HomeMy WebLinkAbout24-620 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
❑ RESULTED ❑ CASE 24-620 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
COLLISION.. 01 - 18 - 2024 1327 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
AIRPORT WAY BLOCK NO. e✓ 200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e LAKE AVE S
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2535039102 0 11
30
6� LAST NAME USHENKO FIRSTNAME OLEH MIDDLE N 1 1 2 31
INITIAL
STREET ❑ 6625 134TH PL SE UNIT 311 CITY NEWCASTLE ST WA ZIP 980593323 2
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO,/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ Pi aT�S� CER0512 sTATe WAurN# 4T18E32K64U367473
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM To
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>;. FROM TO
VEH.YEAR 2004 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 4 TOYT CAMRY 4D DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OLEH USHENK06625134TH PL SE UNIT 311 NEWCASTLE WA 98059 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO AMFAM 410966827697 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 1 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES,/ NO D:2069634154
16 a
LAST NAME TORRES AVILES FIRST NAME REYES MIDDLE I G
INITIAL
17 STREET❑ NEW ADOREss❑' 360 TAYLOR AVE NW APT 107 CITY RENTON ST WA ZIP 980575142 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 01 07 2004 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAU EY 1 NATURE OF INJURIES ❑ 40
LICENSE ❑21❑ PLA E# CFD4798 TATE 41
WA VIN# JA32U2FU3H0003500 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2017 MAKE MITS MODEL LANCER STYLE 4D VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YESfj
NO,/ YES NO
REGISTERED OWNER INFO ANTONIA AVILES 360 TAYLOR AVE NWAPT 107 RENTON WA 98057 VEHICLE NO.2
SHADE DAGED AREA
4
LIABILITY INSURANCE INSU&PORGY#E CO NATIONAL GENERAL 2021186795 5
IN EFFECT
'E""LE ❑ ,J� CITATION# CHARGE C�Q
LEGALLY YES N`L J
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE52796
COLLISION REPORT III III III III III 111
1591972 CASE# 24-620
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'
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.
C.JACOBS 01-22-24 09:25 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 2/22/2024 8:35:32 AM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED; 1:41 PM TIME POLICE ARRIVED i 1:50 PM
PART I PAGE IT]OF 4�
REPORT NO. EE52796 CASE# 24-620 OF COLLISION
01/18/24 13:27
OF CbLLI510N
NARRATIVE
On 1-18-24 at about 1350 1 arrived in the 300 block of Airport Way for a 2-vehicle collision. Both
vehicles were still in the roadway. Driver 1 was identified via WADL as Oleh Ushenko. Ushenko did
not appear to speak English, but 1 was able to get that his native tongue may be Russian. Using the
language line Ushenko told me;
He was Eastbound on Airport way when he swerved to avoid debris in the roadway.
He did not see unit 2 in the lane next to him and they collided.
He was not injured.
Driver 2, was identified via WADL as Reyes Torres-Aviles. Reyes told me;
He was eastbound when unit 1 suddenly came into his lane and they collided.
He was not injured.
There was damage to both vehicles, but they were both able to be driven from the scene. Driver 1
was the proximate cause of this collision.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
PAGE 3 OF 4
REPORT NO. EE52796 CASE# ' 24-620 DATE AND TIME 01/18/24 13:27
OF COLLISION
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PAGE 4 OF 4