Attachment O - AF103-Utility Outage Request Form.pdf

28 KB Posted

Attached to
Replace Two 12, 470V to 480V Transformers
Solicitation number
FA940124B0003
Issued by

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This document is an Air Force Base Civil Engineering Work Clearance Request Form. It is used to coordinate work that may disrupt aircraft/vehicle traffic, utility services, fire/security systems, or base operations. The form requires details on the type of work, location, date clearance is needed, and a signature from the requesting official. Reviewers from various base departments (electrical, fire, communications, etc.) must approve or disapprove the request prior to work commencement. Specific precautionary measures to be taken during the work must be described. This form is used for both contract and in-house work on the air force base.

The related federal contract opportunity is for replacing two 12,470V to 480V transformers and installing a 200A panelboard in Building 27497 on Kirtland Air Force Base. The transformers are outdated from the original building construction and need to be replaced like-for-like, including reconnecting the associated equipment and wiring. The solicitation number is FA940124B0003 and it is being issued by the Department of the Air Force Materiel Command Nuclear Weapons Center.

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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

HAS:
HASNOT:
APPRVD:
DAPPRVD:
Entery date as YYYYMMDD.:
LOCA:
WONO:
CTRNO:
ABC:
ABC_2:
ABC_3:
D:
E:
F:
OVHA:
OVHB:
UNDGA:
UNDGB:
GHI:
GHI_2:
GHI_3:
OTH:
Enter date as YYYYMMDD.:
ReqOffclSig:
TELE:
ORGN:
REMKA:
SIGNATURE1:
REMKA_2:
SIGNATURE2:
REMKA_3:
SIGNATURE3:
REMKA_4:
SIGNATURE4:
REMKA_5:
SIGNATURE5:
REMKA_6:
SIGNATURE6:
REMKA_7:
SIGNATURE7:
REMKA_8:
SIGNATURE8:
ZONE:
REMKB:
SIGNATURE9:
OTHB:
REMKC:
SIGNATURE10:
REMKD:
SIGNATURE11:
REMKD_2:
SIGNATURE12:
REMKD_3:
SIGNATURE13:
REMKD_4:
SIGNATURE14:
REMKD_5:
OTHC:
REMKE:
COMUTIL:
COMUTIL_2:
COMUTIL_3:
AppOffcrSig:
SIGNATURE16:
SIGNATUREfor13:
EF_1:
EF_2:
REMKSF:
SignatureStyle1:
SignatureStyle2:

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