HomeMy WebLinkAbout23-1492 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE#r` 23-1492 z
RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HIT& F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 4 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 02 - 1-- 2023 0448 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 2ND ST BLOCK e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 A❑ 20 00 FMILES EET e S ❑ W e BURNETT AVE S
0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
No ,/ D:4259851741 30
6� INITIAL
LAST NAME S/MS FIRSTNAME TYLER MIDDLE J 1 1 2 31
STREET ❑ 232 BURNETT AVE S A203 CITY RENTON ST WA 2jp, 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs Z/NO YES R NoF,/
LRIIVER # STATE WA SEX'M I EL MMDDYY
$❑ ' 01 — 10 — 1992 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ pl ATFBit B WG8239 sTAr� WA vrN# JF2SH64619H765625
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FR.. ro
TRLR. TRLR. 5 1 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13❑9 2009 SUBA FOREST AT DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO WINSTON SIMS 27601220TH CT SE MAPLE VALLEY WA 98038 D:9999999999 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO STATE FARM 0450228-COI.47F 3 4
IN EFFECT &POLICY# 9TOP
vEHlcl.e CHARGE 5 36
LECALLv res❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLD MET PHONE
16
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES,/ NO D:9999999999
a
LAST NAME SHELTON FIRST NAME CAELAN MIDDLE ID
INITIAL
17 STREET NEW ADOREs7 15024 132ND AVE SE CITY RENTON ST WA ZIP 98058 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YES
❑NO❑
19[—] LICENSE# STATE WA SEX M M D.O.B. 09 _ 10 _ 2004 39
20❑6 HELMET I INJURY 1 NATURE OF INJURIES 3 40
ON DUTY❑ STATUS 3 AIRBAG RESTR EJECT USE 2 CLASS ❑
❑21❑ LICENSE TArE 41
VIN# 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 1 5 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I vE."LE ❑ ,J� CITATION# CHARGE
25 GQ
LEGALLY YES N J
s � e
7JAWEBER
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
12532 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED37021
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1492
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'
Driver 1 stated he was exiting the parking garage gate at the Metro Place apartments when he felt his
driver side wheels go over a bump. When he stopped his vehicle to look and see what he ran over, he
observed Pedestrian 1 laying on the side of the driveway who had been sleeping prior. Driver 1
stopped and called 911. Pedestrian 1 stated he was sleeping under a blanket on the side of the
driveway to the apartments when he was woken by Driver 1 driving over his right knee, hitting it with
both tires. Pedestrian 1 noted he did not have any injuries and initially declined fire, but I was able to
convince him to be evaluated. Pedestrian 1 was evaluated on scene, and it was determined he did
not need to be transported. Both parties provided with appropriate information.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Location Character: APARTMENT COMPLEX
**** END OF AUTO-POPULATED SECTION ****
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JACOB WEBER 02-05-23 05:46 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 2/24/2023 5:59:06 PM
BADGE OR ID# 12532 ORI# WA0171300 TIME POLICE DISPATCHED; 4:49 AM TIME POLICE ARRIVED',4:53 AM
PART I PAGE IT]OF
REPORT NO. ED37021 CASE# 23-1492 DATE AND TIME 02/05/23 04:48
OF COLLISION
2nd St
Pedestrian 1
PAGE 3 OF 3