HomeMy WebLinkAbout23-05297 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-05297 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 7 2$
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 05 - 10 - 2023 2129 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
SUNSET BLVD NE M4700
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ MILES N❑ FEET e S B E e DUVALL AV NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:4256299219 1 9 30
6❑ LAST NAME NAZARENO FIRSTNAME KRISTEN MIDDLE 1 2 31
INITIAL
STREET ❑, 243 EDMONDS PL NE CITY RENTON ST WA ZIP 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 07 1- 05 - 2000 1 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMETU E 2 CLASS 0ICE NATURE OF INJURIES z❑
3
10 9❑ P1 ATNES# CDL1611 STATE WA VIN# 5TDJZRBH5NS221969.
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 0 0 VIN#' VIN#
2022 TOYT HIC�HLA UTYES[:]
❑ FROM
34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO �/ YES NO
13 REGISTERED OWNER INFO KARYI...RENO 243 EDMONDS PL NE RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE INSURANCE CO ALL STATE 920632443
IN EFFECT &POLICY# 9TOP
VE—LE CHARGE 5 36
1 o BOTTOM
15❑ LEGALLv STANDING YES❑NO❑ CITATION#
8 7 6
MOTO PEDAL-
THR
UNIT 02 VEHICILE CYCLE ❑ PEDESTRIAN ❑ OWNERRTY ❑ DYES NO ✓OLD MET PHONE
16 2
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY RENTON ST ZIP $
17❑ NEW ADDRESS❑ ❑ 37
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 U MMDDYY 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
❑ILICENSE 21❑ PLA E# 506YEA TATE WA VIN# 1(B1ND52F44M665984 41
4
42
22❑ PLATE# STATE PLATE# STATE
23❑ TRLR 43
RLR
UIN#. 'IN#.
YEAR 2004 MAKE CHEV MODEL CLASSIC STYLE SD VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
VEH
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO DULCE ANTONIO SANCHEZ,9529126TH PL SE RENTON WA 98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N`LJ
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HUBERMANN ALCEAN 12681 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED61927
COLLISION REPORT III III III III III 111
1591972 CASE# 23-05297
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'
The driver of Vehicle #1 stated on the phone that she was traveling west on Sunset BLVD NE, but
could not remember where on Sunset BLVD NE she was at when the driver of vehicle #2 side swiped
her vehicle and caused damaged to the left side of her vehicle. She said the left side of her vehicle
was damaged.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HUBERMANN ALCEAN 05-12-23 05:05 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 512012023 11:32:19 AM
BADGE OR ID# 12681 ORI#' WA0171300 TIME POLICE DISPATCHED 9:32 Pry TIME POLICE ARRIVED',9:32 PM
PART Ei PAGE IT]OF
REPORT NO. ED61927 CASE# 23-05297 DATE AND TIME 05/10/23 21:29
OF COLLISION
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