HomeMy WebLinkAbout24-864 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 5 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE# z4-ss4 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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 N E IN CITY# ❑
COLLISION.. 01 - 1-- 2024 1630 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 2400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 1912 ,� FEET e S ❑ W e SE 5TH STREET
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:7632690019 0 7 30
6� LAST NAME SLACK FIRSTNAME CALEB MIDDLE E 1 1 2 31
INITIAL
STREET ❑ 26285 238TH LN SE APT L303 CITY MAPLE VALLEY ST WA ZIP 980385032 2
'NEWADDRESS
7❑ CDL I 1/ IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO NTERLOCKYEs NO Z YEs No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES 2❑
3
10 9❑ P1 aT�S� CDV8936 sTArI WAVIN# 4T18K46K87U548118
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# ROM To
TRLR. TRLR 7 3 33
12 0 4 VIN#' VIN#
>;. FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T Y GOVT.VEHICLE J 9 34
13 2 2007 TOYT CAMRY 4D DAMAGE YES 0NO f 14I��/.�TE TOW vEs❑ No
REGISTERED OWNER INFO EMILY VETTER SLACK 26.1238TH LN SE APT L303 MAPLE VALLEY WA 98038 D:7632690019 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI V INSURANCE INSURANCE CO STATE FARM 5174031-F10.47 4
IN EFFECT &POLICY# TOPVEHCLE CHARGE 36
LEGALLYYES❑NO❑ CITATION# W24011610 INATTENTIVE DRIVING <1�3
orrow
15❑ STANDING 7 6
MOTOR PEDAL- '.PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UN�T VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:2067993324 N:2069632120
16 a
LAST NAME GAVINO FIRST NAME RHYS MIDDLE M
INITIAL
17❑ NEW STREETREs7 28831 237TH PL SE CITY BLACK DIAMOND ST WA ZIP 980109404 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INERLOCKYEs❑No� INTERLOCK ves No� YEs NOF
19 DRIVER'S STATE WA SEX F D.O.B. 04 28 _ 2007 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
LICENSE I ❑21❑ PLA E# BMV8342 TArE WA VIN# 41
JF2GTAMC5K8246421 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2019 MAKE SUBA MODEL CROSSJ" STYLE 4H VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO STACY GAVINO 28831237TH PL SE BLACK DIAMOND WA 98010 D:2067993324 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO GEIC04592-36-12-34IN 1 9TOP
VE""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES NII
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
MATTHEW NUGENT 11498 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE44313
COLLISION REPORT III III III III III 111
1591972 CASE# 1 24-864
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 NJURY
POS. NATURE OF INJURIES
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.
MATTHEW NUGENT 01-24-24 05:45 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 1/25/2024 1:38:25 PM
BADGE OR ID# 11498 ORI# WA0171300 TIME POLICE DISPATCHED 4:35 PM TIME POLICE ARRIVED]4:36 PM
PART I PAGE IT]OF 4�
REPORT NO. EE44313 CASE# 24-864 OF COLLISION
01/24/24 16:30
OF CbLLI510N
NARRATIVE
24-864
On 01/24/2024 at approximately 1635 hours, I was dispatched to a blocking vehicle collision in the
2400 block of Maple Valley Highway, within the City Limits of Renton, County of King, State of
Washington.
Upon arrival, I confirmed there were no complaints of injury from either of the involved parties. There,
I collected the each of the involved driver's information and their independent recollection of the
events leading up to the collision.
The driver of Unit#1 said he was the sole occupant of his vehicle and was traveling eastbound in the
2400 block of Maple Valley Highway in lane 2 of 2. The driver of Unit#1 stated he was traveling
directly behind Unit#2 and noticed as Unit#2 had stopped in queued traffic. The driver of Unit#1
stated that he attempted to stop his vehicle but subsequently collided with the rear of Unit#2 causing
significant damage to the front of Unit#1.
The driver of Unit#2 said she was the sole occupant of her vehicle and was also traveling eastbound
in the 2400 block of Maple Valley Highway in lane 2 of 2. The driver of Unit#2 stated she had come
to a stop for queued traffic. While Unit#2 was stopped, Unit#1 collided with the rear of Unit#2
causing moderate damage to the rear bumper of Unit#2.
Based on the above statements, I determined that the Driver of Unit#1 (Slack) was the predominant
factor for the cause of collision due to not paying attention to traffic stopped in front of him causing a
collision.
I issued Slack a written warning in-person for Inattention causing a collision.
Unit#1 was able to move his vehicle off the roadway where he made arrangements for a private tow
due to extensive damage. Unit#2 was able to be driven away without further incident. An exchange
of information was provided to all involved parties.
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer M. Nugent#11498 5:30 PM 1/24/2024 Renton, King County, WA.
PAGE 3 OF 4
REPORT NO. EE44313 CASE# 24-864 DATE AND TIME 01/24/24 16:30
OF COLLISION
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