Atch 47-AF Form 103 - Outage Request.pdf

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)

* UTILITY OUTAGES MUST BE SUBMITTED AT LEAST 30 DAYS IN ADVANCE.

1. What is the specific address and/or location where the work will be done?

2. Include a map with plain view reference points (building numbers, road names, ect...)?

3. Is this outage a road closure? If so provide detailed detour map.

4. Provide a detailed description of work:

4. What is the requested work directly in support of (facility repair, infrastructure repair, project construction)?

5. Requested outage START DATE & TIME?

Start Date: ________ Start Time: ________

End Date: ________ End Time: ________

6. What facility(s) will be affected by this outage?

7. Will Base Housing area be affected by this outage?

8. Who is the Project Manager or Point of Contact within CE?

9. Are there any reasons why work cannot be done after hours (>1700hrs) and/or over the weekend (Saturday & Sunday)?

Yes No If yes, explain: ______________________________________________________________

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)

FOR ELECTRICAL OUTAGES, CONTACT ELECTRICAL SHOP (702-652-3114/8143) AND YOUR 99 CES PROJECT

MANAGER TO COORDINATE AND DISCUSS OUTAGE DETAILS BEFORE SUBMITTING AF FORM 103