Atch_2_AF_Form_103_Work__BCE_Clearance_Request.xfdl

15/11/2002

on

T-7CQY-AK9Z-5K86-Z9YU-AKXC

PAGE1.Email_BUTTON

54B817FA-C804-4C11-BF13-885E984331D1

CalDtA

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST.

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.

Enter date as Y Y Y Y M MD D.

CalDtA_HELP

Entery date as YYYYMMDD.

Enter date as Y Y Y Y M M D D.

CalDtB_HELP

Enter date as YYYYMMDD.

Enter date as Y Y Y Y M M D D.

CalDtC_HELP

Enter date as YYYYMMDD.

Number will be formatted automatically.

CalDtD_HELP

Enter date as YYYYMMDD.

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

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 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)

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 FORM 103, 19940801

(IMT-V1)

2. TYPE OF FACILITY WORK INVOLVED.

Check box A. PAVEMENTS off

14. COMMERCIAL UTILITY COMPANY.

Check box telephone on

14. COMMERCIAL UTILITY COMPANY

Check box Gas on

14. COMMERCIAL UTILITY COMPANY

Check box electric on

C:\Documents and Settings\spugh\My Documents\My Pictures\grey_logo.bmp

C:\Documents and Settings\spugh\My Documents\My Pictures\new toolbar\toolbar_bg_long.bmp