HomeMy WebLinkAbout23-4909 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-4909 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS 02 STRUCK
RESERVATION
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 05 - 01 - 2023 1706 17 ❑.❑ S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 4TH ST BLOCK NO. e✓ 5300
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e 0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2069661159 0 11
30
6� LAST NAME PINON FIRSTNAME EDUWIGES MIDDLE 1 2 31
INITIAL
STREET ❑, 3500 NE 11TH PL CITY RENTON ST WA ZIP 980563441 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES 1/ NO
8❑ LRIIVER # STATE WA SEX'F MM D Y' 10 1— 17 — 1978 2 32
CENS [NATURE OF INJURIES
9 ON DUTY❑ STATUS' AIRBAG 4 RESTR 4 EJECT 1 H USE 2 6 CLASS LEFT ELBOW INJURY 2❑
3
10� P1 ATE 14 TEMP FAG STATE v N# 2GNAXJEV6J6206479
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM ro
TRLR. TRLR 5 7 33
12 3 5 VIN#' VIN#
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 7 $ 34
13 9 2018 CHEV EQU/NO DAMAGE vEs 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO PEMCO CA 1913753 3 4
IN EFFECT &POLICY# 9TOP
VEHICe CHARGE 1 36
LEGALLY YES❑NO❑ CITATION# 3A0357729 FAIL YIELD PRIVATE RD MOTOR I o aorroM
15❑ STANDING 8 6
MOTOR PEDAL-:. PROPERTY DAM THR OLD MET PHONE
UNIT ❑✓ ❑ PEDESTRIAN ❑ ❑ HO 2065566893
VEHICLE CYCLE OWNER YES NO �/
16 a
LAST NAME TENG FIRST NAME KYLE MIDDLE S
INITIAL
17❑ STREET ❑', 5201LWACO AVE NE CITY RENTON ST WA ZIP 980598573 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t l NOF,/
19 D IVERI #
{NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE 2 CLASS ❑
21❑ LICENSE CDU2532 TATe 41
WA VIN# 1G6DK5RK4N0116826
❑
pLATE#
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2022 MAKE CADI MODEL CT4 STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO XUANKHUONG5201LWACOAVENERENTONWA98059 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIAIN BILITY
INSURANCE &POINSURGY#E CO CONNECT A10137,93 02 5
VEHICLE ❑ C—I CITATION CHARGE C�Q
LEGALLY YES N`LJ
25 s � a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
K.LANE 10008 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED57385
COLLISION REPORT III III III III III 111
1591972 CASE# 23-4909
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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 traveling eastbound in the 5300 blk of NE 4th ST with the right of way. Unit 1 was at the
exit driveway of 5335 NE 4th ST, on the south side of NE 4th ST, facing north and intending to turn
left onto westbound NE 4th ST. Unit 1 failed to yield the right of way to Unit 2 and initiated this left
turn pulling into the path of Unit 2. The front end of Unit 2 impacted the driver's side of Unit 1. Unit 1
sustained moderate damage and airbag deployment. Unit 2 sustained minor/moderate front end
damage. Driver 1 complained of injury to her elbow and was transported to the hospital for treatment.
Driver 1 was cited for failure to yield the right of way to a motor vehicle when entering from a private
roadway by pulling out of the private parking lot onto NE 4th ST, into the path of Unit 2 which had the
right of way, and which was the proximate cause of the collision.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
K.LANE 05-04-23 12:14 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
CO.JOHNSON 0505 51512023 10:24:49 AM
BADGE OR ID# 10008 OR]# WA0171300 TIME POLICE DISPATCHED 5:08 Pry TIME POLICE ARRIVED 5:15 PM
PART I PAGE IT]OF
REPORT NO. ED57385 CASE# ' 23-4909 DATE AND TIME 05/01/23 17:06
OF COLLISION
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m
Z
Cfi3
PARKING LOT
5335 NE 4TH ST
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