Matrix Auth Forms 052013

• Document No.

• Audit Title

• Conducted on

  Date

• Prepared by

Customer Information (Pepco Account Holder)

• Company Name

• Business Type (general)

  Select Agriculture Industrial Large Commercial Small Commercial Government Healthcare Education Non-Profit Other (Describe)

  • Agriculture
  • Industrial
  • Large Commercial
  • Small Commercial
  • Government
  • Healthcare
  • Education
  • Non-Profit
  • Other (Describe)

• Business Type (specific)

  Select Farms Dairies Livestock farm Greenhouse Refrigerated Warehouse Food Processor

  • Farms
  • Dairies
  • Livestock farm
  • Greenhouse
  • Refrigerated Warehouse
  • Food Processor

• Business Type (specific)

  Select Fabrication Process Heavy manufacturing Warehouse Laboratories Biotech

  • Fabrication
  • Process
  • Heavy manufacturing
  • Warehouse
  • Laboratories
  • Biotech

• Business Type (specific)

  Select Office building General retail Big box retail Large grocery store chain Warehouse Convenience Store Hospitality/Lodging Assusted Living Data Center Multifamily

  • Office building
  • General retail
  • Big box retail
  • Large grocery store chain
  • Warehouse
  • Convenience Store
  • Hospitality/Lodging
  • Assusted Living
  • Data Center
  • Multifamily

• Business Type (specific)

  Select Grocery Stores Convenience store Restaurants Food services Car dealerships Small Retail Small office Multifamily

  • Grocery Stores
  • Convenience store
  • Restaurants
  • Food services
  • Car dealerships
  • Small Retail
  • Small office
  • Multifamily

• Business Type (specific)

  Federal

  State

  County

  Municipality

• Business Type (specific)

  Hospitals

  Ambulatory health care

  Nursing or residential care

• Business Type (specific)

  Schools

  College or University

• Business Type (specific)

  Large Non-Profit

  Small Non-Profit

  Large Faith-Based

  Small Faith-Based

• Describe

• Address

• City

• Zip

• Contact Person

• Title

• Telephone number

• Fax

• Email

• Secondary contact?

  Yes

  No

• Secondary contact name

• Title

• Phone number

• Email

Project site information

• Expected completion date

  Date

• Building type

  Yes

  No

  N/A

• Other (specify)

• Facility Name (project site)

• Project address

• City

• Zip

• Pepco Electric Account Number at Project Site

No Cost Measures

• 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)

• Quantity

  Yes

  No

  N/A

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

• Quantity

  Yes

  No

  N/A

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

• Quantity

  Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

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

• Yes

  No

  N/A

Customer Agreement

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.

• Authorized Representative Signature

  Sign

Facility Info

• Name on Utility Bill

  Same as Business Name

  Something else

• Actual Name on Utility Bill

• Business Description

• Age of building

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• Facility Sqft.

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• # Employees

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• # Workstations

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  • 100+

• Max Occupancy

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  • 100+

• Max Occupancy if more

• Are there computers?

• # Computers

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• # Computers if more

• Are there cash registers?

• # Cash Registers

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

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• # Cash Registers if more

Map

• Drawing

  Drawing

• Notes

Energy sources

• Electricity

• Natural Gas

• Heating Oil

• Propane

Gas Uses

• Gas Heat

• Gas Water Heat

• Gas Cooking

Business Hours

• Monday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Monday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Tuesday Same as above?

• Tuesday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Tuesday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Wednesday Same as above?

• Wednesday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Wednesday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Thursday Same as above?

• Thursday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Thursday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Friday Same as above?

• Friday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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• Friday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

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  • 4:00 AM
  • 5:00 AM
  • 6:00 AM
  • 7:00 AM
  • 8:00 AM
  • 9:00 AM
  • 10:00 AM
  • 11:00 AM
  • 12:00 PM
  • 1:00 PM
  • 2:00 PM
  • 3:00 PM
  • 4:00 PM
  • 5:00 PM
  • 6:00 PM
  • 7:00 PM
  • 8:00 PM
  • 9:00 PM
  • 10:00 PM
  • 11:00 PM
  • 11:59 PM

• Saturday Same as above?

• Saturday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

  • 12:00 AM
  • 1:00 AM
  • 2:00 AM
  • 3:00 AM
  • 4:00 AM
  • 5:00 AM
  • 6:00 AM
  • 7:00 AM
  • 8:00 AM
  • 9:00 AM
  • 10:00 AM
  • 11:00 AM
  • 12:00 PM
  • 1:00 PM
  • 2:00 PM
  • 3:00 PM
  • 4:00 PM
  • 5:00 PM
  • 6:00 PM
  • 7:00 PM
  • 8:00 PM
  • 9:00 PM
  • 10:00 PM
  • 11:00 PM
  • 11:59 PM

• Saturday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

  • 12:00 AM
  • 1:00 AM
  • 2:00 AM
  • 3:00 AM
  • 4:00 AM
  • 5:00 AM
  • 6:00 AM
  • 7:00 AM
  • 8:00 AM
  • 9:00 AM
  • 10:00 AM
  • 11:00 AM
  • 12:00 PM
  • 1:00 PM
  • 2:00 PM
  • 3:00 PM
  • 4:00 PM
  • 5:00 PM
  • 6:00 PM
  • 7:00 PM
  • 8:00 PM
  • 9:00 PM
  • 10:00 PM
  • 11:00 PM
  • 11:59 PM

• Sunday Same as above?

• Sunday open time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

  • 12:00 AM
  • 1:00 AM
  • 2:00 AM
  • 3:00 AM
  • 4:00 AM
  • 5:00 AM
  • 6:00 AM
  • 7:00 AM
  • 8:00 AM
  • 9:00 AM
  • 10:00 AM
  • 11:00 AM
  • 12:00 PM
  • 1:00 PM
  • 2:00 PM
  • 3:00 PM
  • 4:00 PM
  • 5:00 PM
  • 6:00 PM
  • 7:00 PM
  • 8:00 PM
  • 9:00 PM
  • 10:00 PM
  • 11:00 PM
  • 11:59 PM

• Sunday close time

  Select 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 11:59 PM

  • 12:00 AM
  • 1:00 AM
  • 2:00 AM
  • 3:00 AM
  • 4:00 AM
  • 5:00 AM
  • 6:00 AM
  • 7:00 AM
  • 8:00 AM
  • 9:00 AM
  • 10:00 AM
  • 11:00 AM
  • 12:00 PM
  • 1:00 PM
  • 2:00 PM
  • 3:00 PM
  • 4:00 PM
  • 5:00 PM
  • 6:00 PM
  • 7:00 PM
  • 8:00 PM
  • 9:00 PM
  • 10:00 PM
  • 11:00 PM
  • 11:59 PM

Outdoor Lighting

Outdoor Lighting

• Lamp Type

  Select Incandescent Halogen CFL T12 T8 T5 Metal Halide Mercury Vapor LED U-Tube T12 U-Tube T8 Case LED HTS

  • Incandescent
  • Halogen
  • CFL
  • T12
  • T8
  • T5
  • Metal Halide
  • Mercury Vapor
  • LED
  • U-Tube T12
  • U-Tube T8
  • Case LED
  • HTS

• Base type

  Single pin

  Bi-pin

  Recessed Bi-pin

• Lamp Width

  1 3/8"

  6"

• # of lamps per ballast

• Watts

  Select 15 25 40 60 75 100

  • 15
  • 25
  • 40
  • 60
  • 75
  • 100

• Watts

  Select 35 50 70 100 150 175 200 250 320 350 400 450 1000 1500

  • 35
  • 50
  • 70
  • 100
  • 150
  • 175
  • 200
  • 250
  • 320
  • 350
  • 400
  • 450
  • 1000
  • 1500

• Watts

  25

  40

  60

  75

  100

• Base type

  Medium Screw-in

  Candelabra Screw-in

  MR16

• Watts

  Select 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20

• Base type

  Medium Screw-in

  Mogul Screw-in (large)

  Candelabra Screw-in (small)

  GU-24

• Base type

  Single pin

  Bi-pin

  Recessed Bi-pin

• Ballast Type

  Select Magnetic Electronic Rapid Start Instant Start Programmed Start Dimmable Tandem-Wired

  • Magnetic
  • Electronic
  • Rapid Start
  • Instant Start
  • Programmed Start
  • Dimmable
  • Tandem-Wired

• Size (ex. 2x4)

  Select 1x2 2x2 1x4 2x4 3x4 4x4 1x8 2x8 3x8 4x8 5x8 6x8 7x8 8x8

  • 1x2
  • 2x2
  • 1x4
  • 2x4
  • 3x4
  • 4x4
  • 1x8
  • 2x8
  • 3x8
  • 4x8
  • 5x8
  • 6x8
  • 7x8
  • 8x8

• Shape

  Select A-Lamp R20 R30 R40 Par20 Par30 Par38 Flat Par20 Flat Par30 Flat Par38 capsule deco MR-16 Glober Flame Tip

  • A-Lamp
  • R20
  • R30
  • R40
  • Par20
  • Par30
  • Par38
  • Flat Par20
  • Flat Par30
  • Flat Par38
  • capsule
  • deco
  • MR-16
  • Glober
  • Flame Tip

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
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  • 10
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  • 12
  • 13
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  • 15
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  • 20
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  • 50
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  • 79
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  • 85
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  • 88
  • 89
  • 90
  • 91
  • 92
  • 93
  • 94
  • 95
  • 96
  • 97
  • 98
  • 99
  • 100+

• Height from ground (ft.)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Existing Controls

  Switches

  Timers

  Photocell

• Controls Working?

• Picture

  Media

• Yes

  No

  N/A

• Base type

  2-pin

  4-pin

  GU-24

  bayonette

• Watts

  Select 13 23 26 32 42 57

  • 13
  • 23
  • 26
  • 32
  • 42
  • 57

Indoor Lighting

Indoor Lighting

• Room info

  Same as Above

  New Room

• Room Served

• Floor

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• A/C?

• Install Occ. Sensor?

• Switch plate type

  decora

  decora/toggle

  decora/blank

• Room Type

  Select Private office Conference room Corridor copier room break room general exterior storage room

  • Private office
  • Conference room
  • Corridor
  • copier room
  • break room
  • general
  • exterior
  • storage room

• Footcandles

• Lamp Type

  Select Incandescent Halogen CFL T12 T8 T5 Metal Halide Mercury Vapor LED U-Tube T12 U-Tube T8 Case LED HTS

  • Incandescent
  • Halogen
  • CFL
  • T12
  • T8
  • T5
  • Metal Halide
  • Mercury Vapor
  • LED
  • U-Tube T12
  • U-Tube T8
  • Case LED
  • HTS

• Watts

  Select 15 25 40 60 75 100

  • 15
  • 25
  • 40
  • 60
  • 75
  • 100

• Base type

  2-pin

  4-pin

  GU-24

  bayonette

• Watts

  Select 13 23 26 32 42 57

  • 13
  • 23
  • 26
  • 32
  • 42
  • 57

• Watts

  25

  40

  60

  75

  100

• Base type

  Medium Screw-in

  Candelabra Screw-in

  MR16

• Watts

  Select 35 50 70 100 150 175 200 250 320 350 400 450 1000 1500

  • 35
  • 50
  • 70
  • 100
  • 150
  • 175
  • 200
  • 250
  • 320
  • 350
  • 400
  • 450
  • 1000
  • 1500

• Watts

  Select 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20

• Base type

  Single pin

  Bi-pin

  Recessed Bi-pin

• # of lamps per ballast

• Base type

  Medium Screw-in

  Mogul Screw-in (large)

  Candelabra Screw-in (small)

  GU-24

• Base type

  Single pin

  Bi-pin

  Recessed Bi-pin

• Ballast Type

  Select Magnetic Electronic Rapid Start Instant Start Programmed Start Dimmable Tandem-Wired

  • Magnetic
  • Electronic
  • Rapid Start
  • Instant Start
  • Programmed Start
  • Dimmable
  • Tandem-Wired

• Size (ex. 2x4)

  Select 1x2 2x2 1x4 2x4 3x4 4x4 1x8 2x8 3x8 4x8 5x8 6x8 7x8 8x8

  • 1x2
  • 2x2
  • 1x4
  • 2x4
  • 3x4
  • 4x4
  • 1x8
  • 2x8
  • 3x8
  • 4x8
  • 5x8
  • 6x8
  • 7x8
  • 8x8

• Fixture Width

• Shape

  Select A-Lamp R20 R30 R40 Par20 Par30 Par38 Flat Par20 Flat Par30 Flat Par38 capsule deco MR-16 Glober Flame Tip

  • A-Lamp
  • R20
  • R30
  • R40
  • Par20
  • Par30
  • Par38
  • Flat Par20
  • Flat Par30
  • Flat Par38
  • capsule
  • deco
  • MR-16
  • Glober
  • Flame Tip

• Lamp Color

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
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  • 19
  • 20
  • 21
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  • 25
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  • 30
  • 31
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  • 34
  • 35
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  • 37
  • 38
  • 39
  • 40
  • 41
  • 42
  • 43
  • 44
  • 45
  • 46
  • 47
  • 48
  • 49
  • 50
  • 51
  • 52
  • 53
  • 54
  • 55
  • 56
  • 57
  • 58
  • 59
  • 60
  • 61
  • 62
  • 63
  • 64
  • 65
  • 66
  • 67
  • 68
  • 69
  • 70
  • 71
  • 72
  • 73
  • 74
  • 75
  • 76
  • 77
  • 78
  • 79
  • 80
  • 81
  • 82
  • 83
  • 84
  • 85
  • 86
  • 87
  • 88
  • 89
  • 90
  • 91
  • 92
  • 93
  • 94
  • 95
  • 96
  • 97
  • 98
  • 99
  • 100+

• Height from ground (ft.)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Existing Controls

  Switches

  Occupancy Sensors

  Timers

  Daylighting

  Photocell

• Controls Working?

• Picture

  Media

• Notes (optional)

Exit Signs

• Are there exit signs?

• Room Served

• Lamp Type

  CFL

  Incandescent

  LED

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

  • 1
  • 2
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  • 10
  • 11
  • 12
  • 13
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  • 18
  • 19
  • 20
  • 21
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  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
  • 32
  • 33
  • 34
  • 35
  • 36
  • 37
  • 38
  • 39
  • 40
  • 41
  • 42
  • 43
  • 44
  • 45
  • 46
  • 47
  • 48
  • 49
  • 50
  • 51
  • 52
  • 53
  • 54
  • 55
  • 56
  • 57
  • 58
  • 59
  • 60
  • 61
  • 62
  • 63
  • 64
  • 65
  • 66
  • 67
  • 68
  • 69
  • 70
  • 71
  • 72
  • 73
  • 74
  • 75
  • 76
  • 77
  • 78
  • 79
  • 80
  • 81
  • 82
  • 83
  • 84
  • 85
  • 86
  • 87
  • 88
  • 89
  • 90
  • 91
  • 92
  • 93
  • 94
  • 95
  • 96
  • 97
  • 98
  • 99
  • 100+

• Height from ground (ft.)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Picture

  Media

• Notes (optional)

HVAC

HVAC

• Unit ID

• Location

  Roof

  Ground

  Ceiling

  Window

• Room Served

• Type

  A/C only

  Heat Pump

  Packaged

  Window

  Split

• Size (tons)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Make & Model

• Age

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

  • 1
  • 2
  • 3
  • 4
  • 5
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  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
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  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25
  • 26
  • 27
  • 28
  • 29
  • 30
  • 31
  • 32
  • 33
  • 34
  • 35
  • 36
  • 37
  • 38
  • 39
  • 40
  • 41
  • 42
  • 43
  • 44
  • 45
  • 46
  • 47
  • 48
  • 49
  • 50
  • 51
  • 52
  • 53
  • 54
  • 55
  • 56
  • 57
  • 58
  • 59
  • 60
  • 61
  • 62
  • 63
  • 64
  • 65
  • 66
  • 67
  • 68
  • 69
  • 70
  • 71
  • 72
  • 73
  • 74
  • 75
  • 76
  • 77
  • 78
  • 79
  • 80
  • 81
  • 82
  • 83
  • 84
  • 85
  • 86
  • 87
  • 88
  • 89
  • 90
  • 91
  • 92
  • 93
  • 94
  • 95
  • 96
  • 97
  • 98
  • 99
  • 100+

• Control Type (Thermostat, EMS) & Manufacturer

• Occupied set point (F)

• Unoccupied set point (F)

• Does it have an economizer?

• Yrs since Last Tuneup

  Select 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17

• Programmable Thermostat?

• Recommendations

  Select Tune-Up Econ Test Econ Repair Dual-Enth AQ Op DCV

  • Tune-Up
  • Econ Test
  • Econ Repair
  • Dual-Enth
  • AQ Op
  • DCV

Water Heating

• Existing Water Heating

Water Heating

• Type

  Electric Tank-Type

  Heat Pump

• Energy Star

  Y

  N

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Size (gals)

• Pipes Insulated?

  Y

  N

• Tank wrapped?

  Y

  N

• Age

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25+

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
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  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25+

• Condition/Comments

• Picture

  Media

Refrigeration Equipment

• Existing Refrigerator Equipment

Refrigerator

• Refrigerator Type

  Select Comm refrigerator, solid door Commercial freezer Refrigerated display, glass door Refrigerated display, no door Refrig. display, freezer, glass door Refrig. display, coffin type freezer Residential type refrigerator, small Residential type refrigerator, med Residential type refrig. w/ice dispenser Residential type chest freezer Residential type upright freezer

  • Comm refrigerator, solid door
  • Commercial freezer
  • Refrigerated display, glass door
  • Refrigerated display, no door
  • Refrig. display, freezer, glass door
  • Refrig. display, coffin type freezer
  • Residential type refrigerator, small
  • Residential type refrigerator, med
  • Residential type refrig. w/ice dispenser
  • Residential type chest freezer
  • Residential type upright freezer

• Energy Star?

  Y

  N

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

  • 1
  • 2
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  • 13
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• Picture

  Media

Walk Ins

• Existing Walk Ins

Walk Ins

• Walk In Type

  Walk in cooler

  Walk in freezer

• Energy Star?

  Y

  N

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• Picture

  Media

Ice Makers

• Existing Ice Makers

Ice Makers

• Ice Maker Type

  Select Ice maker, self contained, small Ice maker, self contained, med Ice maker, self contained, large Ice maker, water cooled small Ice maker, water cooled med Ice maker, water cooled large Ice maker, remote Cond. Unit, small Ice maker, remote Cond. Unit, med Ice maker, remote Cond. Unit, large

  • Ice maker, self contained, small
  • Ice maker, self contained, med
  • Ice maker, self contained, large
  • Ice maker, water cooled small
  • Ice maker, water cooled med
  • Ice maker, water cooled large
  • Ice maker, remote Cond. Unit, small
  • Ice maker, remote Cond. Unit, med
  • Ice maker, remote Cond. Unit, large

• Energy Star?

  Y

  N

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• Picture

  Media

Food Services

• Existing Food Service Equipment

Food Service Equipment

• Food Service Type

  Select Standard Fat Fryer Standard Steam Cookers Standard Hot Food Holding Cabinet (Full-size cabinet) Standard Hot Food Holding Cabinet (Three-Quarter size cabinet) Standard Hot Food Holding Cabinet (Half-size cabinet) Standard Griddles Standard Combination Ovens Standard Convection Ovens

  • Standard Fat Fryer
  • Standard Steam Cookers
  • Standard Hot Food Holding Cabinet (Full-size cabinet)
  • Standard Hot Food Holding Cabinet (Three-Quarter size cabinet)
  • Standard Hot Food Holding Cabinet (Half-size cabinet)
  • Standard Griddles
  • Standard Combination Ovens
  • Standard Convection Ovens

• Energy Star?

  Y

  N

• Quantity

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• Picture

  Media

Motors

• Motors

Motor

• Existing Motors

  Select Air Compressor Air Conditioning Chiller Compressor Boiler Draft Fan Boiler Feedwater Pump Building Exhaust Fan Chilled Water (ChW) Pump Condensate Pump (for AC) Condensate Pump (steam system) Condenser Water Pump Cooling Tower Fan Domestic Water Booster Pump Domestic Water Circ Pump Hot Water Pump HVAC Exhaust Fan HVAC Return Air Fan HVAC Supply Air Fan Make-Up Air Fan Other Pool Pump Process Cooling Pump Process Exhaust Fan or Fume Hood Transfer Pump Wastewater Pump Well Pump WSHP Circ Loop Pump

  • Air Compressor
  • Air Conditioning Chiller Compressor
  • Boiler Draft Fan
  • Boiler Feedwater Pump
  • Building Exhaust Fan
  • Chilled Water (ChW) Pump
  • Condensate Pump (for AC)
  • Condensate Pump (steam system)
  • Condenser Water Pump
  • Cooling Tower Fan
  • Domestic Water Booster Pump
  • Domestic Water Circ Pump
  • Hot Water Pump
  • HVAC Exhaust Fan
  • HVAC Return Air Fan
  • HVAC Supply Air Fan
  • Make-Up Air Fan
  • Other
  • Pool Pump
  • Process Cooling Pump
  • Process Exhaust Fan or Fume Hood
  • Transfer Pump
  • Wastewater Pump
  • Well Pump
  • WSHP Circ Loop Pump

• VFD Annual kWh Reduction

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• HP

• Room Served

• Age (yrs)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• Condition/ Comments

• Picture

  Media

Control Equipment

• Existing Control Equipment

Control equipment

• Existing Control Equipment

  "Smart" Power Strips

  Personal Occupancy Sensors

  Hotel Room HVAC Controls

  Hotel Room HVAC and Receptacle Controls

  Other (describe)

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• Location

• Comments

• Picture

  Media

• Are there any non-refrigerated vending machines?

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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  • 99
  • 100+

• Controls

  Timers

  Motion Sensors

• Age (years)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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  • 100+

• Conditions/Comments

• Picture

  Media

• Are there any refrigerated vending machines?

• Quantity

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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  • 100+

• Controls

  Timers

  Motion Sensors

• Age (years)

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+

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• Conditions/Comments

• Picture

  Media

Custom measures

• Custom fixtures?

Fixture type

• Custom Measures

  Select Lighting & Controls Building Controls Chiller VFD HVAC Refrigeration Fluid Flow Thermal Insulation Wndows Process Improvement Compressed Air Water Heating Other

  • Lighting & Controls
  • Building Controls
  • Chiller
  • VFD
  • HVAC
  • Refrigeration
  • Fluid Flow
  • Thermal Insulation
  • Wndows
  • Process Improvement
  • Compressed Air
  • Water Heating
  • Other

• Measure location

• Notes

• Picture

  Media

• Replace T12 lamps and magnetic ballasts with T8 lamps and electronic ballasts.

• Replace T12/T8 lamps with higher efficiency T8 or T5 fixtures.

• Replace T12/T8 lamps with LED fixtures

• Replace incandescent and compact fluorescent lamps with LEDs.

• Install new lighting fixtures with T8 lamps and electronic ballasts.

• Replace HID light fixtures with new high bay fluorescent fixtures.

• Replace standard HID lights with Pulse Start HID lights.

• Install new energy efficient outdoor lighting.

• Install occupancy sensors in your restrooms, equipment rooms, and storage rooms.

• Install LED/LEC exit lights.

• Optimize the performance of existing HVAC systems.

• Replace HVAC units with new high efficiency HVAC units.

• Replace existing food service equipment with high efficiency food service equipment.

• Replace small, shaded-pole motors with ECM motors on refrigeration evaporator fans.

• Install VFDs on motors over 2HP

• Install evaporative fan controllers for walk-in coolers.

• Install automated refrigerator door closes.

• Install vending machine controllers

• Install anti-sweat heater controls for glass refrigerated display doors.

• Install new high efficiency or Energy Star water heaters

• Install hotel room occupancy controls

• Install office equipment controls

• Check and adjust thermostat's programmable settings

• Activate energy-saving features of computers, monitors and copiers

• Install reminder signs to turn off lights in daylit areas

• Check outdoor light controls for proper operation and settings

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

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

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