HomeMy WebLinkAbout23-14657 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-14657 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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 12 - 1-- 2023 1304 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
SW 10TH ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV a LIND AVE SW
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:9019107544 0 11
30
6� LAST NAME BOWEN FIRSTNAME DONAVEN MIDDLE J 1 F 2 31
INITIAL
STREET ❑1 402 HOMEVILLE RD CITY
COLLIERVILLE ST TN Zip, 380178221 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USE INJURY
1 NATURE OF INJURIES 2❑
3
,OF
Pi ATNES# BHC0647 sTAT TN vN# 1GCPTDE18G1393491
IT STATE TRAILER STATE
11 2 5 PLATE# PLATE# ROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 1 $ 34
13 2 2022 CHEV COLOR DAMAGE YES NO MEYER YES[:] NO✓
REGISTERED OWNER INFO DONAVEN BOWEN 402 HOMEVILLE RD COLLIERVILLE TN 380178221 D:9019107544 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO GARRISON GAR0249115017101 3 4
IN EFFECT &POLICY# 9TOP
vECALLv Hla.e 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LE STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066705311
16 a
LAST NAME SALIM FIRST NAME SALIM MIDDLE M
INITIAL
17❑ STREET ❑', 12311 AMBAUM BLVD SW APT A208 CITY' BURIEN ST WA ZIP 981463009 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL t-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I No� YES t l NO❑
19 LDI IVEW # STATE WA SEX M M D.C.B. 01 01 1996 0 39
20❑ ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 HELMET INJURY 7 NATURE OF INJURIEs ❑ 40
USE CLASS UNK
21❑ LICENSE I BXF7150 rare WA vIN1t JTDKN3DU9B1365217
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2011 MAKE TOYT MODEL PRIUS STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO GENE MEYER YES NO
REGISTERED OWNER INFO MOHAMED AHMED 12311 AMBAUM BLVD SWAPTA208 BURIEN WA 98146 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO PROGRESSIVE 974678819IN 1UQI
'E""LE ❑ ,J� CITATION# CHARGELEGALLYYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE34927
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14657
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 12-27-23 07:44 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 12/28/2023 7:09:23 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED' 4:04 Pry] TIME POLICE ARRIVED',1:04 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EE34927 CASE# 23-14657 OF COLLISION12/21/23 13:04
NARRATIVE
wht trk/1 straight blk sedan 2 lane 1 nb
RTF
Within the city limits of Renton/King/WA I responded to a 2 car blocking crash at the intersection of
Lind Ave SW and SW 10th St.
The driver of unit 1 said he had stopped at the stop sign on SW 10th and when it was clear it
proceeded east towards and back entrance to Walmart. He said out of no where unit 2 hit the side of
his truck. He did not complain of injury and damages required a tow truck.
The driver of unit 2 walked over to me and told me he was hit by unit 1. He did not really provide any
additional information. He told me he wanted to me checked by Fire. Fire arrived and checked the
driver of unit 2 and cleared the scene. About 10 minutes later unit 2 told me he thought his arm was
broken and he appeared to be limping. He requested Fire responded.
I requested Renton Fire return to the scene, They told me when they initially checked unit 2 driver he
did not make complaint of injury and now he was limping and saying his right arm was broken. Unit 2
and his father who arrived after the crash made the request for an ambulance. Fire checked him and
called for Tri-Med. Unit 2 driver was showing me his right arm and said that it was numb and painful.
(?) He had his arm hanging straight down and holding his elbow, telling me he couldn't even move it.
Although while Fire was onscene he was able to take, hold elevated and enter his information into a
portable laptop Fire uses to recording patient information. Unit 2 did hold the laptop with his right
hand, with his elbow bent 90 degrees and typed left handed. Unit 2 was transported by ambulance
for additional checks. His vehicle was impounded for damages.
I found it suspicious unit 2 was complaining of numbness and severe pain with a possible fracture,
then hold and manipulate a laptop with no wincing or expression with his right arm/hand.
Information/insurance 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 12/27/2023
PAGE 3 OF 4
REPORT NO. EE34927 CASE# ' 23-14657 DATE AND TIME 12/21/23 13:04
OF COLLISION
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