HomeMy WebLinkAbout23-11580 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-11580 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cowsloN 10 - 10 - 2023 0704 17 ❑.❑ S 8 W H OF e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
TALBOT RD S BLOCK NO. e✓ 1100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 2001. 00 FMILES EET e S B W e RENTON VILLAGE PL
0 1 29
UNIT 01 VEHtOCLE PEDAL-
❑ YESA,GEE NHORESHOLD MET PHONE 0 7 30
6� LAST NAME WOODARD FIRSTNAME MONIQUE MIDDLE L 1 2 31
INITIAL
STREET ❑, 11720 SE 272ND PL CITY KENT ST WA Zjp, 980308706 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi ATNES14 BQW5964 STATE WA VrN KM8J3CA41JU596871
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM ro
TRLR. TRLR 5 1 33
12 0 0 VIN#j VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 9 9 34
13 2 2018 HYUN TUCSO DAMAGE vEs 0NO agW�MEYER vEs❑ No
REGISTERED OWNER INFO GEORGE LA FAZIA.14332ND AVE SE FALL CITY WA 98024 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO SAME. 4
IN EFFECT &POLICY# TOPVEHCLE CHARGE 36
LE ALLv YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
�NiT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ No D:5037241973
16 a
LAST NAME CHANG FIRSTNAME GRACE MIDDLE I C
INITIAL
17❑ STREET ❑', 23518 112TH AVE SE CITY' KENT ST WA ZIP 980313444 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19[ LDI IVEW # STATE WA ]SEX IF M D.C.B. 02 _ 22 _ 1991 El 39
HELMET INJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CDX0452 TATE I WA vIN1i 4T3MWRFVXNU072270
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2022 MAKE TOYT MODEL RAV4 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO GRACE CHANG 23518112TH AVE SE KENT WA 98031 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#ECO STFARM4165642AO347BIN I STOP
"""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES NEI
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE10855
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11580
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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'
gray suv/2 stop lane 1 nb maroon suv/1 rear
RTF
Within the city limits of Renton/King/WA I responded to a 2 car crash near the 1100 block of Talbot
Rd S. Both vehicles pulled into the Home Depot parking lot.
I contacted the driver of unit 2 who told me she was stopped for traffic NB Talbot lane 1 when she
was hit from behind by unit 1. She did not complain of injury and damages did not require a tow
truck.
I contacted the driver of unit 1 who told me she was behind unit 2. Unit 1 said traffic stopped in front
of her suddenly and she rapidly applied her brakes but slide into the back of unit 2. Unit 1 did not
complain of injury and damages did require a tow truck.
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 10/10/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 10-10-23 10:38 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 1011912023 10:46:44 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED! 7:04 AM TIME POLICE ARRIVED 7:09 AM
PART I PAGE IT]OF 3�
REPORT NO.! EE10855 CASE# 23-11580 DATE AND TIME 10/10/23 07:04
OF COLLISION
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