HomeMy WebLinkAbout23-10826 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10826 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
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# ❑
cawsloN 09 - 1-- 2023 1222 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
EAST VALLEYHWY BLOCK NO. e✓ 4224
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 300 00 FEET e S B W e SW 43RD ST
0 1 29
UNIT 01 VEHICLE
MOTPI PEDAL-ORCYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 9 30
6� LAST NAME GUTIERREZPEREZ FIRSTNAME HUGO MIDDLE A 1 1 2 31
INITIAL
STREET ❑, 28515 SE 41ST ST CITY FALL CITY ST WA 2jp, 980247002 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES NO YES No
8 LICIENSE# STATE yyq SEXI M MDMDD 11 - 12 - 1973 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU SE CLASS 1 NATURE OF INJURIES z❑
3
10❑ PIATNES4 34391D sTAT WAuN# 1FDXF46S4SEC94114
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 0 0 VIN#j VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 3 2002 FORD F450 DAMAGE YES NO ✓ YES[:] No✓
REGISTERED OWNER INFO CITYOFISSAQUAH PO BOX 1307 ISSAQUAH WA 98027 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO WA CITIES 206-575-6046 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLY res❑NO❑ CITATION# 10 BOTTOM
15❑ STAIN.D'INGMOTO 8 7 6
UNIT a2 VE ICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
[:]I DYES✓ NO OLD MET PHONE
16 a
LAST NAME FOONG FIRST NAME JERRY MIDDLE I C
INITIAL
17❑ STREET ❑', 5811 BROAD VIEW AVE NE CITY TACOMA ST WA ZIP 984221418 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 D IVEW #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BRU8409 TATe WA VIN1 5N1DLOMM2KC558502
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2019 MAKE INFI MODEL QX60 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO JERRYFOONG 5811 BROAD VIEWAVENE TACOMA WA 9 84 2 214 18 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO GEIC04128-90-59-75IN IU
9TOP
vE""LE CITATION# CHARGE o BOTTOMLEGALYYES NEI25❑ J
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE02085
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10826
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 09-22-23 07:04 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 9/25/2023 9:55:45 AM
BADGE OR ID# 2517 OR]# WA0171300 TIME POLICE DISPATCHED; 12:23 PM TIME POLICE ARRIVED 12:32 PM
PART I PAGE IT]OF 4�
REPORT NO. EE02085 CASE# 23-10826 OF COLLISION
09/20/23 12:22
OF CbLLI510N
NARRATIVE
lane 2 rear yellow/1 blue van/2
RTF
Information/Insurance only
Within the city limits of Renton/King/WA I responded to a 2 vehicle blocking crash near the 4200
block of East Valley Rd. While enroute I requested for a tow truck since the RP said they could not
clear the roadway at a very busy roadway/intersection.
I contacted the driver of unit 2 who told me there were stopped in lane 2 for traffic when they were hit
from behind by unit 1. He did not complain of injury and damages did not require a tow truck.
I contacted the driver of unit 1 who told me that unit 2 had made a rapid lane change in front of him,
then made a sudden stop. He contacted the back of unit 2 with traffic cones mounted on the front of
his truck. Unremarkable damage and no tow truck required. He did not complain of injury.
I explained to both drivers their duty to move off the roadway when its such minor damages and this
would be an insurance event 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 9/22/2023
PAGE 3 OF 4
REPORT NO. EE02085 CASE# ' 23-10826 DATE AND TIME 09/20/23 12:22
OF COLLISION
i
nLs
PAGE 4 OF 4