EMERGENCY GENERATOR - Missouri



Sema5524538106337935center Emergency Generator Site-Survey Critical Public Service Fixed Facility CRITICAL FACILITY PRIORITY: FORMCHECKBOX LIFE SAVING FORMCHECKBOX LIFE SUSTAINING FORMCHECKBOX INFRASTRUCTURENAME OF PUBLIC CRITICAL FIXED FACILITY: FACILITY USE/PURPOSE/PRIORITY: FORMCHECKBOX Hospital FORMCHECKBOX Medical FORMCHECKBOX Public Water FORMCHECKBOX EOC FORMCHECKBOX EMS FORMCHECKBOX Fire FORMCHECKBOX Law Enforcement FORMCHECKBOX 911 Dispatch FORMCHECKBOX EAS Radio/TV FORMCHECKBOX Nursing Home/Special Needs FORMCHECKBOX Mass Shelter FORMCHECKBOX Feeding FORMCHECKBOX Sewer/Wastewater FORMCHECKBOX Lift Station FORMCHECKBOX Cooling/Heating FORMCHECKBOX City Hall/County Seat FORMCHECKBOX Gov Communications FORMCHECKBOX Commercial Cell/Telephone FORMCHECKBOX IT/Data FORMCHECKBOX Public Works/Roads/Maintenance/Refuel FORMCHECKBOX Other (Specify) GIS SYSTEM SITE NUMBER (SEMA USE ONLY): AGE of FACILITY: FORMCHECKBOX < 45 yrs FORMCHECKBOX > 45 yrsSITE in 500 YR FLOODPLAIN (fp) FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX UNKNOWNIf YES, is Site Elevated > 100 yr fp FORMCHECKBOX YES FORMCHECKBOX NO FORMCHECKBOX UNKNOWNPresidential Executive Orders may applyNAME of COUNTY or MUNICIPALITY:SITE PREVIOUSLY DISTURBED: FORMCHECKBOX YES FORMCHECKBOX NOPHYSICAL SITE LOCATION ADDRESS (STREET):THIS SURVEY COORDINATED W/LOCAL EMD: FORMCHECKBOX YES FORMCHECKBOX NOEmergency Management Director’s Name: CITY:STATE:ZIP:LATITUDE:LONGITUDE:PRIMARY POC NAME:PHONE:CELL/Smart Phone:E-MAIL:FACILITY/SERVICE/OTHER POC NAME:PHONE:CELL/ Smart Phone:E-MAIL:NAME OF POWER COMPANY:FACILITY PEAK LOAD:TRANSFORMER TYPE:MAX VOLTAGE: TOTAL AMP DRAW:XFMR MOUNT TYPE: FORMCHECKBOX Pad FORMCHECKBOX Pole EXISTING SERVICE DROP: FORMCHECKBOX Overhead FORMCHECKBOX Underground EXISTING UTILITY CONNECTION: FORMCHECKBOX Above Ground FORMCHECKBOX Below GroundWIRING HARNESS ALREADY IN-PLACE: FORMCHECKBOX YES FORMCHECKBOX NOAUTOMATIC TRANSFER SWITCH (ATS): FORMCHECKBOX YES FORMCHECKBOX NO MANUAL TRANSFER SWITCH (MTS): FORMCHECKBOX YES FORMCHECKBOX NO # OF SERVICE DROPS:DROP SIDE OF FACILITY: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Front FORMCHECKBOX Rear ELECTRICAL BACKFLOW PROTECTION: FORMCHECKBOX YES FORMCHECKBOX NO NO TRANSFERSWITCH (NTS): FORMCHECKBOX YES FORMCHECKBOX NO CO DETECTORONSITE: FORMCHECKBOX YES FORMCHECKBOX NO FEEDER CABLE SIZE:DISTANCE FROM GENERATOR TO CONNECTION POINT: FORMCHECKBOX Feet __________________ &/or FORMCHECKBOX Yards _________________ or FORMCHECKBOX Meters ________________ QUICK CONNECT/DISCONNECT: FORMCHECKBOX YES FORMCHECKBOX NOLENGTH OF CABLE NEEDED TO COMPLETE CONNECTION: FORMCHECKBOX Feet __________________ &/or FORMCHECKBOX Yards _________________ or FORMCHECKBOX Meters ________________ OTHER METHOD OF CONNECTION TO FACILITY: GENERATOR KW RATING REQUIRED AT 75% LOAD:MAX AMPS:PHASE REQUIRED: FORMCHECKBOX Single FORMCHECKBOX Three BRING HOOK UP CABLES: FORMCHECKBOX YES FORMCHECKBOX NO EMERGENCY BACKUP GENERATOR ALREADY ONSITE: FORMCHECKBOX YES FORMCHECKBOX NO KVA:GENERATOR PLACEMENT SITE OBSTRUCTION(S): (Circle Applicable: Route Restrictions/Blockages, Road Disrepair, Fence, Gate, Plants, Limbs Down, Animals, Ice, Civil Unrest, High Wind, Flood, etc.) Other: (Specify)VOLTAGE: FORMCHECKBOX 120/208 FORMCHECKBOX 120/240 FORMCHECKBOX 277/480 FORMCHECKBOX 120/240 wild leg 3 phaseFACILITY MANAGER/OWNERIS WILLING TO PARTICIPATEIN PRACTICE DRILLS FORMCHECKBOX Quarterly FORMCHECKBOX Semi-Annually FORMCHECKBOX Annually FORMCHECKBOX NOT WILLINGSITE HAZARD(S)/CONCERN(S): (Circle Applicable: Soils, HAZMAT, Water, O’head Lines, Security, Theft, Vandalism, Isolation, etc.) Other: (Specify)LOCAL ABILITY TO OFF-LOAD/UP-LOAD GENERATOR: FORMCHECKBOX YES FORMCHECKBOX NO IF YES, TYPE EQUIPMENT: (Circle: Forklift, Lull, K-loader, Wrecker, Manual Only)Other: (Specify) LOCAL STAFF AVAIL TO HOOK UP/MAINTAIN/FUEL GENERATOR: FORMCHECKBOX YES FORMCHECKBOX NO LOCAL ELECTRICIAN AVAIL TO HOOK UP GENERATOR: FORMCHECKBOX YES FORMCHECKBOX NO (NOTE: IF NO, PLEASE EXPLAIN WHY)ON-SITE REFUELING CAPABILITY: FORMCHECKBOX YES FORMCHECKBOX NOTYPE OF FUEL: (Circle: Diesel, Gas, Propane, Natural Gas) Other: (Specify)COMMENTS:DATE OF SURVEY:PREPARED BY (Please Print Name):PREPARERS DUTY TITLE:E-MAIL: PHONE/CELL/BBERRY:SITE PLANPlease include dimensions of available space for a generator. Attach Google Map or other photo map showing the facility, if possible.Note: Age of facility > 45 yrs/No prior site disturbance may trigger environmental requirements. ................
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