HomeMy WebLinkAbout23-7166 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-7166 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 3
HIT&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 N E IN CITY# ❑
cowsloN 06 - 1-- 2023 1741 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LOGAN AVE N BLOCK NO. e✓ 300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET MILES e S B W e N 3RD 0 1 29
MOTU '�01 VEHtOR PI CLE CYDCLE. El �ESAGE NHORE✓LD MET PHONE 0 81
30
6❑ LAST NAME CONTRERAS CONTRERAS FIRST NAME CIRILO MIDDLE 1 1 2 31
INITIAL
STREET ❑, 2903 NE 16TH ST CITY RENTON ST WA Zlp' 98056 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYES NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 02 1— 14 — 1982 2 32
[NATURE OF INJU
9 ON DUTY❑ STATUS' AIRBAG 2 RESTR 9 EJECT 1 H USE 6 7 CLASS NOSE BLEED RIES z❑
3
10❑ PI ATE 14 CBF2767 STATE WA u N# 4T1 BK46KX7U555376
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR 1 5 33
12 0 0 vIN#' UIN#
>;. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 9 34
13 8 2007 TOYT CAMRY SD DAMAGE YES No YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 ❑ INSURANCE CO 3 4
LIABILITY INSURANCE
IN EFFECT &POLICY# 9TOP
vewcLE 10BOTTOM 5 36
LECALLv res�No D CITATION# 3A0465180,3A0465180, CHARGE OP MOT VEH W/OUT INSURANCE,NO
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2066063227
16 a
LAST NAME JACKSON FIRST NAME MATELITA MIDDLE A
INITIAL
17❑ STREET NEW ADOREs7 11810 56TH PL S CITY SEATTLE ST' WA ZIP 98178 37
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19[—] LICENSE# STATE WA SEX F M .C... 12 _ 30 _ 1975 0 39
HELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 1 EJECT 1 USE CLASS ❑
❑ILICENSE 21❑ PLA E# BGL3765 TATe WA VIN# 41
3C4PDCABXHT582479 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2017 MAKE DODG MODEL,TOURNEY STYLE UT DAMAGE TOWED NOO✓ BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO PROGRESSIVE 934381512IN 1 9TOP
VEHICLE YES N CITATION# CHARGE i o BOTTOM
LEGALLYNC[:]25❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
YUSUF XBRIL 12490 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE09138
COLLISION REPORT III III III III III 111
1591972 CASE# 23-7166
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
PM 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 subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
YUSUF XBR/L 06-24-23 07:22 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 1011412023 6:26:07 PM
BADGE OR ID# ! 12490 OR]# WA0171300 TIME POLICE DISPATCHED! 5:41 PM TIME POLICE ARRIVED',5:45 PM
PART I PAGE IT]OF 4]
REPORT NO. EE09138 CASE# 23-7166 OF COLLISION
06/24/23 17:41
OF CbLLI510N
NARRATIVE
On 06/24/2023, at approximately 1744 hours, I was dispatched to investigate a collision at the 300
Logan Ave N. City of Renton, King County, State of Washington.
Upon arrival, I contacted both drivers at the above location. Driver of unit 1 was bleeding from his
nose. Medics treated him on scene, and he declined any further medical treatment. Driver of unit 2
did not report any injuries.
Both vehicles appeared drivable.
The driver of unit 2, reported that she was stopped mid-block on 300 block of Logan Ave N waiting for
the light to change. Unit 2 was stopped on the second lane from the curb and the traffic in front of her
was stopped. Unit 1 was traveling in the same direction when he collided with unit 2. Unit 2 sustained
minor damage to the rear bumper.
Driver of unit 1 reported he was traveling westbound on Logan Ave N. He reported the traffic ahead of
him came to stop abruptly and he rear ended unit 2. Unit 1's said he hit his nose on the steer wheel of
his vehicle causing him to bleed. The driver of unit 1 did not have valid license and he did not have
motor vehicle insurance. Unit 1 sustained minor damaged to the front bumper.
Based on the damages to the vehicles and the drivers' statements, driver of unit 1 was issued citation
for following too close, operating a motor vehicle without valid driver license, and driving motor
vehicle without insurance.
Both drivers were provided with business card and case number.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Traffic Control: TCD
**** END OF AUTO-POPULATED SECTION ****
PAGE 3 OF 4
REPORT NO. EE09138 CASE# ' 23-7166 DATE AND TIME 06/24/23 17:41
OF COLLISION
not to scale
N
PAGE 4 OF 4