How many buildings are at this address? : *

Can you provide single line drawings of the electrical distribution system? (for budgeting purposes only): *
 Yes No

If yes, when were these drawings last updated?

When was the facility built?: *

What type of work is done in your facility? *

Have you made any recent additions, renovations? *
 yes no

If yes, are there any drawings of the electrical work completed? *
 yes no

What is the square footage of your facility? *

How many shifts do you run? *

How many of your maintenance or electrical employees work on energized electrical components? *

Can data be collected between 6 a.m. and 5 p.m.?
 Yes No

If no, when can data be collected?

Will you provide a person who is qualified and familiar with your electrical system to accompany the data collector and assist in tracing circuits and identifying loads? *
 Will provide qualified electrical personnel. Would like Stark Safety Consultants to provide a complete turn key service/proposal.

Will you be able to provide a man lift or scissor lift with an operator to access overhead busways, if needed? *
 Yes No

How many services come in from the electric utility? *

At what voltage? *

What percentage of your electrical distribution panels, breakers, etc. are accurately labeled as to what they feed? *

How many MCCs (motor control centers) do you have? *

What is the approximate number of bucket totals in all MCCs? *

How many overhead bus ducts do you have? *

Estimated number of drops/bus plugs? *

Do you have any equipment that is not accessible due to other obstructions or machines, equipment, etc.? *
 Yes No

If yes, approximately how many? *

Estimate the number of 3-phase panel boards in your facility. *

Does your facility utilize tap boxes (gutters, troughs, etc.) or use line side panel taps to feed multiple 3-phase loads with the same circuit? *
 Yes No Not Sure

Does your facility have any generators on-site for co-generation or power back-up? *
 Yes No Not Sure

What percentage of your facility has exposed ceilings? *

What percentage of your facility has drop ceilings? *

Does your facility have any large panels that require two people for opening? *
 Yes No Not Sure

When did OSHA last visit your facility? *

Was a citation issued at that time? *
 Yes No

Questions or Comments? *