HomeMy WebLinkAbout24-2087 ITFF' "POLCERA II I !�� I III I III I IIII III II I . $ 27c
COLLISION REP FIT 1591971
SASE 24-2087 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFH1C;l F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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 - 1-- 2024 0613 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LOGAN AVE N BLOCK NO. e✓ 600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 1 2 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YEs NO ,/ D:3604343003 1 2 30
6� LAST NAME SOLTYSIAK FIRSTNAME ARTUR MIDDLE R 1 2 31
INITIAL
STREET ❑ 434 4TH ST NE 360 434-3003 CITY PUYALLUP ST WA ZIP 98372 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� AXE5645 sTArr WAurN# 5TDKK3DC2CS199983
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR. 1 5 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 $ 34
13 3 2012 TOYT SIENNA VN DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 4076283649 4
LI EFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YEs NO 1/ D:4254448635
16 2
LAST NAME COLOMBI FIRST NAME DEBORAH MIDDLE JA
INITIAL
17❑ STREET ❑', 1055 S GRADY WAY CITY' RENTON ST WA ZIP 98055 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
INTERLOCK YES❑No� INTERLOCK Y�EsI❑NOF YEs❑NO�
19� LICENSE# STATE WA SEX U M D.C.B. O6 _ 27 1958 0 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE 67638D TAre 41
WA vIN 1GCHSBEA9L1162251
❑
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2020 MAKE CHEV MODEL CORORA STYLE PK VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO OF RENTON CITY 1055 S GRADY WAY RENTON WA 98055 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#ECO CITY OF RENTON SELF INSUREDIN 1 9TOP
VE""LE ❑ Nu,J CITATION# CHARGE
LEGAL i o BOTTOM
LY YES
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
JOSEPH SINGER 12056 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE57562
COLLISION REPORT III III III III III 111
1591972 CASE# 24-2087
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) HACKNEY GERALD J
(LAST FIRST,
ADDRESS&PHONE#
1055 S GRADY WAY RENTON WA 98055 2679748486 SEX M MMDDYyry 05 - 17 - 1969
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGERWITNESS❑'UNIT# 2 POS 3 AIRBAG 2 RESTR. q EJECT USE 2 CLASS i7 NECK AND BACK PAIN
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 2 was merging onto Logan Ave N after turning s/b from N 6th ST. Unit 2 slowed to find a break in
the traffic, Unit 1 rear-ended Unit 2. Unit 1 admitted to the accident advising he had not seen Unit 2.
Possibly injuries in Unit 2.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JOSEPH SINGER 02-26-24 06:59 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 31912024 10:29:56 AM
BADGE OR ID# 12056 OR]# WA0171300 TIME POLICE DISPATCHED! 6:14 AM TIME POLICE ARRIVED'6:21 AM
PART Ei PAGE IT]OF
REPORT NO. EE57562 CASE# 24-2087 DATE AND TIME 02/26/24 06:13
OF COLLISION
a
1 ,
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