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PPE Repair or Replacement Request

2. Routed to Appropriate Apparatus Specialist, CC'd to Program Manager Cortese and Supervisor
   CC'd Recipient: This Form is For Awareness Only, No Further Action Required.

   CC'd Recipient: This Form is For Awareness Only, No Further Action Required.

4. Please Take Any Personal Belongings Out of Pockets Before Placing in Bag

6. First Name*

7. Last Name*

8. Cell Phone Number*

10. Station*
    -- Select One --Station 1Station 2Station 3Station 4Station 5

11. Shift*
    -- Select One --A-ShiftB-ShiftC-Shift

12. Rank*
    -- Select One --Battalion ChiefCaptainDivision ChiefFire ChiefFirefighterFirefighter/Paramedic

13. Employee ID*

15. Do You Have an Alternate Set?*

    1. Yes

    1. No

16. Date*
    Date

20. PPE Item

    1. Bunker Coat Outer

21. MFG/Serial #

22. Qty

23. Action Requested

    1. Repair
    2. Replacement

25. DRD (Drag Rescue Device)

    1. Yes

    1. No

29. PPE Item

    1. Bunker Coat Liner

30. MFG/Serial #

31. Qty

32. Action Requested

    1. Repair
    2. Replacement

36. PPE Item

    1. Bunker Pant Outer

37. MFG/Serial #

38. Qty

39. Action Requested

    1. Repair
    2. Replacement

41. Suspenders

    1. Yes

    1. No

45. PPE Item

    1. Bunker Pant Liner

46. MFG/Serial #

47. Qty

48. Action Requested

    1. Repair
    2. Replacement

52. PPE Item

    1. EMS Jacket

53. MFG/Serial #

54. Qty

55. Action Requested

    1. Repair
    2. Replacement

59. PPE Item

    1. Wild Land Jacket

60. MFG/Serial #

61. Qty

62. Action Requested

    1. Repair
    2. Replacement

66. PPE Item

    1. Wild Land Pant

67. MFG/Serial #

68. Qty

69. Action Requested

    1. Repair
    2. Replacement

73. PPE Item

    1. Hood

74. MFG/Serial #

75. Qty

76. Action Requested

    1. Repair
    2. Replacement

80. PPE Item

    1. Boots

81. MFG/Serial #

82. Qty

83. Action Requested

    1. Repair
    2. Replacement

87. PPE Item

    1. Gloves

88. MFG/Serial #

89. Qty

90. Action Requested

    1. Repair
    2. Replacement

94. Other PPE Item

95. MFG/Serial #

96. Qty

97. Action Requested

    1. Repair
    2. Replacement

99. Special Instructions/Comments

103. Photo #1 - PPE Items in Need of Cleaning and/or Repair

104. Photo #2 - PPE Items in Need of Cleaning and/or Repair

106. Photo #3 - PPE Items in Need of Cleaning and/or Repair

107. Photo #4 - PPE Items in Need of Cleaning and/or Repair

109. Photo #5 - PPE Items in Need of Cleaning and/or Repair

110. Photo #6 - PPE Items in Need of Cleaning and/or Repair

112. Photo #7 - PPE Items in Need of Cleaning and/or Repair

113. Photo #8 - PPE Items in Need of Cleaning and/or Repair

115. Photo #9 - PPE Items in Need of Cleaning and/or Repair

116. Photo #10 - PPE Items in Need of Cleaning and/or Repair

118. Your Supervisor *
     -- Select One --Administrative Battalion Chief BerensBattalion Chief CorteseBattalion Chief GilbertBattalion Chief RhodesCaptain BaraccoCaptain BecerraCaptain BeckerCaptain BurgessCaptain CaldwellCaptain ChamnessCaptain CronbachCaptain CroweCaptain D'AngeloCaptain DavisCaptain DombrowskiCaptain JonesCaptain KochCaptain LangfordCaptain MortimoreCaptain OlivaCaptain VoglerGreg FortuneShuree Egloff

     You Supervisor Will Receive This Request

Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit

* indicates a required field