HomeMy WebLinkAbout24-9056 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
SASE 24-9056 2
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK' BUILDING
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION'. O8 - 1-— 2024 1127 17 ❑-❑ S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
4242 EAST VALLEY RD
BLOCK NO. e✓ --- ----�
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 1 9 29
MOTUNIT U1 VEHIOR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE =30
6� LAST NAME DEREVIANSKA FIRSTNAME OLHA MIDDLE 1 2 31
INITIAL
STREET ❑, 20331 111TH AVE SE CITY KENT ST WA 2jp, 98031 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 3 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
LICENSE CNH6424 STATE WA u N# 5J6RE48749L038077
10❑ Pr ATE�
TRAILER STATE TRAILER STATE
11 1 0 PLATE# PLATE# I I FRom ro
TRLR. TRLR 3 7 33
12❑ VIN#' VIN#.
Rom 34
13� VEH.YEARN MAKE HOND MODEL CR-V STYLE VEHICLE TOWED0NOOffBLIN WAWkkRS yOES❑ENO
DAMAGE IILLJJII tSA1Vi�6
REGISTEREDOWNERINFO ROMANDEREVIANSKYI20331111THAVESE KENTINA98031 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ ABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO �/ D:4253325246
16❑
LAST NAME MARKET FIRST NAME EVERGREEN MIDDLE
INITIAL
17❑ STREET ❑', 4242 EAST VALLEY RD SEAN FIRTH CITY' RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t t- l NO❑
19 LLIICENS # STATE SEX U MMDDYY -�_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TATE VIN# 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ 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 Nu
25 s 7 6
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
M.LEVERTON 2517 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF10938
COLLISION REPORT III III III III III 111
1591972 CASE# 24-9056
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.
M.LEVERTON 08-28-24 02:01 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 9/2/2024 12:19:03 PM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED! 11:30 AM TIME POLICE ARRIVED 11:33 AM
PART I PAGE IT]OF 4�
REPORT NO. EF10938 CASE# 24-9056 OF COLLISION
08/28/24 11:27
OF CbLLI510N
NARRATIVE
gry suv into
Within the city limits of Renton/King/WA I responded to a single vehicle into a building at 4242 East
Valley Hwy.
I arrived and found an SUV over the parking C-curb and its front bumper into an extended structural
beam. No other parts of the vehicle touched the building. Renton Fire responded to check the
building. Both Fire and the Manager agreed there was no damage to the building, just a scuff from
the bumper.
Unit 1 driver was not hurt. She told me that as she was parking she accidently stepped on the
accelerator rather than the brake and jumped the curb, hitting the building. Her car was towed for
damages.
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 8/28/2024
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Action Code: STEPPED ON GAS INSTEAD OF BRAKE
**** END OF AUTO-POPULATED SECTION ****
PAGE 3 OF 4
REPORT NO.! EF10938 CASE# ' 24-9056 DATE AND TIME 08/28/24 11:27
OF COLLISION
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PAGE 4 OF 4
