HomeMy WebLinkAbout23-12456 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-12456 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 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 1323 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RENTON AVE EXT. BLOCK NO. e✓ 100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 8 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:3052188046 0 4 30
6� LAST NAME MEDCNA FIRSTNAME SAMUEL MIDDLE 1 2 31
INITIAL
STREET ❑✓ 10706 SE 232ND PL CITY KENT ST WA Zjp, 98031 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATFBit A6767587 sTArI WA urN#' 1YVHP82A095M01514
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 3 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 $ 34
13 2 2009 MAZE) 6 SE SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 ❑ INSURANCE CO <53 4
LIABILITY INSURANCEIN EFFECT &POLICV# TOPVEIF" CHARGE OTTOM 5 36
LEGALLv YEs❑NO CITATION# 3A0087429,3AO087429 FAIL YIELD PRIVATE RD MOTOR
15❑ STANDING 7 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16 a UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2063568361
LAST NAME SING FIRST NAME PHILIP MIDDLE I L
INITIAL
17❑ STREET ❑', 12227 86TH CT S CITY' SEATTLE ST WA ZIP 981784548 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NOF,/
19 LDI IVER # STATE WA SEX M M D.C.B. 08 _ 17 1947 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE BOH5285 TAre WA vIN1 JTMEWRFV9KJ019879
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2019 MAKE TOYT MODEL RAV4 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO PHILIP SING 1222786TH CTS SEATTLE WA 98178 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU POLICY#E CO pEMCD CA0749809IN I STOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N`LJ
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE15381
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12456
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'
Unit 1 was facing north exiting the parking lot of McDonalds from the south side of the 100 blk of
Renton AVE EXT planning to turn left onto eastbound Renton AVE EXT.. Unit 2 was traveling
westbound in the 100 blk of Renton AVE EXT in the center turn lane turning left into the parking lot of
McDonalds into the same entrance/exit as Unit 1. Unit 1 failed to yield the right of way to Unit 2 when
exiting the private parking lot and proceeded out into the center turn lane to make a right turn onto
eastbound Renton AVE EXT. The front end of Unit 1 struck the rear driver's wheel area of Unit 2.
Unit 1 sustained moderate front end damage while Unit 2 sustained moderate but disabling damage
to the rear driver's wheel. Driver 1 advised he did not have insurance for Unit 1.
Driver 1 cited for failure to yield the right of way to a motor vehicle when coming from a private
roadway by not yielding to Unit 2 established on the roadway which was the proximate cause of the
collision. Driver 1 also cited for operating a motor vehicle without insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 10-30-23 03:44 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 111112023 2:36:14 PM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED 1:24 Pry TIME POLICE ARRIVED 1:28 Pry
PART I PAGE IT]OF
REPORT NO.! EE15381 CASE# ' 23-12456 DATE AND TIME 10/30/23 13:23
OF COLLISION
100 blk Renton AVE EXT.
ffm
q N
***NOT T ► SCALE***
PARKING LOT
McDNALDS
73 Rainier AVE S
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