HomeMy WebLinkAbout23-13454 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-13454 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI 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# ❑
cawsloN 11 - 1-- 2023 1315 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
DUVALL AVE NE BLOCK NO. e✓ 1200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2065011192 0 11
30
6� LAST NAME ANTOINE FIRSTNAME VISHON MIDDLE A 1 2 31
INITIAL
STREET ❑ 1209 N 35TH ST CITY RENTON ST WA 21p 980561965 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 1 RESTR 4 EJECT 1 HELMET ICNLJU:SY 0 NATURE OF INJURIES z❑
3
10 9� P1 ATE 14 BPW2572 STATE WA VIN#' YV4902DZ1 C2296809
TRAILER STATE TRAILERSTATE FROM ro 11 0 0 PLATE# PLATE#
TRLR. TRLR 3 5 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR N MAKE VOLV MODEL XC60 STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
DAMAGE YES NO YES[:] NO✓
13❑ REGISTERED OWNER INFO APHRODYIANTOINE1209N35THSTRENTONWA98056 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILI INSURANCE INSURANCE CO STATE FARM 47-29131476 3 4
IN EFFECT &POLICY# 9TOP
VEHICL'
15❑ 5 36
LECALLv YES❑NO❑ CITATION# CHARGE 1 o BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16 a �IJNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES NO ,/ D:2069790362
LAST NAME CHANG FIRST NAME LIEN MIDDLE I N
INITIAL
17❑ STREET ❑', 4631 NE 5TH ST CITY RENTON ST WA ZIP 980595710 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICALt—T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19 D IVEW #
I INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I BMV4964 TATe WA VIN# JTMDJREV5JD250268
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2018 MAKE TOYT MODEL RAWHV STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO HSIU-CHING CHEN 4631 NE 5TH ST RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#E CO COUNTRY FINACIAL P46A4087878 STOP 5
IN EFFECT0(
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J.M/TCHELL 10377 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE26992
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13454
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) PERROTT/ STEFAN
(IAST FIRST,
ADDRESS&PHONE# D.O.B.
4257655299 SEX' U MMDDYYYY -❑
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
'(LASTr FIRS' MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 11/22/23 1 responded to a 2-vehicle non-injury/non-blocking collision near the 1400 block of SB
Duvall Ave NE.
I contacted the driver of unit 2 who told me they were traveling in the #2 lane of SB Duvall Ave Ne
when they were involved in a collision with unit 1. The driver was not injured. His vehicle had front
driver side damage. Tow was called for unit 2.
1 contacted the driver of unit 1 who told me they were exiting a parking lot (eastside of Duvall Ave NE)
on to SB Duvall Ave Ne when he was involved in a collision with unit 2. The driver was not injured.
His vehicle sustained front passenger side damage.
But not for the action of UNIT 1 DRIVER the result would not have happened.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.MITCHELL 11-29-23 09:17 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 12/5/2023 11:32:14 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED' 1:15 PM TIME POLICE ARRIVED 1:30 PM
PART I PAGE IT]OF 3�
REPORT NO. EE26992 CASE# ' 23-13454 DATE AND TIME 11/22/23 13:15
OF COLLISION
AN
LU
uj
<� z
PAGE 3 OF 3