HomeMy WebLinkAbout24-10278 ("7—
STATETcN
27CERAFFi O EF22198
COLLISION REPCF 1591971
CASE 24-10278 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 1 STATE ROUTE OTHER STOLEN
vEwCLE ❑ LOCALAGENC, 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TRIBAL UN TS#OF 02 STRUCK' 1 8 2$
RESERVATION: 2
3 M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
coislo� 10 - 01 - 2024 1615 17 �.� S e W e OF 8 IN ?070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NONINTERSECTION ❑✓
TALBOT RD S BLOCK NO.
8 1200 .�
4a❑ MILEPOST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 350 MILES N 1. 00 FEET e✓ S e OF SGRADYWAY
2 0 29
MOTOR PEDAL- DAM ETT PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ Yes NaO ,/ D:2063532004 0 1 30
6 LAST NAME SEBASTIAN FIRST NAME JOHN MIDDLE F 1 1 2 31
{N{TIAL
STREET [:] 1100 SW 3RD PL CITY RENTON WA
NEW ADDRESS ST {P 98057 2
7❑ CDL fGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1NTERLOCKYEs NO INTERLOCKYEs No YEs NO
8❑ LDRIV STATE WA SEX'D M LO S 08 - 17 - 1985 1 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT ? H USE T CLA RSY ? NATURE OF INJURIES 2=
�ci ATF# 528ZLY srnr� WA uIN# 2T1 CE22P62C014319 3
10 9❑
11 3 5 PLARA TE# STATE PLATE# STATE ROM To
TRLR. TRLR: 5 1 33
12 3 5 VIN# VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13 2❑ 2002 TOYT CAMRY DAMAGE YES NO ✓ YE,[_] NO 5 1 34
REGISTERED OWNER INFO UGHN SEBASTIAN 11.SW 3RD PL RENTON WA 98057 D:2063532004 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAME. 4
IN EFFECT &POLICY# 9TOF
vtwc�t CHARGE ❑ 36
Fcnuv YES❑NO❑ CITATION# t t0 BOTTOM $
15❑ STAND NG 8 7 6
1 MOTOR PEDAL- .PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE CYCLE ❑ ❑ OWNER YES)/ NO D:2066653668
16F1
LAST NAME ROSALES DE RIVAS FIRST NAME YES/CA MIDDLE V
INITIAL
17 STREET 14428 25TH AVE S CITY SEATAC ST' WA ZIP 981684206 37
NEW ADDRESS
18� IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38
CDL INTERLOCK YES NOF INTERLOCK YES Nb YES NO
19 DRIVERS: STATE WA SEX F 1 D.O.B. O6 22 199? 39
LICENSE# MMDCWY -
20❑ ON DUTY El STATUS AIRBAG 2 RESTR 4 EJECT 1 1HELM USEET CLASS 1 NATURE OF INJURIES ❑ 40
21❑ LICENSE,CA60584 rArE WA VIN# 2HGFB2F92FH538159
❑ 41
PLATE#
ILER TRAILER ❑22❑ PLATE# STATE PLATE# STATE 42
23 4
TRLR RLft
VIN#. IN# 3
VEH.YEAR 201$ MAKE HOND MODEL (',IV/(, STYLE VEHICLE TOWED TO BLIN
TOWED BY GO HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO GUILLERMO RIVAS RAIMUNDO 500 MILL AVE S RENTON WA 98057 VEHICLE NO.2
SHADE IN DAMAGED AREA
INSURANCE CO 3 4
LIABILITY INSURANCE PROGRESSIVE 966490297
IN EFFECT &POLICY# i 4TOP 5
veeia..e ❑ ITATION# CHARGE tOBOTTOM
FFrAFFY YES INC]`'L J
25� a
7IFFLIIERS NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
VERTON 2517 WA0171300
PARTA3000-345-159 FIR11nst PAGE 01 OF
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF22198
COLLISION REPORT III III III III III 111
1591972 CASE# 24-10278
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE
SEXi D.O.B. -
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. ' USE CLASS 1 ----�
:NAME
(LAST FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. -
MMDDYYYY
PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURECFINJURIES
POS. USE CLASS ----�
:NAME
(LOST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX MMDDYY D.O.B.
YY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. I USE CLASS
NARRATIVE
GRY/2 LN 1 SLV/1 LN 2 LN CNG INTO SIDE
RTF
Within the city limits of Renton/King/WA I responded to a 2 vehicle crash that occurred near the 1200
block of Talbot Rd S.
I contacted the driver of unit 2 who explained that she was northbound in lane 1 Talbot Rd S. She
told me that unit 1 changed lanes into the side of her vehicle. The damage was minor. She did not
complain of injury and damages did not require a tow truck.
I contacted the driver of unit 1. He told me that traffic in lane 1 had slowed because a vehicle was
turning towards the parking lot of Home Depot. He said he observed a gap in traffic and believed he
had a safe space to change lanes and did not see unit 2 and brushed the side of her car. He did not
complain of injury and damages was minor and did not require a tow truck.
Information/Insurance only.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 10/02/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 10-02-24 07:11 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 101712024 12:37:06 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 1 4:16 PM TIME POLICE ARRIVED i 4:16 PM
PART B 8800-845.160(R1Vt8) PAGE 0 OF 37
REPORT NO. E F22198 CASE# 24-10278 DATE AND TIME 10/01/24 16:15
OF COLLISION
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