HomeMy WebLinkAbout24-2971 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 24-2971 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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 CITY#
cowsloN 03 - 19 - 2024 0906 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 15000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 150THAVE SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2065398755 0 6 30
6� LAST NAME MEDINA FIRSTNAME ANTONIA MIDDLE I 1 2 31
INITIAL
STREET ❑ 18260 120TH AVE SE CITY RENTON ST WA ZIP 980586628 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 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❑ P1 aT�S� AWF2646 sTArI WAurN# WAUKJAFM1CA165735
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 $ 34
13 2 2012 AUDI A3 GA DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO MARCIA MEDINA 18260120THAVE SE RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAFECO INSURACE H2297328 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER [:]EA.
YES NO ,/ D:2065613489
16 a
LAST NAME DIXON FIRST NAME ANTHONY MIDDLE J
INITIAL
17❑ STREET ❑', 4765 SHATTUCK PL S#C104 UNI CITY RENTON ST WA ZIP 980558347 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALt-T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NoF YES t l NO❑
19 LICENSE# STATE WA SEX M M .C.B. 02 _ O6 _ 1992 0 39
WELMET {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT '1 USE 2 CLASS 1 ❑
21❑ LICENSE I C07719V TAre WA vINIi 2C4JRGAG2ER380308
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2014 MAKE RAM MODEL TRADES STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO APPLIANCE REFRIGERATION HOSPITAL 14018 NW 3RD CT VANCOUVER WA 98685 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU PORGY#E CO MUTUAL OF ENUMCLAW CPPOO11134IN I STOP
"""LE ❑ Nu,J CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES $ '
7CA
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26LAN 12007 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE62774
COLLISION REPORT III III III III III 111
1591972 CASE# 24-2971
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'
On March 19, 2024, at 0906 hours dispatch requested that I respond to a collision that occurred at
150th Ave SE and Maple Valley Hwy, in the City of Renton, WA.
Upon my arrival I spoke with the driver of unit 2 and he explained he was slowing down in the number
two eastbound lane when the collision occurred. He saw a police car running lights and sirens, so
began to slow down to allow the police officer right of away. As he came to a stop, unit 1 struck the
back of his vehicle.
I then spoke with the driver of unit 1 and she explained she was following unit 2. Her vehicles front
windshield is dirty, so the sun glare was affecting her visibility. She did not see unit 2 slowing down,
she struck that back of his vehicle.
Both vehicles sustained moderate damage, so I provided them an exchange of information.
Both vehicles appeared to be drivable.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.CATALAN 03-19-24 12:36 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 3/26/2024 2:23:19 PM
BADGE OR ID# 1Y007 ORI 4$ WA0171300 TIME POLICE DISPATCHED; 9:10 AM TIME POLICE ARRIVED;9i28 AM
PART I PAGE IT]OF
REPORT NO. EE62774 CASE# 24-2971 DATE AND TIME 03/19/24 09:06
OF COLLISION
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AN
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Maple Valley Hwy
NTS
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