HomeMy WebLinkAbout23-2252 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-2252 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#
cawsloN 02 - 1-- 2023 1450 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ --- ----� ❑
SE 180TH ST MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e 108THAVE SE
0 1 29
MOTUNIT O1 VEHICR PI PEDAL-CLE CYCLE ElYYESA✓NO THRESHOLD MET PHONE 0 3 30
6� LAST NAME OTERO-ORTIZ FIRSTNAME EVELIO MIDDLE R 1 1 2 31
INITIAL
STREET ❑1 26836 110TH AVE SE CITY KENT ST WA 2jp, 980307184 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10❑ P1 aT�S� CAR2769 sTArI WAurN# 5N1AN08W86C505835
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FR.. ro
TRLR. A'RLR. 1 5 33
12 3 5 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 7 $ 34
13 2 2006 NISS XTERRA DAMAGE vE8 0NO f �LII� RS vEs❑ No✓
REGISTERED OWNER INFO EVELIO OTERO-ORTIZ 26836110TH AVE SE KENTWA98030 D:2533282001 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO SAME. 3 4
IN EFFECT &POLICY# 9TOP
vEHICLE CHARGE 5 36
LEcnLLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STAIN.F' 8 6
UNIT 02 VEHICLE CYCLE ❑ PEDESTRIAN ❑ OWNER
RTY ❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME AHMED FIRST NAME TIMIRO MIDDLE N
INITIAL
17❑ STREET ❑', 11725 SE 193RD PL CITY' KENT ST WA ZIP 980310359 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19 LDI IVEW # STATE WA ]SEX IF M .C... 01 01 1969 El 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BDR6090 TAre WA YIN# 1(BIZC5E128F218446
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
VEH YEAR 2011 MAKE CHEV MODEL MALIBU STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES✓ NO BANKERS YES NO✓
REGISTERED OWNER INFO HUSSEIN SAHAL 11725 SE 193RD PL KENT WA 98031 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&POLICY#E CO PEMCO CA 1986852IN 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. ED40384
COLLISION REPORT III III III III III 111
1591972 CASE# 23-2252
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'
blk/2 sedan rt from 180 tan suv lane 1 sb
RTF
Within the city limits of Renton/King/WA I responded to a 2 car crash blocking at the intersection
108th Ave SE at SE 180th St.
I contacted the driver of unit 2 who told me she was making a right turn from 180th to 108th (EB to
SB) on her green when unit 1 crashed into the side of her car. She did not complain of injury and
damages did require a tow truck.
I contacted the driver of unit 1 who told me he was on his green light lane one sb on 108th when unit
2 pulled out in front of him. He did not complain of injury and damages required a tow truck.
There were no witnesses or other evidence to corroborate either story.
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 3/2/2023
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 03-02-23 06:02 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 3/7/2023 3:13:47 PM
BADGE OR ID# 2517 ORI# WA0171300 TIME POLICE DISPATCHED 2:54 PM TIME POLICE ARRIVED',2:59 PM
PART I PAGE IT]OF
REPORT NO. ED40384 CASE# ' 23-2252 DATE AND TIME 02/24/23 14:50
OF COLLISION
nt
j
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