HomeMy WebLinkAbout25-1105 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 25-1105 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI 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#
cawsloN 02 - 1-- 2025 0804 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 6 29
MOTUNIT U1 VEHICR Z PEDAL-CLE CYCLE ElYESA,G/E NHORESHOLD MET PHONE 0 81
30
6� LAST NAME SIROTINSKIY FIRSTNAME ALEKSANDR MIDDLE S 1 2 31
INITIAL
STREET ❑ 26526 168TH PL SE CITY COVINGTON ST WA ZIP' 980425807 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 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� CMR9565 sTATI WAurN# 1 C4PJMDX7KD423583
0
----� TRAILER STATE PLAT Eft STATE
11 4 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
DAMAGE YES NO 9 9 34
13 2 2019 JEEP CHERO YES[:] NO✓
REGISTERED OWNER INFO ALEKSANDRSIROTINSKIY 26526168TH PL SE COVINGTON WA980425807 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE z INSURANCE CO NATIONAKGENERAL 2016353862 4
LI EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING , 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES�/ NO D:2533374752
16 2
LAST NAME LAZARO FIRST NAME LEAH MIDDLE I V
INITIAL
17❑ STREET ❑', 16529 115TH AVE SE CITY RENTON ST WA ZIP 980555206 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 DRIVER'S STATE WA ]SEX IF D.O.B. 01 27 1987 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I C77526Z TATe WA VIN1t JTDZN3EU7GJ046452
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2016 MAKE TOYT MODEL PRIUSV STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI �44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO LLC POTENTIAL ENERGY 3847 S PUGET SOUND AVE TACOMA WA 98409 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
INAEFFITY ECTNSURANCE INSU&POLICY#E CO SAME. I 9TOP
VE""LE CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25❑ J s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
M.LEVERTON 2517 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF64625
COLLISION REPORT III III III III III 111
1591972 CASE# 25-1105
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 02-05-25 07:47 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 2/11/2025 10:56:02 AM
BADGE OR ID# 2517 OR]#' WA0171300 TIME POLICE DISPATCHED; 8:04 AM TIME POLICE ARRIVED',8:11 AM
PART I PAGE IT]OF 4�
REPORT NO. EF64625 CASE# 25-1105 OF COLLISION
02/04/25 08:04
OF CbLLI510N
NARRATIVE
siv /2 lane 1 stopped blk/2 slid
RTF
Within the city limits of Renton/King/Wa I responded to a 2 vehicle blocking crash at the intersection
of 108th Ave SE at Se 180th St.
When I arrived onscene both vehicles had pulled from the roadway into the parking lot of Renton Fire
station 13.
1 contacted the driver of unit 2 that told me she was stopped for the red light when he was bumped
from behind by unit 1. She did not complain of injury and damages did not require a tow tuck.
I contacted the driver of unit 1 who told me he wasnt going too fast for conditions but did not realize
the road was icy/that slippery. He said he could not get his car stopped in time to avoid contact with
unit 2. He did not complain of injury and damages did not require a tow truck.
I made a request for additional sanding in the area. While I was onscene addition collisions occurred
at the same location during this inclement weather. Those were also low speed bumper bumps.
I provided both drivers a copy of the information exchange.
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 2/5/2025
PAGE 3 OF 4
REPORT NO. EF64625 CASE# 25-1105 DATE AND TIME 02/04/25 08:04
OF COLLISION
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PAGE 4 OF 4