HomeMy WebLinkAbout24-00676 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 4 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE$# 24-00676 2 576
INTERSTATE CITY STREET ✓ RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
COLLISION'. 01 — 19 — 2024 2130 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
EDMONDS AV NE M1400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET e MILES S B E e NE 14TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4255451020 1 4 30
6 LAST NAME HARO LARES FIRST NAME JOSE MIDDLE 1 2 31
INITIAL
STREET ❑, 1621 MONROE AVE NE CITY RENTON ST WA ZIP 980563369 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I INTERLOCK YES[:]No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES 2❑
3
10� PI ATE SH15919 sTATI WA urN#' 5TDJKRFH5FS183370
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 1 33
12 0 0 VIN#' VIN#
RoM TO
m 34
13❑ VEH.YEAR 2OI S MAKE TOYT MODEL HIC�HLA STYLE VAMCLE TOWED NOO pLSABLIN V )jYRIVATE TOW YEs❑ENO✓
DAMAGE IILLJJII
REGISTERED OWNER INFO JUAN NARO LARES 5006 NE 3RD ST RENTON WA 98059 VEHICLE NO. 1 ❑
❑ SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO NONE 4
IN EFFECT &POLICY# 9TOP
vEcnLLv HICLE 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LE STAIN,'" 8 6
UNIT U2 MOTOVEHIR
Z CYCLE ❑ PEDESTRIAN ❑ OWNFRRTY ❑ DYES✓ H OLD MET PHONE
16❑
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY RENTON ST ZIP
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL—T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 LLIICENS RIVERS# STATE SEX U MMDDYY 39
WELMET 1NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
21❑ LICENSE I BZN6178 TATe WA VIN# 1N6AA07A14N535554
❑ 41
pLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2004 MAKE NISS MODEL TITAN STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO ALFONSO BOLANOS GUEVARA 1417 EDMONDS AVE NE APT 6 RENTON WA 98056 D:4255232058 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO IU
9TOP
"'LE ❑ ,.I— CITATION# CHARGE o BOTTOMLEGALYYES N`LJ25
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID#26 12651 [V7�ENCY
A0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE44451
COLLISION REPORT III III III III III 111
1591972 CASE# 24-00676
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'
Unit 1 traveling north along 1400 block of Edmonds Av NE. Unit 2 legally parked unoccupied along
shoulder of roadway on Edmonds Av NE. Unit 1 driver admits to interior distraction which caused him
to veer into Unit 2 causing reportable disabling front end damage to Unit 1 and reportable disabling
rear end damage to Unit 2. No injuries reported. No evidence of impairment or other crime. Both
involved parties did not have vehicle insurance.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 01-19-24 10:15 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 1/25/2024 9:54:38 PM
BADGE OR ID# ! 12651 ORI#' WA0171300 TIME POLICE DISPATCHED 9:36 PM TIME POLICE ARRIVED 9:39 PM
PART I PAGE IT]OF 3�
REPORT NO. EE44451 CASE# ' 24-00676 DATE AND TIME 01/19/24 21:30
OF COLLISION
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