Attachment 24 AF FORM 103 Work Clearance.pdf
PDF 29 KB Posted
- Attached to
- Fiber Optic Cable Install - Qty 6 Federal contract opportunity
- Solicitation number
- FA671223Q0014
About this file
This document is an Air Force Form 103 Work Clearance Request form. The form requests clearance to proceed with excavation or utility disturbance work at a specified location involving pavements, drainage systems, railroad tracks, overhead and underground utility and communication lines, aircraft or vehicular traffic flow, security systems, fire detection and protection systems, or other facilities. It requires information such as the date clearance is requested, date clearance is needed, signature of requesting official, and contact information. Upon approval, remarks and specific precautions to be taken before and during work are documented. An attached federal contract opportunity involves a solicitation by the Department of the Air Force Reserve Command for the installation of approximately six miles of fiber optic cable with responses due by a specified date.
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DATE PREPARED
BASE 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 FLOW
A. PAVEMENTS
D. FIRE DETECTION & PROTECTION SYSTEMS
H. SECURITY
B. DRAINAGE SYSTEMS
E. UTILITY
OVERHEAD
UNDERGROUND
I. OTHER
C. RAILROAD TRACKS
F. COMM
OVERHEAD
UNDERGROUND
4. DATE OF CLEARANCE
3. DATE CLEARANCE REQUIRED
5. SIGNATURE OF REQUESTING OFFICIAL
6. TELEPHONE NO.
7. ORGANIZATION
REMARKS
(Use Reverse for additional comments)
REVIEWER'S NAME AND INITIALS
ORGANIZATION
8.
A. ELECTRICAL DISTRIBUTION
B A S
B. STEAM DISTRIBUTION
E
C. WATER DISTRIBUTION
C I
D. POL DISTRIBUTION
V I L
E. SEWER DISTRIBUTION
E N
F. ENVIRONMENTAL
G I
G. PAVEMENTS/ GROUNDS
N E E
H. FIRE PROTECTION
R I
I. ZONE
N 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)
APPROVED
DISAPPROVED
16. REQUESTED CLEARANCE
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 IMT 103, 19940801, V3
Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign
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 IMT 103, 19940801, V3
(REVERSE)
8.2.1.3158.1.475346.466429
| HAS: 0 |
| HASNOT: 0 |
| APPRVD: 0 |
| DAPPRVD: 0 |
| Entery date as YYYYMMDD.: |
| LOCA: |
| WONO: |
| CTRNO: |
| ABC: 0 |
| ABC_2: 0 |
| ABC_3: 0 |
| D: 0 |
| E: 0 |
| F: 0 |
| OVHA: 0 |
| OVHB: 0 |
| UNDGA: 0 |
| UNDGB: 0 |
| GHI: 0 |
| GHI_2: 0 |
| GHI_3: 0 |
| OTH: |
| Enter date as YYYYMMDD.: |
| ReqOffclSig: |
| TELE: |
| ORGN: |
| REMKA: Contractor is required to locate and mark all electrical lines |
before excavating.
| SIGNATURE1: |
| REMKA_2: |
N/A
| SIGNATURE2: |
| REMKA_3: Contractor is required to locate and mark all water distribution lines before excavating |
| SIGNATURE3: |
| REMKA_4: Contractor is required to locate and mark all POL distribution lines before excavating |
| SIGNATURE4: |
| REMKA_5: Contractor is required to locate and mark all sewer |
distribution infrastructure before excavating.
| SIGNATURE5: |
| REMKA_6: Adhere to soil and erosion control measures during |
excavation. See comments on the back of the form.
| SIGNATURE6: |
| REMKA_7: |
| SIGNATURE7: |
| REMKA_8: |
| SIGNATURE8: |
| ZONE: N/A |
| REMKB: |
| SIGNATURE9: |
| OTHB: |
| REMKC: |
| SIGNATURE10: |
| REMKD: |
| SIGNATURE11: |
| REMKD_2: |
| SIGNATURE12: |
| REMKD_3: |
| SIGNATURE13: |
| REMKD_4: |
| SIGNATURE14: |
| REMKD_5: |
| OTHC: |
| REMKE: |
| COMUTIL: 0 |
| COMUTIL_2: 0 |
| COMUTIL_3: 0 |
| AppOffcrSig: |
| SIGNATURE16: |
| SIGNATUREfor13: |
| EF_1: |
| EF_2: |
| REMKSF: Utilities shown on attached drawings are approximate and are for reference |
only. Drawing may not show locations of all underground lines and existing lines may not be shown in exact position. Contractor is responsible for marking of utility lines.
Environmental:
The area of excavation is___ or is not___ in an area of known contamination. However, should contaminated soil be encountered, contractor shall stop all excavation and segregate contaminated soil immediately. No further work shall be done until direction is provided by the Environmental Flight through the Contracting Officer.
Proper erosion and sediment controls should be provided by the contractor to ensure that no excavated material enters the storm sewer system.
| SignatureStyle1: |
| SignatureStyle2: |
File details come from the government source that posted it. Updated .