Facilities Services Utilities Shutdown Request Form

Transcription

1 Page 1 of 6 Facilities Services Utilities Shutdown Request Form Please complete all the fields before submitting the form to the shutdown coordinator. If you require additional space, please attach a separate sheet. If you have questions or need assistance or clarification filling out the form, contact Susan Yun at susan.yun@ucsf.edu or (415) Today s Date: Shutdown # (required for tracking purposes): Shutdown Name (Location, Utilities Shut-off): Project Name: Project #: Contractor s Ref #: Recharge #: (optional) Shutdown Requests: Air Electrical Primary Fire Sprinkler System Steam High Pressure Condensate Electrical Secondary Gas Supply Fan CO2 Exhaust Fan Heating Hot Water Vacuum - Dry Distilled Water Eyewash Irrigation Vacuum - Wet Domestic Hot Water Fire Alarm System Steam Low Pressure Ventilation Domestic Cold Water Fire Hose Reel Steam Medium Pressure Other: Start Date of Shutdown:, Start Time: Date Restored:, Time Restored: Total Duration of Shutdown: Location: List ALL Building(s), Floors, Rooms, Corridors, Areas: of Procedure Inaccurate or incomplete information may cause delays to this request. Please indicate any known impact (i.e. Jack-hammering).

2 Page 2 of 6 CP Project Manager: PM Contact #: Project Manager s address: May this person be contacted for: Complaints? Questions / Comments? Contractor performing the work: Main contact name and title: Phone # : Address: May this person be contacted for: Complaints? Questions / Comments? Secondary Contact Name and Title: Same contractor as above? Yes No, please specify: Phone #: Address: May this person be contacted for: Complaints? Questions / Comments? 1. Are prints for the project already approved by UCSF Fire Marshal? Yes No 2. Is a fire permit required? Yes No 3. If a fire permit is required, has it been approved and issued by UCSF Fire Marshal? Yes If not, indicate an estimated date for issuance of fire permit Date: 4. Will hot or cold tapping be performed? Yes No 5. Do you have all of the materials and staffing on site to complete this procedure? Yes If not, indicate when materials will be on-site for Facilities confirmation Date: [Initials] I understand that I am required to submit a shutdown request form with completed information at least (2) weeks prior to the shutdown start date and that requests that are submitted prior are not guaranteed.

3 Page 3 of 6 Method of Procedure (MOP) Shutdown Date: Shutdown #: Project # Recharge #: Location and Utilities Shutoff: MOP Start Time: MOP End Time: Specific Pre-job Meeting Location: MOP of Work: Personnel Contact List List all necessary contacts such as: Jobsite Authorizations, UCSF Facilities Technicians, UCSF Facilities Emergency Contacts, Fire Watch, Capital Programs Project Managers, Contractor Project Managers, General Contractor and Subcontractors (foreman, wireman, pipe fitters, etc.), Contractor Back-up, Contractor Standby, Maintenance Personnel. Full Name Initials Title & of Responsibility Company Phone Number & Address Check Box, if required to be on-site during shutdown 1. UCSF Facilities After-Hours Central Utilities Plant CUP Central Plant Control Room 24/7 Call Number UCSF (415) UCSF Facilities Customer Service Center CSC Facilities Dispatch Center M-F Days UCSF (415) UCSF Facilities Jo Van Fleet JV Facilities Trades Shop M-F Days UCSF (415)

4 Page 4 of 6 MOP Required Tool List Check box for each item and list additional tools, necessary to perform the work, including: power tools, equipment, and PPE. Add any tools used during the shutdown that are not on the MOP Required Tool List. 1. Basic Hand Tools 11. Pipe Threader Concrete Saw 12. Power Drills Electrical / Voltage Meter 13. Scissor Lift Fish Tape 14. Torch (other) Inductance Tester 15. Walk-Talkie / Radio Jack Hammer 16. Welding Machine Ladder Megger Oxy Acetylene Torch Phase Rotation Meter Safety Tools and Requirements Check box for each item and list additional safety tools and requirements that are determined by the job hazard analysis such as LOTO, PPE, and fall protection. 1. Confined Space Permit 11. Safety Glasses Dust Control Walk-off Mat Fire Blanket Fire Extinguisher Fire Permit Fire Watch Flashlight Gloves Hard Hats Lock-out / Tag-Out Kit

5 Page 5 of 6 MOP Procedure List each step of the process in sequential order, including: affected equipment, testing procedure. Step # Detailed of Task Action by: Name of Personnel & Company Start Time Finish Time Duration (min / hr) Sign-off: Completion of work (Initial) 1 Call CUP / Facilities prior to starting shutdown 2 Pre-job meeting

6 Page 6 of 6 DO NOT WRITE BELOW THIS LINE. FOR FACILITIES SERVICES USE ONLY Forwarded for Investigation to: Engineers Electricians HVAC Plumbers Contractor Other : Indicate Shutdown Utilities Impact on occupants work space and environment: Air No ventilation / circulation of air Air No exhaust Air Negative air pressure Air Possible or expected fumes or odor Electricity No overhead lights Electricity No power to outlets Temperature Too cold Temperature Too warm Water no hot water Water no cold water Water no distilled water Water no eyewash Electricity No emergency power Noise Specify construction-related noise: Steam No LPS Impacts room heating and/or hot water Steam No MPS or HPS for autoclaves, sterilizers, dishwashers, cage wash Other: Additional Notes: Shutdown-related details, Impact, Alternative solution for continuous utility usage Confirmed Facilities Personnel, assigned to this Shutdown: 1) 2) Shutdown Notification Needed? No Yes Estimated Post Date: Approved by Susan Yun Date: