HomeMy WebLinkAbout23-14198 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-14198 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
CowsloN 12 - 11 - 2023 1026 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NE 4TH ST BLOCK ST e✓ p ❑
4a❑ MILE POST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e MONROE AVE NE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:7204539322 0 11
30
6❑ LAST NAME MARIN LOPEZ FIRST NAME MA MIDDLE G 1 1 2 31
INITIAL
STREET ❑ 2102 NE 9TH ST CITY RENTON ST WA ZIP 980562948 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 10 1- 04 - 1967 2 32
9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 HELMETU E 2 CLASS 7 [NATURE OF CHEST PAIN DRIES z❑
3
10❑ Pi aT�S� CGG8652 sTArI WAurN# 3N1AB86V2tY260547
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 1 33
12 3 5 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T /g[AWk GOVT.VEHICLE 34
13 4 2020 NISS SENTRA SD DAMAG 3 7 E YES NO YYES[:] ✓No
REGISTERED OWNER INFO MA MARIN LOPEZ 2102 NEDTH ST RENTON WA 980562948 D:7204539322 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO STATE FARM 5154959-E16.47
IN EFFECT &POLICY# 9TOP
15❑ vewCLE 5 36
LECALLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2088179286
16 a
LAST NAME OLSON FIRST NAME TIMOTHY MIDDLE R
INITIAL
17 STREET❑ NEW ADOREss❑' 24830 22ND AVE S CITY KENT ST WA ZIP 98032 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX M D.O.B. 03 _ 11 1987 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# BGD2220 TArE 41
WA VIN# JF1VA1C64J9805169 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2018 MAKE SUBA MODEL WRX STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO TIMOTHY OLSON 2483022ND AVE S KENTWA98032 D:2068179286 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE &POINSURGY#E CO ALLSTATE 817043062IN STOP 5
VEHICLE ,.I—I CITATION# CHARGE
25 io BOTTOM
LEGALLY YES❑ N
' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
E.CHANG 10065 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE30937
COLLISION REPORT III III III III III 111
1591972 CASE# 23-14198
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) OLSON RUBYE
(IAST FIRST,
ADDRESS&PHONE# D O.B. '
24830 22ND AVE S KENT WA 98032 2068179286 SEXi F MMDDYyry 07 - 31 - 2021
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 2 POS, 7 2 11 1 USE 2 CLASS 1
NAME
LAST,FIRs MIDDLE INITIAL JOHANNES SPENCER K
ADDRESS&PHONE# D O B
17419 129TH AVE SE RENTON WA 980586158 SEX M MMDDYYYv 03 _ 31 _ 1991
PASSENGER UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
[:]WITNESS 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 12-11-2023 at about 1026 hours, I was dispatched to a collision at the intersection of NE 4th St
and Monroe Ave NE, in the City of Renton, King County, Washington.
Unit 1 WA plate: CGG8652 Driver: Marin Lopez, Ma G (10-04-1967)
Unit 2 WA plate: BGD2220Driver: Olson, Timothy R (03-11-1987)
1 was informed of the following from all parties including the witness. Unit 1 was stopped on NE 4th
St in the left turn lane. Unit 1 had a yellow blinking light and made a left turn. Unit 2 was traveling
westbound in lane 1 of NE 4th St going through the intersection and struck unit 1. Unit 2 had a green
light.
Driver of unit 1 received trauma to her chest and hip. Combination of airbags were deployed in unit 1.
Driver of unit 1 was seen by fire but did not go to the hospital from the scene.
Occupants of unit 2 said they had no injuries.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.CHANG 12-15-23 12:11 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 12/15/2023 5:46:50 PM
BADGE OR ID# 10065 OR]# WA0171300 TIME POLICE DISPATCHED 40:28 AM TIME POLICE ARRIVED'10:30 AM
PART I PAGE IT]OF❑
REPORT NO. EE30937 CASE# ' 23-14198 DATE AND TIME 12/11/23 10:26
OF COLLISION
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