LOTO Request Form

Submit requests for review at least 48 hours before work begins.

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Job

Electric Room

Select electric room(s)

Temp Power MV Power House Electric Room CSB Catcher Electric Room 1.1C Catcher Electric Room 2.1C Electric Room 1.1 Electric Room 1.2 Electric Room 1.3 Electric Room 1.4 Electric Room 1.5 Electric Room 1.6 Chiller Electric Room 1.1 Chiller Electric Room 1.2 Chiller Electric Room 1.3 Chiller Electric Room 1.4 Chiller Electric Room 1.5 Electric Room 2.1 Electric Room 2.2 Electric Room 2.3 Electric Room 2.4 Electric Room 2.5 Electric Room 2.6 Chiller Electric Room 2.1 Chiller Electric Room 2.2 Chiller Electric Room 2.3 Chiller Electric Room 2.4 Chiller Electric Room 2.5

Date Request Submitted Do You Require Control Power On? Company Name Company Name (please specify) Contact Person Employee Number Contact Phone Contact Email Date Work Will Begin Date Work Will End Duration of Work (Days or Hours) Scope of Work Being Performed Location & Equipment Being Worked On Personnel Involved in the Work (full name, one per line) - only people listed here can sign on at the lockout Supervisor Verified Site-Specific LOTO Training Company Contact Signature (type full name)