HomeMy WebLinkAbout24-11886 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
SASE 24-11886 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AGENC 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 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.. 11 - 1-— 2024 1350 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
116 AVE SE BLOCK NO. e✓ 16200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SE 162 ST
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO N:2062618593 0 11
30
6❑ LAST NAME FERNANDEZH FIRSTNAME ENRIQUE MIDDLE R 1 1 2 31
INITIAL
STREET ❑ 16512 115TH AVE SE CITY RENTON ST WA ZIP 980555206 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
LOB 10 1- 13 - 1971 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ PIATE14 D96821C STATE WA VN# 1GC1KWEY7HF197404
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# IR.. ro
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
:: FROM TO
VEH.YEAR 2017 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
13 4 CHEV SILVER PK DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO USAA 0091339557105 3 4
IN EFFECT &POLICY# 9TOP
vEHA"LE 5 36
LECLLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ NDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:4252699247
16 a
LAST NAME CAPOOT FIRST NAME JENNIFER MIDDLE I L
INITIAL
17❑ STREET ❑', 1712 OLYMPIA AVE SE CITY' RENTON ST WA ZIP 980584749 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LDIIVERICENSE# STATE WA SEX F MMDDW 07 28 _ 1974 0 39
F—NATURE OF INJURIES
20❑ ON DUTY STATUS AIRBAG,4 RESTR 4 EJECT 1 WEB MEET LASSY 7 COMPLAINT OF PAIN TO HER NECK AND CHEST ❑ 40
21❑ LICENSE I CCN1971 TATE WA VIN1I KMHRC8A3XNU161361
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2022 MAKE yyU/4 MODEL VENUE STYLE $D —FEHICLE
TOWED✓ NOO BLIN BANKERS TOW YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGEDAREA
3 4
LIABILITY
INSURANCE INSU&PORGY#E CO THEGENERAL WA2735514IN STOP 5
VEHICLE YES[:] N
C[:] CITATION# CHARGE io BOTTOM
LEGALLY
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
YUSUF XBRIL 12490 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF36880
COLLISION REPORT III III III III III 111
1591972 CASE# 24-11886
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) FERNANDEZ LOLA
(I.P.ST FIRST,
ADDRESS&PHONE# D O.B. '
16512 115TH AVE SE RENTON WA 980555206 SEX M MMDOYyry 08 - 22 -SEAT JJ 2012
PASSENGER RVWITNESS R;UNIT# 1 POS. 3 AIRBAG 2 RESTR. USE CLASS 9 EJECT ? 1 HELMET LASSJURY NATURE OF INJURIES
. !1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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.
YUSUF XBR/L 11-16-24 04:01 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 1111812024 2:41:39 PM
BADGE OR ID# 12490 ORI# WA0171300 TIME POLICE DISPATCHED 1:53 PM TIME POLICE ARRIVED',1:57 PM
PART I PAGE IT]OF 4]
REPORT NO. EF36880 CASE# 24-11886 OF COLLISION
11/16/24 13:50
OF CbLLI510N
NARRATIVE
On 11/16/2024, at approximately 1353 hours, I was dispatched to investigate an injury collision 116
Ave SE/ SE 162 street, City of Renton, King County, State of Washington.
Upon arrival, I observed that unit 2 had severe front-end damage and the vehicle was not drivable.
Driver of unit 2 was complainant of paint to her neck and chest area. Driver of Unit 2 was treated on
scene by RFA medics. Unit 1 had a damage to the front right bumper. The driver and the passenger
of unit 1 did not report any injuries. Unit 1 was drivable.
The collision occurred in the intersection of 116 Ave SE and SE 162 street. The southbound and
northbound traffic of the intersection (116 Ave SE) does not have any control devices. The eastbound
and westbound traffic of the intersection (SE 162 street) has a stop signs. The stop sign controlling
westbound traffic, coming out of the community center parking lot has sign indicating only right turn.
The following information is based on the information provided by the drivers, and the damages 1
observed on the vehicles.
The driver of Unit#1 said he and his young daughter in the front passenger were traveling
northbound. They were coming out of the community center parking lot located at 16200 SE 116 Ave.
The driver of Unit#1 stated he stopped at the stop sign before proceeding to enter the intersection to
head straight on SE 162 street. The driver of Unit#1 said he did not see Unit#2 before the two
vehicles collided in the intersection. No injuries were reported. The stop sign controlling the traffic
coming out of the parking lot has a sign indicating only right turn.
The driver of Unit#2 reported she was traveling southbound on 116 Ave SE. approaching SE 162
street. Unit 2 entered the intersection. The driver of Unit#2 said she did not see Unit#1 enter the
intersection. The driver of Unit#2 was unable to avoid the collision and subsequently collided into
Unit#1 causing significant damage to her vehicle. The driver of Unit#2 was complaining of pain to
her neck and chest area due to the seatbelt and airbag deployment. Unit#2 was not drivable and was
impounded to Bankers Tow lot.
Both drivers were provided with a business card and case number. The driver of unit 1 was given a
warning for failing to yield to Unit#2.
PAGE 3 OF 4
REPORT NO. EF36880 CASE# ' 24-11886 DATE AND TIME 11/16/24 13:50
OF COLLISION
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