Information

Business Info

  • Business Name

  • Conducted on

  • Prepared by

  • Pepco Account Number

  • Address and Suite No.

  • City

  • Zip

Contact Info

  • Name

  • Title

  • Phone

  • E-mail

Facility Info

  • Name on Utility Bill

  • Actual Name on Utility Bill

  • Business Type (General)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Specific)

  • Business Type (Other)

  • Business Description

  • Age of building

  • Facility Sqft.

  • # 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

  • Drawing

  • 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

Outdoor Lighting

    Outdoor Lighting
  • Lamp Type

  • Base type

  • Lamp Width

  • # of lamps per ballast

  • Watts

  • Base type

  • Watts

  • Watts

  • Watts

  • Base type

  • Watts

  • Base type

  • Base type

  • Ballast Type

  • Size (ex. 2x4)

  • Shape

  • Quantity

  • Height from ground (ft.)

  • Existing Controls

  • Controls Working?

  • Picture

Indoor Lighting

    Indoor Lighting
  • Room info

  • Room Served

  • Floor

  • A/C?

  • Install Occ. Sensor?

  • Switch plate type

  • Room Type

  • Footcandles

  • Lamp Type

  • Watts

  • Base type

  • Watts

  • Watts

  • Base type

  • Watts

  • Watts

  • Base type

  • # of lamps per ballast

  • Base type

  • Base type

  • Ballast Type

  • Size (ex. 2x4)

  • Fixture Width

  • Shape

  • 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
  • Unit ID

  • Location

  • Room Served

  • Type

  • Size (tons)

  • Make & Model

  • Age

  • Control Type (Thermostat, EMS) & Manufacturer

  • Occupied set point (F)

  • Unoccupied set point (F)

  • Does it have an economizer?

  • Yrs since Last Tuneup

  • 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

Motors

Motors

  • Motors

  • Motor
  • Existing Motors

  • VFD Annual kWh Reduction

  • Quantity

  • HP

  • Room Served

  • Age (yrs)

  • Condition/ Comments

  • Picture

Control Equipment

Control Equipment

  • Existing Control Equipment

  • Control equipment
  • Existing Control Equipment

  • Quantity

  • Location

  • Comments

  • Picture

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

Custom

Custom measures

  • Custom fixtures?

  • Fixture type
  • Custom Measures

  • Measure location

  • Notes

  • Picture

Recommended Measures

  • 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

No Cost Low Cost Measures

  • 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

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.