HomeMy WebLinkAbout23-1928 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-1928 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
CowsloN 02 - 1-- 2023 1036 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
GLENWOOD AVE NE MILEPOST ST e✓ 1140
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
6❑ 500 00 FMILES
EET e S ❑ W e HARRINGTON AVE NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2064381545 0 11
30
6� LAST NAME SHAVINA FIRSTNAME JIHAN MIDDLE R 1 1 2 31
INITIAL
STREET ❑, 3000 SE ROYAL HILLS DR APT 32 CITy RENTON ST WA ZIP' 980583865 z
NEW ADDRESS
7❑ CDL I
IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES NO INTERLOCK YES No YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1ATE14 CDN3255 STATE WA uN# 2TIBURHE1JC092874
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM To
TRLR. TRLR $ 1 33
12 2 5 VIN#' VIN#
ROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN I
TOWED BY GOVT.VEHCLE $ 1 34
13 2 2018 TOYT COROL DAMAGE YES fn TO YES[:] NOW]1 H
REGISTERED OWNER INFOSARI GUMALA 2580 NE 11 TH PL RENTON WA 98056 VEHICLE NO. 1 ❑
❑
SHADE IN DAMAGED AREA 35❑ INSURANCE CO 4
14 LIABILITY INSURANCE SAME,
IN EFFECT &POLICY# 9TOP
VEHICLe CHARGE to BOTTOM 5 36
LEGALLY YES❑NO❑ CITATION# 1
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4254307500
16 2
LAST NAME DESMET FIRST NAME CHRISTOPHER MIDDLE ,I
INITIAL
17❑ STREET ❑', 1055 S GRADY WAY CITY' RENTON ST WA ZIP 98057 37
NEW ADDRESS ❑
18� CDL ., IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19[ LDI IVER # STATE WA SEX DDY
M M D.O.B.
01 01 1970 El 39
WELMET IN NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS 1 ❑
21❑ LICENSE 66293D TATe WA VIN# 1GNLCDEC1JR302559
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
VEH YEAR 2018 MAKE CHEV MODEL TAHOE STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CITY OFRENTON 3555 NE 2ND ST TON.98056 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&POLICY#E CO SAME,IN 1UQ,
5'E""LE ❑ ,J� CITATION# CHARGELGALYYES 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. ED35841
COLLISION REPORT III III III III III 111
1591972 CASE# 23-1928
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
PM 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 02-17-23 12:41 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 212112023 10:28:24 AM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED; 10:36 AM TIME POLICE ARRIVED',10:36 AM
PART I PAGE IT]OF 4�
REPORT NO. ED35841 CASE# 23-1928 OF COLLISION
02/17/23 10:36
OF CbLLI510N
NARRATIVE
CC
Within the city limits of Renton/King/WA I responded to a 2 car crash near the 1140 block of
Glenwood.
I contacted the driver of unit 2 who told me he was enrt to a call to back another officer was not
utilizing any type of emergency equipment in his marked Renton Police Tahoe. Unit 2 told me he was
at or below 25 mph when he was hit on the driver side of his vehicle. He did not complain of injury
and damages did not require a tow truck.
I contacted the driver of unit 1 who initially told me she was making a left out of a driveway from local
apartments when she was hit on the side of her car. Then told me she had already completed her
turn and was merely going straight ahead when she was hit on the passenger side by unit 2. She did
not complain of injury and damages did not require a tow truck.
I reviewed the dash camera in unit 2 which only revealed about 5 seconds of video pre and post
collision. In the video you can not see unit 1, only a piece of debris fly across the front of unit 2. But
the video does show unit 2 on the proper side of the roadway.
Information/Insurance only
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 2/17/2023
PAGE 3 OF 4
REPORT NO. ED35841 CASE# ' 23-1928 DATE AND TIME 02/17/23 10:36
OF COLLISION
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1140 Glenwood Ave N
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PAGE 4 OF 4