J-1601000-12_Outage request.pdf

PWD Guantanamo Bay – SYSTEM OUTAGE REQUEST

PWD GTMO 4330/18 (REV. JAN 2018)

Requestor: Organization:

Office#: Cell #: Contract #:

Project Title:

Date of Request:

ALL REQUESTS FOR OUTAGES MUST BE SUBMITTED FIFTEEN (15) CALENDAR DAYS

PRIOR TO OBTAINING SUCH OUTAGE TO THE PUBLIC WORKS DEPARTMENT FOR

APPROVAL.

Type of Outage (Electrical/Water/Wastewater/Other (explain)):

Outage Requested: Start Date/Time: Finish Date/Time:

Safe Clearance Form Attached: Yes No (15 Day Timeframe Will Not Start Until Submitted) (Check One)

AREA AFFECTED BY OUTAGE (PROVIDE SPECIFIC FACILITY NUMBERS FOR ALL AFFECTED):

(FOR ALL OUTAGES) SYSTEM INTERUPTION POINT:

Include pole numbers, transformer information, and valve locations, i.e., all applicable field knowledge. This section should clarify which facilities are affected by the outage.

Justification/Reason for Outage:

- Approval Routing -

Contractor: (Mat’l/Equip/Manpower Verified) Title/Signature/Date

BOS Contractor:

Title/Signature/Date

UEM: (Initial Notification) Title/Signature/Date

PAR Notification: (Electric/Water) Title/Signature/Date

UEM: (Final Notification) Title/Signature/Date

Facility Manager: Service Call #:

Title/Signature/Date

PWD Guantanamo Bay – SYSTEM OUTAGE REQUEST

PWD GTMO 4330/18 (REV. JAN 2018)

-Disapproval Routing- (DISAPPROVAL ROUTING SHALL ONLY BE USED IF AN ALTERNATE OUTAGE DATE CANNOT BE NEGOTIATED

BETWEEN REQUESTOR AND TENANT(S))

Tenant: (DISAPPROVAL ONLY) Title/Signature/Date

Justification (Must explain mission impacts and non-availability of alternate accommodations.)

Requestor: (FOR TENANT DISAPPROVAL ONLY) Title/Signature/Date

Justification (Must explain inability to accommodate an alternate outage date.)

Additional Information: