Facilities Services Utilities Shutdown Request...

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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: _________________________

Facilities Services Utilities Shutdown Request...

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