_RFP_Part_D_Attachments_14DEC18.pdf

Solicitation No.

N40192-19-R-2830

8(a) MULTIPLE AWARD

CONSTRUCTION CONTRACT

(8(a) MACC) at

VARIOUS LOCATIONS, GUAM

PART D

ATTACHMENTS

Attachment D-1

Attachment D-2

Attachment D-3

Attachment D-4

Attachment D-4

Attachment D-5

Attachment D-5

Attachment D-6

Attachment D-6

a. Date of report, report number, name of Contractor, Contract number, title and location of Contract and Superintendent present.

b. Weather conditions in the morning and in the afternoon including maximum and minimum temperatures.

c. Identify work performed by corresponding Schedule Activity No., PC#, Modification No., etc.

d. A list of Contractor and subcontractor personnel on the work site, their trades, employer, work location, description of work performed, hours worked by trade, daily total work hours on work site this date (incl. hours on continuation sheets), and total work hours from start of construction.

e. A list of job safety actions taken and safety inspections conducted. Indicate that safety requirements have been met including the results on the following:

1) Was a job safety meeting held this date? (If YES, attach a copy of the meeting minutes.)

2) Were there any lost time accidents this date? (If YES, attach a copy of the completed OSHA report.)

3) Was crane/man lift/trenching/scaffold/high voltage electrical/high work/hazmat work done? (If YES, attach a statement or checklist showing inspection performed.)

4) Was hazardous material/waste released into the environment? (If YES, attach a description of incident and proposed action.)

f. Identify Schedule Activity No. related to safety action and list safety actions taken today and safety inspections conducted.

g. Identify Schedule Activity No., Submittal # and list equipment/material received each day that is incorporated into the job.

h. Identify Schedule Activity No., Owner and list construction and plant equipment on the work site including the number of hours used.

i. Include a "remarks" section in this report which will contain pertinent information including directions received, problems encountered during construction, work progress and delays, conflicts or errors in the Contract documents, field changes, safety hazards encountered, instructions given and corrective actions taken, delays encountered and a record of visitors to the work site. For each remark given, identify the Schedule Activity No. that is associated with the remark.

Additional space required to contain daily information on the Contractor Production Report will be placed on its Continuation Sheet(s). An unlimited number of Continuation Sheets may be added as necessary and attached to the Production Report.

Attachment D-7

Reports are required for each day that work is performed and shall accompany the submission of the Contractor QC Report prepared for the same day. This requirement shall commence at the beginning of the construction phase of work and continue through final completion of the Contract. Account for each calendar day throughout the life of the Contract. The reporting of work shall be identified by terminology consistent with the construction schedule. Contractor Production Reports are to be prepared, signed and dated by the Project Superintendent and shall contain the following information:

(ATTACH ADDITIONAL SHEETS IF NECESSARY)

DATE

CONTRACT NO TITLE AND LOCATION

REPORT NO

CONTRACTOR SUPERINTENDENT

AM WEATHER PM WEATHER MAX TEMP (F) MIN TEMP (F)

Schedule Activity No. DEFINABLE FEATURE OF WORK, WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS

WAS A JOB SAFETY MEETING HELD THIS DATE?

(If YES attach copy of the meeting minutes) YES NO

TOTAL WORK HOURS ON JOB

SITE,

THIS DATE, INCL CON'T SHEETS

WERE THERE ANY LOST TIME ACCIDENTS THIS DATE?

(If YES attach copy of completed OSHA report) YES NO CUMULATIVE TOTAL OF WORK

HOURS FROM PREVIOUS

REPORT WAS CRANE/MANLIFT/TRENCHING/SCAFFOLD/HV ELEC/HIGH WORK/ HAZMAT WORK DONE?

(If YES attach statement or checklist showing inspection performed.) YES NO

WAS HAZARDOUS MATERIAL/WASTE RELEASED INTO THE ENVIRONMENT?

(If YES attach description of incident and proposed action.) YES NO

TOTAL WORK HOURS FROM

START OF CONSTRUCTION

Schedule Activity No. DEFINABLE FEATURE OF WORK AND LIST SAFETY ACTIONS TAKEN TODAY/SAFETY INSPECTIONS CONDUCTED SAFETY REQUIREMENTS HAVE BEEN MET.

EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (INDICATE SCHEDULE ACTIVITY NUMBER)

Schedule Activity No. Submittal # Definable Feature of Work and Description of Equipment/Material Received

CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY. INDICATE HOURS USED AND SCHEDULE ACTIVITY NUMBER.

Schedule Activity No. Owner Definable Feature of Work and Description of Construction Equipment Used Today (incl Make and Model) Hours Used

Schedule Activity No. DEFINABLE FEATURE OF WORK AND REMARKS

CONTRACTOR/SUPERINTENDENT DATE

Attachment D-7

(CONTINUATION SHEET)

DATE

CONTRACT NO TITLE AND LOCATION

REPORT NO

Schedule Activity No. DEFINABLE FEATURE OF WORK, WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS

Schedule Activity No. DEFINABLE FEATURE OF WORK AND LIST SAFETY ACTIONS TAKEN TODAY/SAFETY INSPECTIONS CONDUCTED

EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (INDICATE SCHEDULE ACTIVITY NUMBER)

Schedule Activity No. Submittal # Definable Feature of Work and Description of Equipment/Material Received

CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY. INDICATE HOURS USED AND SCHEDULE ACTIVITY NUMBER.

Schedule Activity No. Owner Definable Feature of Work and Description of Construction Equipment Used Today (incl Make and Model) Hours Used

Schedule Activity No. DEFINABLE FEATURE OF WORK AND REMARKS

INCLUDE ALL PERSONNEL WORK HOURS IN THE WORK PERFORMED SECTION ON THIS SHEET

INTO THE FRONT CONTRACTOR PRODUCTION REPORT

Attachment D-7

a. Specification Section, date of report, and contract number shall be filled out. Duplicate this information in the header of the second page of the report.

b. Definable Feature of Work, Schedule Activity No. and Index # entry and format will match entry in the Preparatory Phase section of the Contractor QC Report

c. Personnel Present: Indicate the number of hours of advance notice that was given to the Government Representative and indicate (Yes/No checkboxes) whether or not the Government Rep was notified. Indicate the Names of Preparatory Phase Meeting attendees, their position and company/government they are with.

d. Submittals: Indicate if submittals have been approved (Yes/No checkboxes), if no indicate what has not been submitted. Are materials on hand (Yes/No checkboxes) and if not, what items are missing.

Check delivered material/equipment against approved submittals and comment as required.

e. Material Storage: Indicate if materials/equipment is stored properly (Yes/No checkboxes) and if not, what action is/was taken.

f. Specifications: Review and comment on Specification Paragraphs that describe the material/equipment, procedure for accomplishing the work and clarify any differences.

g. Preliminary Work & Permits: Ensure preliminary work is in accordance with the Contract documents and necessary permits are on file, if not, describe the action taken.

h. Testing: Identify who performs tests, the frequency, and where tests are to occur. Review the testing plan, report abnormalities, and if the test facilities have been approved.

i. Safety: Indicate if the activity hazard analysis has been approved (Yes/No checkboxes) and comment on the review of the applicable portions of the EM 385-1-1.

j. Meeting Comments: Note comments and remarks during the Preparatory Phase Meeting that was not addressed in previous sections of this checklist.

k. Other Items or Remarks: Note any other remarks or items that were a result of the Preparatory Phase.

l. QC Manager will sign and date the checklist.

Attachment D-8

Each DFOW that is in the Preparatory Phase shall have this checklist filled out for it. The checklist shall be identified by terminology consistent with the construction schedule. This checklist shall accompany the submission of to the Contractor QC Report of the same date.

SPEC SECTION DATE

(CONTINUED ON SECOND PAGE)

CONTRACT NO DEFINABLE FEATURE OF WORK SCHEDULE ACT NO. INDEX #

GOVERNMENT REP

NOTIFIED _____ HOURS IN ADVANCE: YES NO

NAME POSITION COMPANY/GOVERNMENT

REVIEW SUBMITTALS AND/OR SUBMITTAL REGISTER. HAVE ALL SUBMITTALS BEEN APPROVED? YES NO

IF NO, WHAT ITEMS HAVE NOT BEEN SUBMITTED?

ARE ALL MATERIALS ON HAND? YES NO

IF NO, WHAT ITEMS ARE

MISSING?

CHECK APPROVED SUBMITTALS AGAINST DELIVERED MATERIAL. (THIS SHOULD BE DONE AS MATERIAL ARRIVES.)

COMMENTS:

ARE MATERIALS STORED PROPERLY? YES NO

IF NO, WHAT ACTION IS TAKEN?

REVIEW EACH PARAGRAPH OF SPECIFICATIONS.

DISCUSS PROCEDURE FOR ACCOMPLISHING THE

WORK.

CLARIFY ANY DIFFERENCES.

ENSURE PRELIMINARY WORK IS CORRECT AND PERMITS ARE ON FILE.

IF NOT, WHAT ACTION IS TAKEN?

Attachment D-8

(CONTINUED FROM FIRST PAGE)

CONTRACT NO DEFINABLE FEATURE OF WORK SCHEDULE ACT NO. INDEX #

IDENTIFY TEST TO BE PERFORMED, FREQUENCY, AND BY

WHOM.

WHEN REQUIRED?

WHERE REQUIRED?

REVIEW TESTING PLAN.

HAS TEST FACILITIES BEEN

APPROVED?

ACTIVITY HAZARD ANALYSIS APPROVED? YES NO

REVIEW APPLICABLE PORTION OF EM 385-1-1.

NAVY PWD/ROICC COMMENTS DURING MEETING.

OTHER ITEMS OR REMARKS:

QC MANAGER DATE

Attachment D-8

Each DFOW that is in the Initial Phase shall have this checklist filled out for it. The checklist shall be identified by terminology consistent with the construction schedule. This checklist shall accompany the submission of the Contractor Quality Control Report of the same date.

a. Specification Section, date of report, and contract number shall be entered.

b. Definable Feature of Work, Schedule Activity No. and Index # entry and format will match entry in the

Initial Phase section of the Contractor QC Report.

c. Personnel Present: Indicate the number of hours of advance notice that was given to the

Government Representative and indicate (Yes/No checkboxes) whether or not the Government Rep was notified. Indicate the Names of Initial Phase Meeting attendees, their position and company/government they are with.

d. Procedure Compliance: Comment on compliance with procedures identified at Preparatory Phase of Control and assurance that work is in accordance with contract documents.

e. Preliminary Work: Ensure preliminary work being placed is in compliance and if not, what action is/was taken.

f. Workmanship: Identify where initial work is located; if a sample panel is required (Yes/No checkboxes); is the initial work the sample (Yes/No checkboxes); and if Yes, describe the panel location and precautions taken to preserve the sample.

g. Resolution: Comment on any differences and the resolutions reached.

h. Check Safety: Comment on the safety review of the job conditions.

i. Other: Note any other remarks or items that were a result of the Initial Phase.

j. QC Manager will sign and date the checklist.

Attachment D-9

CONTRACT NO DEFINABLE FEATURE OF WORK SCHEDULE ACT NO. INDEX #

GOVERNMENT REP NOTIFIED _____ HOURS IN ADVANCE: YES NO

NAME POSITION COMPANY/GOVERNMENT

IDENTIFIY FULL COMPLIANCE WITH PROCEDURES IDENTIFIED AT PREPARATORY. COORDINATE PLANS, SPECIFICATIONS, AND SUBMITTALS.

COMMENTS:

ENSURE PRELIMINARY WORK IS COMPLETE AND CORRECT. IF NOT, WHAT ACTION IS TAKEN?

ESTABLISH LEVEL OF WORKMANSHIP.

WHERE IS WORK

LOCATED?

IS SAMPLE PANEL REQUIRED? YES NO

WILL THE INIITAL WORK BE CONSIDERED AS A SAMPLE? YES NO

(IF YES, MAINTAIN IN PRESENT CONDITION AS LONG AS POSSIBLE AND DESCRIBE LOCATION OF

SAMPLE)

RESOLVE ANY DIFFERENCES.

COMMENTS:

REVIEW JOB CONDITIONS USING EM 385-1-1 AND JOB HAZARD ANALYSIS

COMMENTS:

OTHER ITEMS OR REMARKS

QC MANAGER DATE

Attachment D-9

As tests are performed, the QC Manager shall record on the "Testing Plan and Log" the date the test was conducted, the date the test results were forwarded to the Contracting Officer, remarks and acknowledgement that an accredited or Contracting Officer approved testing laboratory was used.

Attach a copy of the updated "Testing Plan and Log" to the last daily Contractor QC Report of each month.

Attachment D-10

Attachment D-10

Attachment D-11

The QC Manager shall maintain a list of work that does not comply with the Contract, identifying what items need to be reworked, the date the item was originally discovered, the date the item will be corrected by, and the date the item was corrected. There is no requirement to report a rework item that is corrected the same day it is discovered. Attach a copy of the "Rework Items List" to the last daily Contractor QC Report of each month. The Contractor shall be responsible for including on this list items needing rework including those identified by the Contracting Officer.

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Attachment D-11

CONSTRUCTION CONTRACT NON-COMPLIANCE NOTICE (CCN) NAVFAC 4330/36

A. DESCRIPTION/PURPOSE

This form is used to notify construction Contractors of deficiencies and to record corrective action taken. It is drafted by QA personnel, signed by the appropriate Government representatives and delivered to the appropriate representative of the Construction Contractor who signs to acknowledge receipt of it.

B. PREPARATION INSTRUCTION

Contractor/Responsible Individual: Enter Construction Contractor's company name.

Contract Number and Title: Enter the number of the construction Contract, the title of the Contract."

Notice Number: Number notices sequentially by construction contract.

Date: Enter date of notice using Navy dating system; e.g., 11 Dec 2004 Spec Paragraph and/or Drawing Number: Enter appropriate reference to construction contract documents.

Reference: Enter applicable reference, if any, to shop drawings, certifications, QC Reports.

Contractor Reply by Date: Enter a date that the PWD/ROICC expects a reply from the Contractor.

Deficiency in Workmanship and/or Material: Enter brief narrative description of item not in compliance. Be specific.

Corrective Action Accomplished: Completed by Construction Contractor indicating corrective action to correct deficiency noted.

QA Representative: Signed by QA Representative.

CM: Signed by the Designated Government Representative for the particular construction

Contract.

Contractor's Acknowledgement: Signed by the responsible individual.

C. GENERAL INSTRUCTIONS.

When the QA Rep notes a construction deficiency, the form should be completed listing only one deficiency on each notice. The QA Rep fills out the form, then sign and date the notice.

The QA Rep then obtains the signature of the appropriate Government representative. After the Government representative signs the form, the QA Rep presents it to the QC Manager. The QC Manager should acknowledge receipt of the notice by signing.

After the Construction Contractor’s Representative signs the form, that person is given the original. When the item has been corrected, the Contractor should return the original with the corrective actions noted to the QA Rep. The form should be accepted only after the QA Rep is satisfied that the item is properly corrected.

If appropriate, the QA Rep shall take a photograph of the deficiency and attach a copy to the CCN.

E. CONTRACTOR REPLY DATE

Due with the daily QC Report for the day the deficiency was noted.

F. DISTRIBUTION

The original is given to the Contractor’s QC Manager or Superintendent so the corrective action can be recorded. When the original is received back from the Contractor indicating that corrective action has been taken the original is filed with the appropriate QC Report.

The QA Rep retains a copy with their files. It is used to follow up correction. At the close of each contract the QA Rep shall transfer all uncorrected deficiencies still remaining to the final inspection punch list. Payment deductions or appropriate retention of progress payments should be taken until all corrective actions are acceptable to the QA Rep.

Attachment D-12

CONSTRUCTION CONTRACT NON-COMPLIANCE NOTICE

NAVFAC 4330/36 (Rev. 3/03)

CONTRACTOR/RESPONSIBLE INDIVIDUAL NOTICE NUMBER

CONTRACT NUMBER AND TITLE DATE

SPECIFICATION PARAGRAPH AND/OR DRAWING NUMBER CONTRACTOR REPLY BY DATE

REFERENCE (Shop Drawing, Certification, CQC Report Number, etc.)

DEFICIENCY IN WORKMANSHIP AND/OR MATERIAL

CORRECTIVE ACTION ACCOMPLISHED (This block filled in by Contractor)

QA REPRESENTATIVE

NAME: TITLE:

DATE NOTED: SIGNATURE: ________________________________________

CM

NAME: TITLE:

DATE ISSUED: SIGNATURE: ________________________________________

CONTRACTOR’S ACKNOWLEDGMENT

NAME: TITLE:

DATE RCV’D: SIGNATURE: ________________________________________

This Notice does NOT authorize any work not included in the Contract and shall not constitute a basis for additional payment or time. If you are in disagreement with this Notice, notify the Contracting Officer immediately in writing.

DISTRIBUTION

Original - QC Manager or Superintendent (Original) Copies to - Contractor’s Home Office, QA Representative, Contract File

Attachment D-12

Attachment D-13

ROICC OFFICE: DATE:

CONTRACTOR:

CONTRACT TITLE: CONTRACT % COMPLETE:

CONTRACTOR SUPERINTENDENT:

CATEGORY:

PREPARATORY (Yes) (No) (N/A) 1) Activity Hazard Analysis performed and used on the site for each definable feature of work?

PHASE (Planning) (Yes) (No) (N/A) 2) Are weekly safety meetings and indoctrination held on site and documented for all workers?

Comments/Notes: (Yes) (No) (N/A) 3) Is the submitted safety plan on site and in use?

(Yes) (No) (N/A) 4) Is the Activity Hazard Analysis reviewed during the preparatory inspection?

(Yes) (No) (N/A) 5) Hazardous materials program in place with MSDS sheets on site and maintained?

(Yes) (No) (N/A) 6) EM 385-1-1 available on the site?

(Yes) (No) (N/A) 7) Other? Extra Credit?

OFFICE TRAILER (Yes) (No) (N/A) 8) Are office and storage trailers anchored?

GENERAL (Yes) (No) (N/A) 9) Are emergency phone numbers posted?

Comments/Notes: (Yes) (No) (N/A) 10) Is a phone available?

(Yes) (No) (N/A) 11) First aid log maintained (contractors must use OSHA Form 300)?

(Yes) (No) (N/A) 12) Toilet facilities available?

(Yes) (No) (N/A) 13) Site posted "HARD HAT AREA," "NOISE HAZARD," "CONSTRUCTION AREA," etc., as required?

(Yes) (No) (N/A) 14) Garbage cans and dumpsters available?

(Yes) (No) (N/A) 15) Jobsite cleaned daily?

(Yes) (No) (N/A) 16) Is traffic control around site adequate?

(Yes) (No) (N/A) 17) Other? Extra Credit?

FIRE PREVENTION (Yes) (No) (N/A) 18) Are fire extinguishers available, fully charged, and easily visible within 75 feet for low hazard areas?

Comments/Notes: (Yes) (No) (N/A) 19) Is fuel stored in proper containers?

(Yes) (No) (N/A) 20) Are hot work permits being obtained?

(Yes) (No) (N/A) 21) Are fire watches provided?

(Yes) (No) (N/A) 22) Are gas cylinders stored upright and secured with chain or rope?

(Yes) (No) (N/A) 23) Is Housekeeping acceptable?

(Yes) (No) (N/A) 24) Other? Extra Credit?

SCAFFOLD (Yes) (No) (N/A) 25) Are daily scaffold inspections performed by designated competent person?

SAFETY (Yes) (No) (N/A) 26) Planks overlapped not less than 6" or more than 12" over end supports with toe boards in place?

Comments/Notes: (Yes) (No) (N/A) 27) Tubing pinned properly and all cross bracing in place?

(Yes) (No) (N/A) 28) If scaffold height is 4X smallest base dimension, is system secured to structure?

(Yes) (No) (N/A) 29) All guardrails are in place?

(Yes) (No) (N/A) 30) Full work platform at each working level with no cracks/splits?

(Yes) (No) (N/A) 31) Safe access provided to each working level?

(Yes) (No) (N/A) 32) Scaffold and components not overloaded?

(Yes) (No) (N/A) 33) Is scaffold system plumb and level?

(Yes) (No) (N/A) 34) Suspended scaffold systems using independent personal fall arrest system?

(Yes) (No) (N/A) 35) Other? Extra Credit?

FALL (Yes) (No) (N/A) 36) Is a full body harness used where required?

PROTECTION (Yes) (No) (N/A) 37) Tied off at all times to structural element capable of supporting 5,000 lbs/person?

Comments/Notes: (Yes) (No) (N/A) 38) Is protection provided for all personnel working in areas where they could fall 6' or more?

(Yes) (No) (N/A) 39) Are employees trained for fall protection systems in use?

(Yes) (No) (N/A) 40) Does the contractor have a certified competent person?

(Yes) (No) (N/A) 41) Have standard guardrails been provided where required?

(Yes) (No) (N/A) 42) Have horizontal life lines been designed and installed under supervision of a qualified person?

(Yes) (No) (N/A) 43) Other? Extra Credit?

CONTRACTOR SITE

SAFETY ASSESSMENT

Attachment D-14

CATEGORY:

LADDER SAFETY (Yes) (No) (N/A) 44) Do ladders extend 3' above landing platform and tied to structure?

Comments/Notes: (Yes) (No) (N/A) 45) Are ladders used with hand tools only?

(Yes) (No) (N/A) 46) Are ladder base distances from structure 1/4 height?

(Yes) (No) (N/A) 47) Are floor openings either covered or surrounded by a guardrail?

(Yes) (No) (N/A) 48) Electricians not using portable "conductive" ladders?

(Yes) (No) (N/A) 49) Stairways provided on all structures over 20' during construction and supplied with guardrail?

(Yes) (No) (N/A) 50) Portable step ladders over 20' not used on the site?

(Yes) (No) (N/A) 51) Are ladders properly used?

(Yes) (No) (N/A) 52) Other? Extra Credit?

EXCAVATIONS (Yes) (No) (N/A) 53) Does excavation over 4' deep have a ladder within 25' and two means of egress?

Comments/Notes: (Yes) (No) (N/A) 54) Has proper slope or trench box/shoring been provided?

(Yes) (No) (N/A) 55) Is water controlled/removed?

(Yes) (No) (N/A) 56) Is excavated material at least 2' back from trench edge?

(Yes) (No) (N/A) 57) Is excavation barricaded, etc., to prevent workers and public from falling into trench/hole?

(Yes) (No) (N/A) 58) In locations of known or suspected contamination, is excavation atmosphere monitored?

(Yes) (No) (N/A) 59) Does contractor have certified competent person on site?

(Yes) (No) (N/A) 60) Other? Extra Credit?

ELECTRICAL (Yes) (No) (N/A) 61) Are temporary power panels and receptacles protected from weather?

Comments/Notes: (Yes) (No) (N/A) 62) Are GFCI's in use for site tools ?

(Yes) (No) (N/A) 63) Are temporary lights rigged and secured to supports properly, and with covers?

(Yes) (No) (N/A) 64) If overhead power lines are in area, are operations maintaining required distance or isolation?

(Yes) (No) (N/A) 65) Is lockout/tagout program in effect?

(Yes) (No) (N/A) 66) Has a sketch of proposed temporary power distribution been submitted/accepted before installing?

(Yes) (No) (N/A) 67) Other? Extra Credit?

(Yes) (No) (N/A) 68) Other? Extra Credit?

CRANES (Yes) (No) (N/A) 69) Has periodic inspection been performed prior to use on site IAW EM 385-1-1, App. H?

Comments/Notes: (Yes) (No) (N/A) 70) Are App. H daily start up inspections performed by operator and submitted with DRI?

(Yes) (No) (N/A) 71) Is crane operator qualified IAW EM 385-1-1, App. G, and is crane certification posted in cab?

(Yes) (No) (N/A) 72) Are workers protected from the crane swing radius and prevented from passing under the load?

(Yes) (No) (N/A) 73) Are rigging cables and slings in good repair free of kinks and cracks?

(Yes) (No) (N/A) 74) Is the crane level and on firm ground and outriggers in use with appropriate cribbing?

(Yes) (No) (N/A) 75) Is crane side loading prohibited?

(Yes) (No) (N/A) 76) Near electric power sources, are rules followed for clearance/isolation in operating zone?

(Yes) (No) (N/A) 77) Is crane equipped with anti two-block device if required?

(Yes) (No) (N/A) 78) Other? Extra Credit?

CONFINED (Yes) (No) (N/A) 79) Has entry plan been submitted and accepted?

SPACES (Yes) (No) (N/A) 80) Is atmosphere being monitored?

Comments/Notes: (Yes) (No) (N/A) 81) Is space being ventilated?

(Yes) (No) (N/A) 82) Are entrants, attendants and entry supervisor properly trained?

(Yes) (No) (N/A) 83) Is rescue/retrieval system in place?

(Yes) (No) (N/A) 84) Are daily entry permits posted at point of entry and signed by entry supervisor?

(Yes) (No) (N/A) 85) Is point of entry posted "DANGER CONFINED SPACE"?

(Yes) (No) (N/A) 86) Has blanking or locking out of systems taken place?

(Yes) (No) (N/A) 87) Other? Extra Credit?

ROOFING (Yes) (No) (N/A) 88) Are kettles at least 25 feet away from buildings?

Comments/Notes: (Yes) (No) (N/A) 89) Has an employee fall protection system been implemented and in proper use?

(Yes) (No) (N/A) 90) Are skylights and roof penetrations covered or barricaded appropriately?

(Yes) (No) (N/A) 91) Has the roof been evaluated for its ability to support the intended construction loads?

(Yes) (No) (N/A) 92) Has the roof been surveyed for deterioration?

(Yes) (No) (N/A) 93) Are two fire extinguishers at the kettle?

(Yes) (No) (N/A) 94) Fuel cylinder a minimum of 10' from open flame?

(Yes) (No) (N/A) 95) Other? Extra Credit?

(Yes) (No) (N/A) 96) Other? Extra Credit?

CATEGORY:

Attachment D-14

EQUIPMENT

Comments/Notes: (Yes) (No) (N/A) 98) Does mobile equipment have rollover cages and backup alarms, with moving parts adequately guarded?

(Yes) (No) (N/A) 99) Are equipment operations maintaining safe clearance from electrical power lines?

(Yes) (No) (N/A) 100) Do modifications meet safety rating per manufacturer (i.e., lifting personnel with forklift)?

(Yes) (No) (N/A) 101) Are safety lashings provided for high pressure hose connections, i.e., air compressors?

(Yes) (No) (N/A) 102) Are workers clear of blind spots associated with mobile construction equipment?

(Yes) (No) (N/A) 103) Do aerial lifts have basket/platform with guardrail?

(Yes) (No) (N/A) 104) Are workers not extending over guardrail of aerial lifts?

(Yes) (No) (N/A) 105) Are articulating boom platforms (JLG type) used with Full Body Harness attached to boom or basket?

(Yes) (No) (N/A) 106) Other? Extra Credit?

(Yes) (No) (N/A) 107) Other? Extra Credit?

DEMOLITION (Yes) (No) (N/A) 108) Has demolition plan been submitted and accepted?

Comments/Notes: (Yes) (No) (N/A) 109) If waste is being dropped > 6' is it in an enclosed chute and is area secured from traffic?

(Yes) (No) (N/A) 113) For building demolition, has notification been made to State having jurisdiction?

(Yes) (No) (N/A) 114) Are nails removed from scrap lumber/materials?

(Yes) (No) (N/A) 115) Other? Extra Credit?

(Yes) (No) (N/A) 116) Other? Extra Credit?

PPE (Yes) (No) (N/A) 117) Workers wearing leather shoes (not tennis), long pants, sleeved shirts, and steel toes where required?

Comments/Notes: (Yes) (No) (N/A) 118) Are hare hats being worn?

(Yes) (No) (N/A) 119) Are safety glasses where appropriate?

(Yes) (No) (N/A) 120) Hearing protection where appropriate? (if you need to yell to converse) (Yes) (No) (N/A) 121) Respirators where appropriate?

(Yes) (No) (N/A) 122) Impalement protection provided where personnel could work above vertical impalement?

(Yes) (No) (N/A) 123) Is lighting adequate?

(Yes) (No) (N/A) 124) Other? Extra Credit?

ABATEMENT (Yes) (No) (N/A) 125) Has abatement plan been submitted and accepted?

(Yes) (No) (N/A) 126) Is independent air monitoring being performed as required inside and outside barriers?

Comments/Notes: (Yes) (No) (N/A) 127) Is containment in place without integrity compromise?

(Yes) (No) (N/A) 128) Are employees utilizing appropriate PPE?

(Yes) (No) (N/A) 129) If negative air is used, are fans used continuously and monitored for pressure differential?

(Yes) (No) (N/A) 130) Has baseline been performed and necessary final clearance readings taken?

(Yes) (No) (N/A) 131) Are inspections by independent PQP performed prior to barrier removal?

(Yes) (No) (N/A) 132) Is waste material properly containerized and stored?

(Yes) (No) (N/A) 133) Are air monitoring results provided to ROICC?

(Yes) (No) (N/A) 134) Are waste shipment records provided to ROICC?

(Yes) (No) (N/A) 135) Other? Extra Credit?

WATERFRONT (Yes) (No) (N/A) 136) Are employees wearing appropriate flotation devices (PFDs)?

ACTIVITIES (Yes) (No) (N/A) 137) Is a rescue skiff available?

Comments/Notes: (Yes) (No) (N/A) 138) Are emergency life rings available?

(Yes) (No) (N/A) 139) If diving operations are taking place, has a dive plan been submitted and accepted?

(Yes) (No) (N/A) 140) Does dive team consist of proper number and qualifications for employees?

(Yes) (No) (N/A) 141) Other? Extra Credit?

SCORING: Total applicable for each category = X (where X includes responses for category of "Yes" and "No" but does not include N/A) Total with "Yes" responses for each category = Y

SCORE FOR EACH CATEGORY: SCORE RATE EQUATION = Y / X

1 PREPARATORY PHASE: 6 LADDER SAFETY: 11 ROOFING:

2 OFFICE TRAILER GENERAL: 7 EXCAVATIONS: 12 EQUIPMENT:

3 FIRE PREVENTION: 8 ELECTRICAL: 13 DEMOLITION:

4 SCAFFOLD SAFETY: 9 CRANES: 14 PPE:

5 FALL PROTECTION: 10 CONFINED SPACES: 15 ABATEMENT:

16 WATERFRONT ACTIVITIES:

OVERALL RATING = AVERAGE RATING FOR ALL CATEGORIES:

Attachment D-14 (Yes) (No) (N/A) 97) Are forklift operators qualified through training at the site (certificate included in Safety Plan)?

Attachment D-15

BOSC Utility Services Instruction Guide

Requesting and Paying for Work Directly Through DZSP 21

SSC-I-0001 R4 Printed Document may be obsolete – validate before use Printed Date: 6/23/17 Effective Date: 23 JUN 2017

The procedure for contractors to schedule and pay for utility services from the Navy Base Operations Support Contractor are as follows:

For Project(s) connecting to, or needing/consuming any Navy Utility Commodities (e.g. water, power, etc.), coordination with NAVFAC Marianas Financial Management (NFM FM) is required to establish a NAVFACMARIANAS (NFM) Account/Job Order Number (JON) for consumption usage. NFM Office is located on the 1st Floor of Bldg. 200, Nimitz Hill.

Point of Contact is:

Martha Crisostomo Tel#: 349-2062 Email: Martha.crisostomo@fe.navy.mil Cc: fundingdocument@fe.navy.mil

Submit completed Utility Outage Request Form (UOR) and Customer Payment Information Sheet (CPI) to Service Support Center (SSC) via e-mail at dzsp21ssc@dzsp21.com with required documents:

1. Completed customer Payment Information Sheet for deposit (Payments made by check or credit card must be issued by the organization listed on the Utility Outage Request Form)

2. Drawings/sketches and other required documents for the supporting Annexes

NOTE: A minimum deposit of $1,000.00 is required for each Utility Outage Request. This deposit goes towards DZSP 21 labor hours for the assessment of the outage. This amount does not include any costs associated with utilities consumption or meters.

*Contractors must submit the required deposit to DZSP 21 before any work is scheduled.

Service Support Center (SSC) will review documents to ensure all required fields are completed. Any incomplete requests will be rejected

Utility Outage Request number is provided and forwarded to appropriate Annexes for further processing

SSC proceeds to schedule outages and submits preliminary notices

Supporting Annex will assess the areas affected and provide an estimate to DZSP 21 Contracts who will then provide a cost estimate to the customer

If the cost estimate is less than the $1,000.00 deposit, the difference will be refunded to the customer once the outage is complete. However, if the estimate is greater than the $1,000.00 deposit, the customer will need to fund the difference prior to commencement of scheduling the outage request

Attachment D-16 mailto:Martha.crisostomo@fe.navy.mil mailto:fundingdocument@fe.navy.mil mailto:dzsp21ssc@dzsp21.com

BOSC Utility Services Instruction Guide

Requesting and Paying for Work Directly Through DZSP 21

SSC-I-0001 R4 Printed Document may be obsolete – validate before use Printed Date: 6/23/17 Effective Date: 23 JUN 2017

Annex provides support for the outage NOTE: A Construction Management Engineer and or Engineering Technician (CME and or ET)/ Government Representative assigned to project shall be on site during energizing OR de-energizing of power to include electrical field acceptance testing and Inspection of electrical equipment / connections shall be conducted prior to Energization / Restoration of Power.

Upon completion of outage, DZSP 21 Finance will submit a detailed final invoice to the customer for the actual costs.

Credit Card – DZSP 21 will charge the credit card for the actual costs of the outage if it exceeds the funded amount

Cash, check or credit card – If actual costs are less than the funded amount, the refund for the difference will be issued by check to the organization listed on the “Utility Outage/Connection/Service Request” form. If actual costs are greater than the funded amount, customer will need to submit additional funding

• Service Support Center (SSC) can be reached at (671) 333-2011 or in person in building 372 between the hours of 0730 and 1630, or via e-mail at dzsp21ssc@dzsp21.com.

Services including, but not limited to, water, sewer, electrical, steam or fire system outages, trailer hook-ups, and meter installations should be requested through SSC.

DZSP 21 requires a minimum of 30 days advance notice for utility outages before the 1st requested date. NOTE: Requested dates are subject to change due to the extent of the outage requested.

Attachment D-16 mailto:dzsp21ssc@dzsp21.com

UTILITY OUTAGE/CONNECTION/SERVICE REQUEST

WO NO: PA: UOR NO:

OUTAGE CONNECTION DISCONNECTION SERVICE OTHER

STEAM AND DEMINERALIZED WATER ELECTRICAL POWER

POTABLE WATER WASTEWATER

NFM JON REQUIRED: YES NO CME REVIEWED APPROVED/DISAPPROVED: YES NO

NFM JON: CME SIGNATURE:

CME NAME:

CONTACT INFORMATION:

COMMENTS:

FROM (Name): EMAIL ADDRESS: PHONE/FAX NO.: DATE:

CONTRACTOR/REQUESTOR: PHONE/FAX NO. CONTRACT OR

PROJECT NO:

GOVERNMENT REPRESENTATIVE/CME: EMAIL ADDRESS: PHONE/FAX NO.

LOCATION/AREA

LENGTH AND DATE OF OUTAGE (MUST BE SUBMITTED TO DZSP21 30 DAYS BEFORE REQUESTED DATE)

FIRST CHOICE: FROM DATE/TIME: TO DATE/TIME:

SECOND CHOICE: FROM DATE/TIME: TO DATE/TIME:

JUSTIFICATION

OTHER/SPECIAL INSTRUCTIONS (SPECIFY)

AFFECTED LOCATIONS(S): HYDRANT NO., VALUE NO., STREET NAME, ETC.

ATTACHMENTS: DRAWINGS PERMITS SCOPE OF WORK NONE REQUIRED

AFFECTED FACILITIES

BLDG. NO. BLDG. NAME BLDG. NO. BLDG. NAME

SIGNATURE DATE

AAFB UTILITY OUTAGE COORDINATION FORM SIGNED BY DZSP21: YES NO

DZSP21 SIGNATURE:

SSC-F-0006 R3

Effective Date: 18 JAN 2017

Printed document may be obsolete - validate before use Printed Date: 1/18/2017

FIN-F-0004 R5 Printed document may be obsolete – verify before use Printed on: 9/20/2017 Effective date: 18 SEPT 2017

Customer Payment Information Sheet Company or Command Date

Point of Contact Telephone & Fax No.

Address E-mail Address

Payment Information Please indicate your method of payment:

Credit Card Cash Check

If submitting payment via credit card, please fill in the following information:

(NOTE: Failure to provide this information will cause delay in processing payment). Please e-mail the completed form to: DZSP21CommercialProject@dzsp21.com or fax it to 671- 339-3987.

TO BE COMPLETED BY DZSP 21

UOR No./ Cost Estimate No. Project Abbreviation

Brief Description of Work:

Name on the Credit Card:

Credit Card No. Expiration Date:

Type of Credit Card: (DZSP does NOT accept AMERICAN EXPRESS)

VISA or MASTERCARD

Signature:

mailto:Project@dzsp21.com

NUMBER: FME-P-0001

PROCEDURE

ANNEX 1501 – FACILITIES MANAGEMENT AND

ENGINEERING SERVICES

OFFICE of PRIMARY RESPONSIBILITY: ANNEX 1501

EFFECTIVE

DATE:

REVISION:

08-16-16

1.0 SUBJECT: EXCAVATION PERMIT CLEARANCE PROCEDURE

2.0 PURPOSE:

The purpose of the excavation permit clearance procedure is to detail the process and requirement in receiving and issuing excavation permits for all proposed excavations within U.S. Navy property and easements.

3.0 SCOPE:

This procedure applies to DZSP 21 organizations, including requesters.

4.0 DEFINITIONS:

AAFB Andersen Air Force Base CAD Computer-Aided Design

CE Clearing Element CEPOC Clearing Element Point of Contact Clearing Elements Elements which require investigation and clearance prior to issuance of excavation permit clearance:

- Electrical distribution

- Water distribution

- Communication line

- Steam and hot water distribution

- Sewerage

- Petroleum/fuel oil lines

- TV Cable

- Environmental hazards and historical sites

Customer (Requester) An entity requesting an excavation permit clearance under the following categories:

- Funded Government

- Non-Funded Government

- Commercial

- DZSP21 (Internal)

DZSP 21 A1501 Annex 1501 Facilities Management and Engineering Services

Attachment D-17

EXCAVATION PERMIT

CLEARANCE PROCEDURE

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

2 14

DZSP 21 A1800 Annex 1800 Environmental

Easement Strip of land used to construct and maintain underground utilities

Encroachment Physical intrusion (location) of structure/utilities and part of structure/utilities, or land used in the area of the easement

ESS Explosive Safety Submission

MAXIMO Contractor-owned Computerized Maintenance Management System (CMMS)

NAVFAC Naval Facilities Engineering Command NEPA National Environmental Policy Act POC Point of Contact

5.0 REFERENCE DOCUMENTS:

5.1 PWD Guam Instruction 113310.2C Utilities Excavation and Site Clearing Permit

5.2 Base Operations Support Contract No. N40192-10-C-3000 PWS 3.5.2 Dig Permit/Utility Underground Locating Services

5.3 ENV-D-0101 NEPA Coordinator Desk Guide

6.0 RECORD:

Record Responsible Organization

Retention Period

Excavation Permit Clearance Request Facilities Management and Engineering Services

4 years after final incurred cost audit certification

7.0 PROCEDURE:

7.1 General

7.1.1 Excavation is defined as digging, grading, tunneling, trenching, vertical, and horizontal drilling below grade. Penetrations through concrete slab on grade, including asphalt and sidewalk are also treated as excavation.

Excavation permit clearance applies only for areas outside the building. This procedure requires that all required documentation to support the excavation permit clearance request shall be reviewed thoroughly for hazards.

The Excavation Permit Clearance Procedure has been established to:

a. Assure the safety of personnel

b. Protect environmental and historical sensitive sites

c. Ensure operational reliability

d. Protect communication links

e. Protect underground structures

f. Ensure utilities system maps reflect existing conditions

g. Locate and mark unknown or abandoned utilities

h. Determination of ESS compliance requirements

7.2 Pre-permit Initiation Requirement:

7.2.1 Customer shall complete and submit the following to DZSP 21 A1501 Excavation Permit POC:

a. FME-F-0004 (a) (Current revision), Excavation Permit Clearance Request, (see Appendix A)

b. Detailed scope of work

c. Vicinity map showing location of project

d. Site map showing boundaries of areas to excavate (preferably colored) including estimated excavation depth

e. Outline perimeter of proposed excavation in white (whiskers, flags, or paint) at the construction site NOTE: Excavation permit clearance request will be returned to the Customer if proposed area of excavation is not outlined at the construction site.

f. NEPA documentation NOTE: Excavation permit clearance will not be issued without NEPA documentation, refer to ENV-D-0101 NEPA Coordinator Desk Guide

g. If payment is required, the following must be completed:

− FME-F-0004 (b) (Current revision), Excavation Payment

Responsibility Form, (see Appendix B) − FME-F-0004 (c) (Current revision), Customer Payment

Information Sheet, (see Appendix C) NOTE: All Customer payment information will be kept confidential

h. For excavation permit clearance validity for more than 15 days to 3 months.

i. Coordinate excavation permit clearance request with the following CEPOC, and submit cleared documents to DZSP 21 A1501 Excavation Permit POC.

− Docomo Pacific − GTA Teleguam

EXCAVATION PERMIT

CLEARANCE PROCEDURE

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

3 14

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

4 14

7.2.2 Maximum validity period of an initial excavation permit clearance is 15 calendar days from the issuance date

7.2.3 Maximum validity period of a long-term excavation permit clearance is three months from the issuance date NOTE: Customer may request for an extension of validity period. Extension of validity period shall be considered as new request following the same procedure, including payment responsibility while referencing original excavation permit number.

7.3 Requirements:

7.3.1 The following CEs must be cleared prior to excavation on:

a. U.S. Navy properties and within encroachment of easements:

− Electrical distribution − Water distribution − Communication line − Steam/hot water distribution − Sewerage − Petroleum/oil fuel line − TV cable line − Environmental hazards and historical sites. Possible delay if there is no complete NEPA such as, State Historic Preservation Office (SHPO, Section 106 Consultation- as applicable), refer to ENV-D-0101 NEPA Coordinator Desk Guide

− Explosives Safety Submission (ESS), Determination of ESS compliance requirements will be based upon government maps located in the JRM ESS, Construction Support, Amendment Series.

b. AAFB − Primary electrical lines

7.3.2 When excavation permit clearance request is received, DZSP 21 A1501 Excavation Permit POC shall:

a. Assign an excavation permit number

b. Create a MAXIMO work order (WO)

c. Coordinate and provide a copy of excavation permit clearance request to the following CEPOC:

− Navy Base Communication for communication lines − Navy Fuel Division for petroleum/fuel oil lines − DZSP 21 A1800 for environmental and historical/cultural impact

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

5 14

d. Coordinate excavation permit clearance request to CEPOC for the following clearing elements. Clearing elements are routinely cleared within five working days. Processing time begins next working day after clearance request is received.

− Electrical distribution − Water distribution − Steam/hot water distribution − Sewerage − Storm drains

7.3.3 If CEPOC returns the excavation permit clearance request with a remark or statement of pre-requisite that must be addressed prior to issuing the excavation permit, DZSP 21 A1501 Excavation Permit POC shall coordinate the requirement to the Customer. Excavation permit clearance request will be on-hold until Customer meets the pre-requisite.

7.3.4 If Customer has a comment or statement of concern, DZSP 21 A1501 Excavation Permit POC shall provide feedback to CEPOC.

7.3.5 When excavation permit clearance have been received from CEPOC, DZSP 21 A1501 Excavation Permit POC shall:

a. Prepare final excavation permit by entering required information from original excavation permit clearance request (see Appendix A)

b. Enter all data from clearing elements including job site POC, and

CEPOC comment including verbal communication (if any). Final excavation permit clearance request becomes the excavation permit.

c. Obtain approval signature of authorized person from DZSP21 A1501 once excavation permit is completed.

− DZSP 21 A1501 Manager or A1501 Supervisor shall approve all excavation permit request/extension requests.

− DZSP 21 A1501 Excavation Permit POC shall approve all excavation permits with validity dates of 15 calendar days.

7.3.6 Once the excavation permit has been signed, DZSP 21 A1501 Excavation Permit POC shall:

a. Issue approved excavation permit to Customer through email or

b. Provide a copy of approved excavation permit to NAVFAC through email.

b. Close MAXIMO work order (WO).

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

6 14

7.4 Roles and Responsibilities:

7.4.1 CEPOC shall:

a. Mark identified utilities per Utility Location and Coordination Council of the American Public Works Association (see Appendix D).

b. Comply with applicable Federal and State Health and Safety

Regulations.

7.4.2 DZSP 21 A1501 shall:

a. Receive and process excavation permit clearance request.

b. Initiate and process emergency excavation permit clearance request.

c. Assign personnel and resources to process excavation permit clearance

d. Coordinate with CEPOC to clear excavation area as required by provisions of Ref. 5.3. NAVFACMAR Guam Instruction 11310.2C

e. Mark identified and unknown utilities per Supplementary Marking

(see Appendix D)

f. Report discrepancies to DZSP 21 A1501 CAD Section to ensure utilities system maps reflect existing conditions

g. Maintain a record of all excavation permits

h. Update tracker to identify status of excavation permits, as required

i. Notify Customer:

j. When an excavation permit cannot be issued within five working days due to inclement weather or overload request; provide tentative issuing date.

7.4.3 The Customer shall:

a. Maintain utility markings

b. Comply with excavation permit clearance validity

c. Report damage to underground utilities, structures, or historical sensitive sites as a result of permitted excavation

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

7 14

8.0 EXHIBIT(S):

Appendix A : FME-F-0004 (a) (Current revision), Excavation Permit Clearance Request

Appendix B : FIN-F-0004 (Current revision), Customer Payment Information Sheet

Appendix C : Uniform Color Code

Appendix D : Typical Permit Flow Chart

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

8 14

9.0 APPROVAL:

ORIGINATED BY: CONCURRED BY:

Agustin M. Sapalo Date Shiela Concepcion Date Facilities Management and Quality Manager Engineering Services Manager

CONCURRED BY: CONCURRED BY:

Therese Kidd Date Vincent Salas Date Contracts Manager Project Safety Manager

CONCURRED BY: CONCURRED BY:

Joseph “Bill” Suzuki Date Alejandro Soto Date SRM Manager Environmental Manager

CONCURRED BY: CONCURRED BY:

Anna Sanchez Date David Weakley Date Power System Manager Waste System Manager

CONCURRED BY:

Cesar dela Cruz Date Water System Manager

APPROVED BY:

Mark W. Lopez Date Public Works Director (PWD)

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

9 14

APPENDIX A

EXCAVATION PERMIT CLEARANCE REQUEST

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

10 14

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

11 14

I

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

12 14

APPENDIX B

CUSTOMER PAYMENT INFORMATION SHEET

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

13 14

APPENDIX C

UNIFORM

CODE

UNIFORM COLOR CODE

Utility Location and Coordination Council of the American Public Works Association

RED Electrical Power Lines (by DZSP21)

YELLOW Steam or Gaseous Materials (by NAVY)

BLUE Water Distribution Lines (by DZSP21)

GREEN Sewer and Storm Drains (by DZSP21)

WHITE Proposed Excavation (by requester)

ORANGE Comm. (by NAVY) and TV Cable Lines (by GTA, MCV )

SUPPLEMENTARY MARKING

By DZSP21

? RED Unknown or Abandoned Utilities (by DZSP21)

E RED Electrical Power Lines (by DZSP21)

NOTES:

• Unknown or abandoned utilities are marked in red with a “?”.

• Initial survey by Ground Penetrating Radar (GPR) are marked with dots

(Unspecified color)

DOCUMENT NO.

FME-P-0001

REV NO.

EFFECTIVE DATE

08-16-16

PAGE OF

14 14

ANNEX 1501 FACILITIES MANAGEMENT AND ENGINEERING SERVICES

FME-F-0004 (a) Rev. 9 Printed document may be obsolete - validate before use Printed Date: 04-AUG-16 Effective: 04-AUG-16

U.S. NAVAL BASE GUAM

EXCAVATION PERMIT/CLEARANCE REQUEST

PERMIT NO. __________________________

SECTION A – EXCAVATION PERMIT PROCESS FLOWCHART AND COLOR CODE MARKINGS

R

ES

P O

N

SI

B

IL

IT

IE

S

R e q u e st e r

D

ZS

P

A

V

FA

C M

A R

IA

N

A S

Before Submitting Request After Receiving Request

UNIFORM COLOR CODE

Utility Location and Coordination Council of the American Public Works Association

NOTES:

Initial survey by Ground Penetrating Radar (GPR) are marked with dots (Unspecified color)

Unknown or abandoned utilities are marked in RED with a “? “

“E” denotes electrical

COLOR CLEARANCE RESPONSIBILITIES

WHITE Proposed Excavation by Requester

PINK Survey by Surveyor

RED Electrical by DZSP 21

YELLOW

Petroleum, Oil, & Lubricant(POL) by Fuel Division

Steam by DZSP 21

ORANGE

Communication line by BaseComm

Cable Television by GTA and Docomo Pacific

BLUE Potable Water by DZSP 21

GREEN Waste water by DZSP 21

Mark perimeter in white & provide maps. Obtain Non- Navy Utilities

Clearances from Docomo, GTA, and others if directed

Submit Request to

NAVFACMARIANAS

DZSP 21

project

Submit Request to A1501

Comply with ESS

Forward Request to DZSP21 with funding source Funded

Submit Funds

Clear Waste & Potable Water, Electrical, Steam, and Environmental

Clear Environmental, BaseComm, and POL

Issue Permit

Maintain Validity and Markings. Report Utility

Damage. Comply with ESS

Y

N

N

Y

ESS actions required ahead of construction

Notify

COR

N

Y

Submit Payment info to Requester

FME-F-0004 (a) Rev. 9 Printed document may be obsolete - validate before use Printed Date: 04-AUG-16 Effective: 04-AUG-16

SECTION B – EXCAVATION PERMIT/CLEARANCE REQUEST (To be completed by Requester)

NOTE: Non-Navy utilities require clearances. Directly communicate with respective owner for excavation requests and clearances. Forward approved/signed documents to be attached with this request. This excavation permit will not be release without clearance documents from Docomo Pacific and GTA TeleGuam.

Others may be required as applicable.

1. FROM (ANNEX/DEPT/CONTRACTOR’S NAME) 2. WORK ORDER NO. 3. DATE (MM/DD/YYYY)

4. LOCATION OF EXCAVATION (Specify the Bldg. no./area)

Within DoD Property __________________________________________________________________

Outside DoD Property __________________________________________________________________

5. CONTRACT/MEMO NO.

6. HOW IS THE EXCAVATION AREA OUTLINED/MARKED? (NOTE: Request will be returned if area of excavation is not outline/marked at the construction site)

White paint White flags (do not use flags with metal rods) Other (Specify) __________________________________________

7. EXCAVATION DEPTH

8. METHOD OF EXCAVATION (Check all applicable)

Hand Tools Ditcher Power Shovel

Power Excavator Other (Specify)

9. ACTIVITIES (Check all applicable, if any)

Vegetation Clearing Requester in block no.1 is the ESS contractor Collecting samples; installing erosion control materials, fence posts, sign posts, rods, anchors; vertical drilling, boring

Maintenance work on existing utility trench footprint

Grading Non DoD Project

Routine/Preventive Maintenance

Modification/Demolition to a building or structure

Trenching new utilities

Penetrations through concrete slab on grade, including asphalt and sidewalk

Penetrations through existing building concrete slab

Excavation in the vicinity of wetland/navigable waters

Other (Specify) __________________________________

10. PROJECT TITLE

11. SCOPE OF WORK

12. TERMS AND CONDITIONS

This permit does not grant encroachment to DoD easement or right of way, unless Requester has…