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A <br />❑ <br />Po�tential Change Form <br />Potential Change # <br />Paint 002 <br />(DIsclCraft) (Number) <br />Date: 712119 <br />Client/Project: Hugo, MN-1.5 MG CET <br />Project Number: 236318 <br />Title 1 Short Description: Change to Shop Blast and Shop Prime Paint in Lieu of Field <br />Note: This form Is to be completed in its entirety. <br />Filled% i • <br />Source Document Type or <br />Nature of Change <br />❑ RFI - Request for Information ❑ DCH - Design Change - Scope (Contractual) <br />❑ Rework <br />❑ NCR - Non Conformance Report ❑ DDV - Design Deviation ❑ Safety <br />❑ Back charge <br />■ CLR - Client Request ❑ SMOC — Safety ❑ Reliability <br />Management of Change <br />❑ Discovery <br />❑ PRN — Process Revision Notice ❑ Other _ ❑ Quantity Change <br />❑ Material Substitution <br />❑ Forecast <br />❑ Other <br />Reference(s): (Include any drawings, sketches, pictures, equipment / item numbers, RFI, NCR, etc.) <br />Discussion durin kick-off meetin <br />Detailed Description of Change and Recommendations: (Reference other Disciplines and Functions affected by this change. Attach additional sheet as <br />required.) <br />Shop Blast and Shop Prime Paint. Paint Sheets to be revised to reflect change. <br />r <br />Originator Signature. <br />Date: <br />Impact: Current Status (By Originator) <br />N Cost ❑ Schedule ❑ Work Already Performed ■ Work Not Started ❑ Work Partially <br />Performed ❑ Other <br />Function 1 Hours <br />Cost <br />-$15,000 <br />-5i 6,000 1 <br />Disc.ICraft SuDervisor: <br />CBI Paint <br />Chancre Classification: <br />❑ Internal (IIN) <br />X Contractual (CCR) <br />Home Office (H.O.) <br />_ <br />Fabrication <br />Construction <br />Subcontracts <br />Change Coordinator: <br />Lance Jansen <br />Date: <br />7/2/2019 <br />Initials: <br />Procurement Materials 1 Equipment <br />Accepted <br />Totals <br />Rejected <br />❑ Approved Date:_ _ <br />❑ Rejected Reason:_ <br />11 <br />Project Manage <br />Date -7 zO1f <br />Request For Estimate: ❑ Order of Magnitude ❑ Detail Estimate <br />TYPE Initials ` <br />[103 IIN ❑ Proceed With Work - Provide Estimate <br />❑ Do Not Proceed - Hold for Estimate <br />_ <br />❑ CCR <br />Proceed With Work - Provide Estimate Client (If Requi <br />❑ Do Not Proceed - Hold for Estimate <br />Date <br />Form Number CMS-740-00-FM-31211 Issued for Use: 20 Apr 2009 Page 1 of 1 <br />