HomeMy WebLinkAboutMiscellaneous - 1620 SALEM STREET 4/30/2018 (2) 1620 SALEM STREET • ,, C
210/106.6-0058-0000.0
'
`
�^ `t '
-
`--`^--_ MASSACHUSETTS N F,| | ETl '� �
FIRE INCIDENT RBWRl
l | fdid | in�` dent no. | exp | date | day | alarm tm | arry tm ( time in serv |
A | _1N|X�XXX *1 9015 '--|
| situation found | |, acblon taken | | mutual aid |
� | _CD� __|_4�| �EM{}V{�1fAZ/��D' l 4_1 _�/�L i �
_� _______-_--_--� - - _ -__ --__ �
{ fixed property | | ignition factor ! _ {
C } _1���AMll=Y/YEA _______'_ --_i41-1|�_IMPR[Uz'-5T�\RTUP��S0 '{/F9�]9P__'
zip i |
| correct address p code | census
_ ........... ____ _ ............ .... ................. |___0WN____ L'_2532___--' | �
| | occup. name last, first , mi | telepho,�e I ,`oon or apt |
____'.....J '--__-- |
| | owner name last , first , mi | address / telephone !
F | _____. __|_SA�{ �__-___-'- _ -i-< _->�}AM�E -- |
�� | | district | hift | no alarm� |
| | method of alarms .
| 10f �--�prvice | #tankers | #engines | #aerial app | # other vehicles |
H | ........ ..... ............... |-_. ---�ii1���d___1___-�L|_�L��d_-'
| | hazardous material | substance \ special equip used |
i grglaILt-
|
� | numbersof injuries | number or rata/ zTzes ' rescues '
1 | -0_DTHl R _01_' |
� | mobile property | | vehicle stolen ? | estimated total dollar |
J | -UNl}ET{�RM] ........... '$0�1Z�L_--|
| insurance company | total insurance | claim paid i
|
|
| | year | mak� | model | color | lic no | vin# |
| |
_---______|_____l______-
| ! if equip involved � year | make | model | serial no |
\
� . - _-'
| l | | area of origin | equip inv in ignition |
� compex
| form-�-�� of heat ignition | material ignited | form | type | |
L | 1 IFORM
| method of extinguishment fire origin
M | Al.ER_LEVEL� 1-_8 |
---------����� | construction | |
| numbers of stories |
|
| extent of flame damage i | extent of smoke damage | !
N | --|- �-'|
�
� | -dp+ector performance | | sprinkler performance ! |
� |
P |
| if smoke spread | material generating \ form | ! type | |
| beyond room | most smoke : | 1001 | 001
Q | i
R | weather conditions | �-5_.|
\ -------------------- | entries contained in this report are intended for |
| COLD AND CLEAR. | The sole use of the state fire marshal. Estimat- |
| TEMP 20 DEGREES | ions & evaluations made herin represent "MOST !
| | LIKELY" & "MOST PROBABLE" cause & effect. Any |
| _ } representation as to the conditions outside the |
| | State Fire Marshals Office is neither intended nor |
� | member making report | implied |
.........................................................._ ................................
� �
INCIDENT REPORT NARRATIVE 01 / 15/98 08:56 PAGE 2
CASE#: 4/9P SEQ: 01
A
RRIVED TO FIND CO READINGS OF 38 PPM IN BASEMENT. LOWE�
F 20-22 PPM ON FIRST FLOOR AND 12 PPM ON SECON0 FLOOR.
� WE VENTILATED HOUSE TO GET 0PPM READINGS. . CLOSED WINDOWS AND DOOR
AND TURNED ON OIL BURNING FURNACE. WE GOY 0 PPM TROUGHOUT
HOUSE. A CAR WAS WARMED UP IN THE GARAGE FOR APPROXIMATELY
5 MINUTES. GARAGE IS ATTACHED TO BASEMENT AND BELOW FAMILY ROOm.
�
|
'
!
/
!
�
�U4. rLvr
l � 6 � �-Li74�
CHECKLIST FOR CARBON MONOXIDE
Location of Incident: 1G-22�' -S;If M- S Date of incident
QUICK CHECKLIST OF OCCUPANTS
Headache yes not",/
o� Fatigue yes no'�
Nausea yes no Dizziness yes no
Confusion yes no
Are any members of the household feeling ill? yes no'--
Do the residents feel better away from the house? yes no
Since the detector's alarm went off, what have you die?
Shut- off carbon monoxide sources yes no
If yes which sources OIL Fw rz UA-� C
Let in fresh air? y es no
I
If yes how did you let the air in ->aUn S
Mow long did you let the air in
PPM reading ambient outside the dwelling
Highest PPM reading in the dwelling _
Carbon monoxide detector present? yes no
If yes list the number of detetors locations and make, and serial number of each below.
CoS- ave
2. G g7as7
3.
4.
Which detector(s) by number above activated? /
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening ('ello n- y
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN I OF THE FOLLOWING APPLIANCES LIST EACI-I ADDITIONAL
THE ON TI-IC COMMCNTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove
vent over stove
clothes dryer
water heater
furnace
Oil burner �j
car garage
Entranceway from garage to house �,�
Name of individual operating the.CO monitor `6 �✓ c��
Person completing the Checklist ��°�
RE :NR
VED
't ' t � � AUG9 2004u,� f_ TOWN OFTH ANDOVERHEALTPARTME
NT
"YS
N4 OWNER DDR.E.SS �� � ._
t p�
DATE OF PCIMPtN4�:
rryt_: NC) I/ /
!v.A [I;riIF t:?k .r vWE, F;1311 t'lNt., ✓ hfiFiKCiF'IVt4'�
LMSER rt(-)N 4
ROOTS L'
LEACH.PIELD RUNBACK
F,XCF,SSJVE sol-ID's FLOODED
SOLID CARRYOV'F-R (JTf4*Fft EXPLAIN
's}ax f�LBfS2}9»tl by
L IJN I hN I,:� I K,ANSt-'tXpgR �) 0 t; J
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: /p—,
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
(example: left front of house
9/gyp �" S r
DATE OF PUMPING: :-1e QUANTITY PUMPED
GALLONS
CESSPOOL: NO yES
SEPTIC TANK: NO � YES
'NATURE OF SERVICE: ROUTINE
EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE --- FULL TO COVER
ROOTS BAFFLES IN PLACE
EXCESSIVE SOLIDS LEACRUNBACK
SOLIDS CARRYOVER —"—' FLOODDED ED
OTHER (EXPLAIN)
SYSTEM PUMPED BY:
AND TH
O;til M E N TS: BOARD of HEAL
O "TENTS TRANSFERRED TO: