HomeMy WebLinkAbout23-12003 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-12003 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENC 4100 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 1656 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 4800
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 200 00 FMILES NEET e S ❑ E e DUVALL AVE NE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4254661166 0 11
30
6� LAST NAME BAKER FIRSTNAME CAMI MIDDLE P 1 1 2 31
INITIAL
STREET ❑, 11225 NE 68TH ST APT 4 CITY KIRKLAND ST WA 2jp, 980334001 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ D
RI
VER # STATE WA SEX'F MMDOVY' 01 - 16 - 196.9 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 ATNES# CCX9050 sTAr WAuN# WP1BA2AY2MDA40924
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# Rom To
TRLR. TRLR 7 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34
13 2021 PORS CAYENN SIPDAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO CAMI BAKER 11225 NE 68TH STAPT4 KIRKLAND WA 980334001 D:4254661166 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 905939890 4
IN EFFECT &POLICY# 9TOP
VEH'CLE
15❑ 5 35
LECALLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:4255258357
LAST NAME DEER FIRST NAME JAXSON MIDDLE I A
INITIAL
17❑ NEW STREETREs7 13104 SE 162ND PL CITY RENTON ST WA ZIP 980585522 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 D IVERI # STATE WA SEX M M .C.B. O6 _ 22 _ 2006 39
20 ON DUTY STATUS AIRBAG,3 RESTR 4 EJECT 1 HELMET INJURY 7 NATURE OF INJURIES 40
USE CLASS LEFT SHOULDER PAIN
LICENSE ❑21❑ PLA E# CFY5040 TArE 41
WA vIN1 JF1GPAD66D2808223 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2013 MAKE SIJBA MODEL ►MPREZA STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO DUSTINDEER 13104 SE 162ND PL RENTONWA 98058 D:4255258357 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#ECO STATE FARM 5153748-E13-47BIN STOP 5
VEHICLE ❑ CE J CITATION# CHARGE
25 io BOTTOM
LEGALLY YES N
a
7p-,
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 0(
J
26
TAGNE 12575 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE13689
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12003
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
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'
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.
P.LANTAGNE 10-21-23 08:20 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1012712023 4:43:13 PM
BADGE OR ID# 12575 OR]4f WA0171300 TIME POLICE DISPATCHED 5:00 PM TIME POLICE ARRIVED',5:03 PM
PART I PAGE IT]OF 4�
REPORT NO. EE13689 CASE# 23-12003 OF COLLISION
10/20/23 16:56
OF CbLLI510N
NARRATIVE
23-12003
On 10/20/2023 at approximately 1656 hours, I, Officer Lantagne, responded to a non-blocking,
possible injury collision which occurred on NE 4th ST to the east of the intersection at Duvall AVE NE,
which is located in the City of Renton, County of King, and the State of Washington. I responded in
my fully marked police vehicle, wearing my patrol uniform.
I arrived on scene and observed Unit#1, a 2021 Porsche Cayenne with license plates CCX9050
issued out of Washington State, and Unit#2, a 2013 Subaru Impreza with license plates CFY5040
issued out of Washington State, parked in the lot to the northeast of the intersection. The front airbag
of Unit#2 deployed, and the driver of Unit#2 advised his left shoulder was sore. The driver of Unit#2
declined aid.
I contacted the driver of Unit#1, Cami P. Baker (DOB 01/16/1969), who told me the following: Baker
was driving eastbound on NE 4th ST. Baker was in the left two-way turn lane and traffic backed up
from the signal at Duvall AVE NE in the first two lanes made space for her to make a left turn into the
parking lot. As Baker made the left turn and crossed the third lane, the passenger side of her vehicle
was struck by Unit#2.
1 contacted the driver of Unit#2, Jaxson A. Deer (DOB 06/22/2006), who told me the following: Deer
was driving westbound on NE 4th ST in the curb lane. As Deer approached the intersection at Duvall
AVE NE, Unit#1 made a left turn in front of him, and he was not able to stop his vehicle in time. The
front of Deer's vehicle struck the passenger side of Unit#1.
I observed the damage to the vehicles and other physical evidence was consistent with the
statements made by both drivers. Unit#1 had significant damage to the middle passenger side of the
vehicle which was dented in. Unit#2 had significant damage to the front bumper and hood which
were crumpled in.
The collision diagram is an accurate illustration of the events leading up to the collision.
I provided an exchange of information to Baker and Deer.
I, Officer P. Lantagne #12575, certify (or declare) under penalty of perjury, under the laws of the State
of Washington, the foregoing is true and correct.
Electronically signed by Officer P. Lantagne #12575 at 0810 hours on 10/21/2023 at Renton, WA.
PAGE 3 OF 4
REPORT NO.! EE13689 CASE# ' 23-12003 DATE AND TIME 10/20/23 16:56
OF COLLISION
Duvall Ave NE
Unit #2
1
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2^
qeq I I�I�I�IIIII II
u
Case #23-12003'
NE 4th St Unit #'1 .014111116
N
Not to Scale
P. Lantagne #12575
PAGE 4 OF 4