HomeMy WebLinkAbout25-80403 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 2 27c
COLLISION REP FIT 1591971
CASE 25-80403 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 12 - 1-- 2025 1600 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
201 SW 5TH PL BLOCK NO. e✓ 200
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FEET e S B W e SW 5TH PL
1 5 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO �/ D:4256470020 0 9 30
6� LAST NAME AHYA FIRSTNAME BHAVNA MIDDLE B 1 1 2 31
INITIAL
STREET ❑1 201 S 5TH PL APT J202 CITY RENTON ST WA 21p 98057 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
LRIIVER # STATE WA SEX'F MM D Y' 09
8❑ — 29 — 1971 1 2 32
9 ON DUTY❑ STATUS AIRBAG 1 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� 997JSX sTArI WAvIN# V/N/2T16URHEXKC238707
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 0 0 33
12 0 1
VIN#' VIN#'
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 0 1996 TOYT COROL SD DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO STATE FARM 4464135B2047 3 4
IN EFFECT &POLICY# 9TOP
VEF" 5 36
LECALLv YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STANDING 8
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
16 a UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO 1/ D:4257499849
LAST NAME HOLLAND-JOHNSON FIRST NAME REGINA MIDDLE ID
INITIAL
17 STREET ITH PL APT J 201 CITY' RENTON ST WA ZIP 98057 37
NEW ADOREs�' 201 S 5
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK yEs I I NOF YEs t l NO❑
19 DRIVER'S STATE WA ]SEX IF D.C... 04 08 _ 1960 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET 2 INJURY 7 NATURE OF INJURIES 40
USE CLASS WHIPLASH
❑ILICENSE 21❑ PLA E# A8744126 TArE 41
WA vIN# 2TIBURHEXKC238707 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
G HI 44
VEH YEAR 2019 MAKE 7'Dy7' MODEL CORO!! STYLE $D DAMAGE TOWED NOO✓ BLIN TOWED BY OV YES
NO
24❑ YES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO PROGRESSIVE 865454926IN 1 9TOP 5
VEHICLE YES CITATION# CHARGE i o BOTTOM
ALLY
NCNC[:]25❑ LE s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
KEITH PETTY 12809 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG58491
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80403
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(LAST FIRST,MIDDLE INITIAL)_
ADDRESS&PHONE#
SEX D.O.B. - -
MMDDYYYY.
PASSENGER❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
PM USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D D B
SEX MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. 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.
KEITH PETTY 12-04-25 09:12 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.THiELMAN 11462 1211312025 10:37:47 PM
BADGE OR ID# ( 12809 ORI# WA0171300 TIME POLICE DISPATCHED' 5:03 PM TIME POLICE ARRIVED 5:03 PM
PART I PAGE IT]OF
REPORT NO. EG58491 CASE# 25-80403 OF COLLISION
12/04/25 16:00
OF CbLLI510N
NARRATIVE
25-80403
On 12/04/2025 at approximately 1753 hours, I was dispatched to 201 SW 5th PI in the City of Renton,
County of King, State of Washington for a recent accident with possible injuries report.
Unit 1: dark green 1996 Toyota Corolla (997JSX/WA) VIN/JT2BA02EOT0131179 driven by Bhavna
Bhavesh Ahya (DOB 09/29/1971)
Unit 2: gray 2019 Toyota Corolla (A8744126 temp tag) VIN/2T1 BURHEXKC238707 driven by Reina
D Holland-Johnson (DOB 04/08/1960).
Unit 1 stated she was leaving her assigned parking spot and began backing up. As she backed up,
she collided into unit 2 who had been stopped behind her.
Unit 2 stated she was waiting for her son to meet her in the vehicle. As she waited, she observed unit
1 enter her vehicle and begin backing up. Unit 1 did not see unit 2 parked behind and collided into the
rear driver's side door causing damage.
Unit 2 was feeling off after a few hours of the accident. She was complaining of possible whiplash as
the vehicle had been jolted from the collision.
Unit 2 was going to go to the hospital to be evaluated.
Both parties had previously exchanged information and I informed both of the case number.
I provided an exchange of information to both parties.
This incident was captured on my body worn camera. This report is a summary of the events that
occurred and is not an exact sequencing of events. Statements have been paraphrased and
summarized
"I certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct."
Electronically signed: K.Petty, Date: 12/04/25at 2043 hours, Place: Renton, King County, WA
PAGE 3 OF 5
REPORT NO. EG58491 CASE# 25-80403 OF COLLISION
12/04/25 16:00
OF CbLLI510N
NARRATIVE
PAGE 4 OF 5
REPORT NO. EG58491 CASE# ' 25-80403 DATE AND TIME 12/04/25 16:00
OF COLLISION
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