Header

  • Document No. (increments with each audit, please do not change)

  • Enter a title for your audit. It should be a name unique to only this audit.

  • Conducted on (automatically fills in as date of audit creation)

  • Prepared by (automatically filled out based on user)

Authorization Form

Customer Information (Pepco Account Holder)

  • Company Name

  • Business Type (general)

  • Business Type (specific)

  • Business Type (specific)

  • Business Type (specific)

  • Business Type (specific)

  • Business Type (specific)

  • Business Type (specific)

  • Non Profit & Faith-based

  • Describe

  • Company Address

  • Company City

  • Company Zip

  • Contact Person

  • Title

  • Telephone number

  • Fax

  • Email

  • Secondary contact?

  • Secondary contact name

  • Secondary title

  • Secondary telephone number

  • Secondary email

Project site information

  • Building type

  • Other building type (specify)

  • Is project site name different from company name listed on utility bill?

  • Facility Name (project site)

  • Site address

  • Site city

  • Site zip

  • Pepco Electric Account Number at Project Site

No Cost Measures (Check at least 3 measures to qualify for Pepco retrofit)

  • Check and adjust thermostat's programmable setting

  • Activate energy saving features of computers, monitors and copiers

  • Install reminder signs to turn off lights when not in use and in daylighted areas

  • Check outdoor light controls for proper operation and settings

  • Open window blinds to allow natural light to fill an area instead of artificial light

  • Check and adjust water heater thermostat's settings to 115F - 120F range if dish washing is not a factor

  • Encourage the purchase of energy efficient equipment (Energy Star Certified) as a standard practice

Low Cost Measures

  • Clear blocked supply and return air distribution vents (HVAC and refrigeration equipment, limit: 3 per building)

  • Clean or replace air filter and exposed/accessible condenser coils associated with A/C and refrigeration units (limit: 3 per bldg)

  • Replace incandescent lamps with CFLs (limit: 6 per building)

  • Replace incandescent lamps with LED (limit: 1 per building)

  • Install timers on coffee makers and water coolers (limit: 5 per building)

  • Install "Smart Strips" for computer equipment and associated multiple plug-in loads (limit: 3 per building)

  • Add external insulation blanket to electric water heater (limit: 3 per building)

  • Insulate exposed water heater pipes and accessible refrigerant piping (payment per 6 foot length, limit: 3 lengths per building)

  • Replace worn gaskets on refrigerator (Payment per foot of length, limit: 20 feet per building)

  • Replace worn weather stripping on exterior doors (Payment per foot of length, limit: 40 feet per building)

  • Install insulation gaskets on switch and outlet plates on exterior walls (limit: 10 per building)

  • Reduce air infiltration using caulk and spray foam (apply latter to increase insulation) (Payment per tube of can, limit: 6 per building)

Customer Agreement

  • Authorized Representative Signature - read the agreements below and sign here to agree

  • EAS Signature - EAS verifies that all the data submitted is accurate and the customer has been informed of all measures

WTEA Agreement

  • The Walk-through energy assessment process of the Small Business program requires the installation of at least three (3) different No Cost / Low Cost measures. All lamps and power strips installed through the C&I Energy Savings Program should be purchased through a distributor. Materials purchased through a retailer for the purpose of installing in a commercial facility are not eligible for reimbursement through the Program. I certify that the recommended measures checked above have been installed or performed and the customer and building staff have been informed of these actions. I further certify that they have also been informed of the necessity of performing ongoing maintenance to continue to achieve energy savings. I attest that if the customer was charged, it was only for measures that exceeded the printed Program limits or items not contained on the No Cost / Low Cost checklists above.

NCLC Agreement

  • I have read the entire application and agree to meet all requirements and abide by the Terms and Conditions of this application. I am authorized to sign on behalf of the Customer listed above, and represent that all information provided within is true and correct.
    By signing, customer attests that all low cost/no cost measures identified in the Walk-through Assessment has been completed.

LIA Agreement

  • 1. Customer agrees not to purchase or install any equipment until notified that the proposed project is approved.

    2. Customer agrees to allow Trade Ally to review the company's twelve month billing period.

    3. Customer understands that an approved Small Business Trade Ally or Program Representative will conduct the Walk-Through Energy Assessment.

Quote

Customer Co-payment Quote

  • Customer is required to pay a co-payment if they select to install any of the following measures:
    2 foot lamps
    U-tubes
    8 foot lamps
    Ceiling height of over 15 feet

  • Does the site have any of the above measures?<br>

  • What are the items that require a quote?

  • Quoted measure
  • List all quoted fixtures here.

  • Customer will pay $45.00 per fixture.

  • Customer will pay $55.00 per fixture.

  • Customer will pay $20.00 per fixture.

  • Customer will have to pay up to $200 for scissor lift rental. Actual amount may be less.

  • How many lamps will the customer pay for?

  • How many exactly?

  • Enter the price the customer will have to pay here

  • Customer signature agrees to pay the above price

Facility Info

  • Attach a picture of the storefront.

  • Business Description

  • Age of building

  • How old is it?

  • Facility Square Footage

  • How big is it?

  • # Employees

  • # Workstations

  • Max Occupancy

  • Max Occupancy if more

  • Are there computers?

  • # Computers

  • # Computers if more

  • Are there cash registers?

  • # Cash Registers

  • # Cash Registers if more

  • Please provide a sketch of the floor layout.

  • Map
  • Drawing

  • Facility Notes

Energy sources

  • Electricity

  • Natural Gas

  • Heating Oil

  • Propane

Gas Uses

  • Gas Heat

  • Gas Water Heat

  • Gas Cooking

Business Hours

  • Monday open time

  • Monday close time

  • Tuesday Same as above?

  • Tuesday open time

  • Tuesday close time

  • Wednesday Same as above?

  • Wednesday open time

  • Wednesday close time

  • Thursday Same as above?

  • Thursday open time

  • Thursday close time

  • Friday Same as above?

  • Friday open time

  • Friday close time

  • Saturday Same as above?

  • Saturday open time

  • Saturday close time

  • Sunday Same as above?

  • Sunday open time

  • Sunday close time

Lighting

Lighting Fixtures

  • Lighting

  • lighting fixture
  • Room info

  • Room Served

  • Floor (use 1 for ground floor and 0 for anything underneath)

  • A/C?

  • Install Occ. Sensor?

  • Switch plate type

  • Room Type

  • Footcandles

  • Inside or outside? (blank = inside)

  • Lighting schedule

  • Lamp Type

  • Watts

  • Base type

  • Watts

  • Base type

  • Watts

  • Base type

  • Watts

  • Base type

  • Base type

  • Size (ex. 2x4)

  • Don't forget to get a quote!

  • Ballast Type

  • Size (ex. 2x4)

  • Fixture Width

  • Don't forget to get a quote!

  • Base type

  • Shape

  • 5000K - white
    4100K - cool white
    6500K - daylight

  • Existing Lamp Color

  • Proposed Lamp Color

  • Quantity

  • Height from ground (ft.)

  • Existing Controls

  • Controls Working?

  • Picture

  • Notes (optional)

Exit Signs

  • Are there exit signs?

  • Room Served

  • Lamp Type

  • Quantity

  • Height from ground (ft.)

  • Picture

  • Notes (optional)

HVAC

HVAC

    HVAC
  • Location

  • Room Served

  • Type (mandatory for HVAC)

  • Size (tons) (mandatory for HVAC)

  • Make & Model

  • Age (mandatory for HVAC)

  • Yrs since Last Tuneup (mandatory for HVAC)

  • Control Type (Thermostat, EMS) & Manufacturer

  • Occupied set point (F)

  • Unoccupied set point (F)

  • Does it have an economizer?

  • Programmable Thermostat?

  • Recommendations

Water Heating

Water Heating

  • Existing Water Heating

  • Water Heating
  • Type

  • Energy Star

  • Quantity

  • Size (gals)

  • Pipes Insulated?

  • Tank wrapped?

  • Age

  • Condition/Comments

  • Picture

Kitchen Equipment

Refrigeration Equipment

  • Existing Refrigerator Equipment

  • Refrigerator
  • Refrigerator Type

  • Energy Star?

  • Quantity

  • Picture

Walk Ins

  • Existing Walk Ins

  • Walk Ins
  • Walk In Type

  • Energy Star?

  • Quantity

  • Picture

Ice Makers

  • Existing Ice Makers

  • Ice Makers
  • Ice Maker Type

  • Energy Star?

  • Quantity

  • Picture

Food Services

  • Existing Food Service Equipment

  • Food Service Equipment
  • Food Service Type

  • Energy Star?

  • Quantity

  • Picture

Vending Machines

Vending Machines

  • Are there any non-refrigerated vending machines?

  • Quantity

  • Controls

  • Age (years)

  • Conditions/Comments

  • Picture

  • Are there any refrigerated vending machines?

  • Quantity

  • Controls

  • Age (years)

  • Conditions/Comments

  • Picture

Control Equipment

Control Equipment

  • Existing Control Equipment

  • Control equipment
  • Existing Control Equipment

  • Quantity

  • Location

  • Comments

  • Picture

Motors

Motors

  • Motors

  • Motor
  • Existing Motors

  • VFD Annual kWh Reduction

  • Quantity

  • HP

  • Room Served

  • Age (yrs)

  • Condition/ Comments

  • Picture

Custom

Custom measures

  • Custom fixtures?

  • Fixture type
  • Custom Measures

  • Measure location

  • Notes

  • Picture

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.