HomeMy WebLinkAbout23-9389 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
CASE 23-9389 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 TOTAL#TRIBAL OF OZ OBJECT 1 1 8 28
UNITS
RESERVATION I I
STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 08 - 1-- 2023 2130 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S GRADY WAY BLOCK NO. e ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e OAKSDALEAVESW
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2067738299 0 11
30
6❑ LAST NAME MAGSOMBOL FIRSTNAME CHARMAINE MIDDLE 1 1 2 31
INITIAL
STREET ❑, 209 SW 324TH CT CITY FEDERAL WAY ST WA ZIP, 98023 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LDRIVER # STATE WA SEX'F MID
.O B Y 09 1- 18 - 1990 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET INJURY 6 NATURE OF INJURIES 2❑
USE CLASS RIGHT WRIST CUT AND GENERL PAIN
3
10[1Pl QTNFS# A6544345 STATE WA VIN If 3N1BC13E39L451505
F_ TRAILER STATE TRAILER STATE
11 0 0 PLATE# I PLATE# I I FROM To
TRLR. TRLR 7 1 33
12 0 0 VIN#' VIN#i
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 3 7 34
13 2 2009 NISS VERSA 4D DAMAGE vE5 0NO agW�MEYERS ves❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
14 LIABILITY INSURANCE❑ INSURANCE CO GEICO SHADE IN DAMAGED AREA 354
IN EFFECT &POLICY# 9TOP
15❑ vECEHA"LE 5 36
LLLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4255735731
16 2
LAST NAME NATIVIDAD ORTEGA FIRST NAME KASSANDRA MIDDLE
INITIAL
17❑ STREET ❑', 12618 SE 185TH PL CITY' RENTON ST WA ZIP 98055 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 D IVERI # STATE WA SEX F M .C... 04 18 _ 2006 39
WELMET INJURY 7 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG,6 RESTR 4 EJECT 1 USE CLASS AIRBAG SORENESS
21❑ LICENSE I CGH9793 TATE WA vIN# JHMFC1F73JX017720
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. N#. 43
RLR
'I
VEH YEAR 2018 MAKE HOND MODEL CIVIC STYLE SD I VEHICLE TOWED TO BLIN TOWEDII GOV HI 44
24❑ DAMAGE YES NO GENE MEYERS YES NO
REGISTERED OWNER INFO ELIAS NATIVIDAD ORTEGA 12843 SE 161STST RENTON WA 98055 D:4252479367 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY INSURANCE INSU&PORGY#E CO AMERICAN FAMILY 41043-76425-83 9TOP 5
IN EFFECT
VEHICLE ,.I—I CITATION# CHARGE
25 io BOTTOM
LEGALLY YES❑ N
' e
7TYLER
S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
EDIGER 12807 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED91205
COLLISION REPORT III III III III III 111
1591972 CASE# 23-9389
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MAGSOMBOL JOSHUA
(I.P.ST FIRST,
ADDRESS&PHONE# D O.B. '
209 SW 324TH CT FEDERAL WAY WA 98023 SEX M MMDOYyry 02 - 04 - 2007
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 POS. 11 6 4 1 USE CLASS 11
NAME
(LAST,FIRST,MIDDLE INITIAL) : JONES TERENCE A
ADDRESS&PHONE# D O B
1150 OAKSOALE AVE SW RENTON WA 98055 2536008536 SEX' M MMDDYvvv 05 - 17 - 1966
PASSENGER UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
[:]WITNESS POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
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.
TYLER EDIGER 08-16-23 01:22 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
G.BARFIELD 6476 1 812112023 1:24:46 AM
BADGE OR ID# 1Y807 OR]# WA0171300 TIME POLICE DISPATCHED 10:01 PM TIME POLICE ARRIVED i 10:07 PM
PART I PAGE IT]OF 4�
REPORT NO. ED91205 CASE# 23-9389 OF COLLISION
08/15/23 21:30
OF CbLLI510N
NARRATIVE
23-9389
On 8/15/2023 at approximately 2200 hours, I was dispatched to a two-vehicle collision at the
intersection of S Grady Way and Oaksdale Ave SW in the City of Renton, County of King, State of
Washington.
Upon arrival I identified Unit 1 to be a 2009 Nissan Versa (WA/Lic: A6544345). Unit 1 was drove by
Charmaine Magsombol (09/18/1990). Her son Joshua Magsombol (02/04/2007) was a passenger in
the vehicle.
Unit 2 was a 2018 Honda Civic (WA/Lic: CGH9793) being driven by Kassandra Natividad Ortega
(04/18/2006).
Unit 1 was traveling East bound on S Grady Way making a left turn to go North bound on Oaksdale
Ave SW. Unit 2 was driving West bound straight through the intersection. The vehicles collided in the
intersection.
I observed significant damage to the front passenger side of unit 1. Unit 2 had significant damage to
the front of the vehicle.
Both drivers thought their light was green.
The witness Terence A Jones (05/17/1966) stated that he was in a bus following beside Unit 2. Jones
stated the vehicle traveling westbound had a green light but had the two vehicles confused when he
pointed out which driver was at fault.
When we arrived both drivers had been evaluated by fire and only sustained what appeared to be
minor injuries. Both vehicles had significant damage to the front end. Both vehicles were towed.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically Signed: T.Ediger 12807 Date and Place: 08/15/2023 Renton,
WA
PAGE 3 OF 4
REPORT NO. ED91205 CASE# ' 23-9389 DATE AND TIME 08/15/23 21:30
OF COLLISION
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