HomeMy WebLinkAbout23-11628 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-11628 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4200 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 - 11 - 2023 0755 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
SE 168TH ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 109THAVESE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:2067796912 0 11
30
6 LAST NAME PENOR REIGLE FIRST NAME LIEZCHEL MIDDLE R 1 1 2 31
INITIAL
STREET ❑ 11859 SE 176TH CT CITY RENTON ST WA ZIP 980586500 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 MID
.O B 10 1— 23 — 1982 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� SH09351 sTAr1 WAvIN# 1C4HJXFG2KW615629
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 3 33
12 3 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 2 2019 JEEP WRANG DAMAGE YES No YES[:] No✓
REGISTERED OWNER INFO LIEZCHEL PENOR REIGLE 11859 SE 176THCT RENTON INA 980586500 D:2067796912 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE INSURANCE CO USAA 025630464C 71013 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv YES No CITATION# FAIL YIELD LEFT TURN MOTOR o aorrom
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ No D:2537547768
16 a
LAST NAME LEDERER FIRST NAME ASHLEY MIDDLE N
INITIAL
17❑ STREET ❑', 17405 120TH LN SE APT 1302 CITY RENTON ST WA ZIP 980586214 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l No❑
19 LDI IVER # STATE WA SEX F M D.O.B. 01 04 1991 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE BFF1221 TAre WA VIN# 2FMZA516X66A06069
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TIN# IN RLR
#.UIN#. '
VEH YEAR 2006 MAKE FORD MODEL FREESIA STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO GENE MEYER YES NO
REGISTERED OWNER INFO ASHLEY LEDERER 17405120TH LN SE APT 1302 RENTON WA 98058 VEHICLE NO.2
SHADE IN DA GEbAREA
z Cdd
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO 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
PART A PAGE 01 OF
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE10856
COLLISION REPORT III III III III III 111
1591972 CASE# 23-11628
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 E
DAT
C.JACOBS 1953 1011912023 10:41:13 AM
BADGE OR ID# 2517 OR]# WA0171300 TIME POLICE DISPATCHED 7:56 AM TIME POLICE ARRIVED 8:00 AM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EE10856 CASE# 23-11628 OF COLLISION10/11/23 07:55
NARRATIVE
slv/van/2 wb 168 wht jeep/1 It from 109
CC
Within the city limits of Renton/King/Wa I responded to a 2 car blocking crash at the intersection of
SE 168th St and 109 Ave SE.
I contacted the driver of unit 2 who told me she was west on 168th when unit 1 drove into the side of
her van, spinning her out. She complained of bumping her head. 1 had Renton Fire respond who
checked and released her on scene. Her van was disabled from the crash and required a tow truck to
move it out of the road.
I contacted the driver of unit 1 ID'd by her matching picture WADL. She told me she was stopped on
109th waiting to make a left turn. She told me unit 2 had her blinker on and believed she was going
to turn from WB to NB at 109. Unit 1 said she proceeded and crashed into the side of unit 2. She did
not complain of injury and damages did not require a tow truck.
I cited unit 1 ref RCW 46.61.185 FTYROW Left Turn 2 car crash via complaint.
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
REPORT NO.! EE10856 CASE# 23-11628 DATE AND TIME 10/11/23 07:55
OF COLLISION
nts
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