FBOP WO Tech Facility Minor Work Request NYM TO: FACILITY MANAGER FROM: NYM Footties • Feathers THRU: Facility Manager. HS,/ _ (Entered by:) (Department) (Phone) (Department Head Signature) Site: NYM Building: 3RD Location: LIEUTENANT OFF - LIEUTENANT OFF Work Location: SIS Corn Tech You aro requested to perform the following work: DVR Failure it 2 DVR Failure # ltDVR falure # 2 if Applicable. ensure all safety precautions are fanned b inctude but not limited to tockouttragout. Confined Space Fatty. a Fail Motecton" Date Active: 7119(2019 Status: ACTH TMS No.: 10481 You are authorized to perform the above work: To Foreman: CM01 - CMOI - Skill: Communication IF WORK ORDER WAS CREATED FROM A PM, ENTER PM WORK ORDER ft List below all materials used: Pescrlotion fa° tifteklykie fil .5 roar Priority No: 2 Facility Manager. (AtMang °nature) Warden's signature for greater than $1e000 chiontity Iliad Unit Price Tehl Grand Total: If Applicable, ensure that the equipment bin a MWI label afitad In deer view and legible. PAWI o Asbestos Abatomont is required or has been completed. K FITARA process is required. Completion Comments: Foreman's Total Hours: 2'0 Date Contented: Upon completion of work, complete form and return to the Facility Manager. H Signet e Re94(41 (10744„telod PrW6 EFTA00126230