Atch 4-_DD_Form_1811.pdf

PRE-AWARD SURVEY OF CONTRACTOR'S/CARRIER'S FACILITIES AND EQUIPMENT

DATE (Yr/Mo/Day)

INSTRUCTIONS: THIS SELF EXPLANATORY FORM IS TO BE COMPLETED IN DUPLICATE FOR EACH WAREHOUSE OR SPECIFIC AREA THEREOF IN WHICH HOUSEHOLD GOODS ARE TO BE STORED. THE ORIGINAL TO BE RETAINED BY THE RESPONSIBLE ACTIVITY, DUPLICATE TO THE

CONTRACTOR/CARRIER.

NAME AND ADDRESS OF FIRM (Include ZIP code)

SCAC

NAME OF OPERATING EXECUTIVE

PHONE (Include AREA CODE.)

BUSINESS: HOME:

ADDRESS OF STORAGE LOCATION (Include ZIP CODE.)

WAREHOUSE NUMBER AREA (Floor, Fire Division, etc.)

WAREHOUSE LICENSE NO. OPERATING AUTHORITY

OPEN FOR BUSINESS (Hours and days of week.)

PICK-UP AND DELIVERY EQUIPMENT

NUMBER OF TRUCKS TYPE OF TRUCKS

FIRE PROTECTION

FIRE CONTENTS RATE (Based upon 80 percent co-insurance per $100 per year.)

DOD FIRE CLASSIFICATION CODE WEIGHT LIMITATIONS (LBS.)

NUMBER OF MILES TO NEAREST FIRE DEPARTMENT:

NEAREST

FIRE

HYDRANT

NUMBER OF FEET FROM BUILDING:

POUNDS OF PRESSURE:

ADEQUATE INADEQUATE

DESCRIBE FIRE PROTECTION SYSTEM

FREQUENCY OF TEST/INSPECTION:

MAINTENANCE CONTRACT WITH

SCALES

TYPE AVAILABLE DISTANCE FROM BUILDING

(MILES)

CERTIFIED YES NO CAPACITY

STORAGE METHODS (Give brief description)

RUGS

UPHOLSTERED FURNITURE

PIANOS

FIREARMS SECURITY

OTHER PROPERTY

HAZARDOUS OPERATIONS (Describe operations in or near building which may be hazardous to stored property.)

TYPE OF PROGRAM FIRM HAS FOR RODENT AND/OR INSECT

CONTROL

CONSTRUCTION OF BUILDING

WALLS

ROOF

FLOOR(S) NUMBER OF FLOORS

BASEMENT

GIVE NARRATIVE DESCRIPTION OF BUILDING (Use reverse for diagram of storage area, if desired.)

TOTAL STORAGE SPACE (Square feet.)

OWNERSHIP OF BUILDING

OWNED LEASED (If leased complete the following and attach a copy of lease.)

LEASE EXPIRES PHONE

NAME AND ADDRESS OF OWNER (Include ZIP CODE.)

(CHECK "YES" OR "NO" AS APPROPRIATE)

CATEGORY OF BUSINESS

YES NO

MINORITY BUSINESS ENTERPRISE

SMALL BUSINESS CONCERN

FIRE EXTINGUISHERS

IS THERE A SUFFICIENT NUMBER?

ARE THEY THE PROPER TYPE?

ARE THEY REGULARLY INSPECTED AND MAINTAINED?

FIRE FIGHTING PLAN

IS A FIRE FIGHTING PLAN POSTED?

ARE ALL EMPLOYEES FAMILIAR WITH THE PLAN?

CLIMATE PROTECTION

IS BUILDING PROTECTED FROM EXTREME COLD?

IS BUILDING PROTECTED FROM EXTREME HEAT?

IS BUILDING PROTECTED FROM EXTREME HUMIDITY?

IS VENTILATION ADEQUATE?

ARE UTILITIES AND OTHER SYSTEMS SERVICED

AT LEAST ANNUALLY?

MATERIAL HANDLING EQUIPMENT

IS THE EQUIPMENT PROPERLY MAINTAINED?

SMOKING

ARE "NO SMOKING" SIGNS POSTED?

IS "NO SMOKING" POLICY ENFORCED?

IS BUILDING AND OUTSIDE AREA NEATLY KEPT AND

FREE FROM HAZARDOUS MATERIALS?

ARE COMBUSTIBLE WASTE MATERIALS STORED AT

LEAST 50 FEET AWAY FROM FACILITY?

HOUSEKEEPING

SECURITY

IS BUILDING EQUIPPED WITH BURGLAR ALARM?

IS A WATCHMAN ON DUTY?

DO POLICE PATROL THE AREA?

ARE DOORS AND WINDOWS ADEQUATELY PROTECTED?

IS SEPARATION FROM JOINT OPERATION OCCUPANT,

IF ANY, ADEQUATE? (See "Hazardous Operation" below.)

FLOODING

IS BUILDING SUBJECT TO FLOODING?

I certify that I have inspected the above described facility and find that, to the best of my knowledge, the information herein is true and correct.

SIGNATURE (Inspecting Officer) DATE (Yr/Mo/Day)

I certify that the conditions and policies of this warehouse are, to the best of my knowledge, as indicated above.

SIGNATURE (Warehouseman) DATE (Yr/Mo/Day)

I certify that I have reviewed this survey and REJECT the facility for storage of household goods.

SIGNATURE (Contracting Officer/Trans. Officer) DATE (Yr/Mo/Day)APPROVE, DD Form 1811, JUN 79 EDITION 1 AUG 73 IS OBSOLETE. Adobe Professional 7.0