Chester County Government Forms

Public Safety Training Campus Facilities Use Request

2. Agency:

4. Address:

6. Contact Person and Title:

8. Phone:

9. Email:

13. Date(s):

15. Time Start:

16. Time End:

18. Type of Use:

    1. Training
    2. Meeting

20. Area(s) Requested:

22. Academic Building

    1. Room 121 (36 people
    2. Room 123 (56 people)
    3. Room 126 (36 people)
    4. Room 140 (24 people)
    5. EMS Simulation Lab
    6. Garage / Training Bay
    7. Kitchen / Lunch Area

23. Tactical Village (see map below)

    1. 3 - Drill Tower/Scenario Builidng
    2. 4 - Training Support Pavilion
    3. 5 - Burn Building
    4. 6 - Rehab Pavilion
    5. B - Roof Prop Simulator
    6. C - Confined Space Prop
    7. D - Trench Rescue Prop
    8. E - Drafting/Pump Pit
    9. F - Apparatus Training Pad
    10. G - Training Pad
    11. H - Upper Vehicle Rescue Pad
    12. J - Lower Vehicle Rescue Pad
    13. K - Flashover Simulator
    14. M - Industrial Platform/Tank Simulator

25. Approximate # of Attendees

28. Event Description

32. Details of Training

34. Agency Name

35. Date
    Date

37. EMS Agency on site (live burn training only):

39. Hospital to be used in the Even of an Emergency:

41. Designated transport vehicle (if an ambulance is not a ready option):

43. Staging Area for first aid bag/kit and AED:

47. ----------TO BE COMPLETED THE DAY OF TRAINING----------

49. Agency Officer-In-Charge

50. Signature

52. Agency Safety Officer

53. Signature

55. PSTC Safety Officer

56. Signature

58. EMERGENCY CONTACT INFORMATION:

60. Ambulance/Fire/Police 911
    Modena Fire and Ambulance Company South Coatesville Borough Police

    Modena Fire and Ambulance Company South Coatesville Borough Police

61. Beau Crowding 610-888-3242
    Deputy Director for Fire Services

    Deputy Director for Fire Services

63. Chester County DES 610-344-5100
    Radio Room Supervisor

    Radio Room Supervisor

64. Patrick Davis 610-656-0129
    Deputy Director for Law Enforcement Services

    Deputy Director for Law Enforcement Services

66. Michael Lam 484-883-2779
    Training Systems Specialist

    Training Systems Specialist

67. Jeff Groves 610-888-7713
    Fire Services Training Coordinator

    Fire Services Training Coordinator

69. John Gillespie 484-402-3201
    Assistant Director for the Public Safety Training Campus

    Assistant Director for the Public Safety Training Campus

71. 

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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

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