HomeMy WebLinkAbout24-3696 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-3696 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4Y50 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 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.. 04 - 05 - 2024 0751 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SUNSET BLVD N
0 1 29
UNIT
MOTOR Z PEDAL- ❑CYCLE DAMAGE NHORESHOLD MET PHONE O 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 11
31
INITIAL
STREET ❑ CITY ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNIT{ON : PRESENT MEDICAL TRANSPORTED 3
:NTERLOCKYEs NO INTERLOCK YES NO YES No
8 DRIVERS. STATE : SEX.U D.O.B. 1 1 2 32
❑ :LICENSE# MMDDYY -❑
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H U EEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE sTATI urN#'
10❑ PI ATE 14
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# ROM TO
TRLR 3 7. TRLR 33
12 4 0 vIN# VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 2 DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO [NEW] VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 ABILI INSURANCE❑ NSURANCE CO 3 4
LI EFFECT &POLICY#VEwcLE CHARGE 36
LECALLvYEs❑NO CITATION# EQ,
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2532040039
16 a
LAST NAME HAM FIRST NAME JOHN MIDDLE W
INITIAL
17 STREET NEW ADDRESS❑' 921 N DULUTH AVE CITY' SIOUX FALLS ST' SD ZIP 571042321 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL t-T�RANSPORTED ❑ 38
INTERLOCKYES�NO� INTERLOCK YEs I I No� YES t l NO❑
19 DRIVER'S STATE SD SEX M I D.O.B. 04 O6 _ 1993 39
LICENSE# MMDDYY
HELMET I {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
❑LICENSE I 21❑ PLA E# CHA6581 TATE WA vIN# JF2(BUADC4R8210615 41
Q
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2024 MAKE SUBA MODEL CROSST STYLE VEHICLETOWED TO BLIN TOWEDBY GOV!TN
44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO JOHN HAM 921 N DULUTH AVE SIOUX FALLS SO 571042321 D:2532040039 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO PROGRESSIVE 973812608IN I STOP
VE""LE ❑ Nu,J CITATION# CHARGE i o BOTTOM
LEGALLY YES
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
M.LEVERTON 2517 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE69012
COLLISION REPORT III III III III III 111
1591972 CASE# 24-3696
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'
turning to 405 rear by unknown outside lane
RTF
Within the city limits of Renton/King/Wa I responded to a 2 car hit and run crash near the intersection
of Maple Valley Hwy at Sunset Blvd N.
I contacted the driver of unit 2 who told me he was just proceeding on his green in the outside left turn
lane from MVH to SB 1-405 when he was hit from behind by an unknown vehicle/ driver who fled the
area. Unit 2 was unable to provide any additional information for unit 1/suspect vehicle. 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 4/5/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 04-05-24 02:41 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 4/17/2024 2:07:13 PM
BADGE OR ID# 2517 ORI#' WA0171300 TIME POLICE DISPATCHED! 8i21 AM TIME POLICE ARRIVED 8:21 AM
PART I PAGE IT]OF 3�
REPORT NO. EE69012 CASE# 24-3696 DATE AND TIME 04/05/24 07:51
OF COLLISION
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