Attachment 19 - AF Form 103.pdf
Air Force Form PDF 542 KB Posted
- Attached to
- Repair Taxiway Mike & Delta
- Solicitation number
- FA4855-21-R-0008
About this file
This document contains an Air Force Form 103 for coordinating a civil engineering work clearance request at Cannon Air Force Base in New Mexico, as well as details for a related federal contract solicitation to repair sections of Taxiways Mike and Delta at the base.
The work clearance request form outlines coordination requirements with various base organizations for a project involving excavation or utility disturbance. It details contact information for organizations including airfield management, maintenance operations, ground safety, communications, security forces, and others that must be notified prior to commencement of work. The form also includes logs for contractors to document clearance coordination activities and obtain reviewer signatures and approvals. The solicitation seeks a vendor to complete a two-phased reconstruction project for taxiways at Cannon Air Force Base, with the first phase involving removal and replacement of asphalt and concrete on Taxiway Mike and the second phase reconstructing sections of concrete and asphalt on Taxiway Delta. The work stems from a pavement condition assessment determining the need for repairs on the taxiways. The Department of the Air Force Special Operations Command is the issuing agency.
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Text version
27 SOCES FORM 103v10, 29 Feb 2016 Modified for Cannon AFB NM Page 1 of 4 PREVIOUS EDITIONS ARE OBSOLETE
BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST DATE PREPARED
(ddmmyy)
(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
A. PAVEMENT D. FIRE DETECTION & PROTECTION SYSTEM G. AIRCRAFT OR VEHICULAR
TRAFFIC FLOW
B. DRAINAGE SYSTEM E. UTILITY OVERHEAD UNDERGROUND H. SECURITY
C. RAILROAD TRACKS F. COMM OVERHEAD UNDERGROUND I. OTHER
3. DATES 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 & INITIALS
8. AIRFIELD MANAGEMENT Bldg 135 Contact 72 hrs prior to clearance rqmt/project start 575-784-2801 Airfield access required : POV pass required
9. MAINTENANCE OPERATIONS CENTER Bldg 790 Contact 48 hrs prior to clearance requirement 575-784-2135
10.
GROUND SAFETY Bldg 155 Rm 146 Contact 48 hrs prior to clearance requirement 575-784-4470, 575-784-4472, 575-784-4169, 575-784-4471 or 575-784-2583
11. COMMUNICATIONS Bldg 10 Contact 48 hrs prior to clearance requirement 575-784-6622 - Call for clearance and utility location
12. SCX Bldg 777 Rm 116 Contact 48 hrs prior to clearance requirement 575-784-1369 or 575-784-2318 - Call for clearance and utility location
14a.
SECURITY FORCES Bldg 575 Contact 48 hrs prior to clearance requirement 575-784-4111
13. COMMERCIAL UTILITY COMPANIES
New Mexico 811 Contact 48 hrs prior to clearance requirement 1- 800 -321-2537 - Note date & request number.
Date ____________________
Request # ________________
X TELEPHONE
X CABLE
. B
A
SE
C
IV
IL
E
N G
IN
EE
R
IN
G , B ld g
A. ELECTRICAL DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-4371 - Call for clearance and utility location
B. GAS DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location
C. WATER DISTRIBUTION
D. SEWER DISTRIBUTION
E. IRRIGATION SYSTEMS HAND DIG ONLY (Unless waived by CEO) CEO Approved ________________________
F. POL DISTRIBUTION
G. ENVIRONMENTAL Call 575-904-6736 in the event environmental problems are encountered during excavation
H. PAVEMENTS / GROUNDS Contact 48 hrs prior to clearance requirement 575-784-4383 - Call for clearance and utility location
I. FIRE PROTECTION Contact 48 hrs prior to clearance requirement 575-784-2578 - Call for clearance and utility location
J. EMCS / HVAC Contact 48 hrs prior to clearance requirement 575-784-1132 - Call for clearance and utility location
K. GEOBASE OFFICE Contact 48 hrs prior to clearance requirement 575-784-1628 - Call to update maps or utility tabs
16. OTHER (Specify)
17. REQUESTED CLEARANCE APPROVED DISAPPROVED
18. TYPED NAME AND SIGNATURE OF APPROVING OFFICIAL (Chief of Operations Flight or CEO Designee} 18a. DATE SIGNED (ddmmyy)
Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location
Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location
Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location
WEAPONS SAFETY14b. Bldg 155 Rm 134
Project Manager/COR (Print Name) _______________________________________________
19. Remarks. (This section describes specific precautionary measures to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment should be listed)
Equipment being used: ______________________________________________________________________________
1. Contractor will not proceed with any work until clearance has been coordinated as indicated by remarks that have been provided. Signatures on section 14 A through E and J on page 1 do not constitute approval. Approval for these blocks is provided on page 3.
2. Any drawings provided indicate the APPROXIMATE location of the work area.
3. Contractor shall contact and give notice to all listed organizations by calling the phone numbers as listed in the remarks section next to each organization.
a. It is very important all clearance requests are made and understood by the contractor. The contractor shall log all calls and activities made to each organization as listed on the AF 103. The log information will be placed on page 3 of the AF 103. Each entry will be kept in a numbered, sequential order by date and organization.
Note: If additional pages are required for the clearance log, record is to be attached to the original AF103.
b. If clearance is not required in the location of this request, the contractor will note the reviewer’s name and date/time the organization was contacted and indicate “No Action Required”.
c. If clearance is required by the organization, the contractor will coordinate a site meeting with the reviewer(s) representing that organization. The reviewer will physically spot the clearance issue and/or mark the location. The contractor will then have the reviewer fill in his name and initials in the Reviewers Name and Initials column on page 1 for that organization. The contractor will also log on page 3 of the AF103, the meeting, date/time, person(s) name, and action taken.
6. As-builts for irrigation systems are not available. The contractor will ensure restoration of landscaping and repair of irrigation systems are completed, at no cost to the government, during the course of work.
7. In the event any unknown or unidentified items are discovered during demolition or construction, work shall cease immediately and 27 SOCES/CEAN shall be notified.
Contact the Restoration Program at 575-784-1095.
8. Notify Bioenvironmental Engineering Flight (Bldg 1400; 575-784-4063) at least 3 working days in advance if any type of maintenance/repair/modification is being performed on water mains, pipes and service lines to include emergency repairs; especially if water is being shut off to buildings/facilities in order to complete these repairs.
9. Notify the New Mexico Environment Department of potable water line work associated with this project IAW New Mexico Administrative Code 20.7.10., Drinking Water, Para. 200B. Notification must be made on the form entitled "Application for the Construction or Modification of a Public Water Supply System." Contact the Water Quality Program Manager, 27 SOCES/CEIEC, at 575-904-6736 for questions.
4. The contractor will notify the Contracting Officer Representative (COR) or Project Manager (Box 5) if there are any questions or concerns to ensure proper coordination of this Work Clearance Request.
13.
14.
The contractor or his agent is responsible for removing and disposing of any/all flags or survey marking whiskers within his site upon completion of excavation.
The contractor or his agent will maintain this clearance request on the site and make it available for review by any Government representative upon request.
Notify CE Service Call/After-Hours emergency @ 575-784-2001 and 27 SOCS (TSgt Vitense) @ 916-705-9452 or Mr. Labbour @ 575-693-5220 if any utilities are damaged after normal work hours.
Contractor Representative (Print Name) _______________________________ Telephone No. _____________
Date_________________
Telephone No. _____________
INSTRUCTIONS
The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular 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 re-processed.
Signature__________________________________________________________________
5. The contractor is responsible for maintaining all marks on his work site. Locates that must be re-performed will require the contractor to coordinate line spotting on block 14 sections A through K at the weekly Work Clearance Request meeting.
12.
(NOTE: Work cannot begin until signed by Contractor Representative)
11. If marked utilities are not found (hand excavated, pot-holed etc.) within three feet of the marker or flag, the contractor MUST re-contact the section responsible for placing the mark to verify utility location.
10. Use of reclaimed wastewater for construction activities is highly encouraged and may be a contract requirement. Reclaimed (nonpotable) wastewater is available at a fill stand outside the wastewater treatment plant compound (east side of CAFB). Contact Mr. John Rebman, 27 SOCES/CEIEC (904-6736) prior to obtaining water from this fill stand for important instructions. Note that the reclaimed wastewater fill stand is located in close proximity to the potable water hydrant. Please do not confuse these two sources with one another.
27 SOCES FORM 103V10, 29 Feb 2016 Modified for Cannon AFB NM Page 2 of 4 PREVIOUS EDITIONS ARE OBSOLETE
Prevent potential storm water infiltration into the sanitary sewer system during demolition and construction by blocking pathways (e.g., open sewer drains and manholes during demolition/construction) that lead to the CAFB wastewater treatment plant. Infiltration of excessive storm water and/or mud may lead to violations of an Environmental Protection Agency issued permit.
15.
Action Log
27 SOCES FORM 103v10, 29 Feb 2016 Modified for Cannon AFB NM Page 3 of 4 PREVIOUS EDITIONS ARE OBSOLETE
Base Utility Locater Action Taken Contractor Date/Time Electrical Distribution EMCS / Alarms / HVAC Gas Distribution
Water Distribution Sewer Distribution Irrigation / Landscaping Comm / Americom
GEO Base
New Mexico 811 Locater Action Taken Contractor Date/Time SuddenLink CenturyLink Plateau
Organization Name Action Taken Contractor Date/Time 1.
2.
3.
4.
5.
6.
7.
8.
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11.
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18.
| AF103v6 |
| Dig Permit Building Stops |
| DATE PREPARED ddmmyyBASE CIVIL ENGINEERING WORK CLEARANCE REQUEST See Instructions on Reverse: |
| Contract No: |
| I OTHER: |
| 4 DATE OF CLEARANCE: |
| 6 TELEPHONE NO: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757842801 Call for clearance: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757842135: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757842811: |
| CEO Approved: |
| Date Request Contact 48 hrs prior to clearance requirement 5757841195 Call for clearance and utility location: |
| Date Request Contact 48 hrs prior to clearance requirement 5757841610 Call to update maps or utility tabs: |
| 18a DATE SIGNED ddmmyy18 TYPED NAME AND SIGNATURE OF APPROVING OFFICIAL Chief of Operations Flight or CEO Designee: |
| Equipment being used 1: |
| Equipment being used 2: |
| Contractor Representative Print Name: |
| Telephone No: |
| Date_2: |
| Project ManagerCOR Print Name: |
| Telephone No_2: |
| Electrical Distribution: |
| EMCS Alarms HVAC: |
| Gas Distribution: |
| Water Distribution: |
| Sewer Distribution: |
| Irrigation Landscaping: |
| Comm Americom: |
| GEO BaseRow1: |
| GEO BaseRow2: |
| SuddenLink: |
| CenturyLink: |
| PlateauRow1: |
| PlateauRow2: |
| 1: |
| 2: |
| 3: |
| 4: |
| 5: |
| 6: |
| 7: |
| 8: |
| 9: |
| 10: |
| 11: |
| 12: |
| 13: |
| 14: |
| 15: |
| 16: |
| 17: |
| 18: |
| Text1: |
| Text2: |
| Text5: |
| Text6: |
| 16 OTHER Specify: |
| Date Request Contact 48 hrs prior to clearance requirement 5757844371 Call for clearance and utility location: |
| Date Request Contact 48 hrs prior to clearance requirement 5756932565 Call for clearance and utility location: |
| Date Request Contact 48 hrs prior to clearance requirement 5756932565 Call for clearance and utility location_2: |
| Date Request Contact 48 hrs prior to clearance requirement 5756932565 Call for clearance and utility location_3: |
| Date Request HAND DIG ONLY Unless waived by CEO CEO Approved: |
| Date Request Contact 48 hrs prior to clearance requirement 5757846742 Call for clearance and utility location: |
| Date Request Call 5757841099 in the event environmental problems are encountered during excavation: |
| Date Request Contact 48 hrs prior to clearance requirement 5757844383 Call for clearance and utility location: |
| Date Request Contact 48 hrs prior to clearance requirement 5757842578 Call for clearance and utility location: |
| Request: |
| Date: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757844111: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757846103 Call for clearance and utility location: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757846622 Call for clearance and utility location: |
| Check Box1: Off |
| Check Box2: Off |
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| Check Box4: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
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| Check Box14: Off |
| Check Box15: Off |
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| Check Box17: Off |
| Text18: |
| Text19: |
| Text20: |
| Text21: |
| YES: |
| NO: |
| Weapon Safety REVIEWERS NAME INITIALS: |
| TELEPHONE: |
| CABLE: |
| A ELECTRICAL DISTRIBUTION: |
| B GAS DISTRIBUTION: |
| C WATER DISTRIBUTION: |
| D SEWER DISTRIBUTION: |
| E IRRIGATION SYSTEMS: |
| F POL DISTRIBUTION: |
| G ENVIRONMENTAL: |
| H PAVEMENTS GROUNDS: |
| I FIRE PROTECTION: |
| J EMCS HVAC: |
| K GEOBASE OFFICE: |
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