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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.
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 --Deputy Fire Chief BerensAdministrative Battalion Chief CorteseBattalion Chief GilbertBattalion Chief RhodesBattalion Chief BecerraCaptain AimarCaptain BaraccoCaptain BurgessCaptain CaldwellCaptain ChagonjianCaptain CroweCaptain DavisCaptain GenaroCaptain JonesCaptain LangfordCaptain MortimoreCaptain NylanderCaptain SquibbCaptain OlivaCaptain UlitinCaptain 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