HomeMy WebLinkAbout25-2801 iiTFi " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EF79344oc� RA
COLLISION REPORT 1591971
CASE# 25-2801 2
INTERSTATE CITY STREET❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOCAL AGENCY 4200 3
CODING
COUNTY RD PRIVATE WAY ❑✓ INVOLVED 2❑ TRIBAL UN TS#OF 02 SOTRUCK 2 4 28
RESERVATION I 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
coLLISION' 03 - 28 - 2025 1743 17 =.= S 8 W E IN ?070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
NE 4TH ST BLOCK NO. e 4000 .�
4a❑ MILE POST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 1❑ 50 1.1 00 FEET e✓ S 8 W e UNION AV NE
0 7 29
MOTOR PEDAL- DAMAG THRESHOLD MET PHON
UNIT 01 E
VEHICLE ❑ CYCLE ❑ YES No �/ D:4253434245 1 5 30
6 LAST NAME PRYIOMKA FIRST NAME VOLHA MIDDLE 1
1 2 31
INITIAL
STREET ❑ 5820 NE 7TH PL CITY RENTON ST I WA ZIP 980596?54 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED. 3
INTERLOCKYEs NOR] INTERLOCKYEs NO�/ YES No,/
8 DRIVE STATE WA SEX F MMOr YY' 05 - 07 - 1982 1 2 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELM
USEET CLASS ? NATURE of INJURIES 2
LICENSE, CPB5852 STATE WA VN# JF2SLDRC2SH455846 3
10[9� PI ATP rt
11[-j— TRAILER STATE TRAILER ,STATE ROM TO
11 0 0 PLATE# PLATE#
TRLR TRLR 9 9 33
12 0 Q VIN# VIN#
( FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWEDBY GOVT VEHICLE Q Q 34
13 4 2025 SUBA FOREST SD DAMAGE YES DNO YES NO
REGISTERED OWNER INFO VOLHA PRYIOMKA 5820 NE 7TH PL RENTON WA 98059 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
LIABILITY INSURANCE❑ INSURANCE CO 2 3 4
14 AMER FAM 196784760515FPPA WA
IN EFFECT &POLICY# 4TOP
VEHICLE CHARGE t 5 36
ec LnLLY YES Z NO❑ CITATION# 7 o BOTTOM
15❑ nNowc e
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
VEHICLE
UNIT 02 CYCLE (7WNFR Q ❑ PEDESTRIAN ❑ D:4255472240
YES NO
16�
LAST NAME TOLEDO GARCIA FIRST NAME NAYELI MIDDLE S
INITIAL
STREET ❑ 37
17 '❑ ?190 UNION AV NE A6 CITY RENTON ST, WA ZIP 980594730
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 38
INTERLOCKYEs No IN7ERLOGKYES NO
19 DRIVER' #
INJURY NATURE OF INJURIES 4Q
20❑ ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ? ❑
21 LICENSECLX9011 rarE WA VIN# USE
41
22❑ [TILER AILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2011 MAKE MAZD MODEL 323 STYLE $D VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO CRISTOBAL POLICARPO SANTANA 1190 UNION AV NEA6 RENTON WA 98059 VEHICLE NO,2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSURANCE CO NONE
IN EFFECT &POLICY# t 9TOP
veeiae ❑ ,J—I CITATION# CHARGE tO BOTTOM
LecnLLY YES N`.LJ
25 s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EF79344
COLLISION REPORT III III III III III 111
1591972 CASE# 25-2801
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL} PRYIOMKA ALIAKSANDR N
(LAST,FIRST
ADDRESS&PHONE# DOB
5820 NE 7TH PL RENTON WA 980596154 SEX' M MMDDYYYY 09 — 05 — 1981
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
z 1 POS. 3 2 4 1 USE CLASS '1 --�
'NAME
(LAST FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
S ' D.O
EX .B.MMDD - 1
YYYY
EAT HELMETNJURY URE OF
PASSENGER ❑WITNESS UNIT# S AIRBAG RESTR. EJECT NAT INJURIESPOS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B.M -F L----------�
MDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q' POS. USE CLASS r— ----�
NARRATIVE
Unit 2 backs into Unit 1 within private parking lot of 7-Eleven at 4020 NE 4th St. Unit 2 driver no valid
driver license, ID only, and no vehicle insurance. Unit 2 driver proximate cause of collision. Unit 1
sustains minor non disabling non reportable damage to the front driver side bumper area. Unit 2
sustains non disabling non reportable damage to the rear.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 03-28-25 06:30 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY E
QAT
BRYAN GROZAV 12489 41212025 9:10:50 PM
BADGE OR ID# 12651 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 5:53 PM TIME POLICE ARRIVED 5:56 PM
PART IS 3aaa-345-,aa(R11Y1s) PAGE 27OF 37
REPORT NO. EF79344 CASE# 25-2801 DATE AND TIME 03/28/25 17:43
OF COLLISION
fil
t
i
;
t
s
4
�k
a"
t
, gg
s
r
i�
i
a
k 3
w�
s .
PAGE 3 OF 3