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HomeMy WebLinkAbout24-6910 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET FIRE ❑
CASE 24-sslo 2
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 03 STRUCK
RESERVATION
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION' 07 - 01 - 2024 2007 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
MAIN AVE S MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e S 3RD ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4254522038 0 11
30
6 LAST NAME PONCE GARCIA FIRST NAME CRUZ MIDDLE F 1 2 31
INITIAL
STREET ❑ 1713 CAMAS AVE NE CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ DRIVERS
E#
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 I INJURY [NATURE OF INJURIES
CLASS ,6 HEAD CUT OPEN NEEDED STICHES z❑
3
10 1❑ PI ATE 14 CKJ1930 STATE WA VIN#' 1NXBR12E8XZ215816
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
rRLR. TRLA2 1 5 33
12 2 5 VIN#j VIN#'
FROM TO
❑ VEH.YEAR1999 TOYT COROL SD MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR YMEYERS 7 3 GOVT.VEHICLE 34
13 4 DAMAGE YES NO � YES❑ No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO NATIONAL GENERAL 2011516721 4
IN EFFECT &POLICY# TOPVE"'CLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2532171266
16 a
LAST NAME HOBBS FIRST NAME SUSAN MIDDLE D
INITIAL
17❑ STREET NEW ADDREss❑' 12248 46TH AVE S CITY TUKWILA ST' WA ZIP 98178 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 D IVERI # STATE WA SEX F M D.C.B. 11 29 _ 1961 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ 41
21❑ LICENSE I PLATE# CFW4374 TATE WA vIN1 7FARW1H53KE009702 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 2019 MAKE HOND MODEL CRV STYLE $D —FEHICLE
TOWED✓ NOO BLIN GENE MEYERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO GEICO 6040-42-63-03IN 9TOP 5
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N 6
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# FENCY
26
KEV/N PETERSON 12808 A0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE92195
COLLISION REPORT III III III III III 111
1591972 CASE# 24-6910
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'
I was dispatched to a collision on 07/01/24 at 2008 hours at Main Ave S and S 3rd St intersection in
city Renton, King County WA.
Unit 1 CKJ1930 Driver: Ponce-Garcia F. Cruz (DOB 05/30/1978)
Unit 2 CFW4374 Driver: Susan D. Hobbs (11/29/1961)
Unit 2 D05111 E Driver: Ashley E. Weber (12/23/2003)
Unit 3 was at the intersection of S 3rd St and Main Ave S facing east. When the light turned green,
she proceeded into the intersection when she was hit on her driver side, she stated that Unit 1 ran a
red light. Unit 2 was sitting at the intersection of S 3rd St and Main Ave S facing east. When the light
turned green, she went and then told me she was not sure what had happened. Unit 1 was driving
South on Main Ave S approaching the intersection of Main Ave S and S 3rd St when the accident
happen, he did not explain any further details.
Unit 1 was transported to Valley Medical Center to receive stitches. All 3 units were towed off scene.
All drivers were given an information exchange. Unit 2 and Unit 3 stated they were fine and no
injuries.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 07-02-24 12:54 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 888 1 71212024 4:46:27 PM
BADGE OR ID# ! 1Y808 ORI#' WA0171300 TIME POLICE DISPATCHED 8:08 PM TIME POLICE ARRIVED',8:12 PM
PART I PAGE IT]OF 4�
SUPPLEMENTAL REPORT NO. EE921955
r`) POLICE TRAFFIC 1 1 8 27
COLLISION REPORT CASE# 24-6910
1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G
UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY
;TYPE
2 ❑ 1 28
CARRIER
NAME
3 CARRIER
ADDRESS `
CITY ST ZIP—1 I '
4 ❑ NAME # PLACARD: :❑
GI PLACARD IF NO NUMBER
SOURCE AXLES +
4a ❑ ADDITIONAL UNITS
MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE
5 ❑ UNIT# 3 VEHICLE t_"J CYCLE u PEDESTRIAN � OWNER � YEs� NO
D:7132547614
0 1 Zg
LAST NAME : WEBER FIRST NAME ASHLEY MIDDLE'.. E
INITIAL
STREET 30
NEW AnDRFSP. 1503 39TH ST CITY ANACORTES ST WA ZIP 98221
6 ❑ 1 1 2 31
CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TAN5PORTED
INTERLOCK YEs NO NTERLOCK YES❑N0� YEs N
DRIVER'S
LICENSE STATE I WA SEX F MMDDYYv 12 - 23 - 2003
7
ON DUTY� STATUS AIRBAG' 2 RESTR. Q EJECT 1 HELMET 2 INJURY 1 1 NATURE OF INJURIES
USE CLASS
8 ❑ 1 32
LICENSE D05111E TAr WA VIN# 1FMCU95H05KE01379
PLATE#
9 TRAILER TRAILER
PLATE If STATE PLATE If STATE
10 ❑ TRLR TRLR
VIN.#. VIN.#.
11 2 5 VEH.YEAR2005 MAKE FORD MODELESCAPE STYLE SD I VEHICLE TOWS ET SABLI T�'W,6y'ERS GnVT VFHIGP FROM TO
DAMAGE YES NO YES NO
REGISTERED OWNER INFO OWNED BY DRIVER ] 3 33
12 SHADE IN DAMAGED AREA
4� FROM TO
LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 00673853.0 gl"OI'
IN EFFECT &POLICY#
VEHICLE 70 BDrroM 34
13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE pp��
STANDING } MOTOR
g 7 6
14 ❑ UNIT Tr Vd 1 RE O CYDDAL OWNERRTY YES AGE NOHRESHOLD MET PHONE ❑ 35
PEDESTRIAN
15 LAST NAME FIRST NAME N!I IAL
MIDDLE ❑ 36
STRE
16 ET NEW ETnnR"� CITY ST ZIP
CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED
NTERLOCK YES No INTERLOCK YEs NO YES NO ❑
17 4 37
LICENSE# STATE SEX MMDDDYBYY -� II
18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of 1NJURIEs 38
USE CLASS
19 ❑ LICENSE TAr VIN# 39
PLATE#
20 ❑ TRAILER' STATE TRAILER STATE ❑ 40
PLATE#< PLATE If
21 ❑ ❑ 41
TRLR TRLR
VIN# YIN#i
42
22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO YES NO
23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43
3 4 71
LIABILITY INSURANCE INSURANCE CO '
VINE
EFFECT &POLICY# i 970P - 4 E:l
44
24 LEwcLE YES❑ NO❑ CITATION# CHARGE iq 60TiOM
C=DLv
STANDING 8 7 6
1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
KEVIN PETERSON 07-02-24 12:54 AM
25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED
APPROVED BY DATE
26F7 OR ID# 12808 O#I WA0171300 SUMMERS 7/2/2024 PAGE F3 OF
3000-345-013(R 11118)
REPORT NO. EE92195 CASE# 24-6910 DATE AND TIME 07/01/24 20:07
OF COLLISION
ON 011,
411
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PAGE 4 OF 4