FACILITIES DIVISION REQUEST FOR UTILITY INTERRUPTION WORK SHEET REQUESTOR NAME : DATE : DEPT : PHONE : WORK REQ #: ACCT #: CAMPUS BOX : BUILDING INFORMATION / DATE & TIME ENTIRE BLDG or BUILDING(s): SPECIFIC ROOM : BEGIN DATE / / END DATE : / / : BEGIN TIME : AM / PM END TIME: AM / PM DISCONNECT INFORMATION RUNNING POWER WATER FIRE ALARM HEATING STEAM SYSTEMS Primary Hot Disconnect AIR CONDITIONING Secondary Cold Testing (Chilled Water) Distilled Sprinkler Operational Y / N PROPANE/NATURAL GAS : For all Fire Alarm / Sprinkler Disconnects or Testing, please first obtain approval from the Electronics Shop: (separate form). REASON FOR INTERRUPTION (Scope of Work): Shop Supervisor Signature: Date: Addtl. Supervisor (s) Signature: POLICY # 806 ROUTINE UTILITY INTERRUPTION REQUEST – –
FACILITIES DIVISION REQUEST FOR UTILITY INTERRUPTION WORK SHEET REQUESTOR NAME : DATE : DEPT : PHONE : WORK REQ #: ACCT #: CAMPUS BOX : BUILDING INFORMATION / DATE & TIME BUILDING(s): ENTIRE BLDG or SPECIFIC ROOM : BEGIN DATE : / / END DATE : / / BEGIN TIME : AM / PM END TIME: AM / PM DISCONNECT INFORMATION POWER RUNNING WATER FIRE ALARM HEATING Primary Hot Disconnect STEAM SYSTEMS Secondary Cold Testing AIR CONDITIONING (Chilled Water) Distilled Sprinkler Operational Y / N PROPANE/NATURAL GAS : For all Fire Alarm / Sprinkler Disconnects or Testing, please first obtain approval from the Electronics Shop: (separate form). REASON FOR INTERRUPTION (Scope of Work): Shop Supervisor Signature: Date: Addtl. Supervisor (s) Signature: POLICY # 806 – ROUTINE UTILITY INTERRUPTION REQUEST –
Utility_Interruption_Request.docx