Pre assessment Form by zu9Iq1

VIEWS: 26 PAGES: 16

									     Attn: Energy Services



 Start                       Fort Collins Utilities Business Efficiency
 Customer Info               Pre-assessment Form - Start
 Service History             Welcome!
 Assessor Checklist           Fort Collins Utilities offers businesses free technical support to analyze existing systems and equipment, review current operation
                              opportunities to reduce operating costs and environmental impacts.

     Navigate the            Assessment / Form Overview
     form using
                               Eligibility Requirements
     the above buttons.
                                    All participants must be current Fort Collins Utilities business customers receiving electric and/or water service.
                               Process Summary
                                    1. Pre-assessment Form completed by participant.
                                     2. Completed form submitted to Utilities by participant (using fcgov.com/assessments).
                                     3. Assessment scheduled by Utilities (generally for 2-3 weeks from pre-assessment form submittal) .
                                     3. Assessment performed by Utilities with the participant (generally 1.5 to 2.5 hours long) .
                                         • Includes a sit-down discussion using the Assessor Checklist and then a targeted walkthrough of the building.
                                     4. Assessment report completed and sent to participant within 30 days of assessment.
                                     5. Optional conference call or meeting scheduled to review the assessment report and answer any questions.
                               Pre-assessment Form Summary
                                   Customer Info - Enter general details for the business & building. (helps focus the assessment and reduce the time required o
                                   Service History - Select current service providers and enter historical use/cost data (optional but will increase the level of ana
                                   Assessor Checklist - View a list of topics covered during the assessment (no data entry/input required).
                               Using the From
                                     • Green shaded boxes (cells) indicate inputs.              Example
                                     • Some inputs utilize checkboxes, many of which allow for multiple selections. Example:                              Option One
                                       Left-click on an empty checkbox to select it (this will add a checkmark in the box). Left-click again to remove the checkma
                               Confidentiality
                                  All information gathered through the assessment will remain confidential and will only be provided to the participant unless s
                                  by the participant.
                             General Questions, Comments, Notes, etc.




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nt operations, and identify




e required on-site),
 level of analysis) .




 tion One               Option Two
he checkmark.


 ant unless specifically authorized




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Start                       Fort Collins Utilities Business Efficiency
Customer Info               Pre-assessment Form - Customer Information
Service History             Overview
Assessor Checklist            Complete these sections as thoroughly as possible. Gathered information will help focus the assessment and may reduce the time


                            Business Summary

                              Business Name                                                               Desired Outcomes
                                  Full Legal Name:                                                             1 Environmental Stewardship

                                  Common Name (if applicable):                                                 2 Long-Term Investments

                              Mailing Address                                                                  3 Short Payback / ROI Projects

                                  Street:                                         State:                          Other:

                                  City:                                   Zip Code:                       Source of Referral

                              Primary Business Contact                                                         1 Assessment / Audit                    11

                                  Name:                                                                        2 Bill Insert                           12

                                  Phone:                                                                       3 City Representative                   13

                                  E-mail:                                                                      4 Climate Wise                          14

                              Primary Building Contact (with knowledge of building systems)                    5 Contractor / Consultant               15

                                      Same as business contact                                                 6 E-mail                                16

                                  Name:                                                                        7 Event                                 17

                                  Phone:                                                                       8 Newsletter                            18

                                  E-mail:                                                                      9 Newspaper Ad

                              Affiliations                                                                    10 Outdoor Media

                                      City of Fort Collins Climate Wise partner        ( Web link )               Other:

                            Building Summary

                              Site Address                                                                Building Type(s)
                                      Same as mailing address                                                  1 Education             6 Manufacturing

                                  Street:                                         State: CO                    2 Food Sales            7 Mercantile

                                  City:      Fort Collins                 Zip Code:                            3 Food Service          8 Office

                              Background Details                                                               4 Health Care           9 Public Assembly

                                  Name / Designation:                                                          5 Lodging            10 Public Safety

                                  Date Built:                                                                     Other:

                                  Date Occupied:                                                          Business' Relation(s) to the Building
                                  Square Footage:                                                              1 Building Owner            2 Property Manager

                                  Average Occupant #:                                                             Other:

                                      Previous audits, assessments, or studies performed                  Building Owner
                                      Previous remodels or additions completed                                Name:

                                      Upcoming building changes / upgrades planned                            E-mail:

                              Hours of Operation                                                          Property Manager

                                                                                                                                        Page 3.3
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Start                       Fort Collins Utilities Business Efficiency
Customer Info               Pre-assessment Form - Customer Information
Service History                 Weekday:                                 Name:

                                Weekend:                                 E-mail:




                                                                                   Page 3.4
     Attn: Energy Services

 Start                       Fort Collins Utilities Business Efficiency
 Customer Info               Pre-assessment Form - Customer Information
 Service History             Building Systems

                               Existing Systems and Equipment
                                    1 Air Compressors                       6 Chillers                             11 Furnaces                                16 Space Heat

                                    2 Air Conditioners                      7 Computers                            12 Ice Machines                            17 Sprinklers /

                                    3 Baseboard Heaters                     8 Coolers / Freezers                   13 Kitchen Equipment                       18 Unit Heate

                                    4 Boilers                               9 Data Center                          14 Rooftop Units (heat / cool)             19 Vending M

                                    5 Building Automation System           10 Evaporative Coolers                  15 Showers                                 20 Water Hea

                                       Other:

                               Previous Energy Efficiency Improvements
                                    1 Air Compressors (motors, etc.)        5 Envelope (air sealing, insul.)        9 Interior / Exterior Lighting            13 Temperatu

                                    2 Computer Power Management             6 Freezers / Coolers (motors, etc.)    10 Lighting Controls                       14 Water Hea

                                    3 Economizers / Evap Cooling            7 HVAC (ACs, furnaces, etc.)           11 Programmable Thermostats                15 Windows (

                                    4 Employee Education                    8 HVAC Preventative Maintenance               Renewable Systems (solar, etc.)

                                       Other:

                               Previous Water Conservation Improvements
                                    1 Irrigation Controls                   3 Laundry Equipment                     5 Low-Flow Faucet Aerators                 7 Pools (cove

                                    2 Irrigation Heads/Nozzles              4 Leak Inspection                       6 Low-Flow Toilets / Urinals               8 Raw / Gray

                                       Other:

 The remaining               Solid Waste                                                                                                                            (Climate
 sections should
 only be completed             Solid Waste Service Provider(s)                                                     Solid Waste Bins/Dumpsters
 by Climate Wise
 Partners.
                                    1 Gallegos Sanitation          3 Ram Waste                 4 None                     Quantity & Size:

    (Web Link to details)           2 Waste Management                 Other:                                             Pick-up Frequency:

                               Recycling Service Provider(s)                                                       Recycling Bins/Dumpsters
                                    1 Gallegos Sanitation          3 Self Drop-off             4 None                     Quantity & Size:

                                    2 Waste Management                 Other:                                             Pick-up Frequency:

                               Materials Recycled
                                    1 Paper      3 Glass       5 Electronics    7 Organics (food, coffee grounds, etc.)        9 Hazardous Materials (light bulbs, paint, bat

                                    2 Plastic    4 Metal       6 Yard-waste     8 Wood (pallets, etc.)                             Other:

                             Transportation                                                                                                                         (Climate

                               Employee Transportation Methods                                                     Transportation Details
                                    1 Carpool                  3 Walk                5 Telework                               Alternative transit options realistic for emp

                                    2 Vanpool                  4 Bicycle             6 Public Transit                         Alternative transit supported (bicycle parkin

                                       Other:                                                                                 Alternative transit incentivized ($/mile, rese

                                                                                                                              Business vehicles operated/maintained

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uce the time required on-site.
                 Remove Cell Shading




       4 Reduce Utility Costs

       5 Code Requirement

       6 Building Certification




      Postcard

      Program Participant

      Radio Ad

      Retailer / Vendor

      Television Ad

      Utilities' Website

      Website (other)

      Word of Mouth




            11 Religious Worship

            12 Residential

            13 Service

            14 Storage




y Manager             3 Tenant




                                         Page 3.6
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  Space Heaters

  Sprinklers / Irrigation

  Unit Heaters

  Vending Machines

  Water Heaters




  Temperature Setbacks (unocc.)

  Water Heaters (setpoints, etc.)

  Windows (shades, films, etc.)




  Pools (covers, filters, etc.)

  Raw / Gray Water Irrigation



    (Climate Wise Partners Only)




bs, paint, batteries, etc.)



    (Climate Wise Partners Only)



stic for employees

bicycle parking, showers)

($/mile, reserved parking)

 ntained




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 Start                        Fort Collins Utilities Business Efficiency
 Customer Info                Pre-assessment Form - Utility Service History
 Service History              Overview
 Assessor Checklist             Historical service data can illustrate current facility operations and may indicate specific conservation opportunities.
                                This data is not required but will improve the level of analysis in the final report.

                              Utility Service History
 This data is optional but
 will increase the level of     Electric Service Provider(s)                                                            Electricity                  Water
 analysis performed.
                                         Fort Collins Utilities        Xcel Energy                                  Usage       Cost ($)     Usage         Cost ($)

                                         Poudre Valley REA             None                      2012 - Sep

                                         Other:                                                  2012 - Aug

                                                                                                 2012 - Jul
                                Water Service Provider(s)
                                         Fort Collins Utilities        ELCO                      2012 - Jun

                                         Fort Collins-Loveland         None                      2012 - May

                                         Other:                                                  2012 - Apr

                                                                                                 2012 - Mar
                                Natural Gas Service Provider(s)
                                         Xcel Energy                   Transport Gas             2012 - Feb

                                         Seminole Energy               None                      2012 - Jan

                                         Other:                                                  2011 - Dec

                                                                                                 2011 - Nov
                                Account Numbers (Fort Collins Utilities only - Optional)
                                     Electric:                                                   2011 - Oct

                                                                                                 2011 - Sep

                                     Water:                                                      2011 - Aug

                                                                                                 2011 - Jul

                                                                                                 2011 - Jun

                                                                                                 2011 - May

                                                                                                 2011 - Apr

                                                                                                 2011 - Mar

                                                                                                 2011 - Feb

                                                                                                 2011 - Jan

                                                                                                 2010 - Dec

                                                                                                 2010 - Nov

                                                                                                 2010 - Oct

                                                                                                     Enter Units:


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            Remove Cell Shading



              Natural Gas

Cost ($)   Usage       Cost ($)




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Start                       Fort Collins Utilities Business Efficiency
Customer Info               Pre-assessment Form - Assessor Checklist
Service History             Overview
Assessor Checklist            Assessors use the checklist to guide the assessment. In general, most assessments start with a sit-down discussion using the chec
                              with a targeted walk-through of the building.

The checklist is            Introduction
for informational
purposes only and                 Contact Confirmation
does not require
                                  Agenda Review (site visit, report, post assessment)
any action prior to
the assessment.                   Confidentiality Statement (report, access/picture restrictions)

                                  Desired Outcomes

                            Facility Background

                                  Participant's Relation to Facility

                                  Previous Analysis (assessments, studies)

                                  Building(s)

                                             Date Built

                            Construction/Orientation

                                       Square Footage

                                             Type / Use

                                             Occupants

                                              Weekday
                                     Hours
                                              Weekend

                                     Previous Remodels

                                      Planned Changes

                            Energy

                                  Historical Energy Use

                                  Previous Improvements

                                  Envelope (air sealing, insulation, roof material, window shading/film)

                                  Space Heating & Cooling (systems, controls, setpoints, setbacks, comfort, pipe/duct insulation)

                                  Lighting (interior & exterior types, controls, levels)

                                  Equipment (computers, vending, kitchen, space heaters, phantoms)

                                  Refrigeration (controls, motors, covers, anti-sweat heaters)

                                  Compressed Air (capacity, pressure, controls, uses, maintenance)

                                  Renewable Systems (solar, wind)




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Start                       Fort Collins Utilities Business Efficiency
Customer Info               Pre-assessment Form - Assessor Checklist
Service History




                            Water

                                    Historical Water Use

                                    Previous Improvements

                                    Equipment (dishwashers, clothes washers, ice machines, pools, leak detection)

                                    Fixtures

                                       Faucets

                                        Toilets

                                        Urinals

                                      Showers

                                    Water Heating (systems, pumps, controls, setpoints, pipe insulation)

                                    Landscape Irrigation (systems, controls, zones, schedules, maintenance)




                            Solid Waste                                                                                                                  (Climate

                                    Bins / Dumpsters (quantity, pick-up frequency)

                                    Materials Recycled (paper, plastic, glass, metal, electronics)

                                    Hazardous Materials (proper disposal, batteries, light bulbs, paints)

                                    Composting (sufficient quantity? - coffee grounds, paper towels, etc. through a service or internally)

                                    Employee Education & Awareness (standard bins, signage, trash can minimization)

                                    Products with Recycled Content (paper, pens)

                                    Source Reduction (electronic billing, PDF printing, junk mail reduction, policies)




                            Transportation                                                                                                               (Climate

                                    Employee Transit (realistic? - carpool, vanpool, telework)

                                    Alternative Transit Support (bicycle parking, showers)

                                    Alternative Transit Incentives ($/mile, reserved parking)

                                    Business Vehicles Operated/Maintained

                                    Employee Education / Awareness


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     Attn: Energy Services

 Start                       Fort Collins Utilities Business Efficiency
 Customer Info               Pre-assessment Form - Assessor Checklist
 Service History




version 1.12 (12-04-24)




                                                                          Page 1.13
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ng the checklist and conclude
            Remove Customer Info




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(Climate Wise Partners Only)




(Climate Wise Partners Only)




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