HomeMy WebLinkAbout24-6424 iiTFiNII IIIII III IIIII II IIII IIIII I . 27c REPORT NO EE92198oc� RA
COLLISION REPORT 1591971
CASE# 24-6424 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOC`CO A`GENC'Y 4100 3
COUNTY RD PRIVATE WAY NT&RUN CODING
LVED
2❑ TRIBAL UN TS#OF 02 SOT RUCK 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
cDUISION' 06 - 18 - 2024 2054 17 =.= S 8 W E OF IN M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
SUNSET BLVD NE BLOCK ST e 3200 .=
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 200 00 FEET e✓ S 8 W e MONROE AV NE
0 3 29
MOTOR PEDAL- DAMAG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES V,No D:4259431759 0 3 30
6 LAST NAME PODDUBN/Y FIRST NAME KONSTANTIN MIDDLE I S 1 2 31
INITIAL
STREET ❑ 1931 KIRKLAND PL NE CITY( RENTON ST I WA I Zip' 9805632 33 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYES NOW] INTERLOCKYEs NO�/ YES NbF,/
8� LICIENS# STATE WA SEX M MMDr YY' 01 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET INjURy
CLASS 1 NAruRE of INJURIES 2
10 LI ENSE'ti� A7312594 STATE WA VIN# 5TFNC5DB5RX058213 3
11[-j- TRAILER STATE TRAILER ,STATE ROM TO
11 3 5 PLATE# PLATE#
TRLR TRLR 3 1 33
12 3 5 vIN# vIN#
FROM TO
VER YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE 5 3 34
13 4 2024 TOYT TUNDR TR DAMAGE YES NO YES NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
LIABILITY INSURANCE❑ INSURANCE CO 2 3 4
14 EAGLE WEST 25 PAC-2-2084335
IN EFFECT &POLICY# 4TOP
VEHICLE CHARGE t 5 36
Lemur YES❑NO❑ CITATION# 7 o BOTTOM
15❑ nNowc e
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
VEHICLE
UNIT 02 CYCLE (7WNPR Q ❑ PEDESTRIAN ❑ D:3607439291
YES NO
16�
LAST NAME WILLIAMS FIRST NAME JASMINE MIDDLEI C
❑
17 F1 STREET' 2026 ANACORTES AV NE CITY RENTON ST, W INITIAL q ZIP 98059 37
NEW ADDRESS❑
1g❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED. 38
INTERLOCKYEs ND INTERLOCK YES No YEs NC
19 DRIVER' #
INJURY' NATURE OF INJURIES 40
20❑ ON DUTY� STATUS' AIRBAG'2 RESTR 4 EJECT '1 USE 'CLASS ' 7 LEFT CHEST AND LEFT SHOULDER PAIN ❑
21 LICEN� BYL9415 rare WA vIN# WDBSK75F86F113773 41
PLATE 22❑ STATE TILER PATE# STATE ❑ 42
PLATE#
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2006 MAKE MERZ MODEL SL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO JERREtL LE.1081 SEWARD PARK AVE S APT 15 SEATTLE WA W1118 VEHICLE NO,2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO NONE
IN EFFECT &POLICY# t 9TOP
vewaE ❑ CITATION11 CHARGE tO BOTTOM
LEGnLLY YES N 6
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EE92198
COLLISION REPORT III III III III III 111
1591972 CASE# 24-6424
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — [----------�
MMDDYYYY
PASSENGER F-1 WITNESS El UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES--�
POS. USE CLASS
'NAME
(LAST FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. — L----------�
MMDDYYYY
PASSENGER DWITNESSD UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. — L----------�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS �____ ----j
NARRATIVE
Unit 1 traveling westbound along 3200 block Sunset Blvd NE making right turn into the north parking
lot of the Goodwill at 3210 Sunset Blvd NE. Unit 2 pulling out of the same parking lot of the Goodwill
lot, making right turn onto Sunset Blvd NE. Unit 1 driver stated that due to his lifted truck, he did not
see Unit 2 when he made his right turn coupled with the gradient of the roadway at said parking lot
entrance. Unit 1 collides with Unit 2 causing reportable non disabling front driver side bumper
damage to Unit 1 and reportable non disabling damage to the driver side of Unit 2. Unit 1 driver did
not report any injuries. Unit 2 driver reported chest and shoulder pain on her left side. Renton Fire
was summoned and assessed Unit 2 driver on scene.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 06-18-24 09:58 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 71212024 4:46:49 PM
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 8:58 PM TIME POLICE ARRIVED 9:05 PM
PAIR" IS 3aaa-345-,aa(R11Y1s) PAGE 27OF 37
REPORT NO. EE92198 CASE# 24-6424 DATE AND TIME 06/18/24 20:54
OF COLLISION
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