HomeMy WebLinkAbout25-80480 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
SASE 25-80480 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2❑ TOTAL#OF OBJECT 1 ❑28
TRIBAL UNITS 01 STRUCK' UT/LITYPOLE
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 12 - 1-— 2025 0028 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
UNION AVE NE BLOCK NO. e✓ 1200 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 .❑ FEET e S ❑ w e NE 12TH ST
❑ �
0 3 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063977336 30
6� LAST NAME DENIZ FIRSTNAME PAULO MIDDLE V 1 1 2 31
INITIAL
STREET ❑✓ 2100 LAKE WASHINGTON BLVD N.#Q-107 CITY RENTON ST WA ZIP' 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES 1/ NO
8❑ LRIIVER #
ON DUTY❑ STATUS' AIRBAG 6 RESTR 4 EJECT 1 I [NATURE OF
H U EET 2 1 INJURY
CLASS ju BROKEN NOSE INJURIES z❑
3
10❑ P1 ATE 14 CSM0265 STATE WAa VIN# JTHBA1 D23G5032590
F_ TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR 7 5
2❑ 33
1 VIN#' VIN#'
TRIM
16 LEXS IS-F SO 20
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE
13 2 DAMAGE YES NO YES[:]
NO✓ 34
REGISTERED OWNER INFO pgpLO DENIZ 11.LAKE WASHINGTON BLVD N.#Q-107 RENTON WA 98056 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14❑ LIABILITY INSURANCE z INSURANCE CO GEICO 4522335167 4
LI EFFECT &POLICY# TOPVEHICLE CHARGE 36
LEGALLv res❑NO❑ CITATION# <1�3
OTTOM
15❑ STAIN"'C 7 6
UNIT VE IOOR ❑ CYCLE ❑ PEDESTRIAN ❑ OWNER RTY ❑ DYES NO OLDMET PHONE
16❑
LAST NAME FIRST NAME MIDDLE
INITIAL
STREET
CITY' ST ZIP 4❑ 37
17❑ NEW ADDRESS❑'
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t l NO❑
19 LLIICENS # STATE SEX MMDDYY —❑_ 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TATE VIN# 41
1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1GQ
5
VEHICLE ❑ C[:] CITATION# CHARGE
LEGALLY YES N`LJ
25 s � a
7m-
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
FERNANDES 12848 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EG57693
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80480
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) CET/NO DANIEL I
(I.P.ST FIRST,
ADDRESS&PHONE#
862 PIERCE AVE NE RENTON WA 980563853 4255519218 SEX M MMDDYyry 09 - 29 - 2004
PASSENGER Z WITNESS UNIT# 1 POS 3 AIRBAG 6 RESTR. 4 EJECT ? 1 H U SE 2 INJURY
1 NATURE OF INJURIES
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYVYV
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
Driver 1 was driving eastbound on NE 12TH ST towards Union AVE NE. Driver 1 failed to stop at the
stop sign before attempting to make a right hand (south bound) turn onto Union AVE NE. Driver 1
was unable to complete the turn, lost control of the vehicle and drove into a utility pole on the eastside
of the road in the 1200 block of Union AVE NE. Driver 1 had moderate injuries and was taken to VMC
for medical care. Passenger 1 was uninjured. Vehicle 1 had severe damage to the front bumper and
was towed by Bankers Towing. The utility pole was not damaged.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
MARIA FERNANDES 12-08-25 02:00 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
M.BRAUN 2194 1 1211112025 1:28:37 PM
BADGE OR ID# ` 12848 OR]# WA0171300 TIME POLICE DISPATCHED; 12:29 AM TIME POLICE ARRIVED',12:33 AM
PART I PAGE IT]OF 3�
REPORT NO. EG57693 CASE# ' 25-80480 DATE AND TIME 12/08/25 00:28
OF COLLISION
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