HomeMy WebLinkAbout23-3973 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-3973 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F E: LOCAL AGENCI 4250 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 8 2$
TRIBAL UNITS OZ STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑
cawsloN 04 - 08 - 2023 0945 17 ❑.❑ N E IN S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
LAKE WASHINGTON BLVD BLOCK NO. e✓ 1300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 350 00 FMILES N EET e S B E e HOUSER WAYN
0 1 29
MOTU '�01 VEHtOR Z CLE CYCCLE. El �ESAGE NHORE✓LD MET PHONE 0 4 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 1 2 31
INITIAL
STREET ❑ CITY ST WA 21p 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YEs No�/
8❑ LICIENSE#
STA fE I
SEX u MMDOBYY —F 1 1 2 32
9 ON DUTY❑ STATUS I
AIRBAG 9 RESTR 9 EJECT 9 H USEEr 9 CLAY 0 NATURE OF INJURIES z❑
3
10 9� P1 AT 14 CAE3517 STATE WA VIN# 1 FAFP40473F443916
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FR.. ro
TRLR. A'RLR. 1 5 33
12 2 5 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 3 34
13 4 2003 FORD MUSTAN CP DAMAGE YES NO YES
❑ NO✓
REGISTERED OWNER INFO YAIRA NEGRON VAZOUEZ 231298TH STREET CT S#S258 TACOMA WA 98444 VEHICLE NO. 1
❑ ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VEF" CHARGE 1 5 36
LEGALLv Yes❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:8184975087
16 a
LAST NAME BURRIS FIRST NAME MARLENE MIDDLE IV
INITIAL
17❑ STREET ❑ 534 AVENIDA GAVIOTA CITY CAMARILLO ST' CA ZIP 93012 37
NEW ADDRESS I I I I I ❑
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICALt—T�RANSPORTED 38
INTERLOCK YES - NO INTERLOCK ves NoF YEB t l ND�
19[ DIVE
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAURSY 1 NATURE OF INJURIES 40
21❑ LICENSE 98DM311 TATE CA VINE 2C4RC1L77NR147975
❑ 41
PLATE It
42
22 [TRAILER TILER
❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
UIN It 'IN#.
VEH YEAR 2022 MAKE CHRY MODEL PACIFICA STYLE VN VEHICLE TOWED TO BLIN TOWEDeY GOS HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO PV HOLDING CORP 5721 W 96TH ST LOS ANGELES CA 90045 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE INSU&PORGY#E CO STATE FARM 703 7392-D22-75IN 1GQ,
VEHICLE ❑ ,.I—I CITATION# CHARGE
LEGALLY YES N`LJ
25 s � a
7p-,
S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
TAGNE 12575 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED52139
COLLISION REPORT III III III III III 111
1591972 CASE# 23-3973
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'
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.
P.LANTAGNE 04-12-23 08:27 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 411312023 2:33:20 PM
BADGE OR ID# 12575 ORI#' WA0171300 TIME POLICE DISPATCHED 10:07 AM TIME POLICE ARRIVED]10:47 AM
PART Ei PAGE IT]OF 4�
REPORT NO. ED52139 CASE# 23-3973 OF COLLISION
04/08/23 09:45
OF CbLLI510N
NARRATIVE
23-3973
On 04/08/2023 at approximately 0945 hours, I, Officer Lantagne, responded to a non-blocking, non-
injury collision which occurred on Lake Washington BLVD N at the entrance to the Hampton Inn &
Suites, 1300 Lake Washington BLVD N, which is located in the City of Renton, County of King, and
the State of Washington. I responded in my fully marked police vehicle, wearing my patrol uniform.
I arrived on scene and observed Unit#2, a 2022 Chrysler Pacifica with license plates issued out of
California, parked in front of the hotel. I was advised by the driver of Unit#2, Marlene V. Burris (DOB
12/30/1963), there were no injuries.
Burris told me the following: Burris was driving southbound on Lake Washington BLVD N. As Burris's
vehicle approached the entrance to the Hampton Inn & Suites she began to make a left turn into the
driveway. As Burris was making the left turn, the front bumper of Unit#1, a red Ford Mustang with
license plates CAE3517 issued out of Washington State, struck the right rear bumper of Burris' rental
vehicle. The vehicle was owned by Budget Rentals. Burris described the driver of Unit#2 as a
Hispanic male.
I observed the damage to the vehicle and other physical evidence was consistent with the statements
made by Burris. Unit#2 had minor damage to the right rear bumper which consisted of a small scrape
and red paint transfer.
The collision diagram is an accurate illustration of the events leading up to the collision.
I provided an exchange of information to Burris.
I, Officer P. Lantagne #12575, certify (or declare) under penalty of perjury, under the laws of the State
of Washington, the foregoing is true and correct.
Electronically signed by Officer P. Lantagne #12575 at 0808 hours on 04/12/2023 at Renton, WA.
PAGE 3 OF 4
REPORT NO. ED52139 CASE# 23-3973 DATE AND TIME 04/08/23 09:45
OF COLLISION
Case#23-3973
0 r LAKE WASHINGTON BLVD N'
Not to kale CI
P. Lantagne#1257 I
Unit#1
I
i
PRIVATE WAY TO H MPTON INN &SUITES
Unit#2— 0 LAKE WASH NOTCN BLVD N
I
r
I
i
PAGE 4 OF 4