Contractor Information Company Name: Date Request Submitted: Contact Name: Tides on Work Date: Contact Phone #: Contact Email: Barge Information Barge Name: Date of Work: Barge Dimensions: Time Required: Barge Owner: __________________________________________ Tug Information Description of Work: Tug Name: Tug Dimensions: Crane Information: Tug Call Number: Skipper Name: Is a crane required for ramps or loading? Skipper Cell #: Yes No If yes- Maximum height of crane is Site Supervisor Information Item Description Y N N/A 1 Emergency Spill Name: Kit Signature: _____________________________ 2 Aid 3 General Liability Date: Insurance 4 Tidal Checks 5 No Thrust Zone Victoria Airport Authority-Approval 6 Lighting Name: 7 Communications 8 Navigational Signature: _____________________________ Lighting Date: 9 Site Clean 10 Work Plan Email completed form to: 11 Barge Securing seaplanebase@victoriaairport.com 12 Gate Lock Out NOTE: You are NOT authorized to use the seaplane 13 Notam base until you receive approval. 14 Worksafe
Contractor Information Company Name: Contact Name: Contact Phone #: Contact Email: Date of Work: Time Required: __________________________________________ Description of Work: Crane Information: Is a crane required for ramps or loading? Yes No If yes- Maximum height of crane is Item Description Y N N/A 1 Emergency Spill Kit 2 Aid 3 General Liability Insurance 4 Tidal Checks 5 No Thrust Zone 6 Lighting 7 Communications 8 Navigational Lighting 9 Site Clean 10 Work Plan 11 Barge Securing 12 Gate Lock Out 13 Notam 14 Worksafe Date Request Submitted: Tides on Work Date: Barge Information Barge Name: Barge Dimensions: Barge Owner: Tug Information Tug Name: Tug Dimensions: Tug Call Number: Skipper Name: Skipper Cell #: Site Supervisor Information Name: Signature: _____________________________ Date: Victoria Airport Authority-Approval Name: Signature: _____________________________ Date: Email completed form to: seaplanebase@victoriaairport.com NOTE: You are NOT authorized to use the seaplane base until you receive approval.
New%20Seaplane%20Base%20Form_Mar2017.docx