HomeMy WebLinkAbout26-3651 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 26-3651 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
cowsloN 05 - 12 - 2026 0658 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE PETROVITSKY RD BLOCK NO. e✓ 12500
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2063447864 0 11
30
6� LAST NAME NARDELLA FIRSTNAME JOHN MIDDLE P 1 1 2 31
INITIAL
STREET ❑ 19824 SE 206TH ST CITY MAPLE VALLEY ST WA 21p 980386405 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10 9❑ Pi aT�S� C26160V sTArI WAurN# 3C6UR5DL5tG252570
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM To
TRLR. TRLR. 3 7 33
12 3 5 VIN#' VIN#'
>; FROM TO
VEH.YEAR 2020 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED By GOVT.VEHICLE 3 7 34
13 4 RAM 2500 DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO PURE PA214899807 4
IN EFFECT &POLICY# 9TOP
VEwcLe CHARGE 1 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2065951001
16 a
LAST NAME WEBBER FIRST NAME ANGELA MIDDLE lK
INITIAL
17❑ STREET ❑', 15606 93RD CT NE CITY' BOTHELL ST WA ZIP 980116809 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑NOR INTERLOCK yEs I I NOF YEs t l NO❑
19 DRIVER #
INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I CRF4685 TAre WA vIN# 2LMTJ8LR1GBL24201
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
GI
VEH YEAR 2016 MAKE LINO MODEL IVJK)( STYLE DAMAGE TOWED NOO✓ BLIN TOWED BY ov HyES NO 44
24❑ ES
REGISTERED OWNER INFO OWNED BY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE❑ INSURANCE CO
IN EFFECT &POLICY# I
25 veeL icLEcnLLv YES❑ NEICITATION# 6A0254436 CHARGE OP MOT VEH W/OUT INSURANCE UQ,
E
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
C.ARNOLD 12509 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EH03722
COLLISION REPORT III III III III III 111
1591972 CASE# 26-3651
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'
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.
C.ARNOLD 05-12-26 08:14 AM
NVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOSS 1953 511812026 7:53:16 AM
BADGE OR ID# 12509 ORI# WA0171300 TIME POLICE DISPATCHED; 7:05 AM TIME POLICE ARRIVED 7:21 AM
PART I PAGE IT]OF 4�
REPORT NO. EH03722 CASE# 26-3651 OF COLLISION
05/12/26 06:58
OF CbLLI510N
NARRATIVE
CC 26-3651
On 5/12/2026 at 0705 hours I was dispatched to a motor vehicle collision at around the 12500 block
of SE Petrovitsky Rd in the City of Renton, King County, Washington.
Pre-Collision
Driver 2 stated that she was traveling West on SE Petrovitsky Rd in the #2 lane at around the 12500
block.
Driver 1 stated that he was traveling West on SE Petrovitsky Rd in the #2 lane at around the 12500
block.
Collision
Driver 2 stated that Unit 1 passed her in the oncoming lanes of travel and merged into her vehicle.
Driver 2 stated that the front drivers side fender of Unit 2 collided with the passenger side doors of
Unit 1.
Driver 1 stated Unit 2 had entered the #1 lane and then was trying to merge back into the #2 lane.
Driver 1 stated that Unit 2 merged into Unit 1, causing the front drivers side fender of Unit 2 collided
with the passenger side doors of Unit 1.
Injuries
None reported.
Vehicle Disposition
Both vehicles were operational.
Proximate Cause
I am unable to determine the proximate cause of this collision as both drivers have drastically
different stories as to what happened. This report is for insurance purposes only.
Driver 2 did not have valid insurance at the time of collision and was cited reference RCW 46.30.020.
1 certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer C. Arnold #12509 at 07:53 on 5/12/2026 in the City of Renton, King
County, Washington.
PAGE 3 OF 4
REPORT NO. EH03722 CASE# 26-3651 DATE AND TIME 05/12/26 06:58
OF COLLISION
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PAGE 4 OF 4