AF Form103.pdf

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BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

DATE PREPARED

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

D. FIRE DETECTION & PROTECTION SYSTEMS G. AIRCRAFT OR VEHICULAR TRAFFIC FLOWA. PAVEMENTS

UNDERGROUND OVERHEAD E. UTILITY H. SECURITYB. DRAINAGE SYSTEMS

UNDERGROUND OVERHEAD F. COMM I. OTHER C. RAILROAD TRACKS

3. DATE CLEARANCE REQUIRED 4. DATE OF CLEARANCE

5. SIGNATURE OF REQUESTING OFFICIAL 6. TELEPHONE NO. 7. ORGANIZATION

ORGANIZATION REMARKS (Use Reverse for additional comments) REVIEWER'S NAME AND INITIALS 8.

B A S E

C I V I L

E N G I N E E R I N G

A. ELECTRICAL DISTRIBUTION

B. STEAM DISTRIBUTION

C. WATER DISTRIBUTION

D. POL DISTRIBUTION

E. SEWER DISTRIBUTION

F. ENVIRONMENTAL

G. PAVEMENTS/ GROUNDS

H. FIRE PROTECTION

I. ZONE

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)

16. REQUESTED CLEARANCE APPROVED DISAPPROVED

17. TYPED NAME AND SIGNATURE OF APPROVING OFFICER (Chief of Operations Flight or Chief of Engineering Flight) 17a. DATE SIGNED

AF IMT 103, 19940801, V3 PREVIOUS EDITIONS ARE OBSOLETE.

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)