HomeMy WebLinkAbout23-13968 ITFF' "POLCERA II I !�� I III I III I IIII III II I . $ 27c
COLLISION REP FIT 1591971
CASE 23-13968 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❑ TOTAL#OF OBJECT 1 5 6 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 12 - 1-- 2023 1530 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
S TOB/N ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ V\e SHATTUCKAVES
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063493954 0 11
30
6� LAST NAME MAI FIRSTNAME SON MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 702 NW 3RD CT CITY RENTON ST WA ZIP 980573401 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 P1 ATEB 4 BBJ5541 sTAr WA u N# 2T3ZFREV2DW061074
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR. $ 7 33
12 2 5 VIN#' VIN#'
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 2 2013 TOYT RAV4 DAMAGE YES NO ✓ YES : NO✓
REGISTERED OWNER INFO SON MA1702 NW 1.CT RENTON WA 980573401 D:2063493954 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ST FARM 136 7525-D13.47A 4
IN EFFECT &POLICY# 9TOP
VE—LE CHARGE 5 36
LECALLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
UNIT 02 VE ICCLE CYCLE ❑ PEDESTRIAN ❑ OWNFRRTY ❑ DYESMOTO ✓ NO OLD MET PHONE
16 a
LAST NAME JAMA FIRST NAME HUSSEIN MIDDLE A
INITIAL
17❑ STREET ❑', 9650 8TH PL SW UNIT 203 CITY SEATTLE ST WA ZIP 981063091 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19 DRIVER'S STATE WA SEX M D.C.B. 01 01 1986 0 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CGJ2761 TAre WA vIN# 2C4RC1L76NR122887
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2022 MAKE CHRY MODEL PACIFICA STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO PV HOLDING CORP 15820INTERNATIONAL BLVD TUKWILAWA 98188 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE &POLICY#E CO SELG/PV HOLDING SO50 1UQIIN EFFECT
'E""LE ❑ ,J� CITATION# CHARGELEGALLYYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE32470
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13968
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(LAST FIRST,MIDDLE INITIAL) JOE
ADDRESS&PHONE# D O.B.
4254443892 SEX' U MMDDYYYY -❑
PASSENGER❑WITNESS UNIT# I SEAT AIRBAG RESTR. EJECT ' HELM INJURY
S5
ET CLASS NATURE OF INJURIES
❑✓ SOS. USE
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYV
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'
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.
M.LEVERTON 12-06-23 06:56 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 12/20/2023 10:08:52 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED 3:31 PM TIME POLICE ARRIVED',3:31 PM
PART I PAGE IT]OF 4]
REPORT NO. EE32470 CASE# 23-13968 OF COLLISION
12/05/23 15:30
OF CbLLI510N
NARRATIVE
wht van/2 stop sign blk suv 1 It from rnt hi
RTF
Within the city limits of Renton/King/WA I responded to a 2 car blocking crash at the intersection of S
Tobin St and Shattuck Ave S.
I contacted the driver of unit 1 who said he was making left turn from the high school parking lot when
unit 2 ran the stop sign and hit him. He did not complain of injury and damages did not require a tow
truck.
I contacted the driver of unit 2 who told me he stopped for the stop sign and proceeded when unit 1
pulled in front of him where they collided. He did not complain of injury and damages did not require
a tow truck. Unit 2 said he has on board camera but did not provide video to confirm his version.
I contacted Joe the witness who told me he believed unit 2 did not stop for the stop sign, was slowing
and making a right turn and crashed into unit 1. He told me he did not know any one involved in the
crash.
The stop sign at this intersection is set back about 30 feet from the intersection apex. Without video
to confirm the actions of both drivers this will be for information/insurance purposes only.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 12/5/2023
PAGE 3 OF 4
REPORT NO. EE32470 CASE# ' 23-13968 DATE AND TIME 12/05/23 15:30
OF COLLISION
PAGE 4 OF 4