b. Utility(Inc Fire Spr) Outage Request Form.pdf

VA SAN DIEGO M&O Utility System Outage Request Form

Floor/Wing Outage Requestor:

Form Submission Date:

Assistance is required from:

PLUMBING SHOP

HVAC

STRUCTURAL

LOCK SHOP ELECTRICAL SHOP

• Was detailed plans submitted to Facilities Maintenance Manager or representative for approval?

YES NO

• Was the job site walked? Including Interstitial and was a visual verification of system valves, circuit breakers, or any items related to the outage identified by the requestor?

YES NO

• Does the requestor have at least 3 tentative scheduled days?

YES NO

• These Dates are:

• Will the outage affect any life safety systems? If yes please indicate and attach Fire Alarm+Sprinkler Request Form.

YES NO FIRE SPRINKLER FIRE ALARM

• Is all the required documentation approved? (i.e. ICRA, ILSM, SUPEXMAN)

YES NO N/A

• Does this outage merit a trial run? If yes please provide date(s):

YES NO N/A

• Was the trial run performed to verify that other systems were not affected?

YES N/A

• Name of the requestor or a representative (VA Employee) will be present during the outage.

• Requestor will be the only liaison between VA shops and contractor(s) during the outage.

DAY OF SHUT DOWN CONTACT INFORMATION / REQUIRED SIGNATURE

Revised: 8/2024

Outage Date(s):

Name Phone Signature

Time Frame:

Brief Description of Work:

FIRE SYSTEM OIT

N/A

Utility Operator (Bldg. 2)

NO

VHASDCROCHAE

Line

VHASDCROCHAE

Line

VA SAN DIEGO M&O Utility System Outage Request Form

Revised: 8/2024

Document Submittal Checklist

WORK PLAN

ILSM/ICRA

ACTIVITY HAZARD ANALYSIS (AHA)

CRANE LIFT PLAN

Phone

Phone

Phone

Phone

ADDITIONAL INFORMATION

VASDHS REQUIRED SIGNATURE

• Domestic hot water (Hand washing/ Showers)

• Temperature controls (Heating)

• Equipment (Sterilizers/Autoclaves)

• Trash compactor (Sanipak)

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Impacts include: