HomeMy WebLinkAbout23-12374 ITFF' "POLCERA II I !�� I III I III I IIII III II I . $ 27c
COLLISION REP FIT 1591971
CASE 23-12374 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER HIT F ❑ LOCAL AOENC 4'/00 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# ❑
GawsloN 10 - 1-- 2023 1715 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
200 S 3RD ST BLOCK NO. e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 2001. 00 FEET MILES e S B W e S 3RD ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2066583772 30
6� LAST NAME KIRVIN FIRSTNAME RONALD MIDDLE 1 2 31
INITIAL
STREET ❑, 4508 S GENESEE ST CITY SEATTLE ST WA ZIP 98118 z
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I iNTERLOCKYEs No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USE 2 1 CLASS NATURE OF INJURIES z❑
3
10 9� P1 ATE 14 063XGT STATE WA v N# SALME11485A187041
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR 3 7 33
12❑ VIN#' VIN#.
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 $ 34
13 A 200$ LNDR RANGE UT DAMAGE vesNo ✓ ves❑ No✓
REGISTERED OWNER INFO RONALD KIRVIN 4508 S GENESEE ST SEATTLE WA 98118 D:2066583772 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE INSURANCE CO GENERAL 52-WA-9981090 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ SIANDING 8 6
UNIT 02 VEHICCLE ❑ CYCLE ❑ PEDESTRIAN ❑MOTR ✓ oWNFRRTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME MCCLOSKEY FIRST NAME JUSTIN MIDDLE A
INITIAL
17 STREET❑ NEW ADDREss❑' 345 PELLY AVE N,APT 2 CITY RENTON ST WA ZIP 98057 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NO❑
19[ D IVE
ON DUTY STATUS 5 AIRBAG RESTR EJECT , HELMET 2 INJURY 7 NATURE OF INJURIES 40
USE CLASS UNKNOWN
❑21❑ LICENSE TATE VIN# 41
1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED By Gov HI 44
L4 1 ] DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO I 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
KEVIN PETERSON 12808 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE39846
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12374
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'
I was dispatched to a vehicle vs wheelchair collision on 10/28/23 at 1717 hours at 200 S 3rd St in the
parking lot of Safeway in the 200 block, in city Renton, King County WA.
Unit 1 063XGT Driver Ronald Kirvin (DOB 06/18/1987)
Pedestrian Pedestrian: Justin A. McCloskey (04/05/1992) In a wheelchair
All individuals were identified by their WADL and DOL photo.
Unit 1 was pulling out of the Safeway parking lot when he noticed the pedestrian rolling across the
parking lot. Unit 1 stated that as he tried to avoid the pedestrian he then rolled in front of his vehicle
and Unit 1 hit him. The pedestrian stated he was rolling across the parking lot in his wheelchair when
he suddenly was hit by Unit 1.
Justin was transported to the hospital for unknown injuries.
Incident occupied on private property.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 01-12-24 05:16 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.KORDEL 9676 1 111212024 5:50:44 PM
BADGE OR ID# 12808 OR]# ': WA0171300 TIME POLICE DISPATCHED! 5:17 PM TIME POLICE ARRIVED 5:20 PM
PART I PAGE IT]OF 3�
REPORT NO. EE39846 CASE# ' 23-12374 DATE AND TIME 10/28/23 17:15
OF COLLISION
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