Attch 5 - Utility Power Outage Request Permit Form 103.pdf

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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 involving excavation or utility disturbance per attached sketch. This area. Check box HAS Check box has not been staked or clearly marked.

Check box APPRVD

16. REQUESTED CLEARANCE., Check box disapproved.

Entery date as YYYYMMDD.

Ay F FORM 103, 19940801 I M T V 1. BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST. 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. Enter date as Y Y Y Y M MD D.

1. Clearance is requested to proceed with work at on Work Order Number Contract Number

2. TYPE OF FACILITY WORK INVOLVED. Check box A. PAVEMENTS Check box B. DRAINAGE SYSTEMS Check box C. RAILROAD TRACKS Check box D. FIRE DETECTION and PROTECTION SYSTEMS Check box E. UTILITY Check box F. COMMUNICATIONS Check box OVERHEAD Check box OVERHEAD Check box UNDERGROUND Check box UNDERGROUND Check box G. AIRCRAFT OR VEHICULAR TRAFFIC FLOW Check box H. SECURITY Check box I. OTHER Field Other Enter date as YYYYMMDD.

3. DATE CLEARANCE REQUIRED Enter date as Y Y Y Y M M D D.

6. TELEPHONE Number. Number will be formatted automatically.

7. ORGANIZATION

ORGANIZATION. 8. Base civil engineering. A. Electrical distribution. REMARKS. Use Reverse for additional comments.

B. STEAM DISTRIBUTION. remarks C. WATER DISTRIBUTION. Remarks D. P O L DISTRIBUTION. Remarks E. SEWER DISTRIBUTION. Remarks F. ENVIRONMENTAL. Remarks G. PAVEMENTS or GROUNDS H. FIRE PROTECTION. Remarks I. Zone. Organization.

I. Zone. Organization. Remarks.

J. Other. Specify.

Other remarks.

9. SECURITY POLICE. Remarks

10. SAFETY. Remarks

11. COMMUNICATIONS. Remarks

12. BASE OPERATIONS. Remarks

13. CABLE TV. Remarks Other. Specify.

14. COMMERCIAL UTILITY COMPANY. Remarks

14. COMMERCIAL UTILITY COMPANY. Check box telephone

14. COMMERCIAL UTILITY COMPANY Check box Gas

14. COMMERCIAL UTILITY COMPANY Check box electric

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.