HomeMy WebLinkAbout23-4932 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-4932 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 7 28
TRIBAL UNITS OZ STRUCK
RESERVATION
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# z 0 2
cawsloN 05 - 01 - 2023 2136 17 ❑.❑ S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 400
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 4001. 00 FEET MILES e S B W e S 3RD PL
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2538889227 30
6� LAST NAME RAM FIRSTNAME VINOD MIDDLE 1 1 2 31
INITIAL
STREET ❑, 31500 1ST AVE S,APT 2-102 CITY FEDERAL WAY ST WA ZIP 98003 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
✓ I iNTERLOCKYEs No NTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
LICENSE C6719C STATE WA u N# 15GGD2719K3193420
10 9❑ Pr ATE�
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM ro
TRLR. TRLR 1 5 33
12❑ VIN#' VIN#.
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
13 3 2019 GILG TRANSI BU DAMAGE YES NO ✓ YES[:] No✓
REGISTERED OWNER INFO TRANSPORTA TION KING COUNTY METRO 12200 E MARGINAL WAY S TUKWILA WA 98168 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO KING COUNTYMETRO 3 4
IN EFFECT &POLICY# 9TOP
VEHICLe 5 36
LEGALLv Yes❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ STAIN.D" 8 6
UNIT 02 VE ICCLE ❑ CYCLE ❑ PEDESTRIAN ❑✓ OWNER YES
❑ DYES✓ NO OLD MET PHONE
16 a
LAST NAME AHMED FIRST NAME ASHA MIDDLE F
INITIAL
STREET
17❑ NEW ADDRES ' 23401 104TH AVE SE,APT 90 CITY KENT ST WA ZIP 98031 37
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES t l NO❑
19 LDIIVE # STATE SEX F M .C.B. O6 _ 20 _ 2002 39
20 ON DUTY STATUS 3 AIRBAG RESTR EJECT WEB USE
LASSINJURY 6 [NATURE OF INJURIES CRAPED LEG AND POSSIBLE BROKEN ANKLE 40
❑21❑ TATE LICENSE vIN1 41
1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BV Gov HI 44
24 1 5 DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
VEHICLE ❑ ,.I—I CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
JASON JONES 11635 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. ED56355
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4932
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) MONTGOMERY ANDREW P
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
17735 105TH PL SE,APT D102 RENTON WA 98055 2068524196 SEX M MMDDYyry 08 - 19 - 1986
PASSENGER WITNESS UNIT# SEAT AIR RESTR. EJECT ' HELIVET INJURY NATURE OF INJURIES
❑ 0 SOS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY
POS. NATURE OF INJURIES
USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.Q.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 5-1-23, at about 2137 hours, I was dispatched to a collision that occurred in the 400 block of
Rainier AVE S.
Upon I arrival, I saw a King County Metro Bus (Unit 1) parked on the side of the road in the 400 block
of Rainier AVE S. Unit 1 did not require a tow and did not appear to be damaged. The driver of Unit 1
told me he was driving south on Rainier AVE S and accidently ran over pedestrian 1's leg. He told me
she was laying on the sidewalk on her side, he did not see her, and she stuck out her leg after the
first set of wheels past causing him to run over her leg.
I observed Pedestrian 1. 1 saw obvious trauma to her leg and observed her to be wearing dark
clothing. Due to her pain, I was unable to question her about the incident. Pedestrian 1 was treated
for her injuries and transported to the hospital for a possible broken ankle.
There are video cameras on the bus. I provided my business card with the case number on it so I can
receive a copy of a video of the incident when possible.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JASON JONES 05-01-23 10:56 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
J.CHRISTIANSEN 10437 1 51112023 11:34:54 PM
BADGE OR ID# 11635 ORI# WA0171300 TIME POLICE DISPATCHED 9:37 Pry] TIME POLICE ARRIVED';9:41 PM
PART I PAGE 2�OF❑
REPORT NO. ED56355 CASE# 23-4932 DATE AND TIME 05/01/23 21:36
OF COLLISION
NOT TO SCALE.
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