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FIELD INCIDENT REPORT <br />E F.D. �. <br />ann9_ <br />O <br />CORRECT <br />PHONE <br />ROOM OR <br />ADDRESS 1005 84 th. SO. E. <br />--_ <br />APE. NO. <br />IJ <br />z <br />r <br />OCCUPANT William Outson <br />OWNER game <br />, <br />t <br />ADDRESS <br />= <br />OF OWNER soma <br />none <br />O <br />IIjj T NO. <br />eIGNE Co.11M•M DWJ <br />BAR. <br />B-2 <br />CBlws <br />>'� <br />A TYEY OF <br />341 <br />W <br />yL41 <br />j <br />TEACT <br />NCnort <br />SOURCE OF ALARM O 1. vol. <br />0 S. A.D.T. d S. Sw <br />Dal aF <br />OWN <br />TRaa <br />IA, Ba.N.ad 6Y Alaw ONlpl 0 7. Ma <br />Q A• Relb <br />WAN 3 <br />9 i19/72 <br />2258 <br />O <br />Y <br />OCCUPANCY OR <br />d <br />C <br />PROBABLE CAUSE <br />NON-OCCUPANCT 403 <br />OF IGNITION 029 <br />IN <br />AREA OF <br />D <br />FIRST OBJECT ON <br />FIRE FACTORS <br />F <br />1 <br />2 <br />S <br />BOOR <br />ORIGIN 038 <br />AEATEP AL IGNITED <br />III. Order of bowawal <br />BUILDING <br />TYPE 0 BLDG$. TYPE N NDGS. <br />TYPE V NDGL <br />a <br />❑ 1. TYPE I BLDG. <br />❑ S. 1 HOUR OR MT Cl S. 1 HOUR <br />❑ 7. 1 HOUR <br />CONSTRUCTION <br />❑ E. TYPE E R DD. <br />❑ A. NF OEQ ❑ 6. HP REO <br />❑ 1. PIP u0 <br />EXTN. <br />D 0. M. O <br />S. AUTOMATIC O A. DELUGE O 6. FOAM <br />O 1. I.D. HOSE L <br />n <br />GUISNIIG <br />EXT/IGUISH[I <br />SPRINKLER SYSTEM SYSTEM <br />EOVIFMENT <br />EQUIPMENT <br />SYSTEM <br />O 1. OTHER ISp.aHll <br />0 <br />H <br />1. M. O <br />E. DRY CHEMICAL Q S. Col 07. WET STAND. <br />(Chad Owl <br />OAADEN HOW <br />SYSTEM SYSTEM PIPE <br />............................ <br />IN ►C <br />1% <br />E% <br />Me~ <br />PI. of Ladd n <br />No. of $01.e/0 <br />N► al Madn <br />No. N;;= <br />UNI <br />Covers Wad <br />Urad <br />M►ad <br />1 <br />7• <br />A <br />e <br />1 <br />B <br />B <br />EXTENT OF RILE <br />❑ S. COHPEAED TO <br />MO LORR <br />1.100 <br />JC <br />100.1000 <br />14 - <br />� I. CONNED TO ROOM <br />�� <br />POTOA <br />STRUCTURE <br />CONTENTS <br />x <br />❑ E. CONFINED TO FLOOR <br />❑ A. EXTENDED TO <br />OMER <br />AD), BLDG.ISI <br />GREATER ALARM WES <br />INJURIES <br />DEATHSMN❑ <br />S.S0.60 MN <br />❑I.11❑ 3.11 <br />CIYAMN <br />civil"f <br />MN ❑ A. OYCR 60 MIN. <br />ric7.11 <br />FREEMEN <br />FIREMEN — <br />MOBILE FIRE. <br />YEAR MAKE <br />MODEL LICENSE <br />NO. <br />RE <br />LEGAL 01 <br />REGISTERED OWNER <br />ADDRESS <br />G <br />D. <br />t <br />Z <br />BURN OR INJURY (CIYlllan) (HrRmon) <br />BURN ❑LkODY <br />FATAL ❑ <br />= <br />NAME <br />AGE UK INJURY nB. <br />MOSP. ❑ <br />3 <br />DESCRIPTION OF <br />P- <br />BURN ON INJURY <br />01 <br />0 <br />W <br />DEGREE OF BVRN ❑ 111 ❑ End <br />❑ Srd <br />.6 <br />of <br />CONTINUE ON RcveRSE Y NECESSARY. <br />RESPONSE <br />NUMBER OF <br />NUMBER OF <br />CNN TOTAL <br />AIEN <br />OFF SMITE <br />COI DISPATCHED <br />AS <br />ENGINE COL <br />TRUCK COS. <br />MEN <br />BT RADIO <br />r <br />DISPATCHED <br />2 <br />i6 <br />A <br />1 <br />12 <br />-- <br />-- <br />:; <br />Z� <br />OI/K!R N COMMAND INna., Fa.illvArJP^MI <br />Q <br />D. Hansen t En ine <br />BE <br />_Ce <br />MEMBER MAKING REPORT IN di"WoN Praa a►a.al <br />z <br />I <br />i <br />IREMARKI—USE "IM SIDEI <br />