HomeMy WebLinkAbout23-8207 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-8207 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 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 07 - 1-- 2023 2111 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
e✓ --- ----� ❑
N 4TH ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET) BLOCK NO.
5❑ ❑ FEET e S ❑ VV e WELLS AVE N
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2067393460 0 11
30
6❑ LAST NAME MANA FIRSTNAME PAN MIDDLE 1 2 31
INITIAL
STREET ❑ 2918 S 144TH ST CITy SEATAC ST WA ZIP' 98168 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 09 1- 23 - 1979 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
LICENSE CGJ2376 sTArI WAVrN# JTDKB22U040081456
10 F91 PI ATE#
IT STATE TRAILER STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR. TRLR. 5 1 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 3 ] 34
13 1 2004 TOYT PRIUS SD DAMAGE YES NO YES❑ No✓
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI V INSURANCE❑ NSURANCE CO 3
IN EFFECT &POLICY# 9TOP
vewcLE CHARGE 5 36
LEGALLv YES No clTAnoN# 3A0381060 OP MOT VEH W/OUT INSURANCE o aorrom
15❑ STANDING 8 7 6
MOTOR PEDAL- ',PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2064078933
16 a
LAST NAME NGUYEN FIRST NAME PHUONG MIDDLE H
INITIAL
17 STREET I5TH AVE S CITY' SEATTLE ST' WA ZIP 98178 4❑ 37
NEW ADDREs�' 11842 5
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK yEs I I NOF YEs t l NOF,/
19 DRIVER # STATE WA SEX F M D.C.B. 05 _ 22 _ 1971 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑1 LICENSE 21❑ PLA E# CAY7536 TArE 41
WA VIN# JTH8J46G672070052 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2007 MAKE LEX$ MODEL ES 250 STYLE $D DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE INSU PORGY#E CO STATEFARM 4237781D1347BIN STOP 5
VE—LE ❑ ,J� CITATION# CHARGE to BOTTOM
LEGALLY YES N`L J
25 ' 6
7BRYAN
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26GROZAV 12489 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED84861
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8207
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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.
BRYAN GROZAV 07-18-23 12:29 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 713112023 6:24:36 PM
BADGE OR ID# 12489 ORI# WA0171300 TIME POLICE DISPATCHED! 9:13 PM TIME POLICE ARRIVED]9:13 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED84861 CASE# 23-8207 OF COLLISION
07/17/23 21:11
OF CbLLI510N
NARRATIVE
CASE 23-8207
This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events.
On Monday July 17th, 2023, at approximately 21:13, 1 responded to a 911 call regarding a two-
vehicle collision in the area of N 4TH St and Wells Ave N within the City limits of Renton, King
County, Washington.
*** CALL REMARKS: 2 MVA, BLOCKING RIGHT LANE ON 4TH....UNK INJS. ABOUT 4 SUBJS
SEEN STANDING AROUND VEHS, UNK IF PSBYS OR INVLD. BLK VEH HAS HAZARDS
FLASHING....LINK IF MVA OR JUST BLK DIS.
-UNIT ONE: WHITE 2004 TOYOTA PRIUS WASHINGTON LICENSE: CGJ2376
-UNIT ONE DRIVER: PAN MANA (DOB: 09.03.1979)
-UNIT TWO: BLACK 2007 LEXUS ES WASHINGTON LICENSE: CAY7536
-UNIT TWO DRIVER: PHUONG H. NGUYEN (DOB: 5.22.1971)
1 arrived on scene and contacted the involved parties and confirmed there were no injuries. I noticed
There were minor injuries to both vehicles. Phuong said she was traveling east on N 4th St when unit
one crossed in front of her from Wells Ave N. Phuong was the only occupant in the vehicle at the time
of the collision. Unit two was drivable.
Pan said she crossed N 4th St from Wells Ave N and was hit by unit two. Pan indicated she had
insurance but left it at home. Pan was the only occupant in the vehicle at the time of the collision.
Based on the circumstances I issued Pan a traffic infraction for the following violations (SECTOR
CITE 3A0381060):
•RCW 46.30.020- OP MOT VEH W/OUT INSURANCE
All involved vehicles were provided a copy of the SECTOR exchange of information form. I provided
Pan a copy of her traffic infraction.
This concludes my involvement in this case.
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 B. Grozav #12489 on 7.18.2023 at 00:19 hours in Renton, WA.
PAGE 3 OF 4
REPORT NO. ED84861 CASE# 23-8207 DATE AND TIME 07/17/23 21:11
OF COLLISION
N 4th St
Wells Ave N
PAGE 4 OF 4