Attachment K - Site Clearance and Line Marking Permit.pdf

Page 1 of 29 Oct 2024

Site Clearance and Line Marking Request (AR 420-1) READ and FOLLOW the INSTRUCTIONS on the back side of this form (page 2) before submitting the Excavation Request.

No Ground Disturbance is Authorized until ALL Signatures in ALL SIGNATURE BOXES have been obtained.

BOX A - DPW # (Internal Use) BOX B - 811 Excavation #:

Se ct

To

B e

Co m pl et ed B y Re qu es tin g

Pa rt y (E xc lu di ng

B ox

G , H a nd

I)

BOX C - Name & Title of Primary Individual Requesting

Alternate POC:

Email:

Alt Email:

Phone: Alt. #:

BOX D - Company Name Performing Excavation

Address:

City State Zip Code

Phone Number:

BOX E - Describe Project Purpose & Location of Excavation Request (including BLDG#, depth, intersecting streets, grid coordinates if out on the Ranges, length, etc.): *MUST provide a DETAILED map of work area.* See page 2 for additional space.

Mechanical

Manual

Requestor's Signature:

BOX F - BOX G - Originator

Method of Excavation

BOX H - Government Project Manager/COR/Unit Representative

Name & Title:

Email: Phone:

Govt POC Signature:

Date Signed:

BOX I - DPW Representative

Name & Title:

Email: Phone:

DPW

Signature:

Date Signed:

Se ct

Re qu es tin g Pa rt y

M us t A cq ui re

S ig nt au re s

1. Verified by DPW-Master Planning Division, Bldg 777, Rm 121, Mr. Shell, gary.d.shell.civ@army.mil, (915) 569-8400

Date Received: Comments:

MPD

Date Signed

2. Verified by DPW-Environmental Divison, Bldg 624, Ms. Guerrero, myra.guerrero2.civ@army.mil, (915) 568-1455 / (915) 568-3782

Date Received: Comments:

ED

Date Signed

3. Verified by DPW-Engineering Services Division, Bldg 777, Rm 204, Mr. Guillermo Garcia, guillermo.garcia97.civ@army.mil, (915) 569-8741

Date Received: Comments:

ESD

Date Signed

4. Verified by DPW-Operations & Maintenance Division, Bldg 777, Rm 324, Ms. Arroyo, alma.a.arroyo.civ@army.mil, (915) 568-1261

Date Received: Comments:

OMD

Date Signed

Se ct

Re q.

P ar ty

A cq ui re s

SO

s Obtain Service Order Numbers from the Service Order Desk, BlissSOD@pcsi.org, (915) 642-5477, located at the North End of Building 777 and at Building 56 for NEC.

Texas Gas SO#:

RGEC SO#:

Ft. Bliss Water SO#:

Ft. Bliss Sewer SO#:

Pride SO#: NEC SO#:

Se ct

Re qu es tin g Pa rt y

M us t O bt ai n

Lo ca tio n

Si gn at ur es Network Enterprise Center Representative Bldg 56 Chaffee Rd., (915) 744-4344 Email: usarmy.bliss.106-sig-bde.mbx.nec-dig-permits@army.mil

Locate Required?

Yes No NEC Representative (Print Name) NEC Representative (Signature) Date

Rio Grande Electric Cooperative 10050 Railroad Dr., (915) 778-0152 Email: agomez@rgec.coop

Locate Required?

Yes No RGEC Representative (Print Name) RGEC Representative (Signature) Date

Texas Gas Service Representative 4700 Pollard St., (915) 680-7227 Email: Jose.borrayo@onegas.com / david.sepulveda@onegas.com

Locate Required?

Yes No Texas Gas Representative (Print Name) Texas Gas Representative (Signature) Date

Ft. Bliss Water Services Representative Bldg 516A Pleasonton Rd., (915) 564-1332 Email: tammy.baker@asusinc.com

Locate Required?

Yes No Ft. Bliss Water/Sewer Representative (Print Name) Ft. Bliss Water/Sewer Representative (Signature) Date

Pride Industries Representative Bldg 1118 Irwin Rd., (915) 288-6185 Email: fb-digpermit@prideindustries.com

Locate Required?

Yes No PRIDE Industries Representative (Print Name) PRIDE Industries Representative (Signature) Date

Balfour Beatty Communities Representative Bldg 1991 Marshall Rd., (915) 496-2417 Email:

cwjohnson@bbcgrp.com 215-936-8596

Locate Required?

Yes No BBC Representative (Print Name) BBC Representative (Signature) Date

Se ct

Fi na l R ev ie w b y

D

PW

BOX J - Signature of Requesting Individual / Contractor*

Signature Date:

*By signing this document, the Requestor agrees to comply with DPW comments, procedures, and safety standards established by the Dept. of the Army and OSHA.

BOX K - Signature DPW Representative

DPW-Division

Signature Date:

Box L - Signature required when requesting excavation at Westbrook or the Parade Fields (From Cassidy to Pleasonton). CONTACT PRIDE - Bldg 1118 Irwin Rd.,

(915) 288-6185, fb-digpermit@prideindustries.com

Signature Date:

NOTE: A copy of the completed SCLMR should be at the excavation site at ALL times.

All non-assigned Army requirements must reimburse DPW for the NEC markings and re-markings

BO

X

- E

Co nti nu ati on of ad dit ion al de sc rip tio n i nfo rm ati on mailto: guillermo.garcia97.civ@army.mil

Page 2 of 29 Oct 2024 All non-assigned Army requirements must reimburse DPW for the NEC markings and re-markings

INSTRUCTIONS for Fort Bliss DPW Site Clearance and Line Marking Request (SCLMR): The individual requesting the SCLMR must be familiar with the project and be able to answer ANY technical questions pertaining to the project asked by the signing entities. Incomplete forms will not be processed. For any questions, contact your DPW Project Manager/COR. Note: DPW does NOT route these permits as it is the individual's responsibility. To start the process please contact your DPW Project Manager/COR.

1) BOX A - Leave blank. Number will be provided by DPW-Master Planning Division (during the completion of Section 2).

2) BOX B - Call/Dial 811 from any phone to obtain a locate ticket request number. A copy of the 811 email confirmation memo MUST accompany the SCLMR for approval. You must keep this 811 # active throughout the entire SCLMR process by calling 811 every 10 working days. The penalty for being caught without either the completed form or valid 811 tracking number is $10,000 per instance (assessed by the states themselves). NOTE: If the 811 number expires, the SCLMR will also expire, and the Permit will no longer be valid/accepted.

Section 1 - BOX C to BOX H - To be completed by the REQUESTING INDIVIDUAL:

FOR SERVICE ORDERS ONLY - Provide copy of Service Order with SCLMR Request. If work entails new construction, installation of new signs, reserved parking space signs and posts obtain a DA 4283.

3) BOX C - Enter the Primary and Alternate Individual's name, title & phone number that is responsible this request.

4) BOX D - Enter the name, address & phone number of the COMPANY responsible for performing the excavation.

5) BOX E - **You MUST include a detailed map of work area, clearly marked** Provide building numbers, street locations, excavation depth, important site info (Grid Coordinates if out on the Ranges, etc.) and a brief description of work to be performed. Excavation work should match work described in the Work Order.

6) BOX F - For any work on Fort Bliss, the Tenant or Proponent must obtain authorization. Place authorization number or Work Order (WO) number in BOX C of the SCLMR.

To obtain an approved Work Order, refer to the latest version DA 4283 Work Order Submission, Validation and Prioritization SOP for the requirements on submitting a Work Order. If you need a copy of the SOP, please visit the DPW BOID, Bldg 777 NE corner, Customer Service window to receive a copy (A Proprietary Approval Work Order can also be routed with a coordination memo. Please inform the WO Desk if you prefer this option.) Include a copy of approved Fort Bliss DPW document authorizing the project:

Work Order DA 4283, Service Order, or Fort Bliss DD 1391. Initial date of the SCLMR must be on or after the approval of the Work Order.

7) BOX G - This block will be populated by the DPW Representative.

8) BOX H - Enter the Primary Gov PM/COR/Unit Rep of your contract. For external customers who do not have a Government Representative, please coordinate with Jesus Moore, 915-568-1552, jesus.s.moore.civ@army.mil.

9) BOX I - Dependent on which organization is submitting, a DPW Representative will validate the request prior to proceeding to Section 2.

Upon Completion of Section 1, the DPW Representative will submit the SCLMR to the Master Planning Division for the 1st signature of Section 2. (Greene, Lee - 915-568-5273/lee.m.greene.civ@army.mil & Shell, Gary- 915-569-8400/gary.d.shell.civ@army.mil) After it is returned you may continue to Section 2.

Section 2 - It is the responsibility of the Requesting Party to coordinate, follow up, and obtain all signatures with the DPW Stakeholders. Space is allocated for comments by the DPW, & space for additional comments is provided above. Signatures will be obtained concurrently and returned to the requesting individual. Section 2 contacts are provided by MPD. The Requesting Party will combine all signed returned documents prior to moving to Section 3.

Section 3 - The Service Order Desk will provide Service Order Numbers for this section. If submitted face-to-face, you may need to submit nine (9) copies of the SCLMR packet to the Service Order Desk to receive those numbers. The Service Order desk is located at BLDG 777, corner of Chaffee & Pleasonton, 915-642-5477, BlissSOD@pcsi.org.

Section 4 - Will be signed by the utility company or the company responsible for marking the lines on the ground. The REQUESTING INDIVIDUAL must contract a 3rd party contractor to perform location of Communications Infrastructure. Once located, the Requesting Party must submit the information to the Network Enterprise Center at Bldg. 56 Chaffee St. All signatures are required prior to Section 5.

Section 5 - Final Review and Project Verification. The Individual/Contractor reviews the entire form prior to requesting signature from a DPW Representative, and signs in

BOX J.

8) BOX J - The Individual/Contractor performing the excavation reviews the entire form and signs in Box J. By signing this document, the Requestor acknowledges all comments and agrees to comply with DPW procedures and safety standards established by the Dept. of the Army and OSHA.

9) BOX K - Send the completed SCLMR containing all signatures to your DPW Representative for the final review and signature granting authority for the Site Clearance & Line Marking Request. Your DPW Rep from ESD, MPD, OMD, SED, BOID will sign the final signature.

10) BOX L - If your project is within the Westbrook Area or the Parade Fields (From Cassidy to Pleasonton) Please send the permit to PRIDE - Bldg 1118 Irwin Rd., (915)288-6185, fb-digpermit@prideindustries.com

NOTE: A copy of the completed SCLMR should be at the excavation site at ALL times.

NOTE: A copy of the completed SCLMR should be at the excavation site at ALL times.

All non-assigned Army requirements must reimburse DPW for the NEC markings and re-markings