LO S ANG E LE S CO MMUNI TY CO LLE G E DI S TRI CT

DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT

SUSTAINABLE BUILDNG PROGRAM

WITNESS STATEMENT

Name:      
Title:       Date:      
Incident being Addressed:       Time:      
Temporary Address:      
Phone No.:      
Permanent Address:      
Phone No.:      
Location at Time of Incident:      

Describe, to the best of your knowledge, what happened just before, during, and just after the incident and
include any supporting pictures and additional contact information of others at the incident site:

     

By:            

PLEASE SIGN PRINT NAME DATE

Firm
Name:       Job Description:      

CPS-0422 Page 1 of 1 Revised 04/21/2015