HomeMy WebLinkAbout24-4086 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
SASE 24-4086 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT&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 N E IN CITY#
COLLISION'. 04 - 1-- 2024 1224 17 =-= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
N.SOUTHPORT DR BLOCK NO. e✓ 500 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S B VV a SB l 405
0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YEs NO ,/ D:4256478845 0 4 30
6❑ LAST NAME CHROMY FIRSTNAME KATHERINE MIDDLE E 1 2 31
INITIAL
STREET ❑, 11445 163RD AVE SE CITY RENTON ST WA 2jp, 98056 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 11 1- 26 - 1961 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 1 CLASS NATURE OF INJURIES 2❑
3
10[1P1 ATNES# D52862C sTAr WAu N# 1 FT8W36T8MEE01315
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 1 3 34
13 2 2021 FORD F350 PK DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14� LIABILITY INSURANCE INSURANCECOAMERICANFAMILYINSURANCE#41067.72304.76 4
IN EFFECT &POLICY# 9TOP
VEIF" CHARGE 5 36
LECALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ �STA""
G 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:4252393821
16 a
LAST NAME PETERSON FIRST NAME KRISTIE MIDDLE IL
INITIAL
17 STREET NEW ADDREs7 610 E LAKE STEVENS RD#82 CITY LAKE STEVENS ST WA ZIP 98258 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK yEs I I NOF YEs t l NOF,/
19[-] DRIVER #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ 41
CLS
21❑ LICENSE I PLA E# CKH8119 TArE WA VIN# 7SAYGDEESPF882131 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
Gov HI
VEH D
YEAR 2023 MAKE TESL MODEL Y STYLE $V AMAGE TOWED NOO✓ BLIN TOWED BY 44
fj
YES
NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE INSURANCE
#E CO PEMCO#CA 2140272IN IUL"iKOTITIfl0l�-
CE-SvEwcLE ❑ ,J� CITATION# CHARGE LEGALLY YES N J25 7,L
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
LIAM RIDGEWAY 12500 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE68235
COLLISION REPORT III III III III III 111
1591972 CASE# 24-4086
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) CHROMY DONALD G
(LAST FIRST,
ADDRESS&PHONE#
11445 163RD AVE SE RENTON WA 98059 SEX M MMDOYyry 01 - 15 - 1960
PASSENGER I�IWITNESS�';UNIT# 1 PEA 3 AIRBAG RESTR. 4 EJECT ? 1 HELIVET INJURY NATURE OF INJURIES
L�!1 USE 1 2 1 CLASS +1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER [:]WITNESSO UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIRST MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
W/LLIAM RIDGEWAY 04-14-24 02:54 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
S.WOODWARD 11528 1 4/15/2024 9:59:38 AM
BADGE OR ID# 12500 OR]4f WA0171300 TIME POLICE DISPATCHED 12:26 PM TIME POLICE ARRIVED:12:30 PM
PART I PAGE IT]OF 4�
REPORT NO. EE68235 CASE# 24-4086 OF COLLISION
04/14/24 12:24
OF CbLLI510N
NARRATIVE
24-4086
At about 1226 hours on 04/14/2024, 1 was dispatched to an unknown injury accident that occurred at
N. Southport Dr. and Southbound 1405 in the City of Renton, King County, Washington.
Upon arrival, I confirmed there were no injuries. Unit 1 was a white 2021 Ford F350 (D52862C/WA).
The driver was Katherine Chromy, and the front passenger was Donald Chromy. Both had seatbelts
on. Unit 2 was a gray 2023 Tesla Model Y (CKH8119/WA). The driver was Kristie Peterson. Both
units relocated to the parking lot of Lowes off 1000 Garden Ave N in Renton.
A witness: Nancy R. Buckley (DOB:05/05/1954) was driving her sedan (BUMPA/WA) and was
stopped at the left-hand turn lane to get onto southbound 1405 from N. Southport Dr. Nancy said she
observed the westbound signal light for Southport turn green, after Unit 1 was already in the
intersection. Nancy said after the accident occurred, the female driver of the Ford pickup (Unit 1) told
her that she might have run the red light.
All units were told they were being recorded. All units were wearing their seatbelts.
Unit 1 said she was going through the intersection, continuing westbound on N. Southport Dr, when
she observed Unit 2 about to hit her on the passenger's side. Unit 1 tried to move out of the way but
still contacted Unit 2. Donald said his head might have hit something but did not need medical
attention and felt fine. I advised him to seek medical attention if anything changed.
Unit 2 said they were turning left onto eastbound N. Southport Dr from the southbound 1405 off ramp.
Unit 2 did not remember what color the light was when she made the turn, then the collision occurred.
Both parties exchanged information.
I observed minor damage to Unit 1 on the passenger's side, next to the rear crew cab door. I
observed moderate damage to the front passenger's side corner of Unit 2. Photos were taken and
uploaded to the case.
I provided all parties with a business card and case number. Both units were able to drive off scene.
This concludes my involvement in this case.
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
Electronically signed by W. Ridgeway #12500 on 04/14/2024 at 1650 hours in Renton, Washington.
PAGE 3 OF 4
REPORT NO. EE68235 CASE# ' 24-4086 DATE AND TIME 04/14/24 12:24
OF COLLISION
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