UTILITY INTERRUPTION NOTIFICATION
Check ( X ) the appropriate item:Utility Interruption
Life Safety Interruption*
HVAC System Outage Notification Only*
(8 hours or more & affecting a suite or larger area)
1.Today's Date:Your Name:Telephone Number:
2.What Building(s) Or Areas Will Be Affected?
Building No.
3.Duration Of The Interruption: Must Indicate Start & End Date and Time:
Start Date & Time:End Date & Time:
Alternate Start Date & Time:Alternate End Date & Time:
Alternate Start Date & Time:Alternate End Date & Time:
4a.Your Supervisor/Foreman or Coordinating Supervisor's Signature:
b.Engineering Services/Electronic Technician's Signature (Required For Fire Alarm):*
c.Environmental Health & Safety/Fire Protection Engineer Signature (Required for Sprinkler):*
5.Contractor's Name and Telephone Number (if applicable):
6.Emergency ORScheduled(X One)
7.Job #:Work Order #:Task #:(Only One Number Required)
8.Reason (Specify): Provide a detailed description of work to be performed, listing specific areas impacted, as opposed to just stating "shut off steam, heat, water, electricity, etc." An accurate description will allow supervisors and schedulers to evaluate the situation for approval and to identify any additional utilities or areas that might be affected.
9.Work Location: Record the name of the building in which the work will be performed. Also provide a list of all work areas, such as room numbers, hallways, and/or floor levels, etc.
10.What Utilities Will Be Affected?(X All that Apply)
Distilled WaterHigh-Pressure SteamChilled WaterOther
Domestic Cold WaterMedium-Pressure SteamProcess Cooling Water
Domestic Hot WaterLow-Pressure SteamElectricity
Sanitary SewerHeatingFire Alarm
CondensateAir ConditioningSprinkler/Suppression
Campus AirNatural GasCentral Control System
11.What Trade Codes Will Be Involved?
Customer's Approval Date:
For Questions Regarding This Request Contact:Telephone Number:
NOTE: ONLY FOR OPP--In an effort to expedite this utility interruption in a timely manner, please repond within 24 hours, if you need to make changes or additions to utilities that my be affected. Route any changes/additions back to me via E-mail. Thank you for your cooperation.
NOTE: ONLY FOR OPP-- IF NO RESPONSE IS RECEIVED WITHIN 24 HOURS, I WILL ASSUME THAT NO EXCEPTIONS ARE TAKEN!