COLLETON COUNTY FIRE-RESCUE
Pre – Incident Survey
Completed By: ______Date: ______
PAGES 1-3 MUST BE COMPLETED
COMPANY INFORMATION:
NAME: ______
PHYSICAL ADDRESS: ______
MAILING ADDRESS: ______
PHONE #: ______FAX #: ______
AFTER HOURS PHONE #: ______
OWNER INFORMATION:
OWNER NAME: ______
HOME ADDRESS: ______
PHONE #: ______OR ______
FIXED PROPERTY USE:
WHAT TYPE OF BUSINESS IS THE PROPERTY USED FOR? ______
IF INDUSTRIAL, WHAT IS THE PRODUCT? ______
FIRE ALARM SYSTEM: YES / NO CO. NAME______
DETECTORS? YES / NO WHAT TYPE? Smoke, Heat, or combination
EXTINGUISHING SYSTEM: YES / NO NO. OF STORIES: _____
ELECTRIC CO: ______LP CO:______
2
FIRE FLOW: (check one for each)
CONSTRUCTION FACTOR:OCCUPANCY FACTOR:
FRAME_____COMBUSTIBLE_____
JOISTED MASONARY_____LIMITED COMB_____
MASONARY/NON-COMB _____NON-COMB_____
MODIFIED/FIRE-RESIST_____FREE-BURNING_____
MULTI FORMS_____RAPID BURNING_____
MULTI FORMS_____
ROOF COVERING ______
SQUARE FOOT OF BUILDING______(length X width)
EXPOSURES? YES / NO
CONSTRUCTION OF EXPOSURE: ______
DISTANCE FROM BUILDING: _____FT
HEIGHT: ______FT LENGTH: ______FT WIDTH: ______FT
HYDRANT INFORMATION: (at least 3)
LOCATION OR NUMBER: ______/______/______
DISTANCE FROM BUILDING: ______/______/______FT
INSURANCE COMPANY:
LIST: ______
ANY CHEMICALS LOCATED ON THE PROPERTY?
YES______NO______IF YES, GO TO PAGE 4
STORAGE TANKS (CHEMICALS OR FUEL)?
YES______NO______IF YES, GO TO PAGE 5
3
CONTACT INFORMATION: (at least 2 contacts)
NAME: ______
POSITION: ______
HOME ADDRESS: ______
PHONE #: ______OR ______
KEYHOLDER: YES / NO
NAME: ______
POSITION: ______
HOME ADDRESS: ______
PHONE #: ______OR ______
KEYHOLDER: YES / NO
NAME: ______
POSITION: ______
HOME ADDRESS: ______
PHONE #: ______OR ______
KEYHOLDER: YES / NO
4
List each chemical, with information unless a MSDS Sheet is attached
CHEMICAL NAME:______MAX INVENTORY: ______
AVERAGE INVENTORY: ______
DAYS ON SITE: ______
STORAGE TYPE: ABOVE GROUND OR BELOW ______
STORAGE PRESSURE: ______
STORAGE TEMPERATURE: ______
CHEMICAL NAME:______MAX INVENTORY: ______
AVERAGE INVENTORY: ______
DAYS ON SITE: ______
STORAGE TYPE: ABOVE GROUND OR BELOW ______
STORAGE PRESSURE: ______
STORAGE TEMPERATURE: ______
CHEMICAL NAME:______MAX INVENTORY: ______
AVERAGE INVENTORY: ______
DAYS ON SITE: ______
STORAGE TYPE: ABOVE GROUND OR BELOW ______
STORAGE PRESSURE: ______
STORAGE TEMPERATURE: ______
CHEMICAL NAME:______MAX INVENTORY: ______
AVERAGE INVENTORY: ______
DAYS ON SITE: ______
STORAGE TYPE: ABOVE GROUND OR BELOW ______
STORAGE PRESSURE: ______
STORAGE TEMPERATURE: ______
Continue on back if necessary
5
STORAGE TANKS: needed for each tank
CONTENTS: ______
TANK DESCRIPTION: ______
CAPACITY: ______
STATE REGISTRATION/TANK ID #: ______
CONSTRUCTION: ______
POSITION: (circle) HORIZONTAL / VERTICAL
LOCATION: (circle) ABOVE GROUND / BELOW
STATUS: (circle) INSERVICE / OUT-OF-SERVICE
PIPING: (circle) ABOVE GROUND / BELOW / BOTH
PIPE CONSTRUCTION: ______
TANK MANUFACTURER: ______
DATE BUILT: ______DATE INSTALLED: ______
DATE STOPPED USE: ______
COMMENTS ON TANK: USE BACK OF PAGE
CONTENTS: ______
TANK DESCRIPTION: ______
CAPACITY: ______
STATE REGISTRATION/TANK ID #: ______
CONSTRUCTION: ______
POSITION: (circle) HORIZONTAL / VERTICAL
LOCATION: (circle) ABOVE GROUND / BELOW
STATUS: (circle) INSERVICE / OUT-OF-SERVICE
PIPING: (circle) ABOVE GROUND / BELOW / BOTH
PIPE CONSTRUCTION: ______
TANK MANUFACTURER: ______
DATE BUILT: ______DATE INSTALLED: ______
DATE STOPPED USE: ______
COMMENTS ON TANK: USE BACK OF PAGE
USE BACK OF PAGE IF MORE SPACE IS NEEDED