HomeMy WebLinkAbout23-2239 IT ' " . 27POLCERAFFO 1 c 1I1llI 111I II REPORT NO ED38476
COLLISION REP FIT
1591971
CASE 23-2239 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AGENCI 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 0 28
TRIBAL 1 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 1030 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RAINIER AVE S
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e SW VICTORIA ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066024954 0 4 30
6� LAST NAME SUALOG FIRSTNAME MARK MIDDLE H 1 1 2 31
INITIAL
STREET ❑1 2313 25TH AVE S CITY SEATTLE ST WA ZIP 981445336 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LICENSE# STATE yyq SEX'M MM D Y' 02 — 08 — 1996 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ PIATE14 CCN6032 STATE WA VN# 1G1FD1RX6H0123195
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 5 33
12 3 5 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE ] 1 34
13 2 2017 CHEV CAMAR DAMAGE ves NO ✓ ves❑ NO✓
REGISTEREDOWNER WFO SARAH FERGUSON 156 S 358TH ST FEDERAL WAY WA98003 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE U INSURANCE CO SAME. 3 4
IN EFFECT &POLICY# 9TOP
CHARGE
VEH'CLE 5 36
LECALLv YEs❑NO❑ CITATION# 1 o BOTTOM
15❑ STAIN.D" 8 6
UNIT VE IOOR CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES✓ NO OLDMET PHONE
16 a
LAST NAME SHAH FIRST NAME SHIR MIDDLE N
INITIAL
17❑ STREET ❑', 10705 SE 238TH ST APT 11 CITY KENT ST WA ZIP 980313552 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCKYES�NOF INTERLOCK YES I t I.OF YES t l NO❑
19 LDICENS STATE WA SEX M MMDDYY 03 _ 05 _ 1991 39
HELMET I INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
41
21❑ LICENSE BWF0374 TATE WA VIN# 2TIBURHE6HC915387
❑
PLATE#
42
22❑ PLATILER E# STATE PLATE# STATE
23❑ TRLR R 43
LR
VIN#. N I #.
VEH YEAR 2017 MAKE TOYT MODEL COROLL STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO SHIR SHAH 25246106TH AVE SE APT A211 KENTWA98030 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE I PORGY#ECO ST FARM 413 4 6 70 8 214 7DIN 1GQI
VE""LE ❑ ,J� CITATION# CHARGE
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 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED38476
COLLISION REPORT III III III III III 111
1591972 CASE# 23-2239
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'
yellow 1 It lube gry 2 It victoria
RTF
Within the city limits of Renton/King/WA I responded to a 2 car blocking crash at the intersection of
Rainer Ave S and SW Victoria St.
I contacted the driver of unit 1 who told me he was making a left turn from the lube/oil change shop
when he collided with unit 2. He did not complain on injury and damages did not require a tow truck.
I contacted the driver of unit 2 who told me he was making a left turn from SW Victoria when he
collided unit 1. He 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 2/24/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 02-24-23 10:58 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.MORR/S 2613 3/1/2023 8:57:09 AM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED; 10:31 AM TIME POLICE ARRIVED 10:34 AM
PART I PAGE IT]OF 3�
REPORT NO. ED38476 CASE# ' 23-2239 DATE AND TIME 02/24/23 10:30
OF COLLISION
AV NNW
AML
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