HomeMy WebLinkAbout24-2805 a ITFFi "POLCERA II IfI) 1 IlfII ('II (Illf If( fI I . 1 27c
COLLISION REP FIT 1591971
CASE 24-2805 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4100 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 28
0 5
RESERVATION
TRIBAL UNITS 02 STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 03 - 1-- 2025 1855 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
NE SUNSET BLVD M4600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 100 00 FMILES EET e S ❑ E e DUVALL AV NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:3904412783 1 2 30
5� LAST NAME KITTILA FIRSTNAME MARIANA MIDDLE I L 1 1 2 31
INITIAL
STREET ❑ 2800 DONOVAN AVE CITY BELLINGHAM ST WA 21p 982257628 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER # STATE WA SEX'F MID
IF B 03 - 04 - 1984 1 2 32
[NATURE OF INJURI
9 ON DUTY❑ STATUS' AIRBAG 2 RESTR 4 EJECT 1 HU EET 7 CLASS STOMACHPAINES 2❑
3
10 9❑ Pi ATE 14 BQP3636 STATE WA VIN# 5YFBURHE6HP721393
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
FT -R TPILF1 1 5 33
12 0 0 VIN#' VIN#
FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 2 4 34
13 A 2017 TOYT COROL DAMAGE YES NO YES[:] NO✓
REGISTEREDOWNERINFO MARIANAKITTILAPO BOX 1388 BELLINGHAM WA98227 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE U NSURANCE CO GEICO 6143617980 3 4
IN EFFECT &POLICY# 9TOP
VE— CHARGE 1 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT U2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2067867373
16 a
LAST NAME DO FIRST NAME ETHAN MIDDLE I C
INITIAL
17❑ STREET ❑', 667/L WACO PL NE CITY RENTON ST WA ZIP 980594499 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19� DRIVER'S STATE WA SEX M D.C... 03 09 _ 2007 El
39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CHW9057 TATe I WA vIN# 4T1BF1FK5CU122481
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2012 MAKE TOYT MODEL CAMRY STYLE SD VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO LILLY DO 6671LWACO PL NE RENTON WA 980594499 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO AMER FAM 41110-89499-92IN 1URVE"LE
❑ ,J� CITATION# CHARGELEGALYYES N`LJ
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
HANSEN HSU 12651 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF79346
COLLISION REPORT III III III III III 111
1591972 CASE# 24-2805
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) SCHLICHTING OWEN M
(LAST FIRST,
ADDRESS&PHONE# D O.B.
1918 FIELD AVE NE RENTON WA 980594253 SEX M MMDDYyYv 07 - 13 - 2006
PASSENGER WITNESS❑'I UNIT# 2 PAS AIRBAG 1 RESTR. 4 EJECT ? 1 HELMET INJURY NATURE OF INJURIES
USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL) NGUYEN DAN
ADDRESS&PHONE# D O B
RENTON SEX M MM 0-:vB v -F -
SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER WITNESS UNIT# 2 POS 3 AIRBAG 2 RESTR. 4 EJECT 1 USE CLASS 1
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.Q.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Unit 1 and 2 collide in private parking lot of Albertson's at 4621 NE Sunset Blvd. Unit 2 driver no valid
license with ID. Unit 1 driver reported driving in lane of travel southbound. Unit 2 driver reported
merging from parked stall into travel lane, heading SE. Unit 1 sustained moderate non disabling front
passenger side damage. Unit 2 sustained moderate non disabling driver side damage. No injuries
reported for Unit 2. Unit 1 driver reported stomach pain and possible complications from pregnancy.
Unit 1 driver treated on scene by Renton Fire and reported that she would arrange for transport to
hospital at a later time. Proximate cause of collision was Unit 2 mergining to lane of travel.
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 08:07 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
BRYAN GROZAV 12489 41212025 9:08:40 PM
BADGE OR ID# 12651 ORI#' WA0171300 TIME POLICE DISPATCHED! 6:57 PM TIME POLICE ARRIVED;7:01 PM
PART I PAGE IT]OF 3�
REPORT NO. EF79346 CASE# ' 24-2805 DATE AND TIME 03/28/25 18:55
OF COLLISION
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