HomeMy WebLinkAbout23-10526 ITFF' "POLCERA II I !�� I III I III I IIII III II I . 4 27c
COLLISION REP FIT 1591971
CASE 23-10526 z
INTERSTATE ❑ CITY STREET FIRE ❑RESULTED
1 STOLEN
STATE ROUTE ❑ OTHER ❑ VFHICI F ❑ LOCAL AOENC 4200 3
HIT 8 RUN CODING
COUNTY RD PRIVATE WAY INVOLVED
2 2 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#
cowsloN 09 - 1-- 2023 1332 17 ❑-= S 8 IN e 1070 3
4❑ ON (PRIMARY TRAFFIC WAY) INTERSECTION ❑✓ NON INTERSECTION ❑
SE 168TH ST BLOCK NO. e✓ 11300 ❑
4a❑ MILEPOST
DISTANCE OF(REFERENCE OR CROSS STREET)
5❑ ❑ FEET e S ❑ VV e 113THAVE SE
0 1 29
MOTOR PEDAL- DAMAGE THRESHOLD MET PHONE
UNIT 01 VEHICLE ❑ CYCLE El
,/No D:4255420073 0 9 30
6� LAST NAME CORNUELLE FIRSTNAME TIANA MIDDLE L 1 1 2 31
INITIAL
STREET ❑ 17314 156TH AVE SE CITY RENTON ST WA Zjp, 980589032 z
'NEW ADDRESS
7❑ CDL IGNITION REQUIRED IGNITION PRESENT MEDICAL TRANSPORTED 3
INTERLOCK YES[:]NO 1/ INTERLOCKYEs NO Z/ YES R No�/
8❑ LRIIVER #
ON DUTY❑ STATUS AIRBAG 2 RESTR 4 EJECT 1 HELMET U E 2 CLASS 1 NATURE OF INJURIES z❑
3
10 9❑ PI ATFBit CHM6322 sTArI WA urN#' 2G1WL52M9T1197735
TRAILER STATE TRAILER STATE
11 3 0 PLATE# PLATE# FROM TO
TRLR. TRLR 7 3 33
12 3 0 VIN#' VIN#
>; FROM TO
❑ VEH.YEAR MAKE CHEV LUMINA 4D MODEL STYLE VEHICLE TOWED TO BLIN TOWED BY GOVT.VEHICLE 9 9 34
DAMAGE YES NO
13 4 1996 YES[:] No
REGISTERED OWNER INFO CHRIS CORNUELLE 17314156THAVE SE RENTON WA 98058 VEHICLE NO. 1 ❑
SHADE IN DAMAGED AREA 35
14 LIABILITY INSURANCE INSURANCE CO GEICO 4291.62.79.68 4
LI EFFECT I SUR N# TOPVEHCLE CHARGE 36
LEGALLYYES NO CITATION# 3AO463529 INATTENTIVE DRIVING <1�3
orrom
15❑ STANDING 6
MOTOR PEDAL-:. PEDESTRIAN PROPERTY DAM THR OLD MET PHONE
UNIT 02 VEHICLE ❑ CYCLE ❑ ❑ OWNER ❑ YES NO ,/ D:2066963319
16 a
LAST NAME UBANDO FIRST NAME ARRA MIDDLE /
INITIAL
17❑ NEW STREETREs7 10817 SE 220TH PL CITY KENT ST WA ZIP 98031 37
18❑ CDL IGNITION REQUIRED IGNITION PtR-E-S1ENT MEDICAL-T�RANSPORTED � 38
INTERLOCK YES❑No� INTERLOCK YEs I I NOF YEs t l NOF,/
19 DRIVER'S STATE WA ]SEX IF D.C... 05 _ 20 _ 1987 39
LICENSE# MMDDYY
20❑ ON DUTY STATUS I
AIRBAG 2 RESTR 4 EJECT 1 H U EET 2 NJAURSY 1 NATURE OF INJURIES ❑ 40
❑ 41
21❑ PLA E# ALM5924 TArE WI VIN# 1GNWGPFF3F1245914 1
42
22❑ PLATE# STATE PLATE# STATE
23❑ UIN#. 43
TRLR RLR
'IN#.
VEH YEAR 2015 MAKE CHEV MODEL EXPRESS STYLE V/V VEHICLETOWED TO BLIN TOWEDBY GOV HI 44
L4❑ DAMAGE YES NO,/ YES NO
REGISTERED OWNER INFO BETHESDA COMMUNITIES INC 600 HOFFMANN DR WATERTOWN W153094 VEHICLE NO.2
SHADE IN DAMAGED AREA
2 3 4
LIABILITY INSURANCE INSU8 PORGY#E CO pHIL1DELPHIAINDEM pHPK2546343 1GD
IN EFFECTVE""LE CITATION# CHARGE
LEGALLY YES Nu
25❑ s e
OFFICER'S NAME(PRINT) OFFICER PHONE BADGE OR ID# AGENCY
J
26
C.JACOBS 1953 WA0171300
PART A PAGE 01 OF C7
3000-345-159 OR 11/181
STATE OF
POLICETRAFFICN CORRECTION REPORT NO. EE02914
COLLISION REPORT III III III III III 111
1591972 CASE# 23-10526
ADDITIONAL PERSONS INVOLVED PASSENGERS AND/OR WITNESSES ONLY)
NAME MIDDLE INITIAL) CORNUELLE A MAFOA
(LAST FIRST,
ADDRESS&PHONE# D O.B. '
17314 156TH AVE SE RENTON WA 980589032 SEX M MMDDYyry 11 - 22 - 2021
PASSENGER WITNESS UNIT# SEAT AIRBAG RESTR. EJECT ' HELMET INJURY NATURE OF INJURIES
❑✓ 1 POS. 9 1 10 1 USE 2 CLASS 1
NAME
(LAST,FIRST,MIDDLE INITIAL)
ADDRESS&PHONE# DOB
Ex MMDDYYYY
PASSENGER ❑WITNESS UNIT# SEAT AIRBAG RESTR. EJECT HELMET NJURY 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 9-12-23 at about 1343 1 arrived in the 16700 block of 113th Ave SE for a 2-vehicle collision that
occurred in the intersection. Both vehicles were moved out of the intersection prior to my arrival.
Both drivers identified themselves via WADL.
Driver 1, Tiana Cornuelle told me;
She was driving eastbound on SE 168th st when she looked at her cell phone. Doing this caused her
to not realize that unit 2 had stopped in front of her.
She collided with the rear of unit 2.
She nor her toddler child were injured.
She did not want a tow.
Driver 2 told me;
She was stopped eastbound on SE 168th St waiting to turn North bound when unit 1 struck her
vehicle from the rear.
She was not injured.
She didn't notice any damage to her vehicle, but since it was a company truck she needed a report.
I cited Tiana Cornuelle for inattention via complaint.
This incident occurred in the city of Renton, County of King.
I declare under penalty of perjury under Washington state law that the foregoing is true and correct.
C. Jacobs/1953
I CERTIFY(DECLARE)UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT.
C.JACOBS 09-21-23 09:05 AM
INVESTIGATING OFFICER'S SIGNATURE UNIT OR DIST DET DATED PLACE SIGNED
APPROVED BY DATE
C.JACOBS 1953 1 912712023 10:17:56 AM
BADGE OR ID# 1953 ORI#' WA0171300 TIME POLICE DISPATCHED; 1:36 PM TIME POLICE ARRIVED',1:43 PM
PART I PAGE IT]OF 3�
REPORT NO. EE02914 CASE# ' 23-10526 DATE AND TIME 09/12/23 13:32
OF COLLISION
Not drawn t0 scale
m
s
00
r-r
11 3th Ave SE
Unit
Unit 1
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