Energy Use Self Assessment
This self audit will create a basic inventory and assessment of the major energy-consuming equipment in your facility. Focus on Energy can assist you in developing energy efficient practices or research the installation of new energy efficient equipment. Please choose the appropriate answer or fill in the blanks.
CUSTOMER INFORMATION:
Company name: Parent Company: (if different from above) Address: City / State / Zip: Building contact name: E-mail: Contact phone: Fax: Building -check one: Owned Leased Required utility information: Electric Utility: ______________________________________________ Electric Account#: ________________________________ Utility Rep Name: ____________________________________ Required utility information: Natural Gas Utility: ______________________________________________________ Gas Account#: ___________________________________ Utility Rep Name: ____________________________________ BUILDING INFORMATION: Building Use (check all that apply): Hotel/Motel Office Retail Warehouse Manufacturing Other:________________ Typical Operating Hours Per Day (indicate am/pm): Mon: ____ to _____ Tue: ____ to _____ Wed: ____ to _____ Thr: ____ to _____ Fri: ____ to ____ Sat: ___ to ____ Sun: ____ to ____ Age of Bldg:_______________ Total Sq.Footage:___________ (do not include basement unless occupied) # of stories/floors:___________ Exterior Description: ____________________________ Windows: Newer, insulating glass Functional Leaky/drafty Qty:_____________ Size:___________(total sq/ft.) Doors: Newer, insulating glass Functional Leaky/drafty Qty:_____________ Size:___________(total sq/ft.) Is there insulation on/in the attic or ceiling nearest the roof? Yes No If possible, describe composition, condition & thickness: Any plans for upgrading or expanding this facility? No Yes Briefly describe plans and date:_______________________ _________________________________________________________________________________________________ Please mail form to: Energy Savers-Small Commercial ♦ 9420 Reseda Blvd ♦ Northridge , CA 91324
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HEATING, VENTILATING AND AIR CONDITIONING: Please check applicable types of equipment in the building and if available give additional information: TYPE Qty. MAKE MODEL SIZE BTU/H OR KW AGE/YEAR Boiler Forced Air Furnace Roof top unit Split System PTAC/PTHP Chiller Heat Pump Cooling tower Electric baseboard Other:___________ Who maintains equipment? Staff Member Outside Contractor Contact Name:________________________________ Phone #: Describe make up air / ventilation systems / exhaust fans that supply & exhaust building air: Temperature Control: (check all that apply) Bldg Automation System Standard Thermostats(s) Programmable Thermostat(s) Temperature settings during occupied hours: Winter_______°F / Summer_______°F Temperature adjusted during occupied hours? Yes No WATER HEATING: Please check applicable types of equipment in the building and if available give additional information: TYPE MAKE MODEL Storage Tank Size (gallons) Temperature set to °F AGE/YEAR Natural gas water heater Electric water heater Boiler w/ indirect water heater Other:__________ Does facility have showers? No Yes Approximately how many?____________________ Energy Use Self Assessment Please mail form to: Energy Savers-Small Commercial ♦ 9420 Reseda Blvd ♦ Northridge , CA 91324
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LIGHTING: Description of Lighting Fixture Quantity of Fixture Type of Fixture Controlled by Exit Signs Incandescent Fluorescent LED Switch Timer Sensor Incandescent Lights Switch Timer Sensor 4ft. Fluorescent Lights with 1 or 2 lamp T-12 T-8 Switch Timer Sensor 8ft. Fluorescent Lights with 3 or 4 lamp T-12 T-8 Switch Timer Sensor LAUNDRY / COOKING EQUIPMENT: Laundry # of Washers:____________ # of Dryers:______________ Average Loads per day:________________ Cooking # of Ovens:____________ # of Refrigerators:___________ # of Freezers:___________________ VENDING / ICE MACHINES: # of Snack Machines:___________________ # of Cold Beverage Machines:_________________ # of Ice Machines:___________ Air Cooled Water Cooled Make:____________________ Model:___________________ SWIMMING / WATER FACILITIES: Pool Type Pool Heater Information TYPE MAKE MODEL Efficiency BTU/H Rating AGE/YEAR Lap Pool Activity Pool Whirlpool Children’s Pool Other:____________ Using heat recovery from a dehumidifier to heat pool water? Yes No Don’t know OTHER: Do you have numerous motor, pumps and pools/vats in the building? Yes No Briefly describe any other special equipment required for your operations:
Energy Use Self Assessment
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