HomeMy WebLinkAbout24-2510 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-2510 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 ❑28
TRIBAL UNITS 02 STRUCK' FENCE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 03 - 1-— 2024 0835 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
TALBOT RD S MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e S 194TH ST
0 1 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE =30
6� LAST NAME NGOUN FIRSTNAME KAUTILYAH MIDDLE N 1 2 31
INITIAL
STREET ❑ 13020 SE 231 ST WAY CITY KENT ST WA 2jp, 980313640 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS' AIRBAG 2 RESTR 4 EJECT 1 H U SE CLASS 7 I HEADE OF INJURIES 2❑
3
10❑ P1 ATNES# 902YHN srAT WAu N# JTEBU14R58K034913
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FRom ro
TRLR. TRLR. 5 1 33
12❑ VIN#' VIN#'
Rom 34
13❑ VEH.YEAR2008 MAKE TOYT MODEL 4 STYLE VEHICLETOWED0NOOffBLIN TSIgWgYMEYER vOs❑ENO✓
DAMAGE IILLJJII (��IV6
REGISTERED OWNER INFO KAUTILYAH NGOUN 13020 SE 231STWAY KENT WA 980313640 VEHICLE NO. 1 ❑
❑ SHADE IN DAMAGED AREA 35
14 LIABILI V INSURANCE INSURANCE CO TBA TBA 4
IN EFFECT &POLICY# 9TOP_
VEHICLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 1 o BOTTOM
15❑ STAIN.D'ING 6
UNIT VE IMOTOOR El CYCLE PEDAL- ❑ PEDESTRIAN ❑ OWNER
✓� DYES✓ NO OLD MET PHONE
16❑
LAST NAME UNK FIRST NAME MIDDLE
INITIAL
17❑ STREET ❑', 19297 TA RD S CITY RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑NOR INTERLOCK YEs I I NOF YES t l NO❑
19 LLIICENS # STATE SEX U MMDDYY —❑_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ TATE LICENSE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ &POINSULICY#E CO
IN EFFECT Q'E""LE
❑ ,J� CITATION# CHARGE i o
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# 777T�NCY
26
M.LEVERTON 2517 0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE60142
COLLISION REPORT III III III III III 111
1591972 CASE# 24-2510
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SELYUK IGOR
(LAST FIRST,
ADDRESS&PHONE#
2062182429 SEX i U MMDDYYYY -❑
---------------------------
PASSENGER WITNESS SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓S UNIT# POS. USE CLASS
NAME
'(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
MMD D0 V
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY 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'
nb talbot ice into fence
RTF
Within the city limits of Renton/King/WA I responded to a single vehicle off the roadway near 19400
block of Talbot Rd S.
It was a cold morning with ice of the roadway. It appeared in this location the source of the water/ice
on the road was a broken water line from the east side of the roadway.
Unit 1 said she was northbound at about 35 mph when she hit some black ice, sliding out of control
across south lanes off the roadway over a large dirt mound and into a chain link fence. She was
removed from her vehicle by on scene Renton Fire and later transported to VMC-ER for additional
checks and treatment. Her vehicle was towed for damaged by Gene Meyer.
Information/Insurance 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 3/13/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 03-13-24 07:25 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 311812024 11:59:31 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED; 8:37 AM TIME POLICE ARRIVED',8:43 AM
PART I PAGE IT]OF 3�
REPORT NO. EE60142 CASE# 24-2510 DATE AND TIME 03/07/24 08:35
OF COLLISION
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