facilities services utilities shutdown request form...mop required tool list check box for each...

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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 [email protected]

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 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:

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: ________________________________________________


Secondary Contact Name and Title: _____________________________________________________________________

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

Phone #: _____________________ Email Address: _____________________________________________________


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.

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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

Company Phone Number &

Email 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) 476-4066

2. UCSF Facilities Customer Service Center

CSC Facilities Dispatch Center M-F Days

UCSF (415) 476-2021

3. UCSF Facilities Jo Van Fleet

JV Facilities Trades Shop M-F Days

UCSF (415) 476-0949

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 21.

2. Concrete Saw 12. Power Drills 22.

3. Electrical / Voltage Meter 13. Scissor Lift 23.

4. Fish Tape 14. Torch (other) 24.

5. Inductance Tester 15. Walk-Talkie / Radio 25.

6. Jack Hammer 16. Welding Machine 26.

7. Ladder 17. 27.

8. Megger 18. 28.

9. Oxy Acetylene Torch 19. 29.

10. Phase Rotation Meter 20. 30.

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 11. Safety Glasses 21.

2. Dust Control Walk-off Mat 12. 22.

3. Fire Blanket 13. 23.

4. Fire Extinguisher 14. 24.

5. Fire Permit 15. 25.

6. Fire Watch 16. 26.

7. Flashlight 17. 27.

8. Gloves 18. 28.

9. Hard Hats 19. 29.

10. Lock-out / Tag-Out Kit 20. 30.

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

Step #

Detailed Description 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

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: _________________________

Todays Date: Shutdown required for tracking purposes: Shutdown Name Location Utilities Shutoff: Project Name: Project: Contractors Ref: Recharge: Other: undefined: undefined_2: Total Duration of Shutdown: undefined_3: Inaccurate or incomplete information may cause delays to this request Please indicate any known impact ie Jackhammering: CP Project Manager: PM Contact: Project Managers email address: Contractor performing the work: Main contact name and title: Phone: Email Address: Secondary Contact Name and Title: No please specify: Phone_2: Email Address_2: Date: Date_2: Initials I understand that I am required to submit a shutdown request form with completed information at least: Shutdown Date: Shutdown: Project_2: Recharge_2: Location and Utilities Shutoff: MOP Start Time: MOP End Time: Specific Prejob Meeting Location: MOP Description of Work: JV4: Facilities Trades Shop MF Days4: UCSF4: 415 47609494: JV5: Facilities Trades Shop MF Days5: UCSF5: 415 47609495: JV6: Facilities Trades Shop MF Days6: UCSF6: 415 47609496: JV7: Facilities Trades Shop MF Days7: UCSF7: 415 47609497: JV8: Facilities Trades Shop MF Days8: UCSF8: 415 47609498: JV9: Facilities Trades Shop MF Days9: UCSF9: 415 47609499: JV10: Facilities Trades Shop MF Days10: UCSF10: 415 476094910: JV11: Facilities Trades Shop MF Days11: UCSF11: 415 476094911: 21: 22: 23: 24: 25: 26: 17: 27: 18: 28: 19: 29: 20: 30: 21_2: 12: 22_2: 13: 23_2: 14: 24_2: 15: 25_2: 16: 26_2: 17_2: 27_2: 18_2: 28_2: 19_2: 29_2: 20_2: 30_2: Action by Name of Personnel CompanyCall CUP Facilities prior to starting shutdown: Start TimeCall CUP Facilities prior to starting shutdown: Finish TimeCall CUP Facilities prior to starting shutdown: Duration min hrCall CUP Facilities prior to starting shutdown: Signoff Completion of work InitialCall CUP Facilities prior to starting shutdown: Action by Name of Personnel CompanyPrejob meeting: Start TimePrejob meeting: Finish TimePrejob meeting: Duration min hrPrejob meeting: Signoff Completion of work InitialPrejob meeting: Prejob meeting3: Action by Name of Personnel Company3: Start Time3: Finish Time3: Duration min hr3: Signoff Completion of work Initial3: Prejob meeting4: Action by Name of Personnel Company4: Start Time4: Finish Time4: Duration min hr4: Signoff Completion of work Initial4: Prejob meeting5: Action by Name of Personnel Company5: Start Time5: Finish Time5: Duration min hr5: Signoff Completion of work Initial5: Prejob meeting6: Action by Name of Personnel Company6: Start Time6: Finish Time6: Duration min hr6: Signoff Completion of work Initial6: Prejob meeting7: Action by Name of Personnel Company7: Start Time7: Finish Time7: Duration min hr7: Signoff Completion of work Initial7: Prejob meeting8: Action by Name of Personnel Company8: Start Time8: Finish Time8: Duration min hr8: Signoff Completion of work Initial8: Prejob meeting9: Action by Name of Personnel Company9: Start Time9: Finish Time9: Duration min hr9: Signoff Completion of work Initial9: Prejob meeting10: Action by Name of Personnel Company10: Start Time10: Finish Time10: Duration min hr10: Signoff Completion of work Initial10: Prejob meeting11: Action by Name of Personnel Company11: Start Time11: Finish Time11: Duration min hr11: Signoff Completion of work Initial11: Prejob meeting12: Action by Name of Personnel Company12: Start Time12: Finish Time12: Duration min hr12: Signoff Completion of work Initial12: Prejob meeting13: Action by Name of Personnel Company13: Start Time13: Finish Time13: Duration min hr13: Signoff Completion of work Initial13: Prejob meeting14: Action by Name of Personnel Company14: Start Time14: Finish Time14: Duration min hr14: Signoff Completion of work Initial14: Prejob meeting15: Action by Name of Personnel Company15: Start Time15: Finish Time15: Duration min hr15: Signoff Completion of work Initial15: Prejob meeting16: Action by Name of Personnel Company16: Start Time16: Finish Time16: Duration min hr16: Signoff Completion of work Initial16: Prejob meeting17: Action by Name of Personnel Company17: Start Time17: Finish Time17: Duration min hr17: Signoff Completion of work Initial17: Prejob meeting18: Action by Name of Personnel Company18: Start Time18: Finish Time18: Duration min hr18: Signoff Completion of work Initial18: Prejob meeting19: Action by Name of Personnel Company19: Start Time19: Finish Time19: Duration min hr19: Signoff Completion of work Initial19: Prejob meeting20: Action by Name of Personnel Company20: Start Time20: Finish Time20: Duration min hr20: Signoff Completion of work Initial20: Forwarded for Investigation to: Other_2: Noise Specify constructionrelated noise: Other_3: Additional Notes Shutdownrelated details Impact Alternative solution for continuous utility usage: 1: 2: Yes Estimated Post Date: Date_3: Text 200: Text 100: Text 300: Text 400: Text 500: Text 600: Text 700: Text 800: Check Box 200: OffCheck Box 201: OffCheck Box 202: OffCheck Box 203: OffCheck Box 205: OffCheck Box 206: OffCheck Box 207: OffCheck Box 209: OffCheck Box 210: OffCheck Box 211: OffCheck Box 212: OffCheck Box 213: OffCheck Box214: OffCheck Box215: OffCheck Box216: OffCheck Box217: OffCheck Box218: OffCheck Box219: OffCheck Box220: OffCheck Box221: OffCheck Box222: OffCheck Box223: OffCheck Box224: OffCheck Box1: 1: Off3: Off5: Off6: Off4: Off42323: Off

Check Box 1: 2: Off

Check Box3: 1: Off2: Off3: Off4: Off5: Off6: Off7: Off

Check Box6: 0: Off1: Off2: Off3: Off4: Off5: Off7: Off8: Off9: Off91: Off92: Off

Check Box4: 1: Off2: Off3: Off4: Off5: Off6: Off7: Off8: Off91: Off92: Off93: Off94: Off95: Off96: Off97: Off98: Off

Check Box7: 1: Off2: Off3: Off4: Off5: Off6: Off7: Off8: Off91: Off93: Off92: Off

Dr: [ Monday]ddr: [ Monday]DTS: [ 12:00 AM]DTR: [ 12:00 AM]

facilities services utilities shutdown request form...mop required tool list check box for each...

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