Attachment 4- Appendix E- AF 103 Dig Clearance Permit.pdf
PDF 30 KB Posted
- Attached to
- REPAIR TRUEMPER ROAD JBSA-LACKLAND TX
- Solicitation number
- MPLS239369
About this file
This document is an AF 103 Base Civil Engineering Work Clearance Request form. It is used to coordinate any work that may disrupt aircraft/vehicle traffic, base utilities, or routine installation activities. The form requires clearance approval from various stakeholders including electrical, steam, water, POL, sewer, environmental, pavements/grounds, fire protection, security police, safety, communications, and cable TV. Specific precautionary measures and the approved method of excavation must be described. The form is processed just prior to the start of work and is valid for 30 calendar days.
The related federal contract opportunity is for the REPAIR TRUEMPER ROAD project at JBSA-LACKLAND TX. This is a 100% set-aside for Women-Owned Small Businesses, with a magnitude between $1-5 million. The project has a NAICS code of 237310. Offerors must complete the SF 1442, provide unit pricing, and submit all required certifications. Electronic bids only are accepted, and a site visit is scheduled for July 9, 2024. The contracting agency is the Department of the Air Force, Air Education and Training Command.
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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.: 2024-04-19 |
| 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: Louis Limon 210-671-3093, Cell 210-269-6676 |
Ryan Moreno Secondary lines ONLY
| SIGNATURE1: |
| REMKA_2: Michael Wergin 210-739-3367 |
| SIGNATURE2: |
| REMKA_3: American Water 210-965-8574 |
| SIGNATURE3: |
| REMKA_4: Michael Wergin 210-925-8545, Cell 210-739-3367 |
| SIGNATURE4: |
| REMKA_5: American Water 210-965-8574 |
| SIGNATURE5: |
| REMKA_6: Osmar Alaniz 210-671-9354 |
Sarah Otto 210-671-0396
| SIGNATURE6: |
| REMKA_7: Dan Lange 210-671-3288 |
Located at Bldg. 5495 Rm. 404
| SIGNATURE7: |
| REMKA_8: Dana Pelletier 210-671-2921 |
Also HOT WORK (Weld) permit
| SIGNATURE8: |
| ZONE: HVAC & Fire Sys. |
| REMKB: Michael Wergin 210-739-3367 |
| SIGNATURE9: |
| OTHB: Environmental |
Restoration
| REMKC: Jose Hurtado 210-671-7228 |
| SIGNATURE10: |
| REMKD: Only if work involves road closure or effects traffic. |
Call 210-671-7261 located at building 5725
| SIGNATURE11: |
| REMKD_2: Wing Safety Rep 210-671-5028 Bldg.2484 |
| SIGNATURE12: |
| REMKD_3: Base Communications 210-671-6401, 48 hours before digging. |
| SIGNATURE13: |
| REMKD_4: For Flightline area only, 210-925-5880 or |
210-925-6802 (Flight Line area ONLY)
| SIGNATURE14: |
| REMKD_5: |
TEXAS811 1-800-344-8377
| OTHC: |
| REMKE: For SAWS email "Locates@SAWS.ORG" |
TEXAS811 1-800-344-8377
| COMUTIL: 0 |
| COMUTIL_2: 0 |
| COMUTIL_3: 0 |
| AppOffcrSig: |
| SIGNATURE16: |
| SIGNATUREfor13: |
| EF_1: |
| EF_2: |
| REMKSF: 1-Please fill out the information on No. 1-7 on the form and ensure it has a legible contact information. |
2-Dig permit meeting is every Wednesday at 1300 hours at building 7065, JBSA-Lackland, first floor, room 66, Planning Conf. Rm.
3-All entities must clear the form before the final signature.
4-Final signature can be obtained at same building room 055-A which is inside room 66.
5-Permit with final approval/date will expire in 30 calender days from the date signed.
6-An all clear email must be provided from TEXAS811 before the permit gets final approval.
| SignatureStyle1: |
| SignatureStyle2: |
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