HomeMy WebLinkAbout23-10664 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
CASE 23-10664 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI 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 09 - 1-- 2023 0001 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
N SOUTHPORT DR BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ W e GARDEN AVE N
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4255243651 0 81
30
6❑ LAST NAME TRAN FIRSTNAME KALLIYANA MIDDLE T 1 1 2 31
INITIAL
STREET ❑ 456 ROSARIO AVE NE CITY RENTON ST WA ZIP 98059 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 04 1— 19 — 2006 2 32
9 ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 1❑ PI aTpS� AKT7711 sTAT� WA VIN# 4T18D1FK8CU056580
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 6 2 33
12 0 VIN#' VIN#
FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN TRQ�y,�p y GOVT.VEHICLE 9 9 34
13 4 2012 TOYT CAMRY SD DAMAGE YES NO 6 9 MYERES YES❑ NO✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE INSURANCE CO ALL STATE 917910 746 4
IN EFFECT &POLICY# TOPVEHCLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:2069027234
16 a
LAST NAME KLINGER FIRST NAME ISAAC MIDDLE IC
INITIAL
17 STREET NEW ADDREs7 35 CLEMDNS RD CITY MONTESANO ST WA ZIP 98563 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL t—TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK yyEEsl I I NOF YES
t l NO�
19 LICENSE STATE WA SEX M M.C.B. 02 _ 23 _ 1981 39
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
LICENSE I ❑21❑ PLA E# CGG9024 TATE WA VIN# 41
4F2CZ94134KM13812 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
GoI
VEH YEAR 2004 MAKE IlggZp MODEL TRIBUTE STYLE UT DEHICLEAMAGE TOWED NOO✓ BLIN TOWED BY v HyES NO 1/ 44
24❑ fj
REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGEbAREA
2 3 Cd
INAEFFIECTTY NSURANCE❑ &POINSULICY#E CO 1 9TOP
VE."Le YES N CITATION# CHARGE
� i o BOTTOM
LEGALLY
25❑ J s
7BRYAN
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
26
NAME
1 12489 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. ED99666
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10664
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) BLANCHE-JONES ASHANTI A
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
12845 AMBAUM BLVD SW BURIEN WA 98146 4255455024 SEXi F MMDOYyry 12 - 01 - 1989
PASSENGER Z WITNESS UNIT# 2 PDS 3 AIRBAG 2 RESTR. q EJECT ? 1 HELMET LASS NATURE OF INJURIES
USE 2 CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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 09-16-23 01:29 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
P.SUMMERS 888 1 911712023 4:42:04 PM
BADGE OR ID# ! 1Y489 OR]# WA0171300 TIME POLICE DISPATCHED 12:01 AM TIME POLICE ARRIVED',12:01 AM
PART I PAGE IT]OF 4]
REPORT NO. ED99666 CASE# 23-10664 OF COLLISION
09/16/23 00:01
OF CbLLI510N
NARRATIVE
CASE 23-10664
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 Saturday September 16th, 2023, at approximately 00:01, Officer C. Arnold on viewed a two-
vehicle collision at N Southport Dr and Garden Ave N within the City limits of Renton, King County,
Washington.
-UNIT ONE: WHITE 2012 TOYOTA CAMRY WASHINGTON LICENSE: AKT7711
-UNIT ONE DRIVER: KALLIYANA T. TRAN (DOB: 4.19.2006)
-UNIT TWO: WHITE 2004 MAZDA TRIBUTE WASHINGTON LICENSE: CGG9024
-UNIT TWO DRIVER: ISAAC C. KLINGER (DOB: 2.23.1981)
Officer C. Arnold indicated he on-viewed a collision at the listed location. I responded a short time
later and contacted Kalliyana who stated she was driving east on N Southport Dr and crashed into
unit two. Kalliyana indicated she saw unit two stopped at the red light and tried to stop but couldn't
stop in time. Kalliyana was not injured but was examined by Renton Fire on scene. Kalliyana's
vehicle was towed from the scene due to the front-end damage.
After talking to Kalliyana, I contacted Isaac who said he was stopped at the red light at N Southport
Dr and Garden Ave N when he was hit by unit one in the rear. Isaac and his front passenger Ashanti
A. Blanche-Jones (DOB:12.01.1989) were examined by Renton Fire Department on scene for back
and neck pain.
I provided Isaac and Kalliyana 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 9.16.2023 at 00:58 hours in Renton, WA.
PAGE 3 OF 4
REPORT NO. ED99666 CASE# 23-10664 DATE AND TIME 09/16/23 00:01
OF COLLISION
NOT TO SCALE
Park Ave N ake Wash. Blvd N
Garden Ave
PAGE 4 OF 4