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CORTLAND COUNTY DEPARTMENT OF EMERGENCY RESPONSE AND COMMUNICATIONS 54 Greenbush Street ~ Cortland, New York 13045 Phone [PHONE REDACTED] ~ Fax [PHONE REDACTED] Emergency Contact Information Sheet Date of Information: Business Business Owner (if applicable) : Property Owner (if known): Name: Name: Address: Address: City: City: State: State: Zip: Zip: Phone 1: Phone 1: Phone 2: Phone 2: To be notified in case of an Emergency: 1st Name: Title: Key Holder: □Yes □No Home Cell Address: City, State Zip: 2nd Name: Title: Key Holder: □Yes □No Home Cell Address: City, State Zip: 3rd Name: Title: Key Holder: □Yes □No Home Cell Address: City, State Zip: 4th Name: Title: Key Holder: □Yes □No Home Cell Address: City, State Zip: ---PAGE BREAK--- Business Information: Number of Employees: Number of shifts: Business Type: (Restaurant, manufacturing, retail, etc) Square footage: Number of Exits: Number of □ Basement: Does your business or property have any of the following? (Please check all that apply) Law Enforcement □Surveillance/Security Video □Security Guards □Is building alarmed for burglary, intrusion, panic… □K9 on Premises Local Alarm □Yes □ No □Lights on Timers/Intentionally Left on Regularly Direct Tie In With Company □ Yes □ No □Video Surveillance Alarm Company Alarm Company Phone Number Location of Alarm Panel Fire Service □Fire Alarm System □Knox Box Location of Fire Alarm Location of Knox □Fire Department Connections Gas Shut Off Location of Fuse Box Sprinkler System: □ Yes □ No □Elevators Please list any specific hazards (such as the location of stored flammable liquids, etc.): Person completing form: Telephone: