HomeMy WebLinkAbout23-14435 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-14435 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HIT& F ❑ LOCAL AOENC 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 RESERVATION STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GowsloN 12 - 1-- 2023 1350 17 ❑.= S IN 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 7 29
MOTOR ✓ PEDAL- DAMAGE THRESHOLD MET PHONE
UNITS VEHICLE ❑ CYCLE ❑ YEs �/No D:4255235732 0 3 30
6❑ LAST NAME DIAZ PEREZ FIRST NAME CARLOS MIDDLE F 1 1 2 31
INITIAL
STREET ❑ 200 SW 5TH PL APT F202 CITY RENTON ST WA ZIP 980575813 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LDRIVER # STATE WA SEX' ID
M M LOB 12 — 07 — 1995 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CBJ4451 sTArI WAurN# 4T48F1FK2CR264972
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IRM ro
TRLR. TRLR 9 9 33
12 F
3 5 1
vIN#' VIN#
>;. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 1 34
13FA I 2012 TOYT CAMRY 4D DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO CARLOS DIAZ PEREZ 510 STEVENS AVE SWAPT#N-301 RENTON WA 98057 D:4255235732 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
LEwcLE CHARGE 1060TTOM 5 36
LECALLv YES Z NO❑ CITATION# 1
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNFR ❑ YES 1/ NO D:2063842846
16 a
LAST NAME BOLTZ FIRST NAME PATR►CK MIDDLE
INITIAL
17❑ STREET ❑', 18002 108TH AVE SE CITY RENTON ST WA ZIP 98055 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs❑NOF YES
❑NO❑
19[ LICENSE# STATE WA SEX U M D.C.B. 12 �_ 05 _ 1979 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY Z STATUS AIRBAG 2 RESTR 9 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I C9591C TAre WA vIN1t 1FDUF4HT9KEF73275
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2019 MAKE FORD MODEL F450 STYLE AM VEHICLE TOWED TO BLIN TOWEDeY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO RENTON REGIONAL FIRE AUTHORITY 18002108TH AVE SE RENTON WA 98055 D:4252769500 VEHICLE NO.2
SHADE IN DAGAAGED AREA
2 4
LIABILITY INSURANCE I PORGY#ECO ENDURIS INSURANCE 2024-625-P-001 1GQ,
IN EFFECTVEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`E]
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE31317
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14435
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) KIRSCH STEVEN
(LAST FIRST,
ADDRESS&PHONE#
528 RAINIER AVE S RENTON WA 98057 4252282551 SEX i M MMDDYyry
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY -
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Vehicle #2 drove westbound through the parking lot, turned on it's right turn signal which was visible
from the rear of vehicle #2, and then stopped at the exit of the parking lot prior to making a right hand
turn onto Rainier Ave S. As vehicle #2 was waiting for traffic to clear to make the right hand turn,
vehicle #1 drove westbound through the parking lot and pulled up to the right side of vehicle #2,
putting itself in the path of vehicle #2's right turn. Vehicle #2 then turned right onto Rainier Ave S,
which caused the right side of vehicle #2 to collide with the front left bumper of vehicle #1. This
collision was captured on video surveillance of the nearby MoneyTree business. Employee STEVEN
KIRSCH advised he would provide police with video surveillance of the collision. Based on the
totality of the circumstances, it appeared vehicle #1 caused this collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 12-16-23 05:12 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 1211712023 5:13:48 AM
BADGE OR ID# 11631 ORI# WA0171300 TIME POLICE DISPATCHED', 1:55 PM TIME POLICE ARRIVED I 3:58 PM
PART B PAGE IT]OF 3�
REPORT NO. EE31317 CASE# 23-14435 DATE AND TIME 12/16/2313:50
OF COLLISION
'AN
Vehicle #1
Not to scale
to
Vehicle #2
Text
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