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HomeMy WebLinkAbout24-5484 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-5484 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 7 2$
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 - 23 - 2024 1803 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
LIND AVE SW BLOCK NO. e✓ 1100 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SWGRADYWAY
0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
NO ,/ D:2063342613 0 11
30
6❑ LAST NAME SUSEYI FIRSTNAME CLAUDIA MIDDLE M 1 2 31
INITIAL
STREET ❑ 19851 140TH AVE SE CITY RENTON ST WA Zlp 98058 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LDRIVER # STATE WA SEX'F MID
.O B 07 1- 10 - 1986 2 32
9 ON DUTY❑ STATUS AIRBAG 9 RESTR 9 EJECT 9 H USE SS
9 CLASS 0 NATURE OF INJURIES z❑
3
LICENSE 3022LW sTArI WAurN# JNRBS08W76X401959
10❑ PI ATE 14
0 TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
TRLR. TRLR 7 3 33
12 0 VIN#' VIN#
2006 lNFI FX45 UT ❑ RO�34
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13❑ DAMAGE YES NO �I YES NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO GEICO 4517-44.54.19 3
IN EFFECT &POLICY# 9TOP
VE— CHARGE 36
LEGALLv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7
UNIT U2 VEHIMOTCR PEDAL- PROPECL D
E CYCLE ❑ PEDESTRIAN ❑ OWN RRTY ❑ YES NO OLD MET PHONE
16 a
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY RENTON ST ZIP
17❑ NEW ADDRESS ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑NOR INTERLOCK YEs It I NOF YES
t l NO❑
19 LLIICENS # STATE SEX U MMDDYY -❑_ 39
WELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
❑ ❑ 41
21 LICENSE TArE VIN1t U
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ TRLR 43
L
VIN#. N'RRI #.
TOWED BY GOV HI 44
VEH YEAR MAKE /1J/$$ MODEL SQL)-/Nj�Q STYLE $D DAMAGE TOWED NOO✓ BLIN YES NO
24❑ REGISTERED OWNER INFO UNKNOWN RENTON VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO IGQVE"LE
❑ ,J� CITATION# CHARGE
LEGALLY YES N`L J
25
=TAMAIVENA
AME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 12812 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE80522
COLLISION REPORT III III III III III 111
1591972 CASE# 1 24-5484
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 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 1 was in lane 1 traveling eastbound on SW Grady Way approaching Lind Ave SW. Unit 2 struck
Unit 1 in the rear of Unit 1 vehicle. Unit 2 then left eastbound on SW Grady Way.
I observed minimum damage on Unit 1.
Unit 1 was not able to provide a valid license plate for Unit 2. Unit 1 is able to identify the driver of
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 2045 Renton, WA.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
SITIVENI TAMAIVENA 05-24-24 01:26 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
DESIRES SCOTT 10272 5/26/2024 9:46:12 AM
BADGE OR ID# 1Y892 OR]# WA0171300 TIME POLICE DISPATCHED 6:06 PM TIME POLICE ARRIVED]6:09 PM
PART Ei PAGE IT]OF
REPORT NO. EE80522 CASE# ' 24-5484 DATE AND TIME 05/23/24 18:03
OF COLLISION
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