HomeMy WebLinkAbout23-14031 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-14031 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 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# ❑
COLLISION.. 12 - 1-- 2023 1919 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE CARR ROAD BLOCK NO. e✓ 10600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 20 00 FMILES EET e S ❑ E e 106TH PLACE SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4252873528 0 81
30
6� LAST NAME MOHAMED FIRSTNAME HALIMA MIDDLE M 1 1 2 31
INITIAL
STREET ❑✓ 2100 NW HARVEST PL,UNIT E220 CITY ISSAQUAH ST WA 2jp, 98027 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ L IIER # STATE yyq SEX'F I D.MM0 B 01 — 30 — 1997 1 1 2 32
9 ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELM
USEET I ICNLJA 1 URY NATURE OF INJURIES z❑
3
10[1 PI PI ATE14 CAJ5828 sTAr WA uN#' 3KPF44AC1LE224808
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 3 5 VIN#' VIN#
FROM TO
VEH.YEAR 2020 KIA FORTE SD MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO JASONSTERLING 2100 NWHARVESTPL,UNITE220 ISSAQUAH WA 98027 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE z INSURANCE CO GARRISON 030701439R 4
LI EFFECT &SUR N# TOPVEHICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# 3A0614167 INATTENTION <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT 02 ❑✓ ❑ PEDESTRIAN ❑ ❑ YES,/ No PRO
E 683285
VEHICLE CYCLE OWNER
16 a
LAST NAME YANG FIRST NAME SAMBATH MIDDLE
INITIAL
17❑ STREET ❑', 14300 SE 171ST WAY,APT J1 CITY' RENTON ST WA ZIP 98058 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 LDI IVERI # STATE WA ]SEX IF M D.O.B. 03 _ 01 1978 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BZF4496 TAre WA VIN1t JHLRD1849WC070292
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 1998 MAKE HOND MODEL CR-V EX STYLE UT VEHICLE TOWED TO BLIN TOWED BY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO SAMBATH YANG 14300 SE 171ST WAY,APTJI RENTONWA98058 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE❑ INSURANCE CO NONE NONE
IN EFFECT &POLICY# 1 STOP
VE
HICLE Yes NC cIrATION# 3A0614168 CHARGE NO IN
25SURANCE oaoTroM
LEGALLY
$ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
E.SAG/AO 10339 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE28756
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14031
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
PM 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'
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.
E.SAGIAO 12-06-23 08:46 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 12/10/2023 1:21:06 AM
BADGE OR ID# 10339 ORI# WA0171300 TIME POLICE DISPATCHED 7:25 PM TIME POLICE ARRIVED',7:33 PM
PART I PAGE IT]OF 4�
REPORT NO. EE28756 CASE# 23-14031 OF COLLISION
12/06/23 19:19
OF CbLLI510N
NARRATIVE
On 12-6-23 at 1925 hours I was dispatched to a collision in the 10600 block of SE Carr Road, in the
City of Renton, King County, State of Washington. Additional officers arrived on scene and contacted
Unit#1 and #2 in the parking lot of Fred Meyers.
I arrived and contacted Unit#2 which was a green 1998 Honda CR-V (WA-BZF4496) driven by the
owner, Sambath Yang. She told me she was facing eastbound on Carr Road waiting to make a left
turn into the Fred Meyer parking lot. She was waiting at a stop light. She advised Unit#1 struck her
vehicle from behind while she was waiting at the light. Unit#2 had damage to the rear of the vehicle
and consistent with Yang's account. Yang advised me she did not have any insurance for her vehicle.
She was identified by her WA DL.
Unit#1 was a black 2020 Kia Forte (WA-CAJ5828). The driver of this vehicle, Halima M. Mohamed
was identified by her WA DL. She advised me she was trying to stop and hit the brakes, but the
vehicle did not stop in time. Unit#1 had heavy damage to the front of the vehicle and the front airbags
had been deployed. RFA was called to the scene to evaluate all of the involved parties. They were all
released on scene, and some left prior to my arrival.
Damage and accounts consistent with Unit#1 striking Unit#2 from behind. Unit#1 driver, Mohamed
is the at fault driver and was cited for inattention through Renton court. Unit#2 driver, Yang was cited
through Renton court for not having any insurance. Both drivers were provided business cards with
this case numbers.
The incident was captured on my body worn camera. The report is a summary of events that
occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized.
I certify or declare under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
E.Sagiao/10339
PAGE 3 OF 4
REPORT NO. EE28756 CASE# ' 23-14031 DATE AND TIME 12/06/23 19:19
OF COLLISION
Text
Io Fred
place SE
4
PAGE 4 OF 4