J-1601000-05 UTILITY INTERRUPTIONS ROAD AND PARKING LOT CLOSURE AUTHORIZATIONS REQUEST FORM.xlsx
XLSX spreadsheet 26 KB Posted
- Attached to
- Base Operations Support Services For NSA Annapolis and US Naval Academy, Annapolis, Maryland
- Solicitation number
- N6247026R0017
About this file
This file is a Utility Interruptions Road and Parking Lot Closure Authorizations Request Form template. The spreadsheet serves as a standardized tool for documenting and managing requests to interrupt utility services or authorize temporary closures of roads and parking lots at NSA Annapolis and the US Naval Academy in Annapolis, Maryland. The form provides a structured format for capturing essential information regarding maintenance, construction, or operational activities that may necessitate service interruptions or access restrictions. By establishing a centralized request mechanism, this template enables facility management to coordinate with relevant departments, track authorization status, and ensure proper documentation of closure activities. The form is intended to streamline the approval process for operational disruptions while maintaining organized records of all utility interruption and facility closure activities at the naval installation.
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Text version
J-1601000-05 USNA/NSA Annapolis Utility Interruptions / Roads & Parking Lot Closure Authorizations Request Form
| INSTRUCTIONS: |
| 1. This form shall be completed, with final approval granted, prior to any planned work at the U. S. Naval Academy/NSA Annapolis that |
requires interruptions to base utility services.
2. Requestor must complete sections 1, 2, and 3, and submit for review prior to beginning any work. Clarity and details are required. Any vague or incomplete requests will be disapproved and returned to the requestor. Sections 4 and 5 are for Official Use Only.
3. Requestor will be notified when they can proceed with utility interruption or road/parking closure.
4. Requestor cannot proceed with utility interruption or road/parking closure until final approval has been received in writing from Public Works UEM Outage/Dig Coordinator on this authorization form.
5. A minimum of 21 calendar days will be required for routing and final approval.
| 1. REQUESTOR (POC) | ORGANIZATION | CONTACT INFORMATION |
| PRIMARY: | Phone: | |
| Email: | ||
| ALTERNATE: | Phone: | |
| Email: |
| 2. REQUEST TYPE | 2A. Environmental Concurrence Obtained? | 2B. Is BOS Contractor Support Required? | |||
| Utility Interruption | After speaking with Environmental, is it determined that all applicable permits have been obtained? | ||||
| (If no permits are required check Yes) | If Yes, fill in block 2C. |
If No, proceed to block 3.
| Road / Parking Lot Closure | |||||
| YES | NO | N/A | YES | NO |
| 2C. Detailed description of BOS contractor support needed (who/what/when/where/why). | (OFFICE USE ONLY) |
| LOG# | |
| Date Received: | |
| SERVICE# | |
| WORK ORDER# |
| 3. DETAILS: (Dates/times/locations/excavation type/details/include JON etc.) |
| Date: |
| Time/s: |
| Type of Outage: |
| Aeras Affected by Outage: |
Reason for Outage & any Additional Information:
| 4. OFFICIAL USE ONLY | |
| Affected Facilities were Notified | Date: |
| 5. REMARKS/COMMENTS/REQUIREMENTS TO REQUESTOR |
| 1. Contractors will assume responsibility for any Government property damaged due to negligence or careless work performance on site. |
2. The PWD Trouble Desk must be notified in the event any Government property is damaged, destroyed, or experiences unplanned service interruption in conjunction with requested work. This includes all buried utilities known and unknown.
3. PWD Energy & Utilities must be notified if any unknown, unmarked, or unrecognizeable relics or potentially historic items are unearthed or damaged, or if concerns or questions arise as to the known utilities and markings on site. It is a violation of Federal Code to remove excavated items from project site w/o Government approval. Contact PWD Energy & Utilities Branch: (410) 293-1034 Trouble Desk: (410) 293-4594 USNA Emergency Response (Fire/Ambulance/Security): (410) 293-3333
| FINAL | ||||
| APPROVAL | DISAPPROVED/RESUBMIT | Signature of Approving Authority | Date |
| X_____________________________ | |
| DOCUMENT VERSION 111924 |
File details come from the government source that posted it. Updated .