Southwest Louisiana Mutual Aid Association

P.O. Box 367 Lake Charles, Louisiana 706002-3067

 Phone (337) 721-3800 FAX 437-3583


APPLICATION FOR MEMBERSHIP


Under Construction

Please Review but do not enter data

Facility Name:
Facility Address:

Primary Mutual Aid Contact                                                         Secondary Mutual Aid Contact

Primary Contact Name:
Office Phone Primary:
-
Other Phone Primary:
-
Email Primary:
Secondary Contact Name:
Office Phone Secondary:
-
Other Phone Secondary:
-
Email Secondary:
Applying for:
Briefly describe your organization:
Briefly describe what your agency will provide to the Southwest Louisiana Mutual Aid Association.
Major types of processes and products produced.
Name of Person completing application:
Date:
Does your facility have and utilize a written Emergency Action Plan?
Number of personnel employed my facility:

Southwest Louisiana Mutual Aid Association

Emergency Information Data

24 Hour Emergency Contact Number

24 hr Emergency Contact
-

Emergency Contacts

Facility Manager Name:
Facility Manager Office Number:
-
Facility Manager Other Number:
-
Security Manager Name:
Security Manager Office Number:
-
Security Manager Other Number
-
EHS Manager Name:
EHS Manager Office Number:
-
EHS Manager Other Number:
-
Safety Manager Name:
Safety Manager Other Number:
-
Safety Manager Office Number:
-

Facility Key Locations

Emergency Operation Location /Address:
Emerg Op Center Latitude:
Emerg Op Center Longitude:
Emerg Ops Center Primary Phone:
-
Emerg Ops Center Secondary Phone:
-
Security Location /Address:
Security Office Latitude:
Security Office Longitude:
Security Office Primary Phone:
-
Security Office Secondary Phone:
-
First Aid Location /Address:
First Aid Office Latitude:
First Aid Office Longitude:
First Aid Office Primary Phone:
-
First Aid Office Secondary Phone:
-
SDS/GHS Location /Address:
SDS/GHS Office Latitude:
SDS/GHS Office Longitude:
SDS/GHS Office Primary Phone:
-
SDS/GHS Office Secondary Phone:
-

Staging Area

Primary Staging Area Description::
Primary Address/Location:
Primary Latitude::
Primary Longitude:
Secondary Staging Area Description::
Secondary Address/Location:
Secondary Latitude::
Secondary Longitude:
Tertiary Staging Area Description::
Tertiary Address/Location:
Tertiary Latitude::
Tertiary Longitude:
Other Staging Area Description::
Other Address/Location:
Other Latitude::
Other Longitude:

Communication

Primary Channel:
Primary System:
Primary Distribution:
Primary Purpose:
Secondary Channel:
Secondary System:
Secondary Distribution:
Secondary Purpose:
Tactical Channel:
Tactical System:
Tactical Distribution:
Tactical Purpose:
Mutual Aid Channel:
Mutual Aid System:
Mutual Aid Distribution:
Mutual Aid Purpose:

Traffic Control Points

TCP#1 Description:
TCP#1 Location:
TCP#1 Latitude:
TCP#1 Longitude:
TCP#1 Initially Manned by:
TCP#1 Relieved by:
TCP#2 Description:
TCP#2 Location:
TCP#2 Latitude:
TCP#2 Longitude:
TCP#2 Initially Manned by:
TCP#2 Relieved by:


TCP#3 Description:
TCP#3 Location:
TCP#3 Latitude:
TCP#3 Longitude:
TCP#3 Initially Manned by:
TCP#3 Relieved by:
TCP#4 Description:
TCP#4 Location:
TCP#4 Latitude:
TCP#4 Longitude:
TCP#4 Initially Manned by:
TCP#4 Relieved by:

Security Gates

Gate #1 Name:
Gate Location #1:
Gate #1 Latitude:
Gate #1 Longitude:
Gate #1 Secured:
Gate #2 Name:
Gate #2 Location:
Gate #2 Latitude:
Gate #2 Longitude:
Gate #2 Secured:
Gate #3 Name:
Gate #3 Location:
Gate #3 Latitude:
Gate #3 Longitude:
Gate #3 Secured:
Gate #4 Name:
Gate #4 Location:
Gate #4 Latitude:
Gate #4 Longitude:
Gate #4 Secured:

Section 2

Facility Fire Protection


Facility fire water system?
Facility fire water system pumping capacity (in gpm)
Facility fire water fire threads:
Fire water system Static Pressure (in psi)

Fire Water Supply

Adjacent facility water supply?
Municipal water supply?
Municipal fire water pumping system?
Facility Water Supply Name:
Municipal Water Supply Name:
Municipal fire water system pumping capacity (in gpm)
Municipal fire water fire threads:
Municipal Fire water system Static Pressure (in psi)

Fire Water Delivery Systems

Municipal Water Hydrants
Water District Hydrants
Fire Water Pond
Tankers
Other:
Municipal Name
Water District
Total gallons:
Total gallon capable:
Other

Spray Deluge Systems

Does facility utilize fire water spray systems for process protection?
Does facility utilize fire water spray systems for exposure protection on tankage and vessels?

Sprinkler Systems

Does facility utilize sprinkler systems for structure protection?

Standpipe Systems

Are standpipes available on multi-level structures?

Fire Water Appliances 

Are fire water monitors utilized for process equipment protection?
Are fire hydrants or headers available on house fire water system?
Hydrant or header outlet size:
Thread type:

If facility located on navigable waterway are fire boat headers available?

Number of Marine inlets:
Marine Headers size:
Marine Thread type:

Storage Tank Fire Systems

Are fire protection systems available on atmospheric and low pressure storage tanks?

Types of systems on tankage:  Check all appropriate.

Cooling water sprays
Fixed system foam
Halon
Semi-fixed system foam
Storage Tank Fire Systems Other:
Storage Tank Fire Systems Other Explain:

Firefighting Foam Requirements

Largest chemical storage tank:

Diameter: (in feet)
Product in largest storage tank:

Method of extinguishment:

                    Check appropriate item.

Subsurface injection
Semi-fixed foam chambers
Fixed system
Ground application (portable foam appliances)

Application rate for product and method of extinguishment: (rate per NFPA 11)

       (application rate/ft2 area)

Can facility provide 25% of following resources?
Foam solution delivery rate: 25% of the total solution rate
Foam concentrate: 25% of total concentrate required
Additional Foam Comments:

Fire Extinguishing Agents

Types and amounts of agents available for Mutual Aid:

Agent #1:
Type #1:
Amount #1:

---------------------------------------------------------------

Agent #2:
Type #2:
Amount #2:

---------------------------------------------------------------

Agent #3:
Type #3:
Amount #3:

---------------------------------------------------------------

Agent #4:
Type #4:
Amount #4:

SECTION 3.

EMERGENCY RESPONSE TEAM

General

_________________________________________________________________________________________

Emergency Response Team

Total amount of personnel assigned to emergency response duties?
Number of emergency response personnel available for call out?
Call out response time.
Are command personnel trained and qualified to Level 5: On-Scene Incident Commander as per OSHA Subpart H Hazardous Materials; 1910.120 Hazardous Waste Operations and Emergency Response Standards?
Is a preplan established in which to summon personnel and resources for in house and mutual aid responses?
Are emergency response teams trained on the established Incident Command System (ICS)?

Fire Team

Does facility have a Fire Response Team?
Is your fire teams available for mutual aid?
Are response personnel trained to OSHA Subpart L Fire Protection; 1910.156 Fire Brigades Standards?
Are responding personnel OSHA required respirator trained, medically qualified and fit tested.
Are response personnel trained to a minimum of Level 3: Hazmat Technician Level as per OSHA Subpart H Hazardous Materials; 1910.120 Hazardous Waste Operations and Emergency Response Standards?
Is full firefighting turnout gear and SCBA provided for responder fire team personnel?

Amount of personnel available for mutual aid response.

Days
Nights

Hazardous Materials Response Team

Does facility have a specialized Hazardous Materials Response Team?
Is your hazardous materials teams available for mutual aid?
Are response personnel trained in accordance to OSHA Subpart L Fire Protection; 1910.156 Fire Brigade Standards?
Is full firefighting turnout gear and SCBA provided for responder hazmat team personnel?

Emergency Medical/Rescue

Does facility have an Emergency Medical Service?
Are your medical services available for mutual aid?
Does facility have a Rescue Team?
Is your rescue teams available for mutual aid?
Are responder personnel trained to a minimum of Level 3: Hazmat Technician Level as per OSHA Subpart H
Are responding personnel OSHA respirator trained, medically qualified & respirator fit tested?
Are responding personnel trained to OSHA Subpart L Fire Protection; 1910.153 Fire Brigades Standards?
Is full firefighting turnout gear and SCBA provided for responder Rescue team personnel?

Number of personnel holding EMS certifications available for response?

Emergency Medical Responder
First Aid/CPR
EMT
EMT-Advanced
Paramedic
LPN
Nurse Practitioner
Physician
RN

Mutual Aid Dedicated Equipment


NOTE:

TO BE A MEMBER OF THE SOUTHWEST LOUISIANA MUTUAL AID ASSOCIATION, YOUR FACILITY MUST HAVE AN 800 MHZ RADIO PROGRAMMED WITH THE INTERNATIONAL MUTUAL AID CHANNELS.

By applying to the Southwest Louisiana Mutual Aid Association, we attest that we have read, understand and will follow all the By-Laws and Policies and Procedures of the Southwest Louisiana Mutual Aid Association to the best of our abilities, as written on the date of signing of this application.

Fire Fighting Vehicles
Engines

Engine (E1)

Unit #:(E1)
Class:(E1)
Operator Supplied:(E1)
GPM Capable :(E1)
Agent Storage (gal):(E1)
Foam (gal):(E1)
Dry Chem (gal):(E1)
Drop Tank (gal):(E1)
Fuel Type:(E1)

Engine (E2)

Unit #:(E2)
Class:(E2)
Operator Supplied:(E2)
GPM Capable :(E2)
Agent Storage (gal):(E2)
Foam (gal):(E2)
Dry Chem (gal):(E2)
Drop Tank (gal):(E2)
Fuel Type:(E2)

Engine (E3)

Unit #:(E3)
Class:(E3)
Operator Supplied:(E3)
GPM Capable :(E3)
Agent Storage (gal):(E3)
Foam (gal):(E3)
Dry Chem (gal):(E3)
Drop Tank (gal):(E3)
Fuel Type:(E3)

Engine (E4)

Unit #:(E4)
Class:(E4)
Operator Supplied:(E4)
GPM Capable :(E4)
Agent Storage (gal):(E4)
Foam (gal):(E4)
Dry Chem (gal):((E4)
Drop Tank (gal):(E4)
Fuel Type:(E4)
Aerials

Aerials (A1)

Unit #:(A1)
Class:(A1)
Operator Supplied:(A1)
Aerial Length: (A1)
GPM Capable :(A1)
Agent Storage (gal):(A1)
Foam (gal):(A1)
Dry Chem (gal):(A1)
Drop Tank (gal):(A1)
Fuel Type:(A1)

Aerials (A2)

Unit #:(A2)
Class:(A2)
Operator Supplied:(A2)
Aerial Length: (A2)
GPM Capable :(A2)
Agent Storage (gal):(A2)
Foam (gal):(A2)
Dry Chem (gal):(A2)
Drop Tank (gal):(A2)
Fuel Type:(A2)

Aerials (A3)

Unit #:(A3)
Class:(A3)
Operator Supplied:(A3)
Aerial Length: (A3)
GPM Capable :(A3)
Agent Storage (gal):(A3)
Foam (gal):(A3)
Dry Chem (gal):(A3)
Drop Tank (gal):(A3)
Fuel Type:(A3)

Aerials (A4)

Unit #:(A4)
Class:(A4)
Operator Supplied:(A4)
Aerial Length: (A4)
GPM Capable :(A4)
Agent Storage (gal):(A4)
Foam (gal):(A4)
Dry Chem (gal):(A4)
Drop Tank (gal):(A4)
Fuel Type:(A4)
Tankers

Tanker (T1)

Unit #:(T1)
Class:(T1)
Operator Supplied:(T1)
GPM Capable :(T1)
Agent Storage (gal):(T1)
Foam (gal):(T1)
Dry Chem (gal):(T1)
Drop Tank (gal):(T1)
Fuel Type:(T1)

Tanker (T2)

Unit #:(T2)
Class:(T2)
Operator Supplied:(T2)
GPM Capable :(T2)
Agent Storage (gal):(T2)
Foam (gal):(T2)
Dry Chem (gal):(T2)
Drop Tank (gal):(T2)
Fuel Type:(T2)

Tanker (T3)

Unit #:(T3)
Class:(T3)
Operator Supplied:(T3)
GPM Capable :(T3)
Agent Storage (gal):(T3)
Foam (gal):(T3)
Dry Chem (gal):(T3)
Drop Tank (gal):(T3)
Fuel Type:(T3)

Tanker (T4)

Unit #:(T4)
Class:(T4)
Operator Supplied:(T4)
GPM Capable :(T4)
Agent Storage (gal):(T4)
Foam (gal):(T4)
Dry Chem (gal):(T4)
Drop Tank (gal):(T4)
Fuel Type:(T4)
Miscellaneous Fire Vehicles

Brush Truck (BT1)

Unit #:(BT1)
Class:(BT1)
Operator Supplied:(BT1)
Agent Storage (gal):(BT1)
Foam (gal):(BT1)
Dry Chem (gal):((BT1)
Drop Tank (gal):(BT1)
Fuel Type:(BT1)

Brush Truck (BT2)

Unit #:(BT2)
Class:(BT2)
Operator Supplied:(BT2)
Agent Storage (gal):(BT2)
Foam (gal):(BT2)
Dry Chem (gal):(BT2)
Drop Tank (gal):(BT2)
Fuel Type:(BT2)

Hose Tender (HT1)

Unit #:(HT1)
Class:(HT1)
Operator Supplied:(HT1)
Hose- Amt-Length-Size (1):(HT1)
Hose- Amt-Length-Size (2):(HT1)
Hose- Amt-Length-Size (3):(HT1)
Hose- Amt-Length-Size (4):(HT1)
Fuel Type:(HT1)

Foam Pumper  (FP1)

Unit #:(FB1)
Class:(FB1)
Operator Supplied:(FB1)
Agent Storage (gal):(FB1)
Foam (gal):(FB1)
Dry Chem (gal):(FB1)
Drop Tank (gal):(FB1)
Fuel Type:(FB1)

Hazmat Truck (HAZ1)

Unit #:(Haz1)
Class:(Haz1)
Operator Supplied:(Haz1)
HazMat Equip #1 (Haz1)
HazMat Equip #2 (Haz1)
HazMat Equip #3 (Haz1)
HazMat Equip #4 (Haz1)
Fuel Type:(Haz1)

Hazmat Truck (HAZ2)

Unit #:(Haz2)
Class:(Haz2)
Operator Supplied:(Haz2)
HazMat Equip #1 (Haz2)
HazMat Equip #2 (Haz2)
HazMat Equip #3 (Haz2)
HazMat Equip #4 (Haz2)
Fuel Type:(Haz2)

Service Truck (ST1)

Unit #:(ST1)
Class:(ST1)
Operator Supplied:(ST1)
Service Equip #1 (ST1)
Service Equip #2 (ST1)
Service Equip #3 (ST1)
Service Equip #4 (ST1)
Fuel Type:(ST1)

Rehab Truck (RT1)

Unit #:(RH1)
Class:(RH1)
Operator Supplied:(RH1)
Rehab Equip #1:(RH1)
Rehab Equip #2:(RH1)
Rehab Equip #3:(RH1)
Rehab Equip #4:(RH1)
Fuel Type:(RH1)
Fire Fighting Equipment 
Dry Chemicals