HomeMy WebLinkAbout23-10878 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10878 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2� TOTAL#OF OBJECT 1 �2$
TRIBAL UNITS 01 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 1641 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RENTON AVE S BLOCK NO. e✓ 13200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 150 00 FMILES EET e S ❑ W e HARDIEAVESW
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064762670 30
6❑ LAST NAME GARR/SON FIRSTNAME GARY MIDDLE F 1 1 2 31
INITIAL
STREET ❑, 334 GRANT RD CITY I SEQUIM ST WA ZIP 98382 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 08 — 02 — 1945 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�B� DP49411 sTArI WAvIN# 1 FTZR45E69PA30939
-- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FRom To
TRLR. TRLR 7 3 33
12❑ VIN#' VIN#.
2009 FORD RANGE PK OIIF ❑ RO�34
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED ILJ TO BLIN TOWED BY GOVT.VEHICLE
13 2 DAMAGE YES NO YES NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO STATEFARM 3858280 A1155C 4
LI EFFECT &SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STAIN.D'ING 7 6
UNIT a2 VE IMOTOCLE ❑ CYCLE ❑ PEDESTRIAN ❑ oWNFR PEDAL RTY ❑ DYES NO OLD MET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ 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 LLIICENS # STATE SEX MMDDYY —�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TArE 41
IN#LICENSE V 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
=ORAJEWSKI
(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 12399 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE03555
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10878
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,FIRS 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.
RAYMOND GORAJEWSK/ 09-21-23 05:28 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 912812023 4:16:57 PM
BADGE OR ID# ! 1Y399 OR]# WA0171300 TIME POLICE DISPATCHED! 4:43 PM TIME POLICE ARRIVED',4:48 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EE03555 CASE# 23-10878 OF COLLISION09/21/23 16:41
NARRATIVE
ASSIGNMENT/ARRIVAL
On 09/21/2023 at approximately 1643 hours, I was dispatched to a single vehicle collision into a tree
near Renton Avenue S and SW Victoria Street in the city of Renton, King County, Washington.
I arrived at approximately 1649 hours.
UNIT 1: FORD RANGER
Upon arrival I observed a blue Ford Ranger (WA/ DP49411, Unit 1) stopped facing east, off the
roadway, along the south roadway edge of the eastbound lanes of Renton Avenue S before the
intersection of Hardie Avenue SW. Unit 1's front end was engaged with a tree off the roadway.
DRIVER 1: GARRISON, GARY F.
I located Gary F. Garrison (DOB: 08/02/1945) in the back of a King County Fire District 20
ambulance. I identified Garrison by his valid Washington Driver License. I established Garrison as the
driver of Unit 1 by his admission. Garrison said he was not injured from the collision.
STATEMENT: DRIVER 1
1 spoke with Garrison about the collision. The following is a summary of our conversation:
Garrison drove Unit 1 east on Renton Avenue S in the number one lane (closest to curb) toward
Hardie Avenue SW. An involved, non-contact vehicle (unknown description) merged in front of Unit 1
from lane two and suddenly slowed. To avoid a collision with the vehicle, Garrison turned Unit 1 off
the roadway and into the tree.
This concluded my conversation with Garrison.
PHOTOGRAPHS
I took pictures of Unit 1 with my department issued cell phone and uploaded them to Axon's
Evidence.com.
DISPOSITION
Garrison was transported by ambulance to the hospital for a medical condition unrelated to the
collision.
This concluded my involvement in this case.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
Electronically signed by Officer R. Gorajewski, #12399, on 09/21/2023 at 1709 hours in Renton,
Washington.
PAGE 3 OF 4
REPORT NO. EE03555 CASE# ' 23-10878 DATE AND TIME 09/21/23 16:41
OF COLLISION
Hardie Ave SW
N
Not to Scale
Rento AVU'S
!V
PAGE 4 OF 4