HomeMy WebLinkAbout24-10665 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 0 27c
COLLISION REP FIT 1591971
CASE 24-10665 z
INTERSTATE ❑ CITY STREET FIRE ❑
RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4Y00 3
HIT&RUN CODING'
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 28
5
RESERVATION 1
TRIBAL UNITS 02 STRUCK
z
3❑ DATE of M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY# ❑
COLLISION'. 10 - 1-- 2024 1403 17 ❑.= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑ NON INTERSECTION ❑✓
RAINIER AVE S BLOCK NO. e✓ 700
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ 50 00 FEET e SMILES N B W e SWGRADY WAY
2 0 29
MOTOR PEDAL- DAM THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El YES
NO ,/ D:2534097277 0 11
30
6� LAST NAME GOMEZ FIRSTNAME ANA MIDDLE M 1 1 2 31
INITIAL
STREET ❑1 806 HARRINGTON AVE NE UNIT A CITY RENTON ST WA 2jp, 98056 z
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
1/ I INTERLOCK YES[:]NO NTERLOCKYEs Z/NO YES R NoF,/
LRIIVER # STATE WA SEX'F MM D Y' 03
8❑ - 03 - 1997 1 2 32
9 ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 H USEET ICNLJAURY 1 NATURE OF INJURIES z❑
3
10❑ P1 aTES� CHH2626 sTAr� WAurN# 2HKYF18654H587448
TRAILER STATE TRAILER STATE
11 3 5 PLATE# PLATE# FROM TO
TRLR. A'RLR. 1 5 33
12 3 5 VIN#j VIN#
FROM TO
VEH.YEAR 2004 MAKE MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 1 5 34
13 4 HOND PILOT DAMAGE YES NO YES[:] No
✓
REGISTERED OWNER INFO OWNEDBYDRIVER VEHICLE NO. 1
❑
SHADE IN DAMAGED AREA ❑ 35
14 LIABILI INSURANCE❑ INSURANCE CO 3 4
IN EFFECT &POLICY# 9TOP
VEHICe CHARGE 1 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 ❑ YES 1/ NO D:2668290641
16 a
LAST NAME OGAWA FIRST NAME ESTHER MIDDLE M
INITIAL
17 STREET❑ NEW ADDREss❑' 28020 133RD STREET CT E CITY BUCKLEY ST WA ZIP 98321 37
18❑ CDL IGNITION REQUIRED IGNITION PR-E-1SENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs It I NOF YES
t l NOF,/
19[-] DRIVER'S STATE WA ]SEX IF I D.C... 01 11 1934 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS AIRBAG 2 RESTR 4 EJECT 1 HEJ EET NJAURSY 1 NATURE OF INJURIES 40
❑21❑ PLATE# ATE3641 TArE 41
WA VIN# JTDKN3DU7F1887009 1
42
22❑ PLATE# STATE PLATE# STATE
TRLR
23❑ VIN#. IN#. 43
RLR
'
Gov H
VEH YEAR 2015 MAKE 7'Oy7' MODEL pRIUS STYLE DAMAGE TOWED NOO✓ BLIN TOWED BY 44
YES YES N.7
24❑ REGISTERED OWNER INFO OWNED SY DRIVER VEHICLE N0.2
SHADEDAMAGED AREA
3 4
LIABILITY
INSURANCE I PORGY#ECO ALLSTATE 920 718 739IN IULlliKOTlTlfll;0-
"cE-SVEHICLE ❑ ,.I—I CITATION# CHARGE LEGALLY YES N`LJ25 7p-,
NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
TAGNE 12575 WA0171300
PART A PAGE 01 OF
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EF28129
COLLISION REPORT III III III III III 111
1591972 CASE# 24-10665
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'
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.
P.LANTAGNE 10-12-24 06:30 PM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
CO.JOHNSON 0505 1 1012412024 12:33:46 PM
BADGE OR ID# 12575 OR]# WA0171300 TIME POLICE DISPATCHED 2:05 Pry TIME POLICE ARRIVED 2:06 PM
PART I PAGE IT]OF 4]
REPORT NO. EF28129 CASE# 24-10665 OF COLLISION
10/12/24 14:03
OF CbLLI510N
NARRATIVE
24-10665
On 10/12/2024 at approximately 1403 hours, I, Officer Lantagne, responded to a blocking, non-injury
collision which occurred in the 700 block of Rainier AVE S, which is located in the City of Renton,
County of King, and the State of Washington. I responded in my fully marked police vehicle, wearing
my patrol uniform and body worn vehicle.
I arrived on scene and observed Unit#1, a 2004 Honda Pilot with license plates CHH2626 issued out
of Washington State, and Unit#2, a 2015 Toyota Prius with license plates ATE3641 issued out of
Washington State, blocking the inside center lanes of southbound Rainier AVE S north of SW Grady
Way. I was advised there were no injuries.
I contacted the driver of Unit#1, Ana M. Gomez (DOB 03/03/1997), who told me the following:
Gomez was driving southbound in a center lane of Rainier AVE S in the 700 block. Gomez signaled
to merge into the left lane and the vehicle to her left stopped. Gomez began to merge into the lane to
her left and Unit#2 drove forward and struck the left rear wheel and fender of her vehicle. Gomez did
not have proof of insurance.
I contacted the driver of Unit#2, Esther M. Ogawa (DOB 01/11/1934), who told me the following:
Ogawa was driving southbound in the inside center lane of Rainier AVE S in the 700 block. Unit#1
began merging into Ogawa's lane and the right front of Ogawa's vehicle struck the left rear of Unit#1.
I observed the damage to the vehicles and other physical evidence was consistent with the
statements made by both drivers. Unit#1 had minor damage to the left rear fender and wheel which
was scraped. The front right bumper of Unit#2 was dented in and pulled from the front of the vehicle.
The collision diagram is an accurate illustration of the events leading up to the collision.
I provided an exchange of information to Gomez and Ogawa.
I, Officer P. Lantagne #12575, certify (or declare) under penalty of perjury, under the laws of the State
of Washington, the foregoing is true and correct.
Electronically signed by Officer P. Lantagne #12575 at 1536 hours on 10/12/2024 at Renton, WA.
PAGE 3 OF 4
REPORT NO. EF28129 CASE# ' 24-10665 DATE AND TIME 10/12/24 14:03
OF COLLISION
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