PREM-HAZ FORM

Premise & Hazardous Information Form

You may also download and print a PDF Version of this form and FAX it to 503-655-8250.
(You must have Adobe Acrobat Reader to view the PDF File)

This form is used to identify subjects or situations (such as hazardous materials) that may reside or are stored at a particular address.

Please fill out all fields below (if you are a business owner or representative, you do not need to fill out fields labeled "law or fire agency use only"). The form will be rejected without a name or valid e-mail address. Law and Fire agencies must have supervisor approval.

For law or fire departments, if this is an emergency entry that must be entered in less than 12 hours during the weekday or less than 24 hours on the weekend, please use the PDF form and FAX the information to the number above.

If you came to this form in error, you can return to the C-COM HOME without filling out the form.

If you have questions regarding this form or the submission of your business information, please e-mail Jim Paul or call 503-655-8246.

Your Name:		Your e-mail:
Your Phone:		Agency:	(law or fire agency use only)
Retention Period: (maximum 1 year)		DPSST#:	(law or fire agency use only)
	Supervisor Approving Submission: (required for law or fire agency submission)		(law or fire agency use only)
	Related File or CAD # (for law or fire agency use only)



Reason for premise or hazard flag: (check all that apply)		Hazard Information Lock Information Police Safety Information Fire Safety Information Medical Safety Information General Information


Address of Premise:	(please include street, city and zip in line above)

Business Name: (if applicable)

Premise Phone:



Names of Subjects or Suspects Involved: (for law or fire agency use only)	#1 #2 #3		#4 #5 #6


Information to be entered for responders:

If you would like a copy of this form for your records, you should print this page before submitting it, once it is submitted, you will not be able to print it out.

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Premise & Hazardous Information Form