Attachment 42-Work Request Blank.pdf

PRIORITY (OAO USE) WORK REQUEST

OFFICE OF ARTESIA OPERATIONS

DATE ORIGINATOR'S NAME AND AGENCY/BRANCH BLDG # :

ROOM # :

DESCRIPTION OF WORK REQUESTED: (PROVIDE MEASUREMENTS AND ATTACH SKETCHES WHEN POSSIBLE)

Name/Title: Signature: Date:

Name/Title: Signature: Date:

Name/Title: Signature: Date:

IDIQ Contract:

Name/Title: Signature: Date:

DATE RECEIVED:

WR LOG ENTRY WR FILE CREATED FUNDING CODE MOM ENTRY

COR/PM: Signature: Date:

DATE RECEIVED: PROJECT TITLE:

PRELIMINARY CAPITALIZATION REPORT SUBMITTED:

ELECTRONIC AS-BUILT FILES RECEIVED: FINAL CAPITALIZATION REPORT SUBMITTED:

AD/Designee: Signature: Date:

(REV 6/18) PAGE 1 OF 2

Section VIII - AD, OAO Approval Decision and Funding

(Print) Funding Approval #:

Section IV - Master Plan and Construction Division

* FOR PROCESSING SEND TO BUILDING 190

(Print)

Section II - Supervisor Approval

(Print)

(Print)

(Print)

(Print)

Section VII - Assignment (COR / MCB Project Manager)

Section VI - Clerk Entries

Section V - Contracting Officer / COR

(Continue on Reverse/Page 2)

DESCRIBE WHERE (LOCATION) WORK REQUESTED IS TO BE PERFORMED: REQUESTED COMPLETION DATE:

JUSTIFICATION: CHECK HERE IF SAFETY/HEALTH ISSUES:

(Continue on Reverse/Page 2)

Facilities Contract:

Section III - Second line Supervisor, Agency Representative (Chief/SAC) Approval

Work Request # MCB

PHONE #/EXTENSION

Section I - Request Originator Information

DESCRIPTION OF WORK: (continued from page 1)

JUSTIFICATION: (continued from page 1)

(REV 06/18) PAGE 2 OF 2