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HomeMy WebLinkAbout25-7986 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG31029OLCERA COLLISION REPORT 1591971 INTERSTATE CITY STREET FIRE ❑ CASE# 25-7986 2 RESULTED 1 STATE ROUTE OTHER STOLEN ❑ ❑ VEHICLE ❑ LOCALAGENCY 3 HIT&RUN C©DIN6 COUNTY RD PRIVATE WAY INVOLVED 2 TOTAL#OF OBJECT o 7 28 TRIBAL UNITS 03 STRUCK RESERVATION : 1 1 2 3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# eaCLson' 09 - 13 - 2025 1840 17 =.= S 8 W e IN e 1070 s 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑ BLOCK NO. e .� 4a NE 4TH ST MILE POST ❑ DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 1. FEET e S 8 W e QUEEN AVE NE 0 1 29 MOTOR PEDAL- DAMAG THRESHOLD MET PHONE UNIT 01 VEHICLE ❑ CYCLE ❑ YES ,/No D:4254433041 0 1 30 6 LAST NAME JOHNSON FIRST NAME JEFFREY MIDDLE I W 1 1 2 31 INITIAL STREET ❑ 2417 BLAINE AVE NE CITY; RENTON ST WA ZIP 98056 2 NEW ADDRESS 7 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 INTERLOCK YES NO,/ INTERLOCKYEs No�/ YEs NO,/ 8❑ DCIENSE# STATE WA SEXI M MMDDYY' 03 - 27 - 1971 1 2 32 -NJUR 9 ON DUTY STATUS' AIRBAG 2 RESTR 4 EJECT 1 HELMET 2 CLASSY 1 [NATURE of INJURIES 2 LICENSE, CDW3168 STATE WA VIN# 2HGEJ6445TH112412 3 10 Fl I as ATP rt 0 TRAILER STATE TRAILER STATE 11 0 0 PLATE# PLATE# ROM To TRLR TRLR 3 7 33 12 0 0 VIN#' VIN# FROM TO VEH.YEAR 1996 MAKE HOND MODEL CIVIC STYLE HB VEHICLE TOWED[n TO ZBUN TOWED By GOVT VEHICLE 3 7 34 13 DAMAGE YES II_II NO YESII_I) NO REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE R 1 SHADE IN DAMAGED AREA 35 LIABILITY INSURANCE INSURANCE CO 2 3 14 ❑ NONE PROVIDED IN EFFECT &POLICY# 4TOP VEHICLE CHARGE 36 LecnLLr yes❑NO❑ CITATION# 7 0 80TTOM 15❑ srnNowc 7 MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE UNIT VEHICLE CYCLE nWNFR YES,/ NO D:2064322719 16� LAST NAME NISLEY FIRST NAME ' KARISSA MIDDLE' ' Y INITIAL STREET ❑ 17 ❑ 375 UNION AVE SE UNIT 79 CITY RENTON ST, WA ZIP 98059 q 37 NEW ADDRESS 18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 38 INTERLOCKYEs No INTERLOCK YES No vEs No 19 DRIVER'S STATE WA SEX F I D.O.B. 11 14 2000 39 LICENSE# MMDDYY - 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 R U ET 2 INJURY 1 NATURE OF INJURIES 40 SS 21 LICENSE CEB5888 rare WA vIN# JH4CU2F6XCCO22968 41 22❑ PLATE# STATE[TILER I PLATE# STATE 42 23 TRLR RLR 43 UIN#. 'IN# VEH.YEAR 2012 MAKE ACUR MODEL T$X STYLE $D VEHICLE TOWED TO BLIN TOWED BY GOV HI 44 24 DAMAGE YES NO,/ NO REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE NO.2 SHADFY DAMAGED AREA 3 4 LIABILITY INSURANCE INSURANCE CO USAA 031057497R IN EFFECT &POLICY# 9TOP vewaE ❑ ,J—I CITATION CHARGE t080TTOM EEGnEEy YES N 25 e OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY 26 E.EDMUNDS 12576 WA0171300 PAGE 01 OF PART A 3000-345-189(R 11/18) STATE OF POLICETRAFFICN CORRECTION REPORT NO. EG31029 COLLISION REPORT III III III III III 111 1591972 CASE# 25-7986 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 Unit 3 was stopped at the stop sign, facing southbound on Queen Ave NE entering the intersection with NE 4th ST. Unit 1 was traveling westbound on NE 4th St, approaching the intersection with Queen Ave NE, in the lane closest to the curb. Unit 2 was traveling westbound, directly behind Unit 1. Driver 1 stated the vehicle in front of him made a right turn onto Queen Ave NE, revealing Unit 3 encroaching into his lane of travel. Driver 1 hit his brakes to avoid colliding with Unit 3. Driver 2 stated she braked and swerved to avoid hitting Unit 1. Driver 1 was unable to avoid colliding with Unit 3 and Driver 2 was unable to avoid colliding with Unit 1. All involved parties provided a valid WA driver's license and registration. Driver's 2 and 3 provided proof of insurance. Driver 1 was unable to provide proof at the time of request. No party complained of pain or injury at the scene of the crash, to include 2 other adults and a child in Unit 2. 1 provided an exchange of information to all involved drivers. Unit 1 and Unit 3 were drivable. Unit 2 was towed from the scene by Banker's towing. 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 E. Edmunds/#12576 at 0146 hours on 09/13/2025, in the City of Renton, WA. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. E.EDMUNDS 09-13-25 08:30 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED APPROVED BY DATE J.CHRISTIANSEN 10437 912312025 8:18:54 PM BADGE OR ID# 12576 ORI# WA0171300 TIME POLICE DISPATCHED 1 6:40 PM TIME POLICE ARRIVED i 6:40 PM PAST B 3 Da-3mx—attar(t 1Mff) PAGE 2�OF 4 SUPPLEMENTAL REPORT No. EG31 029 POLICE TRAFFIC 1 1 0 27 COLLISION REPORT CASE# 25-7986 t113197 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE UNIT# USDOT ICC# VEHICLE TYPE CARGO BODY: 3 TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER L ADDRESS CITY ST ZIP 4 ❑ NAME # PLACARa GWVR NAME IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS 'J MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE UNIT# 3 �✓ PEDESTRIAN1:1 El NO D:2064121476 5 VEHICLE CYCLE OWNER 0 3 29 LAST NAME ABBI FIRST NAME XADI$ : MIDDLE' A INITIAL STREET 30 NEW AnnRFs 2100 LAKE WASHINGTON BLVD N APT P305 CITY RENTON ST WA I ZIP 1 917056 6 [2 1 1 2 31 CDL IGNITION REQUIRED IGNITION PRESENT MECiICALTANSPORTED INTERLOCK YEs NO Z/ INTERLOCK YESO NOZ L DRIVER'S STATE WA SEX M D.O.B 01 LICENSE MMDDY - 01 - 1978 ON DUTY STATUS AIRBAG 2 RESTR. 4 EJECT 9 HELMET 2 INJURY 1 NAruREofINJURIEs 7 USE ;CLASS ; 8 ❑ 1 32 LICENSE CDH6912 TAT WA VIN 4T1C31AK8NU583472 PLATE# 9 TRAILER TRAILER L PLATE# STATE PLATE# STATE 0 10 ❑ TRLR TRLR VIN.# VIN#. 11 0 0 VEIL YEAR2022 MAKE TOYT MODELCAMRY STYLE SD VEHICLE TOWE E T ABLIN TOWED BY GovT.vEHICI E FROM TO DAMAGE YES NO ✓ YES NO REGISTERED OWNER INFOOWNED BYDRIVER 7 33 12 � SHADE IN DAMAGED AREA 4 FROM TO INSURANCE CO LIABILITY INSURANCE PEMCO 2064717 5 ❑ IN EFFECT &POLICY# 5Tt7P m 34 13 $ vEnic�E YES NO CITATION CHARGE 1E2801 TOM ecauv sTnNoiNc (� 7 v MOTOR PEDAL_ ' 1:1PROPERTY DAMAGE THRESHOLD MET PHONE 35 14 ❑ UNIT# VEHICLE CYCLE PEDESTRIAN OWNER YES NO 36 15 LAST NAME FIRST NAME NIT AL 16 ❑ STREET �' CITY ST ZIP NEW ADDRESa CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED. INTERLOCK YES NO INTERLOCK YES No :YES NO' ❑ 17 4 37 RIVER'SLLIICENSE# STATE SEX Moog _ C-----� 18 ❑ ❑ HELMET 'INJURY: NATURE OF INJURIES 38 ON DUTY STATUS AIRBAG RESTR. EJECT USE CLASS.: 19 ❑ LICENSE TAT VIN# 39 PLATE# 20 TRAILER' TRAILER 40 PLATE#, STATE PLATE# - STATE ❑ 21 ❑ ❑ 41 TRLR TRLR VIN# VIN#:' 42 22 VEH.YEAR MAKE I MODEL I STYLE VEHICLE TOWED DUET ABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO. SHADE IN DAMAC ED AREA 43 2 3 4 LIABILITY INSURANCE INSURANCE CO IN EFFECT I &POLICY# ).c;Q F. 44 vewc�e ❑ ❑ CITATION# CHARGE 24 I..EGALLY YES NO STIWDING 8 3 G 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. E.EDMUNDS 09-13-25 08:30 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED 26 BADGE 1 OR ID# 12576 O#RI WA0171300 APPROVED 9/223/2025 PAGE OF� 3000-345-013(R 11t18) REPORT NO. EG31029 CASE# 25-7986 DATE AND TIME 09/13/2518:40 OF COLLISION aS } m Y y,H 4, 1 � i a� t . } Y i ; i t f l . f. 1 PAGE 4 OF 4