Appendix_F_-_Dig_Permit.pdf

1 , 2 , 4 , 5 , 6

EMCS

Mohammad R. Emami-Marand 502 CES/CEOI 1555 Gott St. Bldg 5595 Utility Systems Superintendent, 671-7215 JBSA-LAK, TX, 78236

DATE PREPAREDBASE 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 FLOWA. PAVEMENTS D. FIRE DETECTION & PROTECTION SYSTEMS

H. SECURITYB. DRAINAGE SYSTEMS E. UTILITY OVERHEAD UNDERGROUND

I. OTHERC. RAILROAD TRACKS F. COMM OVERHEAD UNDERGROUND

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.

A. ELECTRICAL DISTRIBUTION

B A

S B. STEAM DISTRIBUTION

E

C. WATER DISTRIBUTION

C I

D. POL DISTRIBUTIONV

I L

E. SEWER DISTRIBUTION

E N

F. ENVIRONMENTAL

G

I

G. PAVEMENTS/ GROUNDSN

E

E H. FIRE PROTECTION

R

I

I. ZONEN

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)

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

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

Utilities in area, call 671-3093, 48 hours before digging.

Also see block 18, REMARKS.

Utilities in area, call 671-2447, 48 hours before digging.

Also see block 18, REMARKS.

Utilities in area, call 671-2447, 48 hours before digging.

Also see block 18, REMARKS.

Utilities in area, call 925-8545, 48 hours before digging.

Utilities in area, call 671-2447, 48 hours before digging.

Also see block 18, REMARKS.

Call Environmental 48 hours before digging.

Env. flight, Frank Dieck 671-5356

Contact before digging, 671-2447

Call 671-2921 for HOT WORK (Weld) permit only In case of spill, call fire department @ 911 or 671-0911

Please coordinate with the shop listed in this block.

Utilities in area, call 671-2288/2289, 48 hours before digging.

Also see block 18, REMARKS.

Please ensure security forces are informed of your work area.

They are located in bldg. 5275 @ 671-7261

Barricade open holes, ensure all excavations are barricaded when unattended. Wing Safety is in bldg 2484 @ 671-5028

Utilities in area, call 671-6401, 48 hours before digging.

For Flightline area only, 925-5880

Utilities in area, see block 18, REMARKS

DIG-TESS 1-800-344-8377

see block 18, REMARKS

DIG-TESS 1-800-344-8377

Also call Protel at 1-866-632-6114 ext. 126 or 489-0224 SAWS 233-2009 (No protel in Medina)

1255479420E Typewritten Text 43326

1255479420E Typewritten Text

1255479420E Typewritten Text

1255479420E Typewritten Text x

1255479420E Typewritten Text

1255479420E Typewritten Text

1407491781C Typewritten Text

1407491781C Typewritten Text MPLS150101 Kenly from Luke to Truemper

1407491781C Typewritten Text

1407491781C Typewritten Text x

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)