HomeMy WebLinkAbout25-5613 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG08065OLCERA
COLLISION REPORT 1591971
ASE# ; 25-5613 2
INTERSTATE CITY STREET❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE LOCAL CO A`OENC'Y 4100 3
COUNTY RD PRIVATE WAY ❑✓ INVOLVED CODING
2❑ TRIBAL TOTAL 1
UNITS#OF 02 SO BJECT TRUCK 1 8 28
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
DATE OF'. N E
coulsfoN' 06 - 28 - 2025 1622 17 =.= S 8 W e IN OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION
BLOCK NO.
1201 LAKE WASHINGTON
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 C------�.� FEET e S B W
1 9 29
MOTtlR ✓ PEDAL- DAMAG THRESHOLD MET PHON
UNIT 01 E
VEHICLE CYCLE' YES NO �/ D:2069627261 30
5❑ LAST NAME LEKE FIRST NAME CONNER MIDDLE S 1 2 31
INITIAL
STREET 1:1 15922 20TH AVE SW CITY BURIEN ST WA ZIP 98166 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 3
INTERLOCKYES ✓NO INTERLOCKYES NO✓ YES F NO✓
8 �CIENS # STATE WA SEX M MMOCSYY' 05 32
9 ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELM
USEET 2 1 INJURYCLASS 1 NAruRE of INJURIES 2
LICENSE, CSN1331 STATE WA VN# 1C4PJMBS7FW616107 3
10[9� PI ATF rt
TRAILER STATE TRAILER ,STATE
11 1 0 PLATE# PLATE# ROM TO
rRLR TRLR 7 3 33
12 VIN# VIN
( FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT VEHICLE
13 4 2015 JEEP CHERO DAMAGE YES DNo ✓ YEs No✓ 1 5 34
REGISTERED OWNER INFO CONNOR LEMKE 1592220TH AVE SW BURIEN WA 98166 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO
14 ✓ NATIONAL GENERAL 2028011981
IN EFFECT &POLICY# GQ,
VEHICLE CHARGE 36
YES❑NO❑ CITATION#
15❑ sTANowc B 7 e
MOTOR PEDAL-:. PROPERTY DAM THR OLD MET PHONE
UNIT ❑ ❑ PEDESTRIAN Q✓ D:2068520350
VEHICLE CYCLE' nWNFR YES�/ NO
16�
LAST NAME DAVIS FIRST NAME MARK MIDDLE A
INITIAL
1 37
17 STREET ❑'O 818 69TH ST SE CITY AUBURN ST, WA ZIP 980928782 4
NEW ADDRESS
18 CDL IGNITION REQUIREfl IGNITION PRESENT MEDICAL TRANSPORTED' 38
INTERLOCK YEs No INTERLOCK YES No vEs No'
19 DRIVER'S STATE WA SEX M D 0 B 01 13 1964 39
LICENSE# MMDDYY -
8 HELMET INJURY NATURE OF INJURIES 3 40
20❑ ON DUTY STATUS 3 AIRBAG RESTR EJECT USE 2 CLASS 7 PAIN TO BACK OF HEAD,R HIP,R ANKLELICENSE
❑
21 PLATE# vIN# 41
TATE
22❑ [TILER AILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR r RLR 43
UIN#. 'IN#.
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 0 5 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# 9TOP
VEHICLE ❑ ,.I—I CITATION# CHARGE tO BOTTOM
LEEAILY YES N`LJ
25 a a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
E.CHANG 10065 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EG08065
COLLISION REPORT III III III III III 111
1591972 CASE# 25-5613
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 FIRS,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX' D.O.B. - L----------�
MMDDYYYY
PASSENGER DWITNESSD UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. : USE CLASS ----�
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. - L----------�
MMDDYYYY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
❑ Q POS. USE CLASS �____ ----j
NARRATIVE
On 06-28-2025 at about 1622 hours, I was sent to a collision which occurred in the beach parking lot
of Gene Coulon Park at 1201 Lake Washington Blvd, with in the City of Renton, King County,
Washington.
The collision occurred in the southeastern side of the parking lot.
Upon arrival the driver of unit 1 told me that he was reversing to get a parking space he did not see
anyone and then heard a thump from his rear driver side. He saw he collided with a person.
I tried to speak with the victim, but he was not talkative. I spoke with his family, and they said they
were crossing through the parking lot and emerging between two cars in line where the pedestrian
laid. They did not see the collision occur.
One person said they saw the collision and the car was going 23 mph in reverse. She was not able to
explain why she said 23 mph.
There was no damage on unit 1.
I was told the pedestrian had pain to the back of his head, right hip, and right ankle from the fall.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Action Code: REVERSING
**** END OF AUTO-POPULATED SECTION ****
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.CHANG 07-03-25 04:11 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY E
DAT
M.LEVERTON 2517 71912025 7:58:01 AM
BADGE OR ID# 10065 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 4:22 Pry TIME POLICE ARRIVED 4:22 PM
PART B 3aaa-345-,aa(R11Y1s) PAGE 27OF 37
REPORT NO. EG08065 CASE# 25-5613 DATE AND TIME 06/28/25 16:22
OF COLLISION
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