City of Beech Grove Fire Department Self Inspection Form

Business Name:     Business Phone:

Business Address:     Suite:

City, State, Zip:       Fax:

Email Address:

Property Owner:    Property Owner Phone:

Property Owner Address:                       

City, State, Zip:                                                

Emergency Contact 1:   Emergency Contact 1 Phone:

Emergency Contact 2:   Emergency Contact 2 Phone:

Please enter any additional contact information in the space provided below:



Exterior Inspection

The address is placed in a position on the building that is plainly visible from the street.
Yes No   (If No, Explain)

The gas meter and piping is protected from possible damage.
 Yes No   (If No, Explain)

Combustibles and dumpsters are stored at least 10' from the exterior of building.
 Yes No   (If No, Explain)

Does your business utilize the Knox Box entry program, and if so are the keys in it up to date?
 Yes No   (If No, Explain)
Click here for Knox Box Information


Fire Protection Equipment

One fire extinguisher present every 75 feet of travel.
 Yes No   (If No, Explain)

Extinguishers are serviced, inspected and tagged annually by a fire protection service.
 Yes No   (If No, Explain)

The Fire Extinguishing Hood system is inspected and tagged every 6 months by a fire protection service.
 Yes No   (If No, Explain)

Does your business have a working smoke detector?
 Yes No   (If No, Explain)


Interior Inspection

Holes or breaches are absent from the floors and ceilings.
 Yes No   (If No, Explain)

Combustible materials have a 30” clearance from any heat producing appliance.
 Yes No   (If No, Explain)

Compressed gas cylinders are adequately secured from falling and labeled with the contents.
 Yes No   (If No, Explain)

Oily rags and similar materials are kept in a metal-lined container equipped with tight fitting covers.
Yes No   (If No, Explain)

Trash accumulation is removed from the building daily?
 Yes No   (If No, Explain)


Exits

Exits are free from any obstructions, and are not locked during normal business hours.
 Yes No   (If No, Explain)

Aisles are free from any obstructions that could minimize egress.
 Yes No   (If No, Explain)

Exit signs and emergency lighting are in place and functional.
 Yes No   (If No, Explain)


Electrical Equipment and Wiring

Is your business free from extension cords? (extension cords cannot be used as permanent wiring)
 Yes No   (If No, Explain)

All electrical switches and receptacles have cover plates.
 Yes No   (If No, Explain)

The electrical panel is not obstructed and has a minimum of 30” clearance.
 Yes No   (If No, Explain)

No multi-plug electrical adapters. (not permitted in business locations)
 Yes No   (If No, Explain)

All electrical wiring is covered to prevent accidental shock.
 Yes No   (If No, Explain)

Name of person submitting this form:

Please check the following should your business request additional information. 

Request more information on the Knox Box Rapid Entry System
Click here for Knox Box Information
purchase it directly from their web site, or through our department.

Request an inspection from the Injury Prevention Bureau.           

Request information pertaining to first aid or CPR classes.         

Request a follow up call concerning my inspection.                       

Additional Comments: