Technical Exhibit E - General Maintenance Service Request Form.pdf

G4R#

GENERAL MAINTENANCE SERVICE REQUEST FORM

Control Number: 0002 | Last Revised 9/4/2024 Page 1 of 3

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:

ADDITIONAL COMMENTS:

OFFICE UPGRADE: ☐ N/A ☐ YES (CHOSE FROM OPTIONS BELOW)

PAINT: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Greyish #6001 ☐ Touch of Sand #9085 ☐ Sand Dune #6086 ☐ White FLOORING: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Carpet Tiles ☐ Tile ☐ Laminate KICKBOARD: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Black ☐ Brown LIGHT FIXTURES: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Replace with LED ☐ Replace broken OUTLET COVER: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Beige ☐ Grey ☐ White WHITE BLINDS: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Vinyl vertical ☐ Vinyl horizontal CEILING TILE REPLACEMENT: ☐ If doesn’t apply, check this box ☐ If yes, check this box (Please choose from options listed) ☐ Full ☐ Partial

FUNDING FOR MATERIALS ONLY: ☐ N/A ☐ Credit Card ☐ Other, please explain:

☐ WBS #:

PROPONENT SIGNATURE:

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 mailto:usarmy.apg.devcom-cbc.mbx.g4@army.mil

Control Number: 0002 | Last Revised 9/4/2024 Page 2 of 3

INSTRUCTIONS: FACILITIES STAFF, PLEASE FILL OUT INFORMATION ON PAGE 2

HAZARDS: IF YES, PLEASE ATTACH EXHIBIT A

LEAD ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

MOLD ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

ASBESTOS ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

WILL WORK OCCUR IN A LAB ☐ YES ☐ NO

IF YES, PLEASE ATTACH HAZARDOUS WORK PERMIT-

EXHIBIT B

WATER ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

HEAT / AC ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

ELECTRIC ☐ YES ☐ NO ☐ UNKNOWN ☐ EXHIBIT A IS ATTACHED

OTHER

ATTACH PICTURES TAKEN DURING INITIAL INSPECTION

ATTACH PICTURES TAKEN DURING CONSTRUCTION

ATTACH PICTURES TAKEN AT COMPLETION

Control Number: 0002 | Last Revised 9/4/2024 Page 3 of 3

INSTRUCTIONS: FACILITIES STAFF, PLEASE FILL OUT INFORMATION ON PAGE 2

COST:

☐ MATERIAL QUOTE ATTACHED

COST CENTER:

G-8 BUDGET OFFICER NAME:

G4 LEAD APPROVAL: DATE:

COMPLETION DATE:

INSPECTED BY:

SIGNATURE OF COMPLETION: