HomeMy WebLinkAbout23-12235 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 0 27c
COLLISION REP FIT 1591971
CASE 23-12235 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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# ❑
cawsloN 10 - 1-- 2023 1522 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
108TH AVE SE BLOCK NO. e✓ 19000
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 3001. 00 FEET MILES e S B W e SE 192ND ST
0 1 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 7 30
6� LAST NAME JASWAL FIRSTNAME AMBIT MIDDLE K 1 1 2 31
INITIAL
STREET ❑, 6848 SHERBROOKE ST CITy VANCOUVER ST BC Zjp', V5X4E1 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
❑ DRIVER'S' STATE BC SEXI F MM ovY' 02 1- 24 - 2000 2 32
8 LICENSE#
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELM
USEET I IINLJA
URY 1 [!!RE OF INJURIES z❑
3
10 9� Pi ATE 14 161 STK STATE BC VIN# JTDKN3DU7A0048833
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE J 9 34
13 2010 TOYT PRIUS DAMAGE YES NO MEYER YES[:] NO✓
REGISTERED OWNER INFO JASWALSINOH 6848 SHERTBROOKE ST VANCOUVER BC V5X4E1 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO SAME. 4
IN EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STAIN,DIING 7 6
UNIT U2 VEHIMOTCCLE CYCLE ❑ PEDESTRIAN ❑ OWNFR PEDAL RTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME MEAS FIRST NAME SREY MIDDLE M
INITIAL
17❑ STREET ❑', 30616 114TH PL SE CITY AUBURN ST WA ZIP 980923116 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 DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BJH7858 TATe WA VIN# 5FNYF4H5XBB107053
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2011 MAKE HOND MODEL PILOT STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO SREYMEAS30616114THPLSE AUBURN WA 98092311fi VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#E CO LIB MUTA02-268-290216-40-27 1GD
IN EFFECTVE""LE CITATION# CHARGE
LEGALLY YES Nu
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE15353
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12235
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'
slv suv In 2/2 stp gry prius rear said braked pedal fine
RTF
Within the city limits of Renton/King/Wa I responded to a 2 car blocking crash at about the 19000
block of 108th Ave SE southbound lane 2.
1 contacted the driver of unit 2 who told me was waiting in traffic when unit 1 hit her from behind. She
was checked and released on scene by Renton Fire, just upset. Damages did not require a tow
truck.
I contacted the driver of unit 1 who told me she didnt think her brakes were functioning correctly
because her car was just sliding all over the roadway. I checked her brake pedal which felt normal
and did not go to the floor. A visual of her front brakes did not appear odd/obscure. 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 10/25/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 10-25-23 04:05 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 11/1/2023 2:15:59 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED! 3:22 Pry TIME POLICE ARRIVED',3:28 PM
PART I PAGE IT]OF
REPORT NO.! EE15353 CASE# ' 23-12235 DATE AND TIME 10/25/23 15:22
OF COLLISION
nts
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