Fillable Utility Shutdown Request Environmental Health and Safety (University of Texas at Tyler)

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Utility Shutdown Request Environmental Health and Safety (University of Texas at Tyler)

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  • 14 check-boxes
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File type: PDF

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Environmental Health and
Safety
Utility Shutdown
Request
Project Name and Number
:
Utility System(s) to be shut down
:
☐
Electrical
☐
Gas
☐
Water
☐
HVAC
☐
Fire Alarm
☐
Fire Suppression
Proposed Date for Shutdown
:
Proposed Time for Shutdown
It is requested that noted building system(s) be “shutdown” by the owner to allow for our tie-in of services for the project as
enumerated below. The EH&S department requires 48 hours advance notice (as a minimum) and at least (1) week for
research facilities; all shutdowns should occur during other than regular
working hours. I hereby certify that the required
work has been coordinated and schedule to achieve completion with the requested time period.
Des
cription of work to be performed, including impact prevention plan (Attach to this form):
P
re-Construction Meeting required prior to shut down?
☐
Yes
☐
No / Date: Time:
Signature of Requestor: Phone #:
Check the box for all of the following that are required or are impacted:
☐
Lockout/Tagout
☐
Fire Watch
☐
Confined Space Permit
☐
Fire Alarm System
☐
Fire Suppression System
☐
Impacted Customer Notified:
Environmental Health & Safety Remarks:
Facilities Management Remarks:
Director, Environmental Health & Safety Date Assistant Director, Facilities Management Date
Notify Physical Plant before starting work and when finished:
Name: Phone #
:
Emergency Phone Contact(s) After Hours:
Name Phone #
:
Name Phone #
:
University
of
Texas
at
Tyler
~
3900 University Blvd.
~
EH&S
(903)-566-7011
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Utility Shutdown Request Environmental Health and Safety (University of Texas at Tyler)

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Completed 24 July 2020

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