Routine Shutdown Form

SHUTDOWN REQUEST FORM

Routine (Yellow) Emergency (Pink) Critical (Blue)

Today’s Date: 5/22/2008 / See Attached

What systems are involved?Building W79

Reason for routine shutdown.Phasing of High Voltage Cables because of recent repairs being made.

Building and Rooms Directly Affected:Entire building

Requested Date(s):5/29/2008 / Day(s):Thursday / Duration:2 Hours
(Include prep time) / Start Time:10:00 AM / End Time:12:00 PM

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

Trigger Info

/ Name:Rich Lucas / Page/Radio #:100
Work Order #:4746145 / Phone:617-324-6801 / Cell: 617-594-3460 / E-mail:
Project #: / Cost Object #:1933000 / 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&T / Network Operations / 3-8400
IS&T / Hardware Services / 3-1410
Registrar / Schedules Office (Classrooms) / 3-4788

Types of services affected, check as needed:

POWER

Access controls / WATER
Chilled water / AIR
Supply-ventilation / STEAM
High pressure / OTHER
Fire alarm
Emergency generator / Condenser water / Supply-cooling / Medium pressure / Fire protect water
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.Mark Cote / 2.Kevin Doran / 3.Rich Lucas / 4.

****Lock Out/Tag Out Procedure Is Required****

Approved by: / Mechanical / Utility / Fire Prot.

DISTRIBUTION: The person approving the shutdown 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
Cleared by/Signed by: / Time: / Date:

Revised: September 2006

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