HomeMy WebLinkAbout23-5839 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-5839 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#TRIBAL OF OZ OBJECT 1 1 8 28
UNITS
RESERVATION I I
STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 05 - 1-- 2023 0854 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S GRADY WAY BLOCK NO. e✓ 900 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e W/L!IAMS AVE S
0 5 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2067959908 0 11
30
6� LAST NAME JOHNSON FIRSTNAME TASH MIDDLE K 1 2 31
INITIAL
STREET ❑1 3901 225TH P!SW CITY MOUNTLAKE TERRACE ST WA 2jp, 980434219 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ LICENSE# STATE Wq SEXI M MM D Y' 10 - 18 - 1996 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 CLASS 1 NATURE OF INJURIES z❑
3
10[1 P1 ATE 14
C73877B sTAr WAv N#' JF2SJABC4FH491297
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR. 3 3 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 3 2015 SUBA FOREST UT DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO SINCLAIRMEDIAOFSEATTLELLC1404THAVEN SEATTLEWA98109 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO HARTFORD 30ASRS80302 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LEGAL
Lv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:4254091653
LAST NAME GOLZARIAN FIRST NAME GABRIELLA MIDDLE R
INITIAL
17 STREET NEW ADDRESS❑' 3413 134TH PL SW UNIT A CITY LYNNWOOD ST WA ZIP 980871667 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 DRIVER'S STATE WA ]SEX IF D.O.B. 03 _ 28 _ 1991 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑LICENSE I 21❑ 41
PLA E# C46008E TArE WA VIN1 1FTKRIADOBPA97166 1
42
22❑ PILER LATE# STATE pLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2011 MAKE FORD MODEL RANGER STYLE PK VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO THE DAVY TREE EXPERT COMPANY 1500 N MANTUA ST KENT OH 44240 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO OLD REPUBLIC MWTB31404121IN I STOP 5
VE""LE ❑ Nu,J CITATION# CHARGE
LEGAL i o BOTTOM
LY YES
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JAC08S 1953 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED72938
COLLISION REPORT III III III III III 111
1591972 CASE# 23-5839
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) ZAHN THERON A
(LAST FIRST,
ADDRESS&PHONE#
17924 RlVIERA PL SW NORMANDY PARK WA 981663642 SEX M MMDDYyry 07 - 29 - 1970
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 POS. : 3 2 4 1 USE 2 CLASS 1
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 FIRST MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 5-24-23 at about 0900 1 arrived in the lower parking lot of Renton City Hall, 1055 S Grady Way for
a 2-vehicle collision that occurred at the intersection of S. Grady Way and Williams Ave S. I contacted
all involved in the parking lot near their vehicles. All parties were identified via WADL. Driver 1, Tash
Johnson told me;
He was making a U-turn from Westbound Grady to Eastbound Grady Way while enroute to the city
hall.
He did not see unit 2 coming and they collided.
He nor his passenger were injured.
Driver 2 told me;
She was driving eastbound on S Grady way, through the intersection with Williams Ave S when unit 1
struck the rear quarter panel of her vehicle.
She was not injured.
Both vehicles were driven from the scene.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 06-05-23 01:06 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 6/23/2023 9:50:41 AM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED 9:00 AM TIME POLICE ARRIVED 9:00 AM
PART I PAGE IT]OF
REPORT NO. ED72938 CASE# 23-5839 DATE AND TIME 05/24/23 08:54
OF COLLISION
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