HomeMy WebLinkAbout23-10321 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-10321 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 TOTAL#OF OBJECT 28
0
RESERVATION 1
TRIBAL UNITS 02 STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN ✓ CITY# ❑
cawsloN 09 - 06 - 2023 1741 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD MILEPOST ST e✓ 3116
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W V NE 12TH ST 1 0 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO ✓ D:2062268086 30
6� LAST NAME FUKUNAGA FIRSTNAME JERI MIDDLE Y 1 1 2 31
INITIAL
STREET ❑, 3216 SE 3RD ST CITY RENTON ST WA ZIP 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I iNTERLOCKYEs No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 1 CLASS NATURE OF INJURIES z❑
3
10 9❑ P1 AT 14 ARD9362 STATE WA VIN# JTMBD33V575117432
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FR.. ro
TRLR. TRLR 7 1
2❑ 33
1 VIN# VIN#
:: ;. FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 1 34
13 9 2007 TOYT RAV4 4L DAMAGE YES NO ✓ YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 UABILI V INSURANCE INSURANCE CO FARMERS 3731638430 3
IN EFFECT &POLICY# 9TOP
vECeHA"Le 5 36
LLLv Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ �STA""'
I,I 8 6
UNIT U2 VEHIMOTOCLE ❑ CYCLE ❑ PEDESTRIAN ❑PEDAL ✓ oWNFRRTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME SOMBATH FIRST NAME KAMPHOUVIENG MIDDLE V
INITIAL
17 STREET❑ NEW ADOREs7 CITY' RENTON ST WA ZIP 98056 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCK YES❑NOR INTERLOCK yEEsIII❑NOF YES❑NO❑
19 DRIVE #
ON DUTY STATUS 0 AIRBAG RESTR EJECT HELMET 2 INJURY 6 NATURE of INJURIES 40
USE CLASS NON LIFE THREATENING
❑21❑ LICENSE TATE VIN# 41
1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 1 5 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
BLAKE BOWIE 12105 WA0171300
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE25046
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10321
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MEJIA MOLINA NOHEMI P
(LAST FIRST,
ADDRESS&PHONE#
1408INDEX AVE NE RENTON WA 98056 2063167457 SEXi F MMDOYyry 02 - 04 - 1977
PASSENGER WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
✓�, POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&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.
SLAKE BOWIE 09-06-23 08:14 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 1 11/30/2023 4:28:05 PM
BADGE OR ID# ! 12105 OR]# WA0171300 TIME POLICE DISPATCHED 5:43 PM TIME POLICE ARRIVED',5:45 PM
PART I PAGE IT]OF 4�
REPORT NO. EE25046 CASE# 23-10321 OF COLLISION
09/06/23 17:41
OF CbLLI510N
NARRATIVE
On 09/06/2023 at 1831 hours I was dispatched to 3116 NE Sunset Blvd, in the City of Renton, King
County, Washington. I was responding to an accident with injury.
While enroute, dispatch advised the reporting party hit a pedestrian that was laying on the ground.
The reporting party said they couldn't see him lying on the ground and they ran over him.
Upon arrival I saw a male on the ground that appeared to be in pain but conscious. There was a
female that was driving a Toyota Rav 4 that was identified as the reporting party. I identified Jeri Y.
Fukunaga (DOB:07/16/1957) as the driver of the 2007 Toyota Rav 4 (LICPL: ARD9362). Jeri told me
the following: Jeri said that she was driving West on NE 12th St and turned right into the Rite Aid
parking lot. She said there was a red car that was far over into her turn lane, so she was trying to hug
the right side of the curb as much as possible. While she was pulling forward slowly into the Rite Aid
parking lot, she hit a male who I identified as Kamphouvieng Sombath (DOB: 01/30/1973). Jeri said
Sombath cried out and a witness who was identified as Nohemi Mejia Molina (DOB: 02/04/1977)
stopped her vehicle and came towards her to check on Sombath.
Nohemi said that she saw Jeri slowly try and take a right hand turn into the Rite Aid and as she did so
she drove to close to the curb hitting Sombath who was sprawled out next to the curb laying in the
dirt. Sombath had dark clothing on and was hard to see for vehicles that were turning in.
Sombath was evaluated by Renton Fire and transported to Valley Medical to be evaluated for chest
and arm pain.
I gave Jeri my business card with the case number attached.
I gathered video from the Rite Aid cameras with my department issued cell phone and they were
downloaded to Evidence.com. On the video it shows a red sedan sitting far into the middle lane of the
driveway, you can see Jeri in the Toyota Rav 4 slowly take the right into the parking lot. It appears
she hits a object that slows her vehicle to a stop and that's when you see the witness stop her vehicle
and get out to discover Sombath was ran over while he was laying closely next to the curb in the dirt.
This concludes my involvement in this case.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
Electronically signed by Ofc. W.Nelson #12789, 09/06/2023 at 1945 hours in Renton, Washington.
PAGE 3 OF 4
REPORT NO. EE25046 CASE# ' 23-10321 DATE AND TIME 09/06/23 17:41
OF COLLISION
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DRIVEWAY INTO RITE AID
PAGE 4 OF 4