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2113 PACIFIC AVE 2016-01-01 MF Import
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2113 PACIFIC AVE 2016-01-01 MF Import
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Last modified
2/25/2017 6:30:46 AM
Creation date
2/25/2017 6:30:41 AM
Metadata
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Template:
Address Document
Street Name
PACIFIC AVE
Street Number
2113
Imported From Microfiche
Yes
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� DRTE�^ � �— �� • I TI':.E I CNAIi4E 2❑ O3) <br /> % � /1 / DEIETE 3 O <br /> � ..c a <br /> COn�TLETE LOR ALLINGIDENTS <br /> n�oenrnu��eex SUPP FIELD INCIDENT REPORT FD-200 <br /> 5 0 <br /> i z a � e s <br /> AU%Il1ARY ItICIDfMT T1'PE TYPE OF ACTIDM 7RNEi1 FflCP[PTY N�NE APT.N0. <br /> TRIPi � P <br /> (CNE[q 1 13 <br /> �o i it <br /> CORRECT LOCIlT104/IDDR � CIiY STATE 21P[ODE <br /> A �J/JL��l�ia� v iFi��1 i i i i i i t .0 .�18" <br /> 3� �U � <br /> COM'AU;IIIY OR SUP�IVIS�ON COJ'ITY PRRCFL NIIMBFR OR CENSUS TiACT UISTRICi OURISOIG <br /> I I I I I I � �5 �� (CNECq �� <br /> /iJv�QN7/S 31 <br /> COMPLE% fl%CD PROPENTY USE <br /> D� UB <br /> 50 SI 52 N <br /> P¢OPERTY pfPRESEN:LfIVE:NAME TELEPHONE �U�9ESS(STRCEL CITY, T0.TC.ZIP COOE) ' <br /> ' �_�' D� .z - S"�d S�i,S'����� f�9�//� . <br /> OCCUPANT: f1AME TELEPMONE RElRTI0fl5NIP PROPENTY MAM�GEMEtlT <br /> C CBB 5 CO <br /> ' .>' �v�C r ,� •� — w <br /> COMPLETE IF iIRE <br /> IEVCI. Of OPIGIfI RF[A OF ORIGIN <br /> $ I I(I1� � —K�8 <br /> 1 2 10 Ii _ ❑ N <br /> CQUIPM1'EM�INVOLVE� I11 IG!IITION fOP.M Of HERT OF IGYI710fl <br /> NB� — — NBB <br /> IS 16 17 1! <br /> IF EQUIPM1!EtIT IIIVOLVED IN IGNI710N YCAR IARRE IdODEL SCRIAL N0. VOLTAGE(IF RNY) <br /> TYPE Of tdAi[RIRL ICHITED . FOAM OF MAT[RIALICNITE� <br /> � KCO I� <br /> B ��19 10 _ �11 9I <br /> �CT ON OMISSION—ORICItI Of FIRF b� � �� � CODE VIULATIOM <br /> � ❑ CHECK IF YIOLATION <br /> � 75 <br /> uAn n n 4 3 1 <br /> MRIN l9CNUES OF FIRE SPPERU �����K <� ( � �y-���7 .-` �� �� <br /> ! (/ LA 4— <br /> �11_l-_Lr , ��`'....� _— "__"J 76 21 <br /> 7YY!Oi MRTCRIAL M110ST PESPONSIBLC(OR IPE.PHEA fUR'd OG MATCPUI M1705T RESP011510LE FOR f IR[SPRCA� <br /> (ns�e��4i�n ��p� LBB I3 <br /> �8�� 0 31 <br /> 76 79 — - — <br /> , RLT OR GM1'I5510�1 IdOSi RCSPO!ISIBLE�OP RPC SPREAO COUE YIOLRiIONi <br /> � � CNECK If VIOUTION <br /> 1C11 . 31 <br /> 32 33 <br /> COMPLE7E IF MOBiLE PROPERTY <br /> LICENSE A0. STATC <br /> IAOOIL[ I'kOCfR7Y VSC <br /> /'+ 5 4 I I I _l—�_L 9 so ii <br /> ir °C I �o u i¢ --- - <br /> I 2_ _'_______. __'_ Y[pR VEIIICIC IU.fl0. <br /> MAY.E MO�EI <br /> COtdPLETE IF LO55 INVOLVED <br /> 5 � 5 —� � 6 IIISURED VALUE INSURCO tOSi <br /> � hCTUAL VALUE-- ACTUAL LOSS -- �- 7 ____ <br /> � srnucTuec pl_1— I I I I�_ i� :s io n i� Its <br /> wrnc�rs - - - I I I -�--L— u <br /> 76 33 3/ _ /1 ��� 33 31 ____ <br /> IIISU41,t6C CU'�:PFIIY t1AlAE ----I � <br /> bDIC�. f'�Slil9f6 3i GF EACH CFYJ n:VSL CONiFIII iNE IIICI�ENT Atlb SUPCLtIEt1TFL NUVBERS. <br /> ;., r. <br />
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