HomeMy WebLinkAbout23-8367 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-8367 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 5 6 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#
cawsloN 07 - 1-- 2023 1235 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
WILLIMS AVE N
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e N RIVERSIDE DR
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO ✓ I D:2069609788 30
6� LAST NAME COOPER FIRSTNAME PETRICIE MIDDLE A 1 2 31
INITIAL
STREET ❑ 814 N 2ND ST APT C CITY RENTON ST WA 21p 980575627 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10[1Pi ATNES# CGK0274 sTAr WAv N# 2HKRL18932H533649
5 TRAILER STATE TRAILER STATE
11
2-LATE# PLATE# FROM To
rRLR. TRLR. 1 5 33
12❑ VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 2 2002 HOND ODYSSE DAMAGE YES NO ✓ YES[:] NO✓
REGISTERED OWNER INFO PETRICIE COOPER 814 N 2ND STAPT C RENTON WA 980575627 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
vwcLE YES CHARGE 5 36
❑NO❑ CITATION# 10 BOTTOM
15❑ LEeCALLv STANDING 8 6
MOTOR PEDAL ✓ PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES✓ NO D:4087814141
16 a
LAST NAME BORGMAN FIRST NAME BRADLEY MIDDLE N
INITIAL
17❑ STREET ❑', 4146 BOULEVARD PL CITY MERCER ISLAND ST WA ZIP 98040 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t- l NO❑
19 F] LDI IVER # STATE SEX M M D.C.B. 12 _ 25 _ 1955 39
20 ON DUTY STATUS 1 AIRBAG RESTR EJECT 1 HELMET 7 INJURY 6 NATURE of INJURIES ❑ 40
USE CLASS ARM/WRIST FRACTURE
❑21❑ TArE LICENSE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# 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 I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26 4 9 M.LEVERTON 2517 [V7�ENCY
A0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED85542
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8367
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'
Within the city limits of Renton/King/WA I responded to a car v bicycle crash at Williams Ave N at N
Riverside Dr. This car initially came out as a Fire call for a bicycle down, not involving a car.
I contacted the bicycle rider who told me he was east to west. He said he stopped for the stop sign
and believed it was his turn to go while referencing unit 1. He told me unit 1 started at the same time
as well where the collided in the intersection. He was treated on scene by Renton Fire and later
transported by Tri-Med for a possible arm fracture. His bicycle was in the ambulance with him.
I contacted the driver of unit 1 who told me she had stopped for the stop sign and noticed the bike
rider too. She told me she believed it was her turn to go and she did when she said the bicycle rider
had also started across the intersection and they collided. She did not complain of any injury and
damages did not require a tow truck.
Information/Insurance only.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 7/21/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 07-21-23 01:58 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 8/2/2023 1:14:59 PM
BADGE OR ID# 2517 OR]#' [ WA0171300 TIME POLICE DISPATCHED; ?Y:42 PM TIME POLICE ARRIVED',12:59 PM
PART I PAGE IT]OF
REPORT NO. ED85542 CASE# ' 23-8367 DATE AND TIME 07/21/23 12:35
OF COLLISION
nts
Dr
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