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Business Self-Inspection Form

Steps

1. Business Information This section is complete This section is incomplete
2. Emergency Contact Information This section is complete This section is incomplete
3. Inspection Information This section is complete This section is incomplete
4. Fire Protection This section is complete This section is incomplete
5. Hazardous Materials This section is complete This section is incomplete
6. Acknowledgement This section is complete This section is incomplete

Business Information

Business Self-Inspection Form
If you have questions or would like to speak to one of our inspectors directly about this form, please call us at (970) 453-2474 or email us at inspections@rwbfire.org
Business Name*
Business Owner's First Name*
Business Owner's Last Name*
Business Physical Address*
Unit
City*
State*
Zip Code*
Business Mailing Address*
City*
State*
Zip Code*
Email Address*
Phone Number*
Fax Number
Form Completed By:
First Name*
Last Name*
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Emergency Contact Information

24-hour Emergency Contact #1
First Name*
Last Name*
24-hour Phone Number*
24-hour Emergency Contact #2
First Name*
Last Name*
24-hour Phone Number*
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Inspection Information

Have your locks changed in the past year?
Inspection Questions
Please select an answer to each question from the drop-down menu. All questions require and answer.
Is the building and unit address numbers/letters visible from the street?*
Building address numbers shall be a minimum of 6" tall. Unit numbers shall be affixed to the front and rear doors.
Is there a minimum of 3-foot clearance around the on-site fire department connection?*
This should include trees, brush, flowers, fences, and snow.
Do all exit doors remain unlocked during business hours?*
There shall be a sign above the front door to read "THIS DOOR TO REMAIN UNLOCKED DURING BUSINESS HOURS."
Are the exit doors operable from the inside without the use of a key or special knowledge?*
Double keyed dead-bolts and chains with locks shall not be used.
Are exit signs fully illuminated in the normal and back-up modes?*
Push the test button to determine if the back up power functions properly. Does the sign remain lit with the button pushed?
Do the emergency lighting units work properly?*
Push the test button and hold for 30 seconds. Does the light remain on for the 30 second test?
Are exit aisles, hallways, and stairways clear of obstructions?*
This includes ice and snow during the winter months.
Is there storage in exit corridors, hallways, or under stairs?*
This includes placing trash, boxes, or other items in an egress path.
Are all electrical outlets, switches, and junction boxes covered with proper cover plates?*
Are circuit breakers in the electrical panel labeled to identify what they control?*
Are extension cords in use?*
Extension cords shall not be used in place of permanent wiring. They may be utilized to supply power to a single small appliance such as a fan, radio, or power tool.
Are power strips, with a built-in breaker, plugged directly into the electrical outlet?*
Power strips are required to be plugged directly into an outlet. They can not be plugged into another power strip or an extension cord.
Are portable electric space heaters used?*
If they are being used, they must be plugged directly into an outlet and operated a minimum of 3 feet away from combustibles.
Are combustibles stored in equipment rooms?*
Combustibles shall not be stored in equipment rooms including closets that house hot water heaters and/or furnaces.
Are equipment rooms labeled?*
Labels shall have letters that are at least 1" tall on a contrasting background.
Is storage of combustible items maintained at least 2 feet below the ceiling?*
Heat collects at the ceiling level and combustibles can burst into flames.
Are ceiling tiles fixed in place?*
This allows the ceiling to act as a heat collector for fire protection systems and to prevent the passage of smoke and fire.
Is drywall free of holes that allow smoke and fire to pass to other parts of business?*
A quarter sized hole can fill an adjacent room with smoke in about 5 minutes.
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Fire Protection

Fire Extinguishers
Is there an adequate number of fire extinguishers?*
There should be no more than a 75-foot travel distance to a fire extinguisher. Extinguishers shall be an all purpose ABC type with a minimum rating of 2A-10B:C.
Are fire extinuishers firmly mounted to a stable structure, visible, accessible, and ready for use?*
Extinguishers shall be in a conspicuous location, unobstructed, and at least 4" off the floor.
Do fire extinguishers have a current inspection tag?*
Extinguishers are required to be inspected annually.
Fire Alarm System
If there is a fire alarm system? Has it been inspected within the past 12 months?*
If yes, please attach a copy of the inspection report below.
Fire Alarm Inspection Report
Fire Protection System
If there is a fire sprinkler system? Has it been inspected within the past 12 months?*
If yes, please attach a copy of the inspection report below.
Fire Sprinkler System Report
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Hazardous Materials

Are compressed gas cylinders, such as carbon dioxide, oxygen, acetylene, argon, nitrogen, and nitrous-oxide, secured to a fixed structure or on carts to prevent them from falling?*
If yes, please provide the name(s) of the compressed gas used and quantities on stored below.
Compressed gas information
Do you use or store Hazardous Materials?*
If yes, proved a copy of your Hazardous Materials Inventory Statement (HMIS) identifying the name of the material(s), physical state (solid, liquid, or gas), CAS (Chemical Abstract Service) number, and quantity of each material in a separate attached document below.
HMIS and CAS Information
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Acknowledgement

I acknowledge and agree to the above eligibility requirements and certify that all information provided herein is true and complete to the best of my knowledge and belief. Verification will be provided, if requested.*
1. I acknowledge and agree

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1. Receive an email copy of this form.
Email address

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Business Self-Inspection Form

Steps

Business Information

Emergency Contact Information

Inspection Information

Fire Protection

Hazardous Materials

Acknowledgement

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