Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

BUREAU OF FIRE PROTECTION

Brgy. Malainen Luma, Naic, Cavite

Fire Station

EVIDENCE SUBMISSION FORM 06-04

FOR : CHIEF, BFP

145 Union Square Condominium
15th Avenue, Cubao
Quezon City

ATTN: Chief, Arson Laboratory Section (ALS)

SUBJECT : LABORATORY EXAMINATION, REQUEST FOR

DATE : 30 October 2018

Request Laboratory Examination on the accompanying specimen/ subject(s) specifically for the
purpose of:

For Electrical Analysis

I. FACTS OF THE CASE:

1 Nature of the Case : Accidental fire incident

2 Suspect : N/A
3 Victim : Dorothy Molo, Leamor Refran, Joseph
Viloria, Kate Castillo, Jenny Advincula,
Melissa Mandap, Rossell Gale Ensiso,
100 John Doe and 55 Jane Doe
4 Complainant : Trebuh Tnek
5 Duty Investigator : SFO 1 Ashlea D. Dimakuta
Unit Assignment : Fire Investigator
6 Place of Fire Incident : O Zone Disco, Brgy. Sabang, Naic, Cavite
7 Time & Date of Fire Incident: : 2335H 28 October 2018
8 Place where evidence was collected : O Zone Disco, Brgy. Sabang, Naic, Cavite
9 Time & Date evidence was collected : 0100H 29 October 2018

II. EVIDENCE SUBMITTED:

Circuit board
Light Fixtures
2 pcs. frayed wires

Requested by:

____________________________
Investigator on case

Approved for Submission:

____________________________
City/Municipal Fire Marshal