Routine Shutdown Form

SHUTDOWN REQUEST FORM Routine (Yellow) Emergency (Pink) Critical (Blue)

Today’s Date: 11/12/2008 See Attached

What systems are involved? Domestic hot and cold water Reason for routine shutdown. To replace shower valve in Housemaster's apt. Building and Rooms Directly Affected: W4-West Tower

Requested Date(s):9/28/09 Day(s): Monday Duration: 4 hours (Include prep time) Start Time: 9:00am End Time: 1:00pm

TRIGGER: Complete as much as you can of applicable areas. Forward to [email protected] and the appropriate zone. Shutdowns take five (5) business days to process. Trigger has primary responsibility for communication.

Trigger Info Name: Marsha Whelan Page/Radio #: Maximo #: Phone: 3-4324 Cell: E-mail: [email protected] Project #: Cost Object #: 1346800 R&M SAP #: (R&M Use only)

List names, groups of Facilities’ personnel and occupants contacted and have provided consent/notification to proceed. Electrical and HVAC (chilled water, etc.) shutdowns must involve IS at onset of action planning. Dept./Group Name Phone Dept. Group Name Phone IS Jeff Schiller ([email protected]) 3-8400 IS JJ Morey 3-1410 ([email protected]) Registrar Schedules Office 3-4788 (Classrooms)

Types of services affected, check as needed: POWER WATER AIR STEAM OTHER Access controls Chilled water Supply-ventilation High pressure Fire alarm Emergency Condenser water Supply-cooling Medium pressure Fire protect water generator Emergency power Pure water Supply-heating Low pressure Natural gas Building power Hot domestic Exhaust-laboratory Condensate return Odors Elevators Hot lab process Exhaust-general Smokes Computers Heating hot water Exhaust-toilet DRAINAGE Exhaust hood Telephones Cold domestic Compressed control Lab waste Lighting Cold lab process Compressed lab air Sanitary Corridor/stairs De-ionized Lab vacuum Storm drain

Investigated by: 1. 2. 3. 4.

****LOCK OUT/TAG OUT PROCEDURE IS REQUIRED****

Approved by: Mechanic Utili Fire al ty Prot.

DISTRIBUTION: After each stage, Warren Scott and Paul Stordy will determine distribution as required. Always include: Could include: Other: Trigger 2nd Shift Carp/Constr Zone A Bulletin Board 3rd Shift HVAC Zone B W. Scott Fire Protection Piping Zone C FCS Console Utility Struc/Paint Zone D Technical Elec/Controls Zone E

Revised: March 2001 P:\Public\Shutdowns\Shutdown Request.dot Cleared by/Signed by: Time: Date:

Revised: March 2001 P:\Public\Shutdowns\Shutdown Request.dot