Attachment_16_-_AF_Form_103v10_Work_Clearance_Request_-_29_Feb_2015.pdf

27 SOCES FORM 103v10, 29 Feb 2015 Modified for Cannon AFB NM Page 1 of 4 PREVIOUS EDITIONS ARE OBSOLETE

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST DATE PREPARED

(ddmmyy)

(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

A. PAVEMENT D. FIRE DETECTION & PROTECTION SYSTEM G. AIRCRAFT OR VEHICULAR

TRAFFIC FLOW

B. DRAINAGE SYSTEM E. UTILITY OVERHEAD UNDERGROUND H. SECURITY

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

3. DATES 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 & INITIALS

8. AIRFIELD MANAGEMENT Bldg 135 Contact 72 hrs prior to clearance rqmt/project start 575-784-2801 Airfield access required : POV pass required

9. MAINTENANCE OPERATIONS CENTER Bldg 790 Contact 48 hrs prior to clearance requirement 575-784-2135

10.

GROUND SAFETY Bldg 155 Rm 146 Contact 48 hrs prior to clearance requirement 575-784-4470, 575-784-4472, 575-784-4169, 575-784-4471 or 575-784-2583

11. COMMUNICATIONS Bldg 10 Contact 48 hrs prior to clearance requirement 575-784-6622 - Call for clearance and utility location

12. SCX Bldg 777 Rm 116 Contact 48 hrs prior to clearance requirement 575-784-1369 or 575-784-2318 - Call for clearance and utility location

14a.

SECURITY FORCES Bldg 575 Contact 48 hrs prior to clearance requirement 575-784-4111

13. COMMERCIAL UTILITY COMPANIES

New Mexico 811 Contact 48 hrs prior to clearance requirement 1- 800 -321-2537 - Note date & request number.

Date ____________________

Request # ________________

X TELEPHONE

X CABLE

. B

A

SE

C

IV

IL

E

N G

IN

EE

R

IN

G , B ld g

A. ELECTRICAL DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-4371 - Call for clearance and utility location

B. GAS DISTRIBUTION Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location

C. WATER DISTRIBUTION

D. SEWER DISTRIBUTION

E. IRRIGATION SYSTEMS HAND DIG ONLY (Unless waived by CEO) CEO Approved ________________________

F. POL DISTRIBUTION

G. ENVIRONMENTAL Call 575-904-6736 in the event environmental problems are encountered during excavation

H. PAVEMENTS / GROUNDS Contact 48 hrs prior to clearance requirement 575-784-4383 - Call for clearance and utility location

I. FIRE PROTECTION Contact 48 hrs prior to clearance requirement 575-784-2578 - Call for clearance and utility location

J. EMCS / HVAC Contact 48 hrs prior to clearance requirement 575-784-1132 - Call for clearance and utility location

K. GEOBASE OFFICE Contact 48 hrs prior to clearance requirement 575-784-1628 - Call to update maps or utility tabs

16. OTHER (Specify)

17. REQUESTED CLEARANCE APPROVED DISAPPROVED

18. TYPED NAME AND SIGNATURE OF APPROVING OFFICIAL (Chief of Operations Flight or CEO Designee} 18a. DATE SIGNED (ddmmyy)

Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location

Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location

Contact 48 hrs prior to clearance requirement 575-784-6742 or 575-693-2565 - Call for clearance and utility location

WEAPONS SAFETY14b. Bldg 155 Rm 134

Project Manager/COR (Print Name) _______________________________________________

19. Remarks. (This section describes specific precautionary measures to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment should be listed)

Equipment being used: ______________________________________________________________________________

1. Contractor will not proceed with any work until clearance has been coordinated as indicated by remarks that have been provided. Signatures on section 14 A through E and J on page 1 do not constitute approval. Approval for these blocks is provided on page 3.

2. Any drawings provided indicate the APPROXIMATE location of the work area.

3. Contractor shall contact and give notice to all listed organizations by calling the phone numbers as listed in the remarks section next to each organization.

a. It is very important all clearance requests are made and understood by the contractor. The contractor shall log all calls and activities made to each organization as listed on the AF 103. The log information will be placed on page 3 of the AF 103. Each entry will be kept in a numbered, sequential order by date and organization.

Note: If additional pages are required for the clearance log, record is to be attached to the original AF103.

b. If clearance is not required in the location of this request, the contractor will note the reviewer’s name and date/time the organization was contacted and indicate “No Action Required”.

c. If clearance is required by the organization, the contractor will coordinate a site meeting with the reviewer(s) representing that organization. The reviewer will physically spot the clearance issue and/or mark the location. The contractor will then have the reviewer fill in his name and initials in the Reviewers Name and Initials column on page 1 for that organization. The contractor will also log on page 3 of the AF103, the meeting, date/time, person(s) name, and action taken.

6. As-builts for irrigation systems are not available. The contractor will ensure restoration of landscaping and repair of irrigation systems are completed, at no cost to the government, during the course of work.

7. In the event any unknown or unidentified items are discovered during demolition or construction, work shall cease immediately and 27 SOCES/CEAN shall be notified.

Contact the Restoration Program at 575-784-1095.

8. Notify Bioenvironmental Engineering Flight (Bldg 1400; 575-784-4063) at least 3 working days in advance if any type of maintenance/repair/modification is being performed on water mains, pipes and service lines to include emergency repairs; especially if water is being shut off to buildings/facilities in order to complete these repairs.

9. Notify the New Mexico Environment Department of potable water line work associated with this project IAW New Mexico Administrative Code 20.7.10., Drinking Water, Para. 200B. Notification must be made on the form entitled "Application for the Construction or Modification of a Public Water Supply System." Contact the Water Quality Program Manager, 27 SOCES/CEIEC, at 575-904-6736 for questions.

4. The contractor will notify the Contracting Officer Representative (COR) or Project Manager (Box 5) if there are any questions or concerns to ensure proper coordination of this Work Clearance Request.

13.

14.

The contractor or his agent is responsible for removing and disposing of any/all flags or survey marking whiskers within his site upon completion of excavation.

The contractor or his agent will maintain this clearance request on the site and make it available for review by any Government representative upon request.

Notify CE Service Call/After-Hours emergency @ 575-784-2001 and 27 SOCS (TSgt Vitense) @ 916-705-9452 or Mr. Labbour @ 575-693-5220 if any utilities are damaged after normal work hours.

Contractor Representative (Print Name) _______________________________ Telephone No. _____________

Date_________________

Telephone No. _____________

INSTRUCTIONS

The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular 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 re-processed.

Signature__________________________________________________________________

5. The contractor is responsible for maintaining all marks on his work site. Locates that must be re-performed will require the contractor to coordinate line spotting on block 14 sections A through K at the weekly Work Clearance Request meeting.

12.

(NOTE: Work cannot begin until signed by Contractor Representative)

11. If marked utilities are not found (hand excavated, pot-holed etc.) within three feet of the marker or flag, the contractor MUST re-contact the section responsible for placing the mark to verify utility location.

10. Use of reclaimed wastewater for construction activities is highly encouraged and may be a contract requirement. Reclaimed (nonpotable) wastewater is available at a fill stand outside the wastewater treatment plant compound (east side of CAFB). Contact Mr. John Rebman, 27 SOCES/CEIEC (904-6736) prior to obtaining water from this fill stand for important instructions. Note that the reclaimed wastewater fill stand is located in close proximity to the potable water hydrant. Please do not confuse these two sources with one another.

27 SOCES FORM 103V10, 29 Feb 2016 Modified for Cannon AFB NM Page 2 of 4 PREVIOUS EDITIONS ARE OBSOLETE

Prevent potential storm water infiltration into the sanitary sewer system during demolition and construction by blocking pathways (e.g., open sewer drains and manholes during demolition/construction) that lead to the CAFB wastewater treatment plant. Infiltration of excessive storm water and/or mud may lead to violations of an Environmental Protection Agency issued permit.

15.

Action Log

27 SOCES FORM 103v10, 29 Feb 2015 Modified for Cannon AFB NM Page 3 of 4 PREVIOUS EDITIONS ARE OBSOLETE

Base Utility Locater Action Taken Contractor Date/Time Electrical Distribution EMCS / Alarms / HVAC Gas Distribution

Water Distribution Sewer Distribution Irrigation / Landscaping Comm / Americom

GEO Base

New Mexico 811 Locater Action Taken Contractor Date/Time SuddenLink CenturyLink Plateau

Organization Name Action Taken Contractor Date/Time 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.