HomeMy WebLinkAbout25-965 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE#
2$-96$ z
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4'100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GowsloN 01 - 1-- 2025 0058 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
N 6TH ST BLOCK e✓ 545
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 4 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
No ,/ D:2532456944 30
6� LAST NAME RAY FIRSTNAME RONALD MIDDLE C 1 1 2 31
INITIAL
STREET ❑, 1342 FOREMAN RD CITY DUPONT ST WA 7jp, 98327 2
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES 2❑
3
10❑ Pi aT�S� BCZ9160 sTAr� WAvrN# 1 FMCU9J99HUA62158
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. YRLR. 3 5 33
12❑ vIN#' UIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE ] $ 34
13 A 2017 FORD ESCAPE UT DAMAGE YES NO YES❑ NO✓
REGISTERED OWNER INFO RONALD RAY 1342 FOREMAN RD DUPONT WA 98327 D:2532456944 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 UABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
LEwcLe CHARGE 1 5 36
LECAIIv YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN ✓ PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES,/ No D:4255307739
16 a
LAST NAME UBBEN FIRST NAME THOMAS MIDDLE A
INITIAL
17 STREET ITH PL SW CITY' EVERETT ST' WA ZIP 98204 37
NEW ADOREs�' 506 107
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t— l NO❑
19 DRIVE # STATE SEX M M .O.B. 04 02 _ 1967 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT H SET 2 INJURY6 [NATURE OF CLASS LEFT LEGI PAIN,ERIGHT ARM PAIN,BLEEDING 40
❑21❑ TArE 41
IN1 LICENSE V 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24 0 ] DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I 9TOP 5
vE""LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N J
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
C.ARNOLD 12509 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF63651
COLLISION REPORT III III III III III 111
1591972 CASE# 25-965
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
PM 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'
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.ARNOLD 02-04-25 04:09 PM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 2/8/2025 4:33:03 AM
BADGE OR ID# ! 12509 OR]# WA0171300 TIME POLICE DISPATCHED' 4:00 AM TIME POLICE ARRIVED',4:02 AM
PART I PAGE IT]OF 4�
REPORT NO. EF63651 CASE# 25-965 OF COLLISION
01/30/25 00:58
OF CbLLI510N
NARRATIVE
On 1/30/2025 at 0100 hours, I was dispatched to a vehicle vs. pedestrian collision at around the 545
block of N 6th St.
Pre-Collision
Unit 1's driver stated that he was traveling West on N 6th St preparing to perform a lefthand turn into
the Boeing parking lot.
Pedestrian stated that he was walking across the crosswalk on the South side of N 6th St.
Collision
Driver 1 stated that Unit 1 collided with Pedestrian in or near the crosswalk, and was unsure of where
Unit 1 made contact with Pedestrian.
Pedestrian stated that the front left bumper of Unit 1 collided with him.
I saw that there were fresh marks on the front left bumper and hood area of Unit 1 where dust and dirt
had been wiped off. This signifies that the front left bumper is likely the area in which Unit 1 struck
Pedestrian.
Injuries
Pedestrian complained of right arm and left leg pain. Pedestrian was also bleeding from his nose.
Pedestrian was transported to Valley Medical Center Via ambulance.
Vehicle dispositions
Unit 1 was able to be driven away.
Final disposition
This collision is being investigated by Boeing and this report is merely a courtesy for them to
reference.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer C. Arnold #12509 on 1/30/2025 at 01:35 hours in the City of Renton.
PAGE 3 OF 4
REPORT NO. EF63651 CASE# 25-965 DATE AND TIME 01/30/25 00:58
OF COLLISION
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PAGE 4 OF 4