HomeMy WebLinkAbout24-5877 iiTFiNII IIIII III IIIII II IIII IIIII I . 27c REPORT NO EE83563oc� RA
COLLISION REPORT 1591971
CASE�# 24-5877 2
INTERSTATE CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL A`GENC'Y 4250 3
COUNTY RD NVOLVED CODING
PRIVATE WAY
2❑ TOTAL 1
TRIBAL UNITS#OF 02 SO BJECT TRUCK 2 4 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
GouISION' 06 - 03 - 2024 1612 17 =.= S 8 W E IN OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION �✓ NON INTERSECTION ❑
EDMONDS AV NE BLOCK ST e 1600 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 �. FEET H S 8 W e NE 16TH ST
0 8 29
PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLEMOTtlR ❑ CYCLE' ❑ YES NO F/ D:2064195182 1 5 30
5 LAST NAME NGO FIRST NAME NGOC MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 2009 HARRINGTON CiR NE CITY RENTON ST WA ZIP 980562320 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYES NO✓ INTERLOCKYES N ✓ YES D NO Z
8❑ LICIENS# STATE WA SEX F MMor YY' 03 — 29 — 1972 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET INJURY
CLASS 1 NAruRE of INJURIES 2
LICENSE, CKF5805 STATE WA VIN# 5FNYF6H26NB048900 3
10 PI ATP rt
11[-j— TRAILER STATE TRAILER ,STATE
11 2 5 PLATE# PLATE# ROM TO
TRLR TRLR 9 9 33
12 2 5 VIN# VIN
( FROM TO
VER YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE o o 34
13 4 2022 HOND PILOT SV DAMAGE YES�NO ✓� YES❑ NO✓
REGISTERED OWNER INFO NGOCNGO 2009 HARRINGTON CIRNE RENTON WA 98056 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
LIABILITY INSURANCE❑ INSURANCE CO 3 4
14 ✓ STATE FARM 5529861A1447
IN EFFECT &POLICY# 4TOP
CHARGE 5 36
Lemur yes�NO❑ CITATION# 7 o BOTTOM
15❑ STM ING I
B 7 e
UN# MOTOR PEDAL ❑ PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
1 VEHICLE CYCLE. nWNFR YES NO ✓
16�
LAST NAME UNK FIRST NAME MIDDLE'
INITIAL
17❑ STREET ❑ CITY RENTON ST ZIP ❑ 37
NEW ADDRESS
1$❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYrs No✓ jNTERLOCKYES NO✓ YEs Nol✓
19 LICEENSE# STATE SEX U MMDDYY 39
HELMET INJURY' NATURE OF INJURIES 40
20❑ ON DUTY❑ STATUS' AIRBAG g RESTR g EJECT 9 USE 9 CLASSLICENSE I
0 ❑
21 PLATE# UNK rarE WA vIN# UNK 41
22❑ PLTL ATE# STATE TILER PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR MAKE HOND MODEL (�`{?V STYLE SO VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO UNK RENTON VEHICLE NO,2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSURANCE CO
IN EFFECT 8.POLICY# t 9TOP
VEHICLE ❑ ,.I—I CITATION# CHARGE tO BOTTOM
ALLr YES N`LJ
25 a a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF 1
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EE83563
COLLISION REPORT III III III III III 111
1591972 CASE# 24-5877
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) THAI ELIZABETH N
(LAST,FIRST
ADDRESS&PHONE# DOB
2009 HARRWGTON CIR NE RENTON WA 980562320 2064195182 SEX' F MMDDYYYY 02 - 21 1- 2010
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
Z � 1 POS. 9 1 4 1 USE CLASS 1 ---�
'NAME
LAsr F RST,MIDDLE INITIAL) THAI JAMES Q
ADDRESS&PHONE#
2009 HARRINGTON CIR NE RENTON WA 980562320 2064195182 SEX' M MMDDYVYv 11 _ 19 _ 2007
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER �WITNESS UNIT# 1 Pas 3 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1
NAME MIDDLE INITIAL) KALM JUSTIN
',(LAST,FIRST,
AQQREss&PHONE# 4259564952 M _
SEX D.O.B. F LURIES ----�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF NJ
URIEs
❑ Q POS. USE CLASS
NARRATIVE'
Unit 2 in front of Unit 1 on NE 16th St, at the intersection both facing westbound, turning onto
Edmonds Av NE. Unit 2 did not yield to oncoming traffic, entered Edmonds Av NE prematurely, and
then backed up improperly into Unit 1, causing non disabling non reportable rear end damage to Unit
2 and non disabling non reporatble front end damage to Unit 1. No injuries. Unit 2 does not remain on
scene and drives away without exchanging information with Unit 1. Unit 2 reported as a bronze/brown
Honda CRV with tinted windows. Unknown license plate or description of 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 06-03-24 05:30 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY E
DAT
P.SUMMERS 8887 6/4/2024 8:30:57 PM
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 4:27 PM TIME POLICE ARRIVED 4:Y9 PM
PART IS 3aaa-345-,aa(R11Y1s) PAGE 27OF 37
REPORT NO. EE83563 CASE# 24-5877 DATE AND TIME 06/03/24 16:12
OF COLLISION
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