PART I - REQUEST (Filled out by Requestor)

1. FROM

2. REQUEST NO.

3. TO

4. DATE OF REQUEST

5. REQUEST FOR

☐ COST ESTIMATE ☐ PERFORMANCE OF WORK

5a. REQUEST WORK START

6. FOR FURTHER INFORMATION CALL

7. SKETCH/PLAN ATTACHED

☐ YES ☐ NO

8. DESCRIPTION OF WORK AND JUSTIFICATION (Including location, type, size, quantity, etc.)

9. FUNDS CHARGEABLE

10. SIGNATURE (Requesting Official)

PART II - COST ESTIMATE

(Filled out by Maintenance Control Division if estimate requested)

11. TO:

12. ESTIMATE NO.

13. COST ESTIMATE

14. SKETCH/PLAN ATTACHED

☐ YES ☐ NO

a. Labor

15.

b. Material

☐ APPROVED: PROGRAMMING TO START IN .

☐ APPROVED: BASED ON PRESENT WORKLOAD, THIS JOB CAN BE

PROGRAMMED TO START IN , IF

e. Contingency

AUTHORIZED BY 25TH OF AND FUNDS ARE MADE AVAILABLE.

☐ DISAPPROVED. (See Reverse Side)

f. TOTAL

16. SIGNATURE

17. DATE

PART III - ACTION (Filled out by Requestor)

18. TO:

19. AUTHORIZATION TO PROCEED IS ATTACHED (Check one if other than PW funds are involved)

☐ NAVCOMPT 140 ☐ OTHER

20. WORK REQUESTED

HAS BEEN HAS BEEN WILL BE PERFORMED

☐ CANCELLED ☐ DEFERRED ☐ BY OTHERS

21. SIGNATURE

22. DATE