HomeMy WebLinkAbout24-1172 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-1172 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION 02 - 01 - 2024 0714 17 ❑.❑ S 8 W H OF e 1070 3
4� ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SUNSET BLVD N BLOCK NO. e✓ 400
4a 1❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 5001. 00 FEET ❑ S ❑ W❑ N 3RD ST
❑ MILES
0 3 29
UNIT MOTOR
VEHICL ❑ CYCLE ElDDAMYESA✓THRESHOLD PHONE O 11
30
6� LAST NAME WU FIRSTNAME XIAO MIDDLE R 1 1 2 31
INITIAL
STREET ❑, 216 GLENNWOOD AVE SE CITY RENTON ST WA 2jp, 980568883 z
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 z❑
❑
LICENSE CKG6759 sTATe WA urN# 1C4RJXN67RW167895
3
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 1 33
12 3 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 2 2024 JEEP WRANG DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO MEN YUEN 211 GIENNWOODAVESE RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO ST FARM 548 5151 D23 47 3 4
IN EFFECT &POLICY# 9TOP
VEwcLe CHARGE 1 5 36
LEGALLY YES No CITATION# 4AO078010 FAIL YIELD PRIVATE RD MOTOR o aorrom
15❑ STANDING 6
MOTOR PEDAL-: PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:2063551112
16 a
LAST NAME DEOL FIRST NAME NARBHAI MIDDLE S
INITIAL
17❑ STREET ❑', 22379 SE 282ND LN CITY' MAPLE VALLEY ST WA ZIP 980385172 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK vEs❑NOF YES❑NO❑
19 LDI IVER # STATE WA SEX M M D.C.B. 01 25 _ 1971 39
WELMET INJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 3 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CKP4288 TATe WA VIN# 5TDACAB53RS006945
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2024 MAKE TOYT MODEL GRAND STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO BANKERS YES NO
REGISTERED OWNER INFO NARBHAIDEOL 22379 SE282ND LN MAPLE VALLEY WA 980385172 D:2063551112 VEHICLE NO.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO FIRST NATL H2443480IN 1GQI
VE""LE ❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE46397
COLLISION REPORT III III III III III 111
1591972 CASE# 24-1172
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) ED/GA PRAVEENA
(I.P.ST FIRST,
ADDRESS&PHONE# D.0
.B.
22379 SE 282ND LN MAPLE VALLEY WA 980385172 SEX F MMDDYyry 12 - 01 - 1985
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER I�I WITNESS❑ UNIT# 2 POS S AIRBAG 3 RESTR. 4 EJECT 1 USE CLASS 6 NATURE
E O
NAME L�1
(LAST,FIRST,MIDDLE INITIAL) BUSCH JAY
ADDRESS&PHONE# D O B
4803417184 SEX' U MMDDVVYv
PASSENGER UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
[:]WITNESS POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
grn jeep rt 7-11 blk hilander
CC
Within the city limits of Renton/King/WA I responded to a 2 car blocking unknown if injury crash near
the 400 block of Sunset Blvd N.
I contacted the driver of unit 2 who told me he was north on Sunset Blvd when unit 1 pulled from the 7
-11 parking lot striking his car. He did not complain of injury but his passenger was bleeding from the
head. She was treated on scene by Renton Fire and later transported to VMC-ER for further
treatment. Damages required a tow truck.
I contacted the driver of unit 1 ID'd by her picture WADL. She said she was pulling from the driveway
of 7-11 in heavy traffic and a driver in stopped traffic waved her out. She crossed over lane 1 and into
lane two where she contacted unit 2. She did not complain of injury and damages did not require a
tow truck.
I cited unit 1 ref RCW 46.61.205 FTYROW-Private Drive 2 car injury crash via complaint.
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 2/1/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 02-01-24 12:54 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 21112024 2:50:23 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED` 7:15 AM TIME POLICE ARRIVED 7:17 AM
PART I PAGE IT]OF 3�
REPORT NO. EE46397 CASE# 24-1172 DATE AND TIME 02/01/24 07:14
OF COLLISION
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f, I
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