Hamilton County LEPC
Facility Information Survey

(Please correctly type your responses in the spaces provided.)

1.
Facility:
Address:
Facility Coordinator:
Title/Position
Telephone (H):
Telephone (W):
Telephone (24hr):

Facility Mailing address, if different from that listed above:

2.
Hazardous Chemicals On-Site
List chemicals (or reference current Tier II form) and the Average Daily Quantity (in Pounds)

3.

Site of Evacuation Area (Note: The area involved is for worst case scenario):

4.

Warning and Notification Procedures to be Utilized by Facility:

Fixed Siren:

Telephone:

Radio:

Alarm:

Detection Devices:

Brief Explanation of Warning and External Notification Procedures:

5.

Company Specific Information
a. Do you have a plant layout map designating chemical storage locations, perimeter gates, sewer drains, etc.?
YES     NO     If YES, please provide a copy to the Hamilton County LEPC by mail.
b. Do you have an on-site emergency response team?
YES     NO     If YES, where: 
c. Do you have haz-mat response materials stored on-site?
YES     NO     If YES, where: 
If stored Off-Site, where: 
d. Who (title or position) at your plant would meet the fire department response team after normal working hours?

1st Shift

 Title or Position:
Is this person(s) familiar with the plant layout, storage facilities, keys to storage locations, etc.?
YES     NO    

2nd Shift

 Title or Position:
Is this person(s) familiar with the plant layout, storage facilities, keys to storage locations, etc.?
YES     NO    

3rd Shift

 Title or Position:
Is this person(s) familiar with the plant layout, storage facilities, keys to storage locations, etc.?
YES     NO    
e. Fire Hydrants?  YES     NO       Water Monitors?  YES     NO   
If YES, please identify on Plant Layout Map.
f. Communications: 
YES     NO     If YES, describe:
g. Are there any drain valve systems that should be closed to prevent water run-off?
YES     NO     If YES, please identify on Plant Layout Map and describe systems below:
h. Is any equipment time activated that will require controller shut down (Lock-out/Tag-out) prior to responding inside a particular building?
YES     NO     If YES, where: 
i. List primary cleanup company that would respond to this site in the event their services are required:
Name & Phone Number: 
j. Worst Case Scenario: What is the worst accident that could happen at this plant considering the largest possible release of the most hazardous chemical on site?
k. What public or private facilities, located within 1/2 mile of your location, could be endangered if the worst case accident actually occurs? (Name and Location):
l. Are there any public utilities within 1/2 mile of your facility?
YES     NO     If YES, where: 
m. Give the maximum number of employees on site:  

1st Shift

2nd Shift

3rd Shift
n. Is your facility primarily a shipper of chemicals?     YES     NO     
o. What is your facility's fire district?   
p. List the home addresses of your emergency contact personnel:
(1)
Name:      Email:
Home Phone: 
Cell Phone: 
Pager: 
Street:
City:      State:     Zip: 
(2)
Name:      Email:
Home Phone: 
Cell Phone: 
Pager: 
Street:
City:      State:     Zip: 
q. Give brief directions that describe the location of your facility:
r. Name the cross street closest to your facility:
For further information please contact Wayne Stuntz at (423) 495-1743.  Please provide a copy of your facilities emergency response plan to the Hamilton County Local Emergency Planning Committee (LEPC), 317 Oak Street, Suite 302, Chattanooga, TN 37403.