HomeMy WebLinkAbout25-5501 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 25-5501 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 RESERVATION STRUCK
z
3 DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cowsloN 06 - 1-- 2025 1725 17 ❑.= S IN 1070 3
4� ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
RAINIER AVE S BLOCK NO. e✓ 100 ❑
4a 1❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SW VICTORIA
1 9 29
MOTOR ✓ PEDAL- DAMAGE THRESHOLD MET PHONE
UNITS VEHICLE ❑ CYCLE ❑ YEs �/No D:4254307500 0 6 30
6 LAST NAME NELSON FIRSTNAME DEVIN MIDDLE P 1 1 2 31
INITIAL
STREET ❑✓ 1055 S GRADYWAYATTN:POLICE CITY RENTON ST WA ZIP 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 08 - 25 - 1993 1 2 32
9 ON DUTY✓❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 8❑ P1 ATNFS# 61450D sTAr GOV vN# 1GNLCDECOGR377231
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# Rom To
TRLR. YRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE I MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13FAl 2016 CHEV TAHOE UT DAMAGE YES NO YES[:] NO✓
REGISTEREDOWNERINFO CITY OFRENTON1055SGRADYWAYATTN:POLICERENTONWA98057 D:4254307500 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14� LIABILI INSURANCE U INSURANCE CO CITY OFRENTONSELFINSURED 3 4
IN EFFECT &POLICY# STOP
VE— CHARGE 1 5 36
LECALLv res❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM NO
OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2066368255
16 a
LAST NAME DO FIRST NAME CINDY MIDDLE
INITIAL
17 STREET I❑ 5161 S 117TH ST,SEATTLE WA, CITY' SEATTLE ST WA ZIP 98178 37
NEW ADOREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF vEs t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.C.B. 03 _ 01 2000 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE CL
21❑ PLA E# AEV4414 rare 41
WA VIN# 4T4BF3EK26R141572 1
22❑ PLATE# STATE PLA El 42
TE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2011 MAKE 7'Oy7' MODEL CAMRY STYLE 4D DAMAGE TOWED NOO✓ BLIN TOWED BY ov HYES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU8 PORGY#E CO AMERICAN FAMILY 18621699021.. 1UR
5
IN EFFECT
VE""LE ❑ ,J� CITATION# CHARGE LEGALLYYES N
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG08064
COLLISION REPORT III III III III III 111
1591972 CASE# 25-5501
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 FIRST 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'
On 6-24-25 at about 1710 Officer Nelson informed me that he had been involved in a collision while
running code to an injury collision. He lost the other vehicle in traffic, but was able to retrieve the
vehicle information from his dash camera. Before he sent me the information on the collision, driver
2, Cindy Do was calling in via dispatch. Officer Nelson was able to retrieve all of Do's information and
confirmed there were no injuries.
Officer Nelson voluntarily showed me his Axon in car video. The video showed;
Officer Nelson, Unit 1 in heavy traffic and in a construction zone in the 100 block of Rainier Ave.
There are cones/temporary stantions to the left and unit 2 to the right. As unit 1 attempted to pass unit
2, unit 1 side swiped unit 2 causing damage to both vehicles. Both vehicles were able to drive away
from the scene. The are no reported injuries involved with this collision.
This collision occurred in the city of Renton, County of King.
I declare under penalty of perjury under the laws of Washington state that the foregoing is true and
correct.
C. Jacobs/1953
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Action Code: RUNNING CODE/OVERTAKING VEHICLES
Traffic Control: CONES
Motor Vehicle Unit 2
Traffic Control: CONES
**** CAIr-A /lC AI ITlI 0/l0l 11 AT1=I71 CCl�TIl1A1 ****
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 07-03-25 09:17 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
M.LEVERTON 2517 1 71912025 8:06:11 AM
BADGE OR ID# 1953 ORI#' WA0171300 TIME POLICE DISPATCHED; 5:25 PM TIME POLICE ARRIVED',5:25 PM
PART B PAGE IT]OF 3�
REPORT NO. EG08064 CASE# 25-5501 DATE AND TIME 06/24/2517:25
OF COLLISION
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