C NG HÒA XÃ H I CH NGHĨA VI T NAMỘ Ộ Ủ Ệ
Đc l p - T do - H nh phúcộ ậ ự ạ
........., ngày.........tháng.........năm 20......
BÁO CÁO
M t, cháy, h ng n chấ ỏ ấ ỉ
Tên t ch c, cá nhân làm m t, cháy, h ng n ch :ổ ứ ấ ỏ ấ ỉ ......................................................................................
Mã s thu :ố ế ...................................................................................................................................................
Đa ch :ị ỉ ...........................................................................................................................................................
Căn c Biên b n m tứ ả ấ
Ngày........tháng........năm............., (tên t ch c, cá nhân) phát hi n m t, cháy, h ng n ch nh sau:ổ ứ ệ ấ ỏ ấ ỉ ư
STT Tên nấ
chỉM u sẫ ố Ký hi uệT s …ừ ố
đn s ..ế ố
S nố ấ
chỉ
Liên nấ
chỉGhi chú
1 2 3 4 5 6 7 8
AA/12T
Lý do m t, cháy, h ng n ch :ấ ỏ ấ ỉ .......................................................................................................
Nay đn v báo cáo v i ………………………. Đ ph i h p truy tìm, ngăn ch n l i d ng và ơ ị ớ ể ố ợ ặ ợ ụ
thông báo s n ch trên không còn giá tr s d ng.ố ấ ỉ ị ử ụ
N i nh n:ơ ậ NG I ĐI DI N THEO PHÁP LU TƯỜ Ạ Ệ Ậ
- C quan thu tr c ti p qu n lýơ ế ự ế ả
- L u.ư(Ký đóng d u và ghi rõ h tên)ấ ọ
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