HomeMy WebLinkAbout25-80427 TFFiNouCERA II I III 1 III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 25-80427 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4200 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# ❑
cowsloN 12 - 1-- 2025 0859 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAIN AVE S BLOCK NO. e✓ 400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 150 00 FEET MILES e S B W e S 4TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:5412501459 0 11
30
6� LAST NAME KHLOM FIRSTNAME KEVIN MIDDLE V 1 1 2 31
INITIAL
STREET ❑, 4014 SW 333RD ST CITY FEDERAL WAY ST WA 2jp, 980232924 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� CGK0397 sTArI WAurN# WFODP3TH5G4117475
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 1 34
13 3 2016 FORD FOCUS SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO KEVIN KHLOM 4014 SW 333RD ST FEDERAL WAY WA 98023 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14� IN EFFECT
INSURANCECOSTATEFARM5395784E2147B 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:3607220108
16 a
LAST NAME GOODALL FIRST NAME TEHANNA-MAE MIDDLE I L
INITIAL
17❑ STREET ❑', 316 MEADOW AVE N CITY RENTON ST WA ZIP 980575721 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19[—] LDI IVEW # STATE WA ]SEX IF M D.C.B. 05 _ 05 _ 2001 39
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT '1 USE 2 CLASS ❑
21❑ LICENSE CAX9377 TAre 41
WA vIN# 4S4BSAFC8K3249394
❑
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2019 MAKE SUBA MODEL OUTBAC STYLE SD VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO TEHANNA-MAE GOODALL 17311 W LAKE GOODWIN RD STANWOOD WA 98292 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE 8 POINSURGY#E CO GARRISON PROPERTY 04712 53 11RIN 1 9TOP
'E""LE ❑ N`L J
,J� CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES $ '
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
D.NELSON 12421 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EH10561
COLLISION REPORT III III III III III 111
1591972 CASE# 25-80427
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'
25-80427 ACC
On 12/5/2025 1 was working as a uniformed patrol officer and driving a marked patrol vehicle for the
City of Renton. I was dispatched to a report of a two-vehicle, non-injury, non-blocking collision that
had occurred near the intersection of S Grady Way and Main Ave S Renton/King/WA. The caller was
reporting that both vehicles had moved off the roadway to a nearby parking lot.
I located both vehicles near the intersection of S 4th St and Main Ave S, I confirmed with both drivers
that there were no injuries.
The driver of the 2016 Ford Focus WA/CGK0397 (Unit 1), was identified by his WADL as Kevin V
Kholm DOB: 2/24/1987. Kevin said that he was driving north in the #2 lane on Main Ave S. He said
that Unit 2 was slowing for emergency vehicles that were approaching, and he did not have enough
time to stop and collided with her rear bumper. There was damage to the front bumper/hood of the
Ford. There was no airbag deployment, and the vehicle was drivable.
The driver of the 2019 Subaru Outback WA/CAX9377 (Unit 2), was identified by her WADL as
Tehanna-Mae Goodall DOB: 5/5/2001. Tehanna said that she was driving north in the #2 lane of Main
Ave S and was slowing for emergency vehicles when she was rear-ended by Unit 1. There was minor
damage to the rear bumper of the Subaru. There was no airbag deployment, and the Subaru was
drivable.
Nothing further.
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true
and correct.
D. Nelson #191 12/5/2025 Renton WA
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
D.NELSON 12-05-25 03:17 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 12/22/2025 10:12:27 AM
BADGE OR ID# 12421 ORI# WA0171300 TIME POLICE DISPATCHED' 9:02 AM TIME POLICE ARRIVED 9:06 AM
PART I PAGE IT]OF 3�
REPORT NO.! EH10561 CASE# 25-80427 DATE AND TIME 12/05/25 08:59
OF COLLISION
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