HomeMy WebLinkAbout23-13649 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-13649 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.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 0841 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NE 4TH ST BLOCK NO. e✓ 5100 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e HOQU/AM AVE NE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2023064930 0 11
30
6� LAST NAME SIMMONDS FIRSTNAME KENDRA MIDDLE L 1 1 2 31
INITIAL
STREET ❑ 6911 115TH CT SE CITY NEWCASTLE ST WA Zip 980561027 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES 2❑
3
10❑ PI ATFBit ANV4277 sTArI WA urN#' 1HGCP2F80CA178170
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. A'RLR. 1 3 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR 2012 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 4 HOND ACCOR 4D DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO KEVIN KIR.1.1111115TH CTSE NEWCASTLE WA 98056 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14� LIABILI INSURANCE INSURANCE CO STATE FARM 377-8868A04.47 3 4
IN EFFECT &POLICY# 9TOP
VE—LE 5 36
LEGALLY
Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:4255477925
LAST NAME WU FIRST NAME CHUNSHENG MIDDLE N
INITIAL
17 STREET I❑ s❑' 4840 20TH AVE S CITY SEATTLE ST WA ZIP 981081901 4❑ 37
NEW ADOREs
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX M D.C... 03 _ 12 _ 1983 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# BWN9117 TArE 41
WA vlNf STDDZ3DCXLS252109 1
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2020 MAKE TOYT MODEL SIENNA STYLE VN VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO HAIQIONG WANG 19115 SE 128TH ST RENTON WA 98059 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#E CO AM FAM 41043-23357-66IN 9TOP 5
0(
'E""LE ❑ ,J� CITATION# CHARGE io BOTTOM
LEGALLY YES N`L J
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE60146
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13649
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) ROGERS HANNAH
(LAST FIRST,
ADDRESS&PHONE# D.O.B.
2067398771 SEX' U MMDDYYYY -❑
PASSENGER UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
[:]WITNESS❑✓ POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D O I
SEX MMD DO V
PASSENGER ❑WITNESS❑ UNIT# SEAT I 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 11-28-23 at about 0916 1 arrived at the intersection of NE 4th Stand Hoquiam Ave NE for a 2-
vehicle collision. I contacted all related parties at the intersection near their vehicles. Both drivers
were identified via WADS..
Both drivers said they entered the intersection on a green light when the collision occurred.
Witness Hannah Rogers told me;
She saw both directions had a green light.
This is not the first time that this has occurred.
However unusual, I had no way of disproving what Rogers observed. The lights did not cycle the
same as described while I was at the intersection.
Insurance to sort things out.
Both vehicles released to 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 11-29-23 09:16 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 311812024 12:04:27 PM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED 8:55 AM TIME POLICE ARRIVED',9:16 AM
PART I PAGE IT]OF 3�
REPORT NO. EE60146 CASE# ' 23-13649 DATE AND TIME 11/28/23 08:41
OF COLLISION
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