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Home My WebLink About23-4016 POLICETRAFF'c" III !�� I IIIllI111IN II II I REPORT NO. ED52147 170 27 COLLISION REP FIT 1591971 CASE 23-4016 z INTERSTATE ❑ CITY STREET FIRE ❑ RESULTED 1 STOLEN STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4Y00 3 HIT&RUN CODING COUNTY RD PRIVATE WAY INVOLVED 2� 1 1 8 28 TOTAL#OF OBJECT TRIBAL UNITS 03 STRUCK' BUILDING RESERVATION z 3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES CITY# ❑ cowsloN 04 - 09 - 2023 1942 17 ❑.❑ N E IN S 8 W H OF e 1070 3 4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓ SE PETROVITSKY RD BLOCK NO. e✓ 10900 4a❑ MILEPOST DISTANCE OF(REFERENCE OR CROSS STREET) 5❑ 300 00 FEET MILES e S ❑ W e 108THAVESE 2 0 29 UNIT MOTOR VEHICL Z CYCLE ElOYESA✓NOTHRESHOLDMET PHONE 0 1 30 6� LAST NAME ANDO FIRSTNAME HANNAH MIDDLE H 1 2 31 INITIAL STREET ❑ 6917 FLORA AVE S CITY SEATTLE ST WA 2jp, 98108 z NEW ADDRESS 7❑ ODL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3 iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ vEs No�/ 8❑ LRIIVERCENSE# STATE WASEXI F MM D Y' 06 - 05 - 1989 1 2 32 9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H U SE ICNLJAUSSY 1 NATURE OF INJURIES z❑ 3 10 9❑ PI ATE ATM9182 sTAr WA uN#' JFIGPAL60CG242241 5 TRAILER STATE TRAILER STATE 11 3 5 PLATE# PLATE# FROM TO TRLR. TRLR 3 7 33 12 3 5 VIN#' VIN# >; FROM TO ❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN 3 7 TOWED By GOVT.VEHICLE 34 4 2012 SUBA IMPREZ 4D DAMAGE YES NO YES[:] No ✓ 13 REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1 SHADE IN DAMAGED AREA ❑ 35 14 LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 968485112 4 LI EFFECT I SUR N# TOPVEHICLE CHARGE 36 LEGALLY YES❑NO❑ CITATION# <1�3 OTTOM 15❑ STANDING 6 MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE �NiT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA. YES 1/ NO D:2065578830 16 a LAST NAME LAMORENA FIRST NAME JANE MIDDLE L INITIAL 17❑ STREET NEW ADDREss❑' 517 225TH LN NE APT E-305 CITY SAMMAMISH ST' WA ZIP 98074 4❑ 37 18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38 INTERLOCKYES�NO� INTERLOCK yEs It I NOF YES t l NOF,/ 19 DRIVER'S STATE I WA ]SEX IF I D.C.B. O6 _ 01 1987 39 LICENSE# MMDDYY 20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET NJAU EY 1 NATURE OF INJURIES 40 ❑ILICENSE 21❑ PLA E# BGH1889 TArE 41 WA VIN# JTMBFREV8HJ166837 1 42 22❑ PLATE# STATE PLATE# STATE TRLR 23❑ VIN#. IN#. 43 RLR ' Gov HI VEH YEAR 2017 MAKE 7'Oy7' MODEL RA V4 STYLE —FEHICLE TOWED NOO✓ BLIN TOWED BY 44 fj YES NO 24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2 SHADEDAMAGED AREA 3 4 LIABILITY INSURANCE INSU POLICY#E CO PEMCO#CA1605452IN I 9TOP 5 VEHICLE ❑ C[:] CITATION# CHARGE to BOTTOM LEGALLY YES N 25 s a OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY 26 JASON JONES 11635 WA0171300 PAGE 01 OF PART A 3000-345-159 OR 11/181 STATE OF POLICETRAFFICN CORRECTION REPORT NO. ED52147 COLLISION REPORT III III III III III 111 1591972 CASE# 23-4016 ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY) NAME MIDDLE INITIAL) DONATO JEREMYP (LAST FIRST, ADDRESS&PHONE# 7503 134TH AVE SE NEWCASTLE WA 98059 4258917862 SEX M MMDDYyry 07 - 01 - 1987 PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES ❑✓ ❑ 2 POS. 3 2 4 1 USE CLASS 1 NAME (LAST,FIRST,MIDDLE INITIAL) ADDRESS&PHONE# D O B SEX MMDDYYYY PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY POS. NATURE OF INJURIES USE CLASS NAME (LAST FIR57 MIDDLE INITIAL) AppRESS&PHONE# SEX D.O.B.MMDD -❑ YYYY. PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES ❑ ❑ POS. USE CLASS ----� NARRATIVE' On 4-9-23, at about 1943 hours, I was dispatched to a collision that occurred in the 10900 block of SE Petrovitsky RD. Upon I arrival, I saw a both Unit 1 and Unit 2 parked in a parking lot. I contacted the driver of Unit 1. She relayed the following: She was traveling west on SE Petrovitsky RD. She was not paying attention, did not see Unit 2, switched lanes, and stuck Unit 2. The driver of Unit 1 told me after she struck Unit 2, she steered her vehicle into a parking lot, was unable to stop, and struck a building (10904 SE Petrovitsky RD) causing damage. The driver of Unit 1 stated it was her fault for the collision. I also spoke with the driver of Unit 2 and the passenger of Unit 2 whom both relayed the same account as the driver of Unit 1. All involved stated they were not injured, nor did they need medical attention. Fire responded anyway and confirmed there was no report of any injuries. The driver of Unit 1 was given a verbal warning for inattention. I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. JASON JONES O4-09-23 08:42 PM INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED APPROVED BY DATE DESIREE SCOTT 10272 1 411712023 5:44:02 PM BADGE OR ID# 11635 ORI#' WA0171300 TIME POLICE DISPATCHED 7:43 PM TIME POLICE ARRIVED',7:45 PM PART I PAGE IT]OF 4] SUPPLEMENTAL REPORT NO. ED552147 r`) POLICE TRAFFIC 1 27 COLLISION REPORT CASE# 23-4016 1 COMMERCIAL MOTOR CARRIER INTERSTATE INTRASTATE G UNIT'# USDOT ICC# VEHICLE TYPE CARGO BODY ;TYPE 2 ❑ 1 28 CARRIER NAME 3 CARRIER L ADDRESS ` CITY ST ZIP—1 I ' 4 ❑ NAME # PLACARD: :❑ GI PLACARD IF NO NUMBER SOURCE AXLES + 4a ❑ ADDITIONAL UNITS MOTOR PEDAL- PROPERTY DAMAGE THRESHOLD MET PHONE 5 ❑ UNIT# 3 VEHICLE I_J CYCLE _) PEDESTRIAN � OWNER � YES� NO D:2537320316 MIDDLE.. 29 LAST NAME ESTES FIRST NAME MICHELLE INITIAL STREET 30 NEW AnnRFrtP 10904 SE PETROVITSKY RD CITY RENTON ST WA ZIP 98058 6 CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TANSPORTED 1 31 INTERLOCK YEs No zERLOCK YES E]Na� YEs N DRIVER'S STATE I SEX U M��DYSYv' —� 2 LICENSE 7F-ION DUTY STATUS AIRBAG RESTR. EJECT HELMET INJURY NATURE OF INJURIES F� USE CLASS 8 ❑ ' 1 32 LICENSE+ rar V1N.# PLATE# 9 TRAILER TRAILER PLATE# STATE PLATE# STATE 10 ❑ TRLR TRLR VIN.#. VIN.#. 11 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TOWS E T SABLIN TOWED BY anvi vEHIG E FROM TO DAMAGE YES NO YES NO REGISTERED OWNER INFO. m 33 12 SHADE IN DAMAGED AREA FROM TO LIABILITY INSURANCE❑ INSURANCE CO IN EFFECT &POLICY# tGQ VEHICLE 34 13 ❑ LEGALLY YES[:] NO❑ CITATION# CHARGE STANDING S} 8 7 6 14 ❑ UNIT Tr Vd IRE O CYDCLE OWNER YES AGE NOHRESHOLD MET PHONE El 35 PEDESTRIAN 15 LAST NAME FIRST NAME MIDDLE': INITIAL36 STREET"[—] ❑ 16 NEn+AnnREs.�' CITY'. ST ZIP CDL IGNITION REdUiRED IGNITtGN PRESENT MEDICALTANSPORTED INTERLOCK YES No INTERLOCK YEs NO YEs NO El 17 37 LICENSE# STATE SEX MMDDDYBYY 18 ❑ ON DUTY� STATUS AIRBAG RESTR. ; EJECT HELMET INJURY NATURE of INJURIES 38 USE (CLASS 19 ❑ vIN# 39 LICENSE PLATE# rnr 20 ❑ TRAILER' TRAILER ❑ 40 PLATE# STATE PLATE# STATE 21 ❑ TRLR TRLR 41 VIN# YIN#i 42 22 VEH.YEAR MAKE I MODEL STYLE I VEHICLE TO DUET SABLIN TOWED BY GOVT.VEHICLE DAMAGE YES NO YES NO 23 REGISTERED OWNER INFO_ SHADE IN DAMAGED AREA 43 3 4 71 LIABILITY INSURANCE INSURANCE CO ' VEHICLE EFFECT &POLICY# I 970P - 4 44 24 VEHICLE YES NO❑ CITATION# CHARGE iq 60TiOM E:l C=DLv STANDING 8 7 6 1 CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. JASON JONES O4-09-23 08:42 PM 25 INVESTIGATING OFFICER'S SIGNATURE OFFICER'S PHONE UNIT OR DIST DET DATED: PLACE SIGNED APPROVED BY DATE 26 OR ID# 11635 O#I,WA0171300 SCOTT 4117/2023 PAGE�OF 4 3000-345-013(R 11118) REPORT NO. ED52147 CASE# ' 23-4016 DATE AND TIME 04/09/23 19:42 OF COLLISION NOT TO SCALE SE F ETROVFTSKY RD ff h PAGE 4 OF 4