PAGE 3 OF 4
REPORT NO. ED32151 CASE# ' 23-1573 DATE AND TIME 02/07/23 13:29
OF COLLISION
t
AV IIIIIIIIIIIIIIII11k
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