Customer Name Date. Site Address. Contact #1 Position. Office Phone Mobile Phone. Address. Contact #2 Position. Office Phone Mobile Phone

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1 Pre-Assessment Form Please fill out this form at least 1 week prior to the on-site audit with NCCETC staff and engineers. It is critical that this information be as accurate as possible, as it may be used to calculate energy usage and subsequent recommendations. The form may be scanned and ed to kjconley@ncsu.edu or faxed to: Customer Contact Information Customer Name Date Site Address Contact #1 Position Office Phone Mobile Phone Address Contact #2 Position Office Phone Mobile Phone Address Motivation/Goals/Expectations/Needs for Seeking Energy Efficiency Services Desired Start Date Site Data Building Square Footage (ft 2 ) Number of Floors Age of Building (Years) Date of Last Major Renovation Purpose of Building Clean Power & Industrial Efficiency 1

2 Operating Schedule and Method of Control Building Data This building is owned. This building is leased. If the building is leased: When is the lease up for renewal (date/year)? How long does the lease contract last (years)? Do you anticipate a facility expansion or new construction project within the next 3-5 years? Floor Name or Number Activity Type Floor Square Footage or % of Building Area Number of Occupants Daily Operational Hours (e.g., M-F 8-6, Sa 10-4) Clean Power & Industrial Efficiency 2

3 Product Description S.I.C. Code Annual Sales Number of Employees Annual Production Process Description Example-Generic Box Air Filter Assembly - Paper Pleated and cut -> Molds prepared with wax -> Screens placed onto molds -> Pleated paper added -> Polyurethane mix glued -> Filter body assembled -> Filter heated -> Product cooled -> Packed for shipping Clean Power & Industrial Efficiency 3

4 Process Equipment Equipment Name Technical Specifications Quantity Purpose/Description Clean Power & Industrial Efficiency 4

5 Utility Data Are you concerned about the impact of current or future energy costs on your business? Are you concerned about power reliability? Is there a substantial financial impact to your business if the power goes out for 1 hour? For 5 minutes? History of blackouts? Do you have access to on-site or nearby low cost fuel resources (i.e. landfill gas, farm manure, food processing waste, etc.)? Please check all that apply: The organization receives monthly bills based on accurate meter readings. Meters are read regularly by on-site staff. Bills are compared to monthly meter readings on a regular basis. A Building Automation System or Energy Management Control System is in place and used to track utility data regularly. The building is sub-metered. The building has automated 15-minute interval or SMART meters. If there are multiple meters at a site, include the account/meter numbers that pertain to each area. Please attach electricity, water, natural gas, and other fuel bill data for a 12 month period. Clean Power & Industrial Efficiency 5

6 Please select what is currently installed at the building: Energy-efficient lighting Lighting controls Insulation HVAC system Upgrades Solar hot water Solar PV panels (electric) Wind turbines Micro-hydro Geothermal Green/living roof External shading Composting Anaerobic digestion Low-flush toilets Low-flow faucets Rainwater harvesting Porous pavement Segregated recycling Co-mingled recycling Sustainable procurement Gray-water systems Other: Please specify What is your payback threshold for energy efficient capital improvements? Lighting Application/Area Number of Fixtures Fixture Type Lamp Type Lamps per Fixture Clean Power & Industrial Efficiency 6

7 Plug Loads Equipment Type Manufacturer Model or Size Total Number Hours of Use per Day Days of Use per Year How is Equipment Controlled? Description, Observations, or Notes HVAC Do you have thermal loads throughout most of the year (incl. steam, hot water, chilled water, hot air, etc.)? Does your facility have an existing central heating or cooling plant? Do you expect to replace, upgrade, or retrofit central plant equipment within the next 3-5 years? Clean Power & Industrial Efficiency 7

8 Split, Rooftop, Window AC Units, Chillers, and Heat Pumps ID Manufacturer Size (Cooling & Heating) Unit Model Number Serial number Location Clean Power & Industrial Efficiency 8

9 Pumps ID Purpose HP GPM Δ Ft head AHUs ID Manufacturer Capacity CFM Unit No. Serial No. Clean Power & Industrial Efficiency 9

10 Who is responsible for managing and trouble-shooting the control system? Are there any recurring or major occupant complaints about being too hot, too cold, etc.? Are any capital improvement projects planned? If so, what are they and how will they affect the energy use of the building? Air Compressors ID Company Type Model No. Serial No. Rated/Max Air Pressure (PSIG) Capacity (ACFM) Motor (HP/kW) Operating Pressure, psi Temperature, ᵒF Load Unload Pressure, psi Modulation (Y/N) Clean Power & Industrial Efficiency 10

11 Compressed Air Dryers ID Company System Model Serial No. Capacity (SCFM*) Refrigerant Location Boiler No. Boiler Make Year Model No. Type Boiler Horsepower, HP Max Operating Pressure, psig Operating Pressure, psig Primary Fuel Type of Firing Economizer Boilers Clean Power & Industrial Efficiency 11

12 Please specify where you feel there is room for improvement in energy efficiency Might your company be interested in learning about Combined Heat & Power or Renewable Technologies? Please check off the information that is being provided to NCCETC: Copy of utility bills Copies of previous energy audit reports Copies of action plans or capital improvement plans Copies of any M&V plans Copies of an O&M contract (if outsourced) Electrical, mechanical and civil engineering drawings I, (insert name), do hereby consent to disclosing my facility information to NC Clean Energy Technology Center Energy Efficiency Program with NC State University for the purpose of administering the requested service. Clean Power & Industrial Efficiency 12