HomeMy WebLinkAbout23-6508 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-6508 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.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#
cowsloN 06 - 1-- 2023 1715 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NORTH 4TH STREET BLOCK NO. e✓ 1500 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e FACTORYAVE NORTH
2 0 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/NO D:2066047565 0 11
30
6� INITIAL
LAST NAME MEWBORN FIRSTNAME PANDORA MIDDLE V 1 1 2 31
STREET ❑ 12311 AMBAUM BLVD SW APT A402 CITY BURIEN ST WA 2jp, 98146 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
iNTERLOCKYEs 1/ I NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LICENSE# STATE CO SEX 01'F MM D�Y' — 10 — 1994 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 1 CLASS NATURE OF INJURIES 2❑
3
10 9❑ PI ATE 14 CBF9247 STATE WA u N#' 1 FA6POH78F5128785
11[-j- TRAILER STATE TRAILER STATE
11 2 5 PLATE# PLATE# IR.. ro
TRLR. TRLR 3 7 33
12 2 5 VIN#j VIN#
:: FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 ] 34
13 1 2015 FORD FUSION 4D DAMAGE YES NO ves❑ No
REGISTEREDOWNERINFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO NATIONAL GENERAL 2018948012 3 4
IN EFFECT &POLICY# 9TOP
VEHICLe 1 5 36
LEGALLY YEs No CITATION# 3A0431065 CHARGE IMPROPER LANE USAGE 1 o aorrom
15❑ STANDING 6
MOTOR ✓ PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT a2 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4259194873
16 2
LAST NAME CHISM FIRST NAME SETH MIDDLE A
INITIAL
17 STREET❑ NEW ADOREss❑' 2004 NE 35TH PL CITY RENTON ST WA ZIP 980562089 4❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PR—E-1SENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NO� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE WA SEX M D.O.B. O6 _ 27 1997 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAU EY 1 NATURE OF INJURIES ❑ 40
❑ILICENSE 21❑ PLA E# ADW8314 TATE WA vIN# YV 41
1622FS1C2020737 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
VEH YEAR 2012 MAKE VOLV MODEL S60 STYLE 4D VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO WESLEY CHISM 2004 NE 35TH PL RENTON WA 98056 D:4259194873 VEHICLE NO.2
SHADE IN DAGELLAREA
z Cdd
LIABILITY
INSURANCE &POINSURGY#E CO CONNECT AX01204357IN 1 9TOP 5
'E""LE ❑ Nu,J CITATION# CHARGE i o BOTTOM
LEGALLY YES
25 s � e
=UGENT
(PRINT) OFFICER PHONE BADGE OR ID# 77P�1300
26 11498
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED70713
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6508
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 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 06-08-23 03:17 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 6/16/2023 8:41:11 AM
BADGE OR ID# 11498 ORI# WA0171300 TIME POLICE DISPATCHED! 5:15 PM TIME POLICE ARRIVED i 5:15 PM
PART I PAGE IT]OF 4�
REPORT NO. ED70713 CASE# 23-6508 OF COLLISION
06/07/23 17:15
OF CbLLI510N
NARRATIVE
23-6508
On 06/07/2023 at approximately 1721 hours, I was dispatched to a non-injury and non-blocking
vehicle collision at the intersection of North 4th Street and Factory Avenue North, within the City
Limits of Renton, County of King, State of Washington.
Upon my arrival, I confirmed there were no complaints of injury requiring immediate medical response
at the time of report. There, I was able to collect each involved party's information and independent
summary of the events leading up to the collision.
The driver of Unit#1 said there was an adult and two juvenile passengers in her vehicle while
traveling westbound in about the 1500 block of Factory PI North and approaching the intersection of
N 4th Street in lane 3 of 4. The driver of Unit#1 stated that she needed to get into the left lane (lane 4
of 4) to make an upcoming left turn into a private parking lot located in the 300 block of Factory PI N.
The driver of Unit#1 stated that she believed Unit#2 should have seen her trying to change lanes.
The driver of Unit#1 stated that while making the lane change, Unit#1 and Unit#2 collided in lane 4
of 4 causing minor damage to the front driver's side bumper and quarter panel of Unit#1.
The driver of Unit#2 said he was the sole occupant of his vehicle and was also traveling westbound
in about the 1500 block of Factory PI N approaching the intersection of N 4th ST but in lane 4 of 4.
The driver of Unit#2 stated he was intending to continue straight when Unit#1 changed lanes from
lane 3 of 4 and into lane 4 of 4 which Unit#2 was occupying. Unit#2 was unable to avoid the collision
and subsequently collided with Unit#1. Unit#2 suffered moderate damage to the passenger side
doors and rear fender due to the collision.
Based on the above statements, 1 determined that the Driver of Unit#1 (Mewborn) was the
predominant factor for the cause of collision as Mewborn violated RCW 46.61.140(1) which states
that a vehicle shall be driven as nearly as practicable entirely within a single lane and shall not be
moved from such lane until the driver has first ascertained that such movement can be made with
safety. Mewborn made a lane change into Unit#2's lane of travel which had the right of way and was
underway. Mewborn did not ensure that traffic in lane 4 of 4 was clear of hazard before making the
unsafe lane change. Mewborn was also unable to provide proof of motor vehicle insurance at the time
of collision. Mewborn later emailed me a copy of her insurance with an effective date of 06/07/2023.
1 cited Mewborn via for Improper Lane Usage causing a collision.
Both Unit#1 and Unit#2 were able to be driven away without further incident. An exchange of
information was provided to all involved parties.
I 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 6/8/2023 3:10 PM Renton, King County, WA.
PAGE 3 OF 4
REPORT NO. ED70713 CASE# ' 23-6508 DATE AND TIME 06/07/23 17:15
OF COLLISION
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