Facilities Services Utilities Shutdown Request Form

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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) 502-3332.

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 Condensate CO2 Distilled Water Domestic Hot Water Domestic Cold Water

Electrical Primary Electrical Secondary Exhaust Fan Eyewash Fire Alarm System Fire Hose Reel

Fire Sprinkler System Gas Heating Hot Water Irrigation Steam Low Pressure Steam Medium Pressure

Steam High Pressure Supply Fan Vacuum - Dry Vacuum - Wet Ventilation

Other: __________________________________________________________________________________________

Start Date of Shutdown: Date Restored:

___S__t_a_r_t_D_a__y_____ , _____________________ ____E_n_d__D_a__y_____ , _____________________

Start Time:

___S__ta__rt__T_im__e____

Time Restored: ____E__n_d__T_i_m__e____

Total Duration of Shutdown: ________________________________________________________________________

Location: List ALL Building(s), Floors, Rooms, Corridors, Areas:

Description of Procedure

Inaccurate or incomplete information may cause delays to this request. Please indicate any known impact (i.e. Jack-hammering).

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CP Project Manager: _________________________________ PM Contact #: ______________________________ Project Manager's email address: _____________________________________________________________________ May this person be contacted for: Complaints? Questions / Comments?

Contractor performing the work: _______________________________________________________________________ Main contact name and title: __________________________________________________________________________ Phone # : ________________________ Email Address: ________________________________________________ May this person be contacted for: Complaints? Questions / Comments?

Secondary Contact Name and Title: _____________________________________________________________________

Same contractor as above? Yes No, please specify: _____________________________________________________

Phone #: _____________________ Email 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 No

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

No - 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.

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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 Description 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 & Description of Responsibility

1. UCSF Facilities After-Hours Central Utilities Plant

2. UCSF Facilities Customer Service Center

3.

CUP CSC

Central Plant Control Room 24/7 Call Number

Facilities Dispatch Center M-F Days

Company

UCSF UCSF

Phone Number & Email Address

(415) 476-4066 (415) 476-2021

Check Box, if required to be on-site during shutdown

4. 5. 6. 7. 8. 9. 10. 11.

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MOP Required Tool List

Check box for each applicable 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.

Description

Check if applicable

Description

1. Basic Hand Tools

11. Pipe Threader

2. Concrete Saw

12. Power Drills

3. Electrical / Voltage Meter

13. Scissor Lift

4. Fish Tape

14. Torch (other)

5. Inductance Tester

15. Walk-Talkie / Radio

6. Jack Hammer

16. Welding Machine

7. Ladder

17.

8. Megger

18.

9. Oxy Acetylene Torch

19.

10. Phase Rotation Meter

20.

Check if applicable

21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Description

Safety Tools and Requirements

Check box for each applicable item and list additional safety tools and requirements that are determined by the job hazard analysis such as LOTO, PPE, and fall protection.

Description

1. Confined Space Permit 2. Dust Control Walk-off Mat 3. Fire Blanket 4. Fire Extinguisher 5. Fire Permit 6. Fire Watch 7. Flashlight 8. Gloves 9. Hard Hats 10. Lock-out / Tag-Out Kit

Check if applicable

Description

11. Safety Glasses

12.

13.

14.

15.

16.

17.

18.

19.

20.

Check if applicable

21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Description

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MOP Procedure List each step of the process in sequential order including: affected equipment, testing procedure. For LOTO requests,

provide a general timeline (start/end time, requesting time for LOTO, and other items related to facilities' involvement)

Step

#

Detailed Description of Task

1

Call CUP / Facilities prior to starting shutdown

Action by:

Name of Personnel & Company

Start Time

Finish Time

Duration

(min / hr)

Sign-off: Completion

of work

(Initial)

2 Pre-job meeting

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18 19 20

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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

Temperature ? Too cold

Air ? No exhaust

Temperature ? Too warm

Air ? Negative air pressure

Water ? no hot water

Air ? Possible or expected fumes or odor

Water ? no cold water

Electricity ? No overhead lights

Water ? no distilled water

Electricity ? No power to outlets

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: _________________________

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