HomeMy WebLinkAbout24-3093 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
CASE 24-3093 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIl.I F ❑ LOCAL AOENC 4Y00 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 3 TOTAL#OF OBJECT 1 1 8 28
TRIBAL UNITS OZ RESERVATION STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION.. 03 - 1-— 2024 1947 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
SE PETROVITSKY RD BLOCK NO. e✓ 10800
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 100 00 FEET MILES e S ❑ W e 108THAVESE
0 4 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:2536537114 0 11
30
6� LAST NAME PHAM FIRSTNAME KHANG MIDDLE V 1 1 2 31
INITIAL
STREET ❑ 912 S 36TH P! CITY RENTON ST WA ZIP 98055 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs NO�/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 6 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES 2❑
3
10 9❑ P1ATE14 BZE1314 STATE WA uN# 4T1G11AK7MU482347
11[-j- TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# IR.. ro
TRLR. TRLR 5 7 33
12 0 VIN#' VIN#'
:: FROM TO
❑ VEH.YEAR MAKE MODEL STYLE VEHICLE TOWED TO BLIN T GOVT.VEHICLE 7 $ 34
13 2 2021 TOYT CAMRY SD DAMAGE vEs 0NO f �AWkkRS vEs❑ No
REGISTERED OWNER INFO KHANG PHAM 912S 36TH PL RENTON WA 98055 D:2536537114 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
3 4
14 LIABILITY INSURANCE INSURANCE CO AAA INSURANCE AGENCYAB30077519
IN EFFECT &POLICY# 9TOP
VE"'CLE CHARGE 5 36
LEGALLY YES❑NO❑ CITATION# 10 BOTTOM
15❑ STANDING 8
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER [:]EA.
YES 1/ NO D:2069399379
16 a
LAST NAME TAJIK FIRST NAME ZIYAUDDIN MIDDLE
INITIAL
17❑ NEW STREETREs7 12210 SE PETROVITSKY RD 01B CITY RENTON ST WA ZIP 98058 37
18❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL—T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YYEEsI I I NOF YES
t l NO/
19 D IVERI # STATE WA SEX M MMDDYY 03 _ 21 1994 39
20 ON DUTY STATUS AIRBAG,3 RESTR 4 EJECT 1 HELMET INJURY 6 NATURE OF INJURIES 40
USE CLASS NECK PAIN
❑21❑ PLATE# TATE 41
WA VIN# JTDKN3DU7B5346321 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ UIN#. IN#.
43
RLR
'
TOWED By Gov HI 44
VEH YEAR 2011 MAKE 7'Dy7- MODEL pRIUS STYLE 4H —FEHICLE
TOWED✓ NOO BLIN BANKERS YES No�/
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU&PORGY#E CO AMERICAN FAMILY 41102-55414-55 9TOP 5
IN EFFECT
VEHICLE ❑ C[:] CITATION# CHARGE i o BOTTOM
LEGALLY YES N
25 a
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
STEVEN FAJARILLO 12847 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE61840
COLLISION REPORT III III III III III 111
1591972 CASE# 24-3093
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) DIEP THANHTUNG T
(IAST FIRST,
ADDRESS&PHONE# D O.B.
912 S 36TH PL RENTON WA 98055 SEXi F MMDOYyry 08 - 31 - 1958
PASSENGER WITNESS UNIT# SEAT AIRBAG' RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ ❑ 1 POS. 3 6 4 1 USE CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS❑ UNIT# SEAT I AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS R PHONE#
SEX D.O.B.MMDD -❑
YYYY.
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.
STEVEN FAJARILLO 03-22-24 03:03 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 3/23/2024 4:11:39 PM
BADGE OR ID# 12847 ORI# WA0171300 TIME POLICE DISPATCHED; 7:49 Pry] TIME POLICE ARRIVED 7:56 PM
PART Ei PAGE IT]OF 4❑
TIME
REPORT NO. EE61840 CASE# 24-3093 OF COLLISIONO3/21/2419:47
NARRATIVE
24-3093
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. Statements have been paraphrased and
summarized.
On 03-21-2024 1 was working as a police officer in the city of Renton. At approximately 1949 hours I
was dispatched to the report of a non-injury collision at 10800 SE Petrovitsky Rd, City of Renton,
County of King, WA. This incident was captured on my department issued Axon body camera.
Unit 1 was identified as a red 2021 Toyota Camry (WA/BZE1314) (Unit 1). Unit 2 was identified as a
silver 2011 Toyota Prius (WA/CHP9688) (Unit 2).
Unit 1 was in a parking lot on the north side of SE Petrovitsky Rd prepared to make a left/west turn
onto SE Petrovitsky Rd. Unit 1 drove into the road and as it crossed the eastbound lanes it collided
with Unit 2. Unit two was travelling east on SE Petrovistky Rd when it collided with Unit 1. There was
no traffic control where the collision occurred. The driver of Unit 1 claimed Unit 2 was travelling at a
high rate of speed and changed lanes from the outside to inside lane. There were no traffic cameras
in the area.
The front end of Unit 2 collided with the rear driver side wheel and quarter panel. Both vehicles
sustained moderate damage to their respective damage points. Unit 1 had a combination of side and
front airbag deployment and Unit 2 had the front airbag deploy. Both drivers complained of minor
aches and were treated on scene by Renton Fire. The passenger of Unit 1 claimed she was
uninjured.
Both vehicles were privately towed by Banker's towing. I provided each party with a case number.
Due to the circumstances, I was unable to determine any proximate cause of the collision. This report
is to document the circumstances of the collision, damage to vehicles, and both drivers accounts.
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 S. Fajarillo #12847 on 03/22/2024 @ 0245 hours in Renton WA.
PAGE 3 OF 4
REPORT NO. EE61840 CASE# 24-3093 DATE AND TIME 03/21/2419:47
OF COLLISION
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