HomeMy WebLinkAbout23-11442 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 1 27c
COLLISION REP FIT 1591971
CASE 23-11442 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 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 10 - 1-- 2023 2027 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SHATTUCK AVE S BLOCK NO. e✓ 330 ❑
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:2536539828 0 11
30
6 LAST NAME MORA CHAVEZ FIRST NAME JUAN JOSE MIDDLE 1 2 31
INITIAL
STREET ❑1 445 BURNETT AVE S CITY RENTON ST WA 2jp, 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs Z/NO YES R NoF,/
LRIIVER # STATE WA SEX'M MI MIT Y
8❑ ' 02 - 19 - 1986 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMET U E 9 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� CAt4090 sTArI WAurN# JN1A234D44T161435
IT STATE TRAILER STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR. A'RLA2 1 5 33
12 0 0 VIN#' VIN#'
FROM TO
VEH.YEAR 2004 NISS 350Z SD MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 5 1 34
13 DAMAGE YES NO �LII� RS YES[:] No✓
REGISTERED OWNER INFO JUAN JOSS MORA CHAVEZ 445 BURNETT AVE S RENTONWA98057 D:2536539828 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILI INSURANCE❑ INSURANCE CO NONE
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2069096633
16 a
LAST NAME ASUQUO FIRST NAME KAYETT MIDDLE R
INITIAL
17 STREET NEW ADDREs7 826 LINCOLN AVE SE CITY RENTON ST WA ZIP 98057 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX F D.C•B. 07 17 1957 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES ❑ 40
LICENSE I ❑21❑ PLA E# BKU4444 TArE WA VIN# 41
WBA7W4CO2LBM70777 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2020 MAKE BMW MODEL 745XE STYLE SD VEHICLE TOWED TO BLIN TOWEDBY GOV HI �44
24❑ DAMAGE YES NO BANKERS YES NO
REGISTERED OWNER INFO KAYETTASUQUO 826 LINCOLN AVE SE RENTONWA98057 D:2069096633 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 19636291325470IN I STOP 5
'E""LE ❑ N`L J
,J� CITATION# CHARGE
LEG i o BOTTOM
ALLY YES
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J RAYGOZA 12503 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE06443
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11442
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
PM 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.
J RAYGOZA 10-06-23 02:04 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 101612023 12:35:53 PM
BADGE OR ID# 12503 OR]# WA0171300 TIME POLICE DISPATCHED 8:29 Pry TIME POLICE ARRIVED',8:31 PM
PART Ei PAGE IT]OF 4�
REPORT NO. EE06443 CASE# 23-11442 OF COLLISION
10/05/23 20:27
OF CbLLI510N
NARRATIVE
RPD CASE#: 23-11442
On 10/05/2023 at approximately 2029 hours, I responded to the intersection of Shattuck Ave S and S
3rd PI, in the City of Renton, King County, Washington, for a report of a two-motor vehicle traffic
accident.
Upon arrival I noticed unit 2 parked at the 330 block of Shattuck Ave S facing north. I identified Unit 2
as a gray 2020 BMW 745XE, bearing WA license BKU4444 VIN#WBA7W4CO2LBM70777. Unit 2
sustained damage to the driver's side door and the left passenger side door. I identified the driver of
Unit 2 via her WADL as Asuquo, Kayett Richardson (DOB 07/17/1957). Asuquo told me she was
driving north on Shattuck Ave S towards S 3rd PI and that unit 1 was driving south on Shattuck Ave S
towards S 3rd Pl. Unit 1 then drove onto her lane and collided with her vehicle. Asuquo told me she
was not injured and provided me with her license, registration, and proof of insurance. Banker's
Towing arrived soon after to tow her vehicle.
I identified Unit 2 as a gray Nissan 350Z, bearing WA license CAL4090 VIN#JN1AZ34D44T161435.
Unit 2 sustained heavy damage to the front of the vehicle. I identified the driver of Unit 2 via his
WADL as Mora Chavez, Juan Jose (DOB 02/19/1986). Mora told me he was driving southbound on
Shattuck Ave S towards S 3rd PI and that unit 2 drove onto his lane and collided with his vehicle.
Mora stated that he was not injured and requested a tow truck for her vehicle. Banker's towing was
called to the scene for Mora. Mora failed to provide me with proof of insurance and informed me that
he didn't have insurance.
Both drivers were given an information exchange sheet and both vehicles were towed from the
location. I advised Mora that he would receive a citation in the mail for operating a motor vehicle
without insurance.
Once both parties left the area, I cleared the scene.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by J. Raygoza on 10/06/2023 at 0200 hours in the City of Renton.
PAGE 3 OF 4
REPORT NO. EE06443 CASE# ' 23-11442 DATE AND TIME 10/055/23 20:27
OF COLLISION
PAGE 4 OF 4