HomeMy WebLinkAbout23-11627 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-11627 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4'/00 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# ❑
cawsloN 10 - 11 - 2023 0855 17 ❑.❑ S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
PARKING LOT
BLOCK NO. e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET MILES e S ❑ W e TALBOT RD S
0 1 29
MOTU '�01 VEHtOR Z CLE CYCCLE. El �ESAGE NHORE✓LD MET PHONE 30
6� LAST NAME GOODMAN FIRSTNAME ONICA MIDDLE A 1 1 2 31
INITIAL
STREET ❑, 1107 S 35TH ST TON WA
NEW ADDRESS ST 2jp 980555785 z CITY REN
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8 LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET IINLJAURY 1 NATURE OF INJURIES z❑
3
10 2❑ I P1 ATNES# AQK8058 sTAr WAv N# JTDFR3201 Y0014158
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FR.. ro
TRLR. TRLR. 5 1 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13❑9 ZOOO TOYT MR2CV DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO ONICA GOODMAN 1117 S 35TH ST RENTONWA 98055 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO AARP SAME 3 4
IN EFFECT &POLICY# 9TOP
vEHla.e CHARGE 5 36
LEcnLLv res❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
1/ NO D:8088409140
16 a
LAST NAME AMBIENY FIRST NAME MADIVIE MIDDLE I B
INITIAL
17❑ STREET ❑', 21800 SE WAX RD APT W203 CITY' MAPLE VALLEY ST WA ZIP 980385519 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 DRIVE # STATE SEX F MMDDW 07 21 1989 39
ON DUTY STATUS 3 AIRBAG RESTR EJECT WEB MEET CLASINJURS LEFT
8 [NATURE OF INJURIES LEFT HAND LEFT ANKLE RIGHT BUTTOCKS NECK ❑ 40
❑21❑ LICENSE TArE VIN# 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 Q $ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
M.LEVERTON 2517 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE10848
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11627
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.
M.LEVERTON 10-11-2310:57AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1011912023 10:40:19 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED 6:56 AM TIME POLICE ARRIVED 7:00 AM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EE10848 CASE# 23-11627 OF COLLISION10/11/23 06:55
NARRATIVE
RTF
Within the city limits of Renton/King/Wa I responded to a car v ped in the parking lot of VMC 400 S
43rd St near the main entranced. When I arrived the ped had been wheel chaired to the ER and the
driver had parked her car and was walking back to the POI.
I contacted unit 1 who told me she stopped for her stop sign by the turn around after dropping a
person off at the hospital and then was going to park. She said she did not see the ped until the last
minute and believed she must have ran out in front of her car. There was no obvious indicators to
unit 1 vehicle of ped impact. She did not complain of injury.
I contacted the Ped in ER Rm 32. She complained of multiple injury's but was in good spirits. She
said she was about half way across the marked crosswalk when she was hit by unit 1. She was
crossing from east to west walking towards the hospital.
Ped showed me that she was wearing black pants and shirt and at the time she was crossing it was
dark and heavily raining.
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 10/11/2023
PAGE 3 OF 4
EE10848 CASE# 23-11627 DATE AND TIME 10/11/2306:55