HomeMy WebLinkAbout23-8629 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-8629 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 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# ❑
COLLISION: 07 — 28 — 2023 1122 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SW GRADY WAY BLOCK NO. e✓ 555
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2065486396 0 11
30
6� LAST NAME NUNGARI FIRSTNAME ROSE MIDDLE M 1 F 2 31
INITIAL
STREET ❑, 1030 42ND CT NE I CITY AUBURN ST WA 2jp, 98002 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aTES� BV28806 sTArr WAurN# 1G1JC6SH4F4197007
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34
13 2 2015 CHEV SONIC C4 DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO STANLEYMUCHAH1 13606 96THAVEE PUYALLUP WA 98373 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ALLSTATE 817181290 3 4
IN EFFECT &POLICY# 9TOP
vEHICLE CHARGE 5 36
LEGALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2537405803
16 2
LAST NAME TEP FIRST NAME SOVANN MIDDLE
INITIAL
17 STREET❑ NEW ADOREss❑' 1625E 35TH ST CITY TACOMA ST' WA ZIP 98404 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK Y�EsI❑NOF YEs❑NO�
19 LICENSE# STATE WA SEX M M.C.B. 10 _ 14 1982 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES 40
❑21❑ PLATE# C75170X TArE 41
WA VIN1 1FDUF4GN8MEE11062 1
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2029 MAKE FORD MODEL F450 STYLE CB VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO COMPANYPTL COLLATERAL RT IO GREEN HILLS PO BOX 791 READING PA 19603 VEHICLE NO.2
SHADE IN DAGED AREA
2 4
LIABILITY INSURANCE INSU&PORGY#E CO ZURICH AMERICAN INSURANCE BAP7432154-01 1 STOP 5
IN EFFECT
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N`LJ
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
STEVEN FAJARILLO 12847 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED84283
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8629
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) BENSON GWENDOLYN L
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
19707INTERNATIONAL BLVD 304 SEATAC WA 98188 2062899794 SEXi F MMDDYyry 12 - ET 1957
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER I�IWITNESS�'UNIT# 1 POS. 3 AIRBAG'2 RESTR, 4 EJECT 1 USE CLASS '7 LOWBACKraw
NAME L�1
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 07-28-2023 1 was working as a police officer in the city of Renton. At approximately 1123 hours I
was dispatched to the report of a vehicle collision near the intersection of SW Grady Way/Lind Ave
SW, City of Renton, County of King, WA. This incident was captured on my department issued Axon
body camera and my vehicles Axon camera system.
I arrived on scene and located Unit 1 and Unit 2 facing west in front of 555 SW Grady Way. The driver
of Unit 1 told me she was in the outside lane and signaled to move into the left lane. She then heard a
loud noise and noticed she collided with Unit 2. The passenger of Unit 1 gave the same story.
The driver of Unit 2 was driving on the inside lane and noticed Unit 1 merging into his lane. He could
not move out of the way to avoid the collision.
The passenger of Unit 1 was transported to the hsopital for lower back pain. The other involved were
not injured. I photographed both vehicles and uploaded the pictures to Evidence.com. I provided both
drivers with case numbers. There was no surveillance footage available at 555 SW Grady Way.
There was no further information available at this time.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
STEVEN FAJARILLO 07-29-23 05:15 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
D.SKELTON 9139 713012023 3:54:10 AM
BADGE OR ID# 12847 ORI# WA0171300 TIME POLICE DISPATCHED 11:23 AM TIME POLICE ARRIVED 11:29 AM
PART I PAGE IT]OF 3�
REPORT NO. ED84283 CASE# ' 23-8629 DATE AND TIME 07/28/23 11:22
OF COLLISION
SW Grid W ;
PAGE 3 OF 3