Attachment 2.4 - 27 SOCES Form 103 Work Clearance Request.pdf
PDF 2 MB Posted
- Attached to
- Multiple Award Basic Ordering Agreement for Construction Services at Cannon AFB, NM Federal contract opportunity
- Solicitation number
- FA485524R0004
About this file
This document includes a Work Clearance Request form and related federal contract opportunity. The Work Clearance Request form is used to coordinate required work with key base activities at Cannon Air Force Base, New Mexico. It details the process for contractors to request clearance for any work that may disrupt aircraft/vehicular flow, utilities, fire/intrusion systems, or base activities. Contractors must contact listed organizations in the remarks section to coordinate clearances and log all activities on the form. The related federal contract opportunity is a Multiple Award Basic Ordering Agreement for construction services at Cannon AFB. The BOA would require contractors to accomplish a range of sustainment, maintenance, repair, alteration, renovation, and minor construction projects affecting real property. Work may require design by licensed engineers/architects. Projects would fall under design-build, partial design-build, or construction-only categories as defined in individual Task Order Proposal Requests. The agency is the Department of the Air Force Special Operations Command.
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Text version
Date ____________________ Request # ________________
27 SOCES FORM 103v16, 26 Feb 2020 Modified for Cannon AFB NM Page 1 of 4 PREVIOUS EDITIONS ARE OBSOLETE
BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST
PAGE 1 of 3 (Excluding Map
(See Instructions on Reverse)
1. Clearance is requested to proceed with work at: _________________________ __________________________________________
Contract No.____________________________________involving excavation or utility disturbance per On Work Task No ____ _________________ 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/VEHICLE TRAFFIC FLOW
(ALSO REQUIRES CAFB FORM 3624
B. DRAINAGE SYSTEM E. UTILITY OVERHEAD UNDERGROUND H. SECURITY
C. RAILROAD TRACKS F. COMM OVERHEAD UNDERGROUND I. OTHER
4. DATES CLEARANCE REQUIRED
6. REQUESTING AGENCY NAME (CONTRACTOR/SHOP NAME) 7. TYPED/PRINTED NAME AND SIGNATURE OF REQUESTING OFFICIAL 8. TELEPHONE NO.
ORGANIZATION REMARKS (Use Reverse for additional comments} REVIEWER'S NAME & INITIALS
9. AIRFIELD MANAGEMENT Bldg 135
10. SECURITY
17. GROUND SAFETY Bldg 155 Rm 120
11. COMMUNICATIONS Bldg 10
12. SCX Bldg 777 Rm 116
Bldg 575
13. COMMERCIAL UTILITY COMPANIES
X TELEPHONE
X CABLE
.B
A
SE
C
IV
IL
E
N G
IN
EE
R
IN
G , B ld g
A. ELECTRICAL DISTRIBUTION
B. GAS, WATER, SEWER DISTRIBUTION &
IRRIGATION
14. FIRE PROTECTION (B158)
19. OTHER
20. REQUESTED CLEARANCE DISAPPROVED
21. TYPED/PRINTED NAME & SIGNATURE OF APPOVING OFFICIAL (CEO Infrastructure, Facilities or Heavy Repair Superintendent) 21a. DATE SIGNED (ddmmyy)
18. WEAPONS SAFETY Bldg 155 Rm 134
APPROVED
D. ENVIRONMENTAL (B102)
F. PAVEMENTS / GROUNDS
Contact 72 hrs prior to clearance rqmt/project start 575-784-2801 Airfield access required : POV pass required
Contact 48 hrs prior to clearance requirement 575-784-4111
Contact 48 hrs prior to clearance requirement 575-784-6622 - Call for clearance and utility location
Contact 48 hrs prior to clearance requirement 575-784-1369 or 575-784-2318 - Call for clearance and utility location
New Mexico 811 Contact 48 hrs prior to clearance requirement 1- 800-321-2537 - Note date & request number.
Contact 48 hrs prior to clearance requirement 575-784-2578 - Call for clearance and utility location
E. RESTORATION (B102)
C. POL DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-218-5025 - Call for clearance and utility location
Attach if completed Call 575-904-6736 if environmental issues are encountered.
Contact 48 hrs prior to clearance requirement 575-784-4383 - 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 575-760-0324 or 575-784-4371 - Call for clearance and utility location
Contact 48 hrs prior to clearance requirement 575-784-4470, 575-784-4472, 575-784-4169, 575-784-4471 or 575-784-2583
Contact 48 hrs prior to clearance requirement 575-784-4470, 575-784-4472, 575-784-4169, 575-784-4471 or 575-784-2583
Call 575-904-6744 for restoration inspection or in the event unexpected debris or evidence of soil contamination is encountered
G. STORM SEWER/DRAINAGE Contact 48 hrs prior to clearance requirement 575-784-4383 - Call for clearance and utility location
(B355) Request maps or surveying at https://maps.af.mil/ers/request_new.aspx.
(Requires .mil e-mail). Call 575-784-2829 to update maps/utilities
J. CORROSION ENGINEER (as applicable) (B355)
Contact 48 hrs prior to clearance requirement 575-784-6196 - Call for disturbance of existing systems or installations of new systems.
Contact 48 hrs prior to clearance requirement 575-784-6961 - Call for real property disposition and newly acquired facilities
Block 21 will not be signed until this block is signed and the corresponding block on page 2 is signed
(B355)
(B371)
(B356)
(B356)
(B102)
(B102)
(B3253)
(B3253)
3. EST'D DEPTH OF CONSTRUCTION
(B356)
H. REAL PROPERTY
I. GEOBASE (as applicable)
16. GOVERNMENT PROJECT/DESIGNATED REP
5. DATE PREPARED
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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: ______________________________________________________________________________
13.
14.
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.
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 G 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.
4.
5.
6.
7.
8.
9.
12.
Contractor Representative (Print Name) _______________________________
Signature__________________________________________________________________ (NOTE: Work cannot begin until signed by Contractor Representative)
11.
10.
27 SOCES FORM 103V16, 26 Feb 2020 Modified for Cannon AFB NM Page 2 of 4 PREVIOUS EDITIONS ARE OBSOLETE
The contractor will notify the Contracting Officer Representative (COR) or Project Manager (Box 16) if there are any questions or concerns to ensure proper coordination of this Work Clearance Request.
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 G at the weekly Work Clearance Request meeting.
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.
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 575-904-6744.
Notify Bioenvironmental Engineering Flight (Bldg 1408; 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.
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 or 6738 for questions.
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 27 SOCES/CEIEC (904-6736) or (904-6738) 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.
If marked utilities are not found (hand excavated, pot-holed etc.) within three feet of the marker or flag (defined as 18" on either side of the mark, the contractor MUST re-contact the section responsible for placing the mark to verify utility location and/or hand dig only.
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.
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 Comm Focal Point (575)-784-8500 if any utilities are damaged after normal work hours. This form must be recertified by CAFB AF 103 approval authority every 30 days. NM One Call requires recertification every 10 days (CAFB recommends 7 day renewal for NM One Call to prevent a lapse in certification). Recertification actions are documented on page 3.
Contact CE GEO-Base office if any unmarked lines are found (784-2829).
15.
16.
Government Project Manager/COR (Print Name) same signatory as in block 19
Page 2 of 3 (excluding map) on project/work task/contract number __________________________________________
17.
Action Log
27 SOCES FORM 103v16, 26 Feb 2020 Modified for Cannon AFB NM Page 3 of 4 PREVIOUS EDITIONS ARE OBSOLETE
Base Utility Locater Action Taken Date/Time Electrical
Gas/Water/Sewer/Irrigation
Comm / Strand
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.
9.
Recertification NM One Call week 1 NM One Call week 2 NM One Call week 3 NM One Call week 4 CAFB Recertification
POL distribution
Page 3 of 3 (excluding map) on project/work task/contract number __________________________________________
| AF103v6 |
| Dig Permit Building Stops |
| 2019 af103map.pdf |
| Slide Number 1 |
| 2019 af103map.pdf |
| Slide Number 1 |
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AF FORM 813, 19990901 (EF-V1)
Page of
THIS FORM CONSOLIDATES AF FORMS 813 AND 814.
PREVIOUS EDITIONS OF BOTH FORMS ARE OBSOLETE.
Page of
REQUEST FOR ENVIRONMENTAL IMPACT ANALYSIS
SECTION I - PROPONENT INFORMATION
INSTRUCTIONS: Section I to be completed by Proponent; Sections II and III to be completed by Environmental Planning Function.
Continue on separate sheets as necessary and reference appropriate item number(s).
SECTION II - PRELIMINARY ENVIRONMENTAL SURVEY (Check appropriate box and describe potential environmental effects including cumulative effects) (+=positive effect; 0=no effect; - = adverse effect; U=unknown effect)
U
7. AIR INSTALLATION COMPATIBLE USE ZONE/LAND USE (Noise, accident potential, encroachment, etc.)
8. AIR QUALITY (Emissions, attainment status, state implementation plan, etc.)
9. WATER RESOURCES (Quality, quantity, source, etc.)
10. SAFETY AND OCCUPATIONAL HEALTH (Asbestos/radiation/chemical exposure, explosives safety quantity distance, bird/wildlife aircraft hazard, etc.)
11. HAZARDOUS MATERIALS/WASTE (Use/storage/generation, solid waste, etc.)
12. BIOLOGICAL RESOURCES (Wetlands/floodplains, threatened or endangered species, etc.)
13. CULTURAL RESOURCES (Native American burial sites, archaeological, historical, etc.)
14. GEOLOGY AND SOILS (Topography, minerals, geothermal, Installation Restoration Program, seismicity, etc.)
15. SOCIOECONOMIC (Employment/population projections, school and local fiscal impacts, etc.)
16. OTHER (Potential impacts not addressed above.)
SECTION III - ENVIRONMENTAL ANALYSIS DETERMINATION
17.
8.2.1.4029.1.523496.503679
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| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757842811: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757846622 Call for clearance and utility location: |
| REVIEWER S NAME INITIALSContact 48 hrs prior to clearance requirement 5757842135: |
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File details come from the government source that posted it. Updated .