HomeMy WebLinkAbout24-389 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
SASE#r` 24-389 2
INTERSTATE ❑ CITY STREET FIRE F RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT ❑2$
TRIBAL UNITS 01 STRUCK' TREE OR STUMP
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 01 — 11 — 2024 0447 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BENSON RD S BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e S PUGET DRIVE
2 0 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 30
6❑ LAST NAME SCHAFF FIRSTNAME BRIAN MIDDLE M 1 1 2 31
INITIAL
STREET ❑1 1412 LAKE YOUNGS WAY SE CITY RENTON ST WA 2jp, 98058 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LICENSE# STATE WA SEX'M I D-MMDDYY 09 - 18 - 1983 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USE CLASS
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ PI ATNE 14 CKS8149 sTATe WAvN# 1G6DC7A560211362
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
TRLR. TRLR. 5 1 33
12❑ vIN#' VIN#
Rom 34
13� VEH.YEAR 2000 MAKE CAD/ MODEL STS STYLE SD VEHICLE TOWED NOO pLSABLIN TSIYYEp9vMEYERS vOVT.V
DAMAGE IILLJJII (S�IV6
REGISTERED OWNER INFO BRIAN SCHAFF 1412 LAKE YOUNGS WAY SE RENTON WA 98058 D:2532287276 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14❑ LIABILIT T INSURANCE INSURANCE CO
IN EFFEC POLICY# PROGRESSIVE 900904530 4
& 9TOP
ARGE
vErIICLE CH 5 36
LEGALLY Yes❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
UNIT 02 MOT VEHICCLE ❑ CYCLE ❑ PEDESTRIAN ❑ OWNER
❑ D YES 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 PtR-E-S1ENT MEDICAL-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIRIVEWSTICENS # 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 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. '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
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO IGQVE"LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
=TAMAIVENA
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 12812 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE42475
COLLISION REPORT III III III III III 111
1591972 CASE# 24-389
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 01/11/2024 at approximately 0447 hours, while employed as a uniformed Patrol Officer for the
City of Renton, I was dispatched to an accident with injury, located at Benson Rd S and S Puget Rd,
within the City of Renton, County of King, State of Washington.
I arrived on scene and observed a black Cadillac striking a tree.
I contacted Schaff who was the driver of unit 1. Unit 1 stated that he was turning from S Puget Dr into
Benson Rd S headed northbound in lane 1. He stated that he tried to squeeze in between other
vehicles in lane 2 but couldn't and turned back into lane 1 causing him to lose control and striking the
tree on the sidewalk.
Renton fire was dispatched and cleared Schaff with no injuries.
I certify (declare) under penalty of perjury under the laws the State of Washington that the foregoing
is true and correct. This report was electronically signed by Officer Si. Tamaivena #12812, January
11, 2024, at 0614 hours Renton, WA.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
SITIVENI TAMAIVENA 01-11-24 04:48 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1/21/2024 4:47:18 AM
BADGE OR ID# 12812 OR]# WA0171300 TIME POLICE DISPATCHED 4:49 AM TIME POLICE ARRIVED 4:54 AM
PART I PAGE IT]OF
REPORT NO. EE42475 CASE# ' 24-389 DATE AND TIME 01/11/24 04:47
OF COLLISION
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