HomeMy WebLinkAbout24-4028 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
SASE 24-4028 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STATE ROUTE OTHER STOLEN
❑ ❑ HFHIC;I F ❑ LOCAL AOENC 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 03 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION: 04 - 1-- 2024 1813 17 ❑. S 8 W Li OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 3500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 20 00 FMILES EET e S ❑ W e OLYMP/A AVE NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:9049301550 0 11
30
6� LAST NAME OCANA FIRSTNAME DURAN MIDDLE O 1 1 2 31
INITIAL
STREET ❑, 937 SW 154TH ST APT 6 CITY BURIEN ST WA Zjp, 98166 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ DRIVERS
# STATE WA SEX'M I ELMIDI Y' 02 — 07 — 1986 1 2 32
9 ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H USE CLASS 2 CLASS 1 NATURE OF INJURIES z❑
3
10 99 LICENS P1 ATE 14 Y097DH sTATe FL vN# 1 C4RDHDG2DC530220
- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 3 7 33
12 3 5 VIN#' VIN#'
>; FROM TO
❑ VEH.YEAR 2013 DODO DURAN UT MAKE MODEL STYLE VEHICLE TOWED TO BLIN T BS 3 7 k GOVT.VEHICLE 34
13 4 DAMAGE YES NO YES❑ No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO ASSURANCE AMERICA PFL1830160.4 <�g34
IN EFFECT &POLICY# OPVE"'CLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# TTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES NO ,/ D:5163951947
16 a
LAST NAME SKIN FIRST NAME ANDRIZE MIDDLE J
INITIAL
STREET
17❑ NEW ADDR11 4722 RAINIER AVE S UNIT 114 CITY' SEATTLE ST' WA ZIP 98118 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCKYEB❑NO� INTERLOCK YEs❑NOF YES
❑NOF,/
19 DRIVER'S STATE WA SEX M D.C.B. 02 _ 03 _ 1992 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
❑21❑ PLATE# CEP6209 TATE WA VIN# 3CZRU5H5XJ(3701676 41
1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2018 MAKE HOND MODEL HRV STYLE SD VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ANDRIZE SKIN 4722 RAINIER AVE S UNIT 114 SEATTLE WA 98118 D:5163951947 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#E CO USAA 0274786637102IN 1 9TOP
VEHICLE ❑ ,.I—I CITATION# CHARGE �BOTTOM
LEGALLY YES N
25 $
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
KEV/N PETERSON 12808 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE68251
COLLISION REPORT III III III III III 111
1591972 CASE# 24-4028
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'
I was dispatched to a collision on 04/12/24 at 1814 hours at N 4th St and in the 3500 block, in city
Renton, King County WA.
Unit 1 Y097DH Driver: Duran O. Ocana (DOB 02/07/1986)
Unit 2 CEP6209 Driver: Andrize J. Skin (02/03/1992)
Unit 1 BCK3446 Driver Ana Y. Carbajal (DOB 03/05/1978)
Unit 3 was going West on NE 4th St in lane 2 when she was coming to a fast stop due to traffic. Unit 2
who was traveling West in lane 2 on NE 4th St had to hit his breaks to stop before hitting Unit 3. Unit
1 who was traveling West in lane 2 did not hit his breaks and rear ended into Unit 2 pushing him
slightly into Unit 3.
All 3 drivers stated they had no injuries and did not need medical attention.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 04-13-24 12:04 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIREE SCOTT 10272 1 4/15/2024 11:45:50 AM
BADGE OR ID# 1Y808 ORI#' i WA0171300 TIME POLICE DISPATCHED 6:14 PM TIME POLICE ARRIVED',6:16 PM
PART Ei PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE68251
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 24-4028
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGETHRESHOLD MET PHONE
UNIT# 3 �✓ � PEDESTRIAN YES NO
5 VEHICLE CYCLE OWNER ✓ D:2065815301
0 1 29
LAST NAME : CARBAJAL FIRST NAME ANA MIDDLE Y
INITIAL
STREET 30
NEW AnnRFSP' 5017 NE 5TH ST CITY RENTON ST WA ZIP 98059
6 [2 1 1 2 31
CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TANSPORTED
INTERLOCK YEs NO✓ zERLOCK YES❑N0� YES N ✓
DRIVER'S
LICENSE STATE I WA SEX F MMDDYYv 03 - 05 - 1978
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE BCK3445 [TAT WA VIN# 3N1CN7AP2GL898037
PLATE#
9 9] TRAILER TRAILER
PLATE# STATE PLATE# STATE
10 ❑ TRLR TRLR
VIN It VIN.#.
11 3 5 VEH.YEAR2015 MAKE NISS MODEL VERSA STYLE SO VEHICLE TOWS E T SABLIN TOWED BY anvi vEH1I' P FROM TO
DAMAGE YES NO ✓ YES NO ✓
REGISTERED OWNER INFO OWNED BY DRIVER 3 ] 33
12 � SHADE IN DAMAGED AREA
3 4 FROM TO
LIABILITY INSURANCE INSURANCE CO STATE FARM 5174404F1747A q"i"Olx
IN EFFECT &POLICY#
VEHICLE 34
13 4 LEGALLY YES❑ NO❑ CITATION# CHARGE 0 BOTTUM
STANDING } 8 7 6
14 ❑ UNIT Tr Vd 1RE O CYDCLE OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME INITIAL
MIDDLE ❑ 36
STREET
16 NEW AnnR"Fll
CITY ST ZIP
CDL IGNITION REdUiRED IGNITION PRESENT MEDICALTANSPORTED
NTERLOCK YES No NTERLOCK YEs NO YES NO ❑
17 4 37
LICENSE# STATE SEX MMDDDYBYY
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38
USE CLASS
19 ❑ LICENSE rnr VIN# 39
PLATE#
20 ❑ TRAILER' STATE TRAILER STATE ❑ 40
PLATE#< PLATE#
21 ❑ ❑ 41
TRLR TRLR
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
3 4 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 VEHICLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
LECALLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 04-13-24 12:04 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26 ORRID# 12808 O#IL WA0171300 SCOTT 4115/2024 PAGE F OF 4
3000-345-013(R 11118)
REPORT NO. EE68251 CASE# ' 24-4028 DATE AND TIME 04/12/24 18:13
OF COLLISION
r
as ty.
r
w
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