HomeMy WebLinkAbout23-1721 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-1721 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 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 02 - 10 - 2023 1915 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
AIRPORT WAY BLOCK NO. e✓ 300 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e SHATTUCKAVE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2069096755 0 11
30
6� LAST NAME FLATT FIRSTNAME JACOB MIDDLE J 1 2 31
INITIAL
STREET ❑ 4400 SW ALASKA ST UNIT 305 CITY SEATTLE ST WA 2jp, 98116 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ DRIVERS
E#
� [NATURE OF
9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 H U SE CLASS 6 PAIN IN LEG INJDRIES z❑
3
10 1❑ P1 ATE 14 AHP1180 STATE WAa VIN# 2G1WX12K349415036
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR. 7 1 33
12 0 0 VIN#' VIN#'
>; FROM TO
❑ VEH.YEAR 2004 CHEV MONTE SD MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR YMEYER 3 7 GOVT.VEHICLE 34
13 4 DAMAGE YES NO � YES❑ No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
4 INSURANCE CO 4
14 IN EF IT INSURANCE STATE FARM 2090096.619.47A
IN EFFECT I SUR N# TOPVEHlcl.e CHARGE <1�3
OTTOM 5 36
LEGALLY YES❑NO❑ CITATION# 5
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2536662061
16 a
LAST NAME ROLPH FIRST NAME ANDREW MIDDLE IT
INITIAL
17 STREET❑ NEW ADDREss❑' 33653 7TH CT S CITY FEDERAL WAY ST WA ZIP 98023 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 D IVEW # STATE INA SEX M MMDDW 02 _ 11 1999 39
20❑ ON DUTY STATUS AIRBAG,6 RESTR 4 EJECT 1 HELMET INJURY 6 NATURE of INJURIES ❑ 40
USE CLASS CHEST PAIN
❑21❑ PLATE# D474146 TATE 41
WA vIN# 4F4YR12D66PM02045 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
TOWED BV Gov HI 44
VEH YEAR 2006 MAKE /(ggZp MODEL 62300 STYLE PK -TEHICLE
TOWED✓ NOO BLIN GENE MEYER YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE� &POINSURGY#E CO STATE FARM 4607016-D22-47FIN STOP 5
'E""LE ❑ ,J� CITATION# CHARGE to BOTTOM
LEGALLY YES N J
25 e
7jo
R'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
THAN SELBERT 12641 [V7�ENCY
A0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED47090
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1721
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MERCADO RAMIREZ MELANNY
(LAST FIRST,
ADDRESS&PHONE# D O.B.
1916 S 308TH ST FEDERAL WAY WA 98003 SEX F MMDDYyry 02 - 21 - 2001
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 2 POS 3 AIRBAG 6 RESTR. q EJECT USE CLASS 16 UNKNOWN
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# Id D O 8
E MMDDYVYY
PASSENGER ❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
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.
JONATHAN SELBERT 02-10-23 09:09 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 313112023 1:36:43 AM
BADGE OR ID# 12641 OR]#' WA0171300 TIME POLICE DISPATCHED 7:23 PM TIME POLICE ARRIVED:7:24 PM
PART I PAGE IT]OF 4]
REPORT NO. ED47090 CASE# 23-1721 OF COLLISION
02/10/23 19:15
OF CbLLI510N
NARRATIVE
On 2/10/2023, at 1923, 1 responded for an Accident Blocking Disabled at the intersection Airport Way
and Shattuck Avenue S in the City of Renton, King County, Washington State.
I arrived and observed two vehicles disabled in the left turn lane of eastbound Airport Way just west
of the intersection.
Vehicle 1 was a 2004 black Chevrolet Monte Carlo (WA AHP 1180) with heavy front-end damage.
Vehicle 2 was a 2006 red Mazda B2300 pickup truck (WA D47414B) with heavy front-end damage.
The driver of vehicle 1 stated that he was making a left turn from eastbound Airport Way onto
Shattuck on a yellow signal when vehicle 2 suddenly entered the intersection at a high rate of speed,
striking the front of his vehicle.
The driver of vehicle 2 stated he was driving westbound on Airport Way and that the light was green
when he entered the intersection with Shattuck Avenue. As he did so vehicle 1 began to make a left
turn and the two vehicles collided head on.
The passenger in vehicle 2 also stated that vehicle 2 had a green light when it entered the
intersection.
Driver 1 complained of pain in his leg.
Driver 2 complained of chest pain.
Renton Fire responded to the scene and evaluated driver 1, driver 2 and the passenger from vehicle
2. No one was transported for further treatment.
Gene Meyer Towing responded and removed the two vehicles from the roadway.
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 Officer J. Selbert (12641) in the City of Renton, King County, Washington
State on 2/10/2023 at 2056.
PAGE 3 OF 4
REPORT NO. ED47090 CASE# ' 23-1721 DATE AND TIME 02/10/23 19:15
OF COLLISION
Airport Way
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CDry
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PAGE 4 OF 4