HomeMy WebLinkAbout26-4116 TFFiNouCERA II I III 1 III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 26-4116 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 1 TOTAL#OF OBJECT 1 1 7 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 - 1-- 2026 0853 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
AIRPORT WAY
BLOCK NO. e✓ --- ----� ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e SHATTUCKAVE S
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4254730211 2 01
30
6� LAST NAME MAJORS FIRSTNAME KEYHLIN MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 11042 LOTUS PL S CITY SEATTLE ST WA 2jp, 981783213 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 HELMETU E ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
LICENSE CTB9343 sTArI WAVIN# 2G1FF1E30F9292693
10 F91 PI ATE i4
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T /g[ GOVT.VEHICLE 7 $ 34
13 2 2015 CHEV CAMAR DAMAGE YES NOBS YES : No✓
REGISTERED OWNER INFO KEYHLIN MAJORS 11.2 LOTUS PL S SEATTLE WA 981783213 D:4254730211 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO PROGRESSIVE 4
IN EFFECT &POLICY# 9TOP
15❑ LE
vECALLv Hla.e 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UN�T VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YEs NO 1/ D:4804536688
16 a
LAST NAME GARCIA MEDCNA FIRST NAME PABLO MIDDLE I Y
INITIAL
17❑ STREET ❑', 42421 264TH AVE SE CITY ENUMCLAW ST WA ZIP 980228353 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK Y�EsI I I NOF YEs t l NO❑
19 DRIVER'S STATE WA SEX M D.C.B. O6 _ 14 1984 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I C97688P TAre WA VIN1t 5PVNJ8JP6K4S52716
❑ 41
PLATE#
42
22❑ PILER LATE# STATE pLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2019 MAKE HIND MODEL 258 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO ALBERT LEE INC 1476 ELLIOT AVE W SEATTLE WA 98119 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO VALLEY FORGE 6076524680IN 1UQI
'E""LE ❑ ,J� CITATION# CHARGELEGALLYYES N`L J25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EH12994
COLLISION REPORT III III III III III 111
1591972 CASE# 26-4116
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.
M.LEVERTON 05-28-26 10:38 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
K.LANE 10008 6/17/2026 12:07:37 PM
BADGE OR ID# 2517 OR]# WA0171300 TIME POLICE DISPATCHED 9:09 AM TIME POLICE ARRIVED',9:03 AM
PART I PAGE IT]OF 4�
REPORT NO. EH12994 CASE# 26-4116 OF COLLISION
05/28/26 08:53
OF CbLLI510N
NARRATIVE
unit 1/wht carm lane chagne unit 2 wht truck lane change
RTF
Infornation/insruance only
Within the city limits of Renton/King/Wa I responded to a 2 vehicle blocking crash near the
intersection of Airport Way and Shattuck Ave S.
I contacted the driver of unit 1 who told me he was eastbound on Airport Way in lane 3 and just east
of Shattuck decided to make a lane change into lane 2. This was at the same moment when unit 2
was changing from lane 1 into lane 2 and they made contact. Unit 1 did not complain of injury and he
requested a tow truck for damages.
I contacted the driver of unit 2 who told me he was eastbound on Airport Way in lane 1 and jst as he
was passing Shattuck Ave S he decided to make a lane change from lane 1 into lane 2 while it was
clear based on his statements and thats were he was contacted in the front left wheel by unit 1. He
did not complain of injury and damages did not require a tow truck.
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 5/28/2028
PAGE 3 OF 4
REPORT NO.! EH12994 CASE# 26-4116 DATE AND TIME 05/28/26 08:53
OF COLLISION
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