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.��. CCKTON FIRE DEPARTMENTI EL Q <br /> U N N RELA IONSHIP EAR INCID N <br /> 'Ti;19 r- o;z-. 3 <br /> ADDRESS OF INCIDENT ROOM APT NO. CITY 111 1 16 W 117/ 10 <br /> HOME PHONE <br /> 30Ownm,E v Da ISN . <br /> CITY WORK PHONE <br /> A. INFORMATION <br /> I P . I.D EXPOSURE TIME RtGJTH DAY YEAR OAY G Y STT TIME CENSUS TRACT <br /> 3 9 0 6 5 (� U ( - CODE 3 N CO E <br /> ALARMS PRICO <br /> ME <br /> TES, <br /> B. PROPERTY CLASSIFICATION G AREA MATERIALS B SMOKE SPREAD <br /> CODE TYPE OF INCI T �e 72T�onTE CODE AREA OF ORIGW <br /> 2 I 2 <br /> CODE PROPERTY CLASSIFICATICN (COMPLEX) CODE TYPE OF MATERIAL FIRST IGNITED <br /> CAE PROPERTY CLASSIFICATION INDIVIDUAL) CODE FORM OF MA IAL FIRST IGNITE <br /> CODE _RESULTS OF /ACTION - CODE MAIN AVENUES SMOKE SPREAD <br /> 3 I9'l F-./ /L 4- <br /> D. <br /> D. LOCATION B CAUSE EPROTECTION FACILTTI S <br /> CODE LEVEL OF ORIGIN CODE SPRINKLERS-TYPE <br /> CODE SOURCE OF HEAT CAUSING IGNITION CODE SPRINKLERS- EFFECTIVENESS <br /> CODE FORM OF HEAT CAUSING IGNITION CODE STANDPIPE-TYPE <br /> CODE ACT OR OMISSION CAUSING IGNITION CODE STANDPIPE-EFFECTIVENESS <br /> I <br /> CODE CAUSE CODE PORTABLE EXTINGUISHER-TYPE <br /> CODE PORTABLE EXTINGUISHER- EFFECTIVENESS <br /> F. SPREAD OF FIRE <br /> CODE MAIN AVENUES FIRE SPREAD SPECIALUA H - TYPE <br /> CODE TYPE MATERIAL CAUSING SPREAD <br /> SPECIAL HAZARD PROTECTION-EFFECTIVENESS <br /> A <br /> CODE FORM MATERIAL CAUSING- SPREAD <br /> CODE SIGNAL OR WARNING SYSTEM <br /> TYPE CODE EFFECTIVENESS <br /> A CAUSING SPREAD SIGNALWARNING M Mbm OF ACTIVATION <br /> G. RESPONSE AND HOSE STREAMSSIGNAL/WARNINGY E DETECTORS <br /> I. APPARATUS 2 HOSE STREAMS 3. ON SCENE <br /> � CC& PRIVATEBRIGADE-TYPE <br /> w (X <br /> w _ z 3 R <br /> Z� U) L <br /> V w ~ N 2 W m U1 <br /> Z wa _ a CODE WATCHMANCODE OTHER FACILITIES <br /> EFFECTIVENESS EFFECTIVENESS <br /> A 8 C D A B C D E- F 8 A 8 C D <br /> Q I ql I I I 1 1. LASS PROPERTY 8 PERSONS <br /> H. EXTENT OF DAMAGE CODE VALUE-PROPERTY CODE VALUE-CONTENTS <br /> AMSMOKE <br /> CODE LOSS-PROPERTY CODE LOSS-CONTENTS <br /> WDE EXTENT OF MA - WATER <br /> NO INJURED NO TITS NO WJURED IANZDEATHS <br /> J PROPERTY TYPE FM FORM A SUBMITTED FOR EACH DEATH <br /> PROPERTY MANAGEMENT <br /> PVT FED STATE COUNTY CITY MST FOREIGN OTHER (CHECK BOK IF YES) ❑ <br /> IVED <br /> RE, U INC UK CpVEHICLE PHOPERTY TYPE BUILDING K. (OFFICE 5 INSURANCE 1 <br /> BU0.DLL OR VEIH(IITEMAl1 NSTRUC Ty PE FIRE RATED <br /> TT PE FIRST ARRIVAL TIME TIME SECURED <br /> 1 z s • B B T s <br /> O <br /> F 0 109 <br />