HomeMy WebLinkAboutMiscellaneous - 55 DAVIS STREET 4/30/2018 55 DAVIS STREET
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CHECKLIST FOR CARBON MONOXIDE (FIE-
Location of Incident: c7 S DAJ Ca Date of incident
QUICK CHECKLIST OF OCCUPANTS
Headache yes no v1' Fatigue yes no
Nausea yes no,/ Dizziness yes 1102
Confusion yes nom
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 no—z'
If yes which sources
Let in fresh air? yes no
If yes how did you let the air in
How long did you let the air in
PPM reading ambient outside the dwelling coo
Highest PPM reading in the dwelling dC-)O
Carbon monoxide detector present? yeses[ no
If yes list the number of detetors locations and make, and serial number of each below.
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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 o O 0
vent over stove
clothes dryer
water heater 0p a
furnace
Oil burner
car garage
Entranceway from garage to house
Name of individual operating the CO monitor
Person completing the Checklist _ ,