Appendix_F-_FGUA.pdf

Contractor Utility Locate Acceptance

Date: ____________

Full Name of Applicant: Job Site Phone #:

Contractor Name: Contractor License #:

Job Trailer Located On-Site ( Y / N ) Job Site Location (Bldg./Intersection):

Contractor Supervisor:

Supervisor Phone #:

MacDill Construction Manager: Affiliation (6 CES, USACE):

Construction Manager Phone #: Email:

Project Name:

Project Number:

AF Form 103 (dated): Description of Work:

Planned Work Start Date:

Locate Ticket #:

Date and Time of Utility Locate:

General Terms and Conditions of Acceptance:

(Initials)

Marked ( X ) Service Technician Acceptance

Pressurized Water Main

Water Service Lines

Reclaimed Water Main

Gravity Sewer

Sewage Forcemain

Office Tracking Log Completed: Date:

Relocate #1: Date:

Relocate #2: Date:

Relocate #3: Date:

Utility Damage: Date:

Cost Recovery: Date:

Contractors must report Any/All damage to Water or Sewer Utilities immediately to the FGUA.

9109 Bayshore Boulevard, Building 84

Tampa Florida 33621 Phone (813) 828 -3984 Fax (813) 828 -3212

Location and Acceptance pertains to Water & Sewer Utilities Only and does not consider any other utilities.

The Contractor is responsible for obtaining all other utility locates from other base utility owners/operators.

Utility locates are valid for a period of 90 days from the date of acceptance, after which the Requestor is required to contact the FGUA for a new Utility Locate. A current copy of the Air Force Form 103 and project drawings shall be available at the Job Site.

This Section is Reserved for FGUA Office Use Only

Contractor will be responsible for all costs associated with the repair to utilities damaged as a result of Contractors Work.

Signature Date

Contractor is responsible for maintaining and protecting all utility locate marks during the 90 day period.

Conflicts / Comments

I ______________________________________________, have reviewed and accept the provisions stated within this agreement and understand them in their entirety wherein by signing this agreement I affirm that, to my knowledge, all Water and Sewer utilities have been properly identified.

Rev. (dbs) 042511 Florida Governmental Utility Authority - Form 301

Utility Service Termination Application

Name of Applicant: Date:

Company Name: Company Address:

Company Phone #:

Company Fax #: Company Email:

MacDill Point of Contact: POC Organization:

POC Phone #: POC Email:

Project Name:

Project Number:

MacDill Construction Manager: Phone Number:

Company Project Representative: Phone Number:

Check One: Sanitary Sewer_____ Water Distribution_____

Termination Conducted By: Contractor_________ FGUA________________

Brief description of utility termination requested. Be sure to include facility number/site location and pipe size:

Estimated Project Start Date: ________________ Estimated Date Disconnection Required ________________

Terms and Conditions:

Signature: Date:

Office Tracking Log Completed: Date:

Work ID #

Construction Inspector: Signature:

Date Completed: Time On-Site:

Utility Damage: Date:

Cost Recovery: Date:

9110 Bayshore Boulevard, Building 84

MacDill AFB, Florida 33621 Phone (813) 828-3984 Fax (813) 828 -0000

All requests must be made in writing and delivered to the FGUA in Building 84 during normal business hours of 8:00 to 4:00 Monday through

Friday. Approved applications will be scheduled within 5 business days of the date received.

This Section is Reserved for Office Use Only

All fittings and tools used to cut and cap water piping must be properly disinfected in accordance with AWWA C651, Current Edition.

The purpose of this application is to ensure proper utility terminations and physical line disconnection from FGUA-owned water and sanitary sewer utilities. Applicants must submit a completed application along with the proper fees. Applications that are approved are subject to the following conditions:

Only FGUA personnel are authorized to operate water system valves and sanitary sewer lift station equipment.

I_________________________ (Requesting Person/Company) have reviewed the Utility Service Termination Application and agree to all of the Terms and Conditions.

The Applicant is liable for any damages to FGUA-owned utility lines, including all costs and repairs to marked utility lines damaged by contractor during their work.

All work acomplished by contractor must be inspected by FGUA prior to backfilling. Contractor is required to make all corrections identified by the FGUA constuction inspector.

Contractor is required to excavate and expose all water or sanitary sewer piping at the point of termination; FGUA will perform and complete the proper cut and capping proceedure. Contractor may request, by identifying so on this application, to perform the cut and cap proceedure in accordance with specifications provided by FGUA. If this is approved, Contractor must contact FGUA to schedule an inspection of the work before work commencement.

Full Name of Applicant: Applicant Phone #:

Contractor / Business Name Local Business Address:

Business Phone #:

Business Fax #: Email:

Name of Project Representative that will be coordinating work:

Mobile Phone #: Email:

Justification for Work (please provide details): Part of BASE Project #:

Facilities/ Buildings Impacted:

6CES Project Manager Name: Office Phone #:

Email: _________________________________________

Time Allowable for Shutdown:

HRS MINUTES Signature of Authorization (MacDill PM) Date

Signature of Applicant Date

Payment Received FGUA / USW Reimbursement Received

Work Scheduled for day/time Restoration of Service day/time

FGUA Technician Assigned BACTI TESTING Pass / Fail

FGUA Personnel On-Site

Utility Damage Observed: Boil Water Notice Issued Date/ Time

Est. Additional Costs: Boil Notice Rescinded Date/ Time

This Section is Reserved for FGUA Office Use Only

9109 Bayshore Boulevard, Building 84

Tampa, Florida 33621 Phone (813) 828-3984 Fax (813) 828 -3212

⃝ Termination of Utility Service

⃝ Temporary Outage Request

⃝ Inspection of Work

Applicants are liable for any damages caused by the Applicant during work on or around FGUA-owned utilities located and accepted under the terms of Air Force Form 103 and FGUA Form 301.

Applicant is responsible for chlorination and bacteriological testing in accordance with AWWA C651. All bacteriological test results shall be submitted to FGUA for approval. If, during the initial testing of the water supply and as part of the restoration of service, it is found that proper disinfection and testing has not been performed, the contractor will be required to perform proper disinfection and flushing of the system until passing tests are received. Contractor is liable for the cost of additional testing and services.

This Request for Work must be submitted by all parties anticipating the need to perform work on or adjacent to existing Water or Sewer utilities, where assistance from the FGUA is required. This application ensures that proper construction techniques, utility terminations and physical line disconnections from FGUA-owned Water and Sanitary Sewer systems are followed.

Without exception, FGUA personnel must be present at all times during work of this type. For each work request, applicants must submit a completed form 427 along with the proper fees made payable to the FGUA.

Only FGUA personnel are authorized to operate system valves and sanitary sewer lift station equipment.

Temporary Suspension of Service - FGUA personnel will arrive onsite to perform a shutdown of service at a mutually agreed day and time.

Once complete FGUA personnel will return to the site to restore the service and perform required testing. The maximum amount of time that a service is allowed to be suspended is determined by the Base Wing. Unless indicated during application, FGUA personnel are not required to be present during the time after Suspension and before Restoration of Service

I ___________________________________ (Applicant/ Customer) have reviewed and understand the provisions within this agreement.

All requests must be made at least 2-weeks in advance of the earliest day needed and delivered to the FGUA Office located at Building 84 during normal business hours of 8:00 to 4:00 Monday through Friday. An FGUA Representative will contact you to schedule work accordingly, upon application approval.

Utility Terminations - All Utility Terminations are performed by the FGUA. Prior to the FGUA personnel arrival, the Contractor is required to excavate and expose all water or sanitary sewer piping at the point of termination. All excavations must meet current OSHA regulations for pit excavation.

The following Terms and Conditions apply to all work performed on or around water and sewer utilities installed around MacDill AFB.

Rev. (dbs) 042611 Florida Governmental Utility Authority - form 427

Temporary Water Meter Application

Date: ____________

Full Name of Applicant: Applicant Phone #:

Company Name: Company Address:

Company Phone #:

Company Fax #: Email Address :

MacDill Point of Contact: Division/Rank:

POC Phone #: POC Email Address:

Project Name:

Project Number: Date of Commencement:

MacDill Field Inspector: Phone Number:

Company Project Representative: Phone Number:

Intended Purpose of the Meter:

Estimated Time of Use: ________________ Date Meter is Required: ________________

Location of Hydrant HYDRANT NUMBER:

Signature Date

Meter Number Assigned: Date of Most Recent of Backflow Certification:

Date Installed: Technician:

Removal Request RCVD: Y / N Date:

Confirmation Number:

9109 Bayshore Boulevard, Building 84

Tampa Florida 33621 Phone (813) 828 -3984 Fax (813) 828 -3212

Safety and Security of the Meters assigned to the customer are the responsibility of the Customer.

All requests for installation, relocation and removal of potable water meters must be made in writing at least 3 days in advance and delivered to

Building 84 during normal business hours of 8:00am - 4:00pm, Monday through Friday. Applications received will be scheduled within 3 business days of the date received. When Removal is required the customer must file a written request, in person, and pay outstanding fees (if any). A Confirmation

Number will be issued to the Customer at this time, please retain this confirmation number. Upon account reconciliation a Refund of Deposit will be mailed to the address provided above.

For Office USE ONLY

I __________________________________ (Applicant/ Customer) have reviewed and accept the provisions within this agreement.

The purpose of this agreement is to serve the temporary need for Water Service, such as construction, from a designated source. Applicants must submit completed application, water & sewer contruction fees letter provided by the FGUA and pay all fees outlined in FGUA letter at Building 84. All Payments shall be made by CHECK (cash not accepted) and made payable to

Florida Governmental Utility Authority (FGUA) Approved applications are subject to the following conditions:

Only FGUA authorized personnel are permitted to install, move or remove portable meters from Fire Hydrants. It is against the Law for anyone other than authorized personnel to tamper with or obtain unmetered water from a MacDill AFB Fire Hydrant.

No Private Meters may be installed on Base Hydrants, trucks or equipment. Violations will be reported to 6CES and Security Forces.

FGUA is not responsible for accident or injury caused by unauthorized placement of a portable meter and/or appurtenance.

The Applicant is liable for any damages to FGUA property and equipment during the contract.

This Section is Reserved for Office Use Only

Rev. (dbs) 042711 Florida Governmental Utility Authority - form 11