HomeMy WebLinkAbout24-6464 ITFF' "POLCERA II I !�� I III I III I IIII III II I . B 27c
COLLISION REP FIT 1591971
❑ ❑ FIRE ❑ CASE# 24-6464 2 675
INTERSTATE CITY STREET RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F LOCAL AOENC 4250 3❑HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
cawsloN 06 - 19 - 2024 1638 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
N 31ST ST BLOCK e✓ 900 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a BURNETT AVE N
0 1 29
UNIT MOTOR
VEHICL � CYCLE ❑ DYESA✓NOESHOLD MET PHONE 0 1 30
6� LAST NAME UNKNOWN FIRSTNAME MIDDLE 1 2 31
INITIAL
STREET ❑ CITY RENTON Sr ZIP 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO 1/ INTERLOCKYEs NO�/ YES No�/
8❑ LIRCIENSRE#
SrA fE I
SEX u MMDOBYY '❑- 1 1 2 32
9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 9 EJECT 1 H USEEr 9 CLJU
ASSY 0 [NATURE OF UNKNOWNNJURIEs 2❑
3
10 9❑ P1 ATES14 BZF7370 STATE WA VIN# 5NPDH4AE1GH742089
TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# FR.. ro
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE $ 34
13 2016 HYUN ELANTR 4D DAMAGE YES NO �L kkRS YES❑ No
REGISTERED OWNER INFO JONATHAN JERONWO LOPEZ 201 SW STH PL APT K105 RENTON WA 98057 D:9514185249 VEHICLE NO. 1
SHADE IN DAMAGED AREA 35
4 INSURANCE CO 14 LIABILITYINSURANCE UNKNOWN UNKNOWN
IN EFFECT &POLICY#VEHlcl.e CHARGE <14,
36
LEGALLY YES❑NO❑ CITATION# 515 STANDNG
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2066969741
16 a
LAST NAME GODFREY FIRST NAME CHELSEA MIDDLE C
INITIAL
17❑ NEW STREETREs7 913 FERNDALE CIR NE CITY' RENTON ST WA ZIP 98056 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YEs❑NO� INTERLOCK YEs It I NOF YES t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.O.B. O6 _ 29 _ 1984 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 6 RESTR 4 EJECT 1 H U EET 2 NJAURSY 7 COMPLAINTS OF ARM PAIN+POSS.WHIPLASH ❑F—NATURE OF INJURIES 40
❑ 41
21❑ PLATE# ALW4040 TATE WA vIN# 1HGCM66346A053651 4
42
22❑ PLATE# STATE PLATE ILER# STATE
TRLR
23❑ UIN#. N#.
43
RLR
'I
TOWED BY Gov HI 44
VEH YEAR 2006 MAKE HOND MODEL ACCORD STYLE 4D -7EHICLE
TOWED✓ NOO BLIN BANKERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE &POINSURGY#E CO PEMCO CA 1652302IN 9TOP 5
"'LE ❑ ,J� CITATION# CHARGE i o BOTTOM
LEGALLY YES N`L J
25 ' a
7JUS
NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26KAUPPILA 12883 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE88592
COLLISION REPORT III III III III III 111
1591972 CASE# 24-6464
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
PM 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 attached police report#24-6464, which is hereby incorporated by reference as if fully set
forth herein.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
JUSTIN KAUPPILA 06-20-24 02:46 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.KORDEL 9676 1 6/20/2024 5:30:53 PM
BADGE OR ID# 12883 OR]# WA0171300 TIME POLICE DISPATCHED' 4:44 PM TIME POLICE ARRIVED';4:56 PM
PART I PAGE IT]OF 3�
REPORT NO. EE88592 CASE# ' 24-6464 DATE AND TIME 06/19/24 16:38
OF COLLISION
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