HomeMy WebLinkAbout22-13749 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 22-13749 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑RESULTED
1 STOLEN
STATE ROUTE OTHER ❑ VFHIC;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#
COLLISION.. 12 - 1-— 2022 2150 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
MAPLE VALLEY HWY BLOCK NO. e✓ 14000 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 ❑ FEET e S ❑ W e 140THWAYSE
❑
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2066171189 0 4 30
6� LAST NAME DORE FIRSTNAME ANNA MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 13818 SE 144TH ST CITY RENTON ST WA 2jp, 98053 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YEs NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H U EET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� 034YEN sTAT1 WAVIN# 5FNYF18228B054930
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM ro
TRLR. TRLR 7 3 33
12 3 5 VIN#j VIN#
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 5 7 34
13 4 2008 HOND PILOT UT DAMAGE YES NO �MEYERS YES❑ NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 UABILI INSURANCE INSURANCE CO FARMERS 515782259 4
IN EFFECT &POLICY# TOPVEHCLE CHARGE 36
LEGALLYYES❑NO❑ CITATION# 2A0603282 FAIL TO OBEY TRAFFIC CONTROL <1�3
orroM
15❑ STANDING 7 6
MOTOR PEDAL- PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER ❑ YES 1/ NO D:2069100280
16 a
LAST NAME SCHIFFNER FIRST NAME TRACI MIDDLE A
INITIAL
17❑ NEW STREETREs7 16700 SE 161ST ST CITY RENTON ST WA ZIP 98058 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED ❑ 38
INTERLOCK YEs❑NOR INTERLOCK YEs It I NOF YES t l NO❑
19 DRIVER'S STATE WA ]SEX IF D.C... 12 _ 27 1974 39
LICENSE# MMDDYY
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG,4 RESTR 4 EJECT ''1 USE CLASS ❑
❑21❑ PLA E# CAL8461 TATe WA VIN# Y►/4A221K6M1690988 41
1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV GOV HI 44
VEH YEAR 2021 MAKE VDLV MODEL XC90 STYLE (/T DAMAGE TOWED✓ NOO BLIN GENE MEYERS YES NO�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO TRAVELERS 6082745442031IN 1 9TOP 5
'E""LE ❑ N`L J
,J� CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES $
=KI
(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26 12598 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED22017
COLLISION REPORT III III III III III 111
1591972 CASE# 22-13749
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) KONG FANYI
(LAST FIRST,
ADDRESS&PHONE# D.O.B.
4255535791 SEX' U MMDDYYYY -❑
----------------------------
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ 0 POS. USE CLASS
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On Monday, December 26th at 2153 hours, I was dispatched at a two-vehicle collision in the
intersection of Maple Valley Highway and 140th Way SE.
The following occurred within the City of Renton, King County; Unit 1 - WA/ 034YEN was being
driven by Anna Dore and was driving eastbound on Maple Valley Highway in the 14000 block in lane
#2. Unit 2 - WA/ CAL8461 was driven by Traci Schiffner and was driving northbound on NE 140th
Way SE in lane #2. Unit 1 was driving straight ahead, Anna stated she was lost in thought and did not
observe that the traffic control light was illuminated RED, she proceeded through the intersection and
was unable to avoid colliding with Unit 2. The front bumper of Unit 1 crashed into the rear fender of
Unit 2. Both vehicles sustained reportable damage and neither vehicle needed to be towed. Anna
was distracted and did not stop for the red traffic control device which led to Unit 1 being the
contributing factor and fault for the collision. Anna was issued a citation for failure to obey a traffic
control device.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.WISN/EWSKI 12-26-22 11:43 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.TOLLIVER 10540 1/5/2023 2:29:42 AM
BADGE OR ID# 12598 OR]# WA0171300 TIME POLICE DISPATCHED 9:82 PM TIME POLICE ARRIVED 9:59 PM
PART I PAGE IT]OF 3�
REPORT NO. ED2 O]7 CASE# 2 d a7 9 A m°M/ ]y2 g2 2t5
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