HomeMy WebLinkAbout23-12418 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-12418 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCALAGENCI WA0171.300 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT ❑2$
i TRIBAL UNITS 01 STRUCK TRAFFIC SIGNAL POLE
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
CowsloN 10 - 29 - 2023 2111 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
TALBOT RD S BLOCK NO. e✓ 1400 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a 405 RAMP
1 9 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:9999999999 N:9999999999 30
6❑ LAST NAME SANDOVAL FIRSTNAME ERIC MIDDLE J 1 1 31
INITIAL
STREET ❑ 950 HARRINGTON AVE NE#N-208 CITY RENTON ST WA 7jp, 98056 2 OF
5
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I O 6
iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES No�/
8❑ LDRIVER # STATE WA SEX' ID
M MELO B 12 - 24 - 1981 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 1 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES z❑
3
10❑ P1 ATE 14 CGK4456 STATE WA v N# 3C3CFFGE2GT205322
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FRom ro
TRLR. A'RLR. 1 3 33
12❑ VIN#' VIN#.
Rom 34
13❑ VEH.YEAR 2O16 MAKE FIAT MODEL 500 STYLE P2 IV
AMAGE TOWED NOO pLSABLIN T� I� RS TOWING VEHICLE�
DAMAGE IILLJJII
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
14❑ LIABILITY INSURANCE❑ INSURANCE CO GEICO 6127638176 SHADE IN DAMAGED AREA 35
IN EFFECT &POLICY# 9TOP
vECeHA"Le 5 36
LLLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ �STA""'
I,I 8 6
UNIT U2 vEHIMOTOCLE ❑ CYCLE ❑ PEDESTRIAN ❑ OWN A PEDAL RTY [:]EA.
NO OLD MET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NO❑
19 LLIICENS # STATE SEX MMDDYY -❑_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TATE 41
IN#LICENSE V 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
�LEGA—
❑ C[:] CITATION# CHARGE i o BOTTOM
YES N
25 'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26SI TAMAIVENA 12788 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE14821
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12418
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'
On 10/29/2023, at approximately 2117 hours, I was dispatched to a shooting at accident blocking,
located at S PUGET DR/BENSON DR S, in the City of Renton, King County, Washington.
I spoke with Eric, and he stated that he was traveling northbound in lane #1 (near the curb), which is
a right turn on Talbot RD S, entering the 405 ramp. He claimed while attempting to enter the 405
ramp, he got distracted and noticed the vehicle in front of him stopped at a yield light. He stated that
he avoided hitting the vehicle and ran into the barrier, causing him to hit a streetlight.
I also notified the City of Renton and filled out an incident form.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
SULIASI TAMA/VENA 10-30-23 04:22 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 1013112023 7:13:54 AM
BADGE OR ID# 1Y788 ORI#` WA0171300 TIME POLICE DISPATCHED 9:97 PM TIME POLICE ARRIVED 9:18 PM
PART Ei PAGE IT]OF
REPORT NO.! EE14821 CASE# 23-12418 DATE AND TIME 10/29/23 21:11
OF COLLISION
N GR0SS�A
r
co
DRIVER 1
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