HomeMy WebLinkAbout24-391 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE z4-391 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AOENC 4900 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ STRUCK
RESERVATION
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 01 - 11 - 2024 0740 17 �. S 8 W H OF e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BLOCK NO. e✓ ----� ❑
TALBOT RD S MILEPOST
4a❑
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ W e S 15TH ST
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
No ,/ I D:2064225342 0 81
30
6� LAST NAME OMAR FIRSTNAME SAFIYA MIDDLE A 1 2 31
INITIAL
STREET ❑ 16531 SE 260TH ST CITy COVINGTON ST WA 2jp, 980428277 2=
NEW ADDRESS
7❑ 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 H U SE
ICNLJAUSSY 1 NATURE OF INJURIES 2❑
3
10❑ P1 aT�S� CER9132 sTATI WAurN# 5TDJKRFH1FS216817
TRAILER STATE TRAILER STATE
11 4 0 PLATE# PLATE# FROM TO
TRLR. TRLR. 5 1 33
12 0 0 VIN#' VIN#
>; FROM TO
VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED fn TO VBLINJ TOWED BY GOVT.VEHICLE J 9 34
13 2015 TOYT HIGHLA DAMAGE YES NO YES[:] No✓
REGISTERED OWNER INFOSAFIYA OMAR 20551121ST WAY SE KENT WA 98031 D:2064225342 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILI INSURANCE INSURANCE CO ALLSTATE. 3 4
IN EFFECT &POLICY# 9TOP
VEHICLE 5 36
YES❑NO❑ CITATION# CHARGE 10 BOTTOM
15❑ LEGALLY STANDING 8 7 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2063564364
16 2
LAST NAME HARVEY FIRST NAME DEON MIDDLE M
INITIAL
17❑ STREET ❑', 12002 SE 191ST PL CITY' RENTON ST WA ZIP 980587901 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCKYES�NOR INTERLOCK YEs I I NOF YES t l NO❑
19 D IVEW #
❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET INJURY 7 NATURE OF INJURIES ❑ 40
USE CLASS NECK
21❑ LICENSE I BHD4162 TATE WA VIN# 4T1BD1FKOFU151610
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2015 MAKE TOYT MODEL CAMRY STYLE VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,� YES NO
REGISTERED OWNER INFO DEON HARVEY 12002 SE 191STPL RENTON WA 980587901 D:2063564364 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY
INSURANCE INSU&PORGY#E CO ST FARM 4248503EO347AIN I GD
VE""LE CITATION# CHARGE
LEGALLY YES Nu
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
M.LEVERTON 2517 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE39525
COLLISION REPORT III III III III III 111
1591972 CASE# 24-391
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'
1/slv suv bottle under brake pedal lane 2 blu/2 sedan stopped
RTF
Within the city limits of Renton/King/WA I responded to a 2 car crash near the intersection of Talbot
Rd S at S 15th St.
I contacted the driver of unit 2 who said he was stopped in lane 2 when he was hit from behind by unit
1. He was checked and released on scene by Renton Fire for injury complaint. Damages were minor
and did not require a tow truck.
I contacted the driver of unit 1 who told me as she was braking for the traffic light a bottle rolled
across the floor and went under the brake pedal. She bumped into the back of unit 2. She did not
complain of injury and damages were minor, and did not require a tow truck.
Information/insurance only
I certify (declare) under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
M.Leverton/2517 City of Renton/King/Wa 1/11/2024
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
M.LEVERTON 01-11-24 11:01 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY E
DAT
C.JACOBS 1953 111112024 1:48:27 PM
BADGE OR ID# 2517 OR]# WA0171300 TIME POLICE DISPATCHED 7:40 AM TIME POLICE ARRIVED 7:41 AM
PART I PAGE IT]OF 3�
REPORT NO. EE39525 CASE# ' 24-391 DATE AND TIME 01/11/24 07:40
OF COLLISION
I
i.
i ,
i
i
PAGE 3 OF 3