HomeMy WebLinkAbout23-13012 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-13012 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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 11 - 11 - 2023 1257 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 3RD ST BLOCK NO. e✓ 1000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e MAIN AVE S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2062653065 0 11
30
6❑ LAST NAME NGUYEN FIRSTNAME DAD MIDDLE V 1 2 31
INITIAL
STREET ❑, 2617 FOREST CREEK DR CITY FORT WORTH ST TX Zjp', 761230000 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
�/INTERLOCK YES[:]No INTERLOCKYEs NO YES R NO
8 LDRIVER # STATE TX SEX'M MM ovY' 10 1- 10 - 1951 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 CLASSy 1 NATURE OF INJURIES z❑
3
10 1❑ PI ATE 14 ANJ5821 STATE WA VIN#' 2T3JF4DV9BW092787
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34
13 1 2011 TOYT RAV4 UT DAMAGE YES NO ves❑ No
REGISTEREDOWNERINFO TOM NGO 18615 SE 174TH WAY RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE U INSURANCE CO STATE FARM 5450613C0447 4
IN EFFECT &POLICY# 9TOP
36
VE—LE CHARGE 5❑NO❑ CITATION# 1 o BOTTOM
15❑ LEGALLv STANDING YES 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16 a UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2067083012
LAST NAME ZHENG FIRST NAME LINA MIDDLE N
INITIAL
17❑ STREET Is❑' 5526 S WALLACE ST CITY' SEATTLE ST WA ZIP 981782870 4❑ 37
NEW ADOREs
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NOF INTERLOCK YES I t I.OF YES t l NO❑
19[ DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# BLC5105 TATE 41
WA vIN1 WBXYJ5C37JEF71773 1
42
22❑ PLATILER E# STATE pLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2018 MAKE BMW MODEL XZ STYLE 1 T VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO LINA ZHENG 5526 S WALLACE ST SEATTLE WA 98178 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#E CO SAFECO H2445924IN I �VE""LE
❑ ,J� CITATION# CHARGE i
LEGALLY YES N`L J
25 $
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE60141
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13012
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) NGUYEN NGAN D
(LAST FIRST,
ADDRESS&PHONE# D O.B.
18615 SE 174TH WAY RENTON WA 98058 SEX F MMDDYyry - -
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 POS. ! 3 2 2 1 USE 1 2 CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX' MMDDYVYV
PASSENGER [:]WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY 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 11-11-23 at about 1315 1 arrived in the parking lot of 200 Mill Ave S for a 2-vehicle collision that
occurred in the area of S 3rd and Main Ave S. I contacted all parties in the parking lot in or near their
vehicles. Both drivers were identified via WADL. Driver 1 told me;
He was going straight when he and unit 2 collided. He was not injured.
Driver 2 told me;
She was driving straight when unit 1 came into her lane causing a collision.
Neither party was injured. Both vehicles were driven away by the drivers.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 11-11-23 01:38 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 311812024 12:04:56 PM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED; 1:15 PM TIME POLICE ARRIVED',1:15 PM
PART I PAGE IT]OF 3�
REPORT NO. EE60141 CASE# ' 23-13012 DATE AND TIME 11/11/23 12:57
OF COLLISION
S. cene not obse ry d
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