HomeMy WebLinkAbout23-10953 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. EE03605 170
27
COLLISION REP FIT 1591971
CASE 23-10953 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 09 - 1-- 2023 1803 17 =-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SE PETROVITSKY RD BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 118THAVESE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:4259810720 0 11
30
LAST NAME VIZCARRA FIERRO FIRST NAME CHRISTHIAN MIDDLE C,
6 INITIAL 1 1 2 31
STREET ❑, 1108 MILL CREEK BLVD#A209 CITY BOTHELL ST I WA 2jp, 98012 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO 1/ I INTERLOCK YES NO YES R No�/
8 LRIIVERCENS # STATE SEX'M MDMDD 11 - 09 - 1998 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 CLAY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� CEY1366 sTArI WAvIN# 1J4HR48N85C710991
11[-j-� TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
TRLR. TRLR $ 7 33
12 3 5 VIN#j VIN#
:: FROM TO
❑ VEH.YEAR 2005 MAKE MODEL STYLE VEHICLE TOWED TO BLIN 3 7 TOWED BY GOVT.VEHICLE 34
13 4 JEEP GRAND UT DAMAGE YES NO YES❑ No✓
REGISTERED OWNER INFO GORJERUIZACOSTA 824 WCASINO RD#A7 EVERETT WA 98204 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 ❑ INSURANCE CO eq�T3 4
LIABILITY INSURANCE
IN EFFECT &POLICV# 9TOP 5
VEwcLE CHARGE 10 BOTTOM 36
ALLY YES❑NO CITATION# 3A0615639,3A0615639, IMPROPER LANE USAGE,OP MOT
15❑ STANDING 8 7 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4256061672
16 a
LAST NAME JEMEMICA FIRST NAME SAMUEL MIDDLE M
INITIAL
17❑ STREET SS❑' 12631 S
NEW ADDREE 170TH ST CITY RENTON ST WA ZIP 98058 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER #
❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# ATZ1623 TArE 41
WA VIN# STDDK3DC1BS017939 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2011 MAKE TOYT MODEL SIENNA STYLE VN VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO ALISA JEREMICA 12631 SE 170TH ST RENTON WA 98058 D:4257365305 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#ECO USAA CASUALTY INS CO 01000 79 23C 1 9TOP 5
IN EFFECT
VEHICLE YES[:] N
,.I
LEGALLY _] CITATION# CHARGE i o BOTTOM
25 $
7B-
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
MIN FLICK 12825 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE03605
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10953
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.
BENJAMIN FLICK 09-23-23 08:08 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 912812023 9:46:08 PM
BADGE OR ID# 12825 OR]#' WA0171300 TIME POLICE DISPATCHED 6:12 PM TIME POLICE ARRIVED]6:17 PM
PART I PAGE IT]OF 4�
REPORT NO. EE03605 CASE# 23-10953 OF COLLISION
09/23/23 18:03
OF CbLLI510N
NARRATIVE
23-10953
On 09-23-2023 at approximately 1812 hours I was working a Renton Police Department patrol in full
uniform in the city of Renton, King County, Washington. I responded to a motor vehicle collision at the
cross of SE Petrovitsky RD and 118th Ave SE.
Upon arrival I made contact with both vehicles involved. The involved units and drivers were identified
as follows:
Unit 1 (WA/CEY1366) driver Cristhian G. Vizcarra-Fierro (DOB: 11-09-1998 via Mexico Voter Card).
Unit 2 (WA/ATZ1623) driver Samuel M. Jeremica (DOB: 05-11-2004 via WADL)
Unit 02 was driving Westbound in the far-left lane on SE Petrovitsky Rd. Unit 01 was just south of SE
Petrovitsky on 118th AVE SE, waiting to turn left (Westbound). Unit 01 then turned left, overshot the
turn lane that he was turning into and collided with the passenger side of unit 01.
I provided both parties with a business card and case number.
I observed that the damage to the vehicles was consistent with what the parties had told me.
Driver Vizcarra-Fierro had no driver license, no insurance, no passport, but possessed a Mexican
Voter Card which was a form of photo I.D.
At the conclusion of my investigation, I determined that driver Vizcarra-Fierro had improperly used the
turn lane and overshot it, colliding with unit 02 as a result. 1 confirmed with driver Vizcarra-Fierro that
he would receive mail at the address listed on the Sector citation that I wrote. I informed him that he
would be receiving a citation for improper lane use, NOVOL with ID, and for not having insurance via
mail.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
Electronically signed by B. Flick 12825 on 09-23-2023 in Renton, WA.
PAGE 3 OF 4
REPORT NO. EE03605 CASE# ' 23-10953 DATE AND TIME 09/23/23 18:03
OF COLLISION
SE Petrovitsky RD
Not to scale
Unit O2--
Unit 01
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PAGE 4 OF 4