HomeMy WebLinkAbout23-11549 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-11549 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 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 CITY#
cawsloN 10 - 09 - 2023 0722 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 14000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 ❑ FEET e S ❑ W e 140THWAYSE
❑
0 6 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:3196212093 0 81
30
6� LAST NAME HOLBERT FIRSTNAME KAYDEN MIDDLE G 0 11
31
INITIAL
STREET ❑✓ 4408 NE 3RD LN CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
�/iNTERLOCKYEs No INTERLOCKYEs NO YES R NO
8❑ LRIIVERS STATE WA SEX'F MM DAY' 05 1- 11 - 2004 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ PI ATE CBK6815 sTAr� WA #' 1 GNDM19Z8R6126886
TRAILER STATE TRAILER STATE
11 5 0 PLATE# PLATE# ROM ro
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#'
:: FROM TO
❑ VEH.YEAR1994 CHEV ASTRO VN MAKE MODEL STYLE VEHICLE TOWED fn TO VBLINJ TOWED BY I GOVT.VEHICLE J 9 34
DAMAGE YES NO
13 4 YES[:] No
REGISTERED OWNER INFO ROBERT HOLBERT 4408 NE 3RD LN RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 926528830 4
LI EFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2067537875
16 2
LAST NAME KIM FIRST NAME UN MIDDLE I C
INITIAL
17 STREET❑ NEW ADDREss❑' 16849 148TH AVE SE CITY RENTON ST WA ZIP 980588528 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 NO❑
19 D IVEW # STATE WA SEX F M D.C.B. 02 _ O6 _ 1961 39
20❑ ON DUTY STATUS I
AIRBAG 3 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# A/M3767 TArE WA VIN 1 41
2HNYD2H36CH517704 2
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2012 MAKE ACUR MODEL MDX STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO UN KIM 16849148TH AVE SE RENTON WA 980588528 D:2067537875 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU PORGY#E CO AMFAMA103 5 603
54IN I STOP
VE""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES NEI
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE39386
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11549
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(IAST FIRST,MIDDLE INITIAL) PAK EDEN
ADDRESS&PHONE#
16849 148TH AVE SE RENTON WA 98056 2053972011 SEXi F MMDDYyry 05 - 29 - 2020
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS❑I UNIT# 2 POS. 9 AIRBAG 2 RESTR. 10 EJECT 1 USE 2 CLASS !7 BITTONGUE
NAME
`(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER [:]WITNESSO UNIT# SEAT 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'
On 10-9-23 at about 0730 1 arrived near the intersection of Maple Valley Hwy (MVH) and SE 140th
Way for a 2-vehicle collision. I contacted all involved in or near their vehicles. Both drivers were
identified via WADL. Driver 1, Kayden Holbert told me;
She approached the line of vehicles stopped in front of her and tried to stop, but her vehicle would not
respond, and she collided with the rear of unit 2.
She was aware of an issue with her brakes but had not repaired them prior to the collision.
She was not injured.
Driver 2 was stopped in the line of traffic waiting for the light to change when unit 1 struck her vehicle
from the rear. Her granddaughter, Eden Pak was a passenger seated in the rear of unit 2. Eden bit
her tongue as a result of the collision. There were no other injuries reported.
Unit 1 was towed away at the owners request due to disabling damage.
This incident 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
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 11-11-23 01:23 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 1/1112024 10:15:13 AM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED; 7:25 AM TIME POLICE ARRIVED',7:34 AM
PART I PAGE IT]OF 3�
REPORT NO. EE39386 CASE# 23-11549 DATE AND TIME 10/09/23 07:22
OF COLLISION
y,
d�
Unit,2
�w
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