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21106 SHELL VALLEY RDZ110(0 S4CZ1, WILLE:� RD Incident # 2015-00203919 A MM DO yy" 11 Delete FIRS - 31DOI I WA 1 112 1 122 1 1 2015 0149321 1000 1 0 Change FDID State * Irxident Date Station Incident Number Exposure No Acuvity BLocation Type Check this box to indicate that the add ass for this incident is provided on the Wildland Fire Census Tract 'Alternative for fires. L_J Module in Sectiort B. P Street address Location Specification.' Use only wildland Intersection 21106 ISHELL VALLEY I I RD in front of Number/Mi-tepDst Prefix Sueet or Highway Street Type suffix Rear of I IIEDMONDS I IWAI 1 98026 1.1 Adjacent to Apt./Suile/Room city �i;te ode Directions I I U.S. National Grid Cross Street. Directions or National Grid, as applicable C Incident Type El Dates and Times Midnight is 0000 E2 Shifts and Alarms 11111 IBuilding fire I Month Day Year Hour Min Local Option Incident Type Check boxes if ALARM always ieWtred dates are the same as Alarm Alarm* LL2 J LL2 J 12015 1 1831 000 Shift or Alarms District Aid Given or Received E3 None DDate. Platoon 1 [3 Mutual aid received 2 19 Auto. aid received L_J ARRIVAL regmed, unless Canceled of did not ami" Arrival 1839 Special Studies E3 Local Option 3 U Their FDID Their Imutual aid given Size 4 (3 I- I CONTROLLED optiontil. except V wildand fires Controlled lAuto. aid given 5 U Other aid given Their Incidemo Numbe Last Unit LAST UNIT CLEARED, required except for wilinand Ilres Cleared 2130 Special Special Study [DO Study Value I F Actions Taken -& Gi Resources G2 Estimated Dollar Losses and Values Extinguiii�ent by 1111 Ifire service personnell Check this box and skip this block if an Apparatus of Personnel ModWe is used. Required for all fires if known. LOSSES: Optional for non -fires. None Primary Action Taken (1) Apparatus Personnel Property $ t 000 1, 1025 1,1000 1 0 1511 [Ventilate Suppression Contents $ 10 0 0 1,10 05 1,10 0 0 0 Additional Action Taken (2) EMS PRE -INCIDENT VALUE: OpIxinal 112 1 JSalvage & overhaul _J Other Property $ ", ", " 11 Additional Action Taken (3) Check box if resource counts include aid Contents $ "J LI 11 received resources. I Completed Modules Hl*Casualties None H3 Hazardous Materials Release None Mixed Use [3 Not mixed 13 Fire-2 Property 09 Structure Fire-3 Deaths Injuries Fire 1 []Natural gas: slow leak, no evacuation or HazMat actions 10 8 Assembly use 13 Civilian Fire Cas4 Service 2 Propane gas: .21 -lb tank (as in home BBQ grill) 20 Education use 33 [3 Medical use Fire Service Cas.-5 Civilian 3 Gasoline: vehicle fuel tank or portable container 40 [3 Residential use EMS-6 4 Kerosene: fuel burning equipment or portable storage 51 r] Row of stores HazMat-7 5 []Diesel fuelffuel oil: vehicle fuel tank or portable storage 53 [3 Enclosed mall 58 0 Business & residential H2 Detector Wildland Fire-8 Required for confined fires. 6 E] Household solvents: homeloffice spill, cleanup only 59 [3 Office Use Apparatus-9 1 7 [:]Motor oil: from engine or portable container 60 [3 Industrial use Personnei-lo � Detector alerted occupants 2 Detector 8 El Paint: from Paint cans totaling <55 gallons 63 [3 Military use 0 ArSon-11 did not alert Ul unknown them 0 [:]Other: special HazMat actions required or spill > 55 gal HazMat form.) 65 B Farm use 00 Other mixed use (Please complete the Property Use [3None 341 Clinic, clinic -type infirmary 539 Household goods, sales, repairs Structures 342 Doctor/Dentist office 571 Gas or service station 131 [1 Church, place of worship 361 0 Prison orjail, notjuvenile 579 0 Motor vehiclelboat salesirepairs 161 0 Restaurant or cafeteria 419 12 11- or 2-family dwelling 599 Q Business office 162 C1 BarrFavern or nightclub 429 0 Multifamily dwelling 615 0 Electric -generating plant 213 C1 Elementary school, kindergarten 439 0 Rooming/Boarding house 629 11 Laboratory/Science laboratory 215 High school, junior high 449 0 Commercial hotel or motel 700 Q Manufacturing plant 241 College, adult education 459 1:1 Residential, board and care 819 0 Livestock/Poultry storage (barn) 311 Nursing home 464 1:1 Dormitory/Barracks 882 13 Non-residential parking garage 331 Hospital 519 11 Food and beverage*sales 8910 Warehouse Outside 936 0 Vacant lot 981 0 construction site 1240 Playground or park 938 0 Graded/Cared for plot of land 984 0 Industrial plant yard 655 0 Crops or orchard 946 0 Lake, river, stream Look up no enter a Use code and Property Use 669 0 Forest (timberland) 951 0 Railroad right-of-way Properya 807 0 Outdoor storage area 960 11 Other street description only it you Code have NOT checked a 9190 Dump or sanitary landfill 961 1:1 High�way/Divided highway Property Use box. 931 11 Open land or field 962 11 Residential street/driveway Property Use Description NFIRS-1 Revision 01101105 Printed 07:43 01/21/2016 Incident # 2015-00203919 lt� ' KI Person/Entity Involved I I 1 -1 -1 LocalOption Business Name (it applicable) Area Code Phone Number 13Check this box if same I address as incida"I location (Section 8). Mr., Ms., Mrs. First Name MI Last Name Suft Then skip Me three duplicate address lines. Number Prefix Street or Highway Street Type suffix I I I I I I Q=> Post Office Box Apt./SultedRoom City " I - I State ZIP Code More people Involved? Check this box and attach Supplemental Forms (NFIRS-1S) as necessary. KOwner [] same as person involved? 2 Then check this box and skip 206 934 -1 0577 Local Option the rest of this block, Business Name (it applicable) Area Code Phone Number []Check this box if same I MR I IRickard [Watso I address as incident location (Section B). Mr., Ms., Mrs. First Name Ml Last Name Suffix Then skip the three duplicate address 123425 1 " 139th PL W RD lines. Number Prefix Street or Highway SUM Type Suffix Q:> I I I I jBrier Post Office Box Apt./SuiteiRoom City I WA 98036 Stale ZIP Code 9 TERRI FITZGERALD - L20 December 22,2015 21:22:02 L20 upon arrival was told to ladder the building. L20 extended 35, ground ladder on Alpha/Bravo corner. L20 was sent to roof by command and found heavy smoke from around chimney and eves. L20 coordinated with E17 interior crew and advised we were ventilating on Charlie/Delta corner.E17 confirmed and L20 cut 4X4 hole wiht no smoke/fire or heat found in attic space. L20 also directed by command to check for extension in Delta chimney. No extension found and L20 exited roof without problems. TF THOMAS KEENE - MS021 December 22,2015 21:54:05 ARRIVED ON SCENE AND REPORTED TO COMMAND/BC16. ADVISED TO ESTABLISH MEDICAL GROUP AND THAT THERE WERE NO OCCUPANTS LOCATED WHO NEEDED MEDICAL AID. MEDICAL GROUP ESTABLISHED WITH M17 ASSIGNED TO ME. M17 RESPOSITIONED IN CASE OF FIREFIGHTER INJURY. INFORMAL REHAB PERFORMED FOR ON SCENE PERSONNEL. CLEARED BY COMMAND/BC16 AFTER CREWS NO LONGER PERFORMING FTREGROUND TASKS AND RETURNED TO SERVICE. [13' More remarks? Check this box and attach Supplemental Forms (NFIRS-1S) as necessary. M Authorization I df I 1 11 IIE17 JL12J 122 112015 Check box if Officer in Charge ID Signature Position or rank Assignment Month Day Year same as Officer df -h-rge 02 1 J120D J L12 J L2 2 j 12015 Member making report 10 Signature Position or rank Assignment Month Day Year Printed 07:43 01/21/2016 Incident # 2015-00203919 A MIA CID yyyy 2015 0014!12J 000 ODelete NFIRSAS I 31DO1 WA L2?j L12J 1 1 1 IS FDID * . State Incident Date Station Incident Number Exposure change upplernental K Person/Entity Involved I I Local Option Business Name (if applicable) Area Code Phone Number 0 Check this box if I Li I same address as Mr., Ms., Mrs. incident location, First Name MI Last Name suffix Then skip these three duplicate address lines. Number Prefix Street or Highway Street Type Suffix I I I I I I Post Office Box Apt.lSuitefRoom city State ZIP Code PersonfEntity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number 13Check this box if I I I I Li I I I same address as incident location, Mr., Ms., Mrs. First Name Ml Last Name Suffix Then skip th Mt I these duplice a I " I I I address lines. Number Prefix Street or Highway Street Type suffix I I I I I I Post Office BOX Apt./SuitefRoom city State Zip code Person/Entity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number [3 Check this box if same address as Mr, Ms, Mrs. incident location. First Name MI Last Name Suffix Then skip these three duplicate address lines, Number Prefix Street or Highway Street Type Suffix I I I I I I Post Office Box Apt./Suite/Room city State ZIP Code Person/Entity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number Check this box if same address as incident location. Mr., Ms.. Mrs. First Name Ml Last Name Suffix Then skip these three duplicate add. fines. Number Prefix Street or Highway Saw Type suffix I I I I I I Post Office Box ApUSuitefRoom city state ZIP Code Person/Entity Involved Ki LOCW Option Business Name (if applicable) Area Code Phone Number [3Check this box if I Li I same address as incident lowt, n. Mr., Ms., Mrs, 'o First Name Ml Lost Name Suffix Then skip these three duplicate address lines. Number Prefix Street or Highway Street Type Suffix I I I I I I Pow Office Box Apt,/Suite/Room city State Zip Code Printed 07:43 01/21/2016 Incident # 2015-00203919 Supplemental Special Studies Local Option i I I Special Special Study ID# Study Value 5 1 1 Special Special Study DO Study Value FL I Remarks: Local Option T. KEENE 0610 2 1 1 Special Special Study ID# Study Value 6 1 1 Special Special Study IN Study Value JASON ISOTALO - L23 December 22,2015 22:50:59 3 1 1 Special Special Study [DO Study Value 7 1 1 Special special Study [DO Study Value NFIRSAS 4 1 1 Special Special Study IDS Study Value 8 1 1 Special Special Study ID# Study Value L23 arrived and reported to Command. L23 assigned to assist E17 on floor three with overhauling the wall and ceiling to locate fire in chimney chase. L23 made contact with E17. They requested we open up the wall and ceiling on floor two. L23 pulled the drywall from above the fire box to include approx. two feet of the ceiling in the area of the chimney. All fire was extinguished upon opening up the area. L23 reported our findings to Command. L23 requested to check air status with monitor. All values at zero except for 02 level of 20.9. Results of air monitoring reported to Safety and Command. L23 released by Command. JCI 9906 JAMES FETTER December 22,2015 23:03:07 E17 1st engine on Scene with B16 in command. Command ordered pre connect inside to extinguish fire. 1 3/4 extended fire found burning at base of fire place out side front door. Exposed bottom of fire place, sprayed water and then extended line to floor 3. No smoke or flame seen in the house. Wall on Delta side in floor 2 warm and paint bubbling. Ceiling on floor 3 breached and water directed in hole. Exposed wall and found flame and embers extinguish. CAN report to command. Could not find any extension in floor 3. Coordinated with L20 on roof vent. E17 low on air exit building to decon and rehab. FM 17 on scene investigating. Turned scene back to E17 overhaul completed and further confirmation of no hot spots in the Bravo side residence. Turned residence over to renter and had conversation with owner and left main number of Fire District to contact with questions. WILLIAM PREUNINGER - E18 December 22,2015 23:32:59 Engine 18 arrived to be assigned salvage operations in the affected unit. Crew placed one hall runner up stairs and two tarps for debris control. Crew was then released. JOHN DOWLING NFIRS-lS R&vWon 01101/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 A MM DO yyyy 2 015 00149321 0 Delete NFIRSAS I 31DO1 WA LL2 J L22_j 1 L.LO( I Supplemental FDID State IncidentDate, Station Incident Number Evoisure Change K Person/Enfity Involved i Local Option Business Name (if applicable) Area Code Phone Number OCheck this box d I Li I same address as incident location. Mr., Ms., Mrs. First Name Ml Last Name Suffix Then skip these three duplicate address lines. Number Prefix Street or Highway Street Type Suffix I I I I I I Post Office BOX ApUSuitefRoorn city State ZIP Code Personffintity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number 13Check this box if same address as incident location' Mr., Ms., Mrs. First Name Ml Last Name suffix Then skip these these duplicat address lines. Number Prefix Street or Highway Sow Type Suffix I I I I I I Post Office Box Apt./SuitefRoom city state ZJP Code Person/Entity Involved P11 Local Oly" Business Name (if applicable) Area Code Phone Number 13Check this box if I I I I Li I I I same address as Mr.. Ms., Mrs. incident location. First Name ml Last Name suffix Then sldp these three duplicate address lines. Number Prefix Street or Highway StreetType Suffix I I I I I I Post Offic's, BOX Apt./Suite/Room city State ZIP Code Person/Entity Involved Local Option Business Name (if applicable) Area Code Phone Number 13 Check this box if Li same address as incident location. Mr., W. Mrs. First Name Ml Last Name Suffix Then skip these three duplicate address fines. Number Prefix Street or Highway Sow Type suffix I I I I I I Post Office BOX Apt./SuitetRoom city state ZJPCode Person/Entity Involved P11 Local Option Business Name (if applicable) Area Code Phone Number 13 Check this box if I Li same address as Mr., Ms., Mrs. incident location. First Name Ml Last Name Suffix Then skip these three duplicate address lines. Number Prefix Street or Highway Street Type Suffix I I I I I I Post Office Box Apt,/Suite/Room city State ZJP Code Printed 07:43 01/21/2016 Incident # 2015-00203919 Supplemental Special Studies Local Option I I I Special Special Study 10# Study Value 5 1 1 Special Special Study IN Study Value rL I Remarks: Local Option 2 1 1 Special Special Study IDO Study Value 6 1 1 Special Special study IDS Study Value December 23,2015 07:29:34 3 1 1 Special Special Study IDO Study Value 7 1 1 Special Sipecial Study IDA Study Value INFIRS—IS Supplementla, 4 1 1 Special Special Study ID# Study Value 8 1 1 Special Special Study IDS Study Value A16 became available and added ourselves to the second alarm units. we arrived on scene and were assigned to conduct a primary search of the Bravo exposure (structure was a duplex). Early in our search we discovered a permitted cannabis grow operation in the garage however there were several canisters and containers on the stairs that were unmarked. A16 withdrew from the structure and advised Safety. Safety consulted with Command and Edmonds. After some discussion with the occupant of the Bravo exposure it was determined that we could safely finish our primary search. CHARLES MADDOX December 23,2015 07:45:33 E19 was dispatched to a residential fire. Upon E19s arrival, E19s crew reported to command and were a -singed to pull a backup line for L20 and do the primary search on floor 1,2 and the basement. E19s crew completed that task and assisted E17 with fire suppression and overhaul. E19s crew reported to command. E19s crew was released and returned to service. STEVE ALLISON - B16 December 26,2015 08:17:44 Battalion 16 responded to a reported Residential fire at 21106 Shell Valley road. Arriving on scene, found a two story with garage duplex from the Alpha side with heavy smoke pushing from the attic vents and exterior chimney chases. only occupant. a female was out of the home upon arrival. The fire appeared to be contained in the exterior chimney chase and attic of the duplex. A second alarm was requested along with a Utility package, FM17 and the PIO. DC21 also responded to the CP. Engine 17 and 19 crews was assigned to primary search, fire control and check for extension on floors one and two. Ladder 20 was assigned to get a ventilation profile and used a ground ladder from the Bravo side to get to the roof and conducted a coordinated a ventilation of the primary fire unit and attic space. Engine 14's ove NFIRS-IS Revision 01101/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 A WA MM DID rYYY 12 2015 0014 932 000 Delete 11 NFIRSAS I 31DO1 L!?J 1 1 FIDID * State Incident Date Station Incident Number Exposure A Change Supplemental PersontEntity Involved I - - I Local Option Business Name (if applicable) Area Code Phone Number [:]Check this box if I some address as Mr., Ms., Mrs, incident location. First Name MI Last Name Suffix Then skip these three duplicate address lines, Number Prefix Street or Highway Street Type suffix I I I I I I Post Office Box Apt./SuitelRoom city State ZIP Code PersonfEntity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number 13Check this box if I I I I I same address as incident location, Mr., Ms., Mrs. First Name MI Last Name suffix Then skip these these duplicate address lines. Number Prefix Street or Highway SOW Type Suffix I I I I I I Post Office am Apt./SuiWRoom city State ZJP Code Person/Entity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number Check this box if I I I I I same address - Mr., Ms.. Mrs. incident location. First Name MI Last Name Suffix Then skip these three duplicate address lines. Number Prefix Street or Highway SUM Type Suffix I I I I I I Post Office BOX Aprt./SuitefRoom city State 23P Code Person/Entity Involved Ki Local Option Business Name (if applicable) Area Code Phone Number 13 Check this box if I I I I Li I I I same address as incident location Mr., Ms.. Mrs. First Name MI Last Name Suffix Then skip th d—r "Ifft duplicate ad ass Unes. Number Prefix Street or Highway Street Type suffix I I I I I I Post Office BOX Apt./SuitefRoom city state ZIP Code Person/Entity Involved Ki Local Optiiin Business Name (if applicable) Area Code Phone Number OCheck this box if same address as incident location. Mr.. Ms., Mrs. First Name MI Last Name Suffix Then skip these three duplicate address lines. Number Prefix Street or Highway Street Type suffix I I I I I I Post Office Box Apt./Suite/Roorn city State ZJP Code Printed 07:43 01/21/2016 Incident # 2015-00203919 Supplemental Special Studies Local Option i I I Special Special Study IN Study Value 5 1 1 Special Special Study 09 Study Value r-Li Remarks: Local Option 2 1 1 Special Special Study IN Study Value 6 1 1 Special Special Study IDO Study Value 3 1 1 Special Special Study IDN Study Value 7 1 1 Special Special Study lD# Study Value NFIRS-1§ 4 1 1 special Special S" IN Study Value 8 1 1 Special Special Study ID* SWdy Value rhauled a 411 supply line. Battalion 11 was assigned as the ISO and MS021 as Medical Group. As other crews arrived, they were used to open up the exterior chimney chase. Aid 16's crew conducted a primary search of the Bravo exposure. During the search, they found a marijuana grow operation in the garage of the Brave residence. They backed out and Command requested Edmonds Police respond o the scene. The fire was quickly knocked down and the second alarm units were cancelled. Units were placed back in service as they finished their tasks. Command was transfer to Engine 17 and Battalion 16 returned. KEVIN ZWEBER December 28,2015 11:50:15 FM17 - Arrived on scene at 21106 Shell Valley Rd, found fire extinguished. Interviewed first arriving officer, incident commander, E6 and Occupant (renter who was not home at the time - Girl friend was present) Fire determined to be Accidental due to metal fireplace conducting heat to structural member and debris. Structure loss estimate $25,000, content loss estimate $5,000. NFIRS-IS Remim 01101/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 IMM DD YYYY A 013efete Wik§:2 I 31DO1 I WA I LL2j 122 1 1 2015 1 1 1 00149321 1000 1 I Fire FDID state * Incident Date station Incident Number Exposure 0Change Property Details B c On -Site Materials Complete if there were any significant amounts of commercial. industrial, energy, or agricultural products or Products None me or materials on the property, whether or not they became inwIved 2 Not Residential Eli Enter up to three codes. Check one box for each code entered. On -Site Materials Storage Use Estimated number of residential living units in building of origin whether or not all units 10 Bulk Storage or warehousing ousi.M ,]reh 20 Processing or manufacturing uf.ctu.ng Sale 30 Packaged Igoods for sale - became invohed On -site material (1) 4 E3 R U a Ureeaur mrservice defer ined B2 1 1 []Buildings not involved 10 B lk t relh. -us rehousi to . .1 Lot on 2 0 =sNir.a of w"n f lurijn r��IJZI Number of buildings involved " 1 1 30 Packaged or sale Cin-site material (2) 40 R - U0 UeXur or service etermined B3 1 P None 10 Bulk storage or warehousing Acres burned (outside fires) Less than one acre 2[3 Processing or man', ulacturing 30 Packaged Doods for sale Sa on -site material (3) 4 [3 Repair or service U a undetermined D Ignition Ei Cause of Ignition —.—I Human Factors E3 Wall assembly, ,:>Fs kip 0Check box if this is an exposure repon. 151—G I Contributing to Ignition Di 175 1 Iconcealed wall space 1 0 Intentional Check all applicable boxes 02mone Area of fire origin * 2 F? Unintentional 1 [3Asleep Conducted heat from 3 Q Failure of equipment or heat source 213Possibly impaired by D2 184 1 janother fire 4 Q Act of nature alcohol or drugs Heat source * 5 0 Cause under investigation 3 OUnattended person Structural member u 0 cause undetermined after investigation 4 OPossibly mentally disabled D3 117 1 jor f raming 5 OPhysically disabled Factors Contributing to Ignition* [3None E2 6 0Multiple persons involved item first ignited [gCheck box if ire spread was confined to objecA of origin, Fire spread or control, 7 []Age was a factor Wood chips, sawdust , 70 other D4 1 61 11 shavings Factor contributing to ignition (1) Estimated age of Type of material first ignited Requited only If item first. ignited code is 00 or 00. person involved Factor contributing to ignition (2) 10 Male 2 Female F Equipment Involved in Ignition F2 Equipment Power Source G Fire Suppression Factors ONone [3None c=> If equipment was not involved, skip to 141 1 lWood, Enter up to three codes. Section G. paper 1 122 IFireplace, factory -built Equipment Power Source F3 Equipment Portability Equipment Involved Fire suppression factor (1) Brand 1 [3 Portable model 2 Ug Stationary Fire suppression factor (2) seriai P Portable equipment normally can be moved by one or two persons, is designed to be used in Year multiple locations, and requires no tools to install. Fire suppression factor (3) Mobile Property Involved None H2 Mobile Property Type and Make LocalUse [) Pre -Fire Plan Available Not involved in ignition, but burned Some of the information presented in this report may be 2 Involved in ignition, but did riot bum Mobile property type based upon reports from other agencies: 3 Involved in ignition and burned I I I I I [] Arson report attached Mobile property make Police report attached I I I Coroner report attached 1 Other reports attached Mobile property model Year License Piate Number state VIN Structure fire? Please be sure to complete the Structure Fire form (NIFIRS-31). NFIRS-2 Revision 0110110 5 Printed 07:43 01/21/2016 Incident # 2015-00203919 Structure Type * 12 Building Status 13 Building * 1. 4 Main Floor Size d fire was In an enclosed building or a portablelmobile structure, complete the red of this form K Height Count the root as part of the Enclosed bu Iding 1 Under construction 2 gin highest a". 2 [] Portable/Mobile structure 3 0 Open structure normal use 3 0 Idle, not routinely used 1 002 Total number of stories at or LJ 4 [1 Air -supported structure 4 [1 Under major renovation 6 0 Vacant and secured abO" grade. ToUt! square fee I 5 [] Tent 6 [1 Vacant and unsecured OR 6 0 Open platform (e.g.. piers) 7 [3 Being demolished 01 7 [3 Underground structure (work areas) 0 Other Total number of storles LOJ 03 0 BY LOJ, 1 0 3 0 8 D Connective structure 10-9- fences) U Undetermined below grade. Leno in feet VAdth in feel 0 [) Other type of structure J1 Fire Origin * J3 Number of Stories Damaged by Flame K Type of Material Contributing Most 1 001 Grade 13selow Count the roof as part of the highest story. to Flame Spread story Of fire origin N mber of stories w1minor damage (lutm. 24% flame damage) .!kIp [3Cherk if no flame speed OR if Block D4. _t�w� same as Material First Ignited action L Fire Module) OR if unable to determine. Number of stories wisignificant damage (25 to 49% flame damage) Fire Spread J2 If fire spread was confined to oblect of origin, do not check a box (Ref. Block D3, Fire Module). Number of stories w1heavy damage (50 to 74% flame damage) Ki Item contributing most to flarne spread 2 [3Confined to room of origin 3 DConfined to floor of origin 4 DConfined to building of origin Number of stories vilextrome damage (75 to 100% flame damage) K2 5 [38eyond building of origin Type of material contributing Required only if dern most to flame spread o ontributing code is 00 or �70. LPresence of Detectors i Detector Power Supply L3 Detector Effectiveness Ls (In area of the firel Required it detector operated. Skip to N section M 1 [3 Battery only 2 [3 Hardwire only 1 8 Alerted occupants, occupants responded 2 Alerted occupants, occupants failed I [3Present 3 [3 Plug4n to respond U OUndetermined 4 D Hardwire with battery 3 0 There were no occupants 5 [1 Plug-in with battery 6 [3 Mechanical 7 D Multiple detectors & power 4 [3Failed to alert occupants U [] Undetermined L2 Detector Type L6 Detector Failure Reason supplies 1 0 Smoke [3 Other U 13 Undetermined Required if detector failed to operate. 2 0 Heat 3 0 Combination smoke and heat 1 0 Power failure, shutoff, or disconnect L4 Detector Operation 4 11 Sprinkler, water flow detection 2 [] Improper installation or placement 5 13 More than one type present I [] Fire too small to activate 3 [3 Defective 0 13 Other 4 [3 Lack of maintenance, includes U 11 Undetermined np'OW 2 0 [Ooerated [il-pk not cleaning 5 [] Battery missing or disconnected 3 [3 1 Failed to oDera Ee)0 [� �Pi 6 [3 Battery discharged or dead .. 0 13 Other U 13 Undetermined U U Undetermined M1 Pr ce of Automatic Extinguishing System N 9 None Present 1 13 Present Compi rester 2 [3 iPartial System Present on M LI U Undetermined Type of Automatic Extinguishing System N12 Required if fire was within designed range of AES. 1 0 Wet -pipe sprinkler 2 Dry -pipe sprinkler 3 Other sprinkler system 4 Dry chemical system 6 D Foam system 6 [3 Halogen -type system 7 Carbon dioxide (COJ system 0 Other special hazard system U Undetermined Operation of Automatic M3 Extinguishing System Required if fire was %ithin designed range. I Operatedleffective (go to m4) 2 Operated/Not effective (go to u4) 3 Fire too small to activate 4 Failed to operate (go to ms) 0 Other U Undetermined M4 Number of Sprinkler Heads Operating Required it system operated. I Number of sprinkler heads operating M Reason for Automatic 6 Extinguishing System Failure Required if system failed or not effective. I System shut off 2 Not enough agent discharged 3 0 Agent discharged but did not reach fire 4 Wrong type of system 5 Fire not In area protected 6 0 System components damaged 7 El Lack of maintenance 8 Manual intervention 0 Other U 0 Undetermined NFIRS-3 RevisifflOIJ01M Printed 07:43 01/21/2016 Incident # 2015-00203919 A MM DD YYYY 11 Delete I 31DO1 wA UIJ LL2J L2015 0014932 1 000 []Change NFIRS-9 Apparatus or FDID State incident Date Station incident Number ExpDsure Resources B Apparatus or Dates and Times Midnight is 0000 Sent Number Apparatus Use * Actions Taken Resources Use codes listed below Check it same date as Alarm date on the Basic Module (Block E 11). 'V Of * People Check ONE box for each pparatus to intlicate its main :se List up to 4 actions for each apparatus. Month Day Year HourlMln at the incident. ElID A15 Dispatch P"Ill 11850 0 0 Suppression L__j L__j Arrival D""i 1 1859 EMS Type 75 Clear (01" " 1 1910 Other L_j ID A16 Dispatch 001" " 11847 3 [3 Suppression L__j L_j Arrival D11111 1851 EMS Type 75 Clear [9" " 1 2006 Other L_j L-i F3] ID M2 0 Dispatch [01" " 1 11847 1 Suppression L23 J Arrival 13 ""1 1 EMS Type 76 Clear ED" " 1 1 2028 0 Other L—i ID A14 Dispatch 101""1 118471 0 [3 Suppression L9 3j [__j Arrival 0 111 " I 1 [9 EMS Type 75 Clear 01"111 11850 0 Other ID KCL61 Dispatch D" 1 118471 o D Suppression L93] L__j Arrival [I EMS Type 12 Clear 1907 D Other Li Li ID E15 Dispatch ID" 1 11847 0 Suppression L__j L__j Arrival [P" 1 1 1856 EMS Type 11 Clear ED" I 1 1901 Other Li F71 ID KCE64 Dispatch [0111111 118471 0 Suppression L__j L__j Arrival [D" " 1 11858 EMS Type n Clear 101" " I 1 1901 Other Li Li ID E22 Dispatch 011"111 11847 0 R Suppression L_j L_j Arrival JD" " I 1 1900 [1 EMS Type 11 Clear D11111 1 1900 0 Other ID E17 Dispatch 0111111 118341 Suppression L_j Arrival ED" " 1 1 1840 EMS Type 11 Clear P"Ill 1 2130 0 Other Apparatus or Resource Type Ground Fire Suppression 11 Engine 12 Truck or aerial 13 Quint 14 Tanker and pumper combination 16 Brush truck 17 ARFF (aircraft rescue and firefighting) 10 Ground fire suppression, other Heavy Ground Equipment 21 Dozer or plow 22 Tractor 24 Tanker or tender 20 Heavy ground equipment, other Aircraft 41 Aircraft: fixed -wing tanker 42 Helitanker 43 Helicopter 40 Aircraft, other Marine Equipment 51 Fire boat with pump 52 Boat no pump 50 Marine equipment other Support Equipment 61 Breathing apparatus support 62 Light and air unit 60 Support apparatus, other Medical and Rescue 71 Rescue unit 72 Urban search and rescue unit 73 High -angle rescue unit 75 BLS unit 76 ALS unit 70 Medical and rescue unit, other 91 Mobile command post 92 Chief officer car 93 HazMat unit 94 Type I hand crew 95 Type 11 hand crew 99 Privately owned vehicle 00 Other apparatus/resources NN Norte UU Undetermined NFIRS-9 ReViSion01/01/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 A MM DO MY []Delete I 31DOI LvtA-J 1121 LHJ L2015 1 0014932 1 000 1 [3Chan9e NFIRS-9 Apparatus or FDID state * Incident Date Station Incident Number Exposure 11 Resources ��j B Apparatus or Dates and Times MidnightisWW Sent Number Apparatus Use * Actions Taken Resources Use codes listed below Check if same date as Alarm date on fF the Basic Module (Block Ei). N/ Month Day Of * People Check ONE bo, for each pparatus to indicate its main Ust Up to 4 actions for each apparatus. Year Hour/Min Ua se at the incident. to B14 Dispatch (D" " 1 118321 0 Suppression L__j [__j Arrival D""I 1842 EMS Type 11 Clear 3?" 1924 0 Other Li F21 ID B19 Dispatch [D""I 11832 1 3 Suppression L__j Li 1 18 Arrival [D" 421 EMS Type Clear P" 1 1942 Other Li Li ID B18 Dispatch 1011""1 11832 3 Suppression Arrival ID""I 1844 Q EMS Type 11 Clear ID""I 1918 0 Other ID E10 Dispatch D""I 118321 3 D Suppression L__j Arrival ED" 1 11843 0 EMS Type 11 Clear ID" 1 1 1923 0 Other Li L_j F51 ID M17 Dispatch D""I 118321 2 Q Suppression L__j " Arrival D""i 1 1841 D EMS Type 76 Clear P" 1 1913 Other Li " ID A17 Dispatch P""I 11832 1 1 Q Suppression LL3 J L___j Arrival [3 1 ID EMS Type 75 Clear U?" 1 1834 [3 Other F71 ID B16 Dispatch D" 1 118321 1 0 Suppression L___j L__j Arrival (D" 11 1839 EMS Type Clear ID" 2033 Other L—i ID KCB61 Dispatch D""I 118321 0 P Suppression LL3_j Arrival 0""I 1 0 EMS Type 92 1 Clear 11)" " 1 1 1837 11 Other ID MS021 Dispatch D" " 1 11832 1 Q Suppression L_j Arrival D" " 1 1 1847 1) EMS Type 92 Clear R"111 1949 0 Other Apparatus or Resource Type Ground Fire Suppression 11 Engine 12 Truck or aerial 13 Quint 14 Tanker and pumper combination 16 Brush truck 17 ARFF (aircraft rescue and firefighting) 10 Ground fire suppression, other Heavy Ground Equipment 21 Dozer or plow 22 Tractor 24 Tanker or tender 20 Heavy ground equipment, other Aircraft 41 Aircraft: fixed -wing tanker 42 Helitanker 43 Helicopter 40 Aircraft, other Marine Equipment 51 Fireboat with pump 52 Boat, no pump 50 Marine equipment other Support Equipment 61 Breathing apparatus support 62 Light and air unit 60 Support apparatus, other Medical and Rescue 71 Rescue unit 72 Urban search and rescue unit 73 High -angle rescue unit 75 BLS unit 76 ALS unit 70 Medical and rescue unit, other Other 91 Mobile command post 92 Chief officer car 93 HazMat unit 94 Type I hand crew 95 Type 11 hand crew 99 Privately owned vehicle 00 Other apparatus/resources NN Norte UU Undetermined NFIRS-9 Revision 01101104 Printed 07:43 01/21/2016 Incident # 2015-00203919 A MIM DD YYYY Delete I 31DOI LtAJ LL2-J 1221 L2015 00149321 1 000 1 []Change NFIRS-9 Apparatus or I'DID State * Incident Date Station Incident Number Exposure Resources e B Apparatus or Dates and Times Midnight is 0000 Sent Number Apparatus Use * Actions Taken Resources Use codes listed below Check if same date as Alarm date on the Basic Module (Block E I). fF of * People Check ONE box for ea on app ratus to indicate its main List up to 4 actions for each apparatus. \/ Month Day Year Hour/Min uselat the incident. in ID L23 Dispatch [D" " 11832 3 R Suppression L__j L__j Arrival [P" " 1 1911 0 EMS Type 12 Clear ID" " 1 1943 0 Other L—i L—i F2 I ID AC11 Dispatch D" " 118501 1 Q Suppression L_j L_j Arrival D""I 1 1850 Q EMS Type 92 Clear P""' 1 1903 R Other L—i L_J_ ID L20 Dispatch D""l 118361 2 P Suppression [__j L__j Arrival ED" " 1 1 1841 Q EMS Type 12 Clear [D" " 1 1 2027 0 Other ID B11 Dispatch 10"Ill 118381 1 0 Suppression L__j L__j Arrival D""l 1 1847 Q EMS Type 92 Clear P"111 1954 D Other L—i Li n5 ID DC11 Dispatch ED11111 118441 1 Suppression Arrival J)" 1 1903 EMS Type 92 Clear (P" 1 1935 Other F61 ID FM16 Dispatch R""' 118551 0 Suppression L_j L___j Arrival P11111 1 1925 [1 EMS Type 00 Clear 0" 2130 00, Other L—i ID Dispatch 0 0 Suppression L__j Arrival 0 EMS Type Clear 0 Other Li Li ID Dispatch Suppression L_j L_j Arrival 0 EMS Type Clear 0 Other ID Dispatch 0 Suppression Arrival 0 EMS Type Clear 0 Other L_j L Apparatus or Resource Type Ground Fire Suppression 11 Engine 12 Truck or aerial 13 Quint 14 Tanker and pumper combination 16 Brush truck 17 ARFF (aircraft rescue and firefighting) 10 Ground fire suppression, other Heavy Ground Equipment 21 Dozer or plow 22 Tractor 24 Tanker or tender 20 Heavy ground equipment, other Aircraft 41 Aircraft: fixed -wing tanker 42 Helitanker 43 Helicopter 40 Aircraft, other Marine Equipment 51 Fire boat with pump 52 Boat, no pump 50 Marine equipment, other Support Equipment 61 Breathing apparatus support 62 Light and air unit 60 Support apparatus, other Medical and Rescue 71 Rescue unit 72 Urban search and rescue unit 73 High -angle rescue unit 75 BLS unit 76 ALS unit 70 Medical and rescue unit, other `11II, � Im 91 Mobile command post 92 Chief officer car 93 HazMat unit :4 Type I hand crew 5 Type 11 hand crew 99 Privately owned vehicle 00 Other apparatusiresources NN Nom UU Undetermined NFIRS-9 Revision0`1101/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD 11 Delete A I 31DO1 IWA 1 1121 LL2j 1 2015 1 00149321 1 000 1 11 FDID State * Incident Date Station Incident Number Exposure []Change B Apparatus or Resources Dates and Times Midnight is 0000 Check 11 same date as Alarm date on the Basic Module (Block Eli. �Tlt rith Day Year Hour/Min Sent El Number of * People Apparatus Use * Check ONE box for each I apparatus to indica e its main se at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ElID A15 *Type 7 5 Dispatch 11850 Arrival R"111 11859 Clear 911"1 11910 Sent 0 [3 Suppression R EMS D Other Personnel ID Name Rank or Grade Attend M Action Taken Action Taken Action Taken Action Taken 13 13 1flID A16 *Type 7 5 Dispatch P " " 1 11847 Arrival P""I 11851 Clear 0""1 12006 Sent 3 Q Suppression EMS Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken 0202 JOHN DOWLING 0 9 2 0 ANTONIO ROBINSON 0 2 0 DAVID STEVENS 13 ID M2 0 *Type 7 6 Dispatch 9) 11847 Arrival 13 1 Clear R""I 12028 Sent R 1 0 Q Suppression P EMS 13 Other 93 Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Take n 0 13 13 0 [3 0 NFIRS-10 Revision0lM1104 Printed 07:43 01/21/2016 Incident # 2015-00203919 A 1 311)011 L'�A MM DO YYYY I ElDelete j LL2j 1221 1 2015 0014932 1 000 1 FDID State * Incident Date * Station Incident Number * Exposure * OChange B Apparatus or Resources Dates and Times Midnight is OODO Check if sarne date as Mann date on the Basic Module (Block Elf. 00w nth Day Year Hour/Min Sent El Number of * People apparatus Apparatus Use * Check ONE box for each to indicate its main use at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ElID I A14 *Type 1 7 5 Dispatch R " " 1 11847 Arrival [3" " I 1 Clear 911"1 11850 Sent [1? 1 0 D Suppression 1? EMS D Other 93 Personnel ID Name Rank or Grade Attend El Action Taken Action Taken Action Taken Action Taken 13 13 13 ID KCL61 *Type 12 Dispatch P11"I 11847 Arrival 0""I I Clear " " 1 11907 Sent R 1 0 1 Suppression EMS Other 193 1 Personnel ID Name Rank or Grade Attend Fx Action Taken Action Taken Action Taken Action Taken 1flID E15 *Type 1 Dispatch 1) " " 1 11847 Arrival 9)" " 1 11856 Clear P""I 11901 Sent R 0 R Suppression D EMS 00ther Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken 13 11 13 NFIRS-10 Revision 01)01/04 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DO YYYY Delete A I 31DO1 L'�Aj 1121 LL2j 1 2015 0014 932 000 1 11 FDID State * Incident Date Station Incident Number Exposure OChange B Apparatus or Resources Dates and Times Midn�ht is M Check,f same date as Alarm date on the Basic Module (Block El). �Tl.nth Day Year Hour/Min Sent El Number of * People Apparatus Use * Check ONE box for each apparatus to indicate its main use at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ElID KCH64 *Type Dispatch 11847 Arrival B""I 11858 Clear 911"1 11901 Sent R 0 P Suppression Q EMS Other L--j Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken 13 1flID E22 *Type 1 Dispatch R 11847 Arrival 19 11900 Clear 0""1 11900 Sent 0 R Suppression D EMS Other Personnel ID Name Rank or Grade Attend E Action Taken Action Taken Action Taken Action Taken 0 ID E17 *Type 1 Dispatch 9) " " 1 11834 Arrival 19" " 11840 Clear P""l 12130 Sent Suppression EMS Other Personnel ID Name Rank or Grade Attend El Action Taken Action Taken Action Taken Action Taken df JAMES FETTER ID 0 0 0 NFIRS-10 Revision 011011101 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD YYYY Delete A I 31DO1 IWA I LL2j LL2j 1 2015 0014 9321 1 0 00 1 11 FOID State * Incident Date Station Incident Number Exposure OChange B Apparatus or Resources Dates and Times Midnight is 0000 Check d same date as Alarm date on the Basic Module (Block Ell. Month Day year Hour/Min �?w Sent El Number of * People apparatus use Apparatus Use * Check ONE box for each to indicate its main at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ElID I E14 *Tyile L-L'-J Dispatch R " " 1 11832 Arrival B""I 11842 Clear R""I 11924 Sent R 0 I? Suppression 0 EMS D Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken 13 1flID E19 *Type 1 Dispatch Up " " 1 11832 Arrival 10,11"1 11842 Clear 0111"ll 11942 Sent 3 Suppression EMS Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken CHARLES MADDOX STEVEN BARNES STEVEN VARDEN ID E18 *TYPe 1 Dispatch J) " " 1 11832 Arrival 11844 Clear 11918 Sent 3 R Suppression [3 EMS D Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken WILLIAM PREUNINGER SCOTT CRANE STEVEN LINDSEY 13 13 NFIRS-10 ReWskinOlID1104 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD YM Delete A I 31DO1 L!LAJ L12J LL2j 1 2015 0014 932 000 13 I'DID State * Incident Date Station Incident Number Exposure oChange B Apparatus or Resources Dates and Times Midnight is =0 Check I same date as Ajarm date on ��Ihe Basic Module (Block El). M. Day Year Hour/Min Sent Number of * People Apparatus Use * Check ONE box for each apparatus to indicate its main use at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ID E10 *Type 1 Dispatch 9 " " 1 11832 Arrival R11111 11843 Clear R""I LLL2 3j Sent 3 R Suppression Q EMS 0 Other Personnel ID Name Rank or Grade Attend Fx-i Action Taken Action Taken Action Taken Action Taken TRAVIS WINSTON JESSE MCCORMICK NATHAN CRAWFORD ID M17 *Type 7 6 Dispatch Up " " 1 11832 Arrival P""I 11841 Clear 11913 Sent 2 Suppression EMS Other Personnel ID Name Rank or Grade Attend [ii Action Taken Action Taken Action Taken Action Taken 9 6 0 DEVIN HAAS 10, 0308 BRIAN SCHLEICHER ID I 13 11 11 11 ID A17 *Type 7 5 1 Dispatch 9) " " 1 11832 Arrival 1311"1 1 Clear P11"I 11834 Sent R 1 1 1 0 Suppression R EMS 0 Other 93 Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken df JAMES FETTER 0 0 0 0 0 NFIRS-10 Revision 01/01104 Printed 07:43 01/21/2016 Incident # 2015-00203919 A I 31DO1 IWA 1 I'DID State * MM DO YYYY Delete 1121 LL2j 1 2015 0014932 1 00 0 1 13 Incident Date Station Incident Number Exposure 0Change B Apparatus or Resources Dates and Times Midnight is 0000 Check if same date as AJarm date on the Basic Module (Block E 1). �Tlo mh Day Year Hour/Min Sent El Number of * People apparatus use Apparatus Use * Check ONE box for each to indicate its main at the incident. Actions Taken List up to 4 actions for each apparatus and each personnel. ElID I B16 *Type LL2_j Dispatch 0? " " 1 11832 Arrival R""I 11839 Clear P""I 12033 Sent [P Q Suppression [3 EMS P Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken 1 8 0 0 STEVE ALLISON 13 13 0 13 0 ID KCB 6 1 *Type 9 2 Dispatch P " " 1 11832 Arrival 0 ""1 1 Clear " " 1 11837 Sent ED 0 P Suppression [3 EMS 0 Other 93 Personnel ID Name Rank or Grade Attend Fx� Action Taken Action Taken Action Taken Action Taken 13 11 0 ElID MS021 I *Type 9 2 Dispatch 1 11832 Arrival D""i 11847 Clear 0,11"1 11949 Sent D Suppression P EMS Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken THOMAS KEENE 13 NFIRS-10 Revision 01/01104 Printed 07:43 01/21/2016 Incident # 2015-00203919 mm DD r"y Delete A I 31DO1 L'�A 2 00149321 11 ._j LLJ 1221 1 2015 1 000 1 I'DID State * Incident Date Station Incident Number Exposure 0Change NFIRS-10 Personnel B Apparatus or Resources Dates and Times Midnight is DOW Check I same date as Alarm date on I'h. Bask Module (Block El). Writh Day Year Hour/Min Sent El Number of * People Apparatus Use * Check ONE box for each apparatus to indicate its =in use at the incident, Actions Taken List up to 4 actions for each apparatus and each personnel. ElID I L23 *Type 1 12 Dispatch 9 " " 1 11832 Arrival B11"i 11911 Clear R" " 1 11943 Sent 3 R Suppression Q EMS D Other L—j Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken JASON ISOTALO MATTHEW NELSON BRYAN COLLINS 1 13 11 11 ID AC11 *Type 9 2 Dispatch R " " 1 11850 Arrival P""I 11850 Clear 0""1 11903 Sent 0 Suppression 0 EMS Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken FD7 9 2___j BRAD READING ElID L2 0 *Type 12 Dispatch 11836 Arrival 11841 Clear P11111 12027 Sent 2 R Suppression [3 EMS Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken df TERRI FITZGERALD KEITH BIEN 1 13 1 1 NFIRS-10 Revision 01/01104 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DO YYYY Delete A I 31DO1 WA LL2 J LL2j 1 2 015 0 014 932 1 0 00 1 11 FDID State Incident Date Station Incident Number Exposure []Change M--- ---- ---- B Apparatus or Resources Dates and Times Midnight is 00W Check if same date as Alarm date on the Basic Module (Block E 1). ,i?10 nth Day Year Hour/Min Sent Fx] Number of * People ause Apparatus Use * Check ONE box for each pparatus to indicate its main aft the incident. Actions Taken Lis[ up to 4 actions. for each apparatus and each personnel. ElID B11 *Type 9 2 Dispatch ED " " 1 11838 Arrival P""I 11847 Clear R" 11954 Sent 0 Suppression Q EMS P Other Personnel ID Name Rank or Grade Attend Action Taken Action Taken Action Taken Action Taken STEVE MASON 13 13 13 13 Q ID DC11 *Type 9 2 Dispatch P " " 1 11844 Arrival 011111 11903 Clear 011"1 11935 Sent Q Suppression 0 EMS Other Personnel ID Name Rank or Grade Attend El Action Taken Action Taken Action Taken Action Taken 8 9 0 DOUGLAS DAHL 13 11 1 11 13 ElID FM1 6 *TYPe 0 0 Dispatch 9) " " 1 11855 Arrival 91111 " 1 11925 Clear P""I 12130 Sent Q Suppression Q EMS Other Personnel ID Name Rank or Grade Attend El Action Taken Action Taken Action Taken Action Taken KEVIN ZWEBER ED 13 NFIRS-10 Revision01101104 Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD YYYY [] Deiete A I 31DO1 WA 12 22 2015 0014932 1 000 OChange FDID State Incident Date Station Incident Number Exposure MNIMOFiR'S Fields No Acbvq El Additional Incident Times Month Day Year Hour Min Month Day Year Hour Min PSAPRecieved 112 22 2015 1 1831 Dispatch Notified 2015 BApparatus or Dates and Times Midnight is ODW ID Efl Resources En Route Type District month Day Year Hour[Min ElEn Route 112 11 22 112015 11852 11 ID En Route 1 12 11 22 112015 11847 Type District IIIII I Type District "III I 0 ID En Route 1 12 1122 112015 11847 11 ID En Route 112 11 22 112015 1 1852 Type District Type District ID En Route ID En Route 1 12 11 2 2 112 0 15 1849 Type District Type District " " I EID En Route 1fl ID En Route 1 12 if 22 112015 11835 Type District Type District " " I I I I Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD yyyy Delete A I 31DO1 IWA 1 112 1 L 22 1 2015 0014 9321 1 000 1 Change j ESO-1 Non-NFIRS FDID State Incident Date Station Incident Number Exposure No AcW4 Fields El Additional Incident Times Month Day Year Hour Min Month Day Year Hour Min PSAP Recieved " " I I Dispabeh Notfied B Apparatus or Resources Dates and Times Midnight is 0000 ID E En Route 1 12 11 22 112015 1835 Type District Month Day year HowMn ID En Route 1 12 1122 112015 1 1835 El ID En Route Type District II II I I Type District n2 ID En Route 1 12 11 22 112015 11834 11 ID En Route 1 12 11 22 112015 1 1833 Type District Type District F3] ID En Route 112 11 22 112015 11834 ID E En Route 1 12 11 2 2 112 0 15 1836 Type District II Type District En Route 112 11 22 112015 11834 E ID En Route 1 12 11 22 112015 11834 Type District " " I I I Type District " II I I Printed 07:43 01/21/2016 Incident # 2015-00203919 MM DD YYYY [] Delete A I 31DO1 WA 112 1 22 1 1 0014 9321 1 00 0 1 OChange FDID State incident Date Station Incident Number Exposure * ONo Act" El Additional Incident Times Month Day Year Hour Min Month Day Year Hour Min PSAP Recieved Dh;p=h Notified B Apparatus or Resources Dates and Times Midnight is OODO ID El En Route 1 12 11 22 112015 1 1844 Month Day Year HourfMin Type District II " I I ID En Route 1 12 11 22 112015 11834 El ID En Route 1 12 11 22 112015 11855 Type District Il"I I Type 00 District [ 12 11 22 112015 EID En Route 1 12 11 22 112015 11850 El ID En Route " II Type District " " I I Type District " " ElID En Route 112 11 22 112015 11836 E ID En Route " " Type District " " I I Type District Il " 1flID En Route 112 11 22 112015 11838 E ID En Route Il " Type District II Type District Printed 07:43 01/21/2016