HomeMy WebLinkAbout23-5638 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED65636 170
27
COLLISION REP FIT 1591971
CASE 23-5638 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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 - 19 - 2023 0746 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
S 3RD ST BLOCK e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 300 00 FMILES EET e S ❑ W e SHATTUCKAVES
2 0 29
R PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES ✓NO D:3606084284 0 11
30
6� LAST NAME DICKENSON FIRSTNAME MICHAEL MIDDLE J 1 F 2 31
INITIAL
STREET ❑, 14304 NE 10TH ST CITY VANCOUVER ST WA 2jp, 986847920 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYES NO INTERLOCK YES NO YES No
8❑ LRIIVER # STATE WA SEX'M MM DI,Y' 08 - 22 - 1958CENS K2
32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� C731432 sTArI WAvIN# 1GTEK19T5XE521134
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
TRLR. TRLR 7 3 33
12 2 5 VIN#j VIN#
FROM TO
VEH.YEAR 1999 MAKE GMC M YES NO YES
ODEL NEW STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 1 DAMAGE ❑ NO✓
REGISTERED OWNER INFO MICHAEL DICKENSON 14304 NE 10TH ST VANCOUVERWA 986847920 D:3606084284 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 931739681 3 4
IN EFFECT &POLICY#
VEHICLe 9TOP
CHARGE 1 5 36
LEGALLY
Yes❑NO❑ CITATION# 10 BOTTOM
15❑ ......G 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2538866996
16 a
LAST NAME MENDOZA FIRST NAME JOVY MIDDLE I D
INITIAL
17❑ STREET ❑', 6940 MARTIN LUTHER KING JR WA APT 619W CITY' SEATTLE ST WA ZIP 981183671 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 DRIVER'S STATE WA SEX M D.O.B. 03 �_ 07 1969 El 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CEC9098 TAre WA VIN# 19XFC1F32LE208983
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2020 MAKE HOND MODEL CIVIC STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO✓
REGISTERED OWNER INFO JOVY MENDOZA 6940 MARTIN LUTHER KING JR WA APT 619W SEATTLE WA 981183671 D:2538866996 VEHICLE NO.2
SHADE DA GEbAREA
LIABILITY
INSURANCE INSU&PORGY#E CO ALLSTATE 820146401IN 1GQI
vE""LE ❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
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. ED65636
COLLISION REPORT III III III III III 111
1591972 CASE# 23-5638
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'
blk/unit 2 lane 2 biege trk/unit 1 lane 1 into 2
RTF
Within the city limits of Renton/King/WA I responded to a 2 car non blocking crash near the 300 block
of S 3rd St. S 3rd St is a 2 lane one way road.
I contacted the driver of unit 2 who told me he was EB on S 3rd St lane 2 when unit 1 changes lanes
into the side of him. He did not complain of injury and damages did not require a tow truck.
I contacted the driver of unit 1 who told me he was visiting the area from Vancouver WA. He was in
lane 1 EB on S 3rd St and told me he made a mistake by changing lanes into the side of unit 2. He
was very apologetic. He did not complain of injury and damages did not require a tow truck.
Information/Insurance only.
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 12:41:10 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED 7:46 AM TIME POLICE ARRIVED;7:50 AM
PART I PAGE IT]OF 3�
REPORT NO. ED65636 CASE# 23-5638 DATE AND TIME 05/19/23 07:46
OF COLLISION
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