Attachment F WPB Shutdown Request Form.pdf
PDF 186 KB Posted
- Attached to
- N041--Services: Replace Damaged Ductwork Federal contract opportunity
- Solicitation number
- 36C24820Q0966
View the file
Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment 5 Damaged Duct Survey 2B.pdf | ||
| Attachment 3 7B crushed duct survey.pdf | ||
| Attachment 4 Damaged Duct Survey 2A.pdf | ||
| Attachment G Hot Work Permit Request.pdf | ||
| Attachment D W9 Vendor Form.pdf | ||
| Attachment A Pricing Schedule.xlsx | XLSX spreadsheet | |
| Attachment 7 West Palm Beach VAMC Campus Map.pdf | ||
| COMBINED SYNOPSIS SOLICITATION 36C24820Q0966.pdf | ||
| Attachment 2 7A crushed duct survey.pdf | ||
| 36C24820Q0966.docx | DOCX document | |
| Attachment 1 6A crushed duct survey.pdf | ||
| Attachment K Contractors Manual Feb 2017.pdf | ||
| Attachment H Contruction Safety Infection Prevention and Control Risk Assessment.pdf | ||
| Attachment C New Vendor Form VA10091.pdf | ||
| Attachment B Performance Work Statement.pdf | ||
| Attachment J Interim Life Safety Measures Evaluation.pdf | ||
| Attachment 6 Damaged Duct Survey 2C.pdf | ||
| Attachment E Wage Determination 15 4574.pdf |
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Text version
DATE:
FROM: CHIEF, MAINTENANCE AND OPERATIONS
SUBJ: REQUEST AND PERMISSION FOR SHUTTING DOWN OF UTILITY SYSTEMS
TO: CENTRAL CONTROL PANEL
UTILITY SHUTDOWN REQUEST FORM
TO BE FILLED OUT BY REQUESTOR:
NAME OF REQUESTOR NAME OF CONTRACTOR
C.O.R. CONTRACTOR’S TELE. #
C.O.T.R TELE # AFTER HOURS TELE. #
PROJECT NAME IN HOUSE PERSONNEL YES NO
NEAREST IN-HOUSE TELE # IN-HOUSE PERSONNEL NAME
1. UTILITY OUTAGES:
BUILDINGS AFFECTED: 1☐ 2☐ 3☐ 4☐ 6☐ 7☐ 10☐ 12☐ 13☐ 14☐ 15☐ 16☐ 19☐
BUILDING FLOORS AFFECTED: B☐ 1☐ 2☐ 3☐ 4☐ 5☐ 6☐ 7☐ 8☐ 9☐ 10☐
BUILDING SECTION: A☐ B☐ C☐ NHCU: L☐ J☐ K☐
WORK LOCATION ROOM#:
PENTHOUSE: E☐ W☐
ROOF: A☐ B☐ C☐ EAST☐ WEST☐
2. SYSTEM AFFECTED:
ELECTRICAL
☐ STEAM
☐ COLD WATER
☐ HOT WATER
☐ SILVER
RECOVERY
☐ NATURAL GAS
☐ MEDICAL AIR
☐ LABORATORY AIR
☐ DENTAL AIR
☐ SHOP AIR
☐ CONTROL AIR
☐ MEDICAL VACUUM
☐ LABORATORY VACUUM
☐ ORAL EVACUATION
☐ OXYGEN
☐ NITROUS OXIDE
☐ NITROGEN
☐ DISTILLED WATER
☐ DEIONIZED WATER
☐ REVERSE OSMOSIS
☐ FIRE SPRINKLER SYSTEM
(CANNOT BE ISOLATED WITHOUT
DIRECT AUTHORIZATION OF SUPERVISOR)
3. APPROXIMATE DURATION OF THIS SHUTDOWN DATE AND TIME (PER DAY):
DATE TIME FROM:
4. PURPOSE AND DESCRIPTION OF REQUEST:
5. REQUESTOR MUST RECEIVE APPROVAL FROM ALL DEPARTMENTS AFFECTED
BY OUTAGES:
CONTACT PERSON: LOCATION: EXT:
APPROVED ☐ DISAPPROVED ☐
CONTACT PERSON: LOCATION: EXT:
APPROVED ☐ DISAPPROVED ☐
CONTACT PERSON: LOCATION: EXT:
APPROVED ☐ DISAPPROVED ☐
CONTACT PERSON: LOCATION: EXT:
APPROVED ☐ DISAPPROVED ☐
CHIEF, M&O
APPROVED☐ DISAPPROVED☐ (SIGNATURE)
SUPERVISOR, ENERGY CENTER
APPROVED☐ DISAPPROVED☐ (SIGNATURE)
TO BE COMPLETED BY C.C.P. OPERATOR
C.C.P. OPERATOR DATE TIME
(SIGNATURE)
C.C.P. OPERATOR WILL NOTIFY ALL DEPARTMENTS AFFECTED BY OUTAGES.
C.C.P. OPERATOR WILL NOTIFY:
1. M&O CHIEF ☐
2. ENERGY CENTER OPERATIONS SUPERVISOR ☐
3. ELECTRIC SHOP SUPERVISOR ☐
4. PLUMBING SHOP SUPERVISOR ☐
5. CHIEF, FACILITIES MANAGEMENT SERVICE ☐
ALL PERSONNEL ARE REQUIRED TO USE LOCK-OUT TAG-OUT DEVICES
ON ALL SYSTEMS AND EQUIPMENT.
TO:
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