ESBD_452864_1774291073896_ATTACHMENT G.W - Ellington AFB (EF) AF103_REV.pdf
PDF 28 KB Posted
- Attached to
- EXTEND BARRIER ACCESS ROADS ELLINGTON AFB
- Solicitation number
- TMD25-ANG-WJ-24150011
- Issued by
- Harris County, Texas
About this file
This is a Base Civil Engineering Work Clearance Request form (AF IMT 103) used by the Air Force, specifically for Ellington Air Force Base. The form is designed to request clearance to proceed with construction or maintenance work that may impact aircraft or vehicular traffic flow, base utility services, fire and intrusion alarm system protection, or routine installation activities. The request requires identification of the work order and contract number, specification of the facility type or work involved (including pavements, drainage systems, railroad tracks, fire detection and protection systems, utilities, aircraft or vehicular traffic flow, security systems, and other infrastructure), and documentation of the area via attached sketch. The clearance must be processed immediately prior to work commencement and must be reprocessed if delays occur or job site conditions change.
The form requires coordination and approval from multiple base departments and functions, including electrical distribution, steam distribution, water distribution, petroleum/oil/lubricants distribution, sewer distribution, environmental services, pavements and grounds, fire protection, zone security, base operations, communications, cable television, commercial utility companies (telephone, gas, and electric), and safety personnel. The approving officer must be either the Chief of Operations Flight or Chief of Engineering Flight, and the form requires detailed remarks describing specific precautionary measures to be taken before and during work accomplishment, including comments concerning the approved excavation method and equipment type (hand-operated or powered). The form serves as a coordination and hazard identification tool to minimize customer inconvenience and prevent accidents during contracted or in-house work activities.
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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
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