HomeMy WebLinkAbout23-9625 POLICE
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POLICE TFFITCOREPORT No. ED97763
COLLISION REP FIT 1591971
CITY STREET FIRE CASE# 1 23-9625 2
INTERSTATE RESULTED F
STOLEN ❑STATE ROUTE ❑ OTHER ❑ Vl.IrI F F LOCAL AGENCY] 4200 3
HIT&RUN CODING
F
2 5 COUNTY RD PRIVATE WAY INVOLVED
OF OBJECT 1 28
TRIBAL 02 STRUCK�
RESERVATION 2
3 M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
-7211- 2023 1 1240 [jE] =.= N E IN 3 SH WH OF
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION [:1 NON INTERSECTION ❑
MILEPOST [:] �
4a 108THAVESE B 19100 LOCK NO.
DDISTANCE OF(REFERENCE OR CROSS STREET)
MILE N E
5 F1 1.= FEETs H S H OF FO3]29
MOTOR Z PEDAL- El DAMAGE THRESHOLD MET PHONE —
UNIT 01 VEHICLE CYCLE YES NO D:2069818526 [0 4]30
6❑ LAST NAME CARDONA GONZALEZ FIRST NAME LUIS MIDDLE H I 1 I I INITIAL 31
STREET ❑ 20256 106TH AVE SE T ST I WA 2
NEW ADDRESS IF FEN-----�GNITION PRESENT MEDICAL TRANSPORTED
7 CDL IGNITION REQUIRED 3
I I:NTERLOCK YES[:]NO[:]I�NTERLOCK YES[:]No YESF-]NO
❑ DRIVERS WDL7TZS5J13B STATE I WA I-SEXIM I D, ---] 1 K21 32
8 LICENSE# 141sly F1974
ON DUTY 1 1 [STATUS AIRBAG 2 RESTIR 4 EJECT 1 HELMET 12 1 lNJURY11 I
NATURE OF INJURIES 2❑
9 USE CLASS I' I
LICENSEI C07301N STATEWA VIN# 1GCEK19C69Z155616 3
10 F91 I PI ATF fk l I I
11[-j--]
I TRAILER STATE
0 TRAILER FATE
PLATE#1 T PLATE# FROM TO
JTRLR TRLRj M31 33
1 2 0� VIN# VIN#
I I FROM TO
[4
VEFLYEAR STYLE IVEHICLE TOWED fn TO VK�ED BY I GOVT.VEHICLE
13 N�MAKE CHEV MODEL SILVER 1 DAMAGE YES NO YSl:l NO F,/1 EE 34
REGISTERED OWNER IN"' LUIS CARDONA GONZALEZ 20256 106TH AVE SE KENT WA 98031 VEHICLE NO, 1 ❑
SHADE IN DANOWIED AREA 35
14❑ LIABILI INSURANCE INSURANCE CO DAIRYLAND 11408651852
IN EFFECT &POLICY#
'C CHARGE 36
LEGALL'Y ❑ GGQ, [:1
15❑
2 VEH STANDING YES[:]No CITATION#
MOTOR PROPERTY --ff❑FIA. PHONE
�IJN T 02 VEHICLE ❑Z PEDAL- PEDESTRIAN YES
T.Rrj.LD MET 09138873
CYCLE OWNER NO D:36
16 a
ILAST NAME KOEPP FIRST NAME I MELISSA MIDDLE jINITIAL
17❑ STREET NEW ADDRESS 232BURNETT AVE S#AI14 CITY RENTON I I ST WA I I ZIP 1 98056 ❑ 37
18 IGNITION REQUIRED JIGNITION PRESENT MEDICAL TRANSPORTED 38
CDL :ERLOCK YESF-INORIINTERLO KyEsF�NOF� YES F]NO FVI
WDL7S864GO3B 39
19 1 DRIVE
RIST STATE IWA ]SEXIF I D-O.B. --W68
LICENSE# MMDDYY T
� AIRBAG 2 RESTR 4 EJECT 1 HMET 12 1 'INJURY I NATURE OF INJURIES ❑ 40
20 F1 ON DUTY[:]I STATUS EL I I I I I I I I USE CLASS
21❑ ILICENSE I SH01101 FTATElwA 1--1 JN8AF5MV8DT223904 ❑ 41
PLATE#
42
22❑ TRAILER STATE STATE
TRAILER PLATE
LE PLATE
23❑ J TRU-1 �RLRJ 43 VINV I IN#
VFH,YEAR 2013 IMAKE NISS IMODEL JUKE ISTYLE -TEHICLETOWEDfITOffBLINI TOWEDBY OVffll%� 44
24❑
YES ES NO YES N.7
REGISTERED OWNER INFO OINNEDBYDRIVER VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE 1:1 INSURANCE CO
IN EFFECT 1&POLICY# I
VEHICLE YES[:] NC[ OP MOT VEH WIOUT INSURANCE
25= LEGA- j I CITATION# 3AO492518 CHARGE (:�Q,
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID AGENCY
K.LANE 10008 WA0171300
26= 7 1 PAGE 01 OF
PARTA3000-345-159 OR 11/1M C7
ON
STATE ICE T AFFI CORRECTIONREPORT . ED97763
COLLISION���c�s
1591972 CASE# 23-9625
AWTIONAL PERSON INVOLVED(PASSENGERS ANWOR WITNESSES ONL
tNll::MIDDLE INI"GIAl.?
ADDIRI,$S 3 PHCNE A D,o .
SEX WIh9�DYYYY
��JaT HIrLET oN,aLIRr
PASSNGR❑SMHINESS❑',UNIT t PAS, AIRBAG RHSAR, EJECT FAATURE OF INJURIEu.
usE CIhASS
'NAME
A,ST F9R5T MIDDLE IN8MAL)
ADC5RE5S Aa PHONE
SEX I h9Rr96CYY'YY
PASSENGER WTNESS UNIT# SEAT AIRBAG RESTR. EJECT HeLMET INJURY NATURE GF INJURIES
RIDS, USE CLASS
(LAST FIRST.Dt 0010E INIIIAQ
AD SS S.PHONE R
SEXMODY D.C.Q.
PASSENGER[]
TNESS❑ UNIT a S SE AIRBAG RE TR, EJECT HELMET
fl S NATURE cF INJURIES
NARRATIVE'
Unit 2 was traveling southbound on 108th AVE SE in the center turn lane intending to turn left into the
parking lot of the 76 gas station located on the east side of the roadway. Unit 1 was in the parking lot
of the 76 gas station intending to turn right onto northbound 108th AVE SE. As Unit 2 initiated the left
turn into the parking lot, Unit 1 began its right turn out. The front end of Unit 1 struck the driver's side
of Unit 2. Unit 1 sustained minor front end damage while Unit 2 sustained moderate and disabling
damage to the front drivers side wheel and door.
Driver 2 advised they did not have insurance.
Driver 2 was cited for operating a motor vehicle without insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 08-21-23 02:10 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR LIST.DET DATED PLACE SIGNED
APPROVED BY _..... _ [RATE _.... _.
C.✓ACOBS 1953 1 9/11/2023 9:51:30 AM
BADGE OR 0 P 10008 ORI# WA0171300 TIME POU05 DISPATCHED 12:43 PM TIME POLICE ARRIV50 12:53 PM
FART -34S.160(RII18p PAGE 2 of 1 3
REPORT NO. ED97763 CASE# ' 23-9625 DATE AND TIME 08/21/23 12:40
OF COLLISION
19100 BLK 108TH AVE SE
Br
P T
***NOT TO SCALE***
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