Unit V Project

Date of Inspection:

Committee Officer:

Committee Members:

General Information

Facility/ Business Name:

Street Address:

Nearest Cross Street:

Contact Information

Facility Phone Number: (

)

Other Phone Number: ( )

Business Owner:

Location:

Phone Number: ( )

Primarily works on site: yes □

no □

Mobile Number: ( )

Other:

Emergency Contacts

Name:

Title:

Location:

Phone Number: (

)

Mobile Number: (

)

Other:

Name:

Title:

Location:

Phone Number: (

)

Mobile Number: (

)

Other:

Name:

Title:

Location:

Phone Number: (

)

Mobile Number: (

)

Other:

GPS Information

Latitude:

Longitude:

Method of determining latitude and longitude:

Description of location identified by latitude and longitude:

Construction Information

SIZE

STORIES

BUILDING STATUS

Length:

Above Ground:

Under Construction: □

Vacant & Secured: □

Width:

Below Ground:

Occupied: □

Vacant & Unsecured: □

Area:

Idle (Not Routinely Used): □

CONSTRUCTION TYPE

Fire Resistive: □

Unprotected Non-Combustible: □

Protected Ordinary: □

Protected Wood Frame: □

Heavy Timber: □

Protected Non-Combustible: □

Unprotected Ordinary: □

Unprotected Wood Frame: □

Walls: Floors: Roof:

ROOF COVERING

Tile (clay, cement, slate, etc.): □

Wood Shingles (treated / untreated): □

Composite Shingle (asphalt): □

Built Up: □

Metal: □

No Roof: □

OTHER CONSTRUCTION INFORMATION

Exterior Features:

Date of last known modification:

Architect:

Facility built date:

Construction Company:

Supplied site plans: yes □ no □

Hazardous Material Specific Information

Tier II Facility: yes □ no □

Up to date Chemical Inventory List: yes □ no □

MSDS received with Tier II forms: yes □ no □

Chemical Inventory List provided: yes □ no □

HAZARDOUS MATERIAL STORAGE

Chemical Name

ID#

Quantity

Location

Utility Services Information

Electric Meter Location:

Natural Gas Meter Location:

Breaker Panel Location(s):

Heated by:

Location:

Water Heater type: Natural Gas □ Electric □

Location:

Alarm System

Alarm Present: yes □ no □

Automatic: □

Manual Pull Station: □

Combination: □

DETECTOR TYPE

POWER SUPPLY

Smoke: □

Heat: □

Battery: □

Hardwire w/ Battery Backup: □

Carbon Monoxide: □

Combination: □

Plug In: □

Plug In w/ Battery Backup: □

Sprinkler w/ Water - Flow Detection: □

Hardwire: □

Alarm Panel Location:

Alarm Company:

Phone Number:

Water Supply Information

Sprinkler Riser: yes □ no □

Location:

Sprinkler Standpipe Connection: yes □ no □

Location:

SYSTEM TYPE

Wet Pipe: □

Dry Chemical System: □

Halogen System: □

Class K System: □

Dry Pipe: □

Foam System: □

CO2 System: □

Standpipes: □

Hydrant Location(s):

Hydrant Flow Rate(s):

Red (500gpm or less) □

Orange (500gpm to1000gpm) □

Green (1000gpm to 1500gpm) □

Blue (1500gpm or greater) □