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HomeMy WebLinkAbout24-5481 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-5481 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI 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# ❑
cawsloN 05 - 1-- 2024 1706 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
439 RAINIER AVE S BLOCK ST e✓
MILEPOST 400
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO �/ D:2064224676 0 11
30
6❑ LAST NAME VO FIRSTNAME HIEP MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 11742 87TH AVE S CITY SEATTLE ST WA 2jp, 98178 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
LOB 05 1— 16 — 1975 2 32
9 ON DUTY❑ STATUS' AIRBAG 2 RESTR 9 EJECT 1 H U SE 9 CLASS 0 NONE
OF INJURIES z❑
3
10 9❑ P1 AT 14 C39342K STATE WA VIN# 5TFAY5F15HX633994
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2017 MAKE TOYT MODEL TUNDR STYLE PK VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13❑ DAMAGE YES YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE Z INSURANCE CO STATE FARM 443.4338-E29.47 3
IN EFFECT &POLICY# 9TOP
VE— CHARGE 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:2533370456
16 a
LAST NAME NELSON FIRST NAME RICHARD MIDDLE Ij
INITIAL
17❑ NEW STREETREs7' 1902 E 67TH ST CITY TACOMA ST' WA ZIP 98404 37
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER #
INJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 9 EJECT 1 USE CLASS ❑
21❑ LICENSE I CMH6926 TATe WA VIN# 1FALP6246RH142336
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 1994 MAKE FORD MODEL THUNDE STYLE $D DAMAGE TOWED NOO✓ BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# 9TOP 5
vLFFcnLLYwcLE YES Nc❑ CITATION# 4AO246130 CHARGE OP MOT VEH W/OUT INSURANCE ,o BOTTOM
25 s � a
=TAMAIVENA
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26 12812 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE80521
COLLISION REPORT III III III III III 111
1591972 CASE# 24-5481
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 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 1 was stopped in lane 3 traveling northbound on the 400 block of Rainier Ave S. Unit 1 vehicle
was struck by Unit 2.
Unit 2 stated he was not paying attention to the road and did not realize that Unit 1 had stopped. Unit
2 then struck Unit 1's rear vehicle. Unit 2 stated he was at fault.
I observed minimum damage on Unit 1 and Unit 2.
1 certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct. This report was electronically signed by Officer Si. Tamaivena #12812,
May 23, 2024, at 1902 Renton, WA.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
S/TIVENI TAMAIVENA 05-23-24 07:39 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 5/26/2024 9:46:24 AM
BADGE OR ID# 12812 OR]# WA0171300 TIME POLICE DISPATCHED 5:08 PM TIME POLICE ARRIVED 5:14 PM
PART Ei PAGE IT]OF
REPORT NO. EE80521 CASE# ' 24-5481 DATE AND TIME 05/23/24 17:06
OF COLLISION
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