Building Asset Management System Critical System Form

AC Package Unit

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Condenser Type:

Air CooledWater CooledOther

Unit Heating Type:

ElectricGasHydronicLPG ButaneNatural GasOilPropaneRadiantNo HeatOther

Location:

Computer RoomOfficeResidenceShopOther

BTU:

kW: Tonnage:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Air Handling Unit

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Unit Type:

Single ZoneMulti ZoneVariable Air VolumeOther

Heat System Type:

ElectricGasHydronicLPG ButaneNatural GasOilPropaneRadiantNo HeatOther

Cooling Coils:

DXChilled WaterNoneOther

Heating Coils:

ElectricHeat PumpHot WaterSteamNoneOther

CFM: BTU/MBH: Tonnage:

Horsepower: kW: Voltage:

Amperage: Motor Frame Size: RPM:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Boiler

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Boiler Type:

Cast IronCast Iron Sect.Pulse CondensingResidentialScotch MarineSteelWater Tube PackOther

Fuel Type:

ElectricFuel OilNatural GasLPG/PropaneOther

Boiler Gross Output Rating (Specify BTU or MBH): Capacity (lbs/hr):

GPM: Boiler Heat Transfer Medium:

Hot WaterGlycolSteamOther

Pressure (PSI): Boiler Efficiency Rating:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Chiller

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Tonnage: Chiller Power Source:

Alternative ElectricFuel Oil GasolineKerosene Natural GasOther PropaneSteam

Chiller Cooled Type:

Air CooledWater CooledOther

Chiller Type:

Absorption Centrifugal ReciprocatingScrew Scroll OtherNone

Coolant Type:

BrineEthyleneGlycolPropylene GlycolWaterOther

Water Treatment:

YesNo

Amperage: RPM:

Motor Frame Size: Motor Housing Type:

Explosion ProofStandardSubmersibleOther

Phase:

1 Phase3 PhaseOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Condenser Unit

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Condenser Type:

Air CooledWater CooledOther

Tonnage:

Building Asset Management System Critical System Form

Exterior Windows

* Please use a separate form for each type and size window

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

AwningCasementDouble HungFixedJalousieSingle HungSkylightSlidingOther

Material:

Alum Frame StormAlum Frame ScreenAluminumGlass BlockLouver (Alum)Louver (Steel)Louver (Wood)Metal GratingMetal Wire MeshShutter (Alum)Shutter (Steel)Shutter (Wood)SteelSteel Frame StormSteel Frame ScreenVinyl Clad WoodWindow WallWoodWood Frame ScreenWood Frame StormOther

Height: Width:

Window Operating:

ElectricFixedOperatingOther

Window Insulated Glass:

InsulatedNon-insulated

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Exterior Finish

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Exterior Wall Material:

AdobeAluminum SidingAsphalt ShinglesBrickCementClapboardCMUCompositeConcreteCorrugated MetalFiberglass Exterior Wall PanelGlass BlockInsulated Steel Sandwich PanelLogMasonryMetalPlasticStoneOther

Exterior Wall Finish:

CoatedGold LeafLime PlasterNaturalPaintPaint Oil BasePaint Water BasePatinaSealantStainStain Oil BaseStain Water BaseVinylNo FinishOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Exterior Door

*Please us a separate form for each type and size door

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Door Type:

Emergency EgressGarageHangerOverheadRevolvingScreenSlidingStandardStormSwingingOther

Fire Rated:

YesNo

Door Material:

AluminumGlassScreenSteelWoodOther

Frame Material:

SteelMetalWoodAluminum

Door Core:

HollowSolid

Height: Width:Door Automated:

YesNo

Closing Device:

Door CloserSpring HingeNoneOther

Door Single or Double:

SingleDouble

Door Painted:

YesNo

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Electrical Panel

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Electric Meter Number: Electric Service Provider:

EversourceUnited IlluminatingSolarOther

AMPs: Voltage:

12120/208120/240242400/4160277/48036Other

Number of Poles: Underground Service Connection:

YesNo

Transformers:

YesNo

Emergency/Backup Power:

YesNo

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Fan

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

Axial CentrifugalPropeller UtilityVehicle PropaneOther

Use:

ExhaustRecirculatingSupplyOther

CFM: Extraction Blower HP:Extraction Blower Vacuum (IN):

Horsepower: Voltage: RPM: Amperage:

Motor Frame Size: Pressure (PSI): Phase:

1 Phase3 PhaseOther

Motor Housing Type:

Explosion ProofStandardSubmersibleOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Foundation

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Foundation Sub Material:

BituminousConcreteEpoxy OverlayGravelMasonryMetalPaver BlockPlasticRiprapSoilSteel PilingWoodNoneNot ApplicableOther

Foundation Surface Material:

BituminousConcreteEpoxy OverlayGravelIntegral ConcreteLow Slump ConcreteMasonryMetalModified ConcreteMonolithic ConcretePaver BlockPlasticRiprapSoilSteel PilingWoodNoneNot ApplicableOther

Foundation Type:

WallsPiersSlab on GradeOther

Length: Width:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Furnace

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Furnace Input (Specify MBH or BTU): Furnace Efficiency Rating:

Furnace Cooling Coils:

YesNo

CFM: Cooling Coil Tonnage:

Furnace Fuel Type:

BiofuelCoalDieselElectricFuel OilGasolineLPG/PropaneMulti-FuelNatural GasOil/GasolineWoodOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Generator

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Voltage:

12120/208120/240242400/4160277/48036Other

kW:

Fuel Type:

BiofuelCoalDieselElectricFuel OilGasolineLPG/PropaneMulti-FuelNatural GasOil/GasolineWoodOther

KVA Rating: Generator PF Rating:

Phase:

1 Phase3 PhaseOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form Liquid and Gas Storage Tank

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Tank Contents:

ChemicalGaseous FuelLiquid FuelOilWastewaterWaterOther

Tank Material:

AluminumCMUConcreteFiberglassPlasticPolyethylenePolypropyleneStainless SteelSteelWoodOther

Tank Capacity: Fuel Type:

CoalElectricGasMulti-FuelNatural GasOilOil/GasPropaneWoodOther

Tank Function:

Hydro-pneumaticPressureSepticStorageTransferTreatmentVacuumOther

Tank Location:

Above GroundElevatedInteriorUnder GroundOther

Tank Leak Protection:

Double WalledSingle WalledNoneOther

Tank Insulation:

Ceramic Fiber BlanketFiberglass BlanketMineral WoolPolyurethane FoamRigid FiberglassNot InsulatedOther

Tank Lining:

EpoxyGalvanizedGlassPaintUnlinedOther

Tank Baffled:

YesNo

Tank Cathodic Protection:

ActivePassiveNone

Tank Alarmed:

YesNo

Date Last Inspected by Regulator: Monitoring System:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Water Heater

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Tank Contents:

ChemicalGaseous FuelLiquid FuelOilWastewaterWaterOther

Tank Material:

AluminumCMUConcreteFiberglassPlasticPolyethylenePolypropyleneStainless SteelSteelWoodOther

Tank Capacity: Fuel Type:

CoalElectricGasMulti-FuelNatural GasOilOil/GasPropaneWoodOther

Tank Insulation:

Ceramic Fiber BlanketFiberglass BlanketMineral WoolPolyurethane FoamRigid FiberglassNot InsulatedOther

Tank Lining:

EpoxyGalvanizedGlassPaintUnlinedOther

Building Asset Management System Critical System Form

HVAC/Heat Pump

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:

Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Unit Type:

Geothermal Heat Pump Straight AC Other

Condenser Unit Cooling Type:

Air Cooled Water Cooled Other

Split System Unit SEER: Heating Capacity MBH: Split System Cool Capacity Tonnage:

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560.

If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Roof Surface

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Roof Surface Material:

AsbestosAsphaltBuilt-UpClay TileCompositeConcreteCopperElast Roof CoatFiberglassGlass PanelInverted MembraneLead-Coated CopperMetal PanelMod BitumPlasticPoly Spray-OnRoll RoofingShingle-ArchitectShingle-AsphaltShingle-CedarSingle MembraneSlate TileStand Seam MetalTarTar PaperTin/TarWoodWood Shake RoofNoneOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Solar/Alternative Energy

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Energy Equipment Unit of Measure:

Amp-HourAmpsHertzkAkVkVARSingle PhaseThree PhaseVoltsWattsOther

PV Length: PV Width:PV Peak Power at STC:

Number of Panels: Battery Type:

Lead AcidNickel CadmiumOther

Connected to Power Grid:

YesNo

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Transformer

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

DryWet

Transformer Primary Voltage: Transformer Secondary Voltage:

KVA Rating: Function:

AutotransformerDistributionInstrumentPowerOther

Style:

Pad MountPole MountN/AOther

Phase:

1 Phase3 PhaseOther

Location:

IndoorOutdoorUndergroundOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Unit Heater

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

ElectricGasHot WaterLPG ButaneLPG PropaneNatural GasSteamOther

Capacity (Specify BTU or MBH): CFM:

kW: Amperage: Voltage:

12120/208120/240242400/4160277/48036Other

Phase:

1 Phase3 PhaseOther

Mounting:

Anti-vibrationBase/Pad MountCeilingClose CoupledFlange MountedFoot MountedHorizontal MountIn-line MountRoof MountSuspendedVertical MountWall MountOther

Building Asset Management System Critical System Form

Water Supply (Well)

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

PWSID:Seasonal Operational Period Start Date:

Seasonal Operational Period End Date:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price:Replacement Cost: Latitude: Longitude:

Date Well Completed: Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

GasMonitorTestWaterOther

Use:

Cathodic ProtectionDewateringExtractionGeotechnical ExplorationHeat ExchangeInjectionRemediationSpargingVapor ExtractionWater DomesticWater IndustrialWater IrrigationOther

Well Drilling Method:

Air/Hammer DrillBucket AugerCable ToolDrivenDual-Wall Reverse Circ.Hand DugJettedReverse CirculationRotaryOther

Depth (Ft.):Well Casing Diameter (In.):

Well Water Level Static:

Well Water Level Drawdown:

Well Water Yield (GPM):

Well Casing Depth: Well Casing Material:

SteelABSConcreteCPVCPVCPEX Cross LinkOther

Screened:

YesNoPerforated

Well Treatment:

YesNo

Well Sanitary Seal:

BentoniteConcreteFilter PackNoneOther

Well Production Meter:

YesNo

Public Water Supply:

YesNo

Water Treatment:

YesNo

Raw Water Sample Tap:

YesNo

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.

Building Asset Management System Critical System Form

Pump

Site ID/Facility ID: Site Description/Facility Name:

OPM Building Number: Building Description/Name:

Manufacturer: Model Number:

Serial Number: Quantity:Unit of Measure (Quantity):

Purchase Price: Replacement Cost:

Installation Date:Estimated Design Life: Estimated Remaining Life:

Replacement Date: Warrantee Period:

Type:

HandpumpJetSubmersibleVertical TurbineWellOther

Pump Depth:

Horsepower: Pumping Capacity (GPM):

Voltage: Mounting:

Anti-VibrationBase/Pad MountCeilingClose CoupledFlange MountedFoot MountedHorizontal MountIn-line MountRoof MountSuspendedVertical MountWall MountOther

Once form has been completed, please submit it to andrea.lane@ct.gov or fax to 860-344-2560. If you have any questions or require building related information please contact Andrea Lane at 860-424-4118 or David Cooley at 860-424-4120.