<p> STATE OF NEW MEXICO Fire Number Energy, Minerals and Natural Resources Department Forestry Division Fire Name FIRE DEPARTMENT REIMBURSEMENT REQUEST Fire Department </p><p>INCIDENT DETAILS:</p><p>Fire Start Date: Fire Start Time: IC’s Name: </p><p>County: </p><p>Ownership: </p><p>Forest Cover Type: </p><p>Fuel Type– (what actually burned): </p><p>General Cause: Other </p><p>Structures Threatened Number and Type: </p><p>Number of Structures Burned: </p><p>Fire Location: T. R. Section 1/4Section </p><p> and/or Latitude Longitude </p><p>Acreage Burned by Land Ownership: (number of acres in blanks)</p><p>BIA BLM FWS NPS Private State USFS Other (specify) </p><p>Dispatch: Date Time Acres </p><p>Initial Attack: Date Time Acres </p><p>Controlled: Date Time Acres </p><p>Back To Station: Date Time Acres </p><p>Slope at Origin: </p><p>Aspect at Origin: </p><p>Temperature: (°F) RH: % Wind Speed: Wind Direction: </p><p>Fire Behavior on Initial Attack: </p><p>FORM COMPLETED BY TITLE DATE STATE OF NEW MEXICO FIRE NUMBER: Energy, Minerals and Natural Resources Department Forestry Division </p><p>FIRE DEPARTMENT FIRE NAME: REIMBURSEMENT REQUEST</p><p>Equipment Equipment Description License Number # of Hours *Rate per Hour Total 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 10 0 11 0 12 0</p><p>Total Reimbursement 0 Make Reimbursement Payable to: Name: CITY OF CLOVIS FOR CLOVIS FIRE DEPARTMENT</p><p>Address: P.O. BOX 760 Vendor No.:0000054320</p><p>City: CLOVIS State: NM Zip Code: 88102 </p><p>*Use current equipment rate schedule DIVISION **Checks are made payable to the governing APPROVAL  body or fiscal agent of fire department. District Forester Date CERTIFICATION FIRE DEPARTMENT (Chief) Date I certify that the above services were rendered as stated: that they were necessary and proper, that the amounts claimed are just and reasonable FISCAL AGENT FOR FIRE DEPARTMENT Date and that no part thereof has been paid.</p>