HomeMy WebLinkAbout23-10531 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REPOFIT 1591971
CASE 23-10531 z❑
INTERSTATE ❑ CITY STREET El
1❑
STATE ROUTE ❑ OTHER ❑ LOCAL AOENC 4900 3❑
CODING
COUNTY RD ❑ PRIVATE WAY ❑
2 2 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# ❑
cowsloN 09 - 1-- 2023 1555 17 ❑.= S 8 E IN e 1070 3❑
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
AIRPORT WAY BLOCK NO. e✓ 200 ❑ ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 200 00 FMILES EET ❑ S ❑ E ❑ LAKEAVEN
1 2 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2068985287 0 11
30
6❑ LAST NAME SET SALVADOR FIRST NAME JOSE MIDDLE E 1 2 31
INITIAL
STREET El 9838 62ND AVE S CITY SEATTLE ST WA ZIP 981185831 z❑
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3❑
iNTERLOCKYEs 1/ I NO NTERLOCKYEs NO Z YEs No�/
8❑ LRIIVER # STATE WA SEX'M I EL MMDDYY' 01 - 30 - 1999 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
❑
LICENSE CGT3136 sTArI WWAvIN# 2HGFG12827H566473
3
10 F91 PI ATE#
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR $ 7 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2007 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 HOND CIVIC 2D DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO JOSE SETSALVADOR 983862ND AVE S SEATTLE WA 981185831 D:2068985287 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
❑ LEGALLY LE CHARGE 5 36
15 2 YES❑No❑ clTAnoN# 3A0463530 INATTENTIVE DRIVING s I o eorrom
1.' MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER ❑ YES�/ NO DD 4252278423
16❑
LAST NAME DUONG FIRST NAME KIM MIDDLE K
INITIAL
17 STREET I❑ 22242 98TH PL S CITY KENT ST WA ZIP 980312488 37
NEW ADOREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑jNO� INTERLOCK YEs I I NOF YEs t l NoF,/
19❑ DRIVER #
❑ ON DUTY❑ STATUS AIRBAG,2 RESTR 4 EJECT 1 HE 2 INJURY 7 NATURE of INJURIES ❑ 40
USE CLASS SHOULDER PAIN
❑21❑ PLA E# CBX0137 TArE 41
WA VIN# JTMRWRFVXMD132064 1
22❑ PLATE# STATE PLA 42
TE# STATE
❑
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2021 MAKE TOYT MODEL RAV4 STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YESfj
NO,/ YES NO
REGISTERED OWNER INFO KIM DUONG 2224298TH PL S KENT WA 98031 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#ECO STATE FARM 1923978 F2047EIN STOP 5
'E""LE ❑ Nu,J— CITATION# CHARGE
LEGAL to BOTTOM
LY YES
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF ❑❑
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE02937
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10531
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'
On 9-12-23 at about 1556 1 came upon a collision that had just occurred in the 200 block of Airport
Way. Both vehicles were still in the roadway. Both drivers were identified via WADL.
Driver 1 told me in Spanish;
He was coming from the driveway just south of the collision.
He thought he had enough time to exit safely.
Unit 2 collided with the drivers side of his vehicle as he was entering traffic.
He was not injured.
Driver 2 complained of shoulder pain to a shoulder that she had recently had surgically repaired.
Driver 2 was checked by Renton Fire Authority (RFA) and transported to the hospital via ambulance.
RFA moved unit 2 to a safe location prior to driver 2 being removed from the scene.
Unit 1 was released to Jose Set Salvador.
I cited Jose Set Salvador for inattention via complaint.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 09-21-23 09:05 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 912712023 10:17:52 AM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED 3:56 PM TIME POLICE ARRIVED 3:56 PM
PART I PAGE IT]OF 3�
REPORT NO. EE02937 CASE# ' 23-10531 DATE AND TIME 09/12/23 15:55
OF COLLISION
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