HomeMy WebLinkAbout23-519 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
❑ ✓❑ RESULTED ❑ CASE 23-519 z
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.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 RESERVATION STRUCK
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
CowsloN 01 - 1-- 2023 1904 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
EDMONDS AVE NE BLOCK NO. e✓ 1200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e NE 12TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063538207 0 11
30
6� LAST NAME NAEEMI FIRSTNAME MOHAMMED MIDDLE J 1 2 31
INITIAL
STREET ❑ 510 STEVENS AVE SW CITY RENTON ST WA ZIP 98057 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I INTERLOCK YES[:]No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 2❑ P1 ATNES14 TWX4841 STATE VA VIN# 1NXBR32E03Z040130
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 2 5 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 1 $ 34
13 2 2003 TOYT COROL 4D DAMAGE YES NO ✓ YES[:] No
✓
REGISTERED OWNER INFO MOHAMMED NAEEMI 510 STEVENS AVE SW RENTON WA 98057 D:2063538207 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE MUTUAL A0526101715990
IN EFFECT &POLICY# 9TOP
VE—LE 10 BOTTOM 5 36
LEGALLY
res❑NO❑ CITATION# CHARGE 5
15❑ STANDING 6
UNIT MOT VE IOOR CYCLE ❑PEDAL- PEDESTRIAN ❑ OWNER RTY ❑ DYES✓ NO OLDMET PHONE
16 a
LAST NAME PEARSON FIRST NAME AARON MIDDLE M
INITIAL
17 STREET❑ NEW ADOREss❑' 950 HARRINGTON AVE NW CITY RENTON ST WA ZIP 98056 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 LICENSE# STATE WA SEX M M D.O.B. 10 _ 21 1995 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# BUR7645 TATE 41
WA VIN# 1J4FF68S9Xl585715 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
GI
VEH YEAR 1999 MAKE JEEP MODEL CHEROK STYLE VT DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO✓ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#E CO FARMERS 517082621IN STOP 5
vE"'LE ❑ ,J� CITATION# CHARGE to BOTTOM
LEGALLY YES N`L J
25OQ
s � a
7jo
R'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
THAN SELBERT 12641 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED32890
COLLISION REPORT III III III III III 111
1591972 CASE# 23-519
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.
JONATHAN SELBERT 01-13-23 08:17 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 211112023 1:52:45 AM
BADGE OR ID# 12641 OR]#' WA0171300 TIME POLICE DISPATCHED; 7:08 Pry TIME POLICE ARRIVED]7:14 PM
PART I PAGE IT]OF 4�
REPORT NO. ED32890 CASE# 23-519 OF COLLISION
01/13/23 19:04
OF CbLLI510N
NARRATIVE
On 1/13/2023, at 1908, 1 responded to a call for an Accident at the intersection of Edmonds Avenue
NE and NE 12th Street in the City of Renton, King County, Washington State.
I arrived and observed two vehicles parked on the south shoulder of NE 12th Street just east of
Edmonds Avenue NE. Vehicle 1, a white Toyota Corolla bearing VA license TWX4841, was parked
just behind vehicle 2, a black Jeep Cherokee bearing WA license BUR7645.
I observed Vehicle 1 had damage to the front driver's side.
I observed Vehicle 2 had damage to the front passenger's side. I also noted that fluid leaked form the
engine.
The driver of vehicle 1 stated that he had been driving eastbound on NE 12th Street. After driving
into the intersection of 12th Street and Edmonds Avenue, his vehicle was struck by vehicle 2.
Though driver 1 made this statement in English, it should be noted that he requested translation
assistance from a friend on his phone before leaving the area. He may wish to provide a more
complete account at a later time.
The driver of vehicle 2 stated that he had been driving southbound on NE Edmonds Avenue. He
stated that he stopped at the stop sign at Edmonds Avenue and 12th Street before entering the
intersection. When his vehicle entered the intersection, vehicle 1 appeared "out of nowhere" at a high
rate of speed and struck his vehicle.
Both drivers stated they did not need medical attention.
I facilitated the exchange of insurance information between the two.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer J. Selbert (12641) in the City of Renton, King County, Washington
State on 12/27/2022 at 0005.
PAGE 3 OF 4
REPORT NO. ED32890 CASE# 23-519 DATE AND TIME 01/13/2319:04
OF COLLISION
NE 12th Street
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PAGE 4 OF 4