LSU-IAC Pre-Assessment Form

LSU-IAC Pre-Assessment Form

Please complete this form and press submit at the bottom of the page when complete. Any additional documentation can be sent to chaowang@lsu.edu
Section 1: Company Information
Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Person *
Title/Position *
Phone *
E-mail *
Principal Products *
SIC Code *
NAICS Code
Section 2: General Information

*Please provide information only for the site being assessed.*
Annual Sales ($) *
Annual Production (pieces, parts, pounds, gallons, etc) *
Number of Employees *
Total Plant Area (ft2) *
Number of Buildings *

Building Details *

	Area	Size or Square Feet	Age	Use
Building 1
Building 2
Building 3
Building 4
Building 5

Briefly describe operating process.

Shift Structure *

	Shift Start- Shift End	Days of the Weeks	Number of Employees
1st Shift
2nd Shift
3rd Shift
Office
Others

Please note any special shutdowns, overtimes, different operating hours in different areas of the plant. This information will affect the operating cost calculation.
Contracted Maintenance? (ex. boilers, compressors) *

Yes No Do not know
If yes, please note contractor company and how often:
Do you have a formal startup procedure?

Yes No Do not know
Labor plus overhead rate for production personnel:
Section 3: Utility Information
Electricity
Number of electricity meters
Do you correct for power factor? *

Yes No Do not know
Electricity Delivery Company
Electricity Supplier
Electricity Approximate Annual Cost ($)? (Optional)
Do you generate your own power?

Yes No Do not know
Natural Gas
Natural Gas Delivery Company
Natural Gas Supplier
Natural Gas Approximate Annual Cost ($)? (Optional)
Fuel / Oil
Type of Oil
Size of Tank
Delivery Schedule
Supplier
Approximate Fuel/Oil Annual Cost (S)? (optional)
Please list any other fuels or specialty gases, ex. coal, propane, CO2, Nitrogen, etc.
Water
Water Cost per year
Gallons used/year
Are you treating water?

Yes No
Trash or Landfill
Trash/Landfill Cost per year
Any Hazardous waste?
Any Recyclables?
Section 4: Plant/Facility Information
Do you have a plant layout or floor plan? *

Yes (Please submit to lsuiac@lsu.edu) No
Please list any process that requires heating (other than space heater):
Please list any processes that require refrigeration:
Please list Major Energy Consuming Equipment with model information:
Lighting
Are employees and management satisfied with with existing lighting levels? *

Yes No
Are there any lighting concerns? *

Yes No
Has the facility had a lighting retrofit installed in the past? *

Yes No
If yes, when and what was installed?
HVAC Systems
Central Heating: Steam/hot water or forced air? *
Is there a boiler? *

Yes No
If yes, please answer the following:
Boiler Pressure:
Boiler Capacity
Annual Steam Usage:
Annual Steam Cost:
Production Equipment
Do you use any compressor? *

Yes (Please list details in the following table) No Do not know

Compressor Details

	Type	Horspower	Annual Hours of Operation
Compressor 1
Compressor 2
Compressor 3

Are VFDs installed on the compressors? *

Yes No Do not know
Do you have any motors greater than 50 HP? *

Yes No Do not know
Do you use any cooling towers? *

Yes No Do not know
Do you use any chillers? *

Yes No Do not know
Do you use any ovens? *

Yes No Do not know
Section 5: Potential Improvement Areas Under Consideration
Below, please list those areas that you consider the best opportunities for saving, improvement, or problematic. Describe any future energy reduction projects to help us best focus our efforts and measurements; consider energy usage, manufacturing productivity, and waste reduction. Feel free to attach any additional information as necessary.
Potential measures for energy savings:
Cost reduction measures:
Productivity improvement:
Waste reduction:
Safety Improvement:
Other areas:
Section 6: Assessment Day Information
Will our team be allowed to freely move around the facility? *

Yes No
Will your company provide personnel to escort up to 3 teams around the facility for data collection? *

Yes No
May we take photographs in your plant? (for report only) *

Yes No Some areas only
If some areas only, please specify:
What PPEs will be needed for accessing your facility? *
Will the required PPEs be provided in the facility? *

Yes No
If yes, please list details:
Are there any additional safety protocols required before entering your facility? *

Yes No
If yes, please explain:
Should be Empty:

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LSU-IAC Pre-Assessment Form

Electricity

Natural Gas

Fuel / Oil

Water

Trash or Landfill

Lighting

HVAC Systems

Production Equipment