10. Component Form blank.pdf

595 KB Posted

Attached to
Digester Shelter-Electrical Improvements, Bowling Green, KY
Solicitation number
12505B22R0029
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BUILDER Facility Condition Assessments Recently Replaced Component Form (Not Repairs)

Location/Site name:

Building (CPAIS Asset ID):

Submitted by:

Contact information:

System Equipment Year Installed Location/Room Quantity/Area

Serial Number Model Manufacturer Comments Attachments

Old item

New item

Old item

New item

Old item

New item Notes: 1. If the equipment is not replacing another piece of equipment please use the new installation form

2. Please use this form for equipment replacements as well as building improvements (i.e. roofing, window, or facade replacement projects) greater then $75,000

3. Please provide a PDF of any documents associated with the new install

4. Some columns may not be applicable depending on what is being added

5. If you have suggestions on improvements/questions regarding this form email them to Joshua.Nye@USDA.GOV or call 301-504-1173

Date: ______________________ mailto:Joshua.Nye@ARS.USDA.GOV Joshua.Nye Stamp

Joshua.Nye Stamp

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Location/Site name:

LocationSite name:
Building CPAIS Asset ID:
Submitted by:
Contact information:
EquipmentOld item:
Year InstalledOld item:
LocationRoomOld item:
QuantityAreaOld item:
Serial NumberOld item:
ModelOld item:
ManufacturerOld item:
CommentsOld item:
EquipmentNew item:
Year InstalledNew item:
LocationRoomNew item:
QuantityAreaNew item:
Serial NumberNew item:
ModelNew item:
ManufacturerNew item:
CommentsNew item:
EquipmentOld item_2:
Year InstalledOld item_2:
LocationRoomOld item_2:
QuantityAreaOld item_2:
Serial NumberOld item_2:
ModelOld item_2:
ManufacturerOld item_2:
CommentsOld item_2:
EquipmentNew item_2:
Year InstalledNew item_2:
LocationRoomNew item_2:
QuantityAreaNew item_2:
Serial NumberNew item_2:
ModelNew item_2:
ManufacturerNew item_2:
CommentsNew item_2:
EquipmentOld item_3:
Year InstalledOld item_3:
LocationRoomOld item_3:
QuantityAreaOld item_3:
Serial NumberOld item_3:
ModelOld item_3:
ManufacturerOld item_3:
CommentsOld item_3:
EquipmentNew item_3:
Year InstalledNew item_3:
LocationRoomNew item_3:
QuantityAreaNew item_3:
Serial NumberNew item_3:
ModelNew item_3:
ManufacturerNew item_3:
CommentsNew item_3:
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Uniformat Dropdown2: [ ]
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Button1:
Date:

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