HomeMy WebLinkAbout23-9219 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
INTERSTATE ❑ CITY STREET ❑ FIRE ❑
CASE#r` 23-9219 2
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AGENCI 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 1 28
TRIBAL UNITS 02 STRUCK STREETLIGHT POLE
RESERVATION
2
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
GowsloN 08 - 11 - 2023 1525 17 ❑.❑ S 8 W H OF e 1070 3
4❑ oN (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
4810 NE 4TH ST BLOCK NO. e✓ 4800
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 700 00 FMILES NEET e S ❑ E e DUVALL AVE NE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
NO D:8159190775 30
6❑ LAST NAME MENGUITA FIRSTNAME MYLAINE MIDDLE A 1 1 2 31
INITIAL
STREET 01 707 SHADOW AVE NE CITY RENTON ST WA 2jp, 980594585 2
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'F MID
.O B 11 — 08 — 1971 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET
2 CLASS 1 NATURE OF INJURIES 2❑
3
LICENSE C000883 sTAr1 WAvIN# 7SAYGDEE5PF770297
10❑ PI ATE#
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12❑ vIN#' VIN#
FROM
34
13� VEH.YEARN MAKE TESL MODEL MODEL STYLE SW VEHICLE TOWED NOOp1SSBLIN TOyED.BLRs yOES❑ENO
DAMAGE IILLJJII ttSSAA1IVV/it�cc
REGISTERED OWNER INFO MYLAINEMENGU1TA 707 SHADOWAVENE RENTON WA 980594585 D:8159190775 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14❑ ABILI INSURANCE❑ NSURANCE CO <��34
IN EFFECT &POLICY#VEHICL CHARGE36
LEGALLv YES❑NO CITATION#
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ No D:4254544525
16❑
LAST NAME LEIBSOHN FIRST NAME WALLIN MIDDLE
INITIAL
17 STREET NEW ADDRJ7 PO BOX 305103 CITY NASHVILLE ST' IN ZIP 37230 37
18� CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL TRANSPORTED 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIICENS RIVERIS# STATE SEX U MMDOYY 39
HELMET INJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG RESTR EJECT USE CLASS ❑
❑21❑ LICENSE TArE IN# 41
V 1
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN
TOWED BY Gov HI 44
L4❑ DAMAGE YES NO YES NO
REGISTERED OWNER INFO VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
INAEFFITY ECTNSURANCE❑ &POINSULICY#E CO I 9TOP 5
NODALOVIC
❑ C[:] CITATION# CHARGE i o BOTTOM
YES N
25 s e
'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
11828 WA0171300
PAGE 01 OF
PART A
3000-345-159 fR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED88770
COLLISION REPORT III III III III III 111
1591972 CASE# 23-9219
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.
N.ODALOV/C 08-11-23 05:29 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIREE SCOTT 10272 8/13/2023 12:45:04 PM
BADGE OR ID# 11628 OR]# WA0171300 TIME POLICE DISPATCHED 3:30 PM TIME POLICE ARRIVED',3:37 PM
PART Ei PAGE IT]OF 4�
TIME
REPORT NO. ED88770 CASE# 23-9219 OF COLLISION08/11/23 15:25
NARRATIVE
23-9219
Unless otherwise noted, the following occurred in the City of Renton, County of King, WA.
On 08-11-2023 at approximately 1530 hours I was dispatched to Papa John's Pizza at 4710 NE 4th
St for a single vehicle collision. Dispatch notes stated: "IN PLOT...1 VEH VS LIGHT
POLE...NI,NB...WHI TESLA..."
I arrived on scene at approximately 1536 hours. Upon my arrival, I saw a white Tesla Model Y WA
Lic/CGU0883 high-centered on top of a light pole in between Papa John's and Jack in the Box. The
light pole was completely knocked down onto the ground and the concrete base was lifted out of the
ground. I contacted the registered owner/driver, identified by WA DOL as Mylaine A. Menguita (DOB
11-08-1971) who was sitting on a curb near her vehicle. Mylaine stated she was heading eastbound
in the plot when she noticed another vehicle near her. She did not collide with any other vehicle, but
stated the vehicle accelerated on its own and then she ended high-centered on the base of the light
pole. Mylaine denied having any injuries and declined to be seen by the Renton Fire Authority.
I contacted QFC, 4800 NE 4th St to speak to a manager. The manager stated the entire plot was
owned by Leibsohn Wallin Management and provided their contact information.
Banker's Towing arrived to move the vehicle off the concrete and back onto the pavement.
I stayed on location until the vehicle was towed off the concrete.
Mylaine stated she had insurance; however, it was inside of the glovebox which she could no longer
open due to the vehicle apparently losing power.
I provided an exchange of information sheet to Mylaine. I called the property management company,
Leibsohn Wallin, and was able to leave a voicemail with a secretary providing the incident case
number.
During this incident I was equipped with body-worn camera which records both audio and video.
Portions of the incident were recorded. This report is merely a summary of the incident and is not
intended to be an exact transcription of the entire investigation or what may have been captured with
the recording system.
PAGE 3 OF 4
REPORT NO. EU88770 CASE# 23-0210 DATE AND TIME 08/ 1/231525