Technical Exhibit D - Minor Project Request Form.pdf

G4R#

MINOR PROJECT REQUEST FORM

Control Number: 0003 | Last Revised 9/04/2024 Page 1 of 4

INSTRUCTIONS: PROPONENT, PLEASE FILL OUT INFORMATION ON PAGE 1

TO SUBMIT PLEASE EMAIL TO: usarmy.apg.devcom-cbc.mbx.g4@army.mil

SUBMISSION DATE REQUESTED SERVICE DATE

PROPONENT NAME ORG ☐ CBC-ENG ☐ CBC-R&O ☐ CBC-OOD

CONTACT# DIVISION

EMAIL

BUILDING# ROOM#

STATEMENT OF WORK:

JUSTIFICATION:

ROM COST ESTIMATE: $

ADDITIONAL COMMENTS:

PROPONENT SIGN & DATE:

*DIRECTOR OR DEPUTY DIRECTOR- SIGN BELOW ACKNOWLEDGING YOU HAVE REVIEWED AND APPROVED THIS MPR

DIRECTOR (or) DEPUTY DIRECTOR SIGN & DATE:

SUBMIT THIS SERVICE REQUEST FORM TO THE FOLLOWING EMAIL ADDRESS: usarmy.apg.devcom-cbc.mbx.g4@army.mil mailto:usarmy.apg.devcom-cbc.mbx.g4@army.mil

Control Number: 0003 | Last Revised 9/04/2024 Page 2 of 4

INSTRUCTIONS: G4 LEAD, PLEASE FILL OUT INFORMATION ON PAGE 2

IJO#: DATE SUBMITTED TO DPW: DATE APPROVED BY DPW:

HAZARDS PRESENT IF YES, PLEASE REFERENCE

EXHIBIT A

IF UNKNOWN PLACE NOTES HERE

LEAD ☐ YES ☐ NO ☐UNKNOWN

MOLD ☐ YES ☐ NO ☐UNKNOWN

ASBESTOS ☐ YES ☐ NO ☐UNKNOWN

WATER ☐ YES ☐ NO ☐UNKNOWN

HEAT / AC ☐ YES ☐ NO ☐UNKNOWN

ELECTRIC ☐ YES ☐ NO ☐UNKNOWN

WILL WORK OCCUR IN A LAB ☐ YES ☐ NO

OTHER

MINOR PROJECT SERVICE ORDER CLASSIFICATION:

☐ CLS-DPW does not have the required resources to perform the work. Date contacted: ________________________

☐ CLS-DPW cannot meet the required schedule. Date contacted: _____________________________

☐ ALCS (Above Common Level Service)

WARRANTY INFORMATION (List anything that is covered under an existing warranty. Contact the warranty company to review coverage before making any modifications to ensure warranty will not be voided)

ADDITIONAL COMMENTS:

Control Number: 0003 | Last Revised 9/04/2024 Page 3 of 4

INSTRUCTIONS: G4 LEAD, PLEASE FILL OUT INFORMATION ON PAGE 3

ATTACH PICTURES TAKEN

DURING INITIAL INSPECTION

INITIAL WALK-THROUGH NOTES:

SCOPE OF WORK SUMMARY:

☐ Exhibit A, supplemental risk plan attached.

REVIEWED OPTIONS WITH CUSTOMER

OUTLET COVER: ☐ Beige ☐ Grey ☐ White ☐ Customer Denied LIGHT FIXTURES: ☐ Replace with LED ☐ Replace broken

☐ Customer denied CARPET: ☐ # ☐ # ☐ # ☐ Customer Denied TILE: ☐ # ☐ # ☐ # ☐ Customer Denied LAMINATE: ☐ # ☐ # ☐ # ☐ Customer Denied

WHITE BLINDS: ☐ Vinyl vertical ☐ Vinyl horizontal ☐ Customer denied

KICKBOARD: ☐Black ☐Brown ☐Customer Denied CEILING TILE REPLACEMENT: ☐ Full ☐ Partial ☐ Customer denied PAINT: ☐ Greyish #6001 ☐ Touch of Sand #9085 ☐ Sand Dune #6086 ☐ White ☐ Customer Denied

COST: QUOTE IS ATTACHED TO FILE: ☐ YES ☐ NO

FUNDING: ☐ Minor Service Project Funds ☐ Credit Card ☐ USACE Task Order

CONTRACTING VEHICLE:

*Customer has reviewed the cost associated with the Project & Repairs Request Form and has accepted the Statement of Work*

G4 DIRECTOR APPROVAL: DATE:

COR APPROVAL: DATE:

Control Number: 0003 | Last Revised 9/04/2024 Page 4 of 4

INSTRUCTIONS: G4 LEAD, PLEASE FILL OUT PROJECT CLOSE-OUT INFORMATION ON PAGE 4

ATTACH PICTURES TAKEN

DURING CONSTRUCTION

ATTACH PICTURES AT

COMPLETION

FINAL INSPECTION NOTES:

ADDITIONAL COMMENTS:

COMPLETION DATE:

INSPECTED BY:

SIGNATURE OF COMPLETION: