HomeMy WebLinkAboutMiscellaneous - 31 WALNUT AVENUE 4/30/2018 (2)'~� '�-.~'
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A
I situation found I action taken F-A-l"Tual aid i
B | A __ ZAHD }
| fixed property | | ignition factor | |
C | 1-FAMILY/YERR ___-__-|
| correct address .| zip code | census |
D|
' |
| | o�cup.name last,first,mi | telephone -/room or a0t'|
E }
| | �------------_
owner name last,first,mi | address ---
|
| telephone |
F I /
| | method of alerm | | district | shifT '|-�o.a�'a`m--'|
G|
| Wire service |#tankers |#engines |#aerial app | # other vehicles!
H|
| hazardous material | substance | special eqI---"Ied- |
___
| numbers of Quries | number of fatalities | rescues /
IZI I fit |
| mobile property | | vehicle stolen ? | estimated total do1lar |
J | |
| insurance company |total insurance | claim �--paid
--'|
|
| lif equip involved!year|make |model | serial no |
| 0 AM 738___|
| complex | | area of origin | equip inv in ignition |
K } ST -22i
| form of heat ignition| material ignited |form | type | |
L|
|
| method of extinguishment | | level of fire origin | |
M| |
| numbers of stories | | construction type | !
|
|
| extent of flame damage | | extent of smoke damage | |
N | |
| detector performance | | sprinkler performance | |
P| |
| if smoke spread | material generating|form | /type..���----
| beyond room | most smoke: | 1001 | NN|
R | weather conditions|�l.�_l�� --- '---- 1�---|
/ -------------------- | e_�� ntries contained in this report are intended for |
I CLEAR COLD | The sole use of the state fire marshal. Estimat- |
| TEMP 32 DEGREES | ions & evaluations made herzn represent "MOST |
� | L{KELY" & "MOST PROBABLE" cause & effect. Any |
| | representation as to the conditions outside the |
| } State Fire Marshals Office /s neither intended no'|
| member making report | implied |
FM.RINC4
INCIDENT
REPORT NARRATIVE
01/20/98 11:17 PAGE 2
v5.9]
CASE#:
4865 SEQ: 01
A NEW OVEN WAS
INSTALLED THE DAY BEFORE IN THE HOME.
GAS
COMPANY SAID IT
WAS NOT BURNING
PROPERLY AND NEEDED
TO BE
ADJUSTED BY COMPANY
THAT SOLD
UNIT lO HUMEOWNLR. THE
OVEN
WAS TAGGED BY
THE GAS COMPANY.
r' •
CHECKLIST FOR CARBON MONOXIDE
Location of Incident: -31 (,) a /n U T
QUICK CHECKLIST OF OCCUPANTS
Headache yes no ,/ Fatigue
Nausea yes no Dizziness
Confusion yes no
Date of incident - o? o - p
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 done?
Shut- off carbon monoxide sources yes__Z no
If yes which sources
yes no
yes no ✓
Let in fresh air? yes no
If yes how did you let the air in �yb'i2 S -� (� �� N-y(_.yJ S
How long did -you let the air in 15 Xn- i n T F -S
PPM reading ambient outside the dwelling
Highest PPM reading in the dwelling a
Carbon monoxide detector present? yes v,**-- no
If es list the number of detetors locations and make, and serial number of each below.
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 I OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove,\ M
vent over stove K,
clothes dryer ( e /_ -
water heater —rC: /4�
furnace
Oil burner
car garage
Entranceway from garage to house
Name of individual operating the CO monitor -
Person completing the Checklist