No preview available
HomeMy WebLinkAbout24-10420 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c COLLISION REP FIT 1591971 SASE 24-10420 2 INTERSTATE CITY STREET El ❑STATE ROUTE OTHER LOCAL AOENC 4900 3 CODING COUNTY RD PRIVATE WAY 2 1 TOTAL#OF OBJECT 1 1 8 28 TRIBAL UNITS 03 STRUCK' ❑ RESERVATION I 1 z 3 M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# cat�usloN' 10 - 05 - 2024 1609 17 ❑.= E IN e 1070 3 S 8 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ NE 3RD ST BLOCK NO. e✓ 1800 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 500 00 FMILES EET ❑ S ❑ W e SUNSET BLVD N 0 1 29 U '� MOTOR ❑ PEDAL- El DAMAGE THRESHOLD MET PHONE 01 VEHICLE CYCLE. YES `/No D:4252602434 0 11 30 5� LAST NAME HOLDEN FIRSTNAME CHRISTOPHER MIDDLE L 1 2 31 INITIAL STREET ❑, 123 E POTTER DR.UNIT 6 CITy ANCHORAGE ST AK I 2jp, 995180000 z NEW ADDRESS 7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCK YES[:]NOV INTERLOCKYEs NO Z/ YES R No,/ 8 LRIENSE# STATE AK SEX M MM oBiY' 12 - 10 - 1981 1 1 2 32 9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 H U EELMET 2 CLASS 7 I INJURY [NATURE OF SORE BACK DRIES z❑ ❑P1 ATNFS# CFF3103 sTAr WA V N# 5YJ3E1EBXKF192448 3 10 9❑ 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 T k GOVT.VEHICLE 7 $ 34 13 4 2019 TESL MODEL SD DAMAGE YES NO � RS YES[:] No ./ REGISTERED OWNER INFO TESLA 11C 22006TH AVE S SEATTLE WA 98134 VEHICLE NO. 1 Y ❑ SHADE IN DAMAGED AREA 35 ❑ LIABILITY INSURANCE❑ INSURANCE CO 2 _3 __ 14 � STATE FARM 5115072D0147C IN EFFECT &POLICY# 9TOP VEHICe CHARGE 1 36 LEGALLY YES❑NO❑ CITATION# 10 BOTTOM 15❑ STANDING 6 MOTOR PEDAL- PROPERTY THR OLD MET PHONE UNIT 02 ❑✓ ❑ PEDESTRIAN ❑ [:]E D:5092180226 VEHICLE CYCLE : OWNFR �/ NO 15� LAST NAME PELAYO GOMEZ FIRST NAME JOSE MIDDLE I D INITIAL 17❑ STREET NEW ADOREss❑' 1333 W DALKE AVE CITY SPOKANE ST WA ZIP 992056724 4❑ 37 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38 INTERLOCK YEs❑No� INTERLOCK YEs❑NO YES ❑NOF,/ 19[—] DRIVER'S STATE I WA SEX M I D.C... 11 30 _ 1987 39 LICENSE# MMDDYY 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES 40 LICENSE I ❑21❑ PLA E# D677186 TArE 41 WA vIN1 1N6AA07834N526606 1 42 22❑ PLATE# STATE PLATE# STATE 23❑ UIN#. 43 TRLR RLR 'IN#. TOWED eY Gov HI 44 VEH YEAR 200Q MAKE jyl$$ MODEL TITAN SV STYLE TR DAMAGE TOWED✓ NOO BLIN BANKERS YES No�/ 24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2 SHADE IN DAMAGED AREA 2 3 4 LIABILITY INSURANCE I Ri PORGY#ECO STATE FARM 3988609A20476IN 1UQ, 5VEHICLE ❑ ,.II CITATION# CHARGELEGALLY YES N25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY 26 E.CHANG 10065 WA0171300 PART A PAGE 01 OF C7 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. EF23219 COLLISION REPORT III III III III III 111 1591972 CASE# 24-10420 ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL) HOLDEN KEYL/TH (LAST FIRST, ADDRESS&PHONE# 123 E POTTER DR.UNIT 6 ANCHORAGE AK 99518 SEXi F MMDDvyry 09 - 23 - 1993 PASSENGER I]WITNESS� UNIT# SEA AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES L�l 1 POS. 9 6 11 1 USE 2 CLASS 0 NAME (LAST,FIRST,MIDDLE INITIAL) HOLDEN LUZIANA ADDRESS&PHONE# D O B 123 E POTTER DR.UNIT 6 ANCHORAGE AK 99518 SEX F MMDDvvvv O6 _ 25 _ 2024 SEAT HELMET INJURY NATURE of INJURIES PASSENGER �WITNESS� UNIT# 1 POS 7 AIRBAG'6 RESTR. 4 EJECT 1 USE 2 CLASS 7 SORE LEFT LEG AND LEFT NAME (LAST FIR57 MIDDLE INITIAL) AppRESS&PHONE# SEX D.O.B. MMDDYYYY. - PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES ❑ ❑ POS. USE CLASS ----� NARRATIVE' On 10-05-2024 at about 1609 hours I responded to a collision located near the intersection of NE 3rd St and Sunset Blvd N, in the City of Renton, King County, Washington. Upon arrival I found out that it was a three car collision in the 1800 block of NE 3rd St. Driver of unit 3 and 1 did not know what fully happened. Driver of unit 3 said he was driving in lane 2 westbound and unit 1 passed him in lane 3. Unit 1 and 2 collided and then unit 1 swerved into him and struck the front driver side of his car. Driver of unit 2 said he was driving eastbound on NE 3rd St up the hill in lane 3 and unit 1 came into his lane and struck him. I was informed that the driver of unit 1 did not know how the collision occurred. Unit 1 was a Tesla which may have captured the collision. I found a skid mark from east to west going into eastbound lane 3 to the impact point. The point of impact was located in the middle of the eastbound lane 3. A gouge mark went from point of impact eastbound about 40 yards to the front driver axel of unit 2. Unit 2 had lost his front driver tire. Second skid mark went from impact point westbound back into lane 3. Driver of unit 1 said he had a sore back. Adult passenger said she had sore left leg and left shoulder. This report is only a summary of what occurred and was captured on my body camera. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. E.CHANG 10-06-24 06:46 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE P.KORDEL 9676 1 1011012024 11:34:49 AM BADGE OR ID# 10065 OR]# ': WA0171300 TIME POLICE DISPATCHED 4:09 Pry TIME POLICE ARRIVED'4:15 PM PART I PAGE IT]OF 4] SUPPLEMENTAL REPORT NO. EF2321 9 r`I POLICE TRAFFIC 1 1 8 27 COLLISION REPORT CASE# 24-10420 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G UNIT'# USL70r !CC# VEHICLE TYPE CARGO BODY TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER ADDRESS ` CITY ST' ZIP' 4 ❑ NAME # PLACARD "❑ GINAME IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGETHRESHOLD MET PHONE j� PEDESTRIAN ✓ D:4259997325 5 UNIT# 3 VEHICLE Iv � CYCLE OWNER � YES NO rFO 1 29 LAST NAME SIMMONS FIRST NAME MEKHI MIDDLE A INITIAL STREET 30 NEW AnDRFrtP 4215 NE 5TH ST CITY RENTON ST WA ZIP 980594709 6 ❑ 1 1 2 31 CDL IGNITIttN REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED INTERLOCK YEs No Z/ zERLOCK Y. �NO� YEs N �/ DRIVER'S D.O.B 2 LICENSE STATE WA SEX M MMDDYYv 06 - 17 - 2004 7 ON DUTYl STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 NATURE OF INJURIES USE CLASS 8 ❑ 1 32 LICENSE 639YJR TAr WA VIN# 1HGCS22809AO02703 PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.# 11 0 0 VEH.YEAR2009 MAKE HOND MODELACCORD STYLE SD I VEHICLE TOWS E T SABLIN TOWED BY anvi vFH1I' P FROM TO DAMAGE YES NO �/ YES NO ✓ REGISTERED OWNER INFODARRELL SIMMONS 4215 NE 5TH ST RENTON WA 98059 3 ] 33 12 SHADE IN DAMAGED AREA 7 j 4 FROM TO INSURANCE CO R TOIx LIABILITY INSURANCE STATE FARM 5562316C2347A 1 m 34 IN EFFECT ✓ &POLICY# 13 ❑ VEHICLE ❑ ❑ CHARGE L 0 80TTOM LEGG ALLY YES NO CITATION# STANDNGf} 7 G 14 ❑ UNIT�T VEHICLE O CYDDAL OWNERRTY YES AGE DAM NOHRESHOLD MET PHONE ❑ 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE ❑ 36 STREET 16 NFWAiJnRFS.� CITY ST ZIP CDL IGNITION RFJUIRFD IGNITION PRESENT MEDICAL TANSPORTED INTERLOCK YES No INTERLOCK YEs NO YES NO[ ❑ 17 4 37 LICENSE# SEX MODDYBYY - 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE CLASS 19 ❑ LICENSE TAT VIN# 39 PLATE# 20 ❑ TRAILER STATE TRAILER STATE ❑ 40 PLATE#< PLATE# 21 ❑ ❑ 41 TRLR TRLR VIN# YIN#_ 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWED DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NODI El 23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43 z 3 4 LIABILITY INSURANCE INSURANCE CO ' VEHICLE EFFECT &POLICY# i 970P - 4 44 24 LEHIcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM C=ESTANDING 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. E,CHANG 10-06-24 06:46 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED BADGE O#I' AP 1026 OII 10065 WA0171300 APPROVED BY /1 PAGE F OF 4 3000-345-013(R 11118) REPORT NO. EF23219 CASE# ' 24-10420 DATE AND TIME 10/055/24 16:09 OF COLLISION S ) Y 't ~4 l Y { 1 z d u a, r 00 PAGE 4 OF 4