30 - AF Form 103 Base Civil Engineering Work Clearance Request - 01 Aug 1994.pdf

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

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

4. DATE OF CLEARANCE

3. DATE CLEARANCE REQUIRED

5. SIGNATURE OF REQUESTING OFFICIAL

6. TELEPHONE NO.

7. ORGANIZATION

REMARKS

(Use Reverse for additional comments)

REVIEWER'S NAME AND INITIALS

ORGANIZATION

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)

APPROVED

DISAPPROVED

16. REQUESTED CLEARANCE

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

Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign

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)

8.2.1.3158.1.475346.466429

811. USA NORTH REQUIRES TWO FULL WORKING

DAYS NOTICE BEFORE YOU DIG. USA NORTH

TICKET #

*** REQUESTOR IS RESPONSIBLE FOR MAINTAINING MARKINGS ***

*DIG REQUEST NEEDS TO BE SUBMITTED 30 DAYS IN ADVANCE.*

1. WHAT IS THE PURPOSE OF THE DIGGING?

2. IF THIS WORK IS BEING COMPLETED BY CONTRACT PROVIDE NAME OF NAFB POINT OF CONTACT?

3. INCLUDE MAP WITH PLAIN VIEW REFERENCE POINTS.

4 WHAT IS THE SPECIFIC ADDRESS AND LOCATION OF AREA BEING DUG?

5. WHAT ARE THE DIMENSIONS FOR TOTAL AREA THAT IS GOING TO BE DISTURBED?

6. WHAT IS THE SPECIFIC LOCATION OF DIGGING STARTING POINT?

7. WHAT IS THE SPECIFIC LOCATION OF DIGGING ENDING POINT?

8. IF TRENCHING, PROVIDE THE FOLLOWING?

LINEAR FEET: ____________ DEPTH: ____________ WIDTH: ____________

9. WHAT IS THE PROJECTED DATE DIGGING WILL START/END DATES?

START DATE: ____________ END DATE: ____________

10. WILL THIS DIGGING PERMIT REQUIRE A UTILITY OUTAGE ( ELECT, GAS, WATER)?

11. WILL YOU BE RESTRICTING OR CLOSING ROADS/PARKING LOTS TO FACILITATE THE WORK?