J_0200000_05_Forms.pdf

ATTACHMENT J-0200000-05

FORMS

J-0200000-05

ACCIDENT FORM

EXCAVATION REQUEST FORM

Date: _________

From: ____________________________________________________________

To: Public Works Division (Attn: Utilities Foreman)

Subj: EXCAVATION REQUEST

1. Request an excavation of the following location:

2. Justification:

3. A detailed sketch of the excavation site is attached. I understand that insufficient detail on the sketch could result in the request being returned for clarification.

4. The requested date for excavation is_____________________.

Date cannot be earlier than 10 working days from date of request.

(Signature of Requester) __________________________

Date Received ____________

From: Utilities Foreman, Public Works Division

Date Completed: ____________

To: (Requester) _______________________________________________

1. Subject request is approved/disapproved. Excavation may begin on ______________.

2. All utilities have been identified and flagged 48 hours prior to the excavation.

3. Comments:______________________________________________________

(Signature) __________________

Certified by PWU:

PWC__, PWM__ , Construction Rep __, Telephone Office __ , SCE&G __

DIGGING PERMIT INSTRUCTIONS (This form is for COR notification. The installation may have different requirements and a different form maybe required)

1. A properly processed and completed digging permit is required prior to any action that will disturb the ground. All utilities listed on the permit must be cleared.

2. The party who will disturb the ground is responsible for obtaining all approvals required by the permit.

3. The approved permit shall be “in hand” while the digging is done.

4. Any damages to utility lines within 5 feet either side of a marked/flagged utility shall be the responsibility of the party requesting the permit and shall be repaired at no cost to the government.

5. Requests for digging permits shall be submitted a minimum of 10 calendar days prior to date needed.

6. Digging permits are good for 17 calendar days. If the need for the permit extends beyond 17 days, a request for renewal shall be submitted at the end of 10 days.

7. During digging, if any utilities are encountered that are not identified by the digging permit, work shall be immediately stopped and the appropriate Government representative shall be notified.

Section I (Completed by requesting department or gov’t contractor within (30) to (10) days PRIOR TO START of ANY & ALL scheduled asbestos abatements. Blocks with an (*) are required. Hand deliver, email or fax completed form to NREAO--see bottom)

Serial # (Assigned by NREAO)

* From: PW Gov’t Contractor ROICC Other (list): _________________

*Prime Contractor: *Abatement Contractor: *Phone:

*Affected Bldg/area: Room: *Start Date: Comp Date:

*Asbestos Material Type: Surfacing TSI Misc (describe):

*ACM Condition: Friable Nonfriable Quantity:

“I certify to the best of my knowledge that asbestos containing materials are scheduled to be abated as described above. Asbestos abatement as described will NOT begin without written authorization from Asbestos Program Manager or designated alternate as indicated by NREAO signature below.” A copy of this approved NREAO RIPOUT form must be on the work site at time of actual abatement.

Additional remarks:

Name (Print below): Signature (below): Phone (below): Date (below):

Section II (Completed by NREAO Asbestos Program Manager or NREAO designated alternate and returned to Section I requesting dept )

“Asbestos abatement work as described above and relevant requirements have been reviewed and abatement is: Approved; Not Approved (If not approved: immediately notify NREAO OIC and PW/ROICC as applicable and complete Section III).”

Additional remarks:

Name (Print below): Signature (below): Phone (below): Date (below):

Section III (Completed by NREAO immediately if asbestos abatement RIPOUT is disapproved )

Notified NREAO OIC (Mandatory): Yes Date:

Notified PW: Yes No N/A Name: Date:

Notified ROICC: Yes No N/A Name: Date: