Technical Exhibit E - General Maintenance Service Form.pdf

G4R#

GENERAL MAINTENANCE SERVICE REQUEST FORM

Revised 3/7/24 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#

CHOOSE FROM OPTIONS LISTED

PAINT COLOR Paint colors can be viewed at Sherwin-Williams

☐ Greyish #6001 ☐ Touch of Sand #9085 ☐ White ☐ Sand Dune #6086 ☐ If doesn’t apply, check this box

FLOORING: CARPET TILES ☐ Yes ☐ No ☐ Undecided ☐ If doesn’t apply, check this box FLOORING: TILE ☐ Yes ☐ No ☐ Undecided ☐ If doesn’t apply, check this box FLOORING: LAMINATE ☐ Yes ☐ No ☐ Undecided ☐ If doesn’t apply, check this box KICKBOARD ☐ Black ☐ Brown ☐ If doesn’t apply, check this box

OUTLET COVER COLOR ☐ Beige ☐ White ☐ Grey ☐ If doesn’t apply, check this box LIGHT FIXTURES ☐ Replace with LED ☐ Replace broken lights ☐ If doesn’t apply, check this box BLINDS ☐ Vinyl Vertical White ☐ Vinyl Horizontal White ☐ If doesn’t apply, check this box CEILING TILES ☐ Full replacement ☐ Partial replacement ☐ If doesn’t apply, check this box

STATEMENT OF WORK:

ADDITIONAL COMMENTS:

PROPONENT SIGNATURE:

FUNDING: ☐ Credit Card ☐ Materials only, not labor ☐ N/A

☐ Other, please explain:

mailto:usarmy.apg.devcom-cbc.mbx.g4@army.mil https://sherwin-williams.com/

Revised 3/7/24 Page 2 of 4

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

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)

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

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)

Revised 3/7/24 Page 3 of 4

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

ATTACH PICTURES TAKEN

DURING INITIAL INSPECTION

INITIAL WALK-THROUGH NOTES:

REVISED SCOPE OF WORK (if applicable):

☐Exhibit A, supplemental risk plan attached.

REVIEWED OPTIONS WITH CUSTOMER

PAINT: ☐ Greyish #6001 ☐ Touch of Sand #9085 ☐ Sand Dune #6086 ☐ 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 REPLACEMET: ☐Full ☐ Partial ☐ Customer denied OUTLET COVER: ☐Beige ☐Grey ☐ White ☐Customer Denied

COST: ATTACH QUOTE HERE:

PROPONENT APPROVAL: DATE:

G4 LEAD APPROVAL: DATE:

Revised 3/7/24 Page 4 of 4

INSTRUCTIONS: G4 LEAD, PLEASE FILL OUT INFORMATION ON PAGE4

ATTACH PICTURES TAKEN

DURING CONTRUCTION

ATTACH PICTURES AT

COMPLETION

FINAL INSPECTION NOTES:

COMPLETION DATE:

INSPECTED BY:

SIGNATURE OF COMPLETION: