Loading...
HomeMy WebLinkAboutMiscellaneous - 23 CLEVELAND STREET 4/30/2018 „� . i��� C (eve`Gnd ��. � ,�' , 'I + IO*air ® 1 CHECKLIST FOR CARBON-MONOXIDE Location of Incident: 2-S OLgrlf5L►N 0 8Y Date of incident 14 - 6--q7 QUICK CHECKLIST OF OCCUPANTS Yl Headache yes V-" no Fatigue yes no Nausea yes ✓ no Dizziness yes nom Confusion yes no Are any members of the household feeling ill? yes_ Z no Do the residents feel better away from the house? yes ' no Since the detector's alarm went off, what have you done? Shut- off carbon monoxide sources yes no—Z If yes which sources Let in fresh air? yes no t/ If yes how did.you let the air in How long did you let the air in PPM reading ambient outside the dwelling ©OO Highest PPM reading in the dwelling I I Carbon monoxide detector present? yes_3Z no If yes list the number of detetors locations and make, and serial number of each below. 1. K ITc6-)&rU �i�5"T �2T i4 0 R6 67 2. 3. 4. Which detector(s)by number above activated? SOURCE CHECKLIST LOCATION PPM READING Chimney clogged flue, blocked opening 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 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING) refrigerator stove ---L-L-- vent over stove clothes dryer water heater furnace Oil burner car garage Entranceway from garage to house Name of individual operating the CO monitor Person completing the Checklist 0 ^ MASSACHUSETTS MASSACHUSETTS FIRE INCIDENT REPORT STATE FIRE MARSHAL A | � --- - - -� vr mutualI situation found I action taken I aid B | I fixed property I ignition factor C | I correct address I --, ---- ' c^^~~~ D / ' occup. name last, first, mi E | ' ~^^~r'""= ' ' ""m or apt / F | telephone I I method of alarm I I district I shift I G | no. alar��� H / � � I hazardous material I substance I ,special equip used I I numbers of injuries I number of fatalities rescues I > | mobile property | | vehicle stolen | J | �� ' -- | insurance company � paid| | | year I make | model � � / color / lie no | vzn:R | | | | if equip involved | year | make � / model / serial no | | 401in ignition 01 / complex I I area of gin I equip ~ i - - I K | 41 FIXED ST| form of heat iqnitionl material L | ignited ' ' I | method of extinguishment | | level or fire origin / | M | | | numbers of stories | | L construction type � | | | / -'`.`.. of flame "=may= / / extent or smoke damage | | N | | / detector performance | | sprinkler performance | | P | | | if smoke spread | material gener atixg / /urm / / type | | | beyond room I most smoke : | 1001 } 001 Qi | R | weather conditions | tnaveJL__.UNDE FERM�I.NE.Q OR \L > | -------------------- | entries contained in this report are intended for | | WARM 65 | The sole use of the state fire marshal. Estima . - | | | 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 norl | member making report | implied / | � ^ ' . / 10/06/97 23:54 NORTH ANDOVER FIRE DEPT PAGE: v5. 5k INCIDENT REPORT date : 10/06/97 MONDAY org/ \ ______________________________________________________________________________ ********** CARBON MONOXIDE DETECTOR ACTV **rcv*clr 19:35 * 23 CLEVELAND ST NOH 075 07522 3576 * CARBON MONOXIDE DETECTOR ACTIVATION F10_� * ID #: 1466 : MAZURENKO, NIKKI call-back# ( ) 683-9311 *** UNIT (S) *** 531-" E1 * NOH T, CASALE M, LONG S, NUSSBAU ` r> 19:35 d> 19:35 a> 19:36 k> h> c> 20:36 *** COMMENTS *** E1 NOH 19:35:09 CD-075-CARBON MONOXIDE DETECTOR ACTIVATION 531- 531- E1 NOH 19:36:41 El r��E1TONy �nc SCENE =0 READINGS OF 11 PARTS PER MILLION 531- E1 NOH El REPORTS E1 NOH IN THE KITCHEN. CQ, GAS COMPANY NOTIFIED, AS WELL AS GAS 531- E1 531_ NOH INSPECTOR AND BOARD OF HEALTH. 527 E1 NOH 20:36:34 E1 CLEAR PROBLEM RESOLVED BY THE GAS COMPANY - - � ~ ----------------------------------- 10/06/97 LT. TOM CASALE