HomeMy WebLinkAbout23-01025 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-01025 z
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ HIT F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2� TOTAL#OF OBJECT 1 �2$
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 01 - 1-- 2023 1816 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
BLOCK
FERNDALEAVNE M100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5 MILES 9❑ 30 00 FEET e S B W e NE 1ST ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2537777561 30
6 LAST NAME RAMOS PELAYO FIRST NAME MARITZA MIDDLE 1 2 31
INITIAL
STREET ❑✓ 9704 18 AV CT S#U2 CITY TACOMA ST WA ZIP 98444 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 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ Pi aT�S� CF63156 sTArr WAurN# 4T18E32K15U385199
TRAILER STATE TRAILEk STATE
11 2 5 PLATE# PLATE# Rom TO
TRLR. TR 7 3 LR 33
12❑ VIN#' VIN#
FROM
34
13� VEH.YEAR2OOS MAKE TOYT MODEL CAMRY STYLE SD VEHICLETOWED0NOOffBLIN T,QyYE XTE Es[:] NOW]
DAMAGE IILLJJII YYCIVA
REGISTERED OWNER INFO MARITZA RAMOS PELAYO 970418 AVCTS#U2 TACOMA WA 98444 D:2537777561 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ UABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# STOP
vErIICE CHARGE 5 36
LEGALLv res❑NO❑ CITATION# BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY ,� DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES, NO D:4254307500
16❑
LAST NAME CITY OF RENTON FIRST NAME MIDDLE
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 TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIRIVERS # STATE SEX U MMDDYY 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TArE vIN# 41
PLATE#
42
22❑ PR TRAILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
24❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE❑ INSURANCE
#E CO
IN EFFECT &PO I STOP 5
"'LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES Nu
25 s � a
=HSU
AME(PRINT) OFFICER PHONE BADGE OR ID#
26 12651 [V7�ENCY
A0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED30527
COLLISION REPORT III III III III III 111
1591972 CASE# 23-01025
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) PALMA POLENDO MIGUEL A
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
1815 97TH ST S TACOMA WA 98444 SEX M MMDDYyry 08 - 09 - 1991
PASSENGER WITNESS UNIT# 1 PEA i 3 AIRBAG 2 RESTR. q EJECT ? 1 HELMET NJURY NATURE OF INJURIES
USE CLASS !1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
Ex 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'
Unit 1 driver traveling south on Ferndale Av NE planning on turning left onto NE 1 st St. Unit 1 driver
makes mistakes and turns eastbound, left turn onto a partially paved gravel sidewalk leading into a
city park/rest area. Unit 1 continues past the gravel sidewalk and drives over wet grass field, causing
reportable damages to the grass field owned by the City of Renton. No reportable damage to Unit 1.
No injuries reported. Unit 1 was later privately impounded. No evidence of impairment. Unit 1 driver
admitted that she did not have her prescription glasses on when operating a motor vehicle at night.
Unit 1 driver also admitted that she did not have vehicle insurance.
**** AUTO-POPULATED SECTION ****
THE FOLLOWING ARE DESCRIPTIONS ENTERED FOR ITEMS SELECTED AS "OTHER":
Motor Vehicle Unit 1
Roadway Surface: GRASS
**** END OF AUTO-POPULATED SECTION ****
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
HANSEN HSU 01-25-23 12:16 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.TOLLIVER 10540 2/2/2023 5:15:36 AM
BADGE OR ID# 12651 OR]#' WA0171300 TIME POLICE DISPATCHED 6:17 PM TIME POLICE ARRIVED',6:24 PM
PART I PAGE IT]OF 3�
REPORT NO. ED30527 CASE# ' 23-01025 DATE AND TIME 01/24/23 18:16
OF COLLISION
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car
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NOT TO SCALE F�..
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