HomeMy WebLinkAbout24-174 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 1 27c
COLLISION REP FIT 1591971
❑ ❑ RESULTED ❑ CASE 24-174 2
INTERSTATE CITY STREET FIRE
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHIr.I F ❑ LOCAL AGENCI 4200 3
HIT&RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 TOTAL#OF OBJECT 2$
0 5
RESERVATION
TRIBAL UNITS 02 STRUCK
2
3❑ DATE OF M M D D Y Y Y Y TIME(2400) COUNTY# MILES N E IN CITY#
COLLISION.. 01 - 1-— 2024 2330 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
BENSON RD S BLOCK NO. e ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV a BENSON DR S
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
�/No D:9452093836 0 4 30
6 LAST NAME DOSTYAR FIRSTNAME JAN MIDDLE M 1 1 2 31
INITIAL
STREET ❑ 210O S 260TH ST APT P301 CITY DES MOINES ST WA 7jp, 981989074 2
NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION : PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO�/ YES R No�/
8❑ DRIVERS
E#
-, [NATURE OF
9 ON DUTY❑ STATUS' AIRBAG 6 RESTR 9 EJECT 1 H U SE CLASS 7 I ARM PAIN INJURIES 2❑
3
10❑ P1 aT�S� CFH7760 sTAr� WAurN# 2T18URHE9HC755568
TRAILER STATE TRAILER STATE
11 0 0 PLATE# PLATE# ROM ro
TRLR. TRLR 5 1 33
12 0 VIN#' VIN#
ROM TO
VEH.YEAR 2017 MAKE TOYT MODEL COROL STYLE VEHICLE TOWED fn TO VBLINJ TOWED BY I GOVT.VEHICLE 1 3 34
DAMAGE YES NO YES[:] ✓NO
13❑ REGISTERED OWNER INFO JAN DOSTYAR 2100 S 260TH STAPTP301 DES MOINES WA 98198 VEHICLE NO. 1
SHADE IN DAMAGED AREA ❑ 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 6118594271 4
IN EFFECT &POLICY# 9TOP
vEHICLE CHARGE 5 36
LEGALLv res❑NO❑ CITATION# 1 o BOTTOM
15❑ STANDING 6
MOTOR PEDAL- PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES 1/ NO D:2063047730
16 a
LAST NAME SA K FIRST NAME TANA MIDDLE I C
INITIAL
17❑ STREET ❑', 25316 142ND AVE SE CITY KENT ST WA ZIP 980426654 37
NEW ADDRESS ❑
18� CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL TRANSPORTED ❑ 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 D IVEW # STATE WA SEX F M .O.B. 12 _ 10 _ 1986 39
WELMET INJURY0 NATURE OF INJURIES 40
20❑ ON DUTY STATUS' AIRBAG 9 RESTR 9 EJECT ''1 USE CLASS ❑
21❑ LICENSE I BPP2382 TAre WA VIN# 2T2BZMCA9GC047775
❑ 41
PLATE#
42
22❑ PLATE# STATE PLATE# STATE
23❑ VIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2016 MAKE LEXS MODEL RX STYLE VEHICLE TOWED TO BLIN TOWEDBY GOV HI 44
24❑ D YES NO BANKERS YES NO
REGISTERED OWNER INFO LANG SAK 16619186TH AVE SE RENTON WA 98058 AMA VEHICLE NO.2
SHADE DAGED AREA
4
LIABILITY
INSURANCE &POINSURGY#E CO STATE FARM 537-9854-D21-47IN 9TOP 5
VE""LE ❑ ,J� CITATION# CHARGE E
BOTTOM
LEGALLY YES N`L J
25 ' e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# JAGENCY
26
LACY SMITH 12613 WA0171300
PAGE 01 OF
PART A
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT No. EE57561
COLLISION REPORT III III III III III 111
1591972 CASE# 1 24-174
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) DANG TRAM H
(LAST FIRST,
ADDRESS&PHONE# D.0
.B.
17223 109TH PL SE RENTON WA 980555924 SEX F MMDDYyry 01 - 09 - 1985
{� SEAT HELMET INJURY NATURE OF INJURIES
PASSENGER ZWITNESS� UNIT# 2 POS 8 AIRBAG 9 RESTR. 4 EJECT 1 USE CLASS 16 CHEST PAIN
NAME
'(LAST,FIRST MIDDLE INITIAL)
ADDRESS&PHONE# DOB
SEX' MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
POS. USE CLASS
NAME
(LAST FIR57 MIDDLE INITIAL)
AppRESS&PHONE#
SEX D.O.B.
MMDDYYYY. -
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY NATURE OF INJURIES
❑ ❑ POS. USE CLASS ----�
NARRATIVE'
During this incident, I was equipped with a body-worn camera, which records both audio and video.
Portions of this incident were recorded. This report is merely a summary of the incident and is not
intended to be an exact transcription of the entire investigation or what may have been captured with
the recording system.
On 01/05/2024, 1 was assigned to District 11 as the, 3R11. At approximately 2304 hours I was
dispatched to a two vehicle collision located at BENSON RD S/BENSON DR S . This is located in the
city of Renton, the county of King, and the state of Washington.
I arrived on scene and contacted the driver of unit 1. 1 positively identified the driver of unit 1 as, Jan
Dostyar, via his Washington state driver's license. Unit 1 stated he was traveling Northbound on
Benson Dr S and had the green light through the intersection. Unit 1 stated Unit 2 turned left in front
of him causing the collision.
I contacted the driver of unit 2 and positively identified her as, Tana Sak, via her Washington state
driver's license. Unit 2 stated that she was turning left from Benson Dr S onto Benson Rd S and had a
green light when she was hit by Unit 1.
The light at BENSON RD S/BENSON DR S does not have a turn only arrow. There for if both drivers
had a green light it appears Unit 2 did not grant the right of way to unit 1 and illegally turned left.
All parties on scene were evaluated by Renton Fire and medically cleared on scene.
Both vehicles were towed.
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
LACY SMITH 01-12-24 03:17 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
DESIRES SCOTT 10272 1 1/25/2024 7:27:23 PM
BADGE OR ID# 12613 ORI#' WA0171300 TIME POLICE DISPATCHED! 11:31 PM TIME POLICE ARRIVED';11:35 PM
PART I PAGE IT]OF
REPORT NO. EE57561 CASE# ' 24-174 DATE AND TIME 01/055/24 23:30
OF COLLISION
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