HomeMy WebLinkAbout23-6549 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-6549 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2� TOTAL#OF OBJECT 1 �2$
TRIBAL UNITS 01 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 06 - 08 - 2023 2014 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
116TH AVE SE BLOCK NO. e✓ 16000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 1. 00 FEET MILES e S B W e SE 160TH ST
1 9 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2065668452 30
LAST NAME GUADALUPE-MENDOZA FIRSTNAME EMMANUEL MIDDLE
6 INITIAL 1 2 31
STREET ❑1 1455 S PUGET DR J203 CITY RENTON ST WA Zlp 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS' AIRBAG 1 RESTR 13 EJECT 1 HELMETU E 2 1 INJURY CLASS 7 SORE SHOULDER 1 [NATURE OF INJURIES z❑
3
10� PI ATFBit 052014 sTAT� IL vIN#' JKAEXMJI3CDAB9941
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR. 7 7 33
12❑ VIN# VIN#:
2012 KAWK EX250 MTa FROM 34
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO u BLIN TOWED BY GOVT.VEHICLE
13 9 DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO EMMANUEL GUADALUPE-MENDOZA 1455 S PUGET DR J203 RENTON WA 98055 D:2065668452 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE❑ INSURANCE CO 4
IN EFFECT &POLICY# 9TOP
VEH'CLL CHARGE 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ 1NDIING 8 7 6
UNIT U2 VEHICCMOTOLE ❑ CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES 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❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
L4❑ 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 s 7 6
7TRADER
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 1 4553 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED71267
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6549
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'
Unit 1 was riding his motorcycle on 116th AVE SE and turn on to a private drive in the 16000 block of
116th AVE SE. The private drive was loose gravel. Unit 1 spun out and crashed in the gravel. The
driver complained of shoulder pain. Renton Fire treated and transported to VMC. The driver was not
wearing a helmet at the time of the crash and did not have a valid license.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.TRADER 06-18-23 05:27 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.TRADER 4553 1 611812023 5:29:10 PM
BADGE OR ID# 4553 OR]#' I WA0171300 TIME POLICE DISPATCHED! 8:15 PM TIME POLICE ARRIVED;8:21 PM
PART I PAGE IT]OF 3�
REPORT NO. ED71267 CASE# 23-6549 DATE AND TIME 06/08/23 20:14
OF COLLISION
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