HomeMy WebLinkAbout24-12463 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 5 27c
COLLISION REP FIT 1591971
CASE 24-12463 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 5 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'. 12 - 1-- 2024 0710 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
N 30TH ST BLOCK NO. e✓ 1400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 35 00 FEET e S ❑ W e I-405 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2067189449 0 7 30
6� LAST NAME HARD FIRSTNAME JEFFREY MIDDLE J 1 1 2 31
INITIAL
STREET ❑, 5333 SW ADMIRAL WAY CITY SEATTLE ST I WA 2jp, 98116 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO 1/ I INTERLOCK YES NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CNV8617 sTArI WAvIN# KL79MPSL7R6151301
TRAILER STATE TRAILER. STATE
11 2 5 PLATE# PLATE# ROM ro
TRLR. TRLR 3 7 33
12 2 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR 2024 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 9 34
13 4 CHEV BLAZER UT DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO ,BUR IIEVROLET144001STAVES BURIENWA98168 D:2063952950 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14� IN EF ITY INSURANCE z INSURANCE CO STATE FARM 0787834-DO6.47E 4
LI EFFECT I SUR N# TOPVE—LE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑
16 a OWNER ❑ YES 1/ NO D:2067189447
LAST NAME HARD FIRST NAME EMILIE MIDDLE T
INITIAL
17❑ STREET ❑', 5333 ADMIRAL WAY CITY' SEATTLE ST' WA ZIP 98116 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NO� INTERLOCK YEs I I NOF YEs t l NOF,/
19 LDIIVER # STATE WA SEX F MMDDW 12 _ O6 _ 1952 El 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE BHC9870 TAre WA vIN# JF2(BTAMCXJH227331
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
Gov HI
VEH YEAR 201E MAKE S'(JB�Q MODEL CROSSJ' STYLE UT DAMAGE TOWED NOO✓ BLIN TOWED BY 44
YES
NO
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE 8 POINSURGY#E CO STATE FARM 078-7834-DO6-47EIN 1 9TOP
VEHICLE ❑ ,.I it CITATION# CHARGE 10 BOTTOM
LEGALLY YES N
25 $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
QUINT TIBEAU 07691 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF42533
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12463
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.
QUINT TIBEAU 12-04-24 09:28 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
D.SKELTON 9139 12/5/2024 5:10:11 AM
BADGE OR ID# 07691 OR]# ! WA0171300 TIME POLICE DISPATCHED', 7:33 AM TIME POLICE ARRIVED 7:38 AM
PART I PAGE IT]OF 4�
REPORT NO. EF42533 CASE# 24-12463 OF COLLISION
12/04/24 07:10
OF CbLLI510N
NARRATIVE
24-12463
Narrative
The following occurred in the City of Renton, County of King, State of Washington.
On 12/04/24 at about 0733 hours I was dispatched to a two-vehicle collision on N 30th near Park Ave
N. 1 located the vehicles parked at the Shell station in the 1400 block of Park Ave N. Vehicle #1 was
a white 2024 Chevrolet Blazer, WA license (CNV8617), registered to Burien Chevrolet. Vehicle #2
was a 2018 Subaru Crosstrek registered to Emilie and Jeffrey Hard out of Seattle.
I contacted the driver of V-1 who identified himself as Jeffrey Hard with his WADL. He told me that he
was following his wife to their daughter's house. They had both just gotten off the freeway and were
westbound on N 30th St. His wife stopped for a vehicle ahead of her. He had looked down for a
moment and struck her vehicle from behind with the loaner vehicle he was borrowing from Burien
Chevrolet. His wife had already gone to their daughter's residence to babysit.
This incident was captured on my Axon body worn video camera. This report is a summary of events
that occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized.
Nothing further at this time.
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 Sgt. Q. Tibeau #07691 12/04/24 0925 hours, Renton, WA.
PAGE 3 OF 4
REPORT NO. EF42533 CASE# 24-12463 DATE AND TIME 12/04/24 07:10
OF COLLISION
f �
11�
Sz;
1> �I
Ml�.`fluent � k
v
�e
a
3 l �
ft
c
t
t
t �
PAGE 4 OF 4