HomeMy WebLinkAbout24-3740 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-3740 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS . 03 STRUCK
RESERVATION
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 04 - 06 - 2024 0159 17 ❑.= S IN 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HIGHWAY BLOCK NO. e✓ 14000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 140THWAYSE
OF,1 29
UNIT MOTOR
Z PEAL-CYCLE El DAMAGE YEI✓NO THRESHOLD MET PHONEVEHIC 0 4 30
6 LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 2 31
INITIAL
STREET ❑ CITY ST 21P 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES No YES No
8 DRIVER'S. STATE SEX.U D.O.B. 1 1 2 32
❑ :LICENSE# MMDDYY -❑
9❑ ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EEr 9 CLAY 0 NATURE OF INJURIES z❑
3
10❑ P1 ATF 14 D80588C sTATe WAV N# 1GCCS1441 W8128462
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# Rom ro
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 34
13FAl 1998 CHEV S10 PK DAMAGE YES NO �MEYER rj 7 YES❑ No
REGISTERED OWNER INFO CHRISTOPHER DENESHA 22133 SE 328TH PL AUBURN WA 98092 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
ve'CLE CHARGE 10BOTTOM 5 36
LEGALLv res❑NO❑ CITATION# 5
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNFR ❑ YES 1/ No D:2065048855
a
LAST NAME WEN FIRST NAME HUI MIDDLE K
INITIAL
17 STREET❑ NEW ADOREss❑' 19387 114TH PL SE CITY KENT ST WA ZIP 98031 ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES t l NOF,/
19 DRIVER'S STATE WA SEX M D.C... O6 _ 27 1993 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES ❑ 40
❑LICENSE I 21❑ PLA E# CGL1852 TATE 41
WA VIN# 7SAYGDEESPF684935 4
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2023 MAKE TESL MODEL MODEL Y STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES✓ NO GENE MEYER YES NO
REGISTERED OWNER INFO WELLS FARGO AUTO PO BOX 997517 SACRAMENTO CA 95899 VEHICLE NO.2
SHADEJN DAMAGEDAREA
4� 3 4
LIABILITY INSURANCE INSU&PORGY#ECO AMERICAN FAMILY INSURANCE 410902701136 STOP 5
IN EFFECT
ve
LEGALLY YESwGLE ❑ N J
,J� CITATION# CHARGE toBOTTOM
25 s 7 e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
RYAN KARLO RIVERA 12649 WA0171300
1
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE68250
COLLISION REPORT III III III III III 111
1591972 CASE# 24-3740
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'
Please see attached police report#24-3740 , which is hereby incorporated by reference as if fully set
forth herein. (Officer N. Odalovic's Supplemental)
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
RYAN KARLO R/VERA 04-06-24 07:57 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 4/15/2024 11:45:58 AM
BADGE OR ID# 12649 ORI#' WA0171300 TIME POLICE DISPATCHED; 2:00 AM TIME POLICE ARRIVED',Y:03 AM
PART PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE68250
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 24-3740
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
❑ 1 28
2
CARRIER
NAME
3 CARRIER L
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 3 VEHICLE tSJ CYCLE I_) PEDESTRIAN � OWNER � YES� NO
D:2063352172
0 4 29
LAST NAME : TAYLOR FIRST NAME : JOSIAH MIDDLE'.. D
INITIAL
STREET 30
NEW AnnRFSP' 3006 S COLLEGE ST CITY SEATTLE ST WA ZIP 98144
6 ❑ 1 1 2 31
CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED
INTERLOCK YEs NO zERLOCK YES❑N0� YEs N
DRIVER'S
LICENSE STATE I WA SEX M MMDDYYv 01 TO]
- 2003
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET I INJURY 1 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE A6952742 TAr WA VIN# 2G1WT58NO79326596
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE If STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 U U VEH.YEAR2007 MAKE CHEV I MODELIMPALA STYLE SO VEHICLE TOWS E T SABLIN TOWED BY anvi vFH1I' P FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFO OWNED BY DRIVER 5 ] 33
12 � SHADE IN DAMAGED AREA
j 4 FROM TO
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# 41`OI'
1 34
13 ❑ LEG
VEHICLE
❑ NO❑ CITATION# CHARGE 0 807TOM
Vnuv YES
STANDING �} MOTOR
8 7 6
14 ❑ UNIT Tr Vd 1 RE O CYCLE OW ERRTY � DASMMNOHRESHOLDMET PHONE 35
PEDESTRIAN YE
15 LAST NAME FIRST NAME INITIAL
AL
❑ 36
STREET
16 NEW AnnRFs� CITY ST ZIP
CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED
INTERLOCK YES No INTERLOCK YEs NO YEs NO ❑
17 4 37
LICENSE# STATE SEX MMDDDYBYY -� II
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of 1NJURIEs 38
USE CLASS
19 ❑ LICENSE TAr VIN# 39
PLATE#
20 ❑ TRAILER' STATE TRAILER STATE ❑ 40
PLATE#< PLATE If
21 ❑ ❑ 41
TRLR TRLR
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED 3 a 4 AREA F 43
z
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
RYAN KARLO RIVERA 04-06-24 07:57 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DAL
E
26 ORID# 12649 O#II,WA0171300 SCOTT 4115/2024 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. EE68250 CASE# 24-3740 DATE AND TIME 04/06/24 01:59
OF COLLISION
Renton PD Case
--3740
w
,
s
w N a
R I (
ik r1
,
� 3
r
t rl�
aS o�"owal"«,�i�SvRM a"i.,,,,
PAGE 4 OF 4