HomeMy WebLinkAbout25-6812 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG20579OLCERA
COLLISION REPORT 1591971
INTERSTATE CITY STREET❑ FIRE I
CASE# 25-6812 2
RESULTEDSTOLENSTATE ROUTE OTHER VEHICLE LOCAL ING 4100 3
HIT&RUN CODING
❑ COUNTY RD PRIVATE WAY ❑✓ INVOLVED
2 1 TOTAL#OF OBJECT 1 s 28
TRIBAL UNITS 02 STRUCK
RESERVATION : 1
2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
EDGE s on' 08 - 05 - 2025 1652 17 =.= S 8 W e OF IN e 1070 s
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK NO.
4800 NE 4TH ST
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 MILES 1.1 FEET B S B W e
1 5 29
MOTOR PEDAL- DAMAG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES No �/ D:4255779676 0 1 30
6❑ LAST NAME BARKER FIRST NAME JACOB MIDDLE N 1 2 31
INITIAL
STREET ❑ 20705 SE 145TH ST CITY; RENTON ST I WA ZIP; 980598939 2
NEW ADDRESS
7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCKYEs NO✓ INTERLOCKVEs No✓ YES NO✓
8❑ DCIENSE# STATE WA SEXI Ni MMDDYY' 01 - 28 - 1981 1 2 32
-NJUR
9 ON DUTY STATUS' AIRBAG 1 RESTR 4 EJECT 1 HELMET
2 CLASSY 1 [NATURE of INJURIES 2
LICENSE, C85274G STATE WA VIN#; 1FTFWlEFOEFB35849 3
10 Fq I as ATP rt
TRAILER STATE TRAILER STATE
11 1 0 PLATE# PLATE# FROM To
TRLR zRLR. 0 0 33
12 1 Q VIN#' VIN#
FROM TO
VEH.YEAR 2014 MAKE FORD MODEL F150 STYLE PK VEHICLE TOWED,DLt�TOBLWED By GOVT VEHICLE 1 5 34
13 DAMAGE YES II_II NO ✓ IN TO YESII_] NO✓
REGISTERED OWNER INFO JACOB BARKER 20705 SE 145TH ST RENTON INA 98059 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
A LIABILITY INSURANCE INSURANCE CO 4
14 USAA 019682444U7f085
IN EFFECT &POLICY# 9TOP
v""' CHARGE t S 36
""ALLY yes❑NO❑ CITATION# t a 80TTOM
15❑ STANDING s 7 e
MOTDR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE CYCLE nWNFR D:2067244657
16�
LAST NAME HUYNH FIRST NAME HUE MIDDLE' T
INITIAL
17 F1 STREET ❑❑ 5124 NE 10TH PL CITY RENTON ST, WA ZIP 980594367 4 37
NEW ADDRESS
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38
INTERLOCKYEs NO✓ INTERLOCK YES NO✓ YES NO✓
19 DRIVER'S
MMDDYY I —
20❑ ON DUTY❑ STATUS AIRBAG 2 RESTR 9 EJECT 1 HELMET 2 INJURY 7 NATURE OF INJURIES 40
USE CLASS ' tEFTBACK
21 LICENSE BBX3783 rarE WA vIN# 2T1BURHE6GC663056 41
22❑ [TILER TAILER
PLATE# STATE PLATE# STATE 42
23 TRLR RLR 43
UIN#. 'IN#
VEH.YEAR 2016 MAKE TOYT MODEL COROLL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 DAMAGE YES NO✓ VES NO✓
REGISTERED OWNER INFO CAN CHAU 5124 NE 10TH PL RENTON WA 98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE[Z INSURANCE CO PEMCO CA0603039
IN EFFECT &POLICY# t STOP
VEHICLE ❑ CITATION11 CHARGE to BOTTOM
LEGALLY YES N
25 a e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
E.CHANG 10065 WA0171300
PAGE 01 OF
PART A 3000-345-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG20579
COLLISION REPORT III III III III III 111
1591972 CASE# 25-6812
ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
'.NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEXi D.O.B. —
MMDDYYYY
PASSENGERQ WITNESS� UNIT SEAT AIRBAG RESTR. EJECT ; HELMET NJURY NATURE OF INJURIES
POS. ' USE CLASS 1 ----�
:NAME
(LAST FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX D.O.B. —
MMDDYYYY
PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURECFINJURIES
POS. USE CLASS ----�
:NAME
(LOST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE#
SEX MMDDYY D.O.B.
YY
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. I USE CLASS
NARRATIVE
RTF
On 08-05-2025 at about 1652 hours, I was sent to a collision which occurred in the parking lot of QFC
on 4800 NE 4th St, with in the City of Renton, King County, Washington.
Upon arrival 1 was informed of the following. Unit 1 was reversing out of his stall. Prior to reversing
he thought it was clear. While reversing he collided with a vehicle behind him.
Unit 2 was traveling southbound going straight when unit 1 reversed into the driver door.
The driver of unit 2 said her left lower back was injured. 1 watched her and she did not move as if she
had a back injury or pain. She was able to get in and out of her vehicle without any difficult or signs of
pain.
When Fire arrived her injury grew and she said she almost died. Fire personnel told me they did not
find any injuries and she did not appear to be in any pain or discomfort.
This collision occurred on private property and both parties had insurance.
No citation was issued to either party.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
E.CHANG 08-10-25 11:03 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVECRY DATE
J.TRADER 4553 811912025 1:49:21 PM
BADGE OR ID# 10065 ORI# WA0171300 TIME POLICE DISPATCHED 1 4:56 PM TIME POLICE ARRIVED i 5:11 PM
PAST B 3 Da-3mx—attar(txIMR) PAGE 2�OF F3
REPORT NO. EG20579 CASE# 25-6812 DATE AND TIME 08/05/2516:52
OF COLLISION
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