INSTITUTIONAL CONTROLS EXCAVATION NOTIFICATION

Please fill out the excavation notification form below, prepare it for printing, and submit it to the Navy for approval. The notification number and sign-offs will be conducted by the Navy.
NAVY INSTITUTIONAL CONTROL EXCAVATION NOTIFICATION NUMBER __________________________

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NAME:	PHONE:	LOCATION OF EXCAVATION: Location should be marked by stakes and/or paint. (Coordinates will be transferred from the excavation notification map page.) Northing: Easting: Cross Streets:
COMPANY:	DATE:
CITY	STATE
_______________________________________________________________________________________ PURPOSE OF THE EXCAVATION: Describe the purpose of the excavation Please attach the excavation map.

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EXCAVATION TO BEGIN:
(DATE)
(TIME)

ESTIMATED COMPLETION DATE:

METHOD OF EXCAVATION:

DEPTH OF EXCAVATION:

_________________________________________________________________________________________________ Requester must notify the Navy 3 working days prior to excavation:
Naval Facilities Engineering Command Northwest Code EV4JB 1101 Tautog Circle Silverdale, WA 98315-1101 Telephone: 1-866-239-1219 Fax: (360) 396-0857 If UXO is encountered, stop work, call 911 and 1-866-239-1219.

_________________________________________________________________________________________________ Excavation will not proceed until the following personnel review and comment on the IC environmental excavation notification application. I HAVE READ AND UNDERSTAND THE NAVY'S REQUIREMENTS FOR INSTITUTIONAL CONTROL EXCAVATIONS AND AGREE TO ABIDE BY THEM. SIGNATURE (REQUESTER):_________________________________ DATE: __________________________
Have you received ordnance awareness training briefing?	Yes	No

COMMENTS:

The requester is responsible for ensuring that all IC excavation workers have completed ordnance awareness training prior to beginning the excavation. Work shall immediately stop if suspected ordnance items are encountered during excavation. The workers must immediately evacuate the area and call the Navy at 1(866) 239-1219. An initial exclusion zone of a 300-foot radius around the site will be maintained and all non-essential personnel will be denied access until Navy personnel direct otherwise. In no case will excavation be allowed to resume at the site until the Navy has completed necessary response actions to render an area safe.

Excavation Notification is valid for 120 days from signed approval date.
Permit expires on this date:_______________________________. Please call 1 (866) 239-1219 for waiver.

APPROVED

DISAPPROVED

__________________________
Approver Signature

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Date

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EXTENSION GRANTED:	30 days 90 days	60 days Other _____	__________________________ Approver Signature	______________ Date

Please remember to attach the excavation notification map file when you submit the excavation notification registration form.

The purpose of the institutional control excavation notification is to notify the Navy of intrusive projects that will be performed on institutional control sites. After the Navy reviews the request, the original request will be returned to the requester, approved or disapproved, as appropriate. The Navy will retain a copy. An approved IC Excavation notification must be in the possession of personnel on site during excavation or work will be stopped. The IC Excavation Notification will expire after 120 days. If an IC Excavation notification extension is necessary, the requester shall contact the Navy at 1-866-239-1219 one-week before the current IC Excavation notification expires to request an extension.

Last Updated: January 5, 2008