Critical Public Service Fixed Facility
CRITICAL FACILITY PRIORITY: LIFE SAVING LIFE SUSTAINING INFRASTRUCTURE
NAME OF PUBLIC CRITICAL FIXED FACILITY:
FACILITY USE/PURPOSE/PRIORITY: Hospital Medical Public Water EOC EMS Fire Law Enforcement 911 Dispatch EAS Radio/TV Nursing Home/Special Needs Mass Shelter Feeding
Sewer/Wastewater Lift Station Cooling/Heating City Hall/County Seat Gov Communications
Commercial Cell/Telephone IT/Data Public Works/Roads/Maintenance/Refuel Other (Specify)
GIS SYSTEM SITE NUMBER (SEMA USE ONLY): / AGE of FACILITY:
< 45 yrs > 45 yrs / SITE in 500 YR FLOODPLAIN (fp)
YES NO UNKNOWN
If YES, is Site Elevated > 100 yr fp
YES NO UNKNOWN
Presidential Executive Orders may apply
NAME of COUNTY or MUNICIPALITY: / SITE PREVIOUSLY DISTURBED: YES NO
PHYSICAL SITE LOCATION ADDRESS (STREET): / THIS SURVEY COORDINATED W/LOCAL EMD: YES NO
Emergency 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:
Pad Pole
EXISTING SERVICE DROP:
Overhead
Underground / EXISTING UTILITY CONNECTION:
Above Ground
Below Ground / WIRING HARNESS
ALREADY IN-PLACE:
YES
NO / AUTOMATIC TRANSFER SWITCH (ATS):
YES
NO / MANUAL TRANSFER SWITCH (MTS):
YES
NO
# OF SERVICE DROPS: / DROP SIDE OF FACILITY:
Left Right
Front Rear / ELECTRICAL BACKFLOW PROTECTION:
YES
NO / NO TRANSFER
SWITCH (NTS):
YES
NO / CO DETECTOR
ONSITE:
YES
NO
FEEDER CABLE SIZE:
DISTANCE FROM
GENERATOR TO CONNECTION POINT: / Feet ______&/or
Yards ______or
Meters ______ / QUICK CONNECT/DISCONNECT:
YES
NO
LENGTH OF CABLE
NEEDED TO COMPLETE CONNECTION: / Feet ______&/or
Yards ______or
Meters ______ / OTHER METHOD OF CONNECTION TO FACILITY:
GENERATOR KW RATING REQUIRED AT 75% LOAD: / MAX AMPS: / PHASE REQUIRED:
Single
Three / BRING HOOK UP CABLES:
YES
NO / EMERGENCY BACKUP GENERATOR ALREADY ONSITE:
YES
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:
120/208
120/240
277/480
120/240 wild leg 3 phase / FACILITY MANAGER/OWNER
IS WILLING TO PARTICIPATE
IN PRACTICE DRILLS
Quarterly
Semi-Annually
Annually
NOT WILLING
SITE 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:
YES NO
IF YES, TYPE EQUIPMENT: (Circle: Forklift, Lull, K-loader, Wrecker, Manual Only)
Other: (Specify) / LOCAL STAFF AVAIL TO HOOK UP/MAINTAIN/FUEL GENERATOR:
YES NO
LOCAL ELECTRICIAN AVAIL TO HOOK UP GENERATOR:
YES NO (NOTE: IF NO, PLEASE EXPLAIN WHY)
ON-SITE REFUELING
CAPABILITY:
YES NO / TYPE 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 PLAN
Please 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.
STATE OF MISSOURI EMERGENCY MANAGEMENT AGENCY PUBLIC CRITICAL FIXED FACILITY SITE-SURVEY FORM
PAGE 1 OF 2 PAGES REVISION DATE: 6/4/2012