HomeMy WebLinkAbout26-1607 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
SASE 26-1607 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICCI F ❑ LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2� 1 1 8 28
TOTAL#OF OBJECT
TRIBAL UNITS 02 STRUCK' UTILITY
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 02 - 1-- 2026 1235 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
111TH AVE SE BLOCK NO. e✓ 16600
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTU '�01 VEHtOR Z CLE CYCCLE. El �ESAGE NHORE✓LD MET PHONE 0 6 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNIT{ON PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCK YES NO YES No
8❑ LIRCIENSRE#
SrA fE I
SEX u MMDOBYY - 1 1 2 32
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 1 H USEEr 9 CLAY 0 NATURE OF INJURIES z❑
3
LICENSE sTATI urN#'
10[9 PI ATE#
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
rRLR. TRLR. 1 5 33
12 2 $ VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE $ 34
DAMAGE YES YES❑ N
13 2 O✓
REGISTERED OWNER INFO UNKNOWN VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
vEHICLE CHARGE 5 36
LEGALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066570045
16 a
LAST NAME NDURA FIRST NAME SAMUEL MIDDLE W
INITIAL
17❑ STREET I 16606 111TH AVE SE CITY' RENTON ST WA ZIP 98056 37
EDOREss❑'
18❑ CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL t—T�RANSPORTED ❑ 38
INTERLOCKYES�NO� INTERLOCK YEs I I No� YES t l NO❑
19[—] DCENS STATE WA SEX M M D.C.B. 05 _ 14 2002 El 39
WELMET {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 4 EJECT '1 USE 2 CLASS 1 ❑
❑21❑ PLATE# CEH9586 TATE 41
WA vIN# WBA3C3C5XEF986765 4
42
22 [TRAILER TILER
❑ [PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN It IN#.
VEH YEAR 2014 MAKE BMW MODEL 820 STYLE SD VEHICLE TOWED TO BLIN TOWEDey GOB HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO SAMUELNDURA 16606111THAVESE RENTONWA98056 D:2066570045 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO METROMILELCP708-7020-889IN VEHICLELLY ❑ CITATION# CHARGE
25 <E�00,
LEGA YES N`E]
s � e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# [AGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EG82516
COLLISION REPORT III III III III III 111
1591972 CASE# 26-1607
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
POS. 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'
Unit 2 was traveling southbound on 111th AVE SE approaching their residence at 16606 111th AVE
SE. Unit 1 was traveling behind Unit 2. Unit 2 slowed to make the left (east) turn into their driveway.
Unit 1 did not slow and the front end of Unit 1 struck the rear end of Unit 2. This impact sent Unit 2
forward into a utility pole. Unit 1 fled the scene.
Unit 1 is only described as a black pickup truck-possibly a Dodge Ram. Driver 2 could not identify
Driver 1. Unit 1 or Driver 1 remain unidentified.
Unit 2 sustained minor damage to the rear, but heavy and disabling damage to the front impact with
the pole. As the vehicle was already in the driveway of his residence, Unit 2 did not require a tow.
Driver 2 did not report any injuries.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 02-27-26 01:36 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 3/3/2026 10:03:45 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED 12:46 PM TIME POLICE ARRIVED 12:52 PM
PART I PAGE IT]OF 3�
REPORT NO. EG82516 CASE# ' 26-1607 DATE AND TIME 02/27/26 12:35
OF COLLISION
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