HomeMy WebLinkAbout23-8084 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-8084 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER � VFHIC;I F ❑ LOCAL AGENCI 4300 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 2$
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# ❑
cawsloN 07 - 1-- 2023 1815 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
GARDEN AVE N BLOCK NO. e✓ 1000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 1 9 29
MOTU '�01 VEHtOR PI CLE CYCCLE. El �ESAGE NHORE✓LD MET PHONE 1 4 30
6❑ LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES NO YES No
8 DRIVER'S. STATE SEX.U D.Q.B. 1 32
❑ :LICENSE# MMDDYY —=
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE sTAT1 VrN#'
10❑ PI ATE 14
TRAILER TRAILER
STATE STATE
11 0 0 PLATE# PLATE# Rom ro
TRLR. TRLR m 33
12 0 0 VIN If VIN#'
FROM
34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13❑ DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VEwcLE 5 36
LECALLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8 6
UNIT 02 MOTOVEHIR
CYCLE ❑ PEDESTRIAN ❑ OWNFRRTY ❑ DYES NO OLD MET PHONE
16❑
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET
CITY' Sr ZIP 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL t—T�RANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YES It1 I NoF t l YES NO
19 LLIICENS RIVEWS# STATE SEX U MMDDYY —=_ 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT '1 USE 9 CLASS 0 ❑
❑ILICENSE 21❑ PLA E# CCV8878 TATe 41
WA VIN# KNAFE222495662246 4
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2009 MAKE KJA MODEL SPECTRA STYLE 4D VEHICLE TOWED TO BLIN TOWEDeY GOB HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ANGEL HERNANDEZ RENTERAL 1705 SUNSET WAY CENTRALIA WA 98531 D:3605062184 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO NATIONWIDE 7246J O51962IN 1GQ
VEwCLE ❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25 s � e
7jo
R'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
THAN SELBERT 12641 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED80077
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8084
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.
JONATHAN SELBERT 07-14-23 07:53 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 711612023 2:32:47 PM
BADGE OR ID# 12641 OR]# WA0171300 TIME POLICE DISPATCHED! 6:24 PM TIME POLICE ARRIVED]6:46 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED80077 CASE# 23-8084 OF COLLISION
07/14/23 18:15
OF CbLLI510N
NARRATIVE
On 7/10/2023, at 1840, 1 responded for an assignment for an Accident in the Lowe's hardware store
parking lot located at 1000 Garden Avenue N, in the City of Renton, King County, Washington State.
Call notes stated that the reporting party's vehicle had been struck by an unknown vehicle. The party
remained on scene hoping police could assist viewing Lowe's security footage.
I arrived and made contact with the driver of Vehicle 2. He stated that he had arrived at Lowe's at
1748, parked his car and went inside. At 1824, he returned to his vehicle and found that an unknown
vehicle had struck its rear, passenger-side fender.
I observed very minor, superficial damage to the rear, passenger-side fender of Vehicle 2. 1 noted
black paint transfer, as well.
I contacted Lowe's employees who told me that none of the employees on site had access to the
security video. They did inform me that the area of the parking lot where the accident occurred was
covered by their cameras.
There was no other information about Vehicle 1 or its driver available.
I photographed Vehicle 2 and uploaded the photos via Axon Capture.
My involvement in this incident was captured on my body-worn and in-car camera.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer J. Selbert (12641) in the City of Renton, King County, Washington
State on 7/14/2023 at 1946.
PAGE 3 OF 4
REPORT NO. EU80077 CASE# 23-8084 DATE AND TIME 07/ 4/231815
CD
OF COLLISION
CD
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