HomeMy WebLinkAbout24-9525 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-9525 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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.. 09 - 11 - 2024 0637 17 ❑.❑ S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
108TH AVE SE BLOCK NO. e✓ 18400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 10 00 FEET MILES e S B W e S 4TH LN
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2067735302 0 11
30
6� LAST NAME VARENYTSYA FIRSTNAME ALEX MIDDLE V 1 1 2 31
INITIAL
STREET ❑, 26818 115TH PL SE CITY KENT ST WA ZIP 98030 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� C71801X sTArI WAurN# 1FTBR1C88LK611247
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# ROM ro
TRLR. YRLR. 5 1 33
12 4 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 5 1 34
13 2020 FORD TRANSI VN DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO URBAN RESTORATION REMODEL LLC 14250 NE 21STST BELLEVUE WA 98007 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO TRAVELERS 8T789653-BA 3 4
IN EFFECT &POLICY# 9TOP
VErIICLE CHARGE 5 36
LEGALLY YES No CITATION# 4A0672830 FOLLOW VEHICLE TOO CLOSELY o aorrom
15❑ STANDING 8 6
MOTOR PEDAL-: PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:6824079577
16 a
LAST NAME KILANGI FIRST NAME LILIAN MIDDLE M
INITIAL
17❑ STREET ❑', 10622 SE 252ND ST G-201 CITY KENT ST WA ZIP 98030 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YES❑NO� INTERLOCK yEs I I NOF YEs t l NOF,/
19 LDIIVERS STATE WA SEX F M .C.B. 01 04 1990 39
—NATURE OF INJURIES
H USE
ET LASS 7
Y COMPLAINT OF NECK PAIN 40
20 ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1
21❑ LICENSE I CJY5730 TAre WA VIN# 4JGDF7CE4DA242902
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
TOWED BY GOV HI 44
VEH YEAR 2013 MAKE MERZ MODEL GL320 STYLE UT DAMAGE TO WED NOO✓ BLIN YES
NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO ALLSTATE 820806271IN 1 9TOP
VE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
R.ONISHI 5738 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF16912
COLLISION REPORT III III III III III 111
1591972 CASE# 24-9525
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SHEMED/UK SAMUEL
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
27903 126TH AVE SE KENT WA 98030 4255993797 SEX M MMDDYyry 09 - 18 - 2006
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 POS. 3 2 4 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY
POS. NATURE OF INJURIES
USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 and unit 2 both northbound in the right hand lane of 108th Ave SE, with unit 1 directly behind
unit 2. Unit 2 stopped; unit 1 driver Varenytsya told me that he locked up his brakes, but still collided
with the rear bumper of unit 2. Unit 2 driver Kilangi told me that she stopped for traffic, then unit 1 ran
into her. Kilangi complained of neck pain; evaluated as stable at scene by Fire, transported by
ambulance to VMC for further evaluation. Varenytsya cited for following too closely for conditions (wet
pavement).
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
R.ONISHI 09-11-24 08:22 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 9/21/2024 5:44:06 AM
BADGE OR ID# 5738 OR]# WA0171300 TIME POLICE DISPATCHED 6:38 AM TIME POLICE ARRIVED'6:48 AM
PART Ei PAGE 2�OF❑
REPORT NO.! EF16912 CASE# 24-9525 DATE AND TIME 09/11/24 06:37
OF COLLISION
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