Version 02 Work Impact Control Form (WICF) Page 1 of 2 This document tends to review and evaluate the impacts associated with any work activity conducted by service providers/contractors to prevent any unplanned interruption to the building services (all steps must be followed in order). Step 1: allftlowing information must be complated by work activity requester ae Name: Nader EL Neck? AUST ID Ah oS ii Company/Department: Wa ce / HL Mobile! O55 2tacais Work Dessiption: “E xcaution wwAke concrete & coring im Precot woll to Recti fy wacker supply er ge Meme. tinder oe nee age eal Duration = § Rowe Start Date & time: 5_ ot 2°3/ 8.00 AM End Date&Time: 5- 01-2 / Lem Qe ‘Step 2: the requester needs to tick the box of the impacts to building services for further analysis by MACC maintenance Building Services impact ew Name & Signature aFlol_fa Ouvac Weta supply shukcoumm betden lo.W.m £ Vp. Dlevator ore Ie Electrical fe L Ls ihe soil Dems Nose Tae 2 Orem seer ee | Vie | Yt? DLab system WA d we See Cothers (————) | Chaydraulic & Plumbing sa notification to support services is required? (please choose from below) CIT Network OUtilties Cisecurity Ose Fire Services