A

WB701
FDID

TX
State

MM 09

DD 17

YYYY 2013

Delete

10
Station

13-0026144
Incident Number

000
Exposure

Change No Activity

Incident Date

*
I20

NFIRS -1 Basic

Location* X
Street address Intersection In front of Rear of Adjacent to Directions

Check this box to Indicate that the address for this incident is provided on the Wildland Fire Module In Section B "Alternative Location Specification". Use only for Wildland fires.

Census Tract

HWY
Street Type Suffix

3701

Number/Milepost Prefix

Street or Highway

ARLINGTON
Apt./Suite/Room City Cross street or directions, as applicable

TX
State

76016
Zip Code

Incident Type * 412 Gas leak (natural

E1
gas or LPG)

Date & Times

Month Day
ALARM always required

Midnight is 0000 Year Hr Min Sec

E 2 Shift
C
Shift or Platoon

& Alarms

Incident Type

D
1 2 3 4 5 N X

Aid Given or Received *

Mutual aid received Automatic aid recv. Mutual aid given Automatic aid given Other aid given None
Their FDID Their State

Check boxes if dates are the same as Alarm Date.

Local Option

Alarm

* *

09 09

17 17

2013 23:00:09 2013 23:13:01

01 10
Alarms District

ARRIVAL required, unless canceled or did not arrive

Arrival

E3
Special Studies
Local Option Special Study ID#

CONTROLLED Optional, Except for wildland fires

Controlled
Their Incident Number LAST UNIT CLEARED, required except for wildland fires

Last Unit Cleared

09

18

2013 01:02:48

Special Study Value

Actions Taken * 86
Investigate

G1
X

Resources *
Check this box and skip this section if an Apparatus or Personnel form is used.

G 2 Estimated
LOSSES: Personnel Property Contents

Dollar Losses & Values

None

Required for all fires if known. Optional for non fires.

Primary Action Taken (1)

Apparatus Suppression

$ $ $ $

, ,

000 , 000 ,
Optional

000 000

Additional Action Taken (2)

EMS Other

PRE-INCIDENT VALUE:

0004

0010
Property Contents

Additional Action Taken (3)

, ,

000 , 000 ,

000 000

Check box if resource counts include aid received resources.

Completed Modules
Fire-2 Structure-3 Civil Fire Cas.-4 Fire Serv. Cas.-5 EMS-6 HazMat-7 Wildland Fire-8 Apparatus-9 Personnel-10 Arson-11

H1* Casualties
Deaths
Fire Service Civilian

None

H3
N 1 2 3 4 5 6 7 8 0

Hazardous Materials Release

None Natural Gas: slow leak, no evauation or HazMat actions Propane gas: <21 lb. tank (as in home BBQ grill) Gasoline: vehicle fuel tank or portable container Kerosene: fuel burning equipment or portable storage Diesel fuel/fuel oil:vehicle fuel tank or portable Household solvents: home/office spill, cleanup only Motor oil: from engine or portable container Paint: from paint cans totaling < 55 gallons HazMat actions required or spill > 55gal., Other: Special Please complete the HazMat form

Injuries

Detector H2 Required for Confined Fires.

1 2 U

Detector alerted occupants Detector did not alert them Unknown

X X

I Mixed Use Property Not Mixed NN 10 Assembly use Education use 20 Medical use 33 Residential use 40 51 Row of stores 53 Enclosed mall 58 Bus. & Residential Office use 59 Industrial use 60 63 Military use 65 Farm use 00 Other mixed use

J
131 161 162 213 215 241 311 331 124 655 669 807 919 931

Property Use*

Structures

Church, place of worship Restaurant or cafeteria Bar/Tavern or nightclub Elementary school or kindergarten High school or junior high College, adult education Care facility for the aged Hospital

Outside
Playground or park Crops or orchard Forest (timberland) Outdoor storage area Dump or sanitary landfill Open land or field

341 342 361 419 429 439 449 459 464 519 936 938 946 951 960 961 962

Clinic,clinic type infirmary Doctor/dentist office Prison or jail, not juvenile 1-or 2-family dwelling Multi-family dwelling Rooming/boarding house Commercial hotel or motel Residential, board and care Dormitory/barracks Food and beverage sales Vacant lot Graded/care for plot of land Lake, river, stream Railroad right of way Other street Highway/divided highway Residential street/driveway

539 579 571 599 615 629 700 819 882 891 981 984

Household goods,sales,repairs Motor vehicle/boat sales/repair Gas or service station Business office Electric generating plant Laboratory/science lab Manufacturing plant Livestock/poultry storage(barn) Non-residential parking garage Warehouse Construction site Industrial plant yard

Lookup and enter a Property Use code only if you have NOT checked a Property Use box:

Property Use

982

Oil or gas field

NFIRS-1 Revision 03/11/99

CITY OF ARLINGTON

WB701

09/17/2013

13-0026144

K1

Person/Entity Involved
Local Option Business name (if applicable) Area Code

Phone Number

Check This Box if same address as incident location. Then skip the three duplicate address lines.

Mr.,Ms., Mrs. First Name

MI

Last Name

Suffix

Number

Prefix

Street or Highway

Street Type

Suffix

Post Office Box

Apt./Suite/Room

City

State Zip Code

More people involved? Check this box and attach Supplemental Forms (NFIRS-1S) as necessary

K 2 Owner
Local Option

Same as person involved? Then check this box and skip The rest of this section. Business name (if Applicable)

817
Area Code

- 572

- 4928

Phone Number

PHILLIP X
Check this box if same address as incident location. Then skip the three duplicate address lines. Mr.,Ms., Mrs. First Name MI

KABAKOFF
Last Name Suffix

3700
Number Prefix

FORT HUNT
Street or Highway

DR
Street Type Suffix

3701 W I20 HWY

Post Office Box Apt./Suite/Room

ARLINGTON
City

TX
State

76016
Zip Code

Remarks
Local Option

On 09/17/2013 at 23:00:09 dispatched To 3700 FORT HUNT DR /3701 W I20 HWY/ARLINGTON, TX 76016. The location is a Oil or gas field. The incident was determined to be a(n) Gas leak (natural gas or LPG). 23:13:01 arrived on scene. The following involvements were noted: Name/Business Name Involvement Type ---------------------------------------------------KABAKOFF, PHILLIP Reporting Party KABAKOFF, BETTY Reporting Party

The following actions were performed on scene: Investigate Units responding were: Unit E10 responded. Unit E9 responded. Unit RESCU9 responded. Unit T9 responded.

Authorization CP
Position or rank

01:02:48 in 173 all units back REICHERT, MARK service. Officer in charge ID Signature
Check Box if same as Officer Member making report ID in charge.

T9
Assignment

09
Month

18
Day Year

2013

173

REICHERT, MARK
Signature

CP
Position or rank

T9
Assignment

09
Month

18
Day Year

2013

CITY OF ARLINGTON

WB701

09/17/2013

13-0026144

WB701
FDID

TX
State

MM 9

DD 17

YYYY 2013

10
Station

13-0026144
Incident Number

000
Exposure

Incident Date

Complete Narrative

Narrative: On 09/17/2013 at 23:00:09 76016. The location is a (natural gas or LPG). 23:13:01 arrived on scene.

dispatched To 3700 FORT HUNT DR /3701 W I20 HWY/ARLINGTON, TX Oil or gas field. The incident was determined to be a(n) Gas leak

The following involvements were noted: Name/Business Name Involvement Type ---------------------------------------------------KABAKOFF, PHILLIP Reporting Party KABAKOFF, BETTY Reporting Party

The following actions were performed on scene: Investigate Units responding were: Unit E10 responded. Unit E9 responded. Unit RESCU9 responded. Unit T9 responded.

01:02:48

all units back in service.

CITY OF ARLINGTON

WB701

09/17/2013

13-0026144