HomeMy WebLinkAbout23-2100 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED38473 170
27
COLLISION REP FIT 1591971
CASE 23-2100 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4/00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 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 1548 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SUNSET BLVD N BLOCK NO. e✓ 350
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 6501. 00 FEET MILES e S B W e N 3RD ST
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2062351955 0 11
30
6� LAST NAME GAMPONIA FIRSTNAME JOSHUA MIDDLE C 1 1 2 31
INITIAL
STREET ❑, 12226 SE 258TH PL CITY KENT ST WA Zjp, 980308641 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]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 z❑
3
10 9❑ P1 aT�S� BKU4449 sTArr WAurN# 4T18F3EK7BU685804
TRAILER STATE TRAILED STATE
11 3 0 PLATE# PLATE# FROM To
TRLR. TRLR 1 5 33
12 3 0 VIN#' VIN#
>;. FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 1 $ 34
13 2 2011 TOYT CAMRY DAMAGE vEs 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO JULIUS GAMPONIA 12226 SE 258TH PL KENT WA 98030 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE INSURANCE CO SAME. 4
IN EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLYYES❑NO❑ CITATION# 3AO081050 IMPROPER LANE USAGE <1�3
orroM
15❑ STANDING 7 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO OLD MET D:2064510474
16 a
LAST NAME ELLIS FIRST NAME ANTONIO MIDDLE J
INITIAL
17❑ STREET ❑', 4200 SMITHERS AVE S APT B302 CITY RENTON ST WA ZIP 980556356 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALt-T�RANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs I I NoF YES t l NO❑
19 D IVEW #
I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I BJK9636 TAre WA VIN. 5NPEC4AC1DH569199
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2013 MAKE HYUN MODEL SONATA STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO BANKERS YES NO
REGISTERED OWNER INFO ANTONIO ELLIS 4200 SMITHERS AVE S APT B302 RENTONWA98055 VEHICLE NO.2
SHADE DAGED AREA
4
INAEFFIECTTY NSURANCE� &POINSULICY#E CO SAME. CQl
VEwcLE ❑ ,J� CITATION# CHARGE io
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 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED38473
COLLISION REPORT III III III III III 111
1591972 CASE# 23-2100
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 02-21-23 04:21 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
S.MORR/S 2613 31112023 8:57.29 AM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 3:49 PM TIME POLICE ARRIVED',3:54 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. ED38473 CASE# 23-2100 OF COLLISIONO2/21/23 15:48
NARRATIVE
gry/2 lane 3 wht/1 chang into side
CC
Within the city limits of Renton/King/WA I responded to a 2 car blocking crash near the 350 block of
Sunset blvd N.
I arrived with one car blocking, they were able to move the vehicle out of the roadway.
I contacted the driver of unit 2 who told me he was south on Sunset Blvd when unit 1 made a sudden
lane change into the side of him. He did complain of injury. He didnt look like he was feeling well
from the crash. Renton Fire arrived and treated/released him on scene. Damages did require a tow
truck.
I contacted the driver of unit 1 ID'd by his picture WADL. He told me he was making a lane change
and contacted unit 2. He did not complain of injury. damages did require a tow truck.
I cited unit 1 ref RCW 46.61.140 Improper lane use 2 car injury 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 2/21/2023
PAGE 3 OF 4
REPORT NO. ED38473 CASE# ' 23-2100 DATE AND TIME 02/21/23 15:48
OF COLLISION
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