HomeMy WebLinkAbout23-12533 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-12533 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICCI F ❑ LOCAL AOENC 4Y00 3
HIT 8 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#
cawsloN 10 - 1-- 2023 1800 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
NILE AVE NE MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ We NE7THPL
0 1 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 7 30
6� LAST NAME STARSY FIRSTNAME AIDAN MIDDLE L 1 1 2 31
INITIAL
STREET El5626 NE 6TH PL CITY RENTON ST WA 21p 980594983 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
�/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 3 H USE 2 CLASS 1 NATURE OF INJURIES z❑
3
LICENSE CBM4218 sTArI WAurN#' JA3AJ26E72U060805
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FR.. ro
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GO VT VEHICLE 9 9 34
13 4 2002 MITS LANCER DAMAGE YES NO �MEYERS YES❑ NO✓
REGISTERED OWNER INFO LUDVIK STARSY 2100 NW HARVEST PL UNIT E4171SSAQUAHWA98027 D:2069994575 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
4
14� LIABILITY INSURANCE INSURANCE CO ALLSTATE 807 800 801 3
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LECALLv YES❑NO❑ CITATION# 1 o BOTTOM
15❑ NDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES�/ NO D:2533357973
16 a
LAST NAME NADOYAN FIRST NAME SADKH MIDDLE IR
INITIAL
17 STREET I❑ s❑' 715 NILE AVE NE CITY RENTON ST WA ZIP 98059 4❑ 37
NEW ADOREs
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LLIICENS RIVEWS# STATE SEX U MMDDYY —❑_ 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H EET 2 NJAURY SS 1 NATURE OF INJURIES ❑ 40
❑ 41
21❑ PLATE# CCM1578 TArE WA VIN 1t 4JGDA5H65FA512966 1
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
YEAR 2015 MAKE MERZ MODEL ML STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
VEH
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO SADKH NADOYAN 715 NILE AVE NE RENTON WA 98059 D:2533357973 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU PORGY#E CO PROGRESSIVE 71583845IN 1 9TOP
vE""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES Nu
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JAKE GALL 12617 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE27736
COLLISION REPORT III III III III III 111
1591972 CASE# 23-12533
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.
JAKE GALL 10-31-23 07:30 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 121712023 2:15:56 AM
BADGE OR ID# 12617 OR]#' WA0171300 TIME POLICE DISPATCHED 6:18 PM TIME POLICE ARRIVED i 6:28 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EE27736 CASE# 23-12533 OF COLLISION10/31/23 18:00
NARRATIVE
*This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized. *
The following occurred within the City of Renton, King County WA and was recorded on my body
worn camera.
On 10/31/2023 at around 1818 hours, I was dispatched to a two-vehicle collision located at the
intersection of Nile AVE NE and NE 7th PL.
I arrived on scene and spoke with driver#1. He provided me with all the necessary information.
Vehicle 1 had heavy front-end damage with airbags deployed. Driver 1 stated that he was not injured.
Vehicle 1 was eventually towed from the scene by Gene Meyers Towing as it was not drivable.
I spoke with Driver#2 who provided me with all his information. Vehicle 2 had damage to its rear
bumper but was drivable. Driver 2 was uninjured.
Vehicle 1 was traveling North on Nile Ave NE nearing above listed intersection. Vehicle 2 was
stopped facing North at the intersection waiting for traffic to pass. Driver 2 was about to navigate a left
hand turn into his driveway at 715 Nile Ave NE when the impact occured. Driver 1 did not observe
Driver 2 stopped waiting for traffic to pass. Driver 1 impacted Vehicle 2 at the posted speed limit of 35
MPH.
Insurance information was exchanged with both drivers.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by J. Gall/12617
10/31/23 at 1921 hours, Renton, Washington
PAGE 3 OF 4
REPORT NO. EE27736 CASE# ' 23-12533 DATE AND TIME 10/31/23 18:00
OF COLLISION
NE 7TH Pt
715 NIL E AVE NE —NOT 10 SCALE
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PAGE 4 OF 4