HomeMy WebLinkAbout24-258 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE# z4-zs8 2
INTERSTATE CITY STREET FIRE
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' UT/LITYPOLE
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
C{YLLISION O1 - 1-— 2024 1318 17 ❑.= S 8 W IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BENSON DR S BLOCK NO. e
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e S 15TH ST
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2405770980 30
6� LAST NAME PHAN FIRSTNAME ANH MIDDLE V 1 1 2 31
INITIAL
STREET ❑, 17826 114TH PL SE CITY RENTON ST WA ZIP 98055 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 1 I I INJURY [NATURE OF INJURIES
H U SE CLASS 6 CUT ON LEFT SHIN 2❑
3
10❑ P1 ATE 14 APA8060 STATE WA VIN# 2T3DFREV3DW108333
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 3 33
12❑ VIN#j VIN#
FROM
34
13❑ VEH.YEAR2013 MAKE TOYT MODEL RAV4 STYLE UT VEHICLETOWED0NOOffBLIN WAWkkRSTOWING VEHICLE
DAMAGE IILLJJII
REGISTERED OWNER INFO OUANG NGUYEN 17826114TH PL SE RENTON WA 98055 D:2068238185 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 3 4
14 LIABILI V INSURANCE INSURANCE CO COMMERCE WEST INSURNACE COMPANYACPA-002595206
IN EFFECT &POLICY#
15❑ vECEHA"LE 5 36
LLLv Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:4254306400
16❑
LAST NAME RENTON FIRST NAME CITY OF MIDDLE
INITIAL
17❑ STREET ❑', 1055 S GRADY WAY CITY' RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑NOR INTERLOCK YEs❑NOF YES❑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❑ PIR 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
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1 9TOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
JESSE VANDERHOEK 11631 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE38375
COLLISION REPORT III III III III III 111
1591972 CASE# 24-258
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) ANDREWS MICHELLE L
(LAST FIRST,
ADDRESS&PHONE# D O.B.
2069993835 SEXi F MMDDYyry 03 - 09 - 1973
---------------------------
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
�✓ POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYVYY
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'
Vehicle #1 was traveling nothbound on Benson Dr S, approaching S 15th St. As vehicle #1 turned
right onto S 15th St, the vehicle lost control and slid into a utility pole in this intersection, causing
major front end damage to vehicle #1 and a scrape to the utility pole. This was Renton City utility
pole number 2587C.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JESSE VANDERHOEK 01-08-24 02:47 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 1 11812024 3:26:33 PM
BADGE OR ID# 11631 ORI# WA0171300 TIME POLICE DISPATCHED 1:19 PM TIME POLICE ARRIVED 1:22 Pry
PART I PAGE IT]OF 3�
REPORT NO. EE38375 CASE# ' 24-258 DATE AND TIME 01/08/24 13:18
OF COLLISION
Not to scale'�
St
y
fility pole
co
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