Note: Fields marked in RED are mandatory.
General Information
Requester's  Name:   Requester's Phone #:  
Requester's Email:   Request Sequence #:  
Project Information
UK Project #:   UK Project Name:  
UK Project Manager:   UK Project Coordinator:
Outage Information
Utility to be taken out of service:   Building:
Floor: Room:
Zone:    
Date of Outage Start:
(mm/dd/yyyy)
    Time of Outage Start:
(hh:mm AM|PM)
     
Duration of Outage:      
Description of work performed during outage:  
All required parts & equipment are onsite:
 
If parts not onsite, when will they be available:
(mm/dd/yyyy)
   
Interim Life Safety Measures:
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