Electrical Safety Rules and Procedures – DSC2 – 3rd March 2005
Model Form No 1 - STATEMENT OF SERVICES LOCATIONS
ORIGINAL Page 1 of 2
Daresbury Laboratory
Statement of Services Location Serial Number
(pre-printed)_____________________________
(Complete precisely and legibly in BLOCK CAPITALS)
PART 1 – To be completed by the Supervising Officer /Project Manager
Name of Contractor or Person Undertaking the work
_______________________________________________________________________________________
Address:
_______________________________________________________________________________________
Issue Date: _________________Expiry Date: ______
(not more than 3 months from date of issue)
Location and boundaries of the site:
_______________________________________________________________________________________
_______________________________________________________________________________________
As far as I am able to ascertain from the information available, services are as indicated below: Electrical
Services *
Communications
Services *
Water
Services *
Mechanical
Services *
Fuel Oil
Services
Other
Free of Services
Services identified on
Drawings/documents
(List details of page)
Services are believed to exist
But information is limited
(List details over page)
* Note: enter “X” if applicable
To be completed by the Supervising Officer /Project Manager and forwarded to the Contractor
Signed _________________________________________( Supervising Officer /Project Manager)
Name _________________________________________Time and Date _____________________________
Contact Tel No ___________________________
A review of the services has been carried out as indicated above and the following action(s) shall be taken: 1*
Site is free of services and work can proceed.
2*
Services have been identified and details are listed on the schedule over page. A Safety Programme is to
be submitted before commencing work.
3*
Services are believed to exist but information is limited and available details are listed on the schedule
over page. A Safety Programme is to be submitted before commencing work.
* Note: delete as appropriate
Signed _________________________________________( Reciving Contractor)
Name _________________________________________Time and Date _____________________________
Contact Tel No ___________________________
Daresbury Laboratory Electrical Safety Code No 2 – 3rd March 2005
1
Electrical Safety Rules and Procedures – DSC2 – 3rd March 2005
Model Form No 1 - STATEMENT OF SERVICES LOCATIONS
DUPLICATE – page 1 of 2
Daresbury Laboratory
Statement of Services Location Serial Number
(pre-printed)_____________________________
(Complete precisely and legibly in BLOCK CAPITALS)
PART 1 – To be completed by the Supervising Officer /Project Manager
Name of Contractor or Person Undertaking the work
_______________________________________________
Address:
_______________________________________________________________________________________
Issue Date: _________________Expiry Date: ______
(not more than 3 months from date of issue)
Location and boundaries of the site:
_______________________________________________________________________________________
_______________________________________________________________________________________
As far as I am able to ascertain from the information available, services are as indicated below: Electrical
Services *
Communications
Services *
Water
Services *
Mechanical
Services *
Fuel Oil
Services
Other
Free of Services
Services identified on
Drawings/documents
(List details of page)
Services are believed to exist
But information is limited
(List details over page)
* Note: enter “X” if applicable
To be completed by the Supervisor Officer /Project Manager and forwarded to the Contractor
A review of the services has been carried out as indicated above and the following action(s) shall be taken: 1*
Site is free of services and work can proceed.
2*
Services have been identified and details are listed on the schedule over page. A Safety Programme is to
be submitted before commencing work.
3*
Services are believed to exist but information is limited and available details are listed on the schedule
over page. A Safety Programme is to be submitted before commencing work.
* Note: delete as appropriate
Signed _________________________________________( Supervisor Officer /Project Manager )
Name _________________________________________Time and Date _____________________________
Contact Tel No ___________________________
Daresbury Laboratory Electrical Safety Code No 2 – 3rd March 2005
2
Electrical Safety Rules and Procedures – DSC2 – 3rd March 2005
Model Form No 1 - STATEMENT OF SERVICES LOCATIONS
ORIGINAL– page 2 of 2
Daresbury Laboratory
Statement of Services Location Serial Number
(pre-printed)_____________________________
SERVICES KNOWN TO EXIST
Listed below are the services identified on drawings/documents: Service
Drawing/Document References
Comments/Additional Information
SERVICES BELIEVED TO EXIST
Listed below are the services believed to exist together with any available details: Service
Known Details
Additional Information
I confirm that originals/copies* of the above drawings/documents are available.
necessary
* delete as
Signed __________________________________________ (Supervisor Officer /Project Manager )
Daresbury Laboratory Electrical Safety Code No 2 – 3rd March 2005
3
Electrical Safety Rules and Procedures – DSC2 – 3rd March 2005
Model Form No 1 - STATEMENT OF SERVICES LOCATIONS
DUPLICATE – page 2 of 2
Daresbury Laboratory
Statement of Services Location Serial Number
(pre-printed)_____________________________
SERVICES KNOWN TO EXIST
Listed below are the services identified on drawings/documents: Service
Drawing/Document References
Comments/Additional Information
SERVICES BELIEVED TO EXIST
Listed below are the services believed to exist together with any available details: Service
Known Details
Additional Information
I confirm that originals/copies* of the above drawings/documents are available.
necessary
* delete as
Signed __________________________________________ (Supervisor Officer /Project Manager )
Daresbury Laboratory Electrical Safety Code No 2 – 3rd March 2005
4