Southwest Louisiana Mutual Aid Association

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

Phone (337) 721-3800 FAX 437-3583

APPLICATION FOR MEMBERSHIP

You must go to the last page

(Data Entry)

to record your data.

If this is not done

your data will not be recorded.

Facility Name:

Facility Address:

Street AddressCityState / Province / RegionPostal / Zip Code

Primary Mutual Aid Contact Secondary Mutual Aid Contact

Primary Contact Name:

First

Last

Office Phone Primary:

Area Code

Phone Number

Other Phone Primary:

Area Code

Phone Number

Email Primary:

Secondary Contact Name:

First

Last

Office Phone Secondary:

Area Code

Phone Number

Other Phone Secondary:

Area Code

Phone Number

Email Secondary:

Applying for:

General Membership

General Membership (exempt)

Associate Membership

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?

Yes

Number of personnel employed my facility:

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Page 2

Southwest Louisiana Mutual Aid Association

Emergency Information Data

24 Hour Emergency Contact Number

24 hr Emergency Contact

Area Code

Phone Number

Emergency Contacts

Facility Manager Name:

First

Last

Facility Manager Office Number:

Area Code

Phone Number

Facility Manager Other Number:

Area Code

Phone Number

Security Manager Name:

First

Last

Security Manager Office Number:

Area Code

Phone Number

Security Manager Other Number

Area Code

Phone Number

EHS Manager Name:

First

Last

EHS Manager Office Number:

Area Code

Phone Number

EHS Manager Other Number:

Area Code

Phone Number

Safety Manager Name:

First

Last

Safety Manager Other Number:

Area Code

Phone Number

Safety Manager Office Number:

Area Code

Phone Number

Facility Key Locations

Emergency Operation Location /Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Emerg Op Center Latitude:

Emerg Op Center Longitude:

Emerg Ops Center Primary Phone:

Area Code

Phone Number

Emerg Ops Center Secondary Phone:

Area Code

Phone Number

Security Location /Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Security Office Latitude:

Security Office Longitude:

Security Office Primary Phone:

Area Code

Phone Number

Security Office Secondary Phone:

Area Code

Phone Number

First Aid Location /Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

First Aid Office Latitude:

First Aid Office Longitude:

First Aid Office Primary Phone:

Area Code

Phone Number

First Aid Office Secondary Phone:

Area Code

Phone Number

SDS/GHS Location /Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

SDS/GHS Office Latitude:

SDS/GHS Office Longitude:

SDS/GHS Office Primary Phone:

Area Code

Phone Number

SDS/GHS Office Secondary Phone:

Area Code

Phone Number

Staging Area

Primary Staging Area Description::

Primary Address/Location:

Street AddressCityState / Province / RegionPostal / Zip Code

Primary Latitude::

Primary Longitude:

Secondary Staging Area Description::

Secondary Address/Location:

Street AddressCityState / Province / RegionPostal / Zip Code

Secondary Latitude::

Secondary Longitude:

Tertiary Staging Area Description::

Tertiary Address/Location:

Street AddressCityState / Province / RegionPostal / Zip Code

Tertiary Latitude::

Tertiary Longitude:

Other Staging Area Description::

Other Address/Location:

Street AddressCityState / Province / RegionPostal / Zip Code

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)

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:

Page 1

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Page 3

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

Page 3

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Page 5

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)

Page 4

5/12

Page 6

Fire Fighting Equipment

Dry Chemicals

Quanity (DryChem1)

Type of Agent (DryChem1)

Purpose (DryChem1)

Description (DryChem1)

Amount of Agent (DryChem1)

Transported by (DryChem1)

Quanity (DryChem2)

Type of Agent (DryChem2)

Purpose (DryChem2)

Description (DryChem2)

Amount of Agent (DryChem2)

Transported by (DryChem2)

Quanity (DryChem3)

Type of Agent (DryChem3)

Purpose (DryChem3)

Description (DryChem3)

Amount of Agent (DryChem3)

Transported by (DryChem3)

Quanity (DryChem4)

Type of Agent (DryChem4)

Purpose (DryChem4)

Description (DryChem4)

Amount of Agent (DryChem4)

Transported by (DryChem4)

Foam

Quanity (Foam1)

Type of Agent (Foam1)

Purpose (Foam1)

Description (Foam1)

Amount of Agent (Foam1)

Transported by (Foam1)

Quanity (Foam2)

Type of Agent (Foam2)

Purpose (Foam2)

Description (Foam2)

Amount of Agent (Foam2)

Transported by (Foam2)

Quanity (Foam3)

Type of Agent (Foam3)

Purpose (Foam3)

Description (Foam3)

Amount of Agent (Foam3)

Transported by (Foam3)

Quantity (Foam4)

Type of Agent (Foam4)

Purpose (Foam4)

Description (Foam4)

Amount of Agent (Foam4)

Transported by (Foam4)

Hose

Quanity (Hose1)

Type (Hose1)

Purpose (Hose1)

Description (Hose1)

Hard/Soft (Hose1)

Diameter (Hose1)

Hose Threads (Hose1)

Quantity (Hose2)

Type (Hose2)

Purpose (Hose2)

Description (Hose2)

Hard/Soft (Hose2)

Diameter (Hose2)

Hose Threads (Hose2)

Quantity (Hose3)

Type (Hose3)

Purpose (Hose3)

Description (Hose3)

Hard/Soft (Hose3)

Diameter (Hose3)

Hose Threads (Hose3)

Quantity (Hose4)

Type (Hose4)

Purpose (Hose4)

Description (Hose4)

Hard/Soft (Hose4)

Diameter (Hose4)

Hose Threads (Hose4)

Hose Adapters

Quanity (HoseAdpt1)

Type (HoseAdpt1)

Purpose (HoseAdpt1)

Description (HoseAdpt1)

Diameter (HoseAdpt1)

Hose Threads (HoseAdpt1)

Quanity (HoseAdpt2)

Type (HoseAdpt2)

Purpose (HoseAdpt2)

Description (HoseAdpt2)

Diameter (HoseAdpt2)

Hose Threads (HoseAdpt2)

Quantity (HoseAdpt3)

Type (HoseAdpt3)

Purpose (HoseAdpt3)

Description (HoseAdpt3)

Diameter (HoseAdpt3)

Hose Threads (HoseAdpt3)

Quantity (HoseAdpt4)

Type (HoseAdpt4)

Purpose (HoseAdpt4)

Description (HoseAdpt4)

Diameter (HoseAdpt4)

Hose Threads (HoseAdpt4)

Port. Air Cascade System

Quanity (Air Cass1)

Type (Air Cass1)

Purpose (Air Cass1)

Description (Air Cass1)

PSI (Air Cass1)

Cylinder Connection Type (Air Cass1)

Quantity (Air Cass2)

Type (Air Cass2)

Purpose (Air Cass2)

Description (Air Cass2)

PSI (Air Cass2)

Cylinder Connection Type (Air Cass2)

Quantity (Air Cass3)

Type (Air Cass3)

Purpose (Air Cass3)

Description (Air Cass3)

PSI (Air Cass3)

Cylinder Connection Type (Air Cass3)

Quantity (Air Cass4)

Type (Air Cass4)

Purpose (Air Cass4)

Description (Air Cass4)

PSI (Air Cass4)

Cylinder Connection Type (Air Cass4)

Portable Water Monitors

Quanity (WaterMonitor1)

Type (WaterMonitor1)

Purpose (WaterMonitor1)

Description (WaterMonitor1)

Quanity (WaterMonitor2)

Type (WaterMonitor2)

Purpose (WaterMonitor2)

Description (WaterMonitor2)

Quanity (WaterMonitor3)

Type (WaterMonitor3)

Purpose (WaterMonitor3)

Description (WaterMonitor3)

Quanity (WaterMonitor4)

Type (WaterMonitor4)

Purpose (WaterMonitor4)

Description (WaterMonitor4)

SCBA Spare Bottles

Quanity (SCBABottles1)

Type (SCBABottles1)

Purpose (SCBABottles1)

Description (SCBABottles1)

PSi (SCBABottles1)

Cylinder Connection Type (SCBABottles1)

Time Rating (SCBABottles1)

Manufacturer (SCBABottles1)

Quantity (SCBABottles2)

Type (SCBABottles2)

Purpose(SCBABottles2)

Description (SCBABottles2)

PSi (SCBABottles2)

Cylinder Connection Type (SCBABottles2)

Time Rating (SCBABottles2)

Manufacturer(SCBABottles2)

Quantity (SCBABottles3)

Type (SCBABottles3)

Purpose (SCBABottles3)

Description (SCBABottles3)

PSi (SCBABottles3)

Cylinder Connection Type (SCBABottles3)

Time Rating (SCBABottles3)

Manufacturer (SCBABottles3)

Quanity (SCBABottles4)

Type (SCBABottles4)

Purpose (SCBABottles4)

Description (SCBABottles4)

PSi (SCBABottles4)

Cylinder Connection Type (SCBABottles4)

Time Rating (SCBABottles4)

Manufacturer (SCBABottles4)

6/12

Other Response Vehicles

Aviation Assets

Quanity (Aviation1)

Type (Aviation1)

Purpose (Aviation1)

Description (Aviation1)

Operator (Aviation1)

Fuel Type (Aviation1)

Quanity (Aviation2)

Type (Aviation2)

Purpose (Aviation2)

Description (Aviation2)

Operator (Aviation2)

Fuel Type (Aviation2)

Quanity (Aviation3)

Type (Aviation3)

Purpose (Aviation3)

Description (Aviation3)

Operator (Aviation3)

Fuel Type (Aviation3)

Quantity (Aviation4)

Type(Aviation4)

Purpose(Aviation4)

Description(Aviation4)

Operator(Aviation4)

Fuel Type (Aviation4)

Ambulance

Quanity (Ambulance1)

Type (Ambulance1)

Purpose (Ambulance1)

Description (Ambulance1)

Operator (Ambulance1)

Fuel Type (Ambulance1)

Medical Level (Ambulance1)

Quanity (Ambulance2)

Type (Ambulance2)

Purpose (Ambulance2)

Description (Ambulance2)

Operator (Ambulance2)

Fuel Type (Ambulance2)

Medical Level (Ambulance2)

Quantity (Ambulance3)

Type (Ambulance3)

Purpose (Ambulance3)

Description (Ambulance3)

Operator (Ambulance3)

Fuel Type (Ambulance3)

Medical Level (Ambulance3)

Quanity (Ambulance4)

Type (Ambulance4)

Purpose (Ambulance4)

Description (Ambulance4)

Operator (Ambulance4)

Fuel Type (Ambulance4)

Medical Level (Ambulance4)

Marine Equipment

Quantity (Marine1)

Type (Marine1)

Purpose (Marine1)

Description (Marine1)

Operator (Marine1)

Length (Marine1)

Fire Fighting Capability (Marine1)

GPM (Marine1)

Gallons Storage (Marine1)

Foam (Marine1)

Fuel Type (Marine1)

Draft (Marine1)

Quantity (Marine2)

Type (Marine2)

Purpose (Marine2)

Description (Marine2)

Operator (Marine2)

Length (Marine2)

Fire Fighting Capability (Marine2)

GPM (Marine2)

Gallons Storage (Marine2)

Foam (Marine2)

Fuel Type (Marine2)

Draft (Marine2)

Quantity (Marine3)

Type (Marine3)

Purpose (Marine3)

Description (Marine3)

Operator (Marine3)

Length (Marine3)

Fire Fighting Capability (Marine3)

GPM (Marine3)

Gallons Storage (Marine3)

Foam (Marine1)(2)

Fuel Type (Marine3)

Draft (Marine3)

Quantity (Marine4)

Type (Marine4)

Purpose (Marine4)

Description (Marine4)

Operator (Marine4)

Length (Marine4)

Fire Fighting Capability (Marine4)

GPM (Marine4)

Gallons Storage (Marine4)

Foam (Marine4)

Fuel Type (Marine4)

Draft (Marine4)

Mobile Command Vehicle

Quantity (Mobile Command1)

Type (Mobile Command1)

Purpose (Mobile Command1)

Description (Mobile Command1)

Operator (Mobile Command1)

Fuel Type (Mobile Command1)

Quantity (Mobile Command2)

Type (Mobile Command2)

Purpose (Mobile Command2)

Description (Mobile Command2)

Operator (Mobile Command2)

Fuel Type (Mobile Command2)

Quantity (Mobile Command3)

Type (Mobile Command3)

Purpose (Mobile Command3)

Description (Mobile Command3)

Operator (Mobile Command3)

Fuel Type (Mobile Command3)

Quantity (Mobile Command4)

Type (Mobile Command4)

Purpose (Mobile Command4)

Description (Mobile Command4)

Operator (Mobile Command4)

Fuel Type (Mobile Command4)

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Response Equipment

Auxiliary Power Supply

Quantity (Aux.Light1)

Type (Aux.Light1)

Purpose (Aux.Light1)

Description (Aux.Light1)

Operator (Aux.Light1)

Total KW (Aux.Light1)

Number of 120v outlets (Aux.Light1)

Number of 220v outlets (Aux.Light1)(1)

Fuel Type (Aux.Light1)

Transported by (Aux.Light1)

Quantity (Aux.Light2)

Type (Aux.Light2)

Purpose (Aux.Light2)

Description (Aux.Light2)

Operator (Aux.Light2)

Total KW (Aux.Light2)

Number of 120v outlets (Aux.Light2)

Number of 220v outlets (Aux.Light2)

Fuel Type (Aux.Light2)

Transported by (Aux.Light2)

Quantity (Aux.Light3)

Type (Aux.Light3)

Purpose (Aux.Light3)

Description (Aux.Light3)

Operator (Aux.Light3)

Total KW (Aux.Light3)

Number of 120v outlets (Aux.Light3)

Number of 220v outlets (Aux.Light3)

Fuel Type (Aux.Light3)

Transported by (Aux.Light3)

Quantity (Aux.Light4)

Type (Aux.Light4)

Purpose (Aux.Light4)

Description (Aux.Light4)

Operator (Aux.Light4)

Total KW (Aux.Light4)

Number of 120v outlets (Aux.Light4)

Number of 220v outlets (Aux.Light4)

Fuel Type (Aux.Light4)

Transported by (Aux.Light4)

Cutting Torch

Quantity (CuttingTorch1)

Type (CuttingTorch1)

Purpose (CuttingTorch1)

Description (CuttingTorch1)

Quantity (CuttingTorch2)

Type (CuttingTorch2)

Purpose (CuttingTorch2)

Description (CuttingTorch2)

Quantity (CuttingTorch3)

Type (CuttingTorch3)

Purpose (CuttingTorch3)

Description (CuttingTorch3)

Quantity (CuttingTorch4)

Type (CuttingTorch4)

Purpose (CuttingTorch4)

Description (CuttingTorch4)

Extrication Tools

Quantity (ExtricationTools1)

Type (ExtricationTools1)

Purpose (ExtricationTools1)

Description (ExtricationTools1)

Quantity (ExtricationTools2)

Type (ExtricationTools2)

Purpose (ExtricationTools2)

Description (ExtricationTools2)

Quantity (ExtricationTools3)

Type (ExtricationTools3)

Purpose (ExtricationTools3)

Description (ExtricationTools3)

Quantity (ExtricationTools4)

Type (ExtricationTools4)

Purpose (ExtricationTools4)

Description (ExtricationTools4)

Generator

Quantity (Generator1)

Type (Generator1)

Purpose (Generator1)

Description (Generator1)

Total KW (Generator1)

Number of 120v outlets (Generator1)

Number of 220v outlets (Generator1)

Fuel Type (Generator1)

Transported by (Generator1)

Quantity (Generator2)

Type (Generator2)

Purpose (Generator2)

Description (Generator2)

Total KW (Generator2)

Number of 120v outlets (Generator2)

Number of 220v outlets (Generator2)

Fuel Type (Generator2)

Transported by (Generator2)

Quantity (Generator3)

Type (Generator3)

Purpose (Generator3)

Description (Generator3)

Total KW (Generator3)

Number of 120v outlets (Generator3)

Number of 220v outlets (Generator3)

Fuel Type (Generator3)

Transported by (Generator3)

Quantity (Generator4)

Type (Generator4)

Purpose (Generator4)

Description (Generator4)

Total KW (Generator4)

Number of 120v outlets (Generator4)

Number of 220v outlets (Generator4)

Fuel Type (Generator4)

Transported by (Generator4)

8/12

HazMat

Mitigation Equipment

Quantity (Mig Equip1)

Type (Mig Equip1)

Purpose (Mig Equip1)

Description (Mig Equip1)

Quantity (Mig Equip2)

Type (Mig Equip2)

Purpose (Mig Equip2)

Description (Mig Equip2)

Quantity (Mig Equip3)

Type (Mig Equip3)

Purpose (Mig Equip3)

Description (Mig Equip3)

Quantity (Mig Equip4)

Type (Mig Equip4)

Purpose (Mig Equip4)

Description (Mig Equip4)

Hazmat PPE

Type (PPE1)

Purpose ( (PPE1)

Description (PPE1)

Level 1 S (PPE1)

Level 1 M (PPE1)

Level 1 L (PPE1)

Level 1 XL (PPE1)

Level 1 XXL (PPE1)

Level 1 XXXL (PPE1)

Level 1 XXXXL (PPE1)

Level 2 S (PPE1)

Level 2 M (PPE1)

Level 2 L (PPE1)

Level 2 XL (PPE1)

Level 2 XXL (PPE1)

Level 2 XXXL (PPE1)

Level 2 XXXXL (PPE1)

Level 3 S (PPE1)

Level 3 M (PPE1)

Level 3 L (PPE1)

Level 3 XL (PPE1)

Level 3 XXL (PPE1)

Level 3 XXXL (PPE1)

Level 3 XXXL (PPE1)(3)

Type (PPE2)

Purpose (PPE2)

Description (PPE2)

Level 1 S (PPE2)

Level 1 M (PPE2)

Level 1 L (PPE2)

Level 1 XL (PPE2)

Level 1 XXL (PPE2)

Level 1 XXXL (PPE2)

Level 1 XXXXL (PPE2)

Level S (PPE2)

Level 2 M (PPE2)

Level 2 L (PPE2)

Level 2 XL (PPE2)

Level 2 XXL (PPE2)

Level 2 XXXL (PPE2)

Level 2 XXXXL (PPE2)

Level 3 S (PPE2)

Level 3 M (PPE2)

Level 3 L (PPE2)

Level 3 XL (PPE2)

Level 3 XXL (PPE2)

Level 3 XXXL (PPE2)

Level 3 XXXXL (PPE2)

Type (PPE3)

Purpose (PPE3)

Description (PPE3)

Level 1 S (PPE3)

Level 1 M (PPE3)

Level 1 L (PPE3)

Level 1 XL (PPE3)

Level 1 XXL (PPE3)

Level 1 XXXL (PPE3)

Level 1 XXXXL (PPE3)

Level S (PPE3)

Level 2 M (PPE3)

Level 2 L (PPE3)

Level 2 XL (PPE3)

Level 2 XXL (PPE3)

Level 2 XXXL (PPE3)

Level 2 XXXXL (PPE3)

Level 3 S (PPE1)(2)

Level 3 M (PPE3)

Level 3 L (PPE3)

Level 3 XL (PPE3)

Level 3 XXL (PPE3)

Level 3 XXXL (PPE3)

Level 3 XXXXL (PPE3)

Type (PPE4)

Purpose (PPE4)

Description (PPE4)

Level 1 S (PPE4)

Level 1 M (PPE4)

Level 1 L (PPE4)

Level 1 XL (PPE4)

Level 1 XXL (PPE4)

Level 1 XXXL (PPE4)

Level 1 XXXXL (PPE4)

Level S (PPE4)

Level 2 M (PPE4)

Level 2 L (PPE4)

Level 2 XL (PPE4)

Level 2 XXL (PPE4)

Level 2 XXXL (PPE4)

Level 2 XXXXL (PPE4)

Level 3 S (PPE4)

Level 3 M (PPE4)

Level 3 L (PPE4)

Level 3 XL (PPE4)

Level 3 XXL (PPE4)

Level 3 XXXL (PPE4)

Level 3 XXXXL (PPE4)

9/12

Response Team

Team

Quantity (Teams1)

Specialty (Teams1)

Quantity (Teams2)

Specialty (Teams2)

Quantity (Teams3)

Specialty (Teams3)

Quantity (Teams4)

Specialty (Teams4)

10/12

Other Equipment

Quantity (Other1)

Type (Other1)

Purpose (Other1)

Description (Other1)

Other 1 (Other1)

Other 2 (Other1)

Other 3 (Other1)

Quantity (Other2)

Type (Other2)

Purpose (Other2)

Description (Other2)

Other 1 (Other2)

Other 2 (Other2)

Other 3 (Other2)

Quantity (Other3)

Type (Other3)

Purpose (Other3)

Description (Other3)

Other 1 (Other3)

Other 2 (Other3)

Other 3 (Other3)

Quantity (Other4)

Type (Other4)

Purpose (Other4)

Description (Other4)

Other 1 (Other4)

Other 2 (Other4)

Other 3 (Other4)

11/12

Data Entry

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12/12

Primary Mutual Aid Contact Secondary Mutual Aid Contact

Southwest Louisiana Mutual Aid Association

24 Hour Emergency Contact Number

Emergency Contacts

Facility Key Locations

Staging Area

Communication

Traffic Control Points (TCP)

Security Gates

Section 2

Facility Fire Protection

Fire Water Delivery Systems

Spray Deluge Systems

Sprinkler Systems

Standpipe Systems

Fire Water Appliances

Storage Tank Fire Systems

Firefighting Foam Requirements

Fire Extinguishing Agents

SECTION 3.

EMERGENCY RESPONSE TEAM

General

Emergency Response Team

Fire Team

Hazardous Materials Response Team

Emergency Medical/Rescue

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.

Engine (E1)

Engine (E2)

Engine (E3)

Engine (E4)

Aerials (A1)

Aerials (A2)

Aerials (A3)

Aerials (A4)

Tanker (T1)

Tanker (T2)

Tanker (T3)

Tanker (T4)

Brush Truck (BT1)

Brush Truck (BT2)

Hose Tender (HT1)

Foam Pumper (FP1)

Hazmat Truck (HAZ1)

Hazmat Truck (HAZ2)

Service Truck (ST1)

Rehab Truck (RT1)