HomeMy WebLinkAbout24-8951 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 5 27c
COLLISION REP FIT 1591971
SASE 24-8951 2
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 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# ❑
COLLISION'. 08 - 1-- 2024 1703 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
NE 12TH STREET BLOCK NO. e✓ 2607
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e 0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:2065369146 1 4 30
6� LAST NAME MONGE FIRSTNAME ALBERT MIDDLE S 1 1 2 31
INITIAL
STREET ❑✓ 17735 105 PL SE#A101 CITY RENTON ST WA 2jp, 98055 z=
NEW ADDRESS
]❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]No✓ INTERLOCKYEs NO✓ YES R No
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMETU E 2 CLASS 1 NATURE OF INJURIES z❑
3
10❑ Pi aT�S� CJT4823 sTArI WAurN# JTHAP1D20P5003820
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 3 7 33
12 0 0 VIN#' VIN#
FROM
34
13� VEH.YEAR2O23 MAKE LEXS MODEL SC430 STYLE P4 VEHICLE TOWEDNOOpLSABLIN T� I� RSTOWING YOs❑ENO✓
HICLE
DAMAGE IILLJJII
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14❑ LIABILITY INSURANCE INSURANCE CO PROGRESSIVE 9711782034 4
IN EFFECT &POLICY# 9TOP
vECALLv HICLE 5 36
res❑NO❑ CITATION# CHARGE 1 o BOTTOM
15❑ LE STAIN,DIING 8 7 6
UNIT MOTOVEHIOR Z CYCLE PEDAL- ❑ PEDESTRIAN ❑ OWNER
❑ DYES✓ H OLD MET PHONE
16❑
LAST NAME UNKNOWN FIRST NAME MIDDLE
INITIAL
STREET CITY RENTON ST ZIP 4
17❑ NEW ADDRESS❑ ❑ 37
18❑ CDL IGNITION REQUIRED IGNITION PtR—E—S1ENT MEDICAL—T�RANSPORTED � 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YEs t l NO❑
19 LLIICENS RIVEWS# STATE SEX U MMDDYY 39
WELMET 1NJURY NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE 9 CLASS 0 ❑
❑ILICENSE 21❑ PLA E# A7637682 TAre 41
WA VIN# JS3TX92V124108520 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ 43
TRLR RLR
VIN#. IN#.
VEH YEAR 2002 MAKE SUZJ MODEL XL] STYLE P4 VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ DAMAGE YES✓ NO BANKERS YES NO✓
REGISTERED OWNER INFO KEON WIN 1140 EDMONDS AVE NE RENTON WA 98056 D:3053947903 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO STATEFARM 5290162-E29-47IN 1U"'LE
STOP
❑ ,.I— CITATION# CHARGE o BOTTOMLEGALYYES N`LJ25
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
DES/REE SCOTT 10272 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF10560
COLLISION REPORT III III III III III 111
1591972 CASE# 24-8951
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
POS. 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'
On 8/25/24 around 1703 hours I was dispatched to 2607 NE 12th ST (City of Renton, County of King,
and State of Washington) due to a report of a vehicle collision. Upon arrival I contacted Driver#1
who said he was driving vehicle #1 and his dog jumped from the back seat into the front seat. Driver
#1 is missing his left arm and let go of the steering wheel to push his dog back when Driver#1 lost
control of his vehicle and struck Vehicle #2 that was parked and unoccupied. Driver#1 believes he
struck the parked vehicle going about 25 to 30 miles per hour. Driver#1 was not injured. Owner#2
was contacted via phone. Both vehicles were towed by Bankers Vehicle #2 had damage to its front
drivers side bumper, quarter panels and door. Vehicle #2 had damage to its rear drivers side
bumper, quarter panels and wheel.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
DESIRES SCOTT 09-01-24 08:27AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 9/1/2024 8:30:16 AM
BADGE OR ID# 10272 ORI# WA0171300 TIME POLICE DISPATCHED 5:06 PM TIME POLICE ARRIVED',5:12 PM
PART I PAGE IT]OF
REPORT NO.! EF10560 CASE# ' 24-8951 DATE AND TIME 08/25/24 17:03
OF COLLISION
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