HomeMy WebLinkAbout23-2961 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-2961 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 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# ❑
cowsloN 03 - 1-- 2023 0830 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
MAPLE VALLEY HWY BLOCK NO. e✓ 1900
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 300 00 FMILES EET e S ❑ E e CEDAR RIVER PARK DR
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2062590978 0 7 30
6� LAST NAME RENSHAW FIRSTNAME MARIA MIDDLE I S 1 1 2 31
INITIAL
STREET ❑ 16210 SE 166TH CT CITY RENTON ST WA ZIP 980588247 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET USE 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� 3512D0 sTAT� WAvIN# 1NXBU4EE6A2186271
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE J 9 34
13 2 2010 TOYT COROL DAMAGE YES NO MEYER YES[:] NO✓
REGISTERED OWNER INFO BLAIR RENSHAW 16210 SE 166TH CT RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILI INSURANCE INSURANCE CO ALLSTATE 064 301 795
IN EFFECT &POLICY# 9TOP
vIC CHARGE 5 36
LECALLEHLEv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8 7 6
MOTOR PEDAL PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE- ❑ ❑ OWNER [:]EA.
YEs No ,/ D:9033161675
16 a
LAST NAME TOMLIN FIRST NAME STEPHANIE MIDDLE I D
INITIAL
17❑ STREET ❑', 27026 228TH PL SE CITY' MAPLE VALLEY ST WA ZIP 980387945 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL t—T�RANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YYEEsI I I No� YES t l NO�
19 DRIVER'S STATE WA ]SEX IF D.C... 03 _ 11 1973 39
LICENSE# MMDDYY
HELMET {NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS 1 ❑
21❑ LICENSE BN65799 TATe WA VIN1i USE
❑ 41
pLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN#. 'IN#.
VEH YEAR 2016 MAKE CADI MODEL SRX STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO CHAD TOMLIN 27026228TH PL SE MAPLE VALLEY WA 98038 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO PROGRESSIVE 929324088IN 1 GQO,
VEHICLe CITATION# CHARGE
LEGALLY YES N(�
25❑ JAGENCY
s a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID#
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED42586
COLLISION REPORT III III III III III 111
1591972 CASE# 23-2961
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'
Unit 2 was stopped for traffic on northbound (facing west) Maple Valley HWY in the 1900 blk backed
up from a stop light at Cedar River Park DR. Unit 2 was traveling northbound (west) in the 1900 blk
of Maple Valley Hwy approaching the stopped traffic and Unit 2. For unknown reasons, Unit 1 failed
to stop in time and the front end of Unit 1 struck the rear end of Unit 2. Unit 1 sustained moderate
disabling damage and Unit 2 sustained minor/moderate rear end damage. Unit 1 towed by Gene
Meyer.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 03-13-23 09:55 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 3/15/2023 9:08:44 AM
BADGE OR ID# 10008 ORI# WA0171300 TIME POLICE DISPATCHED! 8i32 AM TIME POLICE ARRIVED 8:42 AM
PART I PAGE IT]OF
REPORT NO. EU42580 CASE# 23-2061 DATE AND TIME 03/ 3/2308:30