HomeMy WebLinkAbout23-11264 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-11264 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 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#
cowsloN 10 - 1-- 2023 0916 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RAINIER AVE S BLOCK NO. e✓ 300 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e S 3RD PL
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2067513048 0 11
30
6� LAST NAME LONG FIRSTNAME SAMNANG MIDDLE N 1 2 31
INITIAL
STREET ❑ 912 S 194TH ST CITY SEATAC ST WA ZIP 981482220 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES z❑
3
10 1❑ PI ATE 14 CE27949 STATE WA u N#' 2HGFC2F72HH517732
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM ro
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 5 1 34
13 4 2017 HOND CIVIC 4D DAMAGE vesNo � �MEYERS YES[:] No
REGISTERED OWNER INFO SAMNANG LONG 912 S 194TH ST SEATAC WA98148 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14LIABILI INSURANCE INSURANCE CO ALLSTATEPENDING 3 4
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 3AO463531 INATTENTIVE DRIVING )o SorroM
15❑ NDING 6
UNIT VEHIMOTCR PEDAL-CLE CYCLE ❑ PEDESTRIAN ❑ OWN RRTY ❑ DYES 1/ NO OLD MET FNE
16 a
LAST NAME VO FIRST NAME THUY MIDDLE N
INITIAL
17❑ NEW STREETR 880 S 4
7 8TH ST CITY RENTON ST WA ZIP 980557337 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER'S STATE WA SEX F D.C.B. 12 _ 04 1986 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑21❑ PLATE# CFF2061 TATE WA VIN 1 41
7SAYGDEE9NF545412 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2022 MAKE TESL MODEL MODEL Y STYLE 4D VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO GENE MEYERS YES NO
REGISTERED OWNER INFO THUY VO 880 S 48TH ST RENTON WA 98055 VEHICLE NO.2
SHADE IN DAGELLAREA
z Cdd
LIABILITY
INSURANCE &POINSURGY#E CO ALLSTATE 820494099IN I 9TOP 5
VE""LE ❑ N`L J
,J� CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JAC08S 1953 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE18083
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11264
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(LAST FIRST,MIDDLE INITIAL) YO ELLIE
ADDRESS&PHONE#
RENTON SEX F MMDDYYYY 06 - O6 - 2020
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ 2 POS. 9 4 10 1 USE 2 CLASS !1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
sE MMDDVYYV
PASSENGER [:]WITNESSO UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&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.
C.JACOBS 10-02-23 12:01 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 111912023 9:55:52 AM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED 9:99 AM TIME POLICE ARRIVED 9:22 AM
PART I PAGE IT]OF 4�
REPORT NO. EE18083 CASE# 23-11264 OF COLLISION
10/02/23 09:16
OF CbLLI510N
NARRATIVE
On 10-2-23 at about 0922 1 arrived at the intersection of Rainier Ave S and S 3rd Place for a 2-vehicle
collision. Both vehicles were still in the roadway. Driver 1, Samnang Long approached me in the
intersection. Long told me;
He ran the red light westbound at S. 3rd PI and Rainier Ave S.
He wasn't paying attention and unit 1 collided with unit 2.
He was the sole occupant of the vehicle.
He was not injured.
He has Allstate insurance, but he could not find his card. He would email me proof of insurance.
Driver 2, Thoy Vo was still seated in her vehicle along with her juvenile daughter. Vo told me;
She was Northbound through the intersection when unit 1 struck her vehicle. She did not see unit 1
approaching and was unable to avoid the collision.
She was shaken up but not injured.
She also has Allstate insurance but was unable to provide proof at the time of our interaction.
Both drivers were identified via WADL. Both drivers stated they had Allstate insurance but were
unable to provide proof of insurance at the collision scene. I gave both drivers my email address for
them to send proof of insurance after the left the scene.
I cited Long for inattention via complaint.
This collision occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
PAGE 3 OF 4
REPORT NO.! EE18083 CASE# 23-11264 DATE AND TIME 10/02/23 09:16
OF COLLISION
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