HomeMy WebLinkAbout22-9511 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED37019 170
27
COLLISION REP FIT 1591971
CASE 22-9511 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 2 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'. O9 - 1-— 2022 1739 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
ROUSER WAYN BLOCK NO. e✓ 1400 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a BRONSON WAYN
0 8 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YEs No ,/ D:9548015234 0 3 30
6� LAST NAME JACKSON FIRSTNAME CHLOE MIDDLE B 1 1 2 31
INITIAL
STREET ❑✓ 1725 156TH ST CT E CITY SEATTLE ST WA ZIP 981225680 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
,/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� CEA5651 sTArI WAurN# KNDJX3AE5H7022204
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 3 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 3 34
13 3 2017 KIA SOUL UT DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO CHLOE JACKSON 1725156TH STREET CTE TACOMA WA 98445 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
IN EFFECT LIABILITY INSURANCE INSURANCE CO STATE FARM 5188884A09.47 4
IN EFFECT &POLICY# 9TOP
Ela.e CHARGE 5 36
LvECALHLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES,/ NO D:2068866235
16 a
LAST NAME KORA FIRST NAME ISHA MIDDLE I D
INITIAL
STREET
17❑ NEW ADDREss❑' 26108 170TH PL SE CITY COVINGTON ST WA ZIP 980428374 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YES
t l NO
�
19 D IVEW #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑LICENSE 21❑ PLA E# CEC7785 TArE 41
WA VIN# 19XF62F99EE232293 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2014 MAKE HOND MODEL CIVIC STYLE 4D VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YESfj
NO,/ YES NO
REGISTERED OWNER INFO ISHA KORA 3005SW325THPL FEDERAL WAYWA 98023 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU8 PORGY#E CO GEICO 6110364210IN 1UR'E""LE
❑ ,J� CITATION# CHARGELEGALLYYES N`LJ
25 OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED37019
COLLISION REPORT III III III III III 111
1591972 CASE# 22-9511
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'
On 9-14-22 at about 1744 1 arrived at the Henry Moses Aquatic center for a collision that occured at
the intersection of Bronson Way N and Houser way N. I contacted both drivers in the parking lot.
Both drivers were identified via WADL.Investigation revealed that both units were turning right from
Houser Way North onto Bronson Way N. when unit 1 failed to maintian its lane and collided with unit
2. Both vehicles were driveable. There were no reported injuries. Both vehicles were released to the
drivers.
This collision occurred in the city of Renton, County of King.
I declare under penalty of perjury under the laws of Washington State that the foregoing is true and
correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 12-12-22 12:13 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 2/24/2023 6:05:50 PM
BADGE OR ID# 1953 ORI# WA0171300 TIME POLICE DISPATCHED{ 5:44 PM TIME POLICE ARRIVED 5:44 PM
PART I PAGE IT]OF
REPORT NO. ED37019 CASE# ' 22-9511 DATE AND TIME 09/14/22 17:39
OF COLLISION
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