11.5.4_FC_Form_420-E_Fort_Carson_Utility_Outage.pdf

FC FORM 420-E, JAN 2015 PREVIOUS EDITIONS ARE OBSOLETE

FORT CARSON UTILITY OUTAGE/CONNECTION REQUEST

(Read instructions on Page 2 of this form. FC REG 420-19 requires that the government receive 3 business days notice on outages performed during normal working hours. If outages require work to be performed during the evening or on weekends; then, 7 days notice is required. Living quarters require a 5 day minimum notice.)

1. Project Contract Numberor Approved Work Request Number:

2. Requester: Name:

FAX:

Company/Unit:

Phone:

Email:

HOT TAP

5. Number of facilities affected:

BLDG#

BLDG#

BLDG#

6. Wll the contractor provide temporary utilities to support this outage?

7. Wll the contractor provide portable latrines to support this outage?

9. Government Representative's Name (print):

Email:

Electric (Primary/Secondary), Fire Sprinkler, and Alarm Systems: Contact: Electrical Services Supervisor Phone: 719-302-0160; BLDG 221 Electric Shop

Water, Sewer, Gas, HTHW, and Chilled Water: Contact: Collection and Distribution Supervisor Phone 719-302-0158; BLDG: 221 Collection & Distribution Shop

Approved:

Approved:

Disapproved

Disapproved

10. Approval Request: Government representative must coordinate and obtain the signature of the appropriate POC for this request to be approved. As-built, red line, or 1 line drawings and traffic control planswill be submitted with this request. A copy of all required testing results (e.g., Bac-T's, pressure tests, etc.) will be provided to the approval POC before any new utility line will be activated or energized. Submit approved form to the Fort Carson Dig Permit Office at BLDG 1225; phone 719-526-

Signature:

Signature:

Signature:

Phone:

Date:

Date:

Date:

Signature:

Signature:

Signature:

(If additional facilities are affected, include information on a separate list and attach to this request. Include BLDG#, POC (printed name), signature, phone number, email, and date.)

BLDG POC NAME:

BLDG POC NAME:

BLDG POC NAME:

Phone:

Phone:

Phone:

Date:Email:

Email:

Email:

Date:

Date:

FIRE FLOW TESTENERGIZEOUTAGE

FIRE PROTECTIONCHILLED WATER

YES

YES

NO

NO

N/A

N/A

ROADSTEAM/HTHWELECTRICGAS

SEWER

OTHER

WATER

3. Work Description:

Location:

Date of Outage or Connection:

4. Type of Outage or Connection:

Time of Outage or Connection:

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8. Does the work require traffic control, detour, or road/lane closure? If yes, DPW, Traffic Engineering Section approval required.

YES NO N/A

Road/Parking lot closure or detour: Contact: DPW, Traffic Engineering Section Phone 719-526-9267; BLDG 1219 Room 117

Approved: Disapproved

Signature: Date:

FC FORM 420-E, JAN 2015 (Back)

INSTRUCTIONS

SECTION 1

SECTION 2

SECTION 3

SECTION 4

SECTION 5

SECTION 6

SECTION 7

SECTION 8

SECTION 9

SECTION 10

The Requester provides project name, contract number, and work order number or project number from DA 4283 or DD 1391.

The Requester provides all contact information (e.g., name, office, and cell phones, fax number, e-mail address, and company name/requesting unit).

The Requester provides a detailed description of the work that requires this utility outage, connection, electric energize, hot tap, or other (road closure, fire hydrant flow test, etc.). The date of the outage or connection. The time of the ouage or connection. All outages or connections will be performed during regular business hours 0730 to 1530, Monday through Friday (excluding Federal holidays). Any outages or connections after the times listed will be handled on a case by case basis. Approval/disapproval of this request shall be coordinated with the DPW, Base Operations and Maintenance Contractor, Fort Carson Support Services (FCSS), seven (7) days prior to the scheduled outage or connection.

The Requester identifies the type of outage or connection. Identifies the utility affected by the outage or connection.

The Requester or Project Government Representative provides a list of buildings affected by the outage or connection. Obtain the BLDG POC's name (printed), signature, phone number, and date. Include any requests the buildings to support this outage or connection.

The Requester or Project Government Representative identifies if the contractor will provide temporary utility support to the affected buildings to support this outage or connection.

The Requester or Project Government Representative identifies if the contractor will provide portable latrines to the affected buildings to support this outage or connection.

The Government Representative provides all the information required in Section 9 of this form. The Government Representative shall verify that sections 1 through 8 have been completed before signing this section.

The Government Representative obtains the request approval from the appropriate utility POC by following the directions of Section 10 of this form. As-built, red line, or 1 line drawing will be submitted with the request. Submit approved and completed form to the Fort Carson Dig Permit Office; phone 719-526-3089, Building 1225.

PREVIOUS EDITIONS ARE OBSOLETE Page 2 of 2

The Requester identifies if traffic control, detour, or road/parking lot closure is required. If "Yes" is checked, you must contact the DPW, Traffic Engineering Section for approval. A detailed traffic control plan is required.