HomeMy WebLinkAbout23-8609 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 23-8609 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 07 - 1-- 2023 1742 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
NILE AVE NE BLOCK NO. e✓ 11600 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ �.❑ FEET e S ❑ VV e SE 116TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4257854740 0 11
30
6❑ LAST NAME CONRAD FIRSTNAME DEANNE MIDDLE E 1 1 2 31
INITIAL
STREET ❑ 15032 131 ST AVE SE CITY RENTON ST WA 21p 98058 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO Z/ YES R No�/
8❑ LDRIVER # STATE WA SEX'F MID
.O B 05 1- 14 - 1975 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ P1 aT�S� ACD3394 sTArI WAurN# 1 N4At 2AP6AN514951
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 0 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR 2010 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
13 4 NISS ALTIMA SD DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO SAFECO H2348537 4
LI EFFECT I SUR N# TOPVEHICLE CHARGE 36
LEGALLY YES❑NO❑ CITATION# <1�3
OTTOM
15❑ STANDING 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT VEHICLE ❑ CYCLE ❑ ❑ : OWNER ❑ YES 1/ NO D:4258295086
16 a
LAST NAME ROBISON FIRST NAME ROBERT MIDDLE IL
INITIAL
17 NEW STREETR 7' 16200 SE 176TH PL CITY RENTON ST WA ZIP 98058 4❑ 37
18� CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL TRANSPORTED 38
INTERLOCK YEs❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19 LICENSE# STATE WA SEX M M .C... 10 _ 15 _ 1957 39
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑21❑ 41
ILICENSE PLA E# B09027Y TArE WA VIN# 1FTCR10A7SPA13100 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
TOWED BV Gov HI 44
VEH YEAR 1995 MAKE FORD MODEL RANGER STYLE PK DAMAGE TOWED✓ NOO BLIN GENE MEYERS YES Noy/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAGED AREA
2 4
LIABILITY
INSURANCE INSURANCE
#E CO PEMCO CA 0479370IN 1 VE—LE ❑ ,J� CITATION# CHARGE
25 GQ
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. ED84852
COLLISION REPORT III III III III III 111
1591972 CASE# 23-8609
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME
(/AST 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 07-27-23 07:17 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 713112023 6:25:17 PM
BADGE OR ID# 12489 ORI# WA0171300 TIME POLICE DISPATCHED 5:46 PM TIME POLICE ARRIVED]6:01 PM
PART Ei PAGE IT]OF 4�
REPORT NO. ED84852 CASE# 23-8609 OF COLLISION
07/27/23 17:42
OF CbLLI510N
NARRATIVE
CASE 23-8609
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 July 27th, 2023, at approximately 17:46, 1 responded to a 911 call regarding a two-
vehicle collision at Nile Ave Ne and Se 116th St within the City limits of Renton, King County,
Washington.
***CALL REMARKS: 2 MVA... NI/NB.... >1 K DAMAGE.... HAZ LIGHTS ON.... BOTH VEH'S PULLED
TO THE SHOULDER...
-UNIT ONE: GRAY 2010 NISSAN ALTIMA WASHINGTON LICENSE: ACD3394
-UNIT ONE DRIVER: DEANNE E. CONRAD (DOB: 5.14.1975)
-UNIT TWO: GREEN 1995 FORD RANGER WASHINGTON LICENSE: B09027Y
-UNIT TWO DRIVER: ROBERT L. ROBISON (DOB: 10.15.1957)
1 arrived on scene and contacted both involved parties. I verified there were no injuries and both
parties declined aid.
I contacted Deanne who reported the following; she was stopped at the stop sign at Se 116th St and
Nile Ave Ne heading east on Se 116th St. As she proceeded straight through the stop sign, she
crashed into unit two who was headed south on Nile Ave Ne. Deanne indicated she did not see unit
two when she proceeded through the intersection.
Robert reported similar sequence of events, he was traveling south on Nile Ave Ne when unit one
crashed into him. Robert's vehicle needed to be towed from the scene since it was not drivable.
Unit one had front end damage. Unit two had damages to the passenger side, mainly near the
passenger side door.
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 7.27.2023 at 19:20 hours in Renton, WA.
PAGE 3 OF 4
REPORT NO. ED84852 CASE# ' 23-8609 DATE AND TIME 07/27/23 17:42
OF COLLISION
_ E 116TH ST
NOT TO SCALE
Y
NILE AVE NE
mmi
PAGE 4 OF 4