01012_Excavation_Pmt_form_1247-R.doc

EXCAVATION PERMIT �

Expiration Date: � ECO Control #: 4156 on DO #: 0866 � Section A - Excavation Information

(Completed by person/contractor performing excavation) Your Control #�

a. Gov’t. Contract #:

b. Your Delivery Order #: �

c. DIO Work Order #: AST01434J�

d. If contract, name of Gov’t. Contracting Officer Representative (COR):

GEORGE PHILLIPS

e. COR Phone #:

410-306-2311�

f. FAX #:

410-306-1187 �

g. Name of Gov’t. Project Mgr:

MICHAEL A. GILBERT

h. PM Phone #:

410-306-1120 �

i. FAX #:

410-306-1187 �

j. Organization and/or Contractor’s Name:

DIXIE CONSTRUCTION CO, INC�

k. Date requested: �

l. Date required: �

m. Excavation Zone/s and Job Site: (Circle one) Aberdeen Edgewood� Bldg #: BUILDING E-5604 �

n. Description of work, location, and justification:

Pave 1592 square feet around Black Bear shed and up to Building E0-5602. Regrade surface area upgrade corner near North End of Building E-5604. Place GSAB and repave an additional 1000 square feet.

Is there a sketch/map of the area attached with the excavation location identified? Yes No�

o. Printed name of Permit Holder (first name, last name) and Signature

DWAYNE DUNNICK

p. Telephone #: 443-604-0974

FAX #: 410-836-2029�

Note: It is the responsibility of all contractors to notify Miss Utility prior to any excavation.� DIO & Gov’t. Tenant Activities only

Miss Utility contact date: Ticket #: Validation Date: � Section B – Excavation Requirements

(Completed by Safety Offices)�

a. (Safety) Magnetometry sweep required? Yes No�

b. (Safety) Soil chemistry analysis required? Yes No�

c. Special safety conditions? Yes No (If Yes, note below or attach separate sheet)

d. Safety Office representative signature

e. Telephone #:�

f. Date: � Section C – Excavation Approval

Completed by Excavation Control Office (ECO)� This Permit:

1. Does not authorize relocating excavated soils or materials outside the immediate job site unless specifically indicated.

2.Must be at the excavation site and available for inspection by government representatives.

3.Is valid ONLY after any Unexploded Ordnance detection, identification, and removal has been performed, if required.

4.Must be signed by a DIO representative to be valid.

5.Must be renewed prior to the expiration date by the above permit holder.� Report all spills (oil, fuel, chemical) to the Emergency Operations Center by dialing “911” � If any of the general or special conditions of this permit conflict with contractual requirements, the Contracting Officer must be contacted prior to excavation.�

ECO Approval Signature:

Date: �

SSB Form 1247-R, revised 11 Jan 02 by ECO (Supersedes STEAP-FE Fm 412, which may not be used)