ATTACHMENT H - Utility Shutdown Request Form.docx
DOCX document 407 KB Posted
- Solicitation number
- 36C25222Q0586
About this file
This document contains a utility shutdown request form for the Oscar G. Johnson VA Medical Center. The form requires contractors to submit requests for utility shutdowns a minimum of 10 business days in advance of the scheduled shutdown. Information such as the contractor's name and contact information, the VA project COR, a description of the work being performed and systems affected, proposed dates and durations of the shutdown, and areas affected must be provided. The VA M&R Supervisor and COR must then review and approve the request as submitted, approved with modifications, or not approved with reasons stated. The form also includes an impact category of minor, moderate or major.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 36C25222Q0586.docx | DOCX document | |
| ATTACHMENT C - Panel list.xlsx | XLSX spreadsheet | |
| ATTACHMENT E - Existing IR ports_ Micro IR port 1.jpg | JPG image | |
| ATTACHMENT I - VA DIRECTIVE 1028 dated 24 Feb 2020.docx | DOCX document | |
| ATTACHMENT D - Basic Site Plan_02Apr13.pdf | ||
| ATTACHMENT G - MEDICAL CENTER ENGINEERING SHUTDOWN SOP.docx | DOCX document | |
| ATTACHMENT B - Bi Ann Med Volt Testing.xlsx | XLSX spreadsheet | |
| ATTACHMENT A - Annual Infrared Testing UPDATED 4_2022.xlsx | XLSX spreadsheet | |
| ATTACHMENT F - ELECTRICAL ONE LINES _12-28-2018_.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Attachment A
Oscar G. Johnson VAMCRevision No.
Shutdown No.
UTILITY SYSTEMS SHUTDOWN REQUEST FORM
NOTE: THIS FROM MUST BE SUBMITTED TO VHAIROUTILITYSHUTDOWNREQUEST@VA.GOV
A MINIMUM OF 10 BUSINESS DAYS PRIOR TO THE SCHEDULED SHUTDOWN UNLESS APPROVED BY COR & M&R SUPERVISOR. NO SHUTDOWN SHOULD PROCEED WITHOUT PRIOR AUTHORIZATION FROM THE VA
M&R SUPERVISOR AND A VA CONSTRUCTION COR.
GENERAL CONTRACTOR INFORMATION INDIVIDUAL PERFORMING SHUTDOWN
NAME: PHONE#: COMPANY: VA PROJECT:TODAY’S DATE:
VA PROJECT COR:
02/01/2018
NAME:
COMPANY NAME:
PHONE:
DESCRIBE WORK BEING PERFORMED: System-Purpose- Location (Floor, Zone, AHU) -Plan to Minimize Downtime-Etc.
SYSTEM(S) AFFECTED:
| CHILLED WATER | MEDICAL GAS** | ELECTRICAL POWER |
| DOM HOT WATER | FIRE SPRINKLER | LIGHTING |
| DOM COLD WATER | SMOKE/FIRE ALARM | BUILDING AUTOMATION |
| HVAC | PNEUMATIC TUBE | NURSE CALL |
| STEAM/HEAT PIPING | WASTE/VENT | OTHER: |
**Use Attachment F Medical Gas Permit to Work for Medical Gas Shutdowns.
PROPOSED DATE(S) (MIN 10 BUSN DAY NOTICE REQD)
PROPOSED START TIME(S) OF SHUTDOWN:
PROPOSED DURATION OF SHUTDOWN:
AREA(s) AFFECTED BY SHUTDOWN(PROVIDE DETAILS)
*Drawing attached identifying areas of shutdown? Other considerations requiring VA assistance:
YES NO
VA USE ONLY BELOW THIS LINE
TO BE REVIEWED AND APPROVED BY VA M&R SUPERVISOR AND VA CONSTRUCTION COR.
APPROVED AS SUBMITTED APPROVED AS MODIFIEDSUBMIT
NOT APPROVED, REASON:
VA COR:
M&R SUPERVISOR:
IMPACT CATEGORY
Minor Moderate Major image1.jpeg
File details come from the government source that posted it. Updated .