08 FA489725B0008 AF Form 103 Work Clearance Request.pdf

Cass Shop

Geo Base

MXG (If in airfield area)- Maj Sullivan, CMSgt Long, SMSgt Darling; Bldg: 7270 Rm: 127; Ph: 5824

DATE PREPAREDBASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

1. Clearance is requested to proceed with work at on Work Order No. , Contract No. , involving excavation or utility disturbance per attached sketch. This area has has not been staked or clearly marked.

2. TYPE OF FACILITY/WORK INVOLVED

G. AIRCRAFT OR VEHICULAR TRAFFIC FLOWA. PAVEMENTS D. FIRE DETECTION & PROTECTION SYSTEMS

H. SECURITYB. DRAINAGE SYSTEMS E. UTILITY OVERHEAD UNDERGROUND

I. OTHERC. RAILROAD TRACKS F. COMM OVERHEAD UNDERGROUND

3. DATE CLEARANCE REQUIRED 4. DATE OF CLEARANCE

5. SIGNATURE OF REQUESTING OFFICIAL 6. TELEPHONE NO. 7. ORGANIZATION

ORGANIZATION REMARKS (Use Reverse for additional comments) REVIEWER'S NAME AND INITIALS

8.

A. ELECTRICAL DISTRIBUTION

B A

S B. STEAM DISTRIBUTION

E

C. WATER DISTRIBUTION

C I

D. POL DISTRIBUTIONV

I L

E. SEWER DISTRIBUTION

E N

F. ENVIRONMENTAL

G

I

G. PAVEMENTS/ GROUNDSN

E

E H. FIRE PROTECTION

R

I

I. ZONEN

G

J. OTHER (Specify)

9. SECURITY POLICE

10. SAFETY

11. COMMUNICATIONS

12. BASE OPERATIONS

13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

TELEPHONE

GAS

ELECTRIC

15. OTHER (Specify)

16. REQUESTED CLEARANCE APPROVED DISAPPROVED

17. TYPED NAME AND SIGNATURE OF APPROVING OFFICER (Chief of Operations Flight or Chief of Engineering Flight) 17a. DATE SIGNED

PREVIOUS EDITIONS ARE OBSOLETE.AF FORM 103, 19940801 (IMT-V1)

To include Cathodic and WIMS cable: Ralph Dupres/Mark Butler Bldg 8210 Ph. 5538/5541

H/W & Chilled Water Lines & Ice Melt at 7502 Mr. Davis, Bldg 8210, Ph 2503

28 CES Utilities Shop (To include irrigation lines) Mr. Smith, Bldg 8210, Ph. 5395 or 6222

Mr. Spicer/Mr. Fairey Bldg 8210, Ph. 2507 or 5402

28 CES Utilities Shop Mr. Smith or Mr. Israel Bldg 8210, Ph. 5395 or 6222

Compliance - Mr. Johnson, Bldg 8225 Ph. 2692 Restoration - Ms. Jensen, Bldg 8225 Ph. 2685

Mr. Macy or Mr. Malone, Bldg 7612 Dock #52 Ph. 2209 This includes RIDS (R/W Ice Detection System)

Mr. Beck Bldg 7502, 385-7306 Mr. Hilton, Fire Dept., Ph. 385-7305

Bldg 8210 Ph. 385-5143 Mr. Davis

Mr.Pape (CEN) Bldg: 1st floor bldg 8225; Ph: 385-6420

SFS Desk 5-4001 (Resource Security office near south door) Bldg 4400 Lori Watson Ph# 5-2988

Mr. Smartt or Mr. Walter, Base Ops.

Bldg 7501 Ph. 385-7233

Bldg 4307 Ph. 385-8353

MSgt Martinez (If on Airfield, Call Before You Dig) Base Ops, Bldg 7501 Ph. 385-1052/4275/1065

Mid-Continent Cable Quest One Stop 800-781-7474 Confirmation #

Telephone Systems O & M Contractor 385-1543 Bldg #4307

Natural Gas Maint.Mr. Smith/Mr. Israel Bldg 8210 Ph. 6222 or 5395

INSTRUCTIONS

The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular traffic flow, base utility services, protection provided by fire and intrusion alarm system, or routine activities of the installation. This form is used to coordinate the required work with key base activities and keep customer inconvenience to a minimum. It is also used to identify potentially hazardous work conditions in an attempt to prevent accidents. The work clearance request is processed just prior to the start of work. If delays are encountered and the conditions at the job site change (or may have changed) this work clearance request must be reprocessed.

18. REMARKS. (This section must describe specific precautionary measure to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment, should be included.)

AF FORM 103, 19940801 (IMT-V1) (REVERSE)