Attachment 4 AF IMT 103.pdf

OVERHEAD

CLEAR

CLEAR

CLEAR

CLEAR

TELEPHONE

GAS

ELECTRIC

APPROVED

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

Call Sunshine (see #14)13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

*Call 72 hours prior for locates

12. BASE OPERATIONS: Air Field Manager

DATE PREPARED

2. TYPE OF FACILTY/WORK INVOLVED

7. ORGANIZATION

on Work Order No. _______________________________ , Contract No. ________________________________ , involving excavation or utility disturbance per

Project:

D. FIRE DETECTION & PROTECTION SYSTEMS

F. COMM

REMARKS (Use Reverse for additional comments)

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

E. UTILITY

ORGANIZATION

1. Clearance is requested to proceed with work at attached sketch. This area has

A. PAVEMENTS

B. DRAINAGE SYSTEMS

C. RAILROAD TRACKS

REVIEWER'S NAME AND INITIALS

I. ZONE

Natural Gas

15. OTHER (Specify)

16. REQUESTED CLEARANCE DISAPPROVED

See reverse side for additional specific or precautionary remarks.

For telephone, cable TV, and natural gas call Sunshine State One Call of Florida: 1-800-432-4770 Web Site: www.callsunshine.com Contractor provides Sunshine project information/location

Write Sunshine Clearance # here.

No Steam Plants on Base

A. ELECTRICAL DISTRIBUTION

D. POL DISTRIBUTION

G. PAVEMENTS/GROUNDS

17a. DATE SIGNED

3. DATE CLEARANCE REQUIRED

5. SIGNATURE OF REQUESTING OFFICIAL

POWER IN AREA

STORMWATER LINES IN AREA

UNDERGROUND

UNDERGROUND

4. DATE OF CLEARANCE

6. TELEPHONE NO.

LINES IN AREA

Call 6 CES at 828-4531 two business days prior for locates

N/A

Call 6 CES at 828-4531 two business days prior for locates

8.

B A S E

C I V

IL

E N G I N E E R I N G

B. STEAM DISTRIBUTION

C. WATER DISTRIBUTION

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

Must call if any road blockages prior to blocking any lanes has not been staked or clearly marked.

G. AIRCRAFT OR VEHICULAR TRAFFIC FLOW

H. SECURITY

I. OTHER

Privatized utility - Call Sunshine (see #14)

11. COMMUNICATIONS: Cable Maint. (1400 - 1600 M - Th)

CABLE IN AREA

9. SECURITY POLICE

10. SAFETY

J. OTHER (SPECIFY): 6 AMDS/Bio Environmental

H. FIRE PROTECTION

Stormwater: Call 6 CES at 828-4531 two business days prior for locates

Must call if any road blockages prior to blocking any lanes

E. SEWER DISTRIBUTION: FGUA Utility Operations Center

F. ENVIRONMENTAL

NVZR:

N/A

N/A

6 CES Tracking Number:

ORGANIZATION REMARKS

IRRIGATION SYSTEMS

ENVIRONMENTAL RESTORATION (ERP)

CADD (6 CES/CADD)

PLUMBING/GAS SERVICE LINES (6 CES/CEOV):

AIRFIELD ATCALS SYSTEMS (6 OSS/OSAM):

HARBOR BAY HOUSING (NLT 7 days prior) Privatized Housing Maint., 2120 Secord Ave, AF IMT 103, 19940801, V3 (REVERSE)

2. In the event any property marked communications cable is severed due to contractor negligence, the cable shall be repaired withing 24 hours by the contractor. Before excavating, the contractor must have a contingency plan in order to comply with repairing the cable within 24 hours of the initial assessment (see 6 CS/SCOW for recommended sources). The 6 CS/SCOW will make the initial assessment of damage and temporarily restore any priority circuit outages. The contractor's 24 hours begins after the initial assessment. The responsible contractor will arrange for permanent repairs using materials specified by the 6 CS/SCOW. As each situation is different, a required list of materials will be provided during the initial assessment. The company chosen to permanently repair the cable will have certified technicians capable of performing fusion splicing for fiber optic cables and 710 modular or VAS3 pic-a-bond splicing for copper cables. All repaired cables will be sealed with PREFORMED splice cases and filled with the proper encapsulant. When the repair is complete the contractor will not bury or otherwise disturb the repair until a post-test and inspection is performed by the 6 CS/SCOW. The 6 CS/SCOW will have two work days after they are notified that work has been completed to complete the inspection and testing of the damaged cable and the contractor will bury and/or otherwise return the site to its original condition.

Contractors initials ____________

3. Groundwater monitoring wells are in or are adjacent to the project area (figure provided by ERP personnel). These groundwater monitoring wells must be protected from damage. If they are damaged, they must be repaired or abandoned and reinstalled in accordance with the MacDill Basewide Environmental Restoration Work Plan, Revision 5, at the contractor's expense. MacDill ERP personnel will determine the corrective action necessary.

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 tocoordinate the required work with key base activities and keep customer inconvenience to a minimum. It is also used to identify potentially hazardouswork conditions in anattempt to prevent accidents. The work clearance request is processed just prior to the start of work. If delays are encountered and theconditions at the job site change (or may have changed) thiswork 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.)

Effective: 11 Apr 17 (was)

Contractors initials ____________

Contractors initials ____________

REVIEWER'S NAME AND INITIALS

4. This work clearance permit is valid under the following conditions:

Failure to follow work clearance instructions may result in contractors being held liable for cost of repairs performed by base agencies (including response to secure a break).

User is responsible to ensure that contact is made for locates prior to work starting.

WARNING: UTILITY MARKING ARE CONSIDERED ACCURATE WITHIN 5' ON BOTH SIDES OF THE MARKING. It is the users responsibility to take precautions necessary to prevent accidental utility damage or verify utility location before digging to include pot-holing for the utility that is marked. Hand-digging will be requested and required around areas congested with utilities, or areas where a utility may be absent of tracer material (i.e., unshielded fiber optic cable).

a. Fenced construction site clearance - period of construction - user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked.

b. Non-fenced constructions sites - valid for the life of the work. The user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked.

c. Multi-job/location sites - the requestor initiates an AF IMT 103 for each new work site. The contractor will be required to get each work clearance approved each time they move from one site to another where the lines have not been marked. The user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked. In cases where user requires remarking due to negligence, weather, etc: user will be required to supply their own marking materials.

840-2000 (call first). Note: any project traversing privatized housing property will require a third party utility locate. It will be the financial responsibility of the contractor to locate the utilities within the privatized housing property boundary.

1. No welding/cutting/open flames permitted without an approved welding permit (AF IMT 592) from the Fire Department Tech Services.

6 CS/Cable Maintenance

AF Form 103 Locating Policy

Permit Number:________________

1. Block one of the AF Form 103 shall be filled out COMPLETELY. He or she shall state the exact location and scope of work to be performed.

2. Requester shall identify area to be marked by highlighting and print/sign name on a copy of the print provided by the customer. If the customer does not have a print, they shall identify the area using electrical records. The customer will highlight, print/sign name, and date these prints/records in agreement with the work to be accomplished.

3. If customer needs to go outside the predetermined area, then he or she shall be RESPONSIBLE for contacting 6 CS/Cable Maintenance Shop at (813) 828-2033 to schedule additional marking.

4. Requester is required to give Cable Maintenance a viable point of contact and 72 hrs notice prior to any excavation. A time and date will be coordinated for the requester to be present when the area is marked.

The customer will verify the entire area has been marked and the circuits’ markings in site match the highlighted areas on the print.

5. The requester and locator will then both sign/print their names acknowledging area has been located properly. The marking of the area are to be maintained by the requester for the duration of the project.

6. The requester must verify the marks, per the instructions on page two (2) of the AF Form 103.

7. There will be “NO” excavation until these requirements are completed. The AF Form 103 shall be maintained at the project site for the duration of the project.

Acknowledgement of agreement:

Requester:

Print Name: ___________________ Sign Name: _______________________ Date: ___________

Permit Number:__________________

Company: ______________________

Phone Number:

Acknowledgement of locate: Both parties, the requester and the locator, agree the communication lines are properly located with orange marking whiskers, and/or orange paint in accordance with the work area outlined on the associated AF Form 103.

Requester: Print Name: ___________________ Sign Name: __________________________

Locator: Print Name: ___________________ Sign Name: __________________________

Date Located: ______________________

Print Name:

Print Name_2:

Print Name_3:

Date9_af_date:

Date10_af_date:

Permit No:

Company:

Phone number:

Text14:

Date:

Requestor:

Signature

Locator:

Date Located: Dig Permit Project #

Acknowledgement of agreement (initials):

5. The requester and locator will then both sign/print their names acknowledging area has been located properly. The markings of the area are to be maintained by the requester for the duration of the project.

6. There will be "NO" excavation until these requirements are completed. The AF Form 103 shall be maintained at the project site for the duration of the project.

7. Must see Harbor Bay when locate is in Base Housing Area. Area shall be located by both companies for their area of responsibility.

ELECTRICAL SECTION

1. Block one of the AF Form 103 shall be filled out COMPLETELY. He or she shall state the exact location and scope of work to be performed.

2. Requester shall identify area to be marked by highlighting and print/sign name on a copy of the print provided by the customer. If the customer does not have a print, they shall identify the area using electrical records. The customer will highlight, print/sign name, and date these prints/records in agreement with the work to be accomplished.

3. If customer needs to go outside the predetermined area, then he or she shall be RESPONSIBLE for contacting 6CES Electrical Shop at (813) 828-2696 for adding marking.

4. Requester is required to give Electrical Shop a viable point of contact and 72 hrs notice prior to any excavation. A time and date will be coordinated for the requester to be present when the area is marked. The customer will verify the entire area has been marked and the circuits' markings in site match the highlighted areas on their print.

Print Name

Project Location

Company

Phone Number

Phone Number:

Print Name_2:

undefined:

Dig Permit Project:

Acknowledgement of agreement initials:

Date:

Print Name:

Project Location:

Company:

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) 304-2694

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

Affiliation 6 CES USACE:

Construction Manager Phone:

Email:

Project Name:

Project Number:

AF Form 103 dated:

Planned Work Start Date:

Locate Ticket:

Date and Time of Utility Locate:

Description of Work 1:

Sewage Forcemain:

Date_2:

Office Tracking Log Completed:

Date_3:

Relocate 1:

Date_4:

Relocate 2:

Date_5:

Relocate 3:

Date_6:

Utility Damage:

Date:

Full Name of Applicant:

Contractor Name:

Job Site Phone:

Contractor License:

Contractor Supervisor:

Job Site Location BldgIntersection 1:

Supervisor Phone:

Job Site Location BldgIntersection 2:

MacDill Construction Manager:

Cost Recovery:

Date_8:

Pressurized Water Main:

Date_7:

Water Service Lines:

Reclaimed Water Main:

Gravity Sewer:

Gravity Sewer Comments:

Reclaimed Water Main Comments:

Water Service Lines Comments:

Pressurized Water Main Comments:

Sewage Forcemain Comments:

PWM Initials:

WSL Initials:

RWM Initials:

GS Initials:

SF Initials:

Check Box2: Off

Check Box4: Off

Check Box3: Off

Check Box5: Off

Dropdown3: [ ]

103 Questionnaire:

1. Contact information:

Company name:

Contact name:

Office number:

Cell number:

Email:

2. NVZR or Contract number:

3. Start Date?

4. Duration of the project?

5. Detailed scope of work?

6. Location of project?

7. Will you be digging?

8. How deep will you be digging?

9. How will you be digging? Hand or Machine

10. Working indoor or outdoor?

11. What equipment is being used?

12. Will you need to dewater?

13. Plans for waste?

14. What’s going to be affected, plants or species?

15. Hazmat items approved?

16. Asbestos or lead based paint?

17. Locate wells onsite?

18. Figures/Map (with location marked on map)?

19. Will you be moving soil from one site to another?

20. Will you have excess soil? Plan for excess soil?

21. Sunshine Clearance#?

undefined_4:

undefined_5:

undefined_6:

undefined_7:

undefined_8:

undefined_9:

undefined_10:

undefined_11:

undefined_12:

undefined_13:

undefined_14:

undefined_15:

undefined_16:

undefined_17:

undefined_18:

undefined_19:

undefined_20:

undefined_21:

undefined_22:

undefined_23:

undefined_24:

Company name:

undefined_2:

undefined_3:

POC:

INSTRUCTIONS FOR AF FORM 103

1. Open attachment to this document by clicking on the arrow ( ) on the left side of the document, then click on the paperclip.

2. Open MacDill AF IMT 103, click on Enable All Features at the top right just under the menu bar, fill out the top portion except #4, complete #14 by going onto sunshine811.com, create ticket and get Sunshine Clearance #, read and initial where indicated on page 2, save on your desktop.

3. Open MacDill AF IMT 103 Questionnaire (attachment in MacDill AF IMT 103), click on Enable All Features at the top right just under the menu bar, fill out the questionnaire, and save.

4. Open Electrical Section AF IMT 103 Locating Policy Form (attachment in MacDill AF IMT 103), click on Enable All Features at the top right just under the menu bar, fill out Requestor information and Dig Permit Project # (same as Work Order No. on MacDill AF IMT 103), and save.

5. Open Cable Maintenance AF IMT 103 Locating Policy Form (attachment in MacDill AF IMT 103), click on Enable All Features at the top right just under the menu bar, fill out Requestor information and Permit Number (same as Work Order No. on MacDill AF IMT 103), and save.

6. Open FGUA Contractor Utility Locate Acceptance Form (attachment in MacDill AF IMT 103), click on Enable All Features at the top right just under the menu bar, fill out, and save. Call FGUA with any questions.

7. Route MacDill AF IMT 103 for digital signatures using routing list below. NOTE: The form MUST be routed to one organization at a time.

a. Email saved MacDill AF IMT 103 with saved attachments to either the Primary or Alternate POC listed below for Electrical Distribution and request they review, provide comments in the REMARKS field, digitally sign in the REVIEWER’S NAME AND INITIALS field next to their organization and then return to you.

Include in your email that if they are unable to send you an email with attachments due to encryption requirements, request they send the signed MacDill AF IMT 103 to 6CES_customerservice@us.af.mil and request that 6 CES Customer Service return the signed MacDill AF IMT 103 to you via the DoD SAFE site.

b. The form can be routed in any order you choose after Electrical Distribution, however, it’s recommended to send to Bay Harbor Housing first since they require their review at least 7 days prior to the date the clearance is required.

mailto:6CES_customerservice@us.af.mill

c. Once you receive the signed MacDill AF IMT 103, email to the next reviewer.

Continue this process until all Reviewer’s signatures appear on the form.

Organization Primary POC Alternate POC

A. ELECTRICAL

DISTRIBUTION

Bldg 11, 8011 Hillsborough Loop Dr

Mr. Victor Nespeca

(813) 828-2653 victor.nespeca.1.ctr@us.af.mil

Mr. Kevin Hudgins

(813) 828-2584 kevin.hudgins.ctr@us.af.mil

C&E. WATER and

SEWER DISTRIBUTION:

FGUA Utility Operations Center Bldg 892, Bayshore Blvd/ Golf Course Ave

Ms. Amber Tilley

(813) 828-3984 atilley@uswatercorp.net

Mr. Randy Edwards

(727) 234-3362 redwards@uswatercorp.net

D&18d. POL DISTRIBUTION and

PLUMBING/GAS

SERVICE LINES

Bldg 247, 8102 Hangar Loop Dr

Ms. Kim Campbell

(813) 828-3040 kimberly.campbell.2.ctr@us.af.mil

F. ENVIRONMENTAL

Bldg 30 (2nd Floor), 7621

Mr. Jason Kirkpatrick

(813) 828-0459 jason.kirkpatrick.2.ctr@us.af.mil

Mr. Chris Sutton

(813) 828-0458 christopher.sutton.14.ctr@us.af .mil

G.

PAVEMENTS/GROUNDS

Bldg 29, 7515 Hillsborough

Mr. Wilfredo Santiago

(813) 828-2101 wilfredo.santiagorivera.ctr@us.af.mil

H. FIRE PROTECTION

Bldg 107, 3411 Firehouse Ln

Mr. Mark Denesha

(813) 828-6062 mark.denesha.1@us.af.mil

Mr. Jay Scott

(813) 828-4304 jay.scott.3@us.af.mil

J: 6 AMDS/Bio Environmental Bldg 1078, 3250 Zemke Ave

Mr. Bob Beamon

(813) 827-9570 robert.beamon.1@us.af.mil

Major Joseph Gitersonke

(813) 827-9570 joseph.gitersonke.1@us.af.mil

9. SECURITY POLICE

Bldg 203, 2505 SOCOM Memorial Hwy

Mr. Darwin Bush

(813) 828-2104 darwin.bush@us.af.mil

Mr. Flint Bloedow

(813) 828-5791 flint.bloedow@us.af.mil

10. SAFETY

Bldg 299, 8208 Hangar

Centralized eMail address

(813) 828-3383 6ARW.SE.1@us.af.mil

Organization Primary POC Alternate POC

11. COMMUNICATIONS:

Cable Maint.

(1400 - 1600 M - Th) Hangar 4 (1st Floor/South), 7813 Hangar Loop Dr

SSgt Nathan Brooks

(813) 828-2033 nathan.brooks.1@us.af.mil

TSgt Matthew Scott matthew.scott.18@us.af.mil or SSgt Derek Robinson derek.robinson.2@us.af.mil

12. BASE OPERATIONS

Hangar 3, 7719 Hangar

Mr. Link Collier

(813) 828-2030 Cell (813) 610-1989 link.collier.1@us.af.mil

Deputy Airfield Manager “DAFM” or NCOIC Airfield Management

“NAMO”

6OSS.BaseOps@us.af.mil

18a. IRRIGATION

SYSTEMS

Bldg 1074, Great Egret Av

Mr. Jim Andriuli

(813) 309-1302 scjonesno6@aol.com

Mr. John Vann

(813) 618-2525 scjonesno7@aol.com

18b. ENVIRONMENTAL

RESTORATION (ERP

Bldg 30 (2nd Floor), 7621

Ms. Tish Matty

(813) 828-0776 patricia.matty@us.af.mil

Ms. Kristy Snyder

(813) 828-0789 kristy.snyder.1.ctr@us.af.mil

18c. CADD (6

CES/CADD)

Bldg 30 (1st Floor), 7621

Mr. Andy Coe

(813) 828-2455 andrew.coe.ctr@us.af.mil

Mr. Joseph Mynatt

(813) 828-3465 joseph.mynatt.ctr@us.af.mil or Mr. Joshua Henry

(813) 828-1841 joshua.henry.13.ctr@us.af.mil

18e. AIRFIELD ATCALS

SYSTEMS

Bldg 57, 7719 Hangar

MSgt Daniel Sparks

(813) 828-4802 daniel.sparks@us.af.mil

SSgt Sean Fitzpatrick

(813) 828-4802 sean.fitzpatrick.7@us.af.mil

18f. HARBOR BAY

HOUSING

8414 Fortress Dr

Mr. Kurt Wicker

(813) 840-2600 kwicker@tmo.com

Ms. Dawn Sousa

(813) 840-2600 dsousa@tmo.com

8. Once all of signatures are obtained, you must also call to schedule utility locates as indicated on the MacDill AF IMT 103.

9. Once all signatures are received and utility locates are scheduled, email MacDill AF IMT 103 to Mr. Lynn Adams at lynn.adams@us.af.mil for final approval.

mailto:lynn.adams@us.af.mil

CLEAR

TELEPHONE

GAS

ELECTRIC

APPROVED

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

Call Sunshine (see #14)13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

*Call 72 hours prior for locates

12. BASE OPERATIONS: Air Field Manager

DATE PREPARED

2. TYPE OF FACILTY/WORK INVOLVED

7. ORGANIZATION

on Work Order No. _______________________________ , Contract No. ________________________________ , involving excavation or utility disturbance per

Project:

D. FIRE DETECTION & PROTECTION SYSTEMS

F. COMM

REMARKS (Use Reverse for additional comments)

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

E. UTILITY

ORGANIZATION

1. Clearance is requested to proceed with work at attached sketch. This area has

A. PAVEMENTS

B. DRAINAGE SYSTEMS

C. RAILROAD TRACKS

REVIEWER'S NAME AND INITIALS

I. ZONE

Natural Gas

15. OTHER (Specify)

16. REQUESTED CLEARANCE DISAPPROVED

See reverse side for additional specific or precautionary remarks.

For telephone, cable TV, and natural gas call Sunshine State One Call of Florida: 1-800-432-4770 Web Site: www.callsunshine.com Contractor provides Sunshine project information/location

Write Sunshine Clearance # here.

No Steam Plants on Base

A. ELECTRICAL DISTRIBUTION

D. POL DISTRIBUTION

G. PAVEMENTS/GROUNDS

17a. DATE SIGNED

3. DATE CLEARANCE REQUIRED

5. SIGNATURE OF REQUESTING OFFICIAL

POWER IN AREA

STORMWATER LINES IN AREA

UNDERGROUND

UNDERGROUND

4. DATE OF CLEARANCE

6. TELEPHONE NO.

LINES IN AREA

Call 6 CES at 828-4531 two business days prior for locates

Call 6 CES at 828-4531 two business days prior for locates

8.

B A S E

C I V

IL

E N G I N E E R I N G

B. STEAM DISTRIBUTION

C. WATER DISTRIBUTION

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

Must call if any road blockages prior to blocking any lanes has not been staked or clearly marked.

G. AIRCRAFT OR VEHICULAR TRAFFIC FLOW

H. SECURITY

I. OTHER

Privatized utility - Call Sunshine (see #14)

11. COMMUNICATIONS: Cable Maint. (1400 - 1600 M - Th)

CABLE IN AREA

9. SECURITY POLICE

10. SAFETY

J. OTHER (SPECIFY): 6 AMDS/Bio Environmental

H. FIRE PROTECTION

Stormwater: Call 6 CES at 828-4531 two business days prior for locates

Must call if any road blockages prior to blocking any lanes

E. SEWER DISTRIBUTION: FGUA Utility Operations Center

F. ENVIRONMENTAL

NVZR:

ORGANIZATION REMARKS

IRRIGATION SYSTEMS

ENVIRONMENTAL RESTORATION (ERP)

CADD (6 CES/CADD)

PLUMBING/GAS SERVICE LINES (6 CES/CEOV):

AIRFIELD ATCALS SYSTEMS (6 OSS/OSAM):

HARBOR BAY HOUSING (NLT 7 days prior) Privatized Housing Maint., 2120 Secord Ave, AF IMT 103, 19940801, V3 (REVERSE)

2. In the event any property marked communications cable is severed due to contractor negligence, the cable shall be repaired withing 24 hours by the contractor. Before excavating, the contractor must have a contingency plan in order to comply with repairing the cable within 24 hours of the initial assessment (see 6 CS/SCOW for recommended sources). The 6 CS/SCOW will make the initial assessment of damage and temporarily restore any priority circuit outages. The contractor's 24 hours begins after the initial assessment. The responsible contractor will arrange for permanent repairs using materials specified by the 6 CS/SCOW. As each situation is different, a required list of materials will be provided during the initial assessment. The company chosen to permanently repair the cable will have certified technicians capable of performing fusion splicing for fiber optic cables and 710 modular or VAS3 pic-a-bond splicing for copper cables. All repaired cables will be sealed with PREFORMED splice cases and filled with the proper encapsulant. When the repair is complete the contractor will not bury or otherwise disturb the repair until a post-test and inspection is performed by the 6 CS/SCOW. The 6 CS/SCOW will have two work days after they are notified that work has been completed to complete the inspection and testing of the damaged cable and the contractor will bury and/or otherwise return the site to its original condition.

Contractors initials ____________

3. Groundwater monitoring wells are in or are adjacent to the project area (figure provided by ERP personnel). These groundwater monitoring wells must be protected from damage. If they are damaged, they must be repaired or abandoned and reinstalled in accordance with the MacDill Basewide Environmental Restoration Work Plan, Revision 5, at the contractor's expense. MacDill ERP personnel will determine the corrective action necessary.

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 tocoordinate the required work with key base activities and keep customer inconvenience to a minimum. It is also used to identify potentially hazardouswork conditions in anattempt to prevent accidents. The work clearance request is processed just prior to the start of work. If delays are encountered and theconditions at the job site change (or may have changed) thiswork 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.)

Effective: 11 Apr 17 (was)

REVIEWER'S NAME AND INITIALS

4. This work clearance permit is valid under the following conditions:

Failure to follow work clearance instructions may result in contractors being held liable for cost of repairs performed by base agencies (including response to secure a break).

User is responsible to ensure that contact is made for locates prior to work starting.

WARNING: UTILITY MARKING ARE CONSIDERED ACCURATE WITHIN 5' ON BOTH SIDES OF THE MARKING. It is the users responsibility to take precautions necessary to prevent accidental utility damage or verify utility location before digging to include pot-holing for the utility that is marked. Hand-digging will be requested and required around areas congested with utilities, or areas where a utility may be absent of tracer material (i.e., unshielded fiber optic cable).

a. Fenced construction site clearance - period of construction - user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked.

b. Non-fenced constructions sites - valid for the life of the work. The user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked.

c. Multi-job/location sites - the requestor initiates an AF IMT 103 for each new work site. The contractor will be required to get each work clearance approved each time they move from one site to another where the lines have not been marked. The user is responsible to maintain markings or to call (as instructed on AF IMT 103) to have areas remarked. In cases where user requires remarking due to negligence, weather, etc: user will be required to supply their own marking materials.

840-2000 (call first). Note: any project traversing privatized housing property will require a third party utility locate. It will be the financial responsibility of the contractor to locate the utilities within the privatized housing property boundary.

1. No welding/cutting/open flames permitted without an approved welding permit (AF IMT 592) from the Fire Department Tech Services.

MacDill AF IMT 103 pg 1

MacDill AF IMT 103 pg 2

6 CS/Cable Maintenance

Permit Number:________________

1. Block one of the AF Form 103 shall be filled out COMPLETELY. He or she shall state the exact location and scope of work to be performed.

2. Requester shall identify area to be marked by highlighting and print/sign name on a copy of the print provided by the customer. If the customer does not have a print, they shall identify the area using electrical records. The customer will highlight, print/sign name, and date these prints/records in agreement with the work to be accomplished.

3. If customer needs to go outside the predetermined area, then he or she shall be RESPONSIBLE for contacting 6 CS/Cable Maintenance Shop at (813) 828-2033 to schedule additional marking.

4. Requester is required to give Cable Maintenance a viable point of contact and 72 hrs notice prior to any excavation. A time and date will be coordinated for the requester to be present when the area is marked.

The customer will verify the entire area has been marked and the circuits’ markings in site match the highlighted areas on the print.

5. The requester and locator will then both sign/print their names acknowledging area has been located properly. The marking of the area are to be maintained by the requester for the duration of the project.

6. The requester must verify the marks, per the instructions on page two (2) of the AF Form 103.

7. There will be “NO” excavation until these requirements are completed. The AF Form 103 shall be maintained at the project site for the duration of the project.

Acknowledgement of agreement:

Requester:

Print Name: ___________________ Sign Name: _______________________ Date: ___________

Permit Number:__________________

Company: ______________________

Phone Number:

Acknowledgement of locate: Both parties, the requester and the locator, agree the communication lines are properly located with orange marking whiskers, and/or orange paint in accordance with the work area outlined on the associated AF Form 103.

Requester: Print Name: ___________________ Sign Name: __________________________

Locator: Print Name: ___________________ Sign Name: __________________________

Date Located: ______________________

Print Name:

Print Name_2:

Print Name_3:

Date9_af_date:

Date10_af_date:

Permit No:

Company:

Phone number:

Text14:

103 Questionnaire:

1. Contact information:

Company name:

Contact name:

Office number:

Cell number:

Email:

2. NVZR or Contract number:

3. Start Date?

4. Duration of the project?

5. Detailed scope of work?

6. Location of project?

7. Will you be digging?

8. How deep will you be digging?

9. How will you be digging? Hand or Machine

10. Working indoor or outdoor?

11. What equipment is being used?

12. Will you need to dewater?

13. Plans for waste?

14. What’s going to be affected, plants or species?

15. Hazmat items approved?

16. Asbestos or lead based paint?

17. Locate wells onsite?

18. Figures/Map (with location marked on map)?

19. Will you be moving soil from one site to another?

20. Will you have excess soil? Plan for excess soil?

21. Sunshine Clearance#?

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Company name:

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POC:

Date:

Requestor:

Locator:

Date Located: Dig Permit Project #

Acknowledgement of agreement (initials):

5. The requester and locator will then both sign/print their names acknowledging area has been located properly. The markings of the area are to be maintained by the requester for the duration of the project.

6. There will be "NO" excavation until these requirements are completed. The AF Form 103 shall be maintained at the project site for the duration of the project.

7. Must see Harbor Bay when locate is in Base Housing Area. Area shall be located by both companies for their area of responsibility.

ELECTRICAL SECTION

1. Block one of the AF Form 103 shall be filled out COMPLETELY. He or she shall state the exact location and scope of work to be performed.

2. Requester shall identify area to be marked by highlighting and print/sign name on a copy of the print provided by the customer. If the customer does not have a print, they shall identify the area using electrical records. The customer will highlight, print/sign name, and date these prints/records in agreement with the work to be accomplished.

3. If customer needs to go outside the predetermined area, then he or she shall be RESPONSIBLE for contacting 6CES Electrical Shop at (813) 828-2696 for adding marking.

4. Requester is required to give Electrical Shop a viable point of contact and 72 hrs notice prior to any excavation. A time and date will be coordinated for the requester to be present when the area is marked. The customer will verify the entire area has been marked and the circuits' markings in site match the highlighted areas on their print.

Project Location

Company

Phone Number

Phone Number:

Print Name_2:

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Dig Permit Project:

Acknowledgement of agreement initials:

Date:

Print Name:

Project Location:

Company:

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) 304-2694

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

Affiliation 6 CES USACE:

Construction Manager Phone:

Email:

Project Name:

Project Number:

AF Form 103 dated:

Planned Work Start Date:

Locate Ticket:

Date and Time of Utility Locate:

Description of Work 1:

Sewage Forcemain:

Date_2:

Office Tracking Log Completed:

Date_3:

Relocate 1:

Date_4:

Relocate 2:

Date_5:

Relocate 3:

Date_6:

Utility Damage:

Date:

Full Name of Applicant:

Contractor Name:

Job Site Phone:

Contractor License:

Contractor Supervisor:

Job Site Location BldgIntersection 1:

Supervisor Phone:

Job Site Location BldgIntersection 2:

MacDill Construction Manager:

Cost Recovery:

Date_8:

Pressurized Water Main:

Date_7:

Water Service Lines:

Reclaimed Water Main:

Gravity Sewer:

Gravity Sewer Comments:

Reclaimed Water Main Comments:

Water Service Lines Comments:

Pressurized Water Main Comments:

Sewage Forcemain Comments:

PWM Initials:

WSL Initials:

RWM Initials:

GS Initials:

SF Initials:

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DATE PREPARED:

Project:

Contract No:

2 TYPE OF FACILTYWORK INVOLVED:

3 DATE CLEARANCE REQUIRED:

4 DATE OF CLEARANCE:

6 TELEPHONE NO:

7 ORGANIZATION:

Write Sunshine Clearance here:

17a DATE SIGNED:

REMARKSIRRIGATION SYSTEMS:

REMARKSENVIRONMENTAL RESTORATION ERP:

REMARKSCADD 6 CESCADD:

REMARKSPLUMBINGGAS SERVICE LINES 6 CESCEOV:

REMARKSAIRFIELD ATCALS SYSTEMS 6 OSSOSAM:

REMARKSRow6:

Contractors initials:

Contractors initials_2:

Contractors initials_3:

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WATER DISTRIBUTION REMARKS:

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SEWER DISTRIBUTION REMARKS:

ENVIRONMENTAL REMARKS:

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FIRE PROTECTION REMARKS:

6 AMDS/Bio Environmental REMARKS:

SECURITY POLICE REMARKS:

SAFETY REMARKS:

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BASE OPERATIONS REMARKS: