SOO Atch I. Work Clearance Request Form.pdf

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DATE PREPARED

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

(See Instructions on Reverse)

1. Clearance is requested to proceed with work at on Work Order No.

, Contract No.

, involving excavation or utility disturbance per attached sketch. This area has has not been staked or clearly marked.

2. TYPE OF FACILITY/WORK INVOLVED

G. AIRCRAFT OR VEHICULAR TRAFFIC FLOW

A. PAVEMENTS

D. FIRE DETECTION & PROTECTION SYSTEMS

H. SECURITY

B. DRAINAGE SYSTEMS

E. UTILITY

OVERHEAD

UNDERGROUND

I. OTHER

C. RAILROAD TRACKS

F. COMM

OVERHEAD

UNDERGROUND

4. DATE OF CLEARANCE

3. DATE CLEARANCE REQUIRED

5. SIGNATURE OF REQUESTING OFFICIAL

6. TELEPHONE NO.

7. ORGANIZATION

REMARKS

(Use Reverse for additional comments)

REVIEWER'S NAME AND INITIALS

ORGANIZATION

8.

A. ELECTRICAL DISTRIBUTION

B A S

B. STEAM DISTRIBUTION

E

C. WATER DISTRIBUTION

C I

D. POL DISTRIBUTION

V I L

E. SEWER DISTRIBUTION

E N

F. ENVIRONMENTAL

G I

G. PAVEMENTS/ GROUNDS

N E E

H. FIRE PROTECTION

R I

I. ZONE

N G J. OTHER (Specify)

9. SECURITY POLICE

10. SAFETY

11. COMMUNICATIONS

12. BASE OPERATIONS

13. CABLE TV

14. COMMERCIAL UTILITY COMPANY

TELEPHONE

GAS

ELECTRIC

15. OTHER (Specify)

APPROVED

DISAPPROVED

16. REQUESTED CLEARANCE

17. TYPED NAME AND SIGNATURE OF APPROVING OFFICER (Chief of Operations Flight or Chief of Engineering Flight) 17a. DATE SIGNED

PREVIOUS EDITIONS ARE OBSOLETE.

AF IMT 103, 19940801, V3

Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign Click to sign

INSTRUCTIONS

The BCE work clearance request is used for any work (contract or in-house) that may disrupt aircraft or vehicular traffic flow, base utility services, protection provided by fire and intrusion alarm system, or routine activities of the installation. This form is used to coordinate the required work with key base activities and keep customer inconvenience to a minimum. It is also used to identify potentially hazardous work conditions in an attempt to prevent accidents. The work clearance request is processed just prior to the start of work. If delays are encountered and the conditions at the job site change (or may have changed) this work clearance request must be reprocessed.

18. REMARKS. (This section must describe specific precautionary measure to be taken before and during work accomplishment. Specific comments concerning the approved method of excavation, hand or powered equipment, should be included.)

AF IMT 103, 19940801, V3

(REVERSE)

8.2.1.3158.1.475346.466429

Grounds shall be kept with a professional appearance and ensure grass height matches surrounding areas. Pick up rocks, debris, and litter prior to mowing. Remove or mulch visible grass clippings before leaving work area. Contractor shall return site to the government in the same conditions as it was before work began.

If Contractor hits a water line, the contractor shall contact CE Customer Service, (830) 298-HELP (x4357), and Bio Environmental Engineering, (830) 298-6859, with the location of the break and details. If the contractor is responsible for the repair they must ensure a certified water works operator is on site to disinfect, sample, and flush the water per the American Water Works Association requirements. The Contractor shall provide documentation of certification to the Government before commencing work. If necessary, a boil water notice will be submitted to Bio-Environmental Engineering for distribution to the required Laughlin AFB population. The Contractor shall provide a copy of all sample results to the Government. Reference 30 TAC 290.46

Dimensions of Dig (Depth and Length/Width/Radius, if applicable)

Location(s)(Nearest Building and GPS):

Type of Equipment being used:

Purpose of Dig: