HomeMy WebLinkAbout24-11963 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-11963 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING'
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 RESERVATION STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
CowsloN 11 - 18 - 2024 1805 17 ❑.❑ N E IN S H W H OF 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 12 ST BLOCK NO. e✓ 3100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FMILES EET e S ❑ W e SUNSET BLVD NE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:4254427690 0 11
30
6 LAST NAME GERLACH FIRSTNAME JOANN MIDDLE H 1 1 2 31
INITIAL
STREET ❑, 201 UNION AVE SE UNIT 229 CITY RENTON ST WA Zjp, 980595181 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10� P1 ATE DP54227 sTATI WAVIN#' ZACCJABTXFP682641
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 1 3 33
12 2 5 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 7 3 34
13 4 2015 JEEP RENEG DAMAGE YES NO YES[:] No
✓
REGISTEREDOWNERINFO EARL GERLACH2O1 UNION AVE SE UNIT 229 RENTONWA98059 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE U INSURANCE CO GEICO 6146631715
IN EFFECT &POLICY#
VENICLE CHARGE 36
LEGALLvYes❑NO❑ CITATION# C��,
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2068547680
16 a
LAST NAME VELASCO FIRST NAME ELOISA MIDDLE N
INITIAL
17❑ STREET ❑', 16224 SE RENTON ISSAQUAH RD CITY' RENTON ST WA ZIP 980596214 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICALt-T�RAIISFORTED 38
INTERLOCK YES�NO INTERLOCK YEs I I NOF YES t l ND�
19 DRIVER'S STATE WA ]SEX IF I D.O.B. O6 _ 05 _ 1975 39
LICENSE# MMDDYY
HELMET I INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE I CBV9414 TATE WA VIN# 1FAHP3M23CL338884
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ TRLR R 43
LR
VIN#. N I #.
VEH YEAR 2012 MAKE FORD MODEL FOCUS STYLE SO VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ARTURO CASTELAN ORTIZ 16224 SE RENTON ISSAQUAH RD RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 523217000147IN 1UR,
"'LE ❑ ,.I— CITATION# CHARGE
LEGALLY YES N`LJ
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EF38798
COLLISION REPORT III III III III III 111
1591972 CASE# 24-11963
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) VELASCO CAROLINA
(I.P.ST FIRST,
ADDRESS&PHONE# D O.B. '
16224 SE RENTON ISSAQUAH RD RENTON WA 980596214 2068547680 SEXi F MMDDYyry 07 - 04 - 1995
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGERWITNESS❑ UNIT# 2 POS 3 AIRBAG 2 RESTR. q EJECT 1 USE CLASS 7 BACK PAIN
NAME
'(LASTr FIRS' MIDDLE INITIAL)
ADDRESS&PHONE# Id DOB
E MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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'
Unit 2 traveling east on NE 12th St approaching Sunset Blvd NE/SR900. Unit 1 entering traffic from a
private driveway at Rite Aid at 3116 Sunset Blvd NE, on the north side of NE 12th St. Unit 1 fails to
yield right of way left turn when entering traffic causing reportable non disabling front passenger
damage to Unit 1 and reportable non disabling damage to the driver side of Unit 2. Only injury
reported was front passenger of Unit 2 who complained of back pain and was treated on scene by
Renton Fire and later transported to hospital for further treatement. Unit 1 driver appeared to be the
proximate cause of collision. No evidence of impairment by either driver.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 11-18-24 07:14 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 1112312024 9:52:51 AM
BADGE OR ID# 12651 OR]# WA0171300 TIME POLICE DISPATCHED 8:08 PM TIME POLICE ARRIVED 6:12 PM
PART B PAGE IT]OF
REPORT NO. EF38798 CASE#', 24-11963 DATE AND TIME 11/18/2418:05
OF COLLISION
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