Shutdown Request Form.pdf

REQUEST FOR UTILITY/EQUIPMENT SHUTDOWN REQUEST#:

(SMOKE DETECTOR/SPRINKLER/ALARM (BELL CIRCUIT)/HVAC SYSTEMS/ELEC CIRCUITS/PLUMBING RISER/BRANCH/STEAM)

TO: CHIEF/ASST CHIEF, ENGINEERING SERVICE (138)

138) SECTION REQUESTING SHUTDOWN:

(SAFETY/P&D/M&R/BIOMED)

ENGINEERING EMPLOYEE REQUESTING SHUTDOWN:

(SIGNATURE) (EXT/PAGER)

IN-HOUSE/CONTRACTOR PROJECT#:

SHUTDOWN INFORMATION

SHUTDOWN DATE:

DATE DAY TIME PERIOD

DEVICE/SYSTEM: A)

B)

C)

LOCATION: BLDG: FLOOR: AREA:

NATURE OF THE SHUTDOWN (WHAT IS BEING DONE):

AFFECTED AREAS (WHOLE BLDG, ETC):

ALTERNATE PLAN (WORK AROUND):

WORK HAS BEEN COORDINATED WITH AFFECTED USERS (NAMES/AREA/PHONE OR N/A):

SPECIFIC HOURS FOR THE SHUTDOWN:

PLEASE NOTE: THIS FORM MUST BE APPROVED AT LEAST 48 HOURS

PRIOR TO THE LAST REVISION DATE FOR SHUTDOWN

EXCEPT IN THE CASE OF EMERGENCYINITIAL DATE:

LAST REVISION DATE:

LENGTH OF TIME WORK WILL TAKE:

PERSONS INVOLVED/ONSITE FROM CFM/ARGO/OTHER:

LOCKOUT/TAG OUTS REQUIRED (YES or NO):

COMPONENTS REQUIRED FOR SHUTDOWN (ACCESS TO PANELS/AREAS WITHIN THE STRUCTURE):

VA PERSONNEL TO BE ONSITE (FLICK THE SWITCH):

ADDITIONAL REQUIREMENTS NEEDED FROM VA ENGINEERING/STAFF:

EXPECTED IMPACT TO THE FACILITY/STAFF WITHIN AFFECTED AREA:

APPROVED DISAPPROVED

CHIEF, ENGINEERING SERVICE (138) CHIEF, ENGINEERING SERVICE (138)

LIST ALL PREVIOUS REVISION DATES AND COMMENTS: (LIST ALL REVISION DATES AND WHAT WAS REVISED)

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