02601 MO 01 28 2020 2020-00000390 000 Delete BASIC FDID State Incident Date Station Incident Number Exposure Change

Page 1 of 17 MM DD YYYY NFIRS - 1 A 02601 MO 01 28 2020 2020-00000390 000 Delete BASIC FDID State Incident Date Station Incident Number Exposure Change Location Type Check this box to indicate that the address for this incident is provided on the Wildland Fire Census Tract B Module in Section B, "Alternative Location Specification." Use only for wildland fires. Street address 500 MISSOURI BLVD Intersection Number/Milepost Prefix Street or Highway Street Type Suffix In front of Rear of Jefferson City MO - Adjacent to Apt./Suite/Room City State ZIP Code Directions US National Grid Cross Street, Directions or National Grid, as applicable Midnight is 0000 C IncidentType E1 Dates and Times E2 Shifts and Alarms Month Day Year Hour/Min Local option 350 Extrication, rescue, oth Check boxes if dates are ALARM always required Incident Type Alarm the same as C 1 F14 Alarm Date. 01 28 2020 1257 Shift or Alarms District Platoon D Aid Given or Received None Arrival ARRIVAL required, unless canceled or did not arrive 01 28 2020 1301 1 Mutual aid received Special Studies CONTROLLED optional, except for wildland fires E3 2 Auto. aid received Controlled Local option Their FDID Their 3 Mutual aid given State 4 Auto. aid given LAST UNIT CLEARED, required except for wildland fires Last Unit Special Special 5 Other aid given Their Incident Number Cleared 01 28 2020 1525 Study ID# Study Value Actions Taken Resources Estimated Dollar Losses and Values F G1 Check this box and skip this block if an G2 Apparatus or Personnel Module is used. Required for all fires if known. LOSSES: Optional for non-fires. None 23 Extricate, disentangle Apparatus Personnel Primary Action Taken (1) Property $ Suppression 8 17 81 Incident command Contents $ EMS 0 0 Additional Action Taken (2) PRE-INCIDENT VALUE:Optional Other 2 2 Property $ Check box if resource counts include aid Additional Action Taken (3) received resources. Contents $ Casualties None Hazardous Materials Release None Mixed Use Not Completed Modules mixed H1 H3 I Property Fire-2 Deaths Injuries 10 Assembly use 1 Natural gas: slow leak, no evacuation or HazMat actions Structure Fire-3 Fire 20 Education use Service 0 0 2 Propane gas: < 21 - lb tank (as in home BBQ grill) Civilian Fire Cas.-4 33 Medical use 3 Gasoline: vehicle fuel tank or portable container Fire Service Cas.-5 Civilian 0 0 40 Residential use 4 Kerosene: fuel burning equipment or portable storage 51 Row of stores EMS-6 5 Diesel fuel/fuel oil: vehicle fuel tank or portable storage 53 Enclosed mall HazMat-7 Detector 58 Business & residential H2 Required for confined fires. 6 Household solvents: home/office spill, cleanup only Wildland Fire-8 59 Office use 7 Motor oil: from engine or portable container Apparatus-9 1 Detector alerted occupants 60 Industrial use 8 Paint: from paint cans totaling < 55 gallons Personnel-10 2 Detector did not alert them 63 Military use 0 Other: special HazMat action required or spill > 55 gal 65 Farm use Arson-11 U Unknown (Please complete the HazMat form.) 00 Other mixed use J Property Use None 341 Clinic, clinic-type infirmary 539 Household goods, sales, repairs Structures 342 Doctor/dentist office 571 Gas or service station 131 Church, place of worship 361 Prison or jail, not juvenile 579 Motor vehicle/boat sales/repairs 161 Restaurant or cafeteria 419 1-or 2-family dwelling 599 Business office 162 Bar/tavern or nightclub 429 Multifamily dwelling 615 Electric-generation plant 213 Elementary school, kindergarten 439 Rooming/boarding house 629 Laboratory/science laboratory 215 High school, junior high 449 Commercial hotel or motel 700 Manufacturing plant 241 College, adult education 459 Residential, board and care 819 Livestock/poultry storage (barn) 311 Nursing home 464 Dormitory/barracks 882 Non-residential parking garage 331 Hospital 519 Food and beverage sales 891 Warehouse Outside 936 Vacant lot 981 Construction site 124 Playground or park 938 Graded/cared for plot of land 984 Industrial plant yard 655 Crops or orchard 946 Lake, river, stream Look up and enter a 669 Forest (timberland) 951 Railroad right-of-way Property Use code and Property Use 807 Outdoor storage area 960 Other street description only if you Code have NOT checked a 919 Dump or sanitary landfill 961 Highway/divided highway Property Use box. 931 Open land or field 962 Residential street/driveway Property Use Description Page: 1 of 23 Page 2 of 17 MM DD YYYY NFIRS - 1 A 02601 MO 01 28 2020 2020-00000390 000 Delete BASIC FDID State Incident Date Station Incident Number Exposure Change Person/Entity Involved Schrimpf landscaping Inc 573 635-6300 K1 Local Option Business Name (if applicable) Area Code Phone Number Check this box if same Mr., Ms., Mrs. First Name MI Last Name Suffix address as incident Location (Section B). then skip the three 2820 BRUSH CREEK CT duplicate address lines. Number Prefix Street or Highway Street Type Suffix JEFFERSON CITY Post Office Box Apt./Suite/Room City MO 65109 - State ZIP Code Owner Same as person involved? Then check K2 Local Option this box and skip the rest of this block. Business Name (if applicable) Area Code Phone Number Check this box if same Mr., Ms., Mrs. First Name MI Last Name Suffix address as incident Location (Section B). then skip the three duplicate address lines. Number Prefix Street or Highway Street Type Suffix Post Office Box Apt./Suite/Room City - State ZIP Code M Authorization 3jn1804 Asst Chief Assistant Chi Check box if Officer in charge ID Signature Jay Niemeyer Position or rank Assignment Month Day Year same as Officer in charge. 3jn1804 Asst Chief Assistant Chi Member making report ID Signature Jay Niemeyer Position or rank Assignment Month Day Year MM DD YYYY NFIRS - 1 A 02601 MO 01 28 2020 2020-00000390 000 Delete BASIC FDID State Incident Date Station Incident Number Exposure Change Remarks L Local Option Page: 2 of 23 Page 3 of 17 MM DD YYYY NFIRS - 1S A 02601 MO 01 28 2020 2020-00000390 000 Delete SUPPLEMENTAL FDID State Incident Date Station Incident Number Exposure Change Person/Entity Involved K1 Local Option Business Name (if applicable) Area Code Phone Number Jacob W Scrimpf Check this box if same Mr., Ms., Mrs. First Name MI Last Name Suffix address as incident Location (Section B). then skip the three 1319 RT C duplicate address lines. Number Prefix Street or Highway Street Type Suffix Russellville Post Office Box Apt./Suite/Room City MO 65036 - State ZIP Code Page: 3 of 23 Page 4 of 17 MM DD YYYY NFIRS - 2 FIRE A 02601 MO 01 28 2020 2020-00000390 000 Delete FDID State Incident Date Station Incident Number Exposure Change Complete if there were any significant amounts of On-Site Materials None Property Details commercial, industrial, energy, or agricultural B C or Products products or materials on the property, whether or not they became involved Not Residential Enter up to three codes. B1 Check one box for each code On-Site Materials Storage Use Estimated number of residential living units in entered. building of origin whether or not all units 1 Bulk storage or warehousing became involved 2 Processing or manufacturing On-site material (1) 3 Packaged goods for sale 4 Repair or service B2 Buildings not involved U Undetermined Number of buildings involved 1 Bulk storage or warehousing 2 Processing or manufacturing On-site material (2) 3 Packaged goods for sale 4 Repair or service U Undetermined None 1 Bulk storage or warehousing B3 2 Processing or manufacturing Acres burned Less than one acre On-site material (3) 3 Packaged goods for sale (outside fires) 4 Repair or service U Undetermined Ignition Cause of Ignition Skip to Human Factors D E1 Section G Contributing to Ignition Check box if this is an exposure report. E3 Check all applicable boxes None D1 1 Intentional Area of fire origin Asleep 2 Unintentional 1 2 Possibly impaired by 3 Failure of equipment or heat source alcohol or drugs D2 4 Act of nature Heat source 3 Unattended person 5 Cause under investigation 4 Possibly mentally disabled U Cause undetermined after investigation 5 Physically disabled D3 Multiple persons involved Item first 1 Check box if fire spread was Factors Contributing to Ignition 6 ignited confined to object of origin. E2 None 7 Age was a factor D4 Estimated age of Type of material first ignited Required only if item first Factor contributing to ignition (1) ignited code is 00 or <70 person involved 1 Male 2 Female Factor contributing to ignition (2) Equipment Involved in Ignition Equipment Power Source Fire Suppression Factors None If equipment was not involved, F1 None F2 G Enter up to three codes. skip to Section G Equipment Power Source Fire suppression factor (1) Equipment Involved Equipment Portability Brand F3 1 Portable Fire suppression factor (2) Model 2 Stationary Serial # Portable equipment normally can be moved by one or two persons, is designed to be used in Fire suppression factor (3) Year multiple locations, and requires no tools to install. Mobile Property Type and Make Local Use Mobile Property Involved None H2 H1 Pre-Fire Plan Available 1 Not involved in ignition, but burned Some of the information presented in Mobile property type this report may be based upon reports 2 Involved in ignition, but did not burn from other agencies: Involved in ignition and burned 3 Arson report attached Mobile property make Police report attached Coroner report attached Other reports attached Mobile property model Year License Plate Number State VIN Structure fire? Please be sure to complete the Structure Fire form (NFIRS-3).

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