HomeMy WebLinkAbout24-793 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
❑ RESULTED ❑ CASE 24-793 z
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 0 5 28
TRIBAL 1 OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 01 - 23 - 2024 1525 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SHATTUCK AVE S BLOCK NO. e✓ ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �,❑ FEET e S ❑ W e AIRPORT WAY
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2069158293 0 4 30
6� LAST NAME JENSEN FIRSTNAME HENNING MIDDLE J 1 1 2 31
INITIAL
STREET ❑1 11701 SE 193RD PL CITY KENT ST WA 7jp, 980310359 2
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
ICNLJAUSSY 1 NATURE OF INJURIES 2❑
3
10❑ P1 aT�S� BDN6186 sTArI WAvIN# 3G1BE6SM3HS549525
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR 1 3 33
12 2 5 VIN#' VIN#'
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 1 3 34
13 2 2017 CHEV CRUZE DAMAGE vEs 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO RENNIN.JENSE111701 SE 193RD PL KENT WA 980310359 D:2069158293 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILITY INSURANCE INSURANCE CO ALLSTATE TBA
IN EFFECT &POLICY# 9TOP
VEHCLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:4254580296
16 a
LAST NAME THYKKUTTATHIL FIRST NAME RANI MIDDLE J
INITIAL
17❑ STREET ❑', P.O.BOX 985070257 257 PMB 5489 CITY' OIL ST WA ZIP 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19 DRIVER'S STATE WA ]SEX IF D.O.B. 09 _ 30 _ 1977 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BPU3986 TAre I WA VIN# NMOGE9F7XE1145134
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2014 MAKE FORD MODEL TRANSIT STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO RAJANI THYKKUTTATHIL 1040367TH AVE S SEATTLEWA98178 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
'E""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25 s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
M.LEVERTON 2517 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE44308
COLLISION REPORT III III III III III 111
1591972 CASE# 24-793
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME(LAST FIRST,MIDDLE INITIAL) S KAREN
ADDRESS&PHONE# D O.B.
2067183202 SEX' U MMDDYYYY -❑
PASSENGER❑ INJURY
S5 WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET CLASS NATURE OF INJURIES
❑✓ SOS. USE
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY
POS. NATURE OF INJURIES
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'
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.
M.LEVERTON 01-23-24 04:36 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 1/25/2024 2:01:12 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED! 3:25 PM TIME POLICE ARRIVED',3:25 PM
PART I PAGE IT]OF 4]
REPORT NO. EE44308 CASE# 24-793 OF COLLISION
01/23/24 15:25
OF CbLLI510N
NARRATIVE
blk van It blk sedan rear It from and wit nb
RTF
Within the city limits of Renton/King/WA I responded to a what was reported as a 2 car hit and run
crash at the intersection of Airport Way Shattuck Ave S.
I contacted the driver of unit 1 who did not provide a recount of the collision. He said somehow he
was hit by unit 2 who had left the scene. He did not complain of injury and damaged did require a tow
truck.
A 911 call came in from unit 2 who was waiting down the road but returned to the scene. She also
did not provide much detail other than she was making a left turn from Shattuck onto Airport and
"paused" when suddenly she was in a crash. She did not complain of injury and damages did not
require a tow truck.
The Wit/Karen provided the following. She said she was proceeding north on her green/Shattuck
when unit 2 started to turn left into the side of her, she braked and honked. She said unit 2 stopped
and was hit from behind by unit. Wit was not contacted by either vehicle, but returned to the scene to
provide her verbal account of her observations.
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 1/23/2024
PAGE 3 OF 4
REPORT NO. EE44308 CASE# 24-793 DATE AND TIME 01/23/2415:25
OF COLLISION
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