HomeMy WebLinkAbout23-13567 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13567 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 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 1705 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RAINIER AVE S BLOCK NO. e✓ 300 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e S.3RD PL
0 2 29
UNIT MOTOORVECL PI CYCLE
ElDDAMYESA✓NOESHOLDMET PHONE 0 11
30
6� LAST NAME AYENEW FIRSTNAME YEMESGEN MIDDLE A 1 1 2 31
INITIAL
STREET ❑ 6801S 133RD ST APT F247 CITY SEATTLE ST WA 2jp, 98178 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 1 CLASS NATURE OF INJURIES 2❑
3
10[1P1 ATNES# BQF5058 sTAr WAu N# JTMEWRFV6KJ017832
5 TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 3 2019 TOYT RAV4 UT DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO yEMESGENAYENEW6801S 133RD STAPTF247 SEATTLE WA 98178 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE
IN EFFECT &POLICY# 9TOP
VEwcLE 36
LECALLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STAIN.D" 8 6
UNIT 02 VE ICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES NO SOLD MET PHONE
16 a
LAST NAME GARCIA HERNANDEZ FIRST NAME FRANCISCO MIDDLE /
INITIAL
17❑ NEW STREETRE87 1502 S 272ND ST CITY DES MOINES ST' WA ZIP 98198 4❑ 37
18 CDL ., IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NO❑
19[ DRIVER'S STATE WA SEX M D.Q.B. 07 07 1989 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 2 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES ❑ 40
❑LICENSE I 21❑ PLATE# C6724C TArE WA VIN 1t 15GGD2718K3193425 41
1
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2019 MAKE METR MODEL BUS STYLE BU VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO FRANCISCO GARCIA HERNANDEZ 1502 S 272ND ST DES MOINES WA 98198 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#E CO SELF INS METRO TRANSITIN 1UQ,
5'E""LE ❑ ,J� CITATION# CHARGELEGALYYES N`L J25
=WA
(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26 10005 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE25462
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13567
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'
On 11-25-23 at approxmimately 1711hrs I was notified of a bus vs vehicle collision that occurred in
the intersection of Rainier Ave S & S. 3rd Pl, in the City of Renton, County of King.
Here is a summary of both drivers statements.
Unit#2 was driving Northbound in the designated bus lane in lane #1. Unit#1 was driving
Northbound on Rainier Ave S in lane #2. Unit#1 changed lanes from #2 lane to the #1 lane of travel.
Upon doing so Unit#1 struck the front bicycle rack of Unit#2. No claims of injuries.
Both vehicle's drove off on their own power.
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 11/23/2023, Renton, WA.
Officer K. Matsukawa/10005 Date & Place
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.MATSUKAWA 11-25-23 06:16 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 121112023 4:18:04 PM
BADGE OR ID# 10005 ORI# WA0171300 TIME POLICE DISPATCHED; 5:11 PM TIME POLICE ARRIVED 5:13 PM
PART I PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE255462
r`) POLICE TRAFFIC 1 27
COLLISION REPORT CASE# 23-13567
1 COMMERCIAL MOTOR CARRIER INTERSTATE ✓ INTRASTATE G
UNIT'# 2 USDOT 1 ICC# ' 1 VEHICLE TYPE 1 CARGO 6ODY 1
;TYPE
2 ❑ 1 28
CARRIER METRO TRANSIT
NAME
3 CARRIER L
ADDRESS 201 S JACKSON ST
CITY SEATTLE ST WA ZIP'', 98104
4 ❑ NAME # PLACARD: :❑
NAME IF NO NUMBER
SOURCE 1 AXLES 03 GI26000 +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES NO
i MIDDLE'... 29
LAST NAME FIRST NAME INITIAL
STREET 30
NFW AnnRFrtP. CITY ST ZIP
6 �
CDL GNITIttN REQUIRED GNITION PRESENT MEDICAL TANSPORTED 1 31
INTERLOCK YES No zERLOCK YES❑N0� vES N
LLIICIENSE STATE I SEX M��DYRYY' 2
7 F-1
ON DUTYl STATUS AIRBAG' RESTR. EJECT HELMET INJURY NATURE OF INJURIES
USE CLASS
8 ❑ ' 1 32
LICENSE+ rar VIN.#
PLATE#
9 TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 VEH.YEAR MAKE MODEL STYLE VEHICLE TOWS T SABLIN TOWED BY anvi vEHII' P FROM TO
DAMAGE Y EES NO YES NO
REGISTERED OWNER INFO. m 33
12 SHADE IN DAMAGED AREA
FROM TO
((ABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# tGQ
VEHICLE 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE
STANDING S} 8 7 6
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNER
YES AGE NOHRESHOLD MET PHONE El
35
PEDESTRIAN
15 LAST NAME FIRST NAME MIDDLE': INITIAL36
STREETIAL
❑
16 NFln+AnnRFs.� CITY'. ST 21P
CDL IGNITION REDUIREE7 IGNITION PRESENT MEDICALTANSPORTED
INTERLOCK YES No INTERLOCK YEs NO YEs NO El
17 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE (CLASS
19 ❑ vIN# 39
LICENSE
PLATE# rnr
20 ❑ TRAILER TRAILER ❑ 40
PLATE# STATE PLATE# STATE
21 ❑ TRLR TRLR 41
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO SHADE IN DAMAGED 3 a 4 AREA F 43
z
LIABILITY INSURANCE INSURANCE CO '
VE EFFECT &POLICY# i 970P - 4 E:l
44
24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.MATSUKAWA 11-25-23 06:16 PM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 OR ID# 10005 O#I,WA0171300 JOHNSON 1211/2023 PAGE 3 OF 4
3000-345-013 IR 11t18)
REPORT NO. EE25462 CASE# ' 23-13567 DATE AND TIME 11/25/23 17:05
OF COLLISION
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Rainier Ave S
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