HomeMy WebLinkAbout23-4170 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-4170 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 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# ❑
CawsloN 04 - 1-- 2023 1326 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 3RD ST BLOCK NO. e✓ 2300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 80 00 FEET MILES e S ❑ W e BLAINEAVENE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2064749989 0 11
30
6� LAST NAME BERRY FIRSTNAME LAQIA MIDDLE S 1 0 6 31
INITIAL
STREET ❑, 2544 BURNETT CT S CITY RENTON ST WA ZIP' 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO✓ YEs No�/
8❑ DRIVERS
# STATE WA SEX'F MIDI Y' 02 - O6 - 1988 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USE 2 CLASS 1 NATURE OF INJURIES 2❑
3
,OF
Pi ATNES# BRV0433 ,TAT WAvN# 4T1CA30P66U099283
0
----� TRAILER STATE PLAT Eft STATE
11 3 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TR Y GOVT.VEHICLE 3 ] 34
13 2 2006 TOYT SOLAR CP DAMAGE YES ✓ NO MEYER YES[:] NO✓
REGISTERED OWNER INFO LAVERNE BERRY 2541 URNETT CIE RENTON WA 98055 D:2064749989 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
2 INSURANCE CO 3 4
14 LIABILITY INSURANCE� GEICO 4314.73.58.14
IN EFFECT &POLICY# QQ
VEHlcl.e CHARGE 36
LEGALLY YEs❑NO CITATION# 3AO055609,3AO055611 DWLS 3RD DEGREE,DEFECTIVE
15❑ STANDING
MOTOR PEDAL-:. PEDESTRIAN : PROPERTY DAM THR OLD MET PHONE
16 a ✓ El UNIT 02 VEHICLE CYCLE OWNER YES✓ No D:4252552446 N:4258917071
LAST NAME THAMMAVONG FIRST NAME PHOUBANE MIDDLE
INITIAL
17 STREET❑ NEW ADOREss❑' 5930 NE 3RD CT CITY RENTON ST WA ZIP 980598557 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 D IVEW #
❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES 40
❑ILICENSE 21❑ PLA E# ASL9227 TArE 41
WA vIN1 JN8AZ1MW9DW312999 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2013 MAKE NISS MODEL MURANO STYLE UT VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24 DAMAGE YES✓ NO GENE MEYER YES NO✓
REGISTERED OWNER INFO PHOUBANE THAMMAVONG 5930 NE 3RD CT RENTON WA 98059 D:4252552446 N:4258917071 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU PORGY#E CO ALLSTATE 064 149 917IN STOP 5
'E""Le ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 ' a
=UGENT
(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26 11498 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED52611
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4170
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) THAMMAVONG TIEN
(I.P.ST FIRST,
ADDRESS&PHONE# D O.B.
5930 NE 3RD CT RENTON WA 980598557 4258917071 SEXi F MMDDYyYv 12 - 02 - 1955
PASSENGER WITNESS E] UNIT# 2 POS 3 AIRBAG 2 RESTR. 4 EJECT ? 1 HELMET NATURE OF INJURIES
USE 2 CLASS
'1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEXI MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE GLASS ----�
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.
MATTHEW NUGENT 04-13-23 03:45 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 4/19/2023 8:16:22 AM
BADGE OR ID# 11498 ORI# WA0171300 TIME POLICE DISPATCHED 1i28 PSI TIME POLICE ARRIVED:1:32 PM
PART I PAGE IT]OF 4�
REPORT NO. ED52611 CASE# 23-4170 OF COLLISION
04/13/23 13:26
OF CbLLI510N
NARRATIVE
23-4170
On 04/13/2023 at approximately 1329 hours, I was dispatched to an unknown-if-injury vehicle
collision at the intersection JWO of NE 3rd Street and Blaine Ave NE, within the City Limits of Renton,
County of King, State of Washington.
Sergeant S. Woodward had arrived on scene prior to me. Upon arrival and with the assistance of
Sergeant Woodward, I began contacting the involved parties. We confirmed there were no reports of
injury from either of the involved parties. I collected each involved party's driving information and
respective statements.
The driver of Unit#1 said she was the sole occupant of her vehicle and was traveling eastbound in
about the 2300 block of NE 3rd Street approaching the intersection of Blaine Ave NE in lane 2 of 2.
The driver of Unit#1 stated that the front wheel and tire had come detached while she was driving.
Unit#1 immediately became disabled as the detached wheel rolled across multiple lanes of traffic
before striking Unit#2.
The driver of Unit#2 said he and his adult passenger were traveling westbound in about the 2300
block of NE 3rd Street in lane 1 of 2. The driver of Unit#2 stated that while traveling, he noticed as a
wheel came rolling into his lane of travel. The driver of Unit#2 stated that the detached wheel collided
with the front of Unit#2 causing moderate damage.
Based on the above statements, 1 determined that the Driver of Unit#1 (Berry) was the predominant
factor for the cause of collision due to operating defective equipment causing a collision. Unit#1 had
to be impounded due to the unsafe equipment and still missing a wheel. Unit#2 was able to be driven
away without further incident. An exchange of information was provided to all involved parties.
A DOL records check revealed that Berry was listed as DWLS 3rd with an Ignition Interlock Device
required. I observed Berry was operating a motor vehicle without an ignition interlock device installed.
Berry violated the crime of Driving While License Suspended (DWLS) in the third degree by operating
a motor vehicle at a time when her license is suspended in the third degree.
I cited Unit#1 (Berry) via complaint for DWLS 3rd and operating defective equipment via mail for
causing a collision as outlined in 46.32.060.
1 certify (or declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically signed by Officer M. Nugent#11498 3:11 PM 4/13/2023 Renton, King County, WA.
PAGE 3 OF 4
REPORT NO. ED52611 CASE# ' 23-4170 DATE AND TIME 04/13/23 13:26
OF COLLISION
Unit:92.
,z �~
Rolling wheel
"L3 iagcam not to scale —
!f NE 3rd ST
Unit:#tt: +1
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PAGE 4 OF 4