HomeMy WebLinkAbout24-12667 iiTFiNII IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF69275oc� RA
COLLISION REPORT 1591971
CASE# 24-12667 2
INTERSTATE CITY STREET FIRE I
RESULTEDSTOLENSTATE ROUTE OTHER VEHICLE LOCCODICENC'Y 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 s 28
TRIBAL UNITS 02 STRUCK
RESERVATION : 1 1
2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF N E
eDLLISION' 12 - 10 - 2024 1114 17 =.�� S W OF 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SE CARR RD BLOCK NO. e 10600 .�
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 �. FEET e S 8 W e 106TH AVE SE
2 0 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YEs Vl No D:2064744621 0 1 30
6 LAST NAME PETRIK FIRST NAME ALEXANDER MIDDLE P 1 1 2 31
INITIAL
STREET ] 2502 EAST BAYDR NW CITY; GIG HARBOR ST WA ZIP; 98335 2
NEW ADDRESS
7 CDL IGN(TIUN REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED. 3
INTERLOCKYEs NO INTERLOCKYEs NO YEs NO
8❑ DCIENSE# STATE WA SEXI M MMDDYY' 08 — 19 — 2002 1 2 32
-NJUR
9 ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASSY 1 [NATURE of INJURIES 2
LICENSE, CLH1129 STATE WA V(N# 5YJ3E1EAXRF725805 3
10 Fl I as ATP rt
TRAILER STATE TRAILER STATE ROM To 11 3 5 PLATE# PLATE#
TRLR TRLR. 3 7 33
12 3 5 VIN# vIN#
FROM TO
VEH.YEAR 2024 MAKE TESL MODEL 3 STYLE 4D V Y EHICLE TOWED TO BLIN TOWED By GOVT VEHICLE 3 7
13� DAMAGE YES II_II NO `/ YESII_I) N 34O
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
4 LIABILITY INSURANCE INSURANCE CO 2 3 4
14 ANYTHING(ALLSTATE)820 707 816
IN EFFECT &POLICY# 4TOP
VEHICLE CHARGE t 5 36
Lemur yes❑NO❑ CITATION# 7 0 80TTOM
15❑ sTnNowc 7 e
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE nWNFR YES'/ NO D:2063356085
16�
LAST NAME AL MAYAHI FIRST NAME ALI MIDDLE' H
INITIAL
STREET ❑
17 ❑ 12214 SE 179TH PL CITY RENTON ST, WA ZIP 98058 q 37
NEW ADDRESS
18❑ IGNITION REQUIRED IGNITION PRESENT MEDICALTRANSPORTED 38
CDL INTERLOCKYES No INTERLOCK YES NO YES NO
19 DRIVERS ' STATE WA SEX M D-DDY 05 — 25 1968 � 39
'..LICENSE# MMDDYY' —
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 R USEET 2 CLASSY 1 NATURE OF INJURIES 40
21[-] LICEN� BVU8640 TATE WA VIN# JTDKN3DU3F1982148 41
PLATE22❑ PLATE# STATE[TILER I PLATE# STATE 42
23= TRLR RLR 43
UIN#. 'IN#
VEH.YEAR 2015 MAKE TOYT MODEL PR/US STYLE 5p VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO NO
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE
N0.2
SHADE IN DA GWREA
2 AAA
LIABILITY INSURANCE INSURANCECO STATE FARM 4748589 B14.47G
IN EFFECT &POLICY# 9TOP
HICLE EEILe L YES❑ NJ—I, CITATION# CHARGE to BOTTOM
VE
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PAGE 01 OF
PART A 3000-348-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF69275
COLLISION REPORT III III III III III 111
1591972 CASE# 24-12667
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE
SEXi D.O.B. —
MMDDYYYY
PASSENGERQ WITNESS� UNIT SEAT AIRBAG RESTR. EJECT ; HELMET NJURY NATURE OF INJURIES
POS. ' USE GLASS 1 ----�
:NAME
(LAST FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. —
MMDDYYYY
PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURECFINJURIES
POS. USE CLASS ----�
:NAME
(LOST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX MMDDYY D.O.B.
YY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. I USE CLASS
NARRATIVE
On 12-10-24 at about 1256 1 arrived at the intersection of SE Carr Rd and 106th Ave SE for a 2-
vehicle collision. 1 contacted both drivers in a nearby parking lot. Both drivers were identified via
WADL. Driver 1, Alexander Petrik told me;
He was exiting a nearby parking lot and drove across 2 lanes of traffic in order to get into the left turn
lane. In the process of doing so, he did not see unit 2 westbound on SE Carr Rd and they collided.
He was not injured.
Driver 2 told me;
He was driving westbound in lane 2 when unit 1 suddenly collided with the passengers side of his
vehicle.
He did not have time to avoid the collision.
He was not injured.
Driver 1 was the proximate cause of the collision by exiting a private drive and improperly changing
lanes into the side of unit 2. Both vehicles were released to the respective drivers.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 12-11-24 04:23 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
K.LANE boos 2/26/2025 12:44:41 PM
BADGE OR ID# j 1953 ORI# WA0171300 TIME POLICE DISPATCHED 12:44 PM TIME POLICE ARRIVED 12:56 PM
PAST B a Da-3mx-attar(txIMR) PAGE 2�OF F3
REPORT NO. EF69275 CASE# 24-12667 DATE AND TIME 12/10/24 11:14
OF COLLISION
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