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Actions Taken <br />11-Extinguishment by fire service <br />personnel <br />Primary Action Taken <br /> Resources <br /> Apparatus or Personnel Module is used. <br />Apparatus Personnel <br />Suppression 9 16 <br />EMS 1 1 <br />Other 0 0 <br />Resource counts include aid received <br />resources. <br />Estimated Dollar Losses and Values <br />Losses:Required for all fires if <br />known. Optional for all <br />non-fires. <br />None <br />Property:$ 200,000.00 <br />Contents:$ 75,000.00 <br />Pre-Incident Values: Optional None <br />Property:$ <br />Contents:$ <br />Completed Modules <br /> 2 - Fire <br /> 3 - Structure Fire <br /> 4 - Civilian Fire Cas. <br /> 5 - Fire Service Cas. <br /> 6 - EMS <br /> 7 - HazMat <br /> 8 - Wildland Fire <br /> 9 - Apparatus <br /> 10 - Personnel <br /> 11 - Arson <br /> Casualties None <br /> Deaths Injuries <br />Fire <br />Service <br />0 0 <br />Civilian 0 0 <br /> Detector <br />Required for Confined Fires <br /> 1 - Detector Alerted Occupants <br /> 2 - Detector Did Not Alert Them <br /> 3 - Unknown <br />Hazardous Materials Release <br /> 1 - Natural Gas <br /> 2 - Propane Gas <br /> 3 - Gasoline <br /> 4 - Kerosene <br /> 5 - Diesel Fuel / Fuel Oil <br /> 6 - Household Solvents <br /> 7 - Motor Oil <br /> 8 - Paint <br /> 0 - Other <br /> None <br /> Mixed Use Property <br /> Not Mixed <br /> 10 - Assembly Use <br /> 20 - Education Use <br /> 33 - Medical Use <br /> 40 - Residential Use <br /> 51 - Row Of Stores <br /> 53 - Enclosed Mall <br /> 58 - Business and <br /> Residential <br /> 59 - Office Use <br /> 60 - Industrial Use <br /> 63 - Military Use <br /> 65 - Farm Use <br /> 00 - Other Mixed Use <br /> Property Use None <br />Structures <br />131 Church, Place of Worship <br />161 Restaurant or Cafeteria <br />162 Bar/Tavern or Nightclub <br />213 Elementary School, Kindegarten <br />215 High School, Junior High <br />241 College, Adult Education <br />311 Nursing Home <br />331 Hospital <br />341 Clinic, Clinic-Type Infirmary <br />342 Doctor/Dentist Office <br />361 Prison or Jail, Not Juvenile <br />419 1- or 2-Family Dwelling <br />429 MultiFamily Dwelling <br />439 Rooming/Boarding House <br />449 Commerical Hotel or Motel <br />459 Residential, Board and Care <br />464 Dormitory/Barracks <br />519 Food and Beverage Sales <br />539 Household Goods, Sales, Repairs <br />571 Gas or Service Station <br />579 Motor Vehicle/Boat Sales/Repairs <br />599 Business Office <br />615 Electric-Generating Plant <br />629 Laboratory/Science Laboratory <br />700 Manufacturing Plant <br />819 Livestock/Poultry Storage (Barn) <br />882 Non-Residential Parking Garage <br />891 Warehouse <br />Outside <br />124 Playground or Park <br />655 Crops or Orchard <br />669 Forest (Timberland) <br />807 Outdoor Storage Area <br />919 Dump or Sanitary Landfill <br />931 Open Land or Field <br />936 Vacant Lot <br />938 Graded/Cared for Plot of Land <br />946 Lake, River, Stream <br />951 Railroad Right-of-Way <br />960 Other Street <br />961 Highway/Divided Highway <br />962 Residential Street/Driveway <br />981 Construction Site <br />984 Industrial Plant Yard <br />Property Use: <br />Description <br />Look up and enter a Property Use code and <br />description only if you have NOT checked a <br />Property Use box. <br />Owner <br />Local Option Person/Entity Type Business Name (if applicable)Phone Number <br />Mr., Ms., Mrs.First Name MI Last Name Suffix <br />Number Prefix Street or Highway Street Type Suffix <br />Post Office Box Apt./Suite/Room City <br />State Zip Code <br />F G1 G2 <br />H1 <br />H2 <br />H3 I <br />J <br />K2 <br />Page 2 of 12