Attachment O&M Part 2 Equipment Enrollment Form.pdf

Coast Guard Maintained Equipment with Corresponding Means PM Plan

Bldg # Floor Room #

D304008 e.g. Air Handling Unit 3159 1st Boiler Rm Carrier YE3666OER21 7112LO3306 10/1/2004 $ 1,200.00 $ 500.00 10/1/2005 300 CFM, 480V, Phase 3, 5 ton 1780‐Q, 1778‐A Q/A

D202002 e g. Backflow Preventer 3159 1st Mech Rm Watts 900 112112 1/1/2000 $ 4,500.00 $ 1,200.00 1/1/2001 2.5 IN 1972‐A A

D303002 e.g. Condensing Unit 3159 Roof N/A Trane TTTR025C10 L204P9GAF 5/15/1996 $ 2,500.00 $ 1,000.00 5/15/1997 R‐22, 4.2lbs, 300/300 PSI 1826Q, 1825A Q/A

D302002 e.g. Hot Water Boiler 3159 1st Mech Rm Cleaver Brooks MCF MB586 6/30/2012 $ 1,500.00 $ 700.00 6/30/2013 900 MBH 1914‐M, 1913‐Q, 1912‐A M/Q/A

D302003 e.g. Package Unit Forced Air, Gas 3159 N/A N/A York D2NX04D09 N1D0784403 9/15/2008 $ 3,000.00 $ 1,500.00 9/15/2009 250 MBH, R‐22, 6.3lbs, 278/144 1937Q, 1936A Q/A

B301099 e.g. Roof 3159 Roof N/A N/A N/A N/A 1/1/1990 $ 25,000.00 $ 10,000.00 1/1/2015 10700 SF, Shingles 9069‐A A

Bldg 3159

CG SAM "JOB PLAN"

Number: (Correlates with a RS Means Preventative

Maintenance Ref number ‐ See Appendix O&M Parts

1&3)

PM Job Plan(s) w/ Frequency

(i.e. 1921‐M, 1920‐Q, 1919‐ A)

Landlord OPFAC SAM Site #

Serial # Installation

Date Purchase Price1 Replacement

Cost2 Warranty Expiration

Date

Equipment Attributes3

(Identification/Name Plate Information)

1. Purchase Price: Total cost of installation to include cost of equipment, labor, shipping, etc…

2. Replacement Cost: Cost of equipment only.

General Instructions:

3. Equipment Attributes: To include sizes (i.e. motor HP, SF, LF, etc…), capacities (other than size), and ratings.

Uniformat II Level 4

To be filled out by Contractor (white blocks)

Landlord/Unit Name

Equipment Enrollment Form

To be filled out by Government (shaded blocks)

Physical Location

Equipment Description Manufacturer

Name Model #

SAM Location/Bldg # SAM Location Description

SAM Location # 4542342 = Bldg 3159

Version 1.0

APPENDIX O&M - PART 2