HomeMy WebLinkAboutSpecial Inspection Fire Damage Report 1985-3-14
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CONTROL EXP,
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ALARM NO.
STATE OF OREGON FIRE REPORT
STATE FIRE MARSHAL
District of Incident S (") ~ ~'\ -aQJ
DAY' \YEAR "\ j DAYOF
WEEK
13 \ I~ \ Itt,<j!15'
INCIDENT ADDRESS /"' -n, ,()
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3 OCCUPANT NAME (Last, First, MI)
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4 BUSINESS OWNER NAME (Last. First. MI) C ADORESS
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Dept. Responding ~ D """' "''' L' \ & J
ALARM TIME ARRIVAL TIME
MO;
County
o Tues
o Wed
~
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CENSUS TRACT
o Satur
- T~E BACK IN
\ I qE7~EI I
ISO CLASS
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:s.. Thur
o Fri
o Sun
o
\ Iq', \
ZIP
9111 Y I 7 17
Mon
313
TELEPHONE
1 'i \c;l S 3 'i
DOB (optional)
.,,'!}
DOB (optional)
TELEPHONE
OWNER NAME (Last. First, ML
S f\ ~ "C.-
6 FIRE REPORTED BY (Last. First, MI)
ADDRESS
S Pt tv\-c
TELEPHONE
DOB (optional)
ADDRESS
DOB (optional)
TELEPHONE
v-.J?-
METHOD OF 3 Telephone Direct 0 Radio
ALARM 0 Municipal Alarm System 0 Verbal
o Private Alarm System 0 No Alarm Rec'd
8 # OF FIRE SERVICE PERSONNEL # OF ENGINES RESPONDED
RESPONDED , "3 \
o 911 (Tie Line)
o Voice Signal Muni Alarm
o Not Classified Above
# OF AERIAL APPARATUS RESPONDED
Mutual Aid (extinguish or investigate only)
o Received 0 Given ~N/A
# OTHER VEHICLES RESPONDED
(do not include PA's)
9 TYPE OF SITUATION FOUND
l)J Structure Fire
o Outside Struct: w /value '
o Vehicle Fire
o Brush, Grass. Leaves
o Trash. Rubbish
, TYPE OF ACTION TAKEN
~
o
o Salvage
o Not Classified
o Undetermined
o Other (List)
10 METHOD OF
EXTINGUISHMENT
o Self,Extinguished
o Make-shift aids
o Portable Extinguisher
o Automatic Ext, System
g Pre-connect hose/tank only
o Pre-connect hose/hydrant, standpipe
Extinguish 0 &moved Hazard
Investigation 0 Stand By
o Hand,laid hose/hydrant, standpipe
o Master Stream Device
o Not Classified Above
FIXED PROPERTY ~SE _,_ () . _ II . , I /....J PROPERTY COMPLEX (If applicable)
\<.~~~'~, I~ I "
M MOBILE YEAR "MAKE '
PROPERTY
11
, MOBILE PROPERTY (Complete line M)
SERIAL' LICENSE'
MODEL
12 ROOM/AREA OF FIRE ORIGIN
) ~''''~ ~ CO\.,,-
E EQUIPMENT YEAJ;t MAKE
mig~i~I~N \ '1.~ l\ UJV\ \) Q.J:-O V- '
13 IGNITION FACTOR
~~~ U-f> ~
14 FORM OF HEAT OF I~NITION
,EQUIPMENT INVOLVED IN IGNITION (Complete Line E)
~ S ~\-o. Cl
MODEL 11
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SERIAL #
VOLTAGE
~~
ITE~~:
o
o
MA~GNITED WAS MADE OF
o 30 to 49 feet 0 Over 70 feet
o 50 to 70 feet 0 Objects in Flight
Contents Vehicle and Contents
;O.OW'oo
,00
,00
~~
15 ,!-~VEL OF FIRE ORIGIN
~rade level to 9 feet
o 10 to 19 feet
o 20 to 29 feet
Building
~(j,OW'oo
o Undetermined
Below grd, level
Not Classified
Other
TOTAL
'50,000
16
VALUE
LOSS
,00
,00
,00
,00
-
-
17 NJ:1,MBER OF STORIES U 2 stories U 5 to 6 stories
IZh.I story 0 3 to 4 stories 0 7 to 12 stories
18 BUILDING AGJB!n Years) I BUILDING SIZE (Gmd Fir Only) 0 1000-4999 sq ft
3 ~ ~O'999 sq ft 0 5000,9999 sq ft
19 CONSTRUCTION TYPE 0 Heavy Timber 0 Unprotect. Steel Bldg
o Sleel & Con ere"', 3,4 hr, PlOt, 0 Protect. Steel Bldg 0 Protect. Masonry Ext, & Wood Int,
EXTENT OF DAMAGE CONFINED TO: Flame Smoke DETECTOR PERFORMANCE
I The object of origin I J5- I 0 0 I In room of origin-oper,
2 Part of room or area of origin 2 0 2 0 0 2 Not in room of origin-oper.
3 Room of origin 3 0 3 0 )gl 3 In rm of origin-not oper-fire too small
20 4 Fire,rated comp, of origin 4 0 4 0 0 4 Not in rm of origin-not oper, fire too small
5 Floor of origin 5 0 5 0 0 5 In room of origin-not oper.,power disconnect
6 Structure of origin 6 0 6 0 0 6 Not in rm of origin-not oper, power discon,
7 Extended beyond structure of origin 7 0 7 0 0 7 In room of origin-not oper, dead battery
D 8 Not in room of origin-not oper. dead battery
9 ,29- 0 9 No detector present 0 10 Undetermined
U 13 to 24 stories
o 25 to 49 stories
o 10.000-19.999 sq ft 0 50.000,99.999 sq ft
o 20,000-49,999 sa ft 0 100,000,499,999 sa ft
o Unprotect. Masonry Ext. & ,Wood Int, g Unprotected Wood Frame
o Protected Wood Frame ' 0 Not Classified Above
SPRINKLER PERFORMANCE
1 0 Equipment operated
~ 0 Equip, should have oper,-did not
3 0 Equip. present fire too small to Opel.
9 0 Not classified above
o 0 Undetermined or notreported
8 0 No equipment present (N/A)
U 50 stories or more
o 500.000 sq ft
Sprinklers Controlled Fire:
# of Heads Opened
YES 0 NO 0
9 No dsmage ofthe type (N/ A)
21 REMARKS Weather Conditions (optional):
.0 cont. on back
22 Follow Up Investigation &quested
Y~ N
~',,,-,-- ~ ~-Q.........._~'o--
If yes, who will investigate
23 Number of Injuries
24 Me:~~ ~~\~a \JL;"U
25 Additional Information bY' (' \:J' -,~ -.
Number of Fatalities
Fire Service
Other
Other
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SPRINGFIELD FIRE DEPARTMENT
SPECIAL INCIDENT INFOR~1ATION FOR~1
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