Appendix A Request for use/closure form

Request for Temporary Use / Closing of Roads / Parking / Sidewalks or Other Paved Area

Location (Describe and note on attached map):


Dates and Time of Usage Requested:


Extent of Usage (road width, no. of lanes, etc.):


Controls to be Provided (barricades, flagmen, etc.)


Requested By: __________________________ ______________
Project Officer Date

__________________________________________________________________

Approved By: _____________________________ _______________
Grounds Maintenance Date
and Landscaping Section, ORF

___________________________ _______________
Fire and Emergency Response Date
Section (NIH Fire Dept.), DPS ___________________________ _______________
Police Branch, DPS Date

Comments or Conditions Imposed by Approving Officials:

________________________________________________________

________________________________________________________

________________________________________________________