HomeMy WebLinkAbout23-0051 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED23087 170
27
COLLISION REP FIT 1591971
CASE 23-0051 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING'
COUNTY RD PRIVATE WAY INVOLVED
2 1 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 01 - 1-- 2023 2102 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 3RD ST BLOCK ST e✓ 111
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ MILES�,❑ FEET e S ❑ W e SHATTUCKAVES
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO I D:2068526073 0 11
30
6� LAST NAME MANN FIRSTNAME D'ANDRELAVELLE MIDDLE D 1 1 2 31
INITIAL
STREET 01 505 110TH STREET CT E APT K30 CITY TACOMA ST WA ZIP 98445 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8 LRIIVERCENS # STATE SEX'M MDMDD 02 - 04 - 1981 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 9 EJECT 1 H U EET ICNIJAU RY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� CED3338 sTArI WAvIN# 1GNFK13097R114212
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T v GOVT.VEHICLE 7 $ 34
13 1 2007 CHEV TAHOE 4D vesNo � �MEYERS TOWING ves❑ No
DAMAGE
REGISTERED OWNER INFO D'ANORE LAVELLE MANN 505110TH STREET CT E APT K30 TACOMAWA98445 D:2068526073 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ALLSTATE 820-051.269 3 4
IN EFFECT &POLICY# 9TOP
LEwcLe CHARGE 1 5 36
LEcnlly Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4258917442
16 a
LAST NAME REBOLLO FIRST NAME MARIO MIDDLE /
INITIAL
17 NEW STREETRE 12707 SE 42ND ST APT 2 CITY BELLEVUE ST WA ZIP 98006 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK vEs I I NOF YEs t l NOF,/
19 DRIVERS
❑ ON DUTY STATUS AIRBAG 1 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES 40
LICENSE ❑21❑ PLA E# BMV9509 TArE WA VIN# 41
KNMAT2MV8JP505421 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2018 MAKE NISS MODEL ROGUE STYLE 4D VEHICLE TOWED TO BLIN TOWEDBv GES HI 44
24 DAMAGE vES�/ NO GENE MEYERS TOWING
ves No�/
REGISTERED OWNER INFO MARIO REBOLLO 12707 SE 42ND ST APT 2 BELLEVUEWA98006 D:4258917442 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 165-2929-A22-476IN STOP 5
'EwCLE ❑ Nu,J CITATION# CHARGE
LEGAL io BOTTOM
LY YES
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J RAYGOZA 12503 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED23087
COLLISION REPORT III III III III III 111
1591972 CASE# 23-0051
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.
J RAYGOZA 01-03-23 03:21 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
G.BARFIELD 6476 1/9/2023 3:27.58 AM
BADGE OR ID# 12503 OR]# WA0171300 TIME POLICE DISPATCHED 9:04 Pry] TIME POLICE ARRIVED',9:05 PM
PART I PAGE IT]OF 4�
REPORT NO. ED23087 CASE# 23-0051 OF COLLISION
01/02/23 21:02
OF CbLLI510N
NARRATIVE
RPD CASE#: 23-0051
On 01/02/2023 at approximately 2104 hours, I responded to 111 S 3rd St, in the City of Renton, King
County, Washington, for a report of a two-motor vehicle traffic accident.
Upon arrival both vehicles were in the middle of the street, located at 111 S 3rd St. I identified Unit 1
as a red 2007 Chevrolet Tahoe WA/license CED3338 VIN#1GNFK13097R114212. Unit 1 sustained
major damage to the driver's side door. I identified the driver of Unit 1 via his WAID as Mann D'Andre
Lavelle Davis DOB (02/04/1981). Mann told me he was in the right lane closest to the curb, driving
eastbound in the 111 block of S 3rd St. Mann told me a can of alcohol "exploded" inside his vehicle
while he was driving. Mann then tried to make a U-turn to try and park at the Safeway parking lot at
200 S 3rd St when unit 2 collided with his vehicle. Mann told me he was not injured and advised me
he did not have a driver's license. Mann was evaluated by fire due to airbag deployment and cleared
medically.
I identified Unit 2 as a white 2018 Nissan Rogue, bearing WA IicenseBMV9509
VIN#KNMAT2MV8JP505421. Unit 2 sustained heavy damage to the front of the vehicle. I identified
the driver of Unit 2 by his WADL as Rebollo Mario Ivan DOB (03/13/1990). Rebollo told me he was in
the left lane of travel, driving eastbound in the 111 block of S 3rd St. Rebollo stated he was driving
eastbound on S 3rd St when unit 1 tried to make a U-turn onto his lane of travel. Rebollo stomped on
his breaks but collided with Unit -1 `s driver's side door. Rebollo stated that he was not injured but that
his wife later identified by her WADL as Resendiz Gonzalez Griselda DOB (09/07/1989) was having
chest pain due to the impact of the crash. Both Rebollo and Resendiz were evaluated by fire due to
airbag deployment and cleared medically.
Both drivers exchanged information and both vehicles were towed from the location. Mann was
advised he was the at fault driver due to improper lane usage. I advised Mann that he would receive a
citation in the mail for improper lane usage and for operating a motor vehicle without a driver's
license.
Once all three parties left the area, I cleared the scene.
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 J. Raygoza on 01/03/2023 at 0330 hours in the City of Renton.
PAGE 3 OF 4
REPORT NO. ED23087 CASE# ' 23-0051 DATE AND TIME 01/02/23 21:02
OF COLLISION
AV mk
Unit 2 N
Unit 1
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