HomeMy WebLinkAbout23-13219 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. EE21046 170
27
COLLISION REP FIT 1591971
CASE 23-13219 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 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#
cowsloN 11 - 1-- 2023 2045 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
140TH WAY SE BLOCK NO. e✓ 15800 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e SE 158TH ST
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2064597355 0 11
30
6� LAST NAME HOLSTROM FIRSTNAME JEFFERY MIDDLE L 1 1 2 31
INITIAL
STREET ❑ 16321 SE 131 ST PL CITY RENTON ST WA 21p 98059 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVERS STATE WA SEX'M MM DAY' 02 1- 24 - 1966 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� BWP8919 sTArI WAurN# SALMF1E46AA325693
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 5 33
12 4 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2010 MAKE M DAMAGE ODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE 1 5 34
13 4 LNDR RANGE I'4 YES No �MEYERS TOWING YYES[:] No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO GARRISON PROP AND CAS INS CO 018657589R 3 4
IN EFFECT &POLICY# 9TOP
VEHICLe CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER [:]EA.
YES 1/ NO D:2067569222
16 a
LAST NAME 1 77771DIAZ PEREZ FIRST NAME DEIVY MIDDLE N
INITIAL
17 STREET NEW ADOREs7 17650 134TH AVE SE#N301 CITY RENTON ST WA ZIP 98058 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK Y�EsI I I NOF YEs t l NO�
19 DRIVER'S STATE WA SEX M D.C... O6 _ O6 _ 2004 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMET 2 INJURY 6 NATURE OF INJURIES ❑ 40
USE CLASS SCRAPE ON FINGER
❑LICENSE I 21❑ PLA E# CGT3217 TArE WA VIN 11 WBAWV13569P123425 41
1
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2009 MAKE BMW MODEL 328 STYLE P4 DAMAGE TO WED✓ NOO BLIN GENE MEYERS TOWING YES NO�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&POLICY#E CO GEICO 6114-95-45-03IN 9TOP 5
VE""LE ❑ Nu,J CITATION# CHARGE io BOTTOM
LEGALLY YES
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
D.NELSON 12421 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE21046
COLLISION REPORT III III III III III 111
1591972 CASE# 23-13219
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 11/15/2023 1 was working as a uniformed patrol officer and driving a marked patrol vehicle for the
City of Renton. I was dispatched to a report of a two vehicle collision in the intersection of 140th Way
SE and 158th St SE Renton/King/WA. Multiple witnesses were calling to report a two vehicle collision
with unknown injuries in the intersection.
I arrived on scene and located a Land Rover Range Rover (WA/BWP8919) driven by Jeffery L
Holstrom (DOB: 2/24/1996). Jeffery advised he was stopped at a red light on 158th St SE attempting
to turn south on 140th Way SE. He said the light was not turning green so he attempted to run it and
believed he could beat the oncoming traffic but was struck on the driver side by the other vehicle. The
Land Rover had extensive damage to the driver side. Jeffery was not injured and was evaluated by
RRFA personnel on scene.
I then located a BMW 328 (WA/CGT3217) driven by Deivy N Diaz Perez DOB: 6/6/2004). He advised
he was driving south on 140th Way when the Land Rover pulled out in front of him causing the
collision. The BMW had extensive damage to the front end. Deivy had minimal injuries but was very
shook up from the wreck. He was evaluated by RRFA on scene and cleared.
Gene Meyers Towing removed both vehicle from the scene.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
D.NELSON 11-15-23 10:10 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 888 1 1111912023 3:36:20 AM
BADGE OR ID# ! 12421 ORI# WA0171300 TIME POLICE DISPATCHED; 8:47 Pry] TIME POLICE ARRIVED',8:53 PM
PART I PAGE IT]OF 3�
REPORT NO. EE21046 CASE# ' 23-13219 DATE AND TIME 11/15/23 20:45
OF COLLISION
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