HomeMy WebLinkAbout23-6853 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-6853 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4Y00 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 2151 17 ❑.= S 8 IN e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
AIRPORT WAY BLOCK NO. e✓ 100
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 10 00 FEET MILES e S ❑ W e LAKEAVES
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO F,/ I D:2064238708 0 11
30
6❑ LAST NAME SANTIAGO CRUZ FIRST NAME JORGE MIDDLE A 1 1 2 31
INITIAL
STREET ❑, 1159 GLENNWOOD AVE NE CITY RENTON ST WA ZIP 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
1/ I iNTERLOCKYEs NO NTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'M MID
-O B 05 1- 03 - 2003 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATFBit CGH7197 sTArI WA urN#' 1FAHP3F26CL285479
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR 2012 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 3 7 34
13 4 FORD FOCUS SD DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
vEcnLLv HICLE 5 36
YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15 LE❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YEs No ,/ D:2063834896
16 a
LAST NAME ZHU FIRST NAME QI MIDDLE R
INITIAL
17 STREET NEW ADOREs7 4501 S HOLDEN ST CITY SEATTLE ST WA Zip 98118 37
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs I I NOF YES
t l NO
�
19 LDICENIVERS STATE WA SEX M I D.MMDDYY 04 25 _ 1963 39
20 ON DUTY STATUS AIRBAG,2 RESTR 4 EJECT 1 H EET 2 NJAU Sy 7 COMPLAINT OF HEAD PAIN ❑F—NATURE OF INJURIES 40
❑21❑ PLATE# CFX2066 TArE 41
WA vIN# JTMRWRFV5PD169043 1
42
22❑ PLATE# STATE pLATE ILER# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BY Gov HI 44
VEH YEAR 2023 MAKE 7'Dy7- MODEL RA V4 STYLE UT DAMAGE TOWED NOO✓ BLIN YES NO 1/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATEFARM 484 4283-A23-47AIN 1 GD
vE—LE ❑ ,J� CITATION# CHARGE
25
LEGALLY YES N`L J
s � e
7BRYAN
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26GROZAV 12489 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED73309
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6853
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.
BRYAN GROZAV 06-19-23 10:45 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 6/24/2023 1:09:45 PM
BADGE OR ID# 12489 ORI# WA0171300 TIME POLICE DISPATCHED 10:05 PM TIME POLICE ARRIVED',10:10 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED73309 CASE# 23-6853 OF COLLISION
06/15/23 21:51
OF CbLLI510N
NARRATIVE
CASE 23-6853
This incident was captured on my body worn video camera. This report is a summary of events that
occurred and is not an exact sequencing of events.
On Thursday June 15th, 2023, at approximately 22:05, 1 responded to a 911 call regarding a two-
vehicle collision in the area of Airport Way and Lake Ave S within the City limits of Renton, King
County, Washington.
*** CALL REMARKS: LANG BARRIER..WPH2 UNC 7..RP GAVE RAINIER AVE S...RP REPORTING
AN MVA...LINE DISCN WHILE GETTING LOCATION...ON CB NO ANSWER..UNK FURTHER.
PHONE SHOWS CLOSEWR TO INTERSECTION AIRPORT WAY/LAKE AVE S.
-UNIT ONE: GRAY 2012 FORD FOCUS WASHINGTON LICENSE: CGH7197
-UNIT ONE DRIVER: JORGE A SANTIAGO CRUZ (DOB: 05.03.2003)
-UNIT TWO: SILVER 2023 TOYOTA RAV 4WASHINGTON LICENSE: CFX2066
-UNIT TWO DRIVER: QI R. ZHU (DOB: 4.25.1963)
1 arrived on scene and contacted the involved parties and checked for injuries, Qi requested aid for
head pain. Renton Fire arrived and examined Qi but was not transported to the hospital. Qi indicated
he was driving on Airport Way when unit 1 rear ended him.
After talking to Qi, I contacted Jorge who indicated he was traveling behind unit two when it stopped
all of a sided and he couldn't stop in time. Jorge did not have insurance.
Unit one and two had minor damage and were drivable.
All involved vehicles were provided a copy of the SECTOR exchange of information form.
This concludes my involvement in this case.
I certify/declare under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct.
Electronically signed by B. Grozav #12489 on 6.19.2023 at 22:44 hours in Renton, WA.
PAGE 3 OF 4
REPORT NO. ED73309 CASE# 23-6853 DATE AND TIME 06/15/23 21:51
OF COLLISION
NOT TO SCALE
100 BUCK AIRPORT WAY
PAGE 4 OF 4