Space Safety and Environmental Checklist.doc

FAA SAFETY AND ENVIRONMENTAL CERTIFICATION CHECKLIST

Building Name:_______________________________________________________________________ Street Address:_________________________________________________________________________ City:_________________________________________, State: ______ Zip Code___________________ Approximate outside dimensions of building:_________________________________________________ Square footage of building___________________, Square footage of proposed space______________ Total number of floors in building_____________, Floors proposed space is on ___________________ Year Building constructed __________________, Year of last major renovation__________________

INSTRUCTIONS: Complete the following information that applies to the building being offered for lease to the Government.

CHECK ALL OF THE FOLLOWING INFORMATION THAT APPLIES:

Security No Provisions Secure Building Alarm System Guard Controlled Entry Other,________________________________________________________ Emergency Illumination:

In Space offered In corridors In Stairwells Building structural support Combustible (Timber, wood, etc.)

Noncumbustible (Concrete, steel, masonry, etc.)

Other types of uses present in the building (check all that apply):

Restaurants Storage Manufacturing Other, describe____________________ Laboratories Retail Industrial ___________________________________ Vertical openings between two or more floor:

Stairs (check one): Open Enclosed with doors Shafts (check one) Open Enclosed with doors;_____________________________________ Other (check one) Open Enclosed with doors;__________________________________________ Sprinklers None Corridors only All but corridors & lobbies Total Building Other, describe locations________________________________________________ Fire fighting capability:

None Fire Extinguishers Standpipes Other,__________________________________________ Fire Alarm:

None Building Alarm (check all that apply): Audible Visual Automatic Fire Dept. Notification Smoke Detectors:

None All Corridors Total Building Other, __________________________________ Wall Interior Finishing in space being offered for lease:

Painted walls of plaster, sheetrock, or masonry Wallpaper or vinyl wall covering Cloth or corkboard Wood paneling Other,___________________________________________

Emergency Egress (Note - attach a sketch of the floor plan that shows the means of egress) Two means of egress from the space offered for lease.

Exit signs for each route.

Some or all space offered is above or below grade level If , so complete the following for applicable stairwells that are a part of the emergency egress routes from above or below grade space offered:

Fire rated construction Stairwell doors that open in direction of egress Discharge Outside or into a protected fire corridor that discharges outside Emergency Lighting in Stairwell Stairwell doors have automatic door closers & latch All stairwells have adequate handrails

Asbestos:

None Nonfriable: Locations________________________________________________________________ Friable: Locations________________________________________________________________________ If asbestos is present, an active asbestos management program is in place.

PCB’s :

None present: locations____________________________________________________________________ Radon:

None Last test under 4.0 picocuries per milliliter (Date tested & results)___________________________ Air Quality:

Air quality in space offered meets all EPA guidelines for clean air.

Air quality in space does not meet EPA guidelines for clean air in the following areas:________________________ Drinking Water:

Drinking water meets all EPA guidelines for drinking water Drinking water does not meet EPA guidelines in the following areas:_______________________________________

Contamination suspected on or in proximity of the site (if yes, describe below):

This information provided by the offeror on this form are materiel facts and representations upon which the Government relies upon for making an award. The Government has the right to require remedy if the information is in anyway misrepresented, or inaccurate. The Owner or Authorized representative certifies that all the features described above are in operating order and properly maintained.

OWNER OR AUTHORIZED REPRESENTATIVE NAME AND ADDRESS:

SIGNATURE:_______________________________________________DATE:____________

2.6.11 Space Safety and Environmental Checklist

April 2012

OMB Control No. 2120-0595

Pg. 1

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