HomeMy WebLinkAbout23-6920 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 6 27c
COLLISION REP FIT 1591971
CASE 23-6920 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIC;I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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 CITY#
cowsloN 06 - 18 - 2023 0740 17 . N E IN� S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
S 43RD ST BLOCK NO. e✓ 100 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e SR 167 NB EXIT
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:7028236835 0 4 30
6� LAST NAME SHINE FIRSTNAME SAKARIA MIDDLE M 1 1 2 31
INITIAL
STREET ❑, 17315121STLN CITY RENTON ST WA Zlp' 98058 z=
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVERCENS # STATE NV SEX I M MMDD� 03 - 01 1- 2003 1 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USEET 2 CLASS 1 I INJURY NATURE OF INJURIES 2❑
3
10[1P1 ATNES# CCK9752 sTAr WAu N# 5YFBURHE8GP526670
5 TRAILER STATE TRAILER STATE
11
3-LATE# PLATE# FROM To
TRLR. TRLR 7 3 33
12 3 5 VIN#' VIN#'
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 5 ] 34
13 2 2016 TOYT COROL DAMAGE YES NO YES[:] NO✓
REGISTERED OWNER INFO MOH .SHINE 17311121ST LN SE APT WW303 RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE Z INSURANCE CO GEICO 4570-09.16.54 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
LECALLv res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ STANDING 8 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:4257735219
16 2
LAST NAME LIM FIRST NAME SOO MIDDLE ,I
INITIAL
17❑ STREET �'L 420 W SMITH ST APT#520 CITY KENT ST WA ZIP 98032 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 DRIVER'S STATE I WA ]SEX IF I D.C.B. 08 _ 31 1990 39
LICENSE# MMDDYY
El
HELMET {NJURY 1 NATURE OF INJURIES 40
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT '1 USE 2 CLASS ❑
21❑ LICENSE BKS5087 TAre 41
WA VIN# 1HGCV1F33JA172493
❑
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
GI
VEH YEAR 2018 MAKE HOND MODEL ACCORD STYLE DAMAGE TOWED NOO✓ BLIN TOWED BY ov HYES NO 1/ 44
24❑ ES
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE I PORGY#E CO STATE FARM 122 5637-D13-47EIN 1 9TOP 5
ES
vETILe ❑ N J
,J� CITATION# CHARGE U
BOTTOM
LEGALLY Y
25 ' a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
C.STEED 8770 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED71221
COLLISION REPORT III III III III III 111
1591972 CASE# 23-6920
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) WILEY STEVEN L
(LAST FIRST,
ADDRESS&PHONE#
18924 110TH AVE SE PUYALLUP WA 98374 2062007773 SEX M MMDDYyry 10 - 07 - 1971
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑ ❑✓ POS. USE CLASS
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# D O B
SEX' MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.MMDD -❑
YYYY.
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
On 06/18/23 at about 0745 hrs I arrived at S 43rd St and the NB Exit from SR 167 for a non-injury
collision, in the City of Renton, County of King, and State of Washington. Unit#1 was traveling EB on
S 43rd St approaching the traffic light at SR 167 NB exit. Unit#2 was on the NB exit turning WB on S
43rd St. The driver of Unit#1 was identified by his NV drivers license and the Driver of Unit#2 was
identified by her WADL. Both drivers said they had green light when the accident occurred. Unit#1
struck Unit#2 on the front driver side bumper with his front passenger side bumper. A witness,
Steven Wiley, who was also exiting off SR 167 advised that they had a green light when Unit#1
collided with unit#2. The witness said he had to swerve to avoid the collision. The driver of Unit#1
advised that the witness originally told him he had the green light and driver#2 ran the red light. I
confirmed with the witness that he saw the light was green for him and Unit#2.
1 certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
Electronically Signed by Officer Steed on 06/18/23 0903 hrs, Renton Washington
Cassidy Steed/8770
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.STEED 06-18-23 09:04 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
D.SKELTON 9139 611812023 10:55:25 AM
BADGE OR ID# 8770 OR]# ! WA0171300 TIME POLICE DISPATCHED 7:43 AM TIME POLICE ARRIVED',7:45 AM
PART I PAGE IT]OF 3�
REPORT NO. ED71221 CASE# 23-6920 DATE AND TIME 06/18/23 07:40
OF COLLISION
i
N
S 43rd'St
ti=
>„ SR 167 NB Exit
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