R9_Ino_Shelter_Request_WR20192953.pdf

Telecommunications Shelter Request Form

SCOPE: This PROPOSAL covers: Replacement Radio Communications Shelter New Shelter with Service Request #:

Prepared By: Date Prepared:

Site Name:

RADIO SHELTER LOCATION

District: City: County: State: Region: Forest:

Location Description:

Site Longitude: W ⁰ ' "

SA Longitude: W ⁰ ' "

Site Elevation: Ft.

SA Elevation: Ft.

Location Site Latitude: N ⁰ ' "

' " Staging area Latitude: N ⁰ Staging Area driving directions:

Shelter delivery address:

Logistics Is the local Forest able to offload the shelter from the delivery truck?

Yes, the equipment to be used is No, equipment will need to be scheduled through the contract

Will the shelter be able to be stored at this location until the time of install (up to a year)?

Site Access Is this a drive to site?

Yes: The road is in great condition, can handle heavy equipment, has no sharp turns and has plenty of room at the top for large equipment.

Yes: The road is drivable but will need a four-wheel drive and some preplanning/repair.

No: A helicopter install is necessary.

Description of installation site:

Other consideration for access to the site:

Other consideration for placement of the shelter:

(Combo or Key) Is there a perimeter fence?

Key access (POC)

Gate Locked?

Phone Number:

Site Info:

Site/Tower Hazards (Nearby cliffs, loose rock, other Shelters or towers etc).

Site accessibility? (Helicopter Only, Road condition, Large/ Heavy Truck Access, Obstructions, etc.)

Is this a High traffic area that would need special considerations? (Foot traffic, camp sites, etc.) No Yes explain:

General Considerations

Are utilities available? No Yes Access Restrictions or Concerns:

If access to the site is in disrepair will the Forest improve: No Yes, if no explain:

Where can the equipment (excavators & tractors, etc.) be stored?

Are there any requirements regarding inspection or washing of equipment to address noxious weed requirements?

No Yes, explain:

Will there be Special equipment required: Notes: Anything not covered above that might have an impact on the project?

Shelter Specifications:

Requested shelter size:

Will an attached monopole/tower need to be included: No Yes, if yes, Height needed ’

Total # of antennas Models of the FS antennas:

Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft Type Antenna @ ft

List identity and models of the Cooperator antennas:

Type Antenna @ ft belonging to Type Antenna @ ft belonging to Type Antenna @ ft belonging to Type Antenna @ ft belonging to

What direction should the tower articulate: West to East East to West Other:

Interior # of racks needed # radios to be installed Shelter wired for: AC DC additional options needed # of battery trays needed # Batteries to be installed Battery make/model:

HVAC Needed No Yes, If Yes which? Air Conditioning Heater Both

Exterior Solar No Yes, If Yes Mounted Top Side Both Other Direction for the door to face: North South East West

Additional solutions needed:

The vendor should provide the following services (please check all work need):

Demolish or remove existing Shelter. Existing Shelter weight: lbs. Size:

Additional considerations (specialty equipment needed, access, etc.):

Will the existing shelter be available for backhaul the day of install? Yes No If not, describe the plan for your existing shelter:

Where will the shelter be backhauled too:

Installation of shelter at site.

Special considerations not addressed already:

Custom shelter design needed. (Attach unique specifications to this request) Other :

Name of NEPA Document:

What is the topographic category of this site?

What is the wind speed at this site? Average mph Maximum mph Site radial ice loading:

Have NEPA, DM or LTF document been completed and approved?

Is the site listed as a Historical site?

Date:

No Yes explain:

@fs.fed.us

Is the site located on Private Land or will a Private Party need to be contacted:

Does the Engineering Staff concur that this shelter needs to be replaced?

Local Engineer Contact: Phone#: EMAIL:

Lands Use Have all other communication sites options (leased/collocation) been reviewed and discarded? No Yes Has it been determined that replacement is the only possible option? No Yes Other options considered:

Does this site have/require a Special use permit? No Yes If yes, has the Communication Site plan been completed? No Yes location:

Forest Special Use coordinator: Phone#: EMAIL: @fs.fed.us

Property

No Yes, if yes NRM ID# No Yes

Are any assets at the site on a Real Property Inventory?

Are any assets at the site on a Personal Property Inventory?

Forest Property Management Officer: Phone#: EMAIL: @fs.fed.us

Contact information:

@fs.fed.us @fs.fed.us @fs.fed.us

@fs.fed.us

Regional Radio Manager:

Radio Supervisor:

Local Service Technician:

COR NAME:

Local Forest/District contact:

Phone# Phone# Phone# Phone# Phone#

Email:

Email:

Email:

Email Email:

Yana Patton 530-226-2779 ypatton@fs.fed.us

Does the Forest Supervisor or District Ranger concur with this project? No Yes Will the Forest be supporting this project according to budgeting guidance in chapter 5b? No Yes http://fsweb.wo.fs.fed.us/results/xfst/local-resources/scripts/pullContent.php?directory=/results/pdb/Program%20Direction/FY%202013/&pagename=FY13%20Program%20Direction&ca tegory=budget&icon=budget

@fs.fed.us Forest Supervisor or District Ranger Contact: Phone#: EMAIL:

CIO Project POC:

Forest Engineer Signature:

Forest Supervisor or District Ranger:

Site Specific Engineering

No Yes explain:

No Yes explain:

http://fsweb.wo.fs.fed.us/results/xfst/local-resources/scripts/pullContent.php?directory=/results/pdb/Program%20Direction/FY%202013/&pagename=FY13%20Program%20Direction&category=budget&icon=budget http://fsweb.wo.fs.fed.us/results/xfst/local-resources/scripts/pullContent.php?directory=/results/pdb/Program%20Direction/FY%202013/&pagename=FY13%20Program%20Direction&category=budget&icon=budget http://fsweb.wo.fs.fed.us/results/xfst/local-resources/scripts/pullContent.php?directory=/results/pdb/Program%20Direction/FY%202013/&pagename=FY13%20Program%20Direction&category=budget&icon=budget