HomeMy WebLinkAbout23-5616 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
CASE 23-5616 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICCI F ❑ LOCAL AOENC 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
cawsloN 05 - 18 - 2023 1516 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
L1ND AVE SW MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SW41ST ST
0 1 29
UNIT MOTOR
VEHICL Z CYCLE ElDDAMYESA✓THRESHOLD PHONE 0 11
30
6� LAST NAME STIVERS FIRSTNAME MICHAEL MIDDLE S 1 0 1 31
INITIAL
STREET ❑ 8827 123RD AVE SE CITY NEWCASTLE ST WA ZIP 980561701 z=
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10❑ P1 ATE 14 BMV5574 STATE WA VIN# 1 P3XP44K8LN208373
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
rRLR. TRLR. 1 5 33
12 2 5 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 3 ] 34
13 2 1990 PLYM SUNDA DAMAGE vEs 0NO f �AWkkRS vEs❑ No✓
REGISTERED OWNER INFO MICHAEL STIVERS 8827123RD AVE SE NEWCASTLE WA 98056 D:4255232306 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4
14 LIABILITY INSURANCE INSURANCE CO SAME. 3
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY YES❑NO CITATION# 3A0329676 FAIL TO OBEY TRAFFIC CONTROL )o sorrow
15❑ STAIN.D'ING 7 6
UNIT VE IMOTDOLS CYCLE ❑ PEDESTRIAN ❑ PROPERTY ❑ DYES✓ NO OLDMET PHONE
16 2
LAST NAME TRAN FIRST NAME TAI MIDDLE H
INITIAL
17❑ STREET ❑', 23609 128TH AVE SE CITY KENT ST WA ZIP 980313660 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LDI IVEW # STATE WA SEX M M D.C.B. 01 24 1964 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE AFW9377 TATe I WA VINIi 4T1GK12E9SU070661
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 1995 MAKE TOYT MODEL CAMRY STYLE VEHICLE TOWED TO BLIN TOWEDev GOV HI �44
24❑ DAMAGE YES✓ NO BANKERS YES NO✓
REGISTERED OWNER INFO TAI TRAIN 23609128TH AVE SE KENT WA 980313660 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU8 POLICY#E CO GEICO 0541-03-87-09IN 1 VEGALwcLE ❑ ,J� CITATION# CHARGE25 GQ
LELY YES N`L J
s � a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED65638
COLLISION REPORT III III III III III 111
1591972 CASE# 23-5616
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 FIRST 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'
gold/unit 1 lane 1 sb ran red blue unit 2 lane 2 westbound
CC
Within the city limits of Renton/King/Wa I responded to a 2 car blocking crash at the intersection of
Lind Ave SW at SW 41 st St.
I contacted the driver of unit 2 who told me he was in lane 2 westbound SW 41st St on his green light
when he was hit on the side by unit 1. He did not complain of injury and damages did require a tow
truck.
I contacted the driver of unit 1 ID'd by his picture WADL. He told me he was southbound on Lind Ave
S lane 1 and ran the red light crashing into the side of unit 2. He did not complain of injury and
damages did require a tow truck.
I cited unit 1 Ref RCW 46.61.055 FTCWTCD-Red Light 2 car crash via complaint.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 5/26/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 05-26-23 09:00 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 5/31/2023 12:40:23 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED! 3:16 PM TIME POLICE ARRIVED',3:22 PM
PART I PAGE IT]OF 3�
REPORT NO. ED65638 CASE# ' 23-5616 DATE AND TIME 05/18/23 15:16
OF COLLISION
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