HomeMy WebLinkAbout23-6691 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 23-6691 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 1 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
cawsloN 06 - 1-- 2023 1200 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 230
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
✓NO D:2533689098 0 81
30
6� LAST NAME VETH FIRSTNAME KAVTALIYA MIDDLE S 1 1 2 31
INITIAL
STREET ❑, 16229 SE 251ST ST CITY COVINGTON ST WA ZIP' 980424152 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs NO INTERLOCKYEs NO YES R NO
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 3 RESTR 4 EJECT 1 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES z❑
3
10❑ P1 aT�S� BRM4212 sTAr� WAvIN# 1HGCR2F38FA196676
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# ROM ro
TRLR. TRLR. 5 1 33
12 3 5 VIN#' VIN#
>; FROM TO
VEH.YEAR N MAKE HOND MODEL ACCOR STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE J 9 34
DAMAGE YES NO YES[:] NO✓
13❑ REGISTERED OWNER INFO SIMLIM-VETH16129SE251STSTCOVINGTONWA98042 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO ENCOMPASS US 282488559 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLYYES NO CITATION# 3A0387732 INATTENTIVE DRIVING <1�3
orrom
15❑ STANDING 7 6
MOTOR 'PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ PEDAL-CYCLE ❑
16 ❑ OWNER ❑ YES 1/ NO D:2059929991
a
LAST NAME VO FIRST NAME HOANG MIDDLE I L
INITIAL
17❑ STREET ❑', 26015 116TH AVE SE CITY' KENT ST WA ZIP 980308479 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs It I NOF YES
t t— l NO❑
19 LDIIVEW # STATE WA SEX M M .O.B. 07 27 1985 39
WELMET INJURY1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 USE CLASS ❑
21❑ LICENSE I BZX6805 TAre WA VIN1t JTEAAAAH6MJ066530
❑ 41
PLATE#
42
22❑ PILER LATE# STATE PLATE# STATE
TRLR
23❑ VIN#. N#. 43
RLR
%
'I
VEH YEAR 2021 MAKE TOYT MODEL VENZA STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO HOANG VO 26015116TH AVE SE KENT WA 98030 VEHICLE NO.2
SHADE IN DAMAGEbAREA
2 3 Cd
LIABILITY
INSURANCE &POINSURGY#ECO STATE FARM 4994676 C0147IN 1 9TOP
'E""LE CITATION# CHARGE
LEG
25 i o BOTTOM
ALLY YES NEI
❑ s
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
J.M/TCHELL 10377 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED70719
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6691
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
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'
On 061223 1 responded to a 2-vehicle non-injury/non-blocking collision at 230 Rainier Ave S.
I contacted the driver of unit 2 who told me they were stopped for traffic in the #2 lane of northbound
Rainier Ave S when unit 1 rear-ended his vehicle. The driver was not injured. Unit 2 sustained rear
bumper area damage.
I contacted the driver of unit 1, identified as KAVTALIYA VETH (dob 08-19-2002) via her was DL.
Veth told me they were traveling northbound in the #2 lane of Rainier Ave S behind unit#2. Veth
says she glanced to the left to look at where she was supposed to turn soon and rear-ended unit 2.
Veth was not injured during the collision. Unit 1 had front-end damage but was drivable.
I cited KAVTALIYA VETH (dob 08-19-2002) for Inattentive Driving, RMC 10-12-25.
1 declare under penalty of perjury under the laws of the State of Washington that the foregoing is true
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
J.MITCHELL 06-12-23 01:04 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 6/16/2023 8:50:00 AM
BADGE OR ID# 10377 ORI# WA0171300 TIME POLICE DISPATCHED' 12:00 PM TIME POLICE ARRIVED 12:10 PM
PART I PAGE IT]OF
REPORT NO. ED70719 CASE# ' 23-6691 DATE AND TIME 06/12/23 12:00
OF COLLISION
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