HomeMy WebLinkAbout24-12079 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
SASE 24-12079 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4900 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 1824 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
AIRPORT WAY BLOCK NO. e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 633 00 FMILES EET e S ❑ E e LAKEAVES
0 1 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES NO �/ D:2065486938 0 7 30
6� LAST NAME WAGNER FIRSTNAME JAY MIDDLE M 1 1 2 31
INITIAL
STREET ❑, 5171 S RUGGLES ST CITY SEATTLE ST WA ZIP 98178 z
NEW ADDRESS
7❑ COL 1/ I IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aTES� C40574X sTArI WAvIN# 1FTEX1EP3FFA62480
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR 2015 FORD 150 TR MAKE MODEL STYLE VEHICLE TOWED fn TO VBLINJ TOWED BY I GOVT.VEHICLE g
13 9 34
4 DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 6178011562 4
LI EFFECT &SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2068805576
16 a
LAST NAME CARRADINE FIRST NAME TRUTH MIDDLE I V
INITIAL
17❑ STREET NEW ADOREss❑' 1229 SW 126TH ST APT 1 CITY BURIEN ST WA ZIP 981463050 4❑ 37
18❑ CDL ., IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED � 38
INTERLOCKYEs❑No� INTERLOCK YEsF-j No� YES
NDF
19 DCENSE# STATE WA SEX M M DDY
D.C.B.
03 _ 15 _ 2001 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES 40
❑ 41
21❑ PLATE# D68589D TArE GOV vIN1 1FMCU9GN6PUA93709 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2023 MAKE FORD MODEL ESCAPE STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO PARKING&TRANSPORTATION MGMT 27246TH AVE S STE 200 SEATTLE WA 98134 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY INSURANCE INSU&PORGY#E CO NATIONAL INTERSTATE INSURANCE COMPANY CAR0139583-00 1 STOP
IN EFFECT
'EwCLE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES N�
❑ s
=RSE
PRINT) OFFICER PHONE BADGE OR ID# AGENCY26 12994 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF38297
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12079
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) FOTHERGILL JOHN M
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
18617 SE 168TH ST RENTON WA 980580841 SEX M MMDOYyry 09 - 03 - 1960
{� SEAT HELfv1ET INJURY NATURE OF INJURIES
PASSENGER Z WITNESS O'UNIT# 2 POS 3 AIRBAG 2 RESTR. 4 EJECT 1 USE 1 2 1 CLASS 7 NECK AND BACK PAIN
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
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.
JAMAAL KEARSE 11-21-24 08:10 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 1112212024 3:12:46 AM
BADGE OR ID# 12994 ORI# WA0171300 TIME POLICE DISPATCHED 6:34 PM TIME POLICE ARRIVED',6:38 PM
PART I PAGE IT]OF 4�
TIME
REPORT NO. EF38297 CASE# 24-12079 OF COLLISION11/21/24 18:24
NARRATIVE
Unless otherwise noted, all events took place in the City of Renton, in the County of King, in the State
of Washington.
This incident was captured on my body worn video camera and in-car cameras. This report is a
summary of events that occurred and is not an exact sequencing of events.
On 11/21/2024, at approximately 1834 hours I was dispatched to a report of a collision with injury at
Lake Ave S and S Tobin St. Dispatch advised 10 ago the collision occurred and one of the involved
parties was complaining of neck and back pain.
At approximately 1838 hours I arrived on scene. Renton Fire was on scene examining the passenger
of Unit 2. The Unit 1 vehicle had already left the scene. I spoke with the driver of Unit 2 and confirmed
he was not injured. He stated that he already exchanged info with the driver of Unit 1 and told the
Driver of Unit 1 he could leave. I was called to the scene due to the complaints of injury by the
passenger. Renton Fire medically cleared the passenger of Unit 2.
The driver of Unit 2 relayed the following information. He was driving westbound in lane 1 of 3 on
Airport Way towards Rainier Ave S. He came to a stop due to traffic being backed up. The driver of
Unit 1 was driving right behind him. Unit 1 hit the rear bumper of Unit 2 with the front bumper of Unit
1. The passenger of Unit 2 had complaints of neck and pack pain. Airbags did not deploy.
The driver of Unit 1 relayed the following information. He was driving westbound in lane 1 of 3 on
Airport Way towards Rainier Ave S. The driver of Unit 2 came to a stop but he did not realize they had
stopped. He collided with them hitting the rear bumper of Unit 2 with the front bumper of Unit 1.
There was minimal damage to his vehicle and he was not injured.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer J. Kearse #12994 11/21/2024 1939 Hours Renton, King County,
Washington
PAGE 3 OF 4
REPORT NO. EF38297 CASE# 24-12079 DATE AND TIME 11/21/2418:24
OF COLLISION
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PAGE 4 OF 4
