SOW Attach 8 - AF Form 103.pdf

BASE CIVIL ENGINEERING WORK CLEARANCE REQUEST

WORK TASK NO.

XXXXXXXXXXXXX

1. CONTACT INFORMATION

NAME OF REQUESTING OFFICIAL

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

TELEPHONE NO.

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

ORGANIZATION

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

NAME OF 21 CES CONTRACT QAE / INSPECTOR (IF APPLICABLE) TELEPHONE NO. ORGANIZATION

2. WORK DETAILS

CLEARANCE IS REQUESTED TO PROCEED WITH WORK AT:

SUPPORTING WORK TASK / CONTRACT / PROJECT NO.

THIS EXCAVATION OR UTILITY DISTURBANCE AREA XX HAS XX HAS NOT BEEN CLEARLY MARKED

OR STAKED PER THE ATTACHED SKETCH.

3. TYPE OF FACILITY / WORK INVOLVED (MARK “ X ” IN ALL APPLICABLE FIELDS)

XX A. PAVEMENTS XX D. FIRE DETECTION & PROTECTION SYSTEMS XX G. AIRCRAFT OR VEHICULAR TRAFFIC

XX B. DRAINAGE SYSTEMS XX E. UTILITY XX OVERHEAD XX UNDERGROUND XX H. SECURITY

XX C. RAILROAD TRACKS XX F. COMM XX OVERHEAD XX UNDERGROUND XX I. OTHER (GAS) XXXXXXXXXXXXXXXXXX

4. ADDITIONAL DETAILS

BRIEF DESCRIPTION OF WORK TO BE ACCOMPLISHED.

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

WHAT TYPE OF DIGGING EQUIPMENT WILL YOU BE USING?

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

CLEARANCE DATE REQUIRED:

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

HOW WIDE OF AN OPENING IS REQUIRED?

XXXXXXXXXXXXXXXXXXXXXXXXXXXX

WHAT IS THE MAXIMUM DEPTH REQUIRED?

XXXXXXXXXXXXXXXXXXXXXXXXXXXX

CAN THE DEPTH BE MODIFIED?

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

5. DECLARATION OF UNDERSTANDING

Initials I certify and/or understand the following:

I am the entity physically performing the excavation.

The proposed excavation site has been clearly marked using white flags or with environmentally safe, water-soluble white paint.

I must contact Colorado 811 for utility line locates (other than Base owned infrastructure).

The CSU Utility Line Locator service is a separate process from the 21 Civil Engineer Squadron (21 CES) Work Clearance.

I have included the Colorado 811 ticket number on my AF 103 Work Clearance Request.

The 21 CES Work Clearance request is valid for the duration of the project; it is my responsibility to maintain locate markings An active and approved 21 CES Work Clearance form must be on the excavation site at all times in the work site.

If excavation begins prior to approval of this Work Clearance request and/or if excavation occurs outside the boundaries of the indicated/marked proposed excavation site I can be held legally and financially liable for repairs.

I will contact 911 during any work related injuries requiring EMS.

I will call 21 CES at 719 556-4030 if utility lines are hit.

Company/Business/Squadron Telephone No.

Signature Of Requesting Official Today’s Date

AF FORM 103, NOV 17 PREVIOUS EDITIONS ARE OBSOLETE PAGE 1

1388453148A Underline

6. BASE AGENCIES

ORGANIZATION LOCATION PHONE REMARKS REVIEWER’S SIGNATURE

COLORADO 811

CO 811 reaches out to

CSU

16361 Table Mountain Pkwy, Golden, CO 80403 811

21 SECURITY FORCES

SQUADRON BLDG. 1376 556-4025

(E) 556-4000

21 SAFETY OFFICE BLDG. 845 556-6780

(E) 556-4555

21 COMMUNICATION

SQUADRON BLDG. 1038 556-3797

(E) 554-COMM

BASE OPERATIONS BLDG. 122 556-4986

(E) 556-4666

CABLE TV 301 MITCHELL ST 597-0873

649-3500

FAA BLDG. 205

C: 719 510-4721 O: 719 380-6744

7. SPECIAL COORDINATION WHEN EXCAVATING IN EITHER THE HOUSING AREA OR ALONG EAST AIR FIELD FENCE LINE

TIERRA VISTA

COMMUNITIES 650 MCCHORD ST

597-2372

(E) 550-1254

425-0790

MAGELLAN

(PETROLIUM LINE)

1004 S Santa Fe Ave, Fountain, CO 80817

C: 719 248-5550

(E) 800-720-2417

8. ADDITIONAL COMMENTS SECTION

AF FORM 103, NOV 17 PREVIOUS EDITIONS ARE OBSOLETE PAGE 2

AF FORM 103 PART II CIVIL ENGINEER USE ONLY

FLIGHT LOCATION PHONE COMMENTS REVIEWER’S

SIGNATURE / INITIALS

ENVIRONMENTAL B1324 556-7305

FIRE DEPARTMENT B218 556-4242

PAVEMENTS B1324 556-1442

IRRIGATION B1324 556-1479

WFSM B1284 556-1462

ELECTRICAL B1324 556-1470

HVAC B1324 556-1451

9. ADDITIONAL COMMENTS

10. IMPORTANT INFORMATION

-CATHODIC TEST STATIONS SHOULD BE VISIBLE IF PRESENT IN THE AREA-

FIRE DISPATCH (556-8376) BIO (556-7721) BLDG 1246 - CONFINED SPACE ENTRY & POTABLE WATER LINE BREAKS SECURITY FORCES BDOC (556-4000)

11. APPROVING OFFICIAL

NAME OF APPROVING OFFICER (CHIEF OF OPERATIONS OR CHIEF OF ENGINEERING FLIGHT)

DATE SIGNED SIGNATURE OF APPROVING OFFICER

AF FORM 103, NOV 17 PREVIOUS EDITIONS ARE OBSOLETE PAGE 3

DENIED

CLEARANCE REQUEST

APPROVED

AF FORM 103 WORK CLEARANCE REQUEST INSTRUCTIONS

The BCE work clearance request is used for all 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. This form is required for all excavation on the installation, regardless of depth and must be completed by the entity physically performing the excavation.

1. Requests to locate utilities by 21 Civil Engineering Squadron (21 CES) must be made no later than 14 days prior to excavation. Large or multi-location requests may take longer than 14 days depending on the size or scope.

2. The requester will complete sections 1-8 of the Work Clearance Form 103 and provide all the necessary work specifications. A diagram of the proposed work area must submitted with all requests or they will be denied. Please use GeoBase map website to create your work area map at: https://maps.af.mil/geoportal/home/webmap/ viewer.html?webmap=f3899106a6e54c5494a3281a75b3480c

3. The designated area must be clearly marked before submitting a work clearance request form. Mark the area with environmentally safe, water-soluble white paint (latex paint), we strongly recommend using flags during rain or snow. The requester will ensure utilities have been marked before excavating and will be responsible for maintaining those markings. The markings of underground utilities shall be considered valid as long as the markings are clearly visible, all markings are good from the 21 CES approval date. The requester is responsible for keeping up with the markings for the duration of the project. The contract QAE/Inspector is responsible for ensuring that the contractor is maintaining the markings by repainting, and putting locate flags. Keep in mind Colorado Springs Utilities (CSU) clearance requests have their own expiration date and must be maintained as well, the Colorado 811 locate request is separate from the AF Form 103 request.

4. The Magellan LP Damage Prevention operator must be on site when digging anywhere near the Magellan Liquid Petroleum Pipeline, please notify Chance Brabham at C: (719) 248-5550. Alternatively, call Magellan LP. at

(800) 720-2417. Please refer to the last page for the location of the pipeline; please contact the R&O office if you have any questions.

5. The requester will not proceed until the form has been fully completed and approved by the 21 CES Operations Flight Commander or Chief. The R&O office will contact the requester once the request has been approved. If any utilities are damaged without an approved AF Form 103 the contractor will be held responsible for the damage and repair.

6. The requester will provide a copy of the completed AF Form 103, with attachments, to the contract QAE/inspector (if applicable) or to a 21 CES Engineering personnel. Additionally a copy of the request form must be kept on the job site. Upon installation of new utilities the requester will provide updated as- built diagrams to 21 CES Engineering Flight.

IN THE EVENT OF UTILITY LINE(S) DAMAGE:

The requester will immediately contact the Base Fire Department at ext. 911 for any situation that requires emergency response. The requester will also immediately notify the Customer Service section of 21 CES at ext.

556-4030 and the Contracting Officer or Inspector when any utility line is damaged. Other agencies listed on the AF Form 103 will be contacted by the requester as appropriate.

AF FORM 103, NOV 17 PREVIOUS EDITIONS ARE OBSOLETE PAGE 4

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