HomeMy WebLinkAbout24-3005 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. EE62773 170
27
COLLISION REP FIT 1591971
CASE 24-3005 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 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# ❑
cawsloN 03 - 1-- 2024 0642 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE PETROVITSKY RD BLOCK NO. e✓ 12200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 300 00 FEET MILES e S ❑ W e 119THAVESE
0 4 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 4 30
6� LAST NAME AMIRI FIRSTNAME HEKMATULLAH MIDDLE N 1 1 2 31
INITIAL
STREET ❑ 12210 SE PETROVITSKY RD APT K CITy RENTON ST WA 2jp, 980586673 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8❑ LRIIVERS STATE WA SEX'M MM DAY' 04 1— 21 — 1991 1 2 32
CENSE 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
LICENSE CLM4867 sTArI WAurN# JTDBR32E660067266
10 F91 PI ATE#
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. RLR 1 3 33
12 3 5 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 1 34
13 2 2006 TOYT COROL DAMAGE YES NO ✓ YES[:] NO✓
REGISTERED OWNER INFO HEKMATULLAHAMIRI 12210 SE PETROVITSKYRDAPTK RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAME. 3 4
IN EFFECT &POLICY# 9TOP
VE—LE 5 36
LEGALLY
res❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDINGMOTOR PEDAL- P I 7 6
UNIT a2 VE ICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER YES
❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME HICKS FIRST NAME YVETTE MIDDLE M
INITIAL
17❑ STREET ❑', 12210 SE PETROVITSKY RD APT 8 CITY RENTON ST WA ZIP 980586626 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL t—T�RANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK YEs I I No� YES t l NO❑
11
19 DRIVER #
I INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I CHP9143 TAre WA VIN 1t 1(BNDX03E33D273975
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2003 MAKE CHEV MODEL VENTURE STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO YVETTE HICKS 12210 SE PETROVITSKY RD APT 8 RENTON WA 980586626 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1 9TOP 5
VE"'LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 $ '
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. EE62773
COLLISION REPORT III III III III III 111
1591972 CASE# 24-3005
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 FIRST 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'
slv/1 ly from dw maroonn van It from petro
RTF
Within the city limits of Renton/King/WA I responded to a crash near the 12200 block of SE
Petrovitsky Rd.
I contacted the driver of unit 2 who told me she was making a left turn into the parking lot of an
apartment complex when she was hit in the side by unit 1 who made a left turn into the side of her
car. She did not complain of injury and because her vehicle was in her parking lot did not request a
tow truck.
I contacted unit 1 who told me he was making a left from the driveway and believed he had the right
of way, which he did not. He did not complain of injury and damages did not require a tow truck.
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 3/20/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 03-20-24 07:52 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 3/26/2024 2:25:08 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 6:42 AM TIME POLICE ARRIVED',6:42 AM
PART I PAGE IT]OF
REPORT NO. EE62773 CASE# 24-3005 DATE AND TIME 03/20/24 06:42
OF COLLISION
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