Title: Isolations, Smoke to Heat Detection Substitutions

Doc. No.: PR0630

Issue no:
A1 Issue date:July
2015
Appendix B Form A Request for Isolation

(THIS FORM IS VALID FOR A MAXIMUM DURATION OF ONE WEEK)

FIRE SAFETY PRECAUTIONS – REQUEST FOR ISOLATION of FIRE DETECTION EQUIPMENT

See 3.3.1 PR0630
Section 1- To be completed by the Originator
Reference No:
LU Station Number Project Number Application Number
L U B 0 7 1 C A P E X 0 6 1 B
(e.g. – LU-N091-LN412-001-A)
To: Location: Managing Line:
Line Fault Report Centre Paddington Underground Bakerloo
Station
From: Name: Project name:
Baljit Singh Paddington Cube
PM (Originator)

Station Paddington Start Date

Work Area Finish Date

(Station I.D., No. of Shifts

Room Numbers)

Contractor PO/Cost Centre/TA No:

Liaise at Liaise
(place) at
(time)
TRAFFIC HOURS ENGINEERING HOURS
(Temporary Reduction of Fire
Safety Measures / Exemptions
Required for Stations to
FROM TO FROM TO
Monday Sun/Mon
Tuesday Mon/Tues
Wednesday Tues/Wed
Thursday Wed/Thurs
Friday Thurs/Fri
Saturday Fri/Sat
Sunday Sat/Sun

Type of Remote Site

work taking
place
Signed TL Fire Telephone nmber:
Eng/PM (Originator)

E Mail address
Date:
Fax Number:
 Title: Isolations, Smoke to Heat Detection Substitutions
Doc. No.: PR0630
Issue no:
A1 Issue date:July
2015
Forward Form A to Fault Report Centre Date Sent:
07/03/2024

E Mail:
JNP:
BCV/SSL:

Form A Request for Isolation

Section 2: To be completed by Fault Report Centre

FRC Commencement Number:

Unique FRC commencement number allocated

Date Sent:
Instruct Maintenance Contractor (*delete as appropriate)
Yes/NA*

Return Form ‘A’ to Originator Date Sent:

Section 3: To be Actioned by Originator on receipt of Form A from FRC

Date Sent:
Instruct approved fire contractor/ trained and
LU certified person and issue copy of Form A Contractor / trained and
LU certified person:

Section 4: To be actioned by Maintenance/Approved Fire Contractor/ LU trained or certified person

on receipt of Form ‘A’ from the FRC/Originator

Name/Contractor:
Carry out listed isolations, take print out of Site Person in
approved isolations, inform site person in Charge informed:
charge. (*delete as Yes/No*
appropriate)

Section 5: To be completed by Maintenance/Approved Fire Contractor / LU trained or certified

person on being informed by the site person in charge that all works have been completed.

FRC Closure Number:

On receipt of instruction that work has been
completed carry out de-isolations, take print out,
obtain a FRC closure number from the Fault Report
Centre

Date Completed:

Note:
At end of works completed form to be copied to the Originator with print out evidence and Contractors
de- isolation form.

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