HomeMy WebLinkAbout25-5685 )STATE
TFcN 0 5 27i t
Oc� RA EG08222
COLLISION REPRT 1591971
CASE# 25-5685 2
INTERSTATE CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VEHICLE ❑ LOt`CO AGENCY. 4200 3
COUNTY RD NVOLVED CODING
2 PRIVATE WAY
❑ 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
COLLISION' 06 - 30 - 2025 2158 17 =.= S 8 W E IN OF M 1070 a
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION Z NON INTERSECTION ❑
SUNSET BLVD NE BLOCK NO.
❑
MILE POST e
4a
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 CYYYYYY�.F--1 FEET e S 8 W e 1405 NORTH ON RAMP
2 0 29
MOTtlR PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE' ❑ YES ✓NO D:2064062522 0 1 30
6❑ LAST NAME JOHNSON FIRST NAME NINA MIDDLE 1 2 31
INITIAL
STREET ❑ 5960 WILSON AVE S
NEW CITY, SEATTLE ST WA ZIP 98118 2
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 3
INTERLOCKYES �/No INTERLOCKYEs NO�/ YES NoF,/
8 DRIVECEN # STATE WA SEX F MMOCSYY' 05 — 31 — 1964 1 2 32
9� ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 N USEET 2 1 INJURY
CLASS 1 NAruRE of INJURIES 2
LICENSE, 9NOB791 STATE CA VIN# 7SAYGAEE5RF164533 3
10[9� PI ATP rt
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR TRLR 5 1 33
12 0 0 VIN# VIN#
FROM TO
VER YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT VEHICLE
13 1 2024 TESL Y UT DAMAGE YES NO ✓ ves❑ No 1 5 34
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
LIABILITY INSURANCE❑ INSURANCE CO 3 4
14 �I TESLA INSURANCE CORP TLA-CA-A-7-X6FSX892
IN EFFECT &POLICY# 4TOP
VEHICLE CHARGE 5 36
Lemur yes❑NO❑ CITATION# 7 o BOTTOM
15❑ sTnNowc 7 e
MOTOR PEDAL YES�/ NO PHONE
UNIT PEDESTRIAN PROPERTY D:20 VEHICLE CYCLE64783626 nWNFR
16�
LAST NAME RA VA FIRST NAME DONNA MIDDLEI M
INITIAL
❑
17 F1 STREET' 1200 GRANT AVE S APT Y204 CITY RENTON ST, WA ZIP 98055 4 37
NEW AbbRESS❑
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDIGALTRANSPORTED' 38
INTERLOCKYEs No INTERLOCK YES No rEs NO
19 DRIVER' #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H UET 2 SE CLA 1 Y NATURE OF INJURIES 40
21 LICENSLATE E CKS8311 TATE WA VIN# 4S4BTACC3L3127240 41
22❑ [TILER AILER
PLATE# STATE PATE# STATE ❑ 42
23 TRLR kRLR 43
UIN#. 'IN#.
VEH.YEAR 2020 MAKE $(JB,G MODEL O(/TB,QC STYLE UT VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO YES NO
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO,2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSURANCE CO pEMCO CA 0596610
IN EFFECT &POLICY# t 9TOP
vewaE ❑ CITATION11 CHARGE tO BOTTOM
LecnLLr YES N J
25 a a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
BRYAN GROZAV 12489 WA0171300
PAGE 01 OF
PART A 3000-345-159(R 11/18)
POLIICFETRAFFICN CORRECTION REPORT NO. EG08222
COLLISION REPORT III III III III III 111
1591972 CASE# 25-5685
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'NAME
(LAST,FIRST MIDDLE INTTIAL)
ADDRESS&PHONE#
SEX' D.O.B. — [----------�
MMDDYYYY
PASSENGER F-1 WITNESS Ej 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
Please see subsequent narrative pages
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
BRYAN GROZAV 07-01-25 02:15 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 8887 71912025 4:15:26 PM
BADGE OR ID# 12489 ORI# ( WA0171300 TIME POLICE DISPATCHED'; 10:00 PM TIME POLICE ARRIVED 10:09 PM
PART B 3 Do-3mx-,ao(Rtrras) PAGE 27 OF 47
REPORT NO.` EG08222 CASE# 25-5685 O COLLI COLLISION TIME
OF 06/30/25 21:58
COLLI
NARRATIVE
CASE 25-5685
This incident was captured on my body worn video camera and/or in-car dash camera. This report is
a summary of events that occurred and is not an exact sequencing of events.
On Monday June 30th, 2025, at approximately 22:00, 1 responded to a 911 call regarding a two-
vehicle collision at Sunset Blvd NE and the north bound 1405 on ramp within the City of Renton, King
County, Washington.
***CALL REMARKS: 2 VEH ACC,NO INJS, NOT BLK'ING.. DK SEDAN PARKED UNDER THE
OVERPASS AND RP ON THE ONRAMP TO 1405 IN A RED TESLA.
I arrived in the area and only noticed one vehicle. A Subaru Legacy Washington license# CKS8311
(unit two) stopped in the roadway with its hazard lights on. I contacted the driver identified by her
WADOL as Donna M. Rava (DOB: 1.11.1954) and had her pull to the 7-11 located at 404 Sunset Blvd
North to get out of traffic.
Donna reported the following; she was traveling south on Sunset Blvd NE when another vehicle (unit
one) struck her while trying to enter the north bound 1405 on ramp. The other involved vehicle
continued onto the on ramp. Donna indicated she was not injured, and her vehicle sustained damage
to the driver door and rear passenger door but was drivable. Donna had a valid driver's license and
valid vehicle insurance.
I called the reporting party Nina Johnson (DOB:5.31.1964) who reported the following; she was
attempting to enter the north bound 1405 on ramp from Sunset Blvd NE and did not see unit two. After
the crash she pulled to the shoulder and called 911 but left the area since she did not see unit two
stop and did not feel safe where she was stopped. Nina texted me photos of her WADOL, insurance,
and vehicle license plate. Nina indicated she was not injured, and her vehicle sustained damage to
the front end. Nina had a valid driver's license and valid vehicle insurance.
I gave Donna a business card with case number and texted Nina the case number. I recommended
Nina stay on scene next time until police arrived.
This concludes my involvement in this case.
I certify/declare under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct.
Electronically signed by B. Grozav#12489 on 7.01.2025 at 02:12 hours in Renton, WA.
PAGE 3 OF 4
REPORT NO. EG08222 CASE# 25-5685 DATE AND TIME i 06/30/25 21:58
OF COLLISION
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