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Potential Change # <br />Civil_- 001 <br />Potential Change Form (Dlscicretr) (Number) <br />Date: 6111/2019 <br />Client/Project: City of Hugo Water Tower No. 4 j Project #235318 <br />Title / Short Description: Substitute Mega -Lug series 1100 Connection in lieu of the American (Flex-Lok Joint (3) required <br />Note: This form is to be completed in Its entirety. <br />Source Document <br />Type or Nature of Change <br />❑ RFI - Request for Information ❑ DCH - Design Change <br />❑ <br />Scope (Contractual) ❑ <br />Rework <br />❑ NCR - Non Conformance Report ■ DDV - Design Deviation <br />❑ <br />Safety <br />❑ <br />Back charge <br />❑ CLR - Client Request ❑ SMOC — Safety <br />Management of Change <br />❑ <br />Reliability <br />❑ <br />Discovery <br />❑ PRN — Process Revision Notice ❑ Other <br />❑ <br />Quantity Change <br />❑ <br />Material Substitution <br />❑ <br />Forecast <br />0 <br />Other (CREDIT OFFEREDi <br />Reference(s): (Include any drawings, sketches, pictures, equipment / item numbers, RFI, NCR, etc.) <br />Sheet F1 Sheet 4 Rev 1 <br />ption of Change and Recommendations: (Reference other Disciplines and Functions affected by this change. Attach additional sheet as <br />required.) <br />Replace the American Flex-Lok Joint with the Mega -Lug Series 1100 Connections (3) required <br />i Originator Signature: <br />I <br />Impact: <br />Current Status (By Originator) <br />Date: �l Lo/rr <br />a Cost ❑ Schedule <br />❑ Work Already Performed <br />■ Work Not Started ❑ Work Partially Performed ❑ Other <br />I Function <br />Hours- Cost <br />Disc./Craft Supervisor: <br />Change Classification: <br />Home Office (H.O.) <br />❑ Internal (IIN) <br />Fabrication <br />Civil -Tank & Tower <br />X <br />-- — <br />Contractual (CCR) <br />Construction <br />Subcontracts <br />($7,000) <br />Change Coordinator: <br />Date: <br />Initials: <br />Procurement Materials / Equipment <br />Lance Jansen <br />6/11/2019 <br />Accepted <br />Totals <br />($7,000) I <br />Rejected <br />❑ Approved Date:_ _ <br />❑ Rejected Reason: <br />Request For Estimate: ❑ Order of Magnitude <br />❑ Detail Estimate Project Manager: <br />TYPE I Initials <br />❑ IIN ❑ Proceed With Work - Provide Estimate <br />❑ Do Not Proceed - Hold for Estimate <br />❑ CCR ❑ Proceed With Work - Provide Estimate <br />❑ Do Not Proceed - Hold for Estimate <br />Client (if Required): <br />Date <br />Date <br />Form Number CMS-740-00-FM-31211 Issued for Use: 20 Apr 2009 Page 1 of 1 <br />