HomeMy WebLinkAbout24-9563 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 24-9563 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION' 09 - 1-- 2024 0742 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
108TH AVE SE
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e SE 180TH ST
0 1 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/ENHORESHOLDMET PHONE 0 81
30
6� LAST NAME NALIVAYKO FIRSTNAME JAMES MIDDLE N 1 1 2 31
INITIAL
STREET ❑ 13901 SE 237TH PL CITY KENT ST WA 2jp, 980423285 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ PI ATE CER1762 sTATI WA urN#' JTHCK262782023852
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. YRLR. 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR ZOO8 MAKE LEXS MODEL IS STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 9 9 34
13 2 DAMAGE YES NO ✓ YES[:] No
✓
REGISTERED OWNER INFO NIKOLAYNALIVAYKO 13101 SE 237TH PL KENT WA 98042 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO SAME. 4
LI EFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLYYES NO CITATION# 4A0652650 INATTENTIVE DRIVING <1�3
orrom
15❑ STAIN,"" 6
UNIT U2 VEHICCLE CYCLE ❑ PEDESTRIAN ❑ OWNER [_LE
❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME OMER FIRST NAME AHMAD MIDDLE 0
INITIAL
17❑ STREET ❑', 23240 88TH AVE S APT XX303 CITY KENT ST WA ZIP 980313185 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK vEs I I NOF YEs t l NO❑
19 DRIVER'S STATE WA SEX M D.O.B. 09 _ 08 _ 1993 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CLW0186 TATe WA VIN# 5TDACAB5XRS010605
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2024 MAKE TOYT MODEL HIGHLAN STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO✓ YES NO✓
REGISTERED OWNER INFO AHMAD OMER 2324088TH AVE S APTXX303 KENTWA980313185 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSURANCE
#E CO TRAVELERS 615689164IN 1U
9TOP
VE""LE CITATION# CHARGE o BOTTOMLEGALYYES N�25❑ J
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF16420
COLLISION REPORT III III III III III 111
1591972 CASE# 24-9563
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'
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.
M.LEVERTON 09-12-24 08:33 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 9/19/2024 12:53:07 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED! 7:47 AM TIME POLICE ARRIVED',7:51 AM
PART I PAGE IT]OF 4�
REPORT NO. EF16420 CASE# 24-9563 OF COLLISION
09/12/24 07:42
OF CbLLI510N
NARRATIVE
wht suv/2 stopped lane 1 wht sedan rear light turned grn unit 2 second
CC
Within the city limits of Renton/King/Wa I responded to a 2 vehicle crash at 108th Ave SE at SE 180th
St.
Both vehicles pulled into the parking lot of Renton Fire station 13.
1 contacted the driver of unit 2 who told me he was stopped for the red light northbound 108th Ave SE
in lane one. He told me he was second vehicle back from the intersection. He said when the light
changed from red to green the car in front of him hadn't yet moved when he was hit from behind by
unit 1. He did not complain of injury and damages did not require a tow truck.
I contacted the driver of unit 1 ID'd by picture WADL. He did not provide any additional information
for why the crash occurred other than he was in lane one northbound and rear-ended unit 2. He did
not complain of injury and although damages required a tow truck he said he would make his own
arraignments to have the car towed.
I cited unit 1 ref RMC 10-12-25 Driver Inattention 2 car crash via complaint.
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 09/12/2024
PAGE 3 OF 4
REPORT NO.! EF16420 CASE# 24-9563 DATE AND TIME 09/12/24 07:42
OF COLLISION
j c
Aa
PAGE 4 OF 4
