HomeMy WebLinkAbout23-8543 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-8543 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
COLLISION' 07 - 1-- 2023 0802 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
PARKING LOT BLOCK NO. e✓ 1120
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 125 00 FMILES
EET e S ❑ W e OAKESDALE AVE SW
0 3 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE =30
6� LAST NAME CINKOVICH FIRSTNAME JOSEPH MIDDLE E 1 1 2 31
INITIAL
STREET ❑, 10811 130TH STREET CT E CITy PUYALLUP ST WA 2jp, 983745605 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 2❑
3
LICENSE C07010Y STATE WA uN# 1GTW7AFG3K1327375
10 9❑ Pr ATE�
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. YRLR. 3 1 33
12❑ VIN#' VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 1 34
13❑9 2019 GMC SA VANA DAMAGE YES NO YES[:] ✓No
REGISTERED OWNER INFO EMERALD FIRE LLC 11821 CRAMER RD NW GIG HARBOR WA 98329 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAME SAME 3 4
IN EFFECT &POLICY# 9TOP
EGA LE CHARGE I 5 36
L EH'C YES❑NO❑ CITATION# 10 BOTTOM
15❑ AM
1NDIING 8 6
UNIT 02 vEHIMOTOCLE ❑ CYCLE PEDESTRIAN ❑ OWNER
❑ DYES NO OLD MET PHONE
16 2
LAST NAME DALIT FIRST NAME MARLA MIDDLE M
INITIAL
17❑ STREET ❑', 1425 S PUGET DR UNIT 04 CITY' RENTON ST WA ZIP 980554368 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19 DRIVE # STATE SEX F Mr D.O.B. 05 _ 31 1989 39
20 ON DUTY STATUS 1 AIRBAG RESTR EJECT 1 HELMET 7 INJURY]7 NATURE of INJURIES ❑ 40
USE CLASS TRANSPORTED
❑21❑ LICENSE TATE VIN# 41
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 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 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED85540
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8543
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'
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.
M.LEVERTON 07-26-23 10:14 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 8/2/2023 12:52:55 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 8:03 AM TIME POLICE ARRIVED]8:06 AM
PART I PAGE IT]OF 4�
REPORT NO. ED85540 CASE# 23-8543 OF COLLISION
07/26/23 08:02
OF CbLLI510N
NARRATIVE
wht van grn bike
Within the city limits of Renton/King/WA I responded to a car v bicycle at 1120 SW Grady Way.
I contacted the driver of unit 1 who told me he was in a light contact collision with a bicycle in the
parking lot of Shell Gas station. He told me he was westbound on Grady and making a right turn into
the parking lot. He described his vehicle as being almost or completely off the roadway before impact
with the bicycle. He apologized for moving it from its POR but showed its basic location at POI. He
told me he believes the contact between his van and bicycle was only tire to tire as there was no
other marks on his van of recent damage or rub marks on the dirty paint. Unit 1 told me he did not
notice the bicycle in the roadway, that she must have been on the sidewalk when he made his turn.
I contacted the bicycle rider later at VMC-ER. While on scene she was being treated by Renton Fire
and later transported by Teri-Med. She told me she was riding her bicycle on the sidewalk
westbound when the van turned across the driveway apron into the parking lot. She told me she
thought they made contact near the sidewalk. She told me she may have bumped her head and didnt
provide any other additional information. She complained of a headache and sore knee.
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 7/26/2023
PAGE 3 OF 4
REPORT NO. ED85540 CASE# 23-8543 DATE AND TIME 07/26/23 08:02
OF COLLISION
nfs
0
5taeil Gasp Station
7 720 S W Grady Way
PAGE 4 OF 4