HomeMy WebLinkAbout23-1622 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-1622 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI 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#
cawsloN 02 - 1-- 2023 1538 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 .❑ FEET e S ❑ VV e 140TH WAY SE
❑ �
0 1 29
UNIT MOTOOR Z CYDDAL ❑ DYESA✓NOESHOLDMET PHONE 0 6 30
6� LAST NAME PECKMAN FIRSTNAME PATRICIA MIDDLE A 1 2 31
INITIAL
STREET ❑ 16621 148TH AVE SE CITY RENTON ST WA ZIP 980588267 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 4 EJECT 1 HELMETU E ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ Pi ATNES# BV22306 sTAr WAu N# 5TDDZRFH5JS864906
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FR.. ro
TRLR. TRLR. 5 1 33
12 4 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13❑2 2018 TOYT HIC�HLA DAMAGE YES NO ✓ YES[:] ✓
No
REGISTERED OWNER INFO PATRICIA PEC 116621148TH AVE SE RENTON WA 98058 D:2063724212 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE z INSURANCE CO SAME. 4
LI EFFECT &POLICY# TOPVENICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STAIN,'I 7 6
UNIT U2 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
[:]I DYES✓ NO OLD MET PHONE
16 a
LAST NAME SLACK FIRST NAME JACKSON MIDDLE I J
INITIAL
17❑ STREET ❑', 24450 249TH AVE SE CITY MAPLE VALLEY ST WA ZIP 980388219 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 M D.Q.B. 01 24 2006 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE AFU2073 TAre WA VIN# JA4LZ31F84U058356
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2004 MAKE MITS MODEL OUTLAN STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO SARAH SLACK 24450249TH AVE SE MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
INAEFFIECTTY NSURANCE INSU&POLICY#E CO SAME, I 9TOP
VE""LE ❑ N`L J
,J� CITATION# CHARGE
25 i o BOTTOM
LEGALLY YES $ '
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. ED34975
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1622
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'
slv suv lane 2 unit 1 rear slowing greenn wagon
RTF
Within the city limits of Renton/King/WA I responded to a 2 car crash at Maple Valley Hwy at 140th
Way SE.
I contacted the driver of unit 2 who told me he was going slow in traffic when he was hit from
behind.by unit 1. He did not complain of injury and damages did not require a tow truck.
I contacted the driver unit 1 who told me she misinterpreted unit 2. She said she thought he was
going to proceed through the green/yellow light. She was still going forward when unit 2 stopped
when she bumped the back end of unit 2. She did not complain of injury and 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 2/9/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 02-09-23 08:19 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 2/17/2023 4:26:39 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED` 3:38 PM TIME POLICE ARRIVED';3:50 PM
PART I PAGE IT]OF
REPORT NO. ED34975 CASE# ' 23-1622 DATE AND TIME 02/08/23 15:38
OF COLLISION
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