Appendix A - AF Form 103 - Work Clearance Request.pdf

DATE PREPAREDJB Charleston - Air Base - 628 CES - DIG PERMIT 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 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. STEAM DISTRIBUTION

C. WATER/SEWER DISTRIBUTION

D. POL DISTRIBUTION

E. WATER/SEWER DISTRIBUTION

F. ENVIRONMENTAL

G. PAVEMENTS/ GROUNDS

H. FIRE PROTECTION

I. ZONE - GEO Thermal

J. HVAC - GEO Thermal

9. SECURITY POLICE

10. SAFETY

11. COMMUNICATIONS

12. BASE OPERATIONS

13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

TELEPHONE

GAS

ELECTRIC

15. MARKING REQUEST APPROVAL

16. REQUESTED CLEARANCE INITIAL APPROVAL DISAPPROVED

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

AB Dig Permit Current a of 2 Aug 2024AF IMT 103, 19940801, V3

Will be completed by 628 CES/Requirements West Locating Service Signature Will be completed by 628 CES/Requirements West Locating Service Signature

Will be completed by 628 CES/Requirements West Locating Service Signature

Will be completed by 628 CES/Requirements West Locating Service Signature N/A for housing areas

Bldg 703 (843)1511 / trever.scott.1@us.af.mil

Will be completed by 628 CES/Requirements West Locating Service Signature

Enter PUPS assigned tracking # here for reference:

Will be completed by 628 CES/Requirements West Locating Service Signature

Call 3 duty days prior to dig

Airfield Only

See block 14

Palmetto Utility Protection Services (www.sc1pups.org) (1-888) 721-7877 / M-F (0730-1730)

Call again 3 duty days prior to dig

Bldg 16000 (843) 963-7989 / 437aw.se@us.af.mil Call 3 duty days prior to dig

SQ FT of area to be marked _____________________________.

Bldg 425 (843) 963-5049 / emmett.martin@us.af.mil

Bldg 129 (843) 963-1290 / 628cs.scoi@us.af.mil

Bldg 169 (843) 963-3028 /sherri.knotts.2@us.af.mil

Bldg 168 (843)963-3122 / christopher.shaw.28@us.af.mil Only for blocked roads/parking lots

Bldg 254 Rm 167 (843) 963-4066 / jennifer.kersey.2@us.af.mil Only for blocked roads/parking lots

B A S E

C I V I L

E N G I N E E R I N G

Bldg 247 (843) 963-2701/laura.powers.3@us.af.mil Bldg 721 (843) 963-1470/mark.darrington.1@us.af.mil

N/A for Housing Areas

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1. AF 103 Completion Instructions:

a) Fill in "Date Prepared"

b) Section 1: Print Building Number/Address, Work Order Number, and Square Footage of area to be marked. If a Contact Number is associated with this work, include the COR and their contact information.

c) Section 2: Print type of work to be completed. Check the appropriate field.

d) Section 3: Print date that the requested work is scheduled to begin.

e) Section 5-7: Print full name, telephone number, and requesting organization. Provide an alternate POC if available.

f) Section 8: Garner signatures from the appropriate agencies for sub-sections "E", "F", "H", "J", as applicable.

g) Section 9-12: Garner signatures from the listed agencies as applicable.

h) Section 13-14: Contact Palmetto Utility Protection Services and print the tracking number that you are provided.

2. Submission Instructions and Information:

a) Submit (1) completed AF 103, (2) detailed description of the work, and (3) map of work area to 628 CES/Requirements. The package may be dropped off at Bldg 721/Suite 3 or emailed to 628CES.CEOER.CustomerService@us.af.mil (843-963-2392).

b) Approved AF 103s are valid for 30 days after the date entered in Section 17a. Requests must be re-submitted if expired.

Requestor is responsible for maintenance of utility markings for duration of project. Approved AF 103 must be on site while excavation is underway.

c) 628 CES requires a minimum between 5 duty days (less than 3 acres) and 8 duty days (over 3 acres) to process dig permits.

After work is complete, the removal of all flags, stakes or non-paint markings is the responsibility of the requestor. By signing this statement you agree to the terms above.

Printed Name

Signature/Date

Description of Work to be accomplished:

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.

AF IMT 103, 19940801, V3.1 (REVERSE)

AB Dig Permit Current as of 2 Aug 2024

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.)

Individual Housing Units only require PUPS and COMMUNICATIONS notification (CE Contractor locates Utilities)

1046596354C

DATE PREPAREDJB Charleston - Weapons Station - 628 CES - DIG PERMIT 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 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. STEAM DISTRIBUTION

C. WATER/SEWER DISTRIBUTION

D. POL DISTRIBUTION

E. WATER/SEWER DISTRIBUTION

F. ENVIRONMENTAL

G. PAVEMENTS/ GROUNDS

H. FIRE PROTECTION

I. ZONE - GEO Thermal

J. OTHER- Natural Gas

9. SECURITY POLICE

10. SAFETY

11. COMMUNICATIONS

12. BASE OPERATIONS

13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

TELEPHONE

GAS

ELECTRIC

15. MARKING REQUEST APPROVAL

16. REQUESTED CLEARANCE INITIAL APPROVAL DISAPPROVED

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

WS Dig Permit Current a of 2 Aug 2024AF IMT 103, 19940801, V3

Will be completed by 628 CES/Requirements West Locating Service Signature Will be completed by 628 CES/Requirements West Locating Service Signature

Will be completed by 628 CES/Requirements West Locating Service Signature

Bldg 2 (843)794-7806 / kurt.gartung.1@us.af.mil

Will be completed by 628 CES/Requirements West Locating Service Signature

Enter PUPS assigned tracking # here for reference:

Will be completed by 628 CES/Requirements West Locating Service Signature

See block 14

Palmetto Utility Protection Services (www.sc1pups.org) (1-888) 721-7877 / M-F (0730-1730)

Call again 3 duty days prior to dig

Bldg 16000 (843) 963-7989 / 437aw.se@us.af.mil Call 3 duty days prior to dig

SQ FT of area to be marked _____________________________.

Bldg 168 (843)963-3122 / christopher.shaw.28@us.af.mil Only for blocked roads/parking lots

B A S E

C I V I L

E N G I N E E R I N G

Bldg 254 Rm 167 (843)963-4066/jennifer.kersey.2@us.af.mil Only for blocked roads/parking lots

See Block 18

Bldg 247 (843) 963-2708 /AFCEC.CZO.JBChasISS@us.af.mil Bldg 721 (843)963-1470/mark.darrington.1@us.af.mil

N/A for housing areas

1531711692A concerning the approved method of excavation, hand or powered equipment, should be included.)

SHORT STAY & Individual Housing units only require PUPS and CE notification (CE Contractor locates Utilities)

1. Complete the AF 103 form as completely as you can. This form is attached to email request. Once a dig permit has been received and is complete with all required coordination and PUPS information, 628th Civil Engineer Squadron requires a minimum of 5 business days for processing and final signature approval.

2. You will need to provide a sketch, print or picture and square footage of area where work is to be accomplished

3. All dig permits require a PUPS number, call (1-888-721-7877) and be sure to include this ticket number on block 14

4. Approval coordination must also be received by :

NIWC Facilities Help Desk (843-218-4015) (ssclant_fac_hdesk@navy.mil) NMCI (843-794-4545) POC Joseph L. Richardson (joseph.l.richardson@nmci-isf.com) SDDC (843-794-0516 POC Christopher M. Fortenberry (christopher.m.fortenberry2.civ@army.mil) AFSBN (843-794-8725) POC James Doherty (james.g.doherty.civ@army.mil) AFSBN (843-794-8717) POC (Alternate) Brent Baxter (brent.c.baxter.civ@army.mil) COMM (843-794-7702) POC Marie Roberson (Bettina.roberson@us.af.mil) ENV (843-963-2708) AFCEC.CZO.JBChaslSS@us.af.mil

SAFETY (843-794-7666) email address: 437aw.se@us.af.mil

ONLY IF NEEDED - Fire Dept. (843-794-7889)

Include a summary and/or email thread for EACH entity contacted for coordination or this may hold up the final approval process. CE needs to know if the agencies above have fiber in the area and where it is in relation to your dig request.

5. Once coordination is complete, forward your AF 103 (including area sketch) to CE Customer Service:

628CES.CEOER.CustomerService@us.af.mil> 843-963-2392

We will assign you a dig permit tracking number and forward your request package on for approval.

6. Final approval for dig permits are completed by:

john.harriger@us.af.mil 843-794-7075 or kurt.gartung.1@us.af.mil 843-794-7806

Please note that approval cannot be accomplished without complete coordination, sketch, SQ Footage, and obtaining a tracking number from CE Customer Service

NOTE: Approved AF Form 103s are valid for 30 days after the date entered in block 17a. Requests must be re-submitted once the form has expired and the work has yet to begin.

NOTE: After Initial approval, it is required that Project Managers ensure that contractor/requesters maintain the utility markings for the duration of the project.

NOTE: After work is complete, the removal of all flags, stakes or non-paint markings is the responsibility of the requester.

NOTE: Approved AF 103 MUST be "on site" while excavation is underway. Emergency contact numbers are on the form if a utility line is hit or discovered.

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

AF IMT 103, 19940801, V3 (REVERSE)

WS Dig Permit Current as of 2 Aug 2024

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Printed Name

Signature/Date

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.

AF IMT 103, 19940801, V3 (REVERSE)

WS Dig Permit Current as of 2 Aug 2024

7. By signing this statement you agree to the terms above.

Description of Work to be accomplished:

Requestor's Email Address:

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COORDINATORS

*Required for Every

Request

COMMENTS

*NIWC

*NMCI

*SDDC

*AFSBN

*ENVIORNMENTAL

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*SAFETY

*COMM

FIRE DEPARTMENT