Common Place Data Information – 2009

Town of Pittsfield,

NH  Fire Department and Ambulance Service

* = required information

*Business/Organization Name:

*Business Address:

*Business Phone:

Business Fax:

Business Owner:

Property Owner Name, Address and Phone:

# of Employees:

Hours of operation:

Number of Shifts:

Contact Information in case of emergency: Please list at least 2 names with phone numbers

1.)

                                    Key Holder ? Yes No       

2.)

                                    Key Holder ? Yes No     

3.)

                                    Key Holder ? Yes No     

Please list any special hazards that may be unique to this location: (Examples are floor to ceiling storage, high temperature manufacturing, large quantity flammability storage)

Do you have or need to maintain Material Safety Data Sheets on file?  ? Yes No

Location of MSDS:

Do you have a Fire Alarm System?  ? Yes No

If so, location of control panel:

Name and phone number of monitoring company:

Do you have a Sprinkler Alarm System? ? Yes No

If so, fire connection and sprinkler room location

Do you have a Knox-Box Rapid Entry System? ? Yes No

If so, location of Knox-Box:

Are there currently any employees who may have difficulty evacuating the building in the event of an emergency?  ? Yes No

If yes, please provide an approximate location of the individual’s work area:

Comments:

Your FAX #:

To prevent Spam, please enter sum of 9+9  ? 8 12 16 18

Then press Submit