HomeMy WebLinkAbout25-8501 IT si " II IIIII III IIIII II IIII IIIII I . 27c REPORT NO EG33737OLCERA
COLLISION REPORT 1591971
CASE# 25-8501 2
INTERSTATE CITY STREET FIRE I
RESULTED STOLENSTATE ROUTE OTHER VEHICLE LOCAI-A`NG 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 28
TRIBAL i UNITS 01 STRUCK ROADWAY DITCH
RESERVATION 2
3� M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY#
eDCL s on' 10 - 01 - 2025 0805 17 =.[� S 8 W e OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO.
MONSTER RD S
4a❑ MILE POST
❑ DISTANCE OF(REFERENCE OR CROSS STREET)
5 1.1 FEET e S 8 W e BEACON COAL MINE RD
0 1 29
MOTOR ✓ PEDAL- DAM AG THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE ❑ YES ✓NO 30
6 LAST NAME ROMERO-PEREZ FIRST NAME ENRIQUE MIDDLE N 1 1 2 31
INITIAL
STREET ] 13000 MLK JR WAY S TRLR 56 CITY; SEATTLE ST WA ZIP' 981784614 2
NEW ADDRESS
7 +CDL IGN(TIUN REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED: 3
INTERLOCKYES NO INTERLOCKYEs N YES F No
8❑ DRIVERCENS # STATE WA SEXI M MMDDYY' 01 - 15 - 1984 32
9 ON DUTY STATUS' AIRBAG 2 RESTR 9 EJECT 1 N USEET CLASSY 1 NATURE of INJURIES 2=
LICENSE, CFD1717 STATE WA y 1GNDM19X23B107045 3
10� as ATP rt IN#
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR TRLR. 5 1 33
12 VIN#' VIN#
FROM TO
13 2 VEH.YEAR2003 MAKE CHEV MODEL ASTRQ STYLE VEHICLE TOYED NO�iS46LIN T�VyED.6LRS GES❑END m 34
DAMAGE IIII._IIII HHttVVii((tt
REGISTERED OWNER INFO ENRIQUE ROMERO-PEREZ 13000 MtK JR WAYS TRLR 56 SEATTLE WA 981784614 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE NSURANCE CO NEW INSURANCE 2030230708
IN EFFECT &POLICY# 9TOP
VEHICLE CHARGE 36
LecnLLY YES❑NO❑ CITATION# t a 80TFOM
15❑ ETnNowc s 7 e
MOTOR PEDAL-:. PROPERTY DAM THR OLD MET PHONE
UNIT 02 PEDESTRIAN
VEHICLE CYCLE' DOWNER YES NO
16❑
LAST NAME FIRST NAME MIDDLE'
INITIAL
17❑ STREET ❑ CITY ST ZIP ❑ 37
NEW ADDRESS
1$❑ CDL IGNITION REQUIRED IGNITION PRESENT MED[CALTRANSPORTED 38
INTERLOCKYEs No INTERLOCK YES R No vEs NQ
19 DRIVERS
# STATE SEX MMDDYY -= 39
HELMET INJURY NATURE OF INJURIES 4Q
20❑ ON DUTY STATUS AIRBAG RESTR EJECT USE CLASSLICENSE
❑
21 PLATE# T-1- VIN# 41
22❑ [TILER TAILER
PLATE# STATE PLATE# STATE 42
23 TRLR RLR 43
UIN#. 'IN It
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY GOV HI 44
24 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# GQ
YemCLE ❑ ,.I—I CITATION# CHARGE
EEEILY YES N`.L J
25a ' s
7'OFFLIl'tER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
VERTON 2517 WA0171300
PAGE 01 OF
PART A 3000-348-189(R 11/18)
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG33737
COLLISION REPORT III III III III III 111
1591972 CASE# 25-8501
E NA ADDITIONAL PERSONS INVOLVED(PASSENGERS AND/OR WITNESSES ONLY)
M
(LAST,FIRST,MIDDLE INITIAL) SHIROKANE TAKATO
ADDRESS&PHONE
2062766962 SEXi M MMDooYBVYv 12 - 21 - 1962
PASSENGER WITNESS UNIT SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS ----�
:NAME
(LAST FIRST MIDDLE INITIAL)
ADDRESS&PHONE#
SEX MMDDYYYY D.O.B. -
PASSENGER❑WITNESS UNIT# : SEAT AIRBAG RESTR. EJECT HELMET INJURY: NATURE CFINJURIES
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
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.
M.LEVERTON 10-01-25 11:26 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST.DET DATED PLACE SIGNED
APPROVED BY DATE
RAYMOND GORAJEWSKI 12399 101212025 8:38:32 AM
BADGE OR ID# ; 2517 ORI# WA0171300 TIME POLICE DISPATCHED 8:05 AM TIME POLICE ARRIVED i 8:09 AM
PAST B 3 Do-3mx-attar(t 1Mff) PAGE 2�OF 4
REPORT NO. EG33737 CASE# 25-8501 O OF COLLISION TIME 10/01/25 08:05
NARRATIVE
wit nb turn left at bcmrd unit 1 late brake into ditch rolled on side ni
RTF
Within the city limits of Renton/King/Wa I responded to a single vehicle roll over into a ditch near the
500 block of Monster Rd SW.
I arrived a located unit 1 on its side blocking northbound Monster near the intersection of Beacon
Coal Mine Rd.
A witness stopped behind where unit 1 was located told me the following. Wit was northbound and
had slowed to a stop signalling his intention to make a left turn onto BCM Rd. He told me it appeared
that unit 1 braked late and skidded off the roadway to avoid contacting him and went into the ditch
rolling his van on its side. He told me he was not contacted by unit 1.
Unit 1 did not provide much information about the crash. He provided a valid WADL and insurance.
He said he steered away from another car and crashed. Unit 1 did not complain of injury and
declined Fire. Damages required a tow truck.
Information/Insurance only
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 10/01/2025
PAGE 3 OF 4
REPORT NO. EG33737 CASE# 25-8501 DATE AND TIME 10/01/25 08:05
OF COLLISION
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